Mazda Farshad

Interreader and intermodality reliability of standard anteroposterior radiograph and magnetic resonance imaging in detection and classification of lumbosacral transitional vertebra

BACKGROUND CONTEXTnDifferent types of lumbosacral transitional vertebra (LSTV) are classified based on the relationship of the transverse process of the last lumbar vertebra to the sacrum. The Ferguson view (30° angled anteroposterior [AP] radiograph) is supposed to have a sufficient interreader reliability in classification of LSTV, but is not routinely available. Standard AP radiographs and magnetic resonance imaging (MRI) are often available, but their reliability in detection and classification of LSTV is unknown.nnnPURPOSEnThe purpose of this study was to evaluate the interreader reliability of detection and classification of LSTV with standard AP radiographs and report its accuracy by use of intermodality statistics compared with MRI as the gold standard.nnnSTUDY DESIGN/SETTINGnRetrospective case control study.nnnPATIENT SAMPLEnA total of 155 subjects (93 cases: LSTV type 2 or higher; 62 controls).nnnOUTCOME MEASURESnInterreader reliability in detection and classification of LSTV usingxa0standard AP radiographs and coronal MRI as well as accuracy of radiographs compared withxa0MRI.nnnMETHODSnAfter institutional review board approval, coronal MRI scans and conventional AP radiographs of 155 subjects (93 LSTV type 2 or higher and 62 controls) were retrospectively reviewed by two independent, blinded readers and classified according to the Castellvi classification. Interreader reliability was assessed using kappa statistics for detection of an LSTV and identification of all subtypes (six variants; 1: no LSTV or type I, 2: LSTV type 2a, 3: LSTV type 2b, 4: LSTV type 3a, 5: LSTV type 3b, 6: LSTV type 4) for MRI scans and standard AP radiographs. Further, accuracy and positive and negative predictive values were calculated for standard AP radiographs to detect and classify LSTV using MRI as the gold standard.nnnRESULTSnThe interreader reliability was at most moderate for the detection (k=0.53) and fair for classification (wk=0.39) of LSTV in standard AP radiograph. However, the interreader reliability was very good for detection (k=0.93) and classification (wk=0.83) of LSTV in MRI. The accuracy and positive and negative predictive values of standard AP radiograph were 76% to 84%, 72% to 86%, and 79% to 81% for the detection and 53% to 58%, 51% to 76%, and 49% to 55% for the classification of LSTV, respectively.nnnCONCLUSIONnStandard AP radiographs are insufficient to detect or classify LSTV. Coronal MRI scans, however, are highly reliable for classification of LSTV.

Associations between lumbosacral transitional anatomy types and degeneration at the transitional and adjacent segments

BACKGROUND CONTEXTnThe relation between specific types of lumbosacral transitional vertebra and the degree of degeneration at and adjacent to the transitional level is unclear. It is also unknown whether the adjacent cephalad segment to a transitional vertebra is prone to greater degeneration than a normal L5-S1 level.nnnPURPOSEnThe purpose of this study was to evaluate the relation between specific lumbosacral transitional vertebra subtypes according to the Castellvi classification, and to determine the severity of degeneration at the transitional level and the adjacent cephalad segment.nnnSTUDY DESIGNnThis study was a retrospective review.nnnPATIENT SAMPLESnNinety-two subjects with lumbosacral transitional vertebra grade 2 or higher and 94 control subjects without were retrieved from a picture archiving and communication system (PACS) search.nnnOUTCOME MEASURESnDisc degeneration parameters at the transitional and at the adjacent cephalad level were measured.nnnMETHODSnAfter institutional review board approval, 92 subjects (42 men; mean age, 57±16 years) with lumbosacral transitional vertebra grade 2 or higher and 94 control subjects (41 men; mean age, 51±16 years) without were retrieved from a PACS search. Degeneration of the last two segments of the lumbar spine was quantified using the Pfirrmann and Modic classifications, along with documentation of annular tears, disc herniations, and disc height, and were compared between the two groups. Furthermore, L5-S1 levels in the control subjects were compared with the adjacent cephalad segments of the transitional vertebrae for the same parameters.nnnRESULTSnAlthough the control subjects, at L5-S1, had moderate to severe degeneration by Pfirrmann grades (31%) and Modic changes ([MC] 20%), in comparison, the discs at the transitional level of the lumbosacral transitional vertebra group demonstrated significant less degeneration (3% and 1%, respectively; each p<.05). The adjacent cephalad segments of the lumbosacral transitional vertebra group showed significantly greater degeneration (Pfirrmann grade 5, 39%; MC, 30%) compared with the L4-L5 level in control subjects (16% and 11%, respectively; each p<.05). The severity of disc degeneration using all parameters correlated with the type of lumbosacral transitional vertebra. The degree of degeneration of L5-S1 in control subjects was similar to the adjacent cephalad segment in lumbosacral transitional vertebrae.nnnCONCLUSIONnIncreasing the mechanical connection of a lumbosacral transitional vertebra protects the disc at the transitional level and predisposes the adjacent cephalad segment to greater degeneration. The adjacent cephalad segment had a comparable degree of degeneration as the L5-S1 level in control subjects.

