Sagittal Scans Research Articles

Effect of Autologous Expanded Bone Marrow Mesenchymal Stem Cells or Leukocyte-Poor Platelet-Rich Plasma in Chronic Patellar Tendinopathy (With Gap >3 mm): Preliminary Outcomes After 6 Months of a Double-Blind, Randomized, Prospective Study

Background: Patellar tendinopathy is common. The success of traditional management, including isometric or eccentric exercises combined with shockwave therapy and even surgery, is limited. Therefore, it is important to determine whether biological treatments such as ultrasound-guided intratendinous and peritendinous injections of autologous expanded bone marrow mesenchymal stem cells (BM-MSCs) or leukocyte-poor platelet-rich plasma (Lp-PRP) improve clinical outcomes in athletic patients with patellar tendinopathy. Study Design: Randomized controlled trial; Level of evidence, 2. Methods: A prospective, double-blinded, randomized, 2-arm parallel group, active controlled, phase 1/2 single-center clinical study was performed in patients who had proximal patellar tendinopathy with a lesion >3 mm. A total of 20 participants (age 18-48 years) with pain for >4 months (mean, 23.6 months) and unresponsive to nonoperative treatments were randomized into 2 groups. Of these, 10 participants were treated with BM-MSC (20 × 106 cells) and 10 with Lp-PRP. Both groups performed the same postintervention rehabilitation protocol. Outcomes included the Victorian Institute of Sport Assessment for pain (VISA-P), self-reported tendon pain during activity (visual analog scale [VAS]), muscle function by dynamometry, tendon thickness and intratendinous vascularity by ultrasonographic imaging and Doppler signal, ultrasound tissue characterization (UTC) echo type changes, and magnetic resonance imaging (MRI) T2-weighted mapping changes. Participants were followed longitudinally for 6 months. Results: The average VAS scores improved in both groups at all time points, and there was a significant reduction in pain during sporting activities (P < .05). In both groups, the average mean VISA-P scores at 6 months were significantly increased compared with baseline (66 BM-MSC group and 72.90 Lp-PRP group), with no significant differences in VAS or VISA-P scores between the groups. There were statistically significant greater improvements in tendon structure on 2-dimensional ultrasound and UTC in the BM-MSC group compared with the Lp-PRP group at 6 months. Similarly, the BM-MSC group demonstrated significant evidence of restoration of tendon structure on MRI compared with the Lp-PRP group at 6 months. Only the participants in the BM-MSC group showed evidence of normalization of tendon structure, with statistically significant differences between the groups on T2-weighted, fat-saturated sagittal and coronal scans and hypersignal in T2-weighted on spin-echo T2-weighted coronal MRI scan. Both treatments were safe, and no significant adverse events were reported in either group. Conclusion: Treatment with BM-MSC or Lp-PRP in combination with rehabilitation in chronic patellar tendinopathy is effective in reducing pain and improving activity levels in active participants. Participants who received BM-MSC treatment demonstrated greater improvement in tendon structure compared with those who received Lp-PRP. Registration: 2016-001262-28 (EudraCT identifier); NCT03454737 (ClinicalTrials.gov identifier)

Evaluation of Cartilaginous Endplate Degeneration Based on Magnetic Resonance Imaging.

In order to carry out the evaluation of cartilaginous endplate degeneration based on magnetic resonance imaging (MRI), this paper retrospectively analyzed the MRI data from 120 cases of patients who were diagnosed as lumbar intervertebral disc degeneration and underwent MRI examinations in the designated hospital of this study from June 2018 to June 2020. All cases underwent conventional sagittal and transverse T1WI and T2WI scans, and some cases were added with sagittal fat-suppression T2WI scans; then, the number of degenerative cartilaginous endplates and its ratio to degenerative lumbar intervertebral discs were counted and calculated, and the T1WI and T2WI signal characteristics of each degenerative cartilage endplate and its correlation with cartilaginous endplate degeneration were summarized, compared, and analyzed to evaluate the cartilaginous endplate degeneration by those magnetic resonance information. The study results show that there were 33 cases of cartilaginous endplate degeneration, accounting for 27.50% of all those 120 patients with lumbar intervertebral disc degeneration (54 degenerative endplates in total), including 9 cases with low T1WI and high T2WI signals, 5 cases with high T1WI and low T2WI signals, 12 cases with high and low mixed T1WI and high or mixed T2WI signals, and 4 cases with both low T1WI and T2WI signals. Therefore, MRI scanning can clearly present the abnormal signals of lumbar intervertebral disc and cartilaginous endplate degeneration, accurately identity their lesion locations, and type their degenerative characteristics, which may be best inspection method for the evaluation of cartilaginous endplate degeneration in the early diagnosis of intervertebral disc degeneration. The study results of this paper provide a reference for further researches on the evaluation of cartilaginous endplate degeneration based on magnetic resonance imaging.

