Sagittal Reconstruction Research Articles

Endoscopic optic nerve fenestration amongst pediatric idiopathic intracranial hypertension: A new surgical option

ObjectiveTo assess the effectiveness of transnasal trans-sphenoid endoscopic optic nerve fenestration for the reversal of vision loss in pediatric idiopathic intracranial hypertension (IIH). Material and methodsThis is a single center observational retrospective case series. Fifteen diagnosed pediatric patients of IIH satisfying the modified Dandy criteria and reported to the out-patient services of otolaryngology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India were included in this study. All children underwent thorough clinical examination, complete neuro-ophthalmological work up including visual acuity (V/A), visual field charting(V/F), fundus venogram and radiological work up with MRI for special optic nerve sections in sagittal reconstruction. cerebro-spinal fluid pressure (CSF) measured pre operatively for all children. Standard endoscopic optic nerve sheath fenestration was performed on all children. Visual improvement was assessed by comparing pre-operative ophthalmological findings. ResultsImprovement in vision was taken as a positive outcome. Vision improved in all except two children, who had pre-existing optic nerve atrophy. ConclusionEndoscopic optic nerve fenestration is an effective minimally invasive procedure to revert visual loss in pediatric Idiopathic Intracranial Hypertension.

Imaging intracranial vessel wall pathology with magnetic resonance imaging: current prospects and future directions.

To date, the probable cause of ischemic stroke is often inferred from the size and location of the infarct, in combination with an evaluation of the heart and the presence of extracranial arterial occlusion or high-grade stenosis.1 Currently used conventional lumenography-based methods such as digital subtraction angiography, computed tomography angiography, and magnetic resonance (MR) angiography are used to determine the presence of such an acute occlusion or high-grade arterial stenosis. From extracranial studies, it is known that luminal narrowing may be absent in patients with severe atherosclerosis owing to arterial remodeling.2–4 Therefore, these methods do not provide information about the underlying pathological processes, which most often involve the vessel wall.5 Vessel wall changes such as vessel wall thickening, enhancement, or the presence of vulnerable atherosclerotic plaques without luminal stenosis are therefore often missed but might be of importance for a better understanding of ischemic stroke.6 Furthermore, intracranial atherosclerosis is an important cause of ischemic stroke7 and often involves the vessel wall. Patients with intracranial atherosclerosis have high recurrent stroke rates,8 and increasingly more attention is being directed to the assessment of the intracranial vessel wall, necessitating an imaging technique directly assessing the intracranial vessel wall. MR imaging (MRI) seems the most promising technique to reliably image intracranial vessel wall pathologies because of its superior soft tissue contrast. Recent advances in MRI9 have made it possible to obtain information about these abnormalities within the intracranial vessel wall, which provides an imaging tool to investigate the role of intracranial vessel wall abnormalities in the diagnosis of stroke. In this review, we discuss the current status of intracranial vessel wall MRI and its potential to identify different intracranial vessel wall pathologies. First, we present the state-of-the-art MRI methods to visualize the intracranial vessel wall …

Point of maximum width: a new measure for anthropometric outcomes in patients with sagittal synostosis.

The esthetic success of sagittal synostosis reconstruction is measured by cephalic index (CI). This limited measure does not fully account for the abnormal head shape in sagittal synostosis. In this retrospective study, we investigate a new objective measure, point of maximum width (PMW) of the skull from a vertex view, to determine where the head is widest for children with sagittal synostosis as compared with normal controls. Preoperative computed tomography (CT) scans of 27 children with sagittal synostosis and 14 postoperative CT scans at least 8 months after surgery were obtained. Normal CT scans were matched for age, sex, and race. Three-dimensional renderings were standardized for orientation. Mean (SE) PMW in patients with sagittal synostosis was 53% (1%) compared with 57% (1%) in controls (P < 0.001). Mean (SE) CI in patients with sagittal synostosis was 66.8% (0.8%) compared with 83.3% (1.0%) in controls (P < 0.001). The correlation between PMW and CI was weak in both controls (r2 = 0.002, P = 0.824) and uncorrected cases (r2 = 0.083, P = 0.145). After surgical correction, both CI and PMW significantly improved. Mean (SE) PMW in patients after surgical release of sagittal synostosis was 58% (1%) compared with 58% (1%) in controls (P = 0.986). The PMW is not a surrogate for CI but is a novel, valid measure of skull shape, which aids in quantifying the widest region of the skull. It is significantly more anterior in children with sagittal synostosis and exhibits a consistent posterior shift along the cranium after surgery, showing no difference compared with healthy children.

