Supine Films Research Articles

Reliability of Preoperative Supine Versus Bending Radiographs in Estimating the Structural Nature of Curves in EOS.

The study sought to evaluate the utility of a single supine radiograph in determining curve flexibility in early-onset scoliosis (EOS) patients. EOS patients with upright (standing/seated), supine, and side-bending radiographs who underwent spinal deformity surgery were identified. Coronal parameters included: proximal thoracic (PT) curve, main thoracic (MT) curve, and thoracolumbar/lumbar (TL/L) curve. Each radiograph was measured twice by 2 different raters. Correlation coefficients were utilized to investigate associations between the different radiographs. Interrater Correlation Coefficient (ICC) assessed intrarater and interrater reliability. Thirty-seven EOS patients were identified (age at diagnosis: 7.0±2.9y, preoperative age: 13.0±2.9y; 73% female; etiologies: 54% idiopathic, 30% syndromic, and 16% neuromuscular). Supine PT and MT curve measurements were highly associated with corresponding side-bending measurements (PT: r=0.75, P<0.001; MT: r=0.80, P<0.001), and TL/L curves were very highly associated (TL/L: r=0.92, P<0.001). The mean absolute differences between supine and side-bending measurements were PT: 11.3±7.8 degrees, MT: 14.8±8.3 degrees, and TL/L: 16.2±7.6 degrees, where the side-bending was on average smaller than the supine measurement. The intrarater reliabilities were excellent, with an ICC ranging from 0.93 to 0.96 for side-bending films and 0.94 to 0.97 for supine films. The interrater reliability was excellent with ICC value of 0.88 for side-bending films and 0.93 for supine films. A single, preoperative supine radiograph was highly predictive of side-bending radiographs in patients with EOS. Supine curves measured an average of 15 degrees larger than bending curves in the MT and TL/L region. A single supine film may eliminate the need for effort-related, dual side-bending radiographs. Level II-retrospective study.

Impact of Supine Radiographs to Assess Curve Flexibility in the Treatment of Adolescent Idiopathic Scoliosis.

Study Design:Retrospective cohort study.Objectives:The purpose of the study is to evaluate the role of supine radiographs in determining flexibility of thoracic and thoracolumbar curves.Methods:Ninety operative AIS patients with 2-year follow-up from a single institution were queried and classified into MT structural and TL structural groups. Equations were derived using linear regression to compute cut-off values for MT and TL curves. Thresholds were externally validated in a separate database of 60 AIS patients, and positive and negative predictive values were determined for each curve.Results:MT supine values were highly predictive of MT side-bending values (TL group: 0.63, P < 0.001; MT group: 0.66, P = 0.006). Similarly, TL supine values were highly predictive of TL side-bending values (TL group: 0.56, P = 0.001 MT group: 0.68, P = 0.001). From our derived equations, MT and TL curves were considered structural on supine films if they were ≥ 30° and 35°, respectively. Contingency table analysis of external validity sample showed that supine films were highly predictive of structurality of MT curve (Sensitivity = 0.91, PPV = 0.95, NPV = 0.81) and TL curve (Sensitivity = 0.77, PPV = 0.81, NPV = 0.94). ROC analysis revealed that the area under curve for MT structurality from supine films was 0.931 (SEM: 0.03, CI: 0.86-0.99, P < 0.001) and TL structurality from supine films was 0.922 (SEM: 0.03, CI- 0.84-0.98, P < 0.001).Conclusions:A single preoperative supine radiograph is highly predictive of side-bending radiographs to assess curve flexibility in AIS. A cut-off of ≥ 30° for MT and ≥ 35° for TL curves in supine radiographs can determine curve structurality.

Supine Imaging Is a Superior Predictor of Long-Term Alignment Following Adult Spinal Deformity Surgery.

