Safety outcomes and improvement in pain scores after radiologist-performed fluoroscopy-guided interlaminar cervical epidural steroid injection.

INTRODUCTION: Image-guided spine injections are an important tool in the management of patients with a variety of spinal pathologies. Our practice offers radiologist-performed fluoroscopy-guided interlaminar cervical epidural steroid injection (ESI) routinely performed in the outpatient setting. The purpose of this study was to evaluate clinical outcomes and improvement in pain scores after radiologist-performed cervical ESI. METHODS: An institutional database was used to retrospectively identify cervical injections performed between October 2016 and October 2022. All injections were performed at the C7-T1 level utilizing 1.0 mL of 10 mg/mL dexamethasone without epidural anesthetic. The Numerical Rating Scale (NRS) was used to assess pain improvement. Cervical MRI was reviewed to assess pre-injection cervical disease severity. Patient charts were reviewed for any post-injection complications. RESULTS: A total of 251 cervical injections in 186 patients met our inclusion criteria with mean clinical follow up of 28.5 months (range 0.2 - 73.0 months). No patients experienced any major complications after injection. Post-injection pain scores were available for 218 of 251 injections (86.9%) with mean follow-up of 11.8 days (range 6 - 57 days). There was a significant improvement in pain scores from a mean pre-injection NRS score of 5.2/10 to 3.0/10 (p < .0001). 117 patients (53.7%) reported ≥ 50% improvement after injection. Patients who had prior injection were more likely to report ≥ 50% pain improvement after subsequent injection (p = .012). CONCLUSION: Radiologist-performed fluoroscopy-guided interlaminar cervical ESI at the C7-T1 level is a safe and effective tool in the management of patients with cervical pathology.

Imaging of osteoarthritis from the ankle through the midfoot.

Ankle, hindfoot, and midfoot osteoarthritis (OA) is most commonly posttraumatic and tends to become symptomatic in younger patients. It often results from instability due to insufficiency of supportive soft tissue structures, such as ligaments and tendons. Diagnostic imaging can be helpful to detect and characterize the distribution of OA, and to assess the integrity of these supportive structures, which helps determine prognosis and guide treatment. However, the imaging findings associated with OA and instability may be subtle and unrecognized until the process is advanced, which may ultimately limit therapeutic options to salvage procedures. It is important to understand the abilities and limitations of various imaging modalities used to assess ankle, hindfoot, and midfoot OA, and to be familiar with the imaging findings of OA and instability patterns.

Musculoskeletal Manifestations of COVID-19: Currently Described Clinical Symptoms and Multimodality Imaging Findings.

COVID-19, the clinical syndrome produced by infection with SARS-CoV-2, can result in multisystem organ dysfunction, including respiratory failure and hypercoagulability, which can lead to critical illness and death. Musculoskeletal (MSK) manifestations of COVID-19 are common but have been relatively underreported, possibly because of the severity of manifestations in other organ systems. Additionally, patients who have undergone sedation and who are critically ill are often unable to alert clinicians of their MSK symptoms. Furthermore, some therapeutic measures such as medications and vaccinations can worsen existing MSK symptoms or cause additional symptoms. Symptoms may persist or occur months after the initial infection, known as post-COVID condition or long COVID. As the global experience with COVID-19 and the vaccination effort increases, certain patterns of MSK disease involving the bones, muscles, peripheral nerves, blood vessels, and joints have emerged, many of which are likely related to a hyperinflammatory host response, prothrombotic state, or therapeutic efforts rather than direct viral toxicity. Imaging findings for various COVID-19-related MSK pathologic conditions across a variety of modalities are being recognized, which can be helpful for diagnosis, treatment guidance, and follow-up. The online slide presentation from the RSNA Annual Meeting is available for this article. ©RSNA, 2022.

Posttreatment Imaging of the Wrist and Hand: Update 2022.

Common indications for surgical procedures of the wrist and hand include acute fractures or fracture-dislocations; nonunited fractures; posttraumatic, degenerative, and inflammatory arthritides and tendinopathies; injuries to tendons, ligaments, and the triangular fibrocartilage complex; and entrapment neuropathies. Soft tissue or osseous infections or masses may also need surgical treatment. Several of these procedures require surgical hardware placement, and most entail clinical follow-up with periodic imaging. Radiography should be the first imaging modality in the evaluation of the postoperative wrist and hand. Computed tomography, magnetic resonance imaging, diagnostic ultrasonography, and occasionally nuclear medicine studies may be performed to diagnose or better characterize suspected postoperative complications. To provide adequate evaluation of postoperative imaging of the wrist and hand, the interpreting radiologist must be familiar with the basic principles of these surgical procedures and both the imaging appearance of normal postoperative findings as well as the potential complications.

Magnetic resonance imaging of musculoskeletal infections.

