Imaging of Peripheral Nerves: AJR Expert Panel Narrative Review.

Peripheral nerve imaging provides information that can be critical to the diagnosis, staging, and management of peripheral neuropathies. MRI and ultrasound are the imaging modalities of choice for clinical evaluation of the peripheral nerves given their high soft tissue contrast and high resolution, respectively. This AJR Expert Panel Narrative Review describes MRI- and ultrasound-based techniques for peripheral nerve imaging; highlights considerations for imaging in the settings of trauma, entrapment syndromes, diffuse inflammatory neuropathies, and tumor; and discusses image-guided nerve interventions, focusing on nerve blocks and ablation.

Arthrocentesis of suspected septic sternoclavicular arthritis: microbial yield and predictors of culture positivity.

OBJECTIVE: Evaluate the microbial yield and factors predicting culture positivity for image-guided arthrocentesis of suspected septic sternoclavicular (SC) arthritis. MATERIALS AND METHODS: An electronic health record search identified image-guided SC joint aspirations for suspected septic arthritis. Data was extracted by retrospective chart review including patient demographics, procedure characteristics, pre-procedure lab testing, joint culture results, final SC joint diagnoses and any effect of positive synovial cultures on subsequent antibiotic therapy. Factors associated with positive joint fluid cultures were assessed using a Chi-squared test for categorical predictors and logistic regression for continuous predictors. RESULTS: A total of 31 SC arthrocenteses met inclusion criteria with most (81%) performed using ultrasound guidance. Synovial fluid was successfully aspirated in 19/31 (61%) of cases, and in all other cases lavage fluid was successfully obtained. Synovial cultures were positive in 9/31 (29%) of cases. A final diagnosis of septic arthritis was assigned to 20/31 cases (65%) in which 9/20 (45%) had positive synovial cultures. There was no statistically significant association between synovial culture positivity and risk factors for septic arthritis, positive blood cultures, pre-aspiration antibiotics and whether synovial fluid or lavage fluid was cultured. Serum white blood cell count (WBC) and erythrocyte sedimentation rate (ESR) demonstrated statistically significant positive correlation with positive synovial cultures. CONCLUSION: Arthrocentesis is effective for microbial speciation in SC septic arthritis, and diagnostic yield may be increased with lavage when encountering a dry tap. Normal serum WBC and ESR values indicate an extremely low likelihood of positive synovial cultures.

Comparison of MRI and arthroscopy findings for transitional zone cartilage damage in the acetabulum of the hip joint.

OBJECTIVE: To assess the performance of morphologic and hypointense signal changes on MRI to predict grades and types of acetabular cartilage damage in the chondrolabral transitional zone (TZ) of the hip identified at arthroscopy. MATERIALS AND METHODS: This retrospective single-center study reviewed conventional 3T MRI hip studies from individuals with symptomatic femoroacetabular impingement (FAI) and subsequent hip arthroscopy surgery within 6 months. Independent review was made by three radiologists for the presence of morphologic damage or a hypointense signal lesion in the TZ on MRI. Fleiss' kappa statistic was used to assess inter-reader agreement. The degree of TZ surfacing damage (modified Outerbridge grades 1-4) and presence of non-surfacing wave sign at arthroscopic surgery were collected. Relationship between sensitivity and lesion grade was examined. RESULTS: One hundred thirty-six MRI hip studies from 40 males and 74 females were included (mean age 28.5 years, age range 13-54 years). MRI morphologic lesions had a sensitivity of 64.9-71.6% and specificity of 48.4-67.7% for arthroscopic surfacing lesions, with greater sensitivity seen for higher grade lesions. Low sensitivity was seen for wave sign lesions (34.5-51.7%). MRI hypointense signal lesions had a sensitivity of 26.3-62% and specificity of 43.8-78.0% for any lesion. Inter-reader agreement was moderate for morphologic lesions (k = 0.601) and poor for hypointense signal lesions (k = 0.097). CONCLUSION: Morphologic cartilage damage in the TZ on MRI had moderate sensitivity for any cartilage lesion, better sensitivity for higher grade lesions, and poor sensitivity for wave sign lesions. The diagnostic value of hypointense signal lesions was uncertain.

A Practical Approach to Echocardiographic Imaging in Patients With Hypertrophic Cardiomyopathy.