Quantitative assessment of retinal and choroidal blood vessels volume using a voxel processing of optical coherence tomography angiography images

Recently, we have proposed a voxel processing algorithm of optical coherence tomography angiography (OCTA) images to increase the accuracy of quantitative assessment of retinal and choroidal blood vessels volume. The purpose of this is to ascertain the effectiveness of the algorithm and to use it for determining the volumetric flow index ratio of the vascular network in the choroid (VChor) and the total vascular network (VAll) across the retinal and choroidal layers. Five patients (seven eyes) aged 25 to 68 years without ophthalmic pathologies and nine patients (12 eyes) aged 64 to 79 years with stage II of primary open angle glaucoma (POAG) were given diagnostic OCTA tests (Spectralis OCT2, Heidelberg Engineering, Germany), each consisting of 512 sagittal scans of the peripapillary area. Testing the feasibility of the method showed that the difference between the values of VChor / VAll ratio in two successive OCTA tests of the same patient’ eye does not exceed 5%, whereas the difference is significant between subjects without eye pathologies and patients with POAG (p < 0.05 according to Mann Whitney U test). The voxel processing algorithm proved useful in quantitative assessment of the volumetric flow index of retinal and choroidal blood vessels and in the estimation of the VChor / VAll—the share of choroidal blood vessels volume in the total blood vessels volume within the peripapillary “retina-choroid” layers.

A modified MRI protocol for the increased detection of sacrococcygeal fractures in patients with thoracolumbar junction fractures

This study aimed to identify concurrent thoracolumbar junction (TLJ) and sacrococcygeal (SC) fractures using a modified MRI protocol and analyze the risk factors associated with tandem fractures. We retrospectively investigated patients with MRI-confirmed TLJ fractures from January 2017 to March 2020. Patients were divided into two study groups: study 1 with a modified MRI protocol and study 2 with a routine protocol. The modified protocol included an extended field of view of sagittal scans in L-spine MRI covering the full SC spine. In study 1, frequency of concurrent TLJ and SC fractures was investigated. And we analyzed risk factors and compared CT and MRI for detecting SC fractures. In study 2, co-occurrence of both fractures was investigated. A total of 176 and 399 patients with TLJ fractures were enrolled in study 1 and 2, then SC fractures were identified in 53 (30.14%) and 36 patients (9.02%), respectively. An axial loading trauma mechanism was a significant risk factor (Odds ratio 7.0, p < 0.001), and MRI was more sensitive than CT in detecting SC fractures (p < 0.002). Thus, a modified MRI protocol was useful to detect the high occurrence of SC fractures in TLJ fractures, which concurrent fractures increased by an axial loading mechanism.

Correlation of vertebral trabecular attenuation in Hounsfield units and the upper instrumented vertebra with proximal junctional failure after surgical treatment of degenerative lumbar disease.

The aim of this study was to investigate whether bone mineral density (BMD) measured in Hounsfield units (HUs) is correlated with proximal junctional failure (PJF). A retrospective study of 104 patients with adult degenerative lumbar disease was performed. All patients underwent posterior instrumented fusion of 4 or more segments and were followed up for at least 2 years. Patients were divided into two groups on the basis of whether they had mechanical complications of PJF. Age, sex ratio, BMI, follow-up time, upper instrumented vertebra (UIV), lower instrumented vertebra, and vertebral body osteotomy were recorded. The spinopelvic parameters were measured on early postoperative radiographs. The HU value of L1 trabecular attenuation was measured on axial and sagittal CT scans. Statistical analysis was performed to compare the difference of continuous and categorical variables. Receiver operating characteristic (ROC) curve analysis was used to obtain attenuation thresholds. A Kaplan-Meier curve and log-rank test were used to analyze the differences in PJF-free survival. Multivariate analysis via a Cox proportional hazards model was used to analyze the risk factors. The HU value of L1 trabecular attenuation in the PJF group was lower than that in the control group (p < 0.001). The spinopelvic parameter L4-S1 lordosis was significantly different between the groups (p = 0.033). ROC curve analysis determined an optimal threshold of 89.25 HUs (sensitivity = 78.3%, specificity = 80.2%, area under the ROC curve = 0.799). PJF-free survival significantly decreased in patients with L1 attenuation ≤ 89.25 HUs (p < 0.001, log-rank test). When L1 trabecular attenuation was ≤ 89.25 HUs, PJF-free survival in patients with the UIV at L2 was the lowest, compared with patients with their UIV at the thoracolumbar junction or above (p = 0.028, log-rank test). HUs could provide important information for surgeons to make a treatment plan to prevent PJF. L1 trabecular attenuation ≤ 89.25 HUs measured by spinal CT scanning could predict the incidence of PJF. Under this condition, the UIV at L2 significantly increases the incidence of PJF.

Lateral Meniscus Height and ACL Reconstruction Failure: A Nested Case-Control Study.

