ACR Appropriateness Criteria® Chronic Hip Pain: 2022 Update.

Chronic hip pain is a frequent chief complaint for adult patients who present for evaluation in a variety of clinical practice settings. Following a targeted history and physical examination, imaging plays a vital role in elucidating the etiologies of a patient's symptoms, as a wide spectrum of pathological entities may cause chronic hip pain. Radiography is usually the appropriate initial imaging test following a clinical examination. Depending on the clinical picture, advanced cross-sectional imaging may be subsequently performed for further evaluation. This documents provides best practice for the imaging workup of chronic hip pain in patients presenting with a variety of clinical scenarios. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Traumatic spondylolisthesis of axis: clinical and imaging experience at a level one trauma center.

PURPOSE: Traumatic spondylolisthesis of the axis (TSA) with bilateral pars interarticularis fracture (a pattern also known as Hangman's fractures) accounts for 4-5% of all cervical fractures. Various classification systems have been described to assist therapeutic decision-making. The goal is to reassess the utility of these classifications for treatment strategy and evaluate additional imaging associations. METHODS: This is an IRB approved, retrospective analysis of patients with imaging diagnosis of TSA from 2016 to 2019. Consensus reads were performed classifying TSA into various Levine and Edwards subtypes and typical vs. atypical fractures. Other imaging findings such as additional cervical fractures, traumatic brain injury, spinal cord injury, and vertebral artery injury were recorded. Treatment strategy and outcome were reviewed from clinical charts. Fisher exact test was used for statistical analysis. RESULTS: A total of 58 patients were included, with a mean age of 62.7 ± 25 years, and male to female ratio of 1:1.2. Motor vehicle collision was the most common cause of TSA. Type I and III injuries were the most and the least common injuries, respectively. Patients with type I injuries were found to have good healing rates with conservative management (p < 0.001) while type IIa and III injuries were managed with surgical stabilization (p = 0.04 and p = 0.01, respectively). No statistical difference was observed in the treatment strategy for type II fractures (p = 0.12) and its prediction of the associated injuries. Atypical fractures were not found to have a higher incidence of SCI (p = 0.31). A further analysis revealed significantly higher-grade vertebral artery injuries (grades III and IV according to Biffl grading) in patients with type IIa and III injuries (p = 0.001) and an 11-fold increased risk of TBI compared to type I and type II fractures (p = 0.013). CONCLUSION: TSA fracture types were not associated with any clinical outcome. Levine and Edwards type II classification itself is not enough to guide the treatment plan and does not account for associated injuries. Additional imaging markers may be needed.

A multicenter retrospective study assessing progression of biliary sludge in dogs using ultrasonography.

BACKGROUND: Biliary sludge (BS) frequently is identified on ultrasonographic examination and is described as incidental. It is hypothesized that biliary stasis and hypersecretion play a role in both BS and gallbladder mucocele (GBM) formation. Recent studies have documented similarities in composition of BS and GBM, and there are several examples of progression from BS to GBM in the veterinary literature. OBJECTIVES: To assess the relationship between the presence of BS and later development of GBM in dogs, over time periods >12 months. ANIMALS: A total of 154 dogs with BS and ultrasonographic follow-up >12 months. METHODS: Medical records were retrospectively collected from 9 UK-based referral centers for all available time points. A semiobjective scoring system was used to track volume of BS within the gall bladder (GB) over time. RESULTS: Twenty dogs developed GBM during the study period. Shetland Sheepdogs (odds ratio [OR], 40.99; 95% confidence interval [CI], 3.61-465.95; P = .003) and Border Terriers (OR, 11.66; 95% CI, 3.28-46.63; P < .001) were independent risk factors for the development of GBM. Non-gravity-dependent BS (NDBS) was noted to form before GBM development in 9/20 dogs, and breeds at-risk for GBM were more likely to have NDBS. Odds for the development of GBM increased with BS score. CONCLUSIONS AND CLINICAL IMPORTANCE: Dogs with NDBS may be at risk for the development of GBM and a stratified BS scoring system could allow for semiobjective monitoring over time, particularly in at-risk breeds.

Incidence of cervical spine fractures on CT: a study in a large level I trauma center.

