Routine Use Of Magnetic Resonance Imaging Research Articles

Abstract PO3-27-03: PROMISE Study: Pre-Operatory MRI is not Effective. A Systematic review of impact of magnetic resonance imaging on surgery-decision and clinical outcomes in women with breast cancer

Abstract Background: The use of magnetic resonance imaging (MRI) in patients with breast cancer before surgery has been a subject of ongoing debate and discussion. The role of MRI as a preoperative tool to guide surgical decision-making remains controversial. Some studies suggest that MRI may improve the detection of additional tumors or assess the extent of disease, while others discuss that it may lead to increased false-positive findings and unnecessary interventions. The potential benefits and potential harms of incorporating MRI into the preoperative assessment of breast cancer patients continue to be topics of research and clinical interest. Clarifying the impact of preoperative MRI on surgical outcomes is crucial to inform evidence-based practices and optimize patient care. Until present, there is no pooled analyses from randomized clinical trials perspective of the clinical impact regarding the routine use of MRI. Objectives: This study aims to conduct metanalysis of randomized controlled trials (RCT) to investigate the association between preoperative MRI and surgical outcomes in women with newly diagnosed invasive breast cancer, providing evidence-based recommendations for clinical practice. Methods: A comprehensive search of electronic databases including PubMed, Medline, Embase, Ovid, Cochrane Library, and Web of Science was conducted by three independent researchers from inception to May 2023. The inclusion and exclusion criteria were based on Cochrane's principles. Relevant data from eligible studies were extracted. A systematic evaluation and meta-analysis were performed using the fixed-effects model to estimate the pooled risk ratio (RR) and 95% CI. Results: Out of 21 studies found, 6 were RCTs and 15 observational comparative studies. The results showed that in RCT preoperative MRI significantly reduce the rate of immediate breast conservative surgery (RR=0.94, 95%CI 0.91~0.96, I2=0%) and increase the mastectomy rate (RR=1.88, 95%CI 1.48~2.38, I2=86%). There wasn’t any change in reoperations rates (RR=0,87, 95%CI 0.71~1.07, I2=72%). Only 1 trial reported data on survival, showing no difference between groups. Conclusion: From RCT standpoint, the evidence suggests that preoperative MRI for newly diagnosed invasive breast cancer may not be beneficial to the patients by increasing rate of mastectomy with no survival benefit and that should be considered when offering as a routine practice to patients with breast cancer before surgery. Forest plot of mastectomy as an outcome Forest plot of re-operation as an outcome Citation Format: Andre Mattar, Andressa Amorim, Evandro Mateus, Fabio Bagnoli, Felipe Zerwes, Francisco Pimentel Cavalcante, Guilherme Novita, Lincon Mori, Marcelo Madeira, Marina Diogenes, Marcelo Antonini, Lucas Okumura. PROMISE Study: Pre-Operatory MRI is not Effective. A Systematic review of impact of magnetic resonance imaging on surgery-decision and clinical outcomes in women with breast cancer [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO3-27-03.

How accurate is MRI for diagnosing tarsal coalitions? A retrospective diagnostic accuracy study

ObjectivesThis study aimed to evaluate the diagnostic accuracy, inter-reader agreement, and associated pathologies on MR images of patients with confirmed TC.Methods and materialsIn this retrospective study, 168 ankle MRI exams were included, consisting of 56 patients with clinically or surgically confirmed TC and 112 controls without TC, matched for age and sex. Images were analyzed independently by three radiologists blinded to clinical information. The evaluation criteria included the presence, type, and location of TC, as well as associated pathologies. After calculating diagnostic accuracy and the odds ratio of demographic data and anatomic coalition type for associated pathologies, inter-reader agreement was assessed using kappa statistics.ResultsThe majority of TCs were non-osseous (91.1%) and located at the calcaneonavicular (33.9%) or talocalcaneal joint (66.1%). Associated pathologies included adjacent and distant bone marrow edema (57.1% and 25.0%), osteochondral defect of the talar dome (OCD, 19.6%), and joint effusion (10.7%) and accessory anterolateral talar facet (17.9%). Talar OCD was associated with increased patient age (p = 0.03). MRI exhibited a cumulative sensitivity and specificity of 95.8% and 94.3% with almost perfect inter-reader agreement (κ = 0.895).ConclusionMRI is a reliable method for detecting tarsal coalition and identifying commonly associated pathologies. Therefore, we recommend the routine use of MRI in the diagnostic workup of patients with foot pain and suspected tarsal coalition.Clinical relevance statementMRI is an accurate and reliable modality for diagnosing tarsal coalitions and detecting associated pathologies, while improving patient safety compared to computed tomography by avoiding radiation exposure.Key Points• Despite the technological progress in magnetic resonance imaging (MRI), computed tomography (CT) is still regarded as the gold standard for diagnosing tarsal coalition (TC).• MRI had a cumulative sensitivity of 95.8% and specificity of 94.3% for detecting tarsal coalition with an almost perfect inter-reader agreement.• MRI demonstrates high accuracy and reliability in diagnosing tarsal coalitions and is useful for identifying associated pathologies, while also improving patient safety by avoiding radiation exposure.