Determinants of evolution of endplate and disc degeneration in the lumbar spine: a multifactorial perspective

AbstractPurposeEvolution and progression of disc and endplate bone marrow degeneration of the lumbar spine are thought to be multifactorial, yet, their influence and interactions are not understood. The aim of this study was to find association of potential predictors of evolution of degeneration of the lumbar spine.nMethodsPatients (nxa0=xa090) who underwent two lumbar magnetic resonance imaging (MRI) exams with an interval of at least 4xa0years and without any spinal surgery were included into the longitudinal cohort study with nested case–control analysis. Disc degeneration (DD) was scored according to the Pfirrmann classification and endplate bone marrow changes (EC) according to Modic in 450 levels on both MRIs. Potential variables for degeneration such as age, gender, BMI, scoliosis and sagittal parameters were compared between patients with and without evolution or progression of degenerative changes in their lumbar spine. A multivariate analysis aimed to identify the most important variables for progression of disc and endplate degeneration, respectively.ResultsWhile neither age, gender, BMI, sacral slope or the presence of scoliosis could be identified as progression factor for DD, a higher lordosis was observed in subjects with no progression (49°xa0±xa011° vs 43°xa0±xa012°; pxa0=xa00.017). Progression or evolution of EC was only associated with a slightly higher degree of scoliosis (10°xa0±xa010° vs 6°xa0±xa09°; pxa0=xa00.04) and not to any of the other variables.ConclusionWhile a coronal deformity of the lumbar spine seems associated with evolution or progression of EC, a higher lumbar lordosis is protective for radiographic progression of DD. This implies that scoliotic deformity and lesser lumbar lordosis are associated with higher overall degeneration of the lumbar spine.

Is the iliolumbar ligament a reliable identifier of the L5 vertebra in lumbosacral transitional anomalies

AbstractObjectiveSufficiently sized studies to determine the value of the iliolumbar ligament (ILL) as an identifier of the L5 vertebra in cases of a lumbosacral transitional vertebra (LSTV) are lacking.MethodsSeventy-one of 770 patients with LSTV (case group) and 62 of 611 subjects without LSTV with confirmed L5 level were included. Two independent radiologists using coronal MR images documented the level(s) of origin of the ILL. The interobserver agreement was analysed using weighted kappa/kappa (wκ/κ) and a Fischer’s exact test to assess the value of the ILL as an identifier of the L5 vertebra.ResultsThe ILL identified the L5 vertebra by originating solely from L5 in 95xa0% of the controls; additional origins were observed in 5xa0%. In the case group, the ILL was able to identify the L5 vertebra by originating solely from L5 in 25–38xa0%. Partial origin from L5, including origins from other vertebra was observed in 39–59xa0% and no origin from L5 at all in 15–23xa0% (wκu2009=u20090.69). Both readers agreed that an ILL was always present and its origin always involved the last lumbar vertebra.ConclusionThe level of the origin of the ILL is unreliable for identification of the L5 vertebra in the setting of an LSTV or segmentation anomalies.Key Points• The origin of the ILL is evaluated in subjects with an LSTV.n • The origin of the ILL is anatomically highly variable in LSTV.n • The ILL is not a reliable landmark of the L5 vertebra in LSTV.