INTRODUCTION/PURPOSE: Though spinal fractures constitute a minority of all traumas, the financial burden imposed is immense especially following cervical spine trauma. There have been several papers in the past describing the incidence of cervical spine fractures. In this paper, we report the incidence of cervical spine fractures and correlate with demographic information and cause of injury and review the mechanism of fractures. MATERIALS AND METHODS: We performed retrospective analysis of 934 patients who had undergone CT scan for cervical spine trauma at our institute which includes 16 hospitals and one level I trauma center over a period of 2 years. This list was created from a wider database of 13,512 patients imaged for suspected cervical spine injury. All patients who had at least one positive finding on CT were included in this study irrespective of any demographic difference. Each patient was analyzed by reviewing the medical records, and correlation was sought between demographics and cause of injury. RESULTS: In our study, the peak incidence of cervical spine trauma was in the age group of 21-30 years followed by 31-40 years with a male:female ratio of 2.1. The major cause of injury in the study population was motor vehicle accidents (66.1%), followed by fall from height of less than 8 ft (12.2%). With regard to the ethnic distribution, Caucasians (46.9%) constituted the major population followed by Hispanic population (23.3%). C1 and C2 were observed to be more frequently fractured as compared with the subaxial spine. Incidence of C2 fractures (188 levels) was higher as compared with C1 (102 levels). Incidence of body and lateral mass fractures was marginally higher as compared with odontoid fractures. C7 (50 levels) was the most fractured vertebral body in the subaxial spine followed by C6 (35 levels) and C5. CONCLUSION: Spinal trauma is on the rise and it helps to know the factors which can guide us for better management of these patients. We can utilize these results to prognosticate and streamline clinical management of these patients.

Is elevated body mass index protective against cervical spine injury in adults?

PURPOSE: Correlate body mass index (BMI) with incidence and type of cervical spine injury seen on CT in adult patients presenting with blunt trauma. MATERIALS AND METHODS: Retrospective chart review of all adult blunt trauma patients who had a cervical spine CT performed at our level 1 trauma center during an approximately 3-year period. RESULTS: A statistically significant (p = 0.01) difference in cervical spine injury incidence was present between different BMI groups. Cervical spine injury incidence was 7.7% for underweight (BMI ≤ 18) patients, 7.1% for normal weight (BMI 18-25) patients, 6.2% for overweight/obese (BMI 25-35) patients, and 4.7% for morbidly obese (BMI > 35) patients. Using BMI > 18-25 as a reference group, females with BMI > 25-35 had an adjusted odds ratio (aOR) of 0.56 (CI 0.41-0.75) and females with BMI > 35 had an aOR of 0.42 (CI 0.26-0.70). Males with a BMI ≤ 18 had an aOR of 2.20 (CI 1.12-4.32) and males with BMI > 35 had an aOR of 0.66 (CI 0.46-0.95). A particularly low incidence of cervical spine injury was observed in patients older than 65 in the obese group with a cervical spine injury rate of only 1.4% in this patient population. No statistical significant difference was seen in injury morphology across the BMI groups. CONCLUSION: An inverse relationship exists between BMI and the overall incidence of cervical spine injury. This protective effect appears to be influenced by gender with elevated BMI having lower relative odds of cervical spine injury in women than in men. A particularly low rate of cervical spine injury was identified in obese patients over the age of 65. Routine imaging of all elderly, obese trauma patients with low energy mechanism of injury may not be warranted.

Use of computed tomography imaging during long-term follow-up of nine feline tuberculosis cases.

Case series summary Feline tuberculosis is an increasingly recognised potential zoonosis of cats. Treatment is challenging and prognosis can vary greatly between cases. Pulmonary infection requires extended courses of antibiotics, but methodologies for sensitively monitoring response to treatment are currently lacking. In this case series, we retrospectively examined the serial computed tomography (CT) findings in nine cats that had been diagnosed with tuberculosis. Changes in pathology (where applicable to tuberculosis) were correlated with the clinical presentation of each of the cats, the treatment protocol, and previous and contemporary diagnostic investigations. This study found that changes in CT findings during the medium- to long-term management of feline tuberculosis were highly variable between cats. The majority of cats had reduced pathology at re-examination during anti-tuberculous therapy, but pathology only resolved in a minority of cases. In some cases recurrence of pathology detected by CT imaging preceded clinical deterioration, allowing for rapid therapeutic intervention. Relevance and novel information When considered in combination with clinical findings, CT studies can aid in decision making regarding tapering of antibiotic protocols, or reintroduction of therapy in cases of recurrence or reinfection. This series also highlights that, in some cases, persistent abnormalities can be detected by CT, so complete resolution of CT pathology should not always be a goal in the management of feline tuberculosis.

Validation and determination of a reference interval for canine HbA1c using an immunoturbidimetric assay.