The Use and Downstream Associations of Magnetic Resonance Imaging for Lateral Epicondylitis

Low-value imaging is associated with wasteful health care spending and patient harm. The routine use of magnetic resonance imaging (MRI) for the work-up of lateral epicondylitis is an example of low-value imaging. As such, our aim was to investigate the use of MRIs ordered for lateral epicondylitis, the characteristics of those undergoing an MRI, and the downstream associations of MRI with other care. We identified patients aged ≥18 years with a diagnosis of lateral epicondylitis between 2010 and 2019 using a Humana claims database. We identified patients with a Current Procedural Terminology code corresponding to an elbow MRI. We analyzed the use and downstream treatment cascades in those undergoing MRI. Multivariable logistic regression models were used to assess the odds of undergoing an MRI, adjusting for age, sex, insurance type, and comorbidity index. Separate multivariable logistic regression analyses were used to determine the association between undergoing an MRI and the incidence of secondary outcomes (eg, receiving surgery). A total of 624,102 patients met the inclusion criteria. Of 8,209 (1.3%) patients undergoing MRI, 3,584 (44%) underwent it within 90 days after diagnosis. There was notable regional variation in MRI use. The MRIs were ordered most frequently by primary care specialties and for younger, female, commercially insured, and patients with more comorbidities. Performance of an MRI was associated with an increase in downstream treatments, including surgery (odds ratio [OR], 9.58 [9.12-10.07]), injection (OR, 2.90 [2.77-3.04]), therapy (OR, 1.81 [1.72-1.91]), and cost ($134 per patient). Although there is variation in the use of MRI for lateral epicondylitis and its use is associated with downstream effects, the routine use of MRI for the diagnosis of lateral epicondylitis is low. The routine use of MRI for lateral epicondylitis is low. Understanding interventions to minimize such low-value care in lateral epicondylitis can be used to inform improvement efforts to minimize low-value care for other conditions.

Acute supralevator abscess: the little we know.

Acute supralevator abscess (SLA) is an uncommon and complicated form of anorectal sepsis. Its correct management is crucial to avoid complex iatrogenic fistula formation. A comprehensive review of the literature was conducted to determine the incidence of SLA and the surgical outcome with particular reference to the direction of drainage. A search of Medline, PubMed and the Cochrane Library was performed to identify all studies reporting surgical drainage of SLA. A total of 19 studies were identified, including 563 patients. The only two prospective studies reported an incidence of SLA of 10% and 3% in 68 and 100 patients, respectively, with anorectal sepsis. In 17 retrospective studies, the incidence ranged from 0% to 28%. Magnetic resonance imaging (MRI) was performed routinely in only one study. The surgical anatomical classification of the abscess was described in six studies diagnosed at surgery. The direction of surgical drainage whether 'inwards' (into the lumen) or 'outwards' (into the ischioanal fossa) was stated in only six studies. In two of these, the direction of drainage was contradictory to the recommendation made by Parks et al. Recurrent sepsis was reported in eight studies and ranged from 0% to 53%. Detailed and prospective data on acute SLA are lacking. Its real incidence is unclear and it is not possible to analyse surgical outcomes conclusively according to different direction of drainage. The routine use of MRI in complicated anorectal sepsis would specify the surgical anatomy of SLA before any drainage is carried out.

Clinical utility of MRI in acute stroke beyond reperfusion therapy.