Yield and clinical predictors of thoracic spine injury from chest computed tomography for blunt trauma.

IntroductionCost and radiation risk have prompted intense examination of trauma patient imaging. A proposed decision instrument (DI) for the use of chest computed tomography (CT), (CCT) in blunt trauma patients includes thoracic spine (TS) tenderness, altered mental status (AMS) and distracting painful injury (DPI) as potential predictor variables. TS CT is a separate, costly study whose value is currently ill-defined. The objective of this study is to determine test characteristics of these predictor variables alone, and in combination, to derive a TS injury DI.MethodsProspective cohort study of blunt trauma patients age > 14 in a Level I Trauma Center who had either CCT or TS CT.ResultsOf 1,798 blunt trauma patients, 1,174 (65.3%) had CCT, and 46 (2.6%) had a TS CT at physician discretion. CCT identified 58 TS injuries in 1,220 patients (4.8%). For 1,032 patients without AMS, 18/35 had TS tenderness, for sensitivity of 51.4%, specificity 84.7%, positive (PPV) and negative predictive values (NPV) of 10.5% and 98.0%. Positive likelihood ratio (+LR) was 3.35, with negative (−LR) 0.57. Among the 58 TS injuries, 23 had AMS for sensitivity of 39.7%, with other test characteristics of 85.8%, 12.2%, 96.6%, with +LR 2.79 and −LR 0.70. Thirty-eight of 58 had DPI, for sensitivity 65.5%, with other test characteristics 65.7%, 8.7%, and 97.4%, with +LR 1.91 and −LR 0.52. Combining 3 predictor variables into a proposed DI found 56/58 injuries for test characteristics of 96.6% (95% CI 88.1–99.6%), 49.1% (46.1–52.0%), 8.6% (6.6–11.1%) and 99.7% (CI 98.7–100%), with +LR 1.90 (1.76–2.04) and −LR 0.07 (0.02–0.28). If validated, the DI would exclude 572/1,220 CCT patients from separate TS CT (46.9%, CI 44.1–49.7%), and 141/511 (27.6%, CI 23.8–31.7%) patients who actually had TS CT in our cohort. Medicare payment at our center for sagittal reconstructions of TS CT is $280 for professional plus technical charges ($3,312 per study). The DI, if validated, would save $39,000–$160,000 in TS imaging payments.ConclusionTS CT is low yield and costly. Patients who are alert, have no TS tenderness and no DPI have a very low likelihood of TS injury (NPV 99.7% 95% CI lower limit 98.7%) with –LR=0.07, 95% CI upper limit 0.28). Avoiding TS CT may save considerable charges and payments.

An imaging study of the compressed area, bony fragment area, and the total fracture-involved area in thoracolumbar burst fractures.

Imaging study. X-ray and computed tomography (CT) sagittal reconstruction images are used to evaluate the stability of the spine. However, we did not know the extent of difference between them. The aim of the study was to compare the differences seen in thoracolumbar burst fractures on lateral radiographs and CT sagittal reconstruction images and investigate their clinical relevance. Lateral radiographs and CT sagittal reconstruction images of 45 patients with thoracolumbar burst fractures were used to record the following measurements: the compressed area of the fractured vertebrae, from lateral radiographs, and the sagittal compressed area, bony fragment area, and total fracture-involved area, from CT sagittal reconstruction images. The percentage of compressed area of fractured vertebrae was 29.32±13.80% on lateral radiographs and 27.93±12.21% on CT sagittal reconstruction images; there was no significant difference between them (P>0.05). The percentage of total fracture-involved area was 53.20±20.64% on CT sagittal reconstruction images, higher than the compressed area measured on lateral radiographs (P<0.01) and CT sagittal reconstruction images (P<0.01). The percentage of bony fragment area was 25.27±15.18% on CT sagittal reconstruction images; there was no significant relationship between bony fragment area and the compressed area (r=0.1258, P>0.05). The compressed area of fractured vertebrae on lateral radiographs could not represent the fracture-involved area and underestimated the total fracture-involved area. We suggested that the above 3 parameters could be easily obtained on CT sagittal reconstruction images, which might be better for assessing the potential instability of the thoracolumbar burst fracture and could become a valuable and indispensable examination for therapeutic decision making.

