Michael E. Mulligan

Measurement of lumbar lordosis. Evaluation of intraobserver, interobserver, and technique variability

Study Design Sixty radiographs were measured on two separate occasions by three physicians using four different techniques to evaluate the reliability and reproducibility of the measurement of lumbar lordosis. Objective To evaluate clinical methods of measuring lumbar lordosis, determining intraobserver and interobserver reliability. Summary of Background Data Several different methods are used to measure lumbar lordosis. The reliability and reproducibility of these has not been well studied. Methods Sixty lateral full spine radiographs were obtained, labeled, and the lumbar lordosis measured independently by three practitioners who routinely perform these measurements. Four measurement techniques were used. These included measurements from the inferior endplate of T12 to the superior endplate of S1; the superior endplate of L1 to the superior endplate of S1; the inferior endplate of T12 to the inferior endplate of L5; and the superior endplate of L1 to the inferior endplate of L5. The measurements then were repeated after relabeling. Results Intraobserver reliability coefficients ranged from 0.83 to 0.92, indicating excellent reproducibility. Ninety‐two percent of repeat measures were within 10°. High overall and pairwise agreement among the three observers also was present; the interobserver reliability coefficients ranged from 0.81 to 0.92. Conclusions The measurement of lumbar lordosis is reproducible and reliable if the technique is specified and one accepts 10° as acceptable variation. Factors that affect the reproducibility of measurement include end vertebra selection (especially with transitional segments) and vertebral endplate architecture.

PET/CT and MR imaging in myeloma

Myeloma is the most common primary bone malignancy. It accounts for 10% of all hematological malignancies and 1% of all cancers. In the United States, there are an estimated 16,000 new cases and over 11,000 deaths yearly due to myeloma. Plasma cell dyscrasias manifest themselves in a variety of forms that range from MGUS (monoclonal gammopathy of undetermined significance) and smoldering myeloma that require no therapy, to the “malignant” form of multiple myeloma. The role of imaging in the management of myeloma includes: an assessment of the extent of intramedullary bone disease, detection of any extramedullary foci, and severity of the disease at presentation; the identification and characterization of complications; subsequent assessment of disease status. This review will focus on the use of PET/CT and MR imaging for myeloma patients at the time of initial diagnosis and for follow-up management, based on current reports in the literature and our practice at the Marlene and Stewart Greenebaum Cancer Center, University of Maryland Medical Center in Baltimore, USA.

The "gray cortex ": an early sign of stress fracture.

The purpose of this report is to describe an early radiographic sign of stress fracture, the “gray cortex.” The imaging findings in three patients with tibial stress fractures were reviewed. The “gray cortex” sign was evident on the initial conventional radiographs in all three cases. It was prospectively reported as a sign of stress fracture in two patients and was evident on the initial radiographs (taken elsewhere) of the third patient, who was referred for additional workup of a possible neoplasm. Special imaging studies (technetium-99m bone scan, computed tomography, and magnetic resonance imaging) confirmed the diagnosis in all three cases.

Medication-induced periostitis in lung transplant patients: periostitis deformans revisited

We report five cases of diffuse periostitis resembling hypertrophic osteoarthropathy and perostitis deformans in lung transplantation patients on chronic voriconazole, a fluoride-containing compound. Although drug-related periostitis has long been known, the association of lung transplant medication with periostitis was only recently introduced in the literature. To our knowledge, imaging findings have not been fully characterized in the radiology literature. Imaging features along with clinical history help to distinguish this benign condition from other disease entities. In this article, we review the current literature and illustrate the variety of imaging characteristics of this entity so that interpreting radiologists can make accurate diagnoses and avoid unnecessary work up.

Imaging techniques used in the diagnosis, staging, and follow-up of patients with myeloma:

Radiologists play a central role in the diagnosis, initial staging, follow-up, and restaging of patients with myeloma. This review article attempts to familiarize the reader with all the various types of myeloma, their imaging appearances and useful imaging strategies. The staging system for myeloma patients has been updated and now includes findings from advanced imaging modalities. Radiologists have a vast array of imaging modalities at their disposal to aid them in diagnosis, staging, and follow-up. Currently, conventional radiographic skeletal surveys, magnetic resonance imaging, and F-18 FDG PET/CT examinations are the most useful instruments.

Multiple myeloma lesion detection with whole body CT versus radiographic skeletal survey.