Hypertrophic cardiomyopathy (HCM) is frequently unrecognized or misdiagnosed. The recently published consensus recommendations from the American Society of Echocardiography provided recommendations for the utilization of multimodality imaging in the care of patients with HCM. This document provides an additional practical framework for optimal image and measurement acquisition and guidance on how to tailor the echocardiography examination for individuals with HCM. It also provides resources for physicians and sonographers to use to develop HCM imaging protocols.

Ultrasound-guided nerve block prior to biopsy of suspected neurogenic tumors: safety and feasibility in a pilot study.

OBJECTIVE: The aim of this study is to investigate the safety and feasibility of ultrasound-guided nerve block prior to biopsy of potentially neurogenic tumors. MATERIALS AND METHODS: A retrospective review of the medical record from June 2017 to June 2022 identified ultrasound-guided biopsies of potentially neurogenic tumors that were performed with a pre-procedural nerve block. Patient demographics, biopsy site, number of passes, needle gauge, use of sedation, pathology results, and procedural complications were recorded and summarized. RESULTS: The structured search found 16 patients that underwent biopsies of 18 potentially neurogenic tumors with the use of a pre-procedural nerve block at a variety of upper and lower extremity locations. Average patient age was 52 (range 18-78) and 9 patients (56%) were female. Of the 16 patients, 10 were performed without intravenous sedation. Three patients were unable to tolerate biopsy until a nerve block was used. All biopsies yielded a diagnostic sample with 13 of the tumors neurogenic in origin. One patient reported mild postprocedural pain which resolved with conservative treatment; no other complications were reported. CONCLUSION: Nerve block prior to ultrasound-guided biopsy of potentially neurogenic tumors is a safe and feasible technique. Further study is needed to determine the extent to which nerve block can decrease intra-procedural pain and reduce or eliminate the need for sedation during biopsy.

Ultrasound-guided temporomandibular joint aspiration: technique and results in six cases of suspected septic arthritis.

OBJECTIVE: The aim of this study is to describe an ultrasound (US)-guided temporomandibular joint (TMJ) arthrocentesis technique and determine its microbial yield in the workup of suspected TMJ septic arthritis. MATERIALS AND METHODS: A retrospective review of US-guided TMJ arthrocentesis for the work-up of septic arthritis performed by radiologists at two institutions was performed. Patient demographics, risk factors for septic arthritis, blood culture results, and pre-procedural imaging findings were recorded. Procedural data included fluid aspirate quantity, needle gauge and length, and any immediate complications. Post-procedural data included synovial fluid analysis including culture, final diagnosis of TMJ disease, type of treatment, and any delayed complications from arthrocentesis. RESULTS: A total of six US-guided TMJ arthrocenteses were identified, all of which yielded at least 1 mL of synovial fluid. Five patients were subsequently diagnosed with septic arthritis, and one patient was diagnosed with GVHD arthritis. The synovial fluid in four out of five patients with a final diagnosis of septic arthritis produced positive cultures. There were no immediate or delayed complications from arthrocentesis. CONCLUSION: Basic US-guided procedural skills are transferrable to TMJ arthrocentesis, which is a low-risk procedure with a high microbial yield in our small series of patients with septic arthritis.

Rationale for fluoroscopic guidance in spine injections.

Spine injections are commonly performed in the treatment of back pain. The purpose of this article is to review the current literature surrounding image guided spine injections focusing on scenarios where fluoroscopic guidance can be advantageous in addition to discussing similarities among the different modalities.

US for Traumatic Nerve Injury, Entrapment Neuropathy, and Imaging-guided Perineural Injection.

US is commonly performed to help diagnose traumatic peripheral nerve injury and entrapment neuropathy, particularly with superficial nerves, where higher spatial resolution provides an advantage over MRI. Other advantages of US include dynamic evaluation, easy contralateral comparison, fewer implant contraindications, less artifact from ferromagnetic debris, and facile needle guidance for perineural injections. The authors review peripheral nerve US for traumatic peripheral nerve injury with an emphasis on injury grading and entrapment neuropathy and describe best-practice techniques for US-guided perineural injections while highlighting specific techniques and indications. Online supplemental material is available for this article. ©RSNA, 2022.

Myocarditis in the Athlete: A Focus on COVID-19 Sequelae.