Chronic Ankle Pain After An Initial ‘Twisting’ Injury To The Ankle

A 42-year-old woman was admitted to our outpatient clinic with chronic left ankle pain that began after having a twisting ankle injury fifteen days prior. Immediately after the injury, she was admitted to the nearest emergency department and foot radiographs were taken. Lateral and oblique foot radiographs revealed no abnormal findings, and the patient was diagnosed as simple ankle sprain and was treated with anti-inflammatory medications, elastic bandage, rest, and ice. Although the soft tissue swelling subsided gradually, the patient suffered from chronic ankle pain and persistent antalgic gait. On physical examination, there was tenderness over the foot distal and inferior to the anterior talofibular ligament (ATFL). The range of ankle movements was slightly painful and inversion of the ankle produced considerable pain. Neurovascular examination was normal. The initial foot radiographs were available and re-evaluated (Figure 1). Figure 1 (a) Lateral and (b) oblique foot radiographs of the patient. DIAGNOSIS: Fracture of Anterior Superior Process of Calcaneus: A Commonly Missed Fracture A careful examination of the initial lateral foot radiograph raised the suspicion of fracture of the anterior superior process of calcaneus (ASPC) (Figure 2a). Further imaging with computerized tomography (CT) and multiplanar reconstruction confirmed our preliminary diagnosis (Figure 2b, c). Below-knee plaster cast was applied and continued for four weeks, after which a gradual return to full activities was allowed. At the final follow-up six months after the initial injury, the patient was free of pain and was able to return to his previous level of activity. Figure 2 (a) Lateral foot radiograph validated a suspected fracture line at the anterior superior process of calcaneous (black drawing). (b) Sagittal and (c) axial CT demonstrated the fracture (white arrows). Fracture of ASPC is a rare fracture that constitutes 3% of all calcaneal fractures.1, 2 The mechanism of the injury is often an inversion injury with the foot in plantar flexion, similar to simple ankle sprain.1, 2, 3 Because of its infrequency, the similarity between typical history and clinical presentation of an ankle sprain and difficulties in direct radiographic evaluationof the fractures of the ASPC is usually misdiagnosed as ankle sprain at initial emergency visits. On the other hand, early identification and prompt treatment of these moderately seeming fractures may prevent chronic ankle problems as observed in our patient. Therefore, emergency physicians should be aware of this fracture. In order to prevent misdiagnosis, a high level of suspicion and investigation is necessary. Furthermore, the physical examination the tenderest point on palpation should be correctly identified. In the fracture of the ASPC, the tender point is 3–4 cm distal to the lateral malleolar tip over the bifurcate ligament.2, 3 Whereas in ankle sprain of the ATFL is usually tender. [4] In addition to a careful physical examination, a careful examination of the foot radiographs is important. Anteroposterior and lateral foot radiographs should be obtained as the first line imaging work-up. However, complex anatomic structure of the foot and superimposition on direct radiography makes the evaluation difficult causing these fractures may easily be missed. In case of suspicion, computed tomography (CT) is the most useful imaging method to detect and define the extent of the fracture.[4] Sagittal reconstruction best demonstrates the fracture.[3] The os calcaneus secundarius is an uncommon accessory ossicle of the midfoot which is present in the 5% of the normal population.3, 4, 5 However, in the context of foot trauma, this normal anatomic variant may be misdiagnosed as a fracture of the ASPC. Thus, os calcaneus secundarius should be considered in the differential diagnosis of acute fractures of the ASPC. The most important radiographic clue to differentiate an os calcaneus secundarius from an acute fracture is the oval configuration and well-corticated margins.3, 4 Conservative treatment in the form of plaster cast immobilization that last 4 weeks is sufficient for the treatment.1, 4

Potential for Ultrasonography to Reduce the Cost and Cumulative Radiation Dose in Routine Incisional Hernias.