ABSTRACTBackground:Stroke is primarily a clinical diagnosis. It can be hemorrhagic or ischemic in etiology. Computed tomography (CT) brain is usually the initial investigation in most patients with suspected stroke. Although it has excellent accuracy in diagnosing hemorrhage, ischemic changes may not be apparent in the first few hours. Some centers use focused magnetic resonance imaging (MRI) studies to help in selecting appropriate patients for reperfusion therapy. However, clinicians often use this investigation even when reperfusion therapy is not being considered. This study aims to find out whether doing an MRI in addition to a CT scan has any clinical utility in this situation.Primary Objective:To determine the proportion of patients who undergo a change in their management based on MRI findings.Secondary Objectives:1. To determine the time duration from the onset of symptoms to presentation at the hospital. 2. To determine the time duration from presentation to the hospital to get CT performed. 3. To determine the proportion of patients who had MRI in addition to CT. 4. To determine the time duration from CT performed to MRI performed.Materials and Methods: Study Design:Retrospective, descriptive observational study.Inclusion Criteria:Patients above age 18 admitted at a tertiary hospital with a clinical diagnosis of stroke between 1/8/2018 and 30/7/2019.Exclusion Criteria:Patients who had already undergone MRI before presentation to the hospital and patients undergoing thrombolysis. Patients meeting the inclusion and exclusion criteria were identified from the hospital information system and the ward admission register and by manual examination of the patients’ case notes. Relevant data were obtained from the case notes and collected on a google form and downloaded in Microsoft Excel 2019. SPSS version 22 was used for data analysis.Results:Out of the 106 patients, 54% (n = 57) were diagnosed as having ischemic stroke, whereas 46% (n = 49) were diagnosed with hemorrhagic stroke after initial assessment and CT scan. Only 2.8% (n = 3) of the patients presented within 4.5 hours of the onset of symptoms. 43.4% (n = 46) presented between 4.5 and 24 hours from the onset, whereas 53.8% (n = 57) presented more than 24 hours after the onset. Twenty-seven patients had their CT scan performed prior to their presentation at the center. For the remaining 79, the median time from presentation to CT scanning was 2 ± 1.5 hours. 24.5% (n = 26) of all patients had an MRI performed in addition to the CT scan. There was wide variation in the time from CT scanning to the MRI. Among the patients who had an MRI, additional information was obtained by the investigation in 58% (n = 15). However, this led to a change in management in only three (11.5%) of the patients. On review, it was found that the change was justified in only two patients. Furthermore, one patient who was diagnosed with tuberculoma had a long history of fever which was missed on initial evaluation. Considering these, MRI can be credited for a meaningful change in management in only 4% (n = 1) of the cases.Conclusion:The findings of this study do not support the routine use of MRI in patients who are not candidates for reperfusion therapy. Their use should be restricted to cases where some specific information is sought or where there is diagnostic uncertainty. Allocation of resources in developing integrated acute stroke pathways is likely to give a better value for money.

Accuracy of MRI Pelvis in the Diagnosis of Ovarian Endometrioma: Using Histopathology as Gold Standard.

BackgroundEndometriosis is defined as the ectopic presence of endometrial mucosa at locations other than the uterine cavity. It results in significant morbidity and is a leading cause of infertility as well. Magnetic resonance imaging (MRI) is establishing its role in the diagnosis of endometriosis and its complications. The objective of this study was to assess the accuracy of MRI in the diagnosis of ovarian endometriosis using histopathology as the gold standard.Materials and methodsAll patients presenting with clinical complaints and suspicion of endometriosis, undergoing MRI followed by surgical resection and confirmation by histopathology, were included in the study. Data were analyzed on a predefined proforma and parameters of accuracy were calculated.Results A total of 170 patients were included in this study, having a mean age of 36.8 years with a standard deviation of 10.4 years. The mean parity for included subjects was 2.25, with a standard deviation of 1.3. Overall, the sensitivity of MRI was 86.7% and the specificity was 81.9%. The positive predictive value (PPV) of MRI was 83.3%, while the negative predictive value (NPV) was 81.9%. Overall, the diagnostic accuracy of MRI was 84.7%.ConclusionThe accuracy of MRI in the diagnosis of endometriosis was found to be acceptable and comparable to most of the worldwide published literature. The routine use of MRI for diagnosis and preoperative planning is justified by the results of this study.

Overview of Subaxial Cervical Spine Fractures and Dislocations

Injuries of the subaxial cervical spine are among the most common and potentially most devastating injuries involving the axial skeleton. The lower cervical spine can suffer minor bony or ligamentous injury that nevertheless results in severe neurologic injury. Plain radiography, computed tomography (CT) scans, and magnetic resonance imaging (MRI) scans are all part of the standard imaging regimen. The delayed timing of dislocation reduction and cost-effectiveness are two issues with routine use of MRI in the diagnosis of cervical facet dislocations. Serval treatment options and approaches can be used. However Orthopedic treatment can be used to reduce the fracture or dislocation returns the vertebral canal to its normal shape and dimensions and decompresses the spinal cord. Immediate treatment should be started if there are signs of spinal cord injury or any factor that could lead to such injuries. In this review we will be looking at epidemiology, causes, evaluation and treatment of such cases.

Emergency neck MRI: feasibility and diagnostic accuracy in cases of neck infection.