Merits of different anatomical landmarks for correct numbering of the lumbar vertebrae in lumbosacral transitional anomalies

PurposeAnatomical landmarks and their relation to the lumbar vertebrae are well described in subjects with normal spine anatomy, but not for subjects with lumbosacral transitional vertebra (LSTV), in whom correct numbering of the vertebrae is challenging and can lead to wrong-level treatment. The aim of this study was to quantify the value of different anatomical landmarks for correct identification of the lumbar vertebra level in subjects with LSTV.MethodsAfter IRB approval, 71 subjects (57xa0±xa017xa0years) with and 62 without LSTV (57xa0±xa017xa0years), all with imaging studies that allowed correct numbering of the lumbar vertebrae by counting down from C2 (nxa0=xa0118) or T1 (nxa0=xa015) were included. Commonly used anatomical landmarks (ribs, aortic bifurcation (AB), right renal artery (RRA) and iliac crest height) were documented to determine the ability to correctly number the lumbar vertebrae. Further, a tangent to the top of the iliac crests was drawn on coronal MRI images by two blinded, independent readers and named the ‘iliac crest tangent sign’. The sensitivity, specificity and the interreader agreement were calculated.ResultsWhile the level of the AB and the RRA were found to be unreliable in correct numbering of the lumbar vertebrae in LSTV subjects, the iliac crest tangent sign had a sensitivity and specificity of 81xa0% and 64–88xa0%, respectively, with an interreader agreement of kxa0=xa00.75.ConclusionWhile anatomical landmarks are not always reliable, the ‘iliac crest tangent sign’ can be used without advanced knowledge in MRI to most accurately number the vertebrae in subjects with LSTV, if only a lumbar spine MRI is available.

A reliable measurement for identifying a lumbosacral transitional vertebra with a solid bony bridge on a single-slice midsagittal MRI or plain lateral radiograph

The purpose of this study was to devise a simple but reliable radiological method of identifying a lumbosacral transitional vertebra (LSTV) with a solid bony bridge on sagittal MRI, which could then be applied to a lateral radiograph. The vertical mid-vertebral angle (VMVA) and the vertical anterior vertebral angle (VAVA) of the three most caudal segments of the lumbar spine were measured on MRI and/or on a lateral radiograph in 92 patients with a LSTV and 94 controls, and the differences per segment (Diff-VMVA and Diff-VAVA) were calculated. The Diff-VMVA of the two most caudal vertebrae was significantly higher in the control group (25° (sd 8) than in patients with a LSTV (type 2a+b: 16° (SD 9), type 3a+b: -9° (SD 10), type 4: -5° (SD 7); p < 0.001). A Diff-VMVA of ≤ +10° identified a LSTV with a solid bony bridge (type 3+4) with a sensitivity of 100% and a specificity of 89% on MRI and a sensitivity of 94% and a specificity of 74% on a lateral radiograph. A sensitivity of 100% could be achieved with a cut-off value of 28° for the Diff-VAVA, but with a lower specificity (76%) on MRI than with Diff-VMVA. Using this simple method (Diff-VMVA ≤ +10°), solid bony bridging of the posterior elements of a LSTV, and therefore the first adjacent mobile segment, can be easily identified without the need for additional imaging.

Is an annular tear a predictor for accelerated disc degeneration

PurposeIt is questionable whether an annular tear (AT) is a predictor for accelerated degeneration of the intervertebral discs. The aim of the present study was to answer this question via a matched case–control study design that reliably eliminates potential confounders.MaterialsPresence or absence of AT, defined as a hyperintense lesion within the annular fibrosus on T2-weighted non-contrast MRI images, was documented in 450 intervertebral lumbar discs of 90 patients who could be followed up for at least 4xa0years with MRI. Discs with an AT (nxa0=xa036) were matched 1:1 to control discs according to the level, degree of initial disc degeneration on MRI (both Pfirrmann grade median 4, range 3–4), age (59.5xa0±xa015.0 versus 59.3xa0±xa014.6xa0years), BMI (26.7xa0±xa04.4 versus 26.9xa0±xa04.4xa0kg/m2) and interval to the follow-up MRI (4.8xa0±xa00.9 versus 5.1xa0±xa00.8xa0years). The degree of disc degeneration after a minimum of 4xa0years was graded on the follow-up MRI in both groups according to the Pfirrmann classification.ResultsOne-fourth (25xa0%) of the 36 discs with an AT on the initial MRI exam progressed in degeneration. This was similar to the rate of the matched control discs with no AT, in which also around one-fourth (22xa0%) showed a progression of degeneration (pxa0=xa01.00), also without any difference in the degree of degeneration.ConclusionDiscs with a Pfirrmann grade >2 with an AT, defined by a hyperintense signal intensity on MRI, are not prone to accelerated degeneration if compared to discs without an AT. Therefore, the presence of an AT per se does not predict accelerated disc degeneration.