Previous work has shown that the morphology of the knee joint is associated with the risk of primary anterior cruciate ligament (ACL) injury. The objective of this study is to analyze the effect of the meniscal height, anteroposterior distance of the lateral tibial plateau, and other morphological features of the knee joint on risk of ACL reconstruction failure. A nested case-control study was conducted on patients who underwent an ACL reconstruction surgery during the period between 2008 and 2015. Cases were individuals who failed surgery during the study period. Controls were patients who underwent primary ACL reconstruction surgery successfully during the study period. They were matched by age (±2 years), gender, surgeon, and follow-up time (±1 year). A morphological analysis of the knees was then performed using the preoperative magnetic resonance imaging scans. The anteroposterior distance of the medial and lateral tibial plateaus was measured on the T2 axial cuts. The nonweightbearing maximum height of the posterior horn of both menisci was measured on the T1 sagittal scans. Measurements of the medial and lateral tibial slope and meniscal slope were then taken from the sagittal T1 scans passing through the center of the medial and lateral tibial plateau. A binary logistic regression analysis was done to calculate crude and adjusted odds ratios (ORs) estimates. Thirty-four cases who underwent ACL revision surgery were selected and were matched with 68 controls. Cases had a lower lateral meniscal height (6.39 ± 1.2 vs. 7.02 ± 0.9, p = 0.008, power = 84.4%). No differences were found between the two groups regarding the bone slope of the lateral compartment (6.19 ± 4.8 vs. 6.92 ± 5.8, p = 0.552), the lateral meniscal slope (-0.28 ± 5.8 vs. -1.03 ± 4.7, p = 0.509), and the anteroposterior distance of the lateral tibial plateau (37.1 ± 5.4 vs. 35.6 ± 4, p = 0.165). In addition, no differences were found in the medial meniscus height between cases and controls (5.58 ± 1.2 vs. 5.81 ± 1.2, respectively, p = 0.394). There were also no differences between cases and controls involving the medial bone slope, medial meniscal slope, or anterior posterior distance of the medial tibial plateau. Female patients had a higher medial (4.8 degrees ± 3.2 vs. 3.3 ± 4.1, p = 0.047) and lateral (8.1 degrees ± 5.1 vs. 5.6 degrees ± 5.6, p = 0.031) tibial bone slope, and a lower medial (5.3 mm ± 1.0 vs. 6.1 mm ± 1.2, p = 0.001) and lateral (6.6 ± 1.0 vs. 7.0 ± 1.2, p = 0.035) meniscus height, and medial (4.3 ± 0.4 vs. 4.8 ± 0.4, p =0.000) and lateral (3.3 ± 0.3 vs. 3.9 ± 0.4, p = 0.000) anteroposterior distance than males, respectively.The adjusted OR of suffering an ACL reconstruction failure compared to controls was 5.1 (95% confidence interval [CI]: 1.7-14.9, p = 0.003) for patients who had a lateral meniscus height under 6.0 mm. The adjusted OR of suffering an ACL reconstruction failure was 2.4 (95% CI: 1.0-7.7, p = 0.01) for patients who had an anteroposterior distance above 35.0 mm. Patients with a lateral meniscal height under 6.0 mm have a 5.1-fold risk of suffering an ACL reconstruction failure compared to individuals who have a lateral meniscal height above 6.0 mm. Patients with a higher anteroposterior distance of the lateral tibial plateau also have a higher risk of ACL reconstruction failure.

Micro-computed tomographic evaluation of single-cone obturation with three sealers.

ObjectivesThis study used micro-computed tomography (µCT) to compare voids and interfaces in single-cone obturation among AH Plus, EndoSequence BC, and prototype surface pre-reacted glass ionomer (S-PRG) sealers and to determine the percentage of sealer contact at the dentin and gutta-percha (GP) interfaces.Materials and MethodsFifteen single-rooted human teeth were shaped using ProTaper NEXT size X5 rotary files using 2.5% NaOCl irrigation. Roots were obturated with a single-cone ProTaper NEXT GP point X5 with AH Plus, EndoSequence BC, or prototype S-PRG sealer (n = 5/group).ResultsThe volumes of GP, sealer, and voids were measured in the region of 0–2, 2–4, 4–6, and 6–8 mm from the apex, using image analysis of sagittal µCT scans. GP volume percentages were: AH Plus (75.5%), EndoSequence BC (87.3%), and prototype S-PRG (94.4%). Sealer volume percentages were less: AH Plus (14.3%), EndoSequence BC (6.8%), and prototype S-PRG (4.6%). Void percentages were AH Plus (10.1%), EndoSequence BC (5.9%), and prototype S-PRG (1.0%). Dentin-sealer contact ratios of AH Plus, EndoSequence BC, and prototype S-PRG groups were 82.4% ± 6.8%, 71.6% ± 25.3%, and 70.2% ± 9.4%, respectively. GP-sealer contact ratios of AH Plus, EndoSequence BC, and prototype S-PRG groups were 65.6% ± 29.1%, 80.7% ± 25.8%, and 87.0% ± 8.6%, respectively.ConclusionsPrototype S-PRG sealer created a low-void obturation, similar to EndoSequence BC sealer with similar dentin-sealer contact (> 70%) and GP-sealer contact (> 80%). Prototype S-PRG sealer presented comparable filling quality to EndoSequence BC sealer.

Reliability of tibiofemoral contact area and centroid location in upright, open MRI