As our population ages, becomes more obese, continues to smoke, and develops type 2 diabetes mellitus, incisional hernias and recurrences are becoming more prevalent. Management of these complex hernias has become so challenging that the Americas Hernia Society has become one of the fastest growing surgical specialty organizations. As surgeons becomemore skilled at treating incisional hernias, theneed todiagnose recurrences andcharacterize the abdominal wall of an affected patient has become increasingly important.1 Computed tomography (CT) is the criterion standard for evaluating the abdominalwall, butBaucomet al2 have shown that ultrasonography can beused to characterize the dimensions of the hernia defects as effectively as CT. The advantage of CT for a hernia is that it shows the layers of the abdomen in a formatwithwhichmost surgeons are familiar. Sagittal and coronal reconstructions aid in preoperativeplanning,particularly in recurrentherniaoperations.However, if a patient has had multiple abdominal operations and recurrenthernias, thenumberof lifetimeCTsperpatient is often in the double digits. In addition to multiple CTs increasing the cost of treating incisional hernias, it has been hypothesized that the cumulative radiation could contribute to abdominal cancers.3 The level of ionizing radiation during a single multiphase CT of the abdomen-pelvis has been estimated to increase the lifetime risk to 4 cancers per 1000 patients.4 Although the risk for additional cancers associated with modern imaging is up for debate, reducing the number of CT scans will help decrease both the radiation exposure and the cost of treating abdominalwall hernias.Ultrasonographymay not completely replace CT, particularly inmore complex hernias; however, it can be useful in the diagnosis andmeasurementof a suspectedhernia andmay reduce thenumberofCTs that are obtained.

Epidemiological Survey of Ossification of the Posterior Longitudinal Ligament in an Adult Korean Population: Three-dimensional Computed Tomographic Observation of 3,240 Cases

The prevalence rates of ossification of the posterior longitudinal ligament (OPLL) in the Korean population were reported as 3.4 and 0.6%. However, these studies were performed before the era of three-dimensional computed tomography (3D CT). We investigated the prevalence of cervical OPLL on the basis of 3D CT and features of OPLL distribution in an adult Korean population. During 2011 and 2012, a total of 3,240 patients were enrolled who had undergone thyroid 3D CT. A total of 1,084 men and 2,156 women were included. Axial and sagittal reconstruction images were used for observations. More than 2 mm thickness in an axial image was the criterion for the presence of OPLL. The prevalence rate was adjusted according to a standardized population according to Statistics Korea. The OPLL prevalence rate was 5.7%. The standardized prevalence rate was 4.60%. The standardized prevalence rates in men and women were 6.43 and 3.61%, respectively. The over-70 age group had the highest OPLL prevalence. Age and prevalence rate were positively correlated in men and women (correlation coefficient 0.991 and 0.991, P<0.001 and P<0.0001, respectively). Among OPLL types, the multiple segmental type was most frequent (37.3%). The most commonly involved level was C5 (4.8% in men, 2.2% in women), C4 (4.6% in men, 1.2% in women), and C6 (3.7% in men, 2.4% in women) segments, in decreasing order. To our knowledge, this study is the first 3D CT-based epidemiologic study on cervical OPLL in a Korean population.

Is there a biomechanical cause for spontaneous pneumothorax?