Myocarditis is a leading cause of sudden death in athletes. Early data demonstrating increased prevalence of cardiac injury in hospitalized patients with COVID-19 raised concerns for athletes recovered from COVID-19 and the possibility of underlying myocarditis. However, subsequent large registries have provided reassuring data affirming low prevalence of myocarditis in athletes convalesced from COVID-19. Although the clinical significance of subclinical myocarditis detected by cardiac MRI remains uncertain, clinical outcomes have not demonstrated an increase in acute cardiac events in athletes throughout the pandemic. Future directions include defining mechanisms underlying "long-haul" COVID-19 and the potential impact of new viral variants.

Case 298: Skeletal Fluorosis Secondary to Huffing.

History A 37-year-old man from the United States presented with a 1-year history of neck pain and stiffness that had been unsuccessfully treated with manipulative therapy by a chiropractor at another institution. Past medical history was remarkable only for marijuana and air duster abuse. He denied use of any prescription medications. Physical examination was notable for markedly reduced range of motion of the cervical spine. Laboratory work-up revealed an elevated alkaline phosphatase level (302 U/L [5.0 µkat/L]; normal range, 40-100 U/L [0.7-1.67 µkat/L]), but all other laboratory findings, including complete blood count, renal function, liver function, vitamin A level, serum protein electrophoresis, and hepatitis C antibodies were within normal limits. Cervical spine radiography was performed, followed by MRI. Subsequently, a full skeletal survey was ordered. Included are representative radiographs of the pelvis, left forearm, and distal right leg with ankle.

Successful Nonsurgical Management of a Posteriorly Displaced Medial Clavicular Physeal Fracture in an Adolescent Athlete: A Case Report.

ABSTRACT: Traumatic and sport-related sternoclavicular (SCJ) injuries in adolescent athletes are more commonly physeal fractures rather than true SCJ dislocations. Although rare, posterior displacement of the medial clavicular metaphysis after a physeal fracture necessitates prompt evaluation and treatment. Despite the inherent healing ability of physeal separations, delayed or failed diagnosis has the capacity to cause serious complications or fatality secondary to injury of retrosternal structures. Even with the potential severity, a lack of consensus exists in the literature regarding the most appropriate treatment modality. We report an adolescent football player with a medial clavicular physeal fracture with posterior metaphyseal displacement abutting the left brachiocephalic vein. After nonsurgical management and progression to play, the patient returned to play football. This case not only highlights the diagnostic principles of medial clavicular physeal fractures with posterior metaphyseal displacement but also discusses how these challenging injuries can be managed successfully with conservative treatment.

Cardiac Transplantation in Danon Disease.

BACKGROUND: Danon disease (DD) is a rare X-linked dominant cardioskeletal myopathy caused by mutations in the lysosome-associated membrane protein-2 (LAMP-2) gene that is usually lethal without cardiac transplantation. The purpose of this study was to characterize post-transplant outcomes in a large cohort of patients with DD who underwent cardiac transplantation. METHODS: The clinical phenotype and outcome data of patients with DD who underwent cardiac transplantation (n = 38; 19 males and 19 females) were obtained from 8 centers. Study outcomes included graft survival, defined as death or retransplantation, and episodes of acute cellular and antibody-mediated rejection and cardiac allograft vasculopathy at 1 year. RESULTS: Median follow-up time after transplantation for the entire cohort was 4.4 years (IQR: 1.5-12.8 years). The median age at transplant for the cohort was 20.2 years (15.8-27.9 years), with no difference in age between sexes. Median pretransplant left-ventricular ejection fraction for the entire cohort was 30% (range 11%-84%). Males had higher pretransplant aspartate aminotransferase, alanine aminotransferase and creatine phosphokinase levels than females (P < 0.001). There were 2 deaths in the entire cohort and 2 retransplants. There was no difference in actuarial graft survival between males and females (P = 0.8965); the estimated graft survival was 87.1% (95%CI: 63.6%-95.9%) at 5 years. One episode (2.7%) of antibody-mediated rejection, grade 2, and 7 episodes (19%) of acute cellular rejection, grade 2 or 3, were reported in patients who survived to discharge (6 females and 1 male; P = 0.172). CONCLUSIONS: Heart transplantation outcomes are acceptable in DD with high probabilities of 5-year graft survival for males and females suggesting that cardiac transplantation is an effective treatment option for DD patients.

Vertebroplasty, Kyphoplasty, and Implant-Based Mechanical Vertebral Augmentation.