Objective: To compare accuracy of CT versus radiographs in detecting myeloma lesions. Materials and Methods: Retrospective review of patients who were simultaneously evaluated with radiographs and PET/CT scans. Two radiologists independently assessed each modality. Results: Total number of lesions detected with CT was 968 versus 248 for radiographs (p < .001). Nine patients (18%) had no lesions on either CT or radiographs. Of the remaining 42 patients, 39 had more lesions on CT. CT could have resulted in upstaging of disease in 31 cases (61%). Conclusion: CT is superior for detecting myeloma lesions.

Central skeletal sarcoidosis mimicking metastatic disease

Sarcoidosis is a systemic disease that histologically typically shows non-caseating granulomas. The most common radiologic finding is hilar and mediastinal adenopathy. Patients with widely disseminated disease may show involvement of the peripheral appendicular skeleton in 1–13% of such cases. A primary skeletal presentation without other manifestations typical of the disease is rare. We present a case of sarcoidosis in a middle-aged Caucasian man in whom the disease presented with widespread lytic lesions in the axial skeleton and long bones, mimicking metastatic disease. There was no involvement of the peripheral skeleton, skin or lungs.

CT-Guided Shoulder Arthrography at the Rotator Cuff Interval

OBJECTIVE The purpose of this study was to describe a CT-guided approach to the glenohumeral joint at the rotator cuff interval and to compare that approach to the more traditional approach, including technical considerations. CONCLUSION CT-guided glenohumeral joint injections at the rotator cuff interval are faster and easier to perform than those performed using the more traditional approach.

Characterizing and Predicting Pathologic Spine Fractures in Myeloma Patients With FDG PET/CT and MR Imaging

Objectives: To determine if FDG PET/CT scans can be used to discriminate between old and new pathologic spine fractures in myeloma patients and also to determine if there is any combination of PET/CT and MR imaging findings that may indicate an impending spine fracture. Materials and methods: Retrospective review, after IRB approval, by two musculoskeletal radiologists and one nuclear medicine physician was done. PET/CT database was searched to identify studies performed in myeloma patients, using the search terms myeloma, plasmacytoma, or plasma cell. Records, for this group of 176 patients, were searched for concurrent spine MR imaging and report of fracture. The SUVmax was recorded for each vertebral level from C2 through L5. All other imaging studies carried out in each patient (spine radiographs, spine CTs, and spine MRIs) and clinical records also were reviewed. Spine fractures were identified using the Genant system. MR imaging findings noted included signal intensity, pattern of involvement, as well as the size and location, within the vertebral body, of individual focal lesions. Results: 31 of the 176 patients had concurrent spine MR imaging and report of fracture. Five of these 31 patients were excluded because they had no documentation of the age of fracture prior to PET/CT imaging. The 26 remaining patients (598 vertebral levels) included 17 men and 9 women. There were a total of 59 PET/CTs, 104 spine X-ray studies, 25 spine CT exams, and 71 spine MRI exams. There were a total of 134 vertebral body fractures: 27 were determined to be acute/subacute and pathologic due to active myeloma, 1 was determined to be new but owing to simple osteoporosis, and 106 were determined to be old. The mean SUVmax in the acute/subacute pathologic fractures was 2.9 with a range from 1.1 to 4.3 (standard deviation 0.98). The old fractures had a mean SUVmax of 1.6 with a range from 0.6 to 3.1 (standard deviation 0.55). This was a statistically significant difference with p value <.0001. The 464 vertebral bodies without fracture had a mean SUVmax of 1.8. SUVmax ≥2.5 was seen at 49 vertebral levels, including 27 with a fracture and 22 without a fracture. SUVmax ≥3.5 was found at 9 vertebral levels, including 6 with a fracture and 3 without a fracture. The combination of diffuse or multifocal MR patterns and SUV > 3.5 was seen at 7 levels, all but one with new pathologic fractures. Conclusion: PET/CT SUV > 3.2 alone can be used in myeloma patients to discriminate between old and new pathologic fractures, just as it has been reported in other types of cancer patients. The combination of PET/CT SUV > 3.5 and MR findings of diffuse or multifocal vertebral body involvement seems to indicate an impending fracture.

Osteochondrosis dissecans of the glenoid

Osteochondrosis dissecans of the glenoid is a rare condition that has been mentioned only once in the literature, by Lavner in 1947. Trauma is generally accepted as a cause of this disorder. Injury produces an ischemic insult to the subchondral bone and possible loose body formation if fragmentation of the articular surface occurs. Endocrine abnormalities, genetic influences, and the presence of anomalous centers of ossification may also contribute to the development of this condition. We present two patients whose clinical histories indicate a traumatic etiology of Osteochondrosis dissecans of the glenoid. We also discuss the radiological, clinical, and etiological features of this entity.