BackgroundComputed tomography (CT) has traditionally been the first-line imaging method in neck emergencies such as deep neck infections. Due to superior soft-tissue contrast, magnetic resonance imaging (MRI) may be an alternative to CT, also in emergency situations.PurposeTo characterize the use of routine MRI in neck emergencies, with an emphasis on clinical feasibility and diagnostic accuracy in cases of neck infection.Material and MethodsWe conducted a retrospective cohort study of all primary neck MRI scans performed using a 3-T MRI device during a five-year follow-up period in a tertiary emergency radiology department. Imaging data were compared with final clinical diagnosis and surgical findings as reference standards.ResultsThe search identified 461 primary neck MRI scans, of which 334 (72%) were performed on the basis of clinical suspicion of infection. Radiological evidence of infection was observed in 95% of these scans, and at least one abscess was detected in 229 cases (72% of confirmed infection). MRI had an overall technical success rate of 95% and had high positive predictive value for both infection (0.98) and detection of abscess (0.95).ConclusionWe found that emergency neck MRI can be successfully performed on most patients, and that MRI detects neck infection with a high accuracy. These results suggest that MRI may be an alternative to CT as the first or only imaging modality in neck emergencies.

PD48-02 DECISION-ANALYTIC MODELING STUDY OF THE PRECISION TRIAL: DOES PRE-BIOPSY MRI DO MORE GOOD THAN HARM?

You have accessJournal of UrologyProstate Cancer: Detection & Screening V (PD48)1 Apr 2020PD48-02 DECISION-ANALYTIC MODELING STUDY OF THE PRECISION TRIAL: DOES PRE-BIOPSY MRI DO MORE GOOD THAN HARM? Andrew Vickers* and Sigrid Carlsson Andrew Vickers*Andrew Vickers* More articles by this author and Sigrid CarlssonSigrid Carlsson More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000942.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Several recent studies, including the randomized PRECISION trial, have investigated whether men with elevated prostate-specific antigen (PSA) levels should undergo magnetic resonance imaging (MRI) before prostate biopsy, with targeted biopsy performed if MRI is positive and no biopsy for MRI negative patients. The finding that MRI reduces the number of low-grade and increases the number of high-grade cancers has been interpreted as supporting MRI. However, a technique that overgraded tumors would report similar findings. Study findings at the group level need to be complemented by modeling studies of individual patient counterfactuals. For instance, a patient who would have been grade Grade Group (GG) 1 by regular transrectal ultrasound (TRUS) biopsy but GG2 by MRI would only benefit if confirmatory biopsy after TRUS would show GG2 (hence MRI would avoid an additional biopsy) or if delayed treatment affected chance of cure. If neither are true, the patient would be harmed by curative treatment resulting from the increased grade. METHODS: We used the PRECISION trial results to create different scenarios for individual patient counterfactuals, varying the proportion of MRI-detected high-grade cancers that were reclassified from low-grade vs. benign TRUS biopsy. We assumed that only patients diagnosed with GG2+ would be treated curatively with active surveillance for GG1. We considered treatment to constitute high harm, active surveillance to be moderate harm and additional biopsy to constitute minor harm. As there is evidence that long-term rates of prostate cancer death are very low for both patients with negative TRUS biopsy and those with GG1 followed on active surveillance, delayed treatment was considered to be a moderate harm. We tested a range of scenarios for degree of harm. RESULTS: In most scenarios, MRI was associated with very low levels of net benefit that were highly dependent on assuming that the higher rates of GG2+ disease on MRI resulted from reclassification from benign disease on TRUS. In the base case, the highest net benefit for MRI across scenarios was the equivalent of 50 MRIs to prevent one overdiagnosis of GG1. MRI had was harmful in many scenarios. MRI had important benefit only under the scenario where MRI and TRUS tumors were, grade for grade, of similar oncologic risk, a position not supported by best evidence. CONCLUSIONS: Decision-analytic modelling of how MRI impacts the treatment of individual patients does not support the routine use of MRI before diagnostic biopsy, with biopsy only targeted to suspicious lesions and no biopsy for negative MRI. Source of Funding: This work was supported in part by the National Institutes of Health/National Cancer Institute (NIH/NCI) with a Cancer Center Support Grant to Memorial Sloan Kettering Cancer Center [P30 CA008748], and a SPORE grant in Prostate Cancer [P50-CA92629]. © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e993-e994 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Andrew Vickers* More articles by this author Sigrid Carlsson More articles by this author Expand All Advertisement PDF downloadLoading ...

Differential diagnosis of peripheral facial nerve palsy: a retrospective clinical, MRI and CSF-based study.