Vertebral compression fractures are a global public health issue with a quantifiable negative impact on patient morbidity and mortality. The contemporary approach to the treatment of osteoporotic fragility fractures has moved beyond first-line nonsurgical management. An improved understanding of biomechanical forces, consequential morbidity and mortality, and the drive to reduce opioid use has resulted in multidisciplinary treatment algorithms and significant advances in augmentation techniques. This review will inform musculoskeletal radiologists, interventionalists, and minimally invasive spine surgeons on the proper work-up of patients, imaging features differentiating benign and malignant pathologic fractures, high-risk fracture morphologies, and new mechanical augmentation device options, and it describes the appropriate selection of devices, complications, outcomes, and future trends.

Case 298.

History A 37-year-old man from the United States presented with a 1-year history of neck pain and stiffness that had been unsuccessfully treated with manipulative therapy by a chiropractor at another institution. Past medical history was remarkable only for marijuana and air duster abuse. He denied use of any prescription medications. Physical examination was notable for markedly reduced range of motion of the cervical spine. Laboratory work-up revealed an elevated alkaline phosphatase level (302 U/L [5.0 µkat/L]; normal range, 40-100 U/L [0.7-1.67 µkat/L]), but all other laboratory findings, including complete blood count, renal function, liver function, vitamin A level, serum protein electrophoresis, and hepatitis C antibodies were within normal limits. Cervical spine radiography was performed (Fig 1), followed by MRI (Fig 2). Subsequently, a full skeletal survey was ordered. Included are representative radiographs of the pelvis (Fig 3), left forearm (Fig 4), and distal right leg with ankle (Fig 5).

Ultrasound-guided diagnostic deep peroneal nerve blocks prior to potential neurectomy: a retrospective review.

OBJECTIVE: To describe our technical and preliminary clinical experience with ultrasound-guided diagnostic deep peroneal nerve (DPN) blocks for patients considering deep peroneal neurectomy. MATERIALS AND METHODS: Retrospective analysis of ultrasound-guided diagnostic DPN blocks performed in the anterior lower leg in patients pursuing deep peroneal neurectomy for foot pain not directly attributable to the DPN. Patient age, sex, foot laterality, diagnosis, nerve block complications, location of the DPN with respect to vascular landmarks in the lower leg, pain relief from nerve block, and pain relief from neurectomy (if performed) were recorded. RESULTS: Twenty-six DPN blocks were performed for 25 feet, of which a majority had pain attributable to midfoot osteoarthritis (22/25). Variable DPN locations with respect to vascular landmarks in the lower leg were observed, including lateral to the anterior tibial artery (12/25), anterior to the artery (5/25), medial to the artery (3/25), lateral to the lateral paired vein (4/25), and 1-cm lateral to the artery (1/25). After DPN blocks, patients reported pain relief in 22/25 feet. Of the eleven patients who proceeded to have a deep peroneal neurectomy, ten reported improved foot pain. CONCLUSION: Diagnostic deep peroneal nerve blocks for patients considering deep peroneal neurectomy for denervation therapy should be performed in the anterior lower leg where the anterior tibial vessels serve as anatomic landmarks. Those who perform DPN blocks with ultrasound guidance should be aware of variable DPN position with respect to the vascular landmarks.

Mitigating clinical waste in the trauma intensive care unit: Limited clinical utility of cardiac troponin testing for trauma patients with atrial fibrillation.

BACKGROUND: The clinical significance of obtaining cardiac troponin (cTn) levels among trauma patients with new onset arrhythmias is unknown. We aimed to assess whether cTn levels actually influence clinical decision making or represent an inappropriate use of resources. METHODS: Trauma patients admitted from 2013 to 2014 diagnosed with atrial fibrillation (AF) were retrospectively reviewed using the institutional trauma database. Demographics, cTn levels, and myocardial infarction (MI) diagnosis data were recorded. Standard univariate tests were used to compare data between patients with and without cTn. RESULTS: There were 258 patients included of which 126 patients had cTn levels obtained (48.8%, TEST group). The remaining 132 patients (51.2%) were untested (noTEST group). Among TEST patients, use of echocardiography nearly doubled and cardiology consultations increased (all p < 0.05). No TEST patients suffered MI or PE. CONCLUSIONS: Obtaining cTn values in trauma patients with new-onset AF resulted in increased resource utilization without clinical utility.