Study Design:Retrospective cohort study.Objective:To investigate correlations between preoperative supine imaging and postoperative alignment.Methods:A retrospective review was conducted of a single-institution database of patients with adult spinal deformity (ASD). Patients were stratified by fusion location in the lumbar or thoracic spine. Outcomes of interest were postoperative lumbar lordosis (LL) and thoracic kyphosis (TK). Sagittal alignment parameters were compared and correlation analyses were performed. Multilinear stepwise regression was conducted to identify independent predictors of postoperative LL or TK. Regression analyses were repeated within the lumbar and thoracic fusion cohorts.Results:A total of 99 patients were included (mean age 63.2 years, 83.1% female, mean body mass index 27.3 kg/m2). Scoliosis Research Society classification demonstrated moderate to severe sagittal and/or coronal deformity (pelvic tile modifier, 18.2% ++; sagittal vertical axis, 27.3% ++, pelvic incidence minus lumbar lordosis mismatch, 29.3% ++, SRS type, 29.3% N type curve and 68.7% L or D type curve). A total of 73 patients (73.7%) underwent lumbar fusion and 50 (50.5%) underwent thoracic fusion. Correlation analyses demonstrated a significant association between pre- and postoperative LL and TK. Multilinear regression demonstrated that LL supine and pelvic incidence were significant predictors of postoperative LL (r2 = 0.568, P < .001). LL supine, TK supine, and age were significant predictors of postoperative TK (r2 = 0.490, P < .001).Conclusion:Preoperative supine films are superior to standing in predicting postoperative alignment at 1-year follow-up. Anticipation of undesired alignment changes through supine imaging may be useful in mitigating the risk of iatrogenic malalignment.

136. Can supine radiographs help in saving fusion levels in adolescent idiopathic scoliosis?

BACKGROUND CONTEXT Supine radiographs have previously been used to indicate flexibility in patients with adolescent idiopathic scoliosis (AIS). However, their utility for selecting LIV has not been previously demonstrated. PURPOSE To demonstrate whether supine radiographs may be used to determine lowest instrumented vertebral (LIV) level. STUDY DESIGN/SETTING Retrospective cohort study. PATIENT SAMPLE This study included 22 patients with Lenke 1 or 2 AIS treated with posterior fusion. OUTCOME MEASURES Coronal imbalance (CSVL) on immediate postoperative films and final follow-up. METHODS Preoperative standing and supine radiographs were taken and changes in stable vertebra (SV), last touched vertebra (LTV), neutral vertebra (NV), and end vertebra (EV) from preoperative standing and supine films were determined. This was used to define supine flexibility as any change in SV or LTV between standing and supine radiographs. Multivariate analysis, controlling for preoperative coronal imbalance (CSVL) and lumbar apical translation, was used to determine the relative change in postoperative CSVL based on LIV to the standing SV, standing LTV, or supine LTV. RESULTS There was a significant decrease in main thoracic (MT) (-15.1°), thoracolumbar (TL) (-11.0°) Cobb angle, and in thoracic kyphosis (TK) (-9.2°) between standing and supine radiographs (p 0.05). In total, 15 patients (68.2%) demonstrated supine flexibility, or a change in SV or LTV between standing and supine radiographs. Postoperatively, there was a significant decrease in MT (59.2°to 18.3°) and TL Cobb angle (32.8° to 10.6°) and an increase in TK (26.6° to 31.4°; p CONCLUSIONS In patients who demonstrate supine flexibility (change in stable or last touched vertebra on from standing to supine radiographs), fusion to the supine last touched vertebra may be appropriate. This may save as many as 2.1 levels in 68.2% percent of patients compared to fusion to the standing stable vertebra. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

No Differences in Hip Joint Space Measurements Between Weightbearing or Supine Anteroposterior Pelvic Radiographs