Facial nerve palsy is the most common cranial nerve disorder. There is no consensus on a single diagnostic tool deemed as the 'gold standard' for distinguishing between idiopathic (Bell's palsy) and symptomatic causes. The diagnosis is one of exclusion and most often made on physical examination. In the present study, we describe the etiological background of peripheral facial palsy in N = 509 patients and evaluate the relevance of cerebrospinal fluid (CSF) analysis and magnetic resonance imaging (MRI) in differential diagnosis. We carried out a retrospective data analysis of 509 patients with the clinical diagnosis of peripheral facial palsy admitted to our emergency unit between January 2006 and January 2017. All patients were seen clinically; their CSF was analyzed and MRI was performed. Of N = 526 patients with isolated facial palsy, 17 patients were excluded because they did not consent to CSF analysis. Of the remaining N = 509 patients, 383 patients (75.2%) were diagnosed with idiopathic facial palsy. In the remaining 126 patients (24.8%), the following etiologies for facial palsy could be found: Ramsay-Hunt-Syndrome (N = 34), Lyme Neuroborreliosis (N = 32), other viral/bacterial central nervous system (CNS) infections (N = 8), neoplasias (N = 18), autoimmune disease (N = 12), otogenous processes (N = 6), or other etiologies (N = 16). Analysis of the CSF showed 85% sensitivity for Ramsay-Hunt-Syndrome and 100% for Lyme Neuroborreliosis and other viral/bacterial CNS infections. CSF analysis proved a reliable diagnostic tool for identifying these subgroups. MRI with contrast compounds, as performed in 409 patients, was the most important tool in diagnosing neoplasias (88% sensitivity) and otogenous processes (83% sensitivity). MRI with contrast-enhancing compounds did not reveal additional information concerning inflammatory facial nerve lesions when performed the same day as hospital admission. Although peripheral facial palsy was predominantly idiopathic (75.3%) in our cohort, the disease was caused in approximately 25% of the patients by factors which require specific treatment. In the present study, CSF analysis proved to be the leading method for the diagnosis of Ramsay-Hunt-Syndrome, Lyme Neuroborreliosis, and other CNS infections. These subgroups made up approximately 15% of our cohort. To detect these subgroups reliably, routine use of CSF analysis in peripheral facial palsy may be advisable, whereas MRI proved to be useful for exclusion of otogenic and neoplastic processes with a sensitivity of 83% and 88%. We found that the use of MRI with contrast-enhancing compounds does not provide additional diagnostic information on the day of hospital admission. Hence, the potential benefits of routine use of MRI in patients with facial nerve palsy should be weighed against health care cost factors.

Is routine MRI of the spine necessary in trauma patients with ankylosing spinal disorders or is a CT scan sufficient?

BackgroundAnkylosing spinal disorder (ASD) patients are at a greater risk for spinal fractures due to osteoporosis and rigidity of the spinal column. These fractures are associated with a high risk of neurologic compromise resulting from delayed or missed diagnoses. Although computed tomography (CT) is usually the initial imaging modality, magnetic resonance imaging (MRI) has been proposed as mandatory to help identify spinal injuries in ASD patients with unexplained neck or back pain or known injuries to help identify noncontiguous fractures. However, some studies have also shown that neurological injury can result from the required patient transfer and positioning for an MRI. PurposeThe purpose of our study was to assess the frequency with which an MRI identified an injury not previously identified with CT, and whether this affected the treatment and outcome of the patient. Secondarily, we attempted to identify clinical or CT findings that may render an MRI particularly useful. Study DesignRetrospective review. Patient SamplePatients with ASD who sustained acute spine fractures from 2005 to 2015. Outcome MeasuresAcute fractures identified by CT scan and MRI upon admission; neurologic status upon admission and discharge, mode of injury, type of fracture, and final intervention before and after MRI assessment. MethodsA total of 124 patients with a diagnosis of diffuse idiopathic skeletal hyperostosis (DISH) or ankylosing spondylitis (AS) were identified by searching the radiology database of a level I trauma center with diagnosis keywords. Final radiology reports were assessed to determine presence and type of fracture(s) from CT. MRI report was then reviewed to assess if additional fractures or injuries were identified beyond that already known from the CT. Neurologic status upon admission and discharge, mode of injury, type of fracture, and final intervention were determined by inpatient notes and/or operative reports. No source funding or conflict of interest was present pertaining to this study. ResultsIn the designated time frame, 124 ASD patients with injuries of the spine were identified who had obtained both a baseline CT and MRI. Six patients (4.8%) had additional injuries on MRI that had not been identified with CT. Four of these six patients had a change in treatment plan (three operative and one nonoperative) based on subsequent MRI findings. These included a (1) C4–5 hyperextension injury, (2) C6–7 hyperextension injury, (3) C7 bony fracture with C5–T4 epidural hematoma, and (4) C5–C6 hyperextension injury treated in a brace. Two of the six patients that had additional injuries identified on MRI had no change in their treatment plan. One patient had an additional lumbar extension injury identified above a previously diagnosed injury on CT, which was managed with a Thoracolumbosacral Orthosis (TLSO) according to the original plan. One patient died who had a known odontoid fracture and a suspected C6–7 hyperextension injury, and was identified on MRI as also having a C3–C4 hyperextension injury and a C2 spinal cord transection. ConclusionsIn this study, 3.2% (4/124) of patients with ASD who presented to a level I trauma center with an acute spine injury identified with CT required a change in their treatment plan based on subsequent MRI findings. Only one fracture was missed on CT imaging, with the other missed injuries all being either disco-ligamentous hyperextension injuries through mobile discs or intracanal pathology. Our recommendation is that the routine use of MRI be limited to patients with nonankylosed levels in which a disco-ligamentous injury may have occurred, and in patients with neurological deficits that require investigation of the spinal canal to assess for causes of neurological injury.