BackgroundImaging cannot be performed during natural weightbearing in biomechanical studies using conventional closed-bore MRI, which has necessitated simulating weightbearing load on the joint. Upright, open MRI (UO-MRI) allows for joint imaging during natural weightbearing and may have the potential to better characterize the biomechanical effect of tibiofemoral pathology involving soft tissues. However open MRI scanners have lower field strengths than closed-bore scanners, which limits the image quality that can be obtained. Thus, there is a need to establish the reliability of measurements in upright weightbearing postures obtained using UO-MRI.MethodsKnees of five participants with prior anterior cruciate ligament (ACL) rupture were scanned standing in a 0.5 T upright open MRI scanner using a 3D DESS sequence. Manual segmentation of cartilage regions in contact was performed and centroids of these contact areas were automatically determined for the medial and lateral tibiofemoral compartments. Inter-rater, test-retest, and intra-rater reliability were determined and quantified using intra-class correlation (ICC3,1), standard error of measurement (SEM), and smallest detectable change with 95% confidence (SDC95). Accuracy was assessed by using a high-resolution 7 T MRI as a reference.ResultsContact area and centroid location reliability (inter-rater, test-retest, and intra-rater) for sagittal scans in the medial compartment had ICC3,1 values from 0.95–0.99 and 0.98–0.99 respectively. In the lateral compartment, contact area and centroid location reliability ICC3,1 values ranged from 0.83–0.91 and 0.95–1.00 respectively. The smallest detectable change in contact area was 1.28% in the medial compartment and 0.95% in the lateral compartment. Contact area and centroid location reliability for coronal scans in the medial compartment had ICC3,1 values from 0.90–0.98 and 0.98–1.00 respectively, and in the lateral compartment ICC3,1 ranged from 0.76–0.94 and 0.93–1.00 respectively. The smallest detectable change in contact area was 0.65% in the medial compartment and 1.41% in the lateral compartment. Contact area was accurate to within a mean absolute error of 11.0 mm2.ConclusionsKnee contact area and contact centroid location can be assessed in upright weightbearing MRI with good to excellent reliability. The lower field strength used in upright, weightbearing MRI does not compromise the reliability of tibiofemoral contact area and centroid location measures.

A non-invasive ultrasound imaging method to measure acute radiation-induced bladder wall thickening in rats

BackgroundMethods for the non-invasive quantification of changes in bladder wall thickness as potential predictors of radiation cystitis in pre-clinical research would be desirable. The use of ultrasound for this aim seems promising, but is still relatively unexplored. A method using ultrasound for bladder wall thickness quantification in rats was developed and applied to measure early radiation-induced bladder wall thickness changes.MethodsTwo groups (n = 9 each) of female Fischer rats were treated with a single radiation dose of 25–30 and 35–40 Gy respectively, using an image-guided micro-irradiator; six untreated rats were monitored as a control group. Empty, half-filled and fully-filled bladder volumes were determined for four non-irradiated rats by measuring axes from ultrasound 3D-images and applying the ellipsoid formula. Mean bladder wall thickness was estimated for both ventral and dorsal bladder sides through the measurement of the bladder wall area along a segment of 4 mm in the central sagittal scan, in order to minimize operator-dependence on the measurement position. Ultrasound acquisitions of all fully-filled rat bladders were also acquired immediately before, and 4 and 28 days after irradiation. Mean bladder wall thickness normalized to the baseline value and corrected for filling were then used to evaluate acute bladder wall thickening and to quantify the dose–effect.ResultsThe relationship between mean bladder wall thickness and volume in unirradiated rats showed that for a bladder volume > 1.5 mL the bladder wall thickness is almost constant and equal to 0.30 mm with variations within ± 15%. The average ratios between post and pre irradiation showed a dose–effect relationship. Bladder wall thickening was observed for the 25–30 Gy and 35–40 Gy groups in 2/9 (22%) and 5/9 (56%) cases at day 4 and in 4/9 (44%) and 8/9 (89%) cases at day 28, respectively. The two groups showed significantly different bladder wall thickness both relative to the control group (p < 0.0001) and between them (p = 0.022). The bladder wall thickness increment was on average 1.32 ± 0.41, and was 1.30 ± 0.21 after 25–30 Gy and 1.47 ± 0.29 and 1.90 ± 0.83 after 35–40 Gy at days 4 and 28 respectively.ConclusionsThe feasibility of using ultrasound on a preclinical rat model to detect bladder wall thickness changes after bladder irradiation was demonstrated, and a clear dose–effect relationship was quantified. Although preliminary, these results are promising in addressing the potential role of this non-invasive approach in quantifying radiation cystitis.

A Novel Intraoperative Technique to Determine Cranio-Caudal Angulation of Pedicle Screws in Thoracolumbar Spine: A Prospective Computerized Tomography-Based Analysis of 428 Screws.

We report a novel technique of directing the sagittal profile of thoracic and lumbar pedicle screws using a freehand technique without the use of intraoperative monitoring. This is a prospective computerized tomography (CT)-based evaluation of pedicle screw insertion in the thoracic and lumbar spine of 64 patients operated upon for varied etiologies. All the patients were operated upon independently by 2 young surgeons with 1 year of spinal-fellowship experience. Intraoperatively, a right-angle retractor was positioned to determine the sagittal inclination of the pedicle screw. Postoperatively, sagittal CT scans were analyzed for the sagittal profile of the screw. The vertebral bodies were divided into 3 equidistant zones (A, B, and C) from the superior to inferior endplates, and the positions of the screw tips were noted. There were 41 men and 23 women (mean age = 45.5 years). A total of 428 screws were inserted. There were 2 cases of superior pedicle wall violation in D1 and D5. The majority (96.97%) of the pedicle screws were inserted into zones A and B. We introduced a simple, accurate, and safe method of directing the sagittal inclination of the pedicle screw in the thoracic and lumbar spine without intraoperative image guidance.

Morphology, ultrasonographic and computed tomography configuration of the dog pelvis and perineum.