Multiple myeloma exacerbation following utilization of bone morphogenetic protein-2 in lateral lumbar interbody fusion: a case report and review of the literature.

BACKGROUND CONTEXTnRecent studies generated antithetic results regarding the safety of bone morphogenetic protein-2 (BMP-2) use in spine surgery, and the effect of this biologic adjunct on myeloma cells remains to be fully elucidated.nnnPURPOSEnThe purpose of this study was to present a case of multiple myeloma (MM) exacerbation after BMP-2 implantation in the setting of lateral lumbar interbody fusion (LLIF).nnnSTUDY DESIGNnCase report and literature review.nnnMETHODSnThe medical records, laboratory findings, and radiographic imaging studies of an 86-year-old female patient with exacerbation of previously undiagnosed MM were reviewed.nnnRESULTSnThe patient presented with a 10-year history of debilitating lower back pain and bilateral lower extremity claudication. Radiographic studies depicted lumbar scoliosis and lateral spondylolisthesis. Preoperative serum immunofixation electrophoresis showed a serum immunoglobulin A kappa paraprotein-peak; however, the patient had never been diagnosed with MM or reported any unexplained fever, night sweats, or weight loss indicative of MM. The patient underwent LLIF from L1-L5 supplemented by BMP-2. On postoperative day 1, the patient was evaluated by the hematology department for paraproteinemia. Serum electrophoresis showed decreased albumin, hypogammaglobulinemia, and suspicious broadening of the complement component in the beta region. Postoperative imaging studies (19 weeks) depicted progression of a previously visible intraosseous lesion, and anterior cortical breakthrough (L5), in addition to a soft tissue mass at the T10 level. Histological examination of iliac crest and T10 vertebral biopsies showed fatty marrow infiltration by plasma cells and plasma cell dyscrasia, proving the diagnosis of MM. The patient died 10 months after surgery due to complications related to a methicillin-resistant Staphylococcus aureus infection.nnnCONCLUSIONSnBased on the present case, perhaps one should consider that in patients with abnormal electrophoresis results, even in the absence of a prior diagnosis of MM as well as in the absence of symptoms indicative of MM, BMPs should be administered only after preoperative exclusion of neoplastic disease.

The Primer for Sports Medicine Professionals on Imaging The Shoulder

Because of its inherent superior soft tissue contrast and lack of ionizing radiation, magnetic resonance imaging (MRI) is highly suited to study the complex anatomy of the shoulder joint, particularly when assessing the relatively high incidence of shoulder injuries in young, athletic patients. This review aims to serve as a primer for understanding shoulder MRI in an algorithmical approach, including MRI protocol and technique, normal anatomy and anatomical variations of the shoulder, pathologic conditions of the rotator cuff tendons and muscles, the long head of the biceps tendon, shoulder impingement, labral and glenohumeral ligament pathology, MR findings in shoulder instability, adhesive capsulitis, and osteoarthritis.

Imaging of Acute Cervical Spine Trauma: When to Obtain Which Modality

The current knowledge and evidence around the merits of different imaging modalities for the evaluation of cervical spine injuries are reviewed. The National Emergency X-Radiography Use Study, Canadian Cervical Spine rule, and American College of Radiology appropriateness criteria are reviewed and summarized. The advantages and disadvantages of available imaging modalities for selected cervical spine injury patterns are also illuminated to simplify the decision making on when to use which modality.