Posterolateral Endoscopic Thoracic Discectomy: Transforaminal Approach

Objective: Symptomatic soft herniated thoracic disc (HTD) before the use of magnetic resonance imaging (MRI) was a rare disease with less than 1% of all spinal disc herniation. The frequency of diagnosis of thoracic disk herniation has increased with the routine use of MRI. To avoid high morbidity and complications associated with conventional approach, the authors applied posterolateral endoscopic technique.Methods: From January 2001 to December 2016, 87 patients with non-sequestrated and soft lateral or central thoracic disc herniation underwent posterolateral endoscopic thoracic discectomy (PLETD). Under local anaesthesia with intravenous sedation, we removed the herniated disc through thoracic intervertebral foramen after foraminoplasty. The enlargement of the foramen by partially cutting the lateral aspect of superior facet with a Reamer or high-speed diamond drills. Clinical outcome was measured by the Oswestry Disability Index (ODI) and the visual analogue scale.Results: Fifty-one males and thirty-six females, aged 21 to 89 years were enrolled in this study. Mean follow-up period was 10 months (1 to 56 months). The mean ODI scores improved from 53.7 before surgery to 16.9 at the final follow-up (p <0.05). Mean VAS scores improved from 7.3 before surgery to 2.1 at the final follow-up (p <0.05). One patient required conversion to an open procedure for recurred disc protrusion in 17 days. Another one patient required repeated PLETD for recurring disc in l year. Three patients experienced transient low extremity paresthesia but all improved. There were no other serious complications associated with this procedure.Conclusion: Conventional treatment of HTD is known for its high morbidity and complications, posing a challenge to physicians. This PLETD technique for symptomatic non-sequestrated and soft HTD is a safe and effective method that provides a direct route to the lesion under local anaesthesia with less morbidity.

Posterolateral Endoscopic Thoracic Discectomy: Transforaminal Approach

Objective: Symptomatic soft herniated thoracic disc (HTD) before the use of magnetic resonance imaging (MRI) was a rare disease with less than 1% of all spinal disc herniation. The frequency of diagnosis of thoracic disk herniation has increased with the routine use of MRI. To avoid high morbidity and complications associated with conventional approach, the authors applied posterolateral endoscopic technique.Methods: From January 2001 to December 2016, 87 patients with non-sequestrated and soft lateral or central thoracic disc herniation underwent posterolateral endoscopic thoracic discectomy (PLETD). Under local anaesthesia with intravenous sedation, we removed the herniated disc through thoracic intervertebral foramen after foraminoplasty. The enlargement of the foramen by partially cutting the lateral aspect of superior facet with a Reamer or high-speed diamond drills. Clinical outcome was measured by the Oswestry Disability Index (ODI) and the visual analogue scale.Results: Fifty-one males and thirty-six females, aged 21 to 89 years were enrolled in this study. Mean follow-up period was 10 months (1 to 56 months). The mean ODI scores improved from 53.7 before surgery to 16.9 at the final follow-up (p <0.05). Mean VAS scores improved from 7.3 before surgery to 2.1 at the final follow-up (p <0.05). One patient required conversion to an open procedure for recurred disc protrusion in 17 days. Another one patient required repeated PLETD for recurring disc in l year. Three patients experienced transient low extremity paresthesia but all improved. There were no other serious complications associated with this procedure.Conclusion: Conventional treatment of HTD is known for its high morbidity and complications, posing a challenge to physicians. This PLETD technique for symptomatic non-sequestrated and soft HTD is a safe and effective method that provides a direct route to the lesion under local anaesthesia with less morbidity.

Is routine MRI necessary to exclude pathological fractures in patients with an oncological history?