The current study used topographic anatomy, distribution of arteries and nerves, sectional anatomy of the pelvis, computed tomography (CT) and ultrasonography examination to describe the canine pelvis and its organs. This study was conducted on twenty male and female baladi dogs, weighing 30-35kg and aged between 1.5 and 2years. The pelvis dorsal boundary appeared long and reached to the level of the third caudal vertebra. The vesicogenital pouch in the female extended further caudally than the rectogenital pouch while in the male the two pouches were at the same level and extended to the level of the first sacral vertebra. The plexus lumbosacralis formed from the ventral branches of the last three lumbar nerves and the first three sacral nerves. The obturator nerve arose from the ventral branches of the fifth and sixth lumbar nerves. We developed an anatomical atlas of the pelvis of both sexes of the dog using CT scans compared to anatomical sections. Our study is the first research on the pelvis in both sexes of the dog to compare sagittal CT scan data to sagittal anatomical sections. In the CT slices, the prostate appeared homogenous, relatively hypodense presenting with a soft tissue density. It appeared oval in the longitudinal sections and elliptical to round at the cross sections. It was situated on the floor of the pelvic cavity or the pelvic brim depending on its size. The present study is also the first to describe the fascia diaphragmatic pelvis.

Effectiveness of percutaneous lumbar foraminoplasty in patients with lumbar foraminal spinal stenosis accompanying redundant nerve root syndrome: A retrospective observational study.

The clinical outcomes of redundant nerve root syndrome (RNRS) in patients with lumbar foraminal spinal stenosis (LFSS) are currently unknown. The purpose of this study was to evaluate the postprocedural outcomes of RNRS in LFSS after percutaneous lumbar foraminoplasty (PLF) and identify the factors associated with RNRS by comparative analysis between patients with and without RNRS.Patients with LFSS who underwent PLF were retrospectively analyzed. RNRS is defined as the presence of thick, elongated, and tortuous structures in the cauda equine associated with lumbar spinal stenosis. Based on the sagittal or transverse magnetic resonance imaging scans obtained before the PLF, the patients were stratified into 2 groups. Comparative analysis was performed between patients with RNRS (group R) and those without RNRS (group C).From March 2016 to January 2019, 8 of the 21 (38.1%) patients undergoing PLF showed signs of RNRS on magnetic resonance imaging images. PLF showed a tendency for less therapeutic effect with respect to changes in pain intensity in group R as compared to group C, but there were no statistically significant differences between the 2 groups. RNRS correlated with the cross-sectional area (CSA) of the dural sac and LFSS grade (P < .05). The CSA of the dural sac was smaller and the grade of LFSS was higher in group R than in group C.RNRS is commonly associated with lumbar spinal stenosis and could affect the treatment outcomes. Clinical outcomes in group R were not statistically different from those in group C, although group R showed slightly worse outcomes. The independent factors associated with RNRS were CSA of the dural sac and the LFSS grade.

The importance of multisection sagittal and coronal magnetic resonance imaging evaluation in the assessment of temporomandibular joint disc position

ObjectivesThe aim of this study was to evaluate diagnoses of temporomandibular (TMJ) disc displacement by comparing evaluations done on the basis of central sagittal scans only, the most often used in temporomandibular disorder (TMD) patients, with a multisection evaluation done with both sagittal and coronal scans.Materials and methodsMultisection MRI analysis of 382 TMJs was conducted in 191 patients with disc displacement according to RDC/TMD criteria. Disc position in the intercuspal position (IP) was assessed two times using two different methods. The first method involved a TMJ disc position evaluation on the central slide in the oblique sagittal plane only. In the second method, the TMJ disc position was assessed on all oblique sagittal and coronal images. McNemar’s χ2 test was used to evaluate the differences between the sensitivities of two methods.ResultsThe first method (central oblique sagittal scans assessment) identified 148 TMJs (38.7%) with normal disc position compared with 89 TMJs (23.3%) with normal disc position found by the second method (all oblique sagittal and coronal scans assessment). The sensitivity of analysis in both planes was significantly higher than in the sagittal plane only (p < 0.001).ConclusionsThe multisection analysis in the sagittal and coronal plane allows to distinguish the correct disc position from disc displacement and thus improve evaluation of TMJ internal derangement.Clinical relevanceThe multisection sagittal and coronal images should be recommended as a standard in MRI of the TMJ disc displacement in patients with TMD to avoid false-negative diagnoses.

Frontal Sinus Variations and Prevalence of Frontal Recess Cells among Adult Egyptians: Computerized Tomography Study

Abstract Background: The frontal sinus is often considered as the most challenging area to approach in Functional Endoscopic Sinus Surgery (FESS). Considerable variations in the shape, capacity and symmetry of frontal sinus have been reported. Aim of Study: To provide better understanding of frontal sinus morphometry and anatomical variations of specific frontal recess cells and their prevalence among adult Egyptians. Material and Methods: Coronal and sagittal CT scans of sixty adult persons of the Egyptian population (30 males and 30 females, assigned into Group 1; from 20 to 30 years, group 2; from 31 to 50 years and group 3; more than 50 years) were done to demonstrate the anatomy of the frontal sinus. Results: A statistically significant difference in the width of the right sinus between group 2 and group 3 was revealed. Eighty percent of frontal sinuses were asymmetrical. Agger nasi cell was the most common encountered frontal recess cell and mostly bilateraly presented. The second common was Interfrontal sinus septal cell (IFSC). Statistically significant association was found between Fronta Bullar Cell (FBC) and frontal cell type 4 (FC4) but no statistically significant differ-ence was found between males and females except for frontal cell type 3 (FC3) which was higher among females than males. Statistically significant positive correlation between A-P length of left FR and AP length of right FR was revealed, while no significant correlation was found between AP length and volume of ANC. Conclusion: Awareness of frontal sinus dimensions frontal recess cells variations among Egyptians should be taken in consideration in safe frontal endoscopic surgery.