BACKGROUND: Hemoglobin A1c (HbA1c) provides a reliable measure of glycemic control over 2-3 months in human diabetes mellitus. In dogs, presence of HbA1c has been demonstrated, but there are no validated commercial assays. OBJECTIVE: The purpose of the study was to validate a commercially available automated immunoturbidimetric assay for canine HbA1c and determine an RI in a hospital population. METHODS: The specificity of the assay was assessed by inducing glycosylation in vitro using isolated canine hemoglobin, repeatability by measuring canine samples 5 times in succession, long term inter-assay imprecision by measuring supplied control materials, stability using samples stored at 4°C over 5 days and -20°C over 8 weeks, linearity by mixing samples of known HbA1c in differing proportions, and the effect of anticoagulants with paired samples. An RI was determined using EDTA-anticoagulated blood samples from 60 nondiabetic hospitalized animals of various ages and breeds. Hemoglobin A1c was also measured in 10 diabetic dogs. RESULTS: The concentration of HbA1c increased proportionally with glucose concentration in vitro. For repeat measurements, the CV was 4.08% (range 1.16-6.10%). Samples were stable for 5 days at 4°C. The assay was linear within the assessed range. Heparin- and EDTA-anticoagulated blood provided comparable results. The RI for HbA1c was 9-18.5 mmol/mol. There was no apparent effect of age or breed on HbA1c. In diabetic dogs, HbA1c ranged from 14 to 48 mmol/mol. CONCLUSIONS: The assay provides a reliable method for canine HbA1c measurement with good analytic performance.

Core curriculum illustration: posterior column acetabular fracture.

This is the 17th installment of a series that will highlight one case per publication issue from the bank of cases available online as part of the American Society of Emergency Radiology (ASER) educational resources. Our goal is to generate more interest in and use of our online materials. To view more cases online, please visit the ASER Core Curriculum and Recommendations for study online at: http://www.aseronline.org/curriculum/toc.htm.

Unusual Presentations of Focal Periphyseal Edema Zones: A Report of Bilateral Symmetric Presentation and Partial Physeal Closure.

Focal periphyseal edema (FOPE) zones are areas of periphyseal edema seen near the time of physeal closure which are believed to be a physiologic phenomenon related to changes in distribution of forces around the physis as it closes. Since the original case series describing these areas of periphyseal edema, there has been little published in regard to FOPE zone outside of review articles. We present a set of three patients identified with focal periphyseal edema zones around the knee and compare our findings with the initial case series. We include a patient presenting with bilateral, nearly symmetric, focal periphyseal edema zones of the proximal tibia physis and a patient with partial closure of the physis at time of presentation, which were not reported in the original case series.

Osseous Scaphotrapezial Coalition.

Osseous scaphotrapezial coalition is one of the rarest forms of carpal coalition of the hand. Often discovered incidentally, pain and functional limitation have not been reported. Carpal coalitions occurring across the carpal rows are thought to occur as a result of some insult or congenital anomaly. Isolated scaphotrapezial coalition calls into question the traditional thinking that fusion between the proximal and distal carpal rows must be acquired or associated with congenital syndromes.

Congenital indifference to pain: an illustrated case report and literature review.

Congenital indifference to pain is a rare and debilitating congenital disease. Individuals with the disorder may have one or a combination of sensory or autonomic deficits, which can range from lack of mechanical nociception, diminished ability to detect heat and cool stimulation, to the devastating and fatal form which includes autonomic dysfunction. It is important for radiologists to be able to recognize the radiographic presentations of this rare disorder, as delay in diagnosis can lead to extensive and sometimes unnecessary workup. We present a case of congenital indifference to pain initially interpreted as a mass of the distal femur.

Traumatic portacaval shunt: a case report and literature review.

Computed tomography (CT) evaluation of the acute polytrauma patient has become well established as a mainstay of ER triage in hemodynamically stable patients. The radiologist plays a pivotal role in directing management by identifying and appropriately categorizing the severity of a patient's injuries. High-grade liver injuries have undergone an increasing trend of nonoperative management over the last several decades, with concurrent decrease in mortality. However, we present a case of a patient with a grade V liver laceration, in whom a rare portacaval shunt was also present. In the setting of this rare injury, the radiologist will likely be the first person to recognize and categorize a severe complication, which may indicate the need for a fundamental change in patient management.

Emergent right upper quadrant sonography.

OBJECTIVE: The purpose of this presentation is to review the sonographic spectrum of disease entities evaluated by right upper quadrant (RUQ) sonography on an emergent basis. METHODS: Right upper quadrant sonography was performed on an emergent basis in patients who came to the emergency department with signs and symptoms suspicious for or simulating acute cholecystitis or diseases of the liver and biliary tree. RESULTS: A wide gamut of acute and chronic cholecystitis and diseases of the liver and biliary tree were visualized on RUQ sonography. Several other entities in addition to hepatic and biliary disease were also suspected on sonography and further evaluated by computed tomography. CONCLUSIONS: Right upper quadrant sonography is the first line of imaging in patients with signs and symptoms of hepatic, gallbladder, or biliary disease as well as RUQ pain. Patient triage or additional imaging may be obtained on the basis of emergent RUQ sonographic findings.