Magnetic resonance imaging (MRI) is the radiological modality of choice for diagnosing pathological fractures in situations of diagnostic uncertainty. With the increasing availability of MRI, we have observed a disturbing trend in utilising routine MRI scans to exclude pathological fractures in all patients with a history of cancer. The study objective was to determine if routine use of MRI scans in such patients is truly necessary and if other predictive factors can be utilised in lieu of the MRI scan. A 3-year retrospective study was conducted reviewing all extremity MRI scans performed for suspected pathological fractures and compared to X-rays. All patients presented with an extremity fracture, a known diagnosis of solid organ cancer and had an MRI to determine if the fracture was pathological. Subjects were followed up with serial X-rays up to 1year. 84 subjects were recruited. Comparing X-rays alone with MRI scans revealed 92% sensitivity and 98% specificity in detecting pathological fractures. Using X-rays in combination with an absent history of trauma increases the sensitivity to 100% but reduced the specificity to 91%. None of subjects in cancer remission had pathological fractures. MRI is an imperative tool for operative planning in pathological fractures; however, we recommend against the routine use of MRI to diagnose pathological fractures in oncological patients. Patients with solid organcancer remission, a positive history of significant trauma prior to sustaining the fracture, and the absence of pathological features on plain radiographs are strongly predictive against pathological fractures.

Utility of repeat magnetic resonance imaging in surgical patients with lumbar stenosis without disc herniation

BACKGROUND CONTEXTRoutine use of magnetic resonance imaging (MRI) as a diagnostic tool in lumbar stenosis is becoming more prevalent due to the aging population. Currently, there is no clinical guideline to clarify the utility of repeat MRI in patients with lumbar stenosis, without instability, neurological deficits, or disc herniation. PURPOSETo evaluate the utility of routine use of MRI as a diagnostic tool in lumbar stenosis, and to help formulate clinical guidelines on the appropriate use of preoperative imaging for lumbar stenosis. STUDY DESIGN/SETTINGRetrospective radiographic analysis. PATIENT SAMPLERetrospective chart review was performed to review patients with lumbar stenosis, who underwent lumbar decompression without fusion from 2011 to 2015 at a single institution. OUTCOME MEASURESPreviously established stenosis grading systems were used to measure and compare the initial and the subsequent repeat lumbar MRIs performed preoperatively. If patients were found to have a moderate or severe grade change, and if the surgical plan was altered due to such exacerbated radiographic findings, then their grade changes were considered clinically meaningful. METHODSWe identified patients with lumbar stenosis without radiographic instability or neurological deficits, who had at least two preoperative lumbar MRIs performed and underwent decompressive surgeries. At each pathologic disc level, the absolute value of the change in grade for central and lateral recess stenosis, right foraminal stenosis, and left foraminal stenosis from the first preoperative MRI to the repeated MRI was calculated. These changed data were then used to calculate the mean and median changes in each of the three types of stenosis for each pathologic disc level. Identical calculations were carried out for the subsample of patients who only underwent discectomy or had a discectomy included as part of their surgery. RESULTSAmong the 103 patients who met the inclusion criteria, 37 of those patients had more than one level surgically addressed, and a total of 161 lumbar levels were reviewed. Among the subset of patients that had any grade change, the majority of the grades only had a mild change of 1 (36 out of 42 patients, 85.7%, 95% confidence interval [CI]: 73.1%–94.1%); there was a moderate grade change of 2 in two patients (4.8%, CI: 0.8%–14.0%), and a severe change of 3 in one patient (2.4%, CI: 0.2%–10.1%). There were three patients with decreased grade change (7.1%, CI: 1.8%–17.5%). All clinically meaningful grade changes were from the subset of patients who had only discectomy or discectomy as part of the procedure. Lastly, both patients that had a clinically meaningful grade change had their MRIs performed at an interval of greater than 360 days. CONCLUSIONSThe radiographic evaluation of the utility of routinely repeated MRIs in lumbar stenosis without instability, neurological deficits, or disc herniations demonstrated that there were no significant changes found in the repeated MRI in the preoperative setting, especially if the MRIs were performed less than one year apart. The results of this present study can help to standardize the diagnostic evaluation of lumbar stenosis and to formulate clinical guidelines on the appropriate use of preoperative imaging for lumbar stenosis patients.

Clinical, Magnetic Resonance Imaging, and Arthroscopic Correlation in Anterior Cruciate Ligament and Meniscal Injuries of the Knee: 膝關節前交叉韌帶和半月板損傷的臨床、磁共振成像和關節鏡的相關性