Resorbable polylactic acid polymer plates in repair of blow-out orbital floor fractures.

To evaluate the use of the resorbable polylactic acid polymer implants (Resorb X) in the management of orbital floor blow-out fractures as regards safety, cosmetic, and functional results. In a prospective, interventional case series, 22 patients with traumatic blow-out floor fractures underwent lower fornix transconjunctival repair using polylactic acid implant insertion over the defect without fixation. Orbital imaging was done preoperatively, at 1 month and 1 year postoperatively with orbital computed tomography with 2 mm cuts of axial, sagittal, and coronal scans. Outcome measures included the maximum vertical height of the orbit at the fracture plane and its changes over time. At the final follow-up, both limitation of elevation and diplopia improved in 82% of cases, while 63.6% of cases showed improvement of enophthalmos. Radiological restoration of the orbital vertical height was recorded in 100% of cases without implant displacement at 1 month. However, after 1 year, a significant floor bowing was found in 45.5% of cases, which showed a strong positive correlation with preoperative defect size (r = 0.820). Resorb X mesh plates can be a good option for the safe reconstruction of orbital floor blow-out fractures. Good anatomical and functional results were obtained in small orbital floor defects. Late bowing under pressure may limit their use in medium-sized floor defects.

Evaluation of the relationship between tympanic plate morphology and degenerative bone changes of condyle and articular eminence

IntroductionThis study aimed to evaluate the relationship between tympanic plate morphology and degeneration of temporomandibular joint (TMJ) condyle and articular eminence (AE). Material and methodsCone beam computed tomography images of 700 patients (345 males, 355 females) were evaluated. The prevalence and location of tympanic plate pneumatization (TPP) and foramen tympanicum (FT) were recorded. Sagittal scans of the TMJs were classified according to the degenerative bone changes of condyle and AE (flattening, osteophytes, erosion, sclerosis, and subcortical cysts). ResultsTPP was found in 106 of 700 patients (15.2%) while FT was found in 165 (23.2%) of the patients. TPP and FT were bilateral in 52 (49.1%) patients and 46 (27.9%) patients, respectively. The mean axial diameter of FT was 2.53mm and the mean sagittal diameter was 2.52mm. The most common degenerative changes for condyle and AE were flattening. ConclusionTo know these structures is important for surgical operations in the region of TMJ and ear to prevent complications. CBCT is useful to evaluate these anatomical landmarks and the relationship between them and the degenerative bone changes of condyle and AE.

A critical evaluation of computed tomography-derived depth of invasion in the preoperative assessment of oral cancer staging.

Depth of invasion (DOI) has been introduced into the latest TNM classification of oral squamous cell carcinoma (OSCC). Despite its primarily pathological definition (pDOI), a preoperative evaluation of a radiological DOI (rDOI) would be useful but a standard and practical definition is lacking. The primary aim of this study is to measure the rDOI by computed tomography (CT) and compare it to the pDOI in a cohort of OSCC patients. Then, we analyze the utility and reliability of rDOI in the preoperative setting. 58 cases of OSCC operated at our Institution from 2016 to 2019 were included. After accounting for plane-specific shrinkage factors and for different oral subsites, we have compared pDOI and rDOI for each spatial plane by paired difference test and correlation coefficient. Radiological accuracy and survival analysis were also determined to identify rDOI's clinical value. For lateral tongue, pDOI was more strongly related with axial rDOI (P<0.01); for hard palate, the best plane was the sagittal one (P<0.01); in floor of mouth (FOM) lesions, the strongest correlation was with coronal rDOI (P<0.01), as well as for cheek buccal mucosa; sagittal scans seem to be the best to evaluate dorsum of the tongue and retromolar trigone; gingiva (P<0.01) was most correctly evaluated in the coronal plane. Overall accuracy of rDOI restaging was 75.41%. Disease-free survival seems to be worse as rDOI increases. We suggest that with a standardized imaging protocol patients could be better classified according to CT-derived DOI.

ARTICULAR CARTILAGE THICKNESS IN PEDIATRIC AND ADOLESCENT KNEES DECREASES WITH AGE AND SKELETAL MATURITY: IMPLICATIONS FOR OSTEOCHONDRAL GRAFTING PROCEDURES