Primary spontaneous pneumothorax has long been explained as being without apparent cause. This paper deals with the effect of chest wall shape and explains how this may lead to the pathogenesis of primary spontaneous pneumothorax. Rib cage measurements were taken from chest radiographs in 12 male pneumothorax patients and 12 age-matched controls. Another group of 15 consecutive male thoracic computerised tomography (CT) were investigated using paramedian coronal and sagittal CT reconstructions to assess apical lung shape. A finite element analysis (FEA) model of a lung apex was constructed, including indentations for the first rib guided by CT scan data, to assess pleural stress. This model was tested using different anteroposterior diameter ratios, producing a range of thoracic indexes. The pneumothorax patients had a taller chest (P = 0.03), wider transversely (P = 0.009) and flatter (P = 0.03) when compared with controls, resulting in a low thoracic index. Prominent rib indentations were found anteriorly and posteriorly on the lung surface, especially on the first rib on CT. FEA of the lung revealed significantly higher stress (×5-×10) in the apex than in the rest of the lung. This was accentuated (×4) in low thoracic index chests, resulting in 20-fold higher stress levels in their apex. The FEA model demonstrates a 20-fold increase in pleural stress in the apex of chests with low thoracic index typical of spontaneous pneumothorax patients. Mild changes in thoracic index, as occurring in females or with aging, reduce pleural stress. Spontaneous pneumothorax occurring in young male adults may have a biomechanical cause.

Horse shoe appearance of vertex extradural hematoma

Vertex epidural hematomas (VEDHs) are well-known subtype of extradural hemorrhage, their clinical presentation can be misleading and these lesions may be missed by routine CT axial scanning. In the presented case we describe a case of 35-year man who had a large hyperdense collection with horse shoe shaped distribution on axial images. Sagittal and coronal reconstruction of the images showed greater details of the vertex extradural hematoma. 3D CT reconstruction showed diastasis of the coronal suture with fracture lines involving parietal bones. While the patient was waiting for the surgery he developed weakness of both lower limbs. The patient underwent evacuation of extradural hematoma in emergency. It is recommended to obtain CT slices until the bone of vertex in head injury patients so the diagnosis of VEDH should not be missed.

Biometry of the temporomandibular joint using computerized tomography

In the present study, we performed biometric characterization of the temporomandibular joints (TMJs) of clinically normal subjects. Fifty-one healthy volunteers underwent high-resolution computerized tomography examination of the TMJs in the position of maximal intercuspidation according to a standardized protocol. Frontal and sagittal reconstructions were then performed to obtain measurements and indexes in three planes of space. Correlations are observed with age, gender, amplitude of mouth opening and presence of dental abrasion. The lateral stability index reflects the degree of mobility of the temporo-discal compartment of the joint. The coverage index reflects how much the mandibular condyle is inserted into the articular fossa and may be related to the risk of occurrence and severity of regressive remodeling phenomena. This study supports the interest in examining morphological aspects of the TMJ and performing intra-articular measurements. The biometric examination of the TMJ has important applications in the domain of TMJ pathology.

Assessing Long-Term Outcomes of Open and Endoscopic Sagittal Synostosis Reconstruction Using Three-Dimensional Photography

Sagittal synostosis has been successfully managed with numerous surgical techniques. Nevertheless, few data on long-term outcomes exist to justify use of one surgical technique over another. In this study, we compared children with surgically corrected sagittal synostosis to their age-matched control subjects to assess the longevity of their corrections. Furthermore, the outcomes of open repairs were compared with endoscopic repairs.Following institutional review board approval, three-dimensional photographs of patients who underwent surgical reconstruction for nonsyndromic sagittal synostosis were analyzed to determine biparietal and anterior-posterior diameter, circumference, cephalic index, cranial vault volume, cranial height, and forehead inclination. Thirteen patients who had undergone open repair, including 6 total cranial vault and 7 modified-pi reconstructions, and 6 patients who had undergone endoscopic strip craniectomy with barrel-stave osteotomies and postoperative helmeting were compared with nonsynostotic age-matched control subjects. Mean follow-up was 97.5 months after open and 48.9 months after endoscopic repair. Student t tests were used for analysis. In the second arm of this study, 33 patients who had undergone endoscopic repair were compared with the 13 patients who had undergone open repair; mean follow-up was 24.8 months after endoscopic repair. Linear regression models were used to adjust for age and sex.After comparing three-dimensional photographs of children who were more than 3 years postoperative from surgical correction for sagittal synostosis with their age-matched control subjects, no statistically significant differences were found in any of the measured parameters. In addition, no differences were detected between open reconstruction versus endoscopic repair, suggesting equivalence in final results for both procedures.