BackgroundThe aim of this study is to compare and correlate the clinical, magnetic resonance imaging (MRI), and arthroscopy findings in anterior cruciate ligament (ACL) and meniscal injuries of the knee. MethodsThis was a prospective study of 30 cases of ACL and meniscal injuries of the knee admitted between September 2014 and May 2016, who underwent clinical examination, MRI, and arthroscopy of the knee. ResultsIn our study of 30 cases, there were 26 male and four female patients with age ranging from 18 years to 60 years, with most patients in between 21 years and 30 years. Clinical examination had sensitivity of 90.91%, specificity of 100%, and accuracy of 93.33% for ACL, sensitivity of 83.33%, specificity of 77.78%, and accuracy of 80% for medial meniscus, and sensitivity of 75%, specificity of 77.27%, and accuracy of 76.67% for lateral meniscus. MRI had sensitivity of 95.45%, specificity of 87.5%, and accuracy of 93.33% for ACL, sensitivity of 91.67%, specificity of 55.56%, and accuracy of 70% for medial meniscus, and sensitivity of 62.5%, specificity of 72.73%, and accuracy of 70% for lateral meniscus. ConclusionIn conclusion, the present study supports that clinical diagnosis is of primary necessity, as the positive predictive value is high for all the lesions. MRI is an additional diagnosing tool for ligament and meniscal injuries of the knee. Routine use of MRI to confirm the diagnosis is not indicated, as the positive predictive value is low, but can be used to exclude pathology, as the negative predictive value is high for all the lesions.

The Role of MRI in the Follow-up of Women Undergoing Breast-conserving Therapy.

Breast-conserving therapy (BCT) represents a standard of care in the management of breast cancer. However, unlike mastectomy, women treated with BCT require follow-up imaging of the treated breast as well as the contralateral breast as part of posttreatment surveillance. Traditionally, surveillance has consisted of clinical exams and mammograms. However, magnetic resonance imaging (MRI) has emerged as a breast imaging technique utilized as part of high-risk screening programs as well as part of the initial diagnosis and workup of women considered for BCT. At this time, the role of MRI as part of follow-up for women treated with BCT remains unclear. A systematic review was performed to evaluate the role of MRI following BCT. Although there is no randomized evidence supporting the routine use of MRI in surveillance post-BCT, a review of the literature demonstrates that MRI (1) has increased sensitivity as compared with mammography to detect recurrences, and (2) can help evaluate mammographic abnormalities before biopsy and/or surgery. In patients with higher risk of local recurrence, surveillance with MRI may represent an effective surveillance strategy though subgroups benefiting have not been identified nor has the impact on quality of life and cost been evaluated.

Diagnostic imaging and radiation exposure in inflammatory bowel disease.

Diagnostic imaging plays a key role in the diagnosis and management of inflammatory bowel disease (IBD). However due to the relapsing nature of IBD, there is growing concern that IBD patients may be exposed to potentially harmful cumulative levels of ionising radiation in their lifetime, increasing malignant potential in a population already at risk. In this review we explore the proportion of IBD patients exposed to high cumulative radiation doses, the risk factors associated with higher radiation exposures, and we compare conventional diagnostic imaging with newer radiation-free imaging techniques used in the evaluation of patients with IBD. While computed tomography (CT) performs well as an imaging modality for IBD, the effective radiation dose is considerably higher than other abdominal imaging modalities. It is increasingly recognised that CT imaging remains responsible for the majority of diagnostic medical radiation to which IBD patients are exposed. Magnetic resonance imaging (MRI) and small intestine contrast enhanced ultrasonography (SICUS) have now emerged as suitable radiation-free alternatives to CT imaging, with comparable diagnostic accuracy. The routine use of MRI and SICUS for the clinical evaluation of patients with known or suspected small bowel Crohn's disease is to be encouraged wherever possible. More provision is needed for out-of-hours radiation-free imaging modalities to reduce the need for CT.

Magnetic resonance imaging findings in children with tinnitus.

Tinnitus in adults is generally investigated by contrast-enhanced magnetic resonance imaging (MRI) to rule out the diagnosis of acoustic neuroma. Acoustic neuroma is rare in children and, therefore, the role of MRI in children with tinnitus is unclear. This study was undertaken to determine the value of MRI in the investigation of tinnitus in children. Retrospective study of children younger than 18 years who underwent MRI for the investigation of tinnitus over a 10-year period. Sixty-five patients were identified, but there were only 34 who had also undergone audiologic assessment. Among the 25 patients with normal audiology, MRI abnormalities were present in 9, but these were all thought to be nonspecific. Nine patients had abnormal audiograms and the MRI was abnormal in 4 of these cases, which included 3 children who were found to have multiple sclerosis. Magnetic resonance imaging would appear to be mandatory in the investigation of tinnitus in children who are found to have sensorineural hearing loss, particularly to rule out the diagnosis of multiple sclerosis. Although our study does not support the routine use of MRI in children with normal audiology, the numbers in our series are too small for a conclusive recommendation.

Breast Magnetic Resonance Imaging As It Is, in Contrast to How We Wish It to Be

Breast Magnetic Resonance Imaging As It Is, in Contrast to How We Wish It to Be