To to assess whether there are any significant differences in hip joint space width (JSW) between weight-bearing versus supine pelvic radiographs. Standing and supine anteroposterior pelvic radiographs of 86 patients (146hips) were included. Sample size was sufficiently powered to assess for equivalence between standing and supine films for JSW measurements made at the medial, lateral, and central aspects of the sourcil line. Measurements were made by 2 independent reviewers blinded to patient positioning. Each reviewer repeated a subset of the measurements to assess intra-rater reproducibility. Mean differences in joint space measurements between standing and supine radiographs were reported for each point of the sourcil. Intraclass correlation coefficients (ICCs) for inter and intra-rater reliability were also calculated. There were no significant differences between JSW measurements made on standing and supine pelvic radiographs (P= .468). Furthermore, equivalence testing demonstrated statistical equivalence between standing and supine JSW measurements made based on an equivalence threshold of ±0.5 mm. Inter-rater reliability demonstrated good agreement with an overall ICC of 0.775 (95% confidence interval [CI] 0.734-0.809). Intra-rater reliability also demonstrated good agreement with ICCs of 0.84 (95% CI 0.758-0.889) and 0.798 (95% CI 0.721-0.851) for the 2 reviewers, respectively. JSW measurements on standing and supine pelvic radiographs were not significantly different, and their inter-rater agreement and intra-rater reproducibility demonstrated good reliability and repeatability. Therefore, either may be used to assess JSW, including measurements that may impact treatment decisions for hip arthroscopy. Level III; retrospective comparative study.

DIFFERENCES IN RADIOGRAPHIC MEASUREMENTS ON STANDING VERSUS SUPINE PELVIC RADIOGRAPHS

Background:Accurate pelvic radiographic measurements is of clear clinical importance, as these measurements can drive the indications for surgery, the surgical approach utilized, and/or the degree of correction during hip preservation surgery. Currently, there are a large number of measurements available and reported on the literature when referencing anterior-posterior (AP) pelvic radiographs. However, there is no standardization of whether these pelvic radiographs are obtained in the standing or supine position.Hypothesis/Purpose:Standing vs. Supine radiographs, obtained in the same patient, will result in different value for standard radiographic measurements used in making hip pathology diagnoses.Methods:All new patients who presented for evaluation of hip pain between September 2016 and July 2018 were retrospectively reviewed. Inclusion criteria included age 18-50, no prior hip surgery/injury, and both standing and supine AP pelvis radiographs dated within 2 years of each other. Measurements were obtained on 26 radiographs (52 hips), blinded to patient demographics and standing versus supine radiograph. Measurements included minimum joint space, lateral center edge angle (LCEA), acetabular depth, acetabular inclination, Tönnis Grade, crossover sign, posterior wall sign, ischial spine sign.Results:Standing films resulted in significantly lower LCEA and acetabular depth measurements, and higher acetabular inclination. Supine measurements for crossover sign were 5.69 times more likely to be positive than standing measurements. Similarly, supine measurements for ischial spine were 7.93 times more likely to be positive (see Table 1).Conclusion:Based on our study, supine films are almost 6 times more likely to give a positive crossover sign and almost 8 times more likely to give a positive ischial spine sign than a standing film in the same patient. Additionally, LCEA, acetabular depth will be lower and acetabular inclination will be higher on standing films. As such, our recommendation is to obtain standing AP pelvis radiographs to obtain the most accurate pelvic radiographic measurements in hip preservation patients.Tables:Table 1.Radiographic measurements on standing and supine AP pelvis radiographs. Measurement LSmean Standing LSmean Supine p-value Min joint space3.84 (0.18)4.00 (0.18)0.29LCEA-ischium23.45 (1.22)24.94 (1.22)0.007LCEA- teardrops24.09 (1.29)25.35 (1.29)0.01Acetabular depth9.40 (0.55)10.94 (0.55)<0.001Acetabular inclination11.44 (0.78)10.41 (0.78)0.02 Measurement Odds Ratio for Modality 95% CI p-value Tönnis Grade0.47 (0.26)0.16, 1.400.18X-over5.69 (2.89)2.10, 15.42<0.001Posterior Wall2.55 (1.30)0.94, 6.920.07Ischial Spine7.93 (6.73)1.51, 41.800.01

Comparison of radiographic hip joint space in weight bearing and supine X-rays in patients with hip pathology

Comparison of radiographic hip joint space in weight bearing and supine X-rays in patients with hip pathology

Volvulus of the ascending colon in a non-rotated midgut: Plain film and MDCT findings