Diagnosis of Superior Labrum Anterior-to-Posterior Tears by Using MR Imaging and MR Arthrography: A Systematic Review and Meta-Analysis.

Purpose To evaluate the diagnostic accuracies of nonenhanced magnetic resonance (MR) imaging and MR arthrography for diagnosis of superior labrum anterior-to-posterior (SLAP) tears by using a systematic review and meta-analysis. Materials and Methods A comprehensive literature search was performed on the two main concepts of MR imaging (MR imaging, and direct and indirect MR arthrography) and SLAP tears. Inclusion criteria consisted of original studies that assessed the diagnostic accuracy of MR imaging, direct MR arthrography, and/or indirect MR arthrography for the detection of SLAP tears, by using surgical findings as the reference standard. The Quality Assessment of Diagnostic Accuracy Studies 2, or QUADAS-2 Quality Assessment of Diagnostic Accuracy Studies 2 Quality Assessment of Diagnostic Accuracy Studies 2 , tool was used to assess methodologic quality. Meta-analyses were performed that compared MR imaging studies to direct MR arthrography studies and indirect MR arthrography studies, 3-T studies to 1.5-T studies, and low-bias MR imaging studies to low-bias direct MR arthrography studies. Study variation was analyzed by using the Cochran Q test of heterogeneity and the I2 statistic. Results Thirty-two studies met inclusion and exclusion criteria, including 3524 imaging examinations: 1963 direct MR arthrography examinations (23 studies), 1402 MR examinations (14 studies), and 159 indirect MR arthrography examinations (three studies). Twelve studies had low risk for bias, two had questionable risk, and 18 had high risk. Mean sensitivities of direct MR arthrography, MR imaging, and indirect MR arthrography for SLAP tear diagnosis were 80.4%, 63.0%, and 74.2%, respectively. Mean specificities of direct MR arthrography, MR imaging, and indirect MR arthrography were 90.7%, 87.2%, and 66.5%, respectively. Summary receiver operator characteristic (ROC) curve demonstrated superior accuracy of direct MR arthrography compared with those of MR imaging and indirect MR arthrography. Similar findings were observed in the low-bias subanalysis. Summary ROC curve demonstrated overall superiority of 3-T imaging, with or without intra-articular contrast material compared with 1.5-T imaging, with or without intra-articular contrast material. Significant variance was observed for MR imaging and direct MR arthrography (P < .001) studies for both mean sensitivity and specificity. Conclusion Direct MR arthrography appears to be more accurate than nonenhanced MR imaging for diagnosis of SLAP tears, whereas 3-T MR imaging with or without intra-articular contrast material appears to improve diagnostic accuracy compared with 1.5-T MR imaging with or without intra-articular contrast material. © RSNA, 2017 Online supplemental material is available for this article.

Percutaneous Image-Guided Cryoablation of Musculoskeletal Metastases: Pain Palliation and Local Tumor Control.

PURPOSE: To evaluate the safety and effectiveness of cryoablation of musculoskeletal metastases in terms of achieving pain palliation and local tumor control. MATERIALS AND METHODS: A retrospective review was performed of 92 musculoskeletal metastases in 56 patients treated with percutaneous image-guided cryoablation. Mean age of the cohort was 53.9 y ± 15.1, and cohort included 48% (27/56) men. Median tumor volume was 13.0 cm3 (range, 0.5-577.2 cm3). Indications for treatment included pain palliation (41%; 38/92), local tumor control (15%; 14/92), or both (43%; 40/92). Concurrent cementoplasty was performed after 28% (26/92) of treatments. RESULTS: In 78 tumors treated for pain palliation, median pain score before treatment was 8.0. Decreased median pain scores were reported 1 day (6.0; P < .001, n = 62), 1 week (5.0; P < .001, n = 70), 1 month (5.0; P < .001, n = 63), and 3 months (4.5; P = .01, n = 28) after treatment. The median pain score at 6-month follow-up was 7.5 (P = .33, n = 11). Radiographic local tumor control rates were 90% (37/41) at 3 months, 86% (32/37) at 6 months, and 79% (26/33) at 12 months after treatment. The procedural complication rate was 4.3% (4/92). The 3 major complications included 2 cases of hemothorax and 1 transient foot drop. CONCLUSIONS: Cryoablation is an effective treatment for palliating painful musculoskeletal metastases and achieving local tumor control.