Background:Quantifying native cartilage thickness in pediatric and adolescent knees can help match donor and recipient sites for articular cartilage restoration procedures such as osteochondral autograft transplantation (OATS) and osteochondral allograft transplantation (OCA).Hypothesis/Purpose:The purpose of the current study was to quantify articular cartilage thickness in pediatric and adolescent knees using magnetic resonance imaging (MRI). We hypothesized that cartilage thickness is inversely correlated with skeletal maturity and age.Methods:One hundred and twenty MRI scans were evaluated in a cohort of patients 9 to 18 years old without osteochondral lesions, chondral wear or pathology, intraarticular fractures, history of knee surgery, or inflammatory arthropathy. Measurements of articular cartilage thickness at the medial femoral condyle, lateral femoral condyle, lateral trochlea, and patella were made on axial, coronal, and sagittal MRI scans (Figure 1). Skeletal maturity was categorized as ‘open’, ‘closing’, or ‘closed’ based on the status of the proximal tibial and distal femoral growth plates. Descriptive statistics was used to evaluate cartilage thickness by age and sex. Independent samples t-test, analysis of variance (ANOVA), and linear regression were performed to investigate for associations with sex, skeletal maturity, and age.Results:On the femur, cartilage was thickest at the lateral trochlea with mean articular thickness of 4.2 ± 1.4 mm in males and 3.6 ± 1.3 mm in females (p=0.015) (Table 1). Skeletally immature patients with open physes had significantly thicker cartilage at the medial femoral condyle, lateral femoral condyle, and lateral trochlea compared to patients with closing and closed physes (Figure 2). Linear regression analysis also revealed a significant association between femoral cartilage thickness and age (Figure 3). Age explained 63% of the variance at the medial femoral condyle (B=6.1, p<0.001), 64% of the variance at the lateral femoral condyle (B=4.9, p<0.001), and 68% of the variance at the lateral trochlea (B=8.2, p<0.001) (Table 2). In contrast, cartilage thickness at the patella did not significantly vary by age, sex, or skeletal maturity (Figures 2 and 4).Conclusion:There is a strong inverse association between increasing age and cartilage thickness of the femoral condyles and lateral trochlea. In particular, pediatric knees demonstrate relatively thick cartilage at the lateral trochlea that decreases with age. This information will help surgeons understand recipient site anatomy and identify appropriate donor site tissue for articular cartilage restoration procedures such as OATS and OCA in children and adolescents.Tables:Table 1.Mean articular cartilage thickness of the femur and patellaCombined (n=120)Male(n=40)Female(n=60) p valueMedial femoral condyle3.2 ± 1.03.5 ± 1.02.9 ± 0.80.001Lateral femoral condyle2.8 ± 0.72.9 ± 0.72.7 ± 0.70.056Lateral trochlea3.9 ± 1.44.2 ± 1.43.6 ± 1.30.015Median ridge of patella4.2 ± 0.94.4 ± 0.94.1 ± 0.90.080Medial facet of patella4.7 ± 1.04.8 ± 1.04.6 ± 0.90.320Lateral facet of patella4.6 ± 0.84.7 ± 0.84.5 ± 0.80.185Table 2.Linear regression of articular cartilage thickness of the femur and patella by ageR2 B p valueMedial femoral condyle0.636.1<0.001Lateral femoral condyle0.644.9<0.001Lateral trochlea0.688.2<0.001Median ridge of patella0.024.80.090Medial facet of patella0.045.50.032Lateral facet of patella0.0014.50.741Figures:Figure 1.Measurements of patellofemoral articular cartilage thickness Measurements of articular cartilage thickness were made on (A) coronal, (B, C) sagittal, and (D) axial magnetic resonance imaging (MRI) of the knee. For the medial femoral condyle, cartilage thickness was measured at five regions: midpoint of the medial condyle (MFC) and midpoints of Cahill zones 1 (MID1), 2 (MID2), B (MIDB) and C (MIDC). Similarly, measurements of cartilage thickness of the lateral femoral condyle were made at the midpoint of the lateral condyle (LFC) and midpoints of Cahill zones 4 (MID4), 5 (MID5), B (MIDB), and C (MIDC). Measurement of the lateral trochlea was made at midpoint of Cahill zone A (MIDA). Measurements on the patella were made at the midpoint of the medial facet (MF), midpoint of the lateral facet (LF), and the median ridge (MR) on axial and sagittal MRI scans. Figure 2.Mean articular cartilage thickness of the femur and patella by growth plate statusFigure 3.Mean articular cartilage thickness of the femur by ageFigure 4.Mean articular cartilage thickness of the patella by age

A multi-institute automated segmentation evaluation on a standard dataset: Findings from the international workshop on osteoarthritis imaging segmentation challenge