Colonic volvulus is a relatively uncommon cause of large bowel obstruction usually involving mobile, intra-peritoneal, colonic segments. Congenital or acquired anatomic variation may be associated with an increased risk of colonic volvulus which can occasionally involve retro-peritoneal segments. We report a case of 54-year-old female who presented to our Institution to perform a plain abdominal film series for acute onset of cramping abdominal pain. Both the upright and supine films showed signs of acute colonic obstruction which was thought to be due to an internal hernia of the transverse colon into the lesser sac. The patient was therefore submitted to a multi-detector contrast-enhanced computed tomography (CT). CT findings were initially thought to be consistent with the presumed diagnosis of internal hernia but further evaluation and coronal reformatting clearly depicted the presence of a colonic volvulus possibly resulting from a retro-gastric colon. At surgery, a volvulus of the ascending colon was found and a right hemi-colectomy had to be performed. However, a non rotated midgut with a right-sided duodeno-jejunal flexure and a left sided colon was also found at laparotomy and overlooked in the pre-operative CT. Retrospective evaluation of CT images was therefore performed and a number of CT signs of intestinal malrotation could be identified.

The Mandibular Angle as a Landmark for Identification of Cervical Spinal Level

Retrospective radiographic review. To determine the utility of the mandibular angle as a landmark for identification of cervical spinal level. Improper localization of the skin incision during anterior cervical spine surgery may lead to increased technical difficulty of the surgery. Although the use of traditional palpable anterior neck landmarks (hyoid bone, cricoid cartilage, thyroid cartilage, and carotid tubercle) help identify appropriate spinal levels, their reliability has not been validated in actual surgeries. We hypothesize that the angle of the mandible (AM) is a consistently palpable landmark, and that the mandible can be used to accurately template the distance to subaxial cervical levels using preoperative radiographs. As a pilot study, we prospectively evaluated 30 consecutive patients who underwent anterior cervical diskectomy and fusion to assess the interobserver accuracy of palpating the mandibular angle, hyoid, carotid tubercle, and thyroid and cricoid cartilages. In a second set of 26 consecutive patients undergoing anterior cervical diskectomy and fusion, we then retrospectively reviewed standing preoperative lateral plain radiographs of the cervical spine, in addition to supine lateral cervical spine radiographs taken at the time of surgery, to assess: (1) the position of the AM relative to the corresponding cervical spinal level, and (2) whether or not the position of the AM relative to the subaxial cervical levels is different on preoperative standing films and intraoperative supine films. In these same 26 patients, we also measured the vertical distance between the AM and the location of each subaxial intervertebral disc space. These measurements were repeated for the hyoid bone as a control for each patient. The interobserver accuracy was 100% between observers for identifying the AM, hyoid bone, thyroid cartilage, and cricothyroid membrane, and 93% for carotid tubercle. The frequency with which anterior neck landmarks were palpable by the surgeon and assisting senior residents was as follows: AM (100%), hyoid bone (83%), thyroid cartilage and cricothyroid membrane (93%), and carotid tubercle (Surgeon: 63%, Resident: 57%, P = 0.79). There was 100% correlation between the position of the mandibular angle in the preoperative standing lateral radiograph and the intraoperative supine lateral radiograph, compared with 65% with the hyoid bone. The distances between the AM or hyoid to each disc space did not vary significantly between preoperative and intraoperative radiographs (P > 0.05). The mandibular angle was shown to be the most consistently palpable landmark. Further, the distance from the mandible, measured on preoperative plain lateral cervical spine radiographs, is an accurate template to determine cervical spine levels during anterior cervical spine surgery.