Pediatric Idiopathic Intracranial Hypertension: A not so Rare and Benign Condition

ABSTRACTObjectivePediatric idiopathic intracranial hypertension is an underdiagnosed entity with catastrophic presentations. High index of suspicion with early diagnosis and prompt treatment is the key to successful management. Trans-nasal trans-sphenoid Endoscopic Optic Nerve Fenestration is an effective surgical modality for the reversal of vision loss in pediatric idiopathic intracranial hypertension (IIH).Materials and methodsThis is a single center observational prospective case series. Five diagnosed pediatric patients of IIH satisfying the modified Dandy criteria and reported to the out-patient services of otolaryngology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India in the year 2012 were included in this study. All children underwent thorough clinical examination, complete Neuro-ophthalmological work-up including Visual acuity (V/A), Visual field charting (V/F), Fundus venogram and Radiological work-up with MRI for special optic nerve sections in sagittal reconstruction. Cerebro-Spinal Fluid pressure (CSF) measured preoperatively for all children. Standard endoscopic optic nerve Sheath Fenestration was performed on all children. visual improvement was assessed by comparing preoperative ophthalmological findings.ResultsImprovement in vision was taken as a positive outcome. Vision improved in all except one child, who had pre-existing optic nerve atrophy.ConclusionEndoscopic optic nerve fenestration is an effective minimally invasive procedure to revert visual loss in pediatric idiopathic intracranial hypertension.How to cite this articleGupta AK, Gupta K, Modi M, Gupta A. Pediatric Idiopathic Intracranial Hypertension: A not so Rare and Benign Condition. Clin Rhinol An Int J 2014;7(1):5-9.

The Anatomical Relationship between the Anterior Ethmoid Artery, Frontal Sinus, and Intervening Air Cells; Can the Artery Be Useful Landmark?

Background and ObjectivesZZThe anatomy surrounding the frontal sinus (FS) and the anterior ethmoid artery (AEA) is variable and complex. We tried to determine the value of AEA as a landmark for finding FS during endoscopic sinus surgery. Subjects and MethodZZUsing the high-resolution CT scans of coronal and sagittal reconstruction, the distance between AEA and FS (D-AF) and the number and type of intervening cells between these two structures were investigated. Next, the distance between AEA and the anterior skull base (D-AS) was measured and the correlation between D-AF and D-AS was analyzed. ResultsZZA total of 119 nasal cavities from 70 subjects was analyzed. Of these analyzed, AEA was located just behind the frontal recess in only 17 nasal cavities (14%) and one or two intervening cells were located between FS and AEA in the remaining 86% of the nasal cavities. The most frequent type of intervening cells was supra bullar cell, followed by supraorbital and frontal bullar cells. The mean D-AF and D-AS measurements were 8.58±5.56 mm (0-22.6 mm) and 1.65±1.90 mm (0-6.7 mm), respectively. D-AS was not significantly correlated with the dis tance between the FS and AEA (p=0.433), therefore, D-AS could not be predicted. ConclusionZZThe relationship between FS and AEA was non-predictable, and in most cases, there were one or two intervening cells between FS and AEA. Therefore a thorough review of thin section CT scans is necessary. Korean J Otorhinolaryngol-Head Neck Surg 2014;57(10):687-91 Key WordsZZComputed tomography ㆍEndoscope ㆍEthmoid ㆍFrontal sinus ㆍParanasal sinus.