Purpose: Changes in cartilage thickness are predictive of radiographic joint-space loss and joint arthroplasty. While manual segmentation is the gold-standard for evaluating cartilage morphology, it is time-consuming and has high inter-reader variability. Advances in deep-learning and convolutional neural networks (CNNs) are promising for automatic tissue segmentation, however, the heterogeneity of datasets used for network evaluation have limited pervasive utilization of these techniques. To address these limitations, a segmentation challenge was organized at the 2019 International Workshop on Osteoarthritis Imaging (IWOAI). Here, we summarize the challenge submissions and discuss efficacy of diverse, multi-institutional deep-learning approaches for segmenting knee cartilage and meniscus. Methods: For the challenge, six teams trained CNNs to segment femoral cartilage, tibial cartilage, patellar cartilage, and menisci from 3D sagittal double-echo steady-state scans from the Osteoarthritis Initiative. The dataset consisted of 88 subjects scanned at two timepoints, split into cohorts of 60 for training, with baseline Kellgren-Lawrence grades (KLG) 1/2/3/4 distribution of (1,22,36,1), 14 for validation (1,4,8,1), and 14 for testing (0,5,8,1). Challenge participants were blinded to the all subject-identifying information. Approaches among all teams varied in CNN design and data augmentation methods, and are presented in a blinded manner below. Team 1 trained a multi-class 3D U-Net with dilated convolutions using a joint weighted cross-entropy and soft-Dice loss. Team 2 used a DeeplabV3+ architecture with dense convolutional blocks and a soft-Dice loss. Team 3 designed a multi-stage network built with a cascaded ensemble of 3D and 2D V-Nets, and used intensity and geometric transforms for data augmentation. Team 4 sampled 2D slices from multiple planes in the volume to train a 2D U-Net with batch normalization and nearest-neighbor upsampling. Team 5 used a generative adversarial framework to differentiate between real and generated 2D slices and 2D volumetric projections of segmentations that supervised the segmentation network. Following the challenge, a sixth submission (Team 6) utilized a simplified 2D, multi-class U-Net optimized with a soft-Dice loss. Dice overlap (Dice), volumetric overlap error (VOE), coefficient of variation (CV), and average symmetric surface distance (ASSD) assessed pixel-wise segmentation accuracy compared to expert-annotated ground truth. Cartilage thickness was computed for the automatic and manual approaches. Inter-network segmentation Dice overlaps were used to evaluate the similarity between different networks. Correlation between pixel-wise segmentation metrics (Dice, VOE, CV, and ASSD) and cartilage thickness error was measured using Pearson correlation coefficients (R). Statistical comparisons were performed using Kruskal-Wallis tests and Dunn post-hoc tests with Bonferroni correction (α=0.05). Results: All networks showed similar segmentation performance (violin plots Figure 1). No significant differences were observed in Dice, CV, VOE, ASSD for femoral cartilage (p=1.0), tibial cartilage (p=1.0), patellar cartilage (p=1.0), and menisci (p=1.0) among the four top-performing networks (Teams 1,3,4 and 6, respectively). Inter-network Dice overlaps were highest for femoral cartilage and above 0.85 for all tissues (Figure 2). There was no systematic bias or significant differences among a majority of the networks (p=0.99) for thickness estimates (Bland Altman plots in Figure 3). Correlation between pixel-wise segmentation accuracy metrics and cartilage thickness ranged from very-weak to moderate (highest R=0.41, thickness error vs segmentation metrics plot in Figure 4). Highest correlations were observed with femoral cartilage thickness (R less than 0.25), while very-weak correlation was observed with tibial cartilage (R less than 0.2). Conclusions: Despite the vast variety of network approaches, most methods achieved similar segmentation and thickness accuracy across all tissues, along with high inter-network Dice correlations. The similarity in performance and limitations may suggest that independent networks, regardless of their design and training framework, may learn to represent and segment the knee similarly. While networks performed comparably, there was variability in their thickness estimates. The correlation between standard segmentation metrics and cartilage thickness was weak, suggesting that traditional evaluation metrics on high-performing models may not be predictive of differences in thickness accuracy outcomes. Thus, through the segmentation challenge, we created a standardized and easy-to-use dataset to train and evaluate knee segmentation algorithms. Using deep-learning-based segmentation algorithms from multiple institutions, we showed that networks with varying training paradigms achieve similar performance and that amongst models achieving high segmentation performance, current segmentation accuracy metrics are weakly correlated with cartilage thickness endpoints.

Anterior selective stabilization combined with laminoplasty for cervical myelopathy due to massive ossification of the posterior longitudinal ligament: report of early outcomes in 14 patients.

Surgical management of massive ossification of the posterior longitudinal ligament (OPLL) is challenging. To reduce surgical complications, the authors have performed anterior selective stabilization combined with laminoplasty (antSS+LP) for massive OPLL since 2012. This study aimed to elucidate the short-term outcome of the antSS+LP procedure. The authors' analysis was based on data from 14 patients who underwent antSS+LP for cervical myelopathy caused by massive OPLL and were followed up for at least 2 years after surgery (mean follow-up duration 3.3 years). Clinical outcome was evaluated preoperatively, at 6 months and 1 year postoperatively, and at the final follow-up using the Japanese Orthopaedic Association (JOA) scoring system for cervical myelopathy and the recovery rate of the JOA score. The following radiographic parameters were measured preoperatively, immediately after surgery, at 1 year after surgery, and at the final follow-up: the C2-7 angle, measured on lateral plain radiographs, and the segmental lordosis angle (SLA), measured on sagittal CT scans. The correlation between radiographic parameters and clinical outcomes was evaluated. The mean JOA score increased from 10.4 before surgery to 13.6 and 13.8 at 6 months and 1 year after surgery, respectively; at the final follow-up the mean score was 13.4. This postoperative recovery was significant (p = 0.004) and was maintained until the final follow-up. No patient required revision surgery due to postoperative neurological deterioration. However, the C2-7 angle gradually deteriorated postoperatively. Similarly, the SLA was significantly increased immediately after surgery, but the improvement was not maintained. The recovery rate at the final follow-up correlated positively with the change in C2-7 angle (r = 0.60, p = 0.03) and the change in SLA (r = 0.72, p < 0.01). AntSS+LP is safe and effective and may be an alternative to anterior decompression and fusion for the treatment of patients with massive OPLL. No postoperative neurological complications or significant postoperative exacerbation of neck pain were observed in our case series. Not only reducing intervertebral motion and decompressing the canal at the maximal compression level but also acquiring segmental lordosis at the maximal compression level are crucial factors for achieving successful outcomes of antSS+LP.