The Reliability of Preoperative Supine Radiographs to Predict the Amount of Curve Flexibility in Adolescent Idiopathic Scoliosis

Retrospective review. To determine the reliability of supine long-cassette radiographs as compared with side-bending films in predicting curve flexibility in operative cases of adolescent idiopathic scoliosis (AIS). The value of side-bending films is important in the classification of AIS, as well as predicting curve flexibility. A total of 675 patients with a diagnosis of operative AIS were evaluated. All curves were classified by the Lenke classification. Coronal parameters included: proximal thoracic (PT), main thoracic (MT), and thoracolumbar/lumbar (TL/L) Cobb measurements; sagittal data including: T2-T5, T5-T12, and TL/L measurements. Curves were divided into Lenke Types 1 (N = 263), 2 (N = 118), 3 (N = 52), 4 (N = 31), 5 (N = 57), and 6 (N = 54). Lenke Types 1 to 4 (Group I-MT Major) were compared with Types 5 and 6 (Group II-TL/L Major). For Group I, MT supine films were highly predictive of MT side-bending while TL/L supine films were highly predictive of TL/L side-bending and standing films. An equation was derived to predict the value of the side-bending radiographs for each part of the curve. For Group II, MT supine films were highly predictive of MT side-bending and standing films. TL/L supine films were highly predictive of TL/L side-bending and standing films. Contingency table analysis for Group I resulted in the supine film providing a strong statistical ability to predict a nonstructural PT curve (sensitivity = 0.952, PPV = 0.864, NPV = 0.865) and also a nonstructural TL/L curve (sensitivity = 0.958, PPV = 0.916). Similarly, in Group II, we found a strong statistical ability to predict a nonstructural PT (sensitivity 1.00, PPV = 0.982, NPV = 1.00) and a nonstructural MT curve (sensitivity 0.789, specificity = 0.842, PPV = 0.833, NPV = 0.80). A single preoperative supine radiograph is highly predictive of side-bending radiographs and can be used as an adjunct to predicting curve type, flexibility, and structurality. Thus, this singular, reproducible, and non-effort-related radiograph can potentially replace the need for dual side-bending films.

Crohn's disease presenting as enterolithic intestinal obstruction

A 44-year-old woman who had 1-year history of intermittent mild abdominal pain was admitted to the emergency ward with a 1-day history of severe abdominal pain associated with obstipation, abdominal distension, and vomiting. She denied any history of fever, altered bowel function, exposure to tuberculosis, prior abdominal surgery, anorexia, and weight loss. On examination she was afebrile, hemodynamically stable, and had moderate abdominal distension with diffuse tenderness all over. Bowel sounds were exaggerated. Anorectal examination was normal. An abdominal radiograph revealed dilated small bowel with multiple airfluid levels and five large enteroliths in erect and supine films, respectively ( Fig. 1). Her hemoglobin was 11 g%, and her white blood cell count was 9,200/mm 3 (P 78%, L 22%). Serum electrolytes and renal and liver functions were within normal limits. She was operated on after 72 hours of failed conservative treatment. Exploration revealed diffuse jejunoileal disease with sparing of the distal 60 cm of ileum. Affected bowel was thick, edematous with increased vascularity, and had mesenteric fat creeping with multiple large lymph nodes in thickened mesentery. Stomach, duodenum, colon, and bowel between the diseased segments were normal looking. There were six partial small bowel strictures: one in the distal jejunum and five in the mid ileum lying 2 to 4 cm apart. Five enteroliths of 2 cm to 5 cm in size were found in the ileum, four of which were present between the last two strictures and could not be milked in either direction. A smaller enterolith was impacted in the lumen at the distal stricture producing complete obstruction. The jejunal stricture was treated by strictureplasty and 30 cm of ileum having strictures with contained enteroliths was resected with primary anastomosis of the bowel (Fig. 2). The remaining enterolith was milked out. Opened up bowel showed transverse areas of ulceration corresponding to the stricture sites, and mucosa between strictures appeared normal. Microscopic examination revealed mucosal ulceration, focal areas of hemorrhagic necrosis, and transmural infiltration of the chronic inflammatory cells. No well-defined

Emergency Bedside Ultrasound to Detect Pneumothorax

AbstractA relatively new application of emergency ultrasound is its use in the diagnosis of pneumothorax. In patients with major trauma, early detection and treatment of pneumothorax are vital. Chest radiography in these patients is limited to anteroposterior (AP) supine films, in which radiographic features of pneumothorax may be quite subtle. Hence, rapid and accurate bedside ultrasonography can expedite resuscitation. Sonographic features of pneumothorax have been identified in a number of studies. The technique involves identification of the pleural line and observation for features such as “lung sliding” and comet‐tail artifacts, which are absent in pneumothorax. Based on a review of the literature, the author describes these features and discusses the utility of emergency ultrasound in detecting pneumothorax.