Imaging characteristics of “dynamic” versus “static” spondylolisthesis: analysis using magnetic resonance imaging and flexion/extension films

Background contextTraditionally, the “dynamic” and “static” types of spondylolisthesis have been lumped into a single group in the literature. The goal of this study was to define the radiographic characteristics of “dynamic” and “static” spondylolisthesis with the use of magnetic resonance imaging (MRI) and flexion/extension radiographs. PurposeDescribe the characteristic findings present on MRI and flexion/extension radiographs that are associated with dynamic versus static spondylolisthesis. Study designRetrospective radiographic/imaging study. MethodsFrom 2009 to 2011, patients who underwent elective primary posterior spinal fusion for the diagnosis of spondylolisthesis had their plain films assessed for the degree of spondylolisthesis and were designated “dynamic” or “static,” as defined by historical measures. Axial and sagittal T2 MRIs were evaluated for associated facet fluid (FF), facet cysts, interspinous fluid (ISF), and facet hypertrophy. These finding were then statistically evaluated for associations between dynamic and static spondylolisthesis on flexion/extension radiographs and characteristic MRI findings. ResultsNinety patients were included in the study with 114 levels examined for spondylolisthesis. Patients with greater than 3 mm of instability on flexion/extension films were more likely to have FF (p=.018) and ISF (p<.001). Of the patients who had a greater than 3 mm of instability, 39.5% did not demonstrate spondylolisthesis on the sagittal MRI reconstruction. If ISF was present on MRI, there was a positive predictive value of 69.0% that there would be greater than 3 mm instability on flexion/extension films. Absence of FF on MRI had a positive predictive value of 75.6% for instability less than 3 mm on flexion/extension films. In the presence of ISF on MRI, the likelihood ratio of finding more than 3 mm of instability on flexion/extension films was 3.68. The presence of FF on MRI had a likelihood ratio of 1.43 for instability. A total of 36.8% of all spondylolisthesis reduced when supine on MRI. ConclusionsThe presence of FF and/or ISF is associated with instability greater than 3 mm in flexion/extension radiographs.

Case–control study to estimate the performance of dual-energy computed tomography for anterior cruciate ligament tears in patients with history of knee trauma

Computed tomography (CT) is used to assess for fracture after knee trauma, but identification of ligamentous injuries may also be beneficial. Our purpose is to assess the potential of dual-energy computed tomography (DECT) for the detection of complete anterior cruciate ligament (ACL) disruption. Sixteen patients with unilateral traumatic ACL disruption (average of 58 days following trauma) confirmed by MRI, and 11 control patients without trauma, underwent DECT of both knees. For each knee, axial, sagittal, and oblique sagittal images (with DECT bone removal, single-energy (SE) bone removal, and DECT tendon-specific color mapping) were reconstructed. Four musculoskeletal radiologists randomly evaluated the 324 DECT reconstructed series (54 knees with 6 displays) separately, to assess for ACL disruption using a five-point scale (1 = definitely not torn, to 5 = definitely torn). ROC analysis was used to compare performance across readers and displays. Sagittal oblique displays (mixed kV soft tissue, SE bone removal, and DECT bone removal) demonstrated higher areas under the curve for ACL disruption (AUC = 0.95, 0.93 and 0.95 respectively) without significant differences in performance between readers (p > 0.23). Inter-reader agreement was also better for these display methods (ICC range 0.62-0.69) compared with other techniques (ICC range 0.41-0.57). Mean sensitivity for ACL disruption was worst for DECT tendon-specific color map and axial images (24 % and 63 % respectively). DECT knee images with oblique sagittal reconstructions using either mixed kV or bone removal displays (either DECT or SE) depict ACL disruption in the subacute or chronic setting with reliable identification by musculoskeletal radiologists.

Periaortic cutaneous fistula 10 years after type A aortic dissection

Figure 1: (A) Computed tomography (CT) axial image with contrast injection in the wound with illustration of the peri-aortic cutaneous fistula (arrow) and the aortic prosthesis. (B) Sagittal CT reconstruction demonstrating the fistula (arrow). (C) Axial CT image of the aortic prosthesis and the omentum plasty. (D) Sagittal image of the omentum plasty and no signs of a fistula. Ao: aorta; Om: omentum.