Emergency bedside ultrasound to detect pneumothorax.

A relatively new application of emergency ultrasound is its use in the diagnosis of pneumothorax. In patients with major trauma, early detection and treatment of pneumothorax are vital. Chest radiography in these patients is limited to anteroposterior (AP) supine films, in which radiographic features of pneumothorax may be quite subtle. Hence, rapid and accurate bedside ultrasonography can expedite resuscitation. Sonographic features of pneumothorax have been identified in a number of studies. The technique involves identification of the pleural line and observation for features such as "lung sliding" and comet-tail artifacts, which are absent in pneumothorax. Based on a review of the literature, the author describes these features and discusses the utility of emergency ultrasound in detecting pneumothorax.

Diagnosis of pneumoperitoneum on supine abdominal radiographs.

A blinded, retrospective study was performed to determine the value of supine abdominal radiographs in diagnosing pneumoperitoneum. Supine films from 44 cases of pneumoperitoneum were randomly interspersed among supine films from 87 control subjects without free air, and the films were reviewed for the presence or absence of various signs of pneumoperitoneum, including Rigler's sign (gas on both sides of the bowel wall), the falciform ligament sign (gas outlining the falciform ligament), the football sign (gas outlining the peritoneal cavity), the inverted-V sign (gas outlining the medial umbilical folds), and the right-upper-quadrant gas sign (localized gas in the right upper quadrant). One or more of these signs were present in 26 cases (59%) of pneumoperitoneum, including the right-upper-quadrant gas sign in 18 cases (41%), Rigler's sign in 14 cases (32%), and the falciform ligament and football signs in one case each (2%). Unfortunately, there were frequent errors in the interpretation of the right-upper-quadrant gas sign and Rigler's sign, with a total of 11 false-positive cases (13%). Further analysis of the true-positive right-upper-quadrant gas signs showed that these gas collections were always triangular or linear with an inferolateral to superomedial orientation and, if triangular, a concave superolateral border. In the true-positive Rigler's signs, the bowel wall thickness ranged from 1 to 8 mm, whereas the false positives all had a bowel wall thickness of 1 mm or less. Proper interpretation of the various signs of pneumoperitoneum on supine films should lead to more accurate diagnosis of this condition.

Determination of normal transverse mediastinal width and mediastinal-width to chest-width (M/C) ratio in control subjects: implications for subjects with aortic or brachiocephalic arterial injury.

We measured transverse mediastinal width and mediastinal-width to chest-width (M/C) ratio on supine films of 100 nontraumatized controls. In 95% the transverse mediastinal width was less than 7.5 cm and the M/C ratio was less than 0.38. Thus a transverse width of 7.5 cm or more or an M/C ratio of 0.38 or more can be defined as abnormal with 95% confidence. Application of these values to determine abnormality in 32 patients with proven aortic or brachiocephalic injury showed that the transverse mediastinal width was within normal limits in 41% and M/C ratio was normal in 69%. Utilizing smaller values that would identify all abnormals resulted in false positive rates in the controls of 74% and 87%, respectively. However, one or more of eight specific signs of mediastinal abnormality related to hemorrhage or pseudoaneurysm formation were present in 94% of abnormals compared to only 11% of controls. Because of extreme overlap of transverse mediastinal width and M/C ratio between normals and abnormals, precise measurement of the mediastinum cannot reliably separate the two groups. The subjective assessment of anatomic mediastinal abnormality remains a superior plain film method in determining the need for aortography.