Transforaminal lumbar interbody fusion rates in patients using a novel titanium implant and demineralized cancellous allograft bone sponge

BackgroundTransforaminal lumbar interbody fusion (TLIF) with grafting and implant options like iliac crest bone graft (ICBG), recombinant bone morphogenetic protein (rhBMP), and polyetheretherketone (PEEK) cages have been reported to achieve extremely high fusion rates. Unfortunately, these options have also been frequently cited in the literature as causing postoperative morbidity and complications at a high cost. Knowing this, we sought to investigate TLIF using an acid-etched, roughened titanium cage that upregulates osteogenesis to see if similar fusion rates to those cited for ICBG, rhBMP, and PEEK cages could be safely achieved with minimal morbidity and complications. Materials and methodsA radiographic fusion study of 82 patients who underwent TLIF using an acid-etched, roughened titanium cage with demineralized cancellous bone graft was conducted. Fusion was assessed and graded by an independent radiologist using computed tomography scan with sagittal and coronal reconstructions. ResultsFusion rates at 6 months were 41 of 44 (93.2%) and at 12 months were 37 of 38 (97.4%). There were no radiographic device-related complications. ConclusionsTLIF with an acid-etched, roughened titanium cage filled with a decalcified bone graft achieved similar fusion rates to historical controls using ICBG, rhBMP, and PEEK.

Evaluation of buccal bone coverage in the anterior region by cone-beam computed tomography

The purpose of this study was to compare the sensitivity of diagnoses of buccal bone coverage in anterior teeth between axial and sagittal reconstructions using cone-beam computed tomography. Five dry skulls were clinically evaluated to detect bone defects in the anterior maxilla and mandible to establish a gold standard. The skulls were prepared and placed on a Kodak 9000 3-dimensional scanner (Trophy, Marne La Vallée, France) for image acquisition. The images were processed and reconstructed using Kodak Dental Imaging software 3-dimensional module (version 2.4; Kodak Dental Systems, Atlanta, Ga). All bone defects were identified and recorded. In the sagittal and axial reconstructions, regions without bone coverage were diagnosed in 91.03% of cases as "cortex not seen" or "minimum thickness, fine, without marrow bone." Cone-beam computed tomography can help in the diagnosis of lack of bone coverage on the buccal surfaces of anterior teeth. There was no difference in the performance of the axial and sagittal reconstructions.

Reliability and accuracy of scout CT in the detection of vertebral fractures

The aim of the present study was to evaluate the reliability of scout CT (sCT) lateral radiograph, in terms of diagnostic accuracy and intra- and interobserver agreement in the detection of vertebral fractures (VFs). 300 CT examinations of the thoracic and/or lumbar spine were collected and independently analysed by 3 musculoskeletal radiologists in 2 different sessions. A semi-quantitative approach was used for VF assessment on sCT, and morphometric analysis was performed when a VF was suspected. Results of multiplanar sagittal CT reconstructions interpreted by the most expert radiologist were considered as gold standard. Arthrosis was also scored. Only vertebral bodies assessable by both sCT and gold standard were considered for the analysis. Area under the receiver operating characteristic curve (AUROC), Cohen's kappa statistic and linear-by-linear association were used for statistical analysis. 1522 vertebrae were considered (130 males and 170 females; ages, 73.0±2.8 years). 73 of 1522 (4.8%) VFs were identified in 34/300 patients (11.3%). In the detection of VFs, the sensitivity and specificity of sCT were 98.7% and 99.7%, respectively. Accuracy (AUROC=0.992±0.008), as well as interobserver agreement (k=0.968±0.008), was excellent. Intra-observer agreement was perfect (k=1.000). Performance of this method was independent of arthrosis, vertebral level and type and grade of VFs. sCT is a simple but very accurate method for the detection of VFs. It should be introduced as a spine evaluation tool for the detection of VFs in examinations that are performed for other diagnostic purposes. sCT lateral radiograph is an accurate tool for the detection of VFs. This technique may be used with several advantages in clinical practice.