Aortic injury: Comparison of supine and upright portable chest films to evaluate the widened mediastinum

Despite many reports of radiologic findings that may be suggestive of aortic injury, most authors believe the recognition of a widened mediastinum on chest film remains the sine qua non. Few studies have confirmed the widely held belief that the supine AP chest film is inaccurate in assessing the width of the mediastinal structures, and that one should use only the upright or sitting chest films. This study was undertaken to assess the accuracy of both upright and supine chest films in the evaluation of mediastinal widening after blunt deceleration chest injury. Both supine and upright sitting chest films were obtained immediately on arrival in the resuscitation areas for 55 patients. Twenty-one (38%) exhibited a mediastinum that appeared wide on supine view but within normal limits on the upright view, as attested by two radiologists. Aortography was not performed on any of these patients. Daily upright chest films, repeated until discharge, failed to demonstrate any change in mediastinal anatomy, and all patients recovered without incident. Twelve patients' films (22%) demonstrated widened mediastinum on both views, and these 12 patients underwent immediate aortography. Aortic rupture was revealed in four (33%). This study clarifies the diagnostic value of the upright chest film in assessing the mediastinum after blunt injury. It confirms the belief that supine films are not accurate, and that they may lead to numerous false positives and unnecessary aortograms. The initial upright or sitting chest film is accurate, and its use is cost-effective and time-saving for patient and physician.(ABSTRACT TRUNCATED AT 250 WORDS)

Seed Calculi in an Ectopic Ureterocele: A Case Report

We report a case in which the gravitational properties of seed calculi were demonstrated on plain films and excretory urography in an ectopic ureterocele. Upright and supine films are of importance to preclude other etiologies for abdominal calcification.

Early ambulation with localizer cast following posterior spinal fusion without internal fixation.

One hundred fourteen patients have been treated with posterior spinal fusion with no internal fixation, followed by early ambulation in localizer casts. The group included 114 patients (104 girls and 10 boys) with an average age of 14.5 years at the time of surgery. All patients underwent preoperative Cotrel traction. Localizer casts were fitted during the first postoperative week, and ambulation was begun as soon as supine films in the cast showed acceptable correction. Six months postfusion the localizer casts were removed and replaced with underarm casts, which were maintained for an additional 4 months. We have found this treatment to be quite effective in patients with single curves, with an average curve correction of 44 degrees. Results in patients with double structural curves have been less encouraging, and it would seem that such patients are best treated with internal fixation.

Rationalising abdominal radiography in the accident and emergency department

A retrospective analysis is presented of 100 consecutive patients attending an accident department and referred for abdominal radiography. In general the reasons for requesting supine films appeared sound. Five per cent of referrals were for haematemesis which is not a valid reason for plain radiography. An erect abdominal film as a routine request is indicated only in suspected intestinal obstruction (4% in this series), but 83% of patients were referred for both erect and supine films. If haematemesis were excluded as a reason for X-ray referral, and if erect films were limited to suspected intestinal obstruction, 95% of the patients would still have been referred for radiography, but almost half the abdominal films would not have been required. This would have reduced film wastage, workload and more important, gonadal irradiation.

Strangulating obstruction of the bowel: a reevaluation of radiographic criteria

Fifty consecutive cases of strangulating obstruction were compared with 100 consecutive cases of surgically proven simple obstruction due to adhesions or hernia. All cases were studied by the usual supine and either erect or decubitus abdominal films, and by two successive supine films made at 5 min intervals. Radiographic criteria previously described as signs of possible strangulation were evaluated in the two series. Reduced activity of the small bowel loops on the successive supine films was the only frequent sign (58% of the cases with strangulating obstruction) which showed a statistically significant difference in incidence between the two groups. Other signs seen with some frequency (22%-28% of the group with strangulation) were long air-fluid levels, loss of valvulae conniventes, retention of bubbly fecal matter in the right colon, and predominance of fluid-filled loops; however, they occurred with the same frequency in simple obstruction. The more specific signs of bowel congestion and necrosis (i.e., a narrow rigid loop or intramural gas) were seen in 10% and 2% of the cases, respectively. Only the incidence of a narrow rigid loop in strangulation reached statistical significance. This study confirms the difficulty of diagnosing strangulating obstruction using plain films of the abdomen. Successive abdominal films were shown to be valuable in providing information about small bowel activity, which can help in the differential diagnosis.