Magnetic resonance imaging (MRI) is a powerful imaging modality in the evaluation of musculoskeletal (MSK) soft tissue, joint, and bone infections. It allows prompt diagnosis and assessment of the extent of disease, which permits timely treatment to optimize long-term clinical outcomes. MRI is highly sensitive and specific in detecting the common findings of MSK infections, such as superficial and deep soft tissue oedema, joint, bursal and tendon sheath effusions, lymphadenopathy, bone marrow oedema, erosive bone changes and periostitis, and bone and cartilage destruction and sequestration. Contrast-enhanced MRI allows detection of non-enhancing fluid collections and necrotic tissues, rim-enhancing abscesses, heterogeneously or diffusely enhancing phlegmons, and enhancing active synovitis. Diffusion-weighted imaging (DWI) is useful in detecting soft-tissue abscesses, particularly in patients who cannot receive gadolinium-based intravenous contrast. MRI is less sensitive than computed tomography (CT) in detecting soft-tissue gas. This article describes the pathophysiology of pyogenic MSK infections, including the route of contamination and common causative organisms, typical MR imaging findings of various soft tissue infections including cellulitis, superficial and deep fasciitis and necrotizing fasciitis, pyomyositis, infectious bursitis, infectious tenosynovitis, and infectious lymphadenitis, and of joint and bone infections including septic arthritis and osteomyelitis (acute, subacute, and chronic). The authors also discuss MRI findings and pitfalls related to infected hardware and diabetic foot infections, and briefly review standards of treatment of various pyogenic MSK infections.

Magnetic resonance neurography findings in three critically ill COVID-19 patients with new onset of extremity peripheral neuropathy.

PURPOSE: Coronavirus-19 (COVID-19) is most commonly associated with respiratory syndromes, although patients are presenting more frequently with neurological symptoms. When they occur, neurological conditions most commonly involve the central nervous system, and peripheral nervous system effects, particularly in the extremities, have been less commonly described. The mechanisms of peripheral neuropathy in critically ill patients with COVID-19 are likely to be multifactorial, and extremity peripheral nerve imaging in these cases has not been well described. CASE PRESENTATION: In this case series, we describe the magnetic resonance neurography (MRN) findings in 3 critically ill patients who presented with new onset of peripheral neuropathies in the extremities, and we discuss possible common mechanisms of nerve injury, including the role of position-related nerve injury. CONCLUSIONS: MRN can be useful in identifying and localizing peripheral nerve abnormalities in the extremities of COVID-19 patients, and patients who are placed in the prone position during ventilation may be more susceptible to these injuries.

With or without? A retrospective analysis of intravenous contrast utility in magnetic resonance neurography.

OBJECTIVE: To determine the utility of intravenous contrast in magnetic resonance neurography (MRN). MATERIALS AND METHODS: A search of our PACS for MRN studies performed in 2015 yielded 74 MRN exams, 57 of which included pre- and post-contrast images. All studies were independently reviewed by 3 musculoskeletal radiologists with peripheral nerve imaging experience for presence/absence of nerve pathology, presence/absence of muscle denervation, and contrast utility score based on a 4-point Likert scale. The medical record was reviewed for demographic and clinical data. RESULTS: The mean contrast utility score across all readers and all cases was 1.65, where a score of 1 indicated no additional information and a score of 2 indicated mild additional information/supports interpretation. The mean contrast utility score was slightly higher in cases with a clinical indication of amputation/stump neuroma or mass (2.3 and 2.1 respectively) and lower in cases with a clinical indication of trauma (1.5). The mean contrast utility score was lowest in patients undergoing MRN for pain, numbness, and/or weakness (1.2). CONCLUSION: Intravenous contrast provides mild to no additional information for the majority of MRN exams. Given the invasive nature of contrast and recent concerns regarding previously unrecognized risks of repetitive contrast exposure, assessment of the necessity of intravenous contrast in MRN is important. Consensus evidence-based practice guidelines regarding intravenous contrast use in MRN are necessary.

Partial rupture of the distal biceps brachii tendon: a magnetic resonance imaging analysis.

BACKGROUND: This study is the largest cohort of partial distal biceps brachii tendon ruptures in the literature that was analyzed according to rupture morphology of the long and short tendon heads. METHODS: Patients with partial distal biceps tendon ruptures were identified using an institutional enterprise data warehouse query at a single institution. A retrospective chart review was performed to record patient demographics, past medical history, and injury mechanism for each patient. Each patient's magnetic resonance images were reviewed to determine injury patterns, specifically the extent of long head (LH) and short head (SH) tendon involvement, and associated injuries. Rupture morphologies were correlated with mechanism of injury, diabetes status, and smoking history. RESULTS: Seventy-seven patients were included in the study. The average age was 52 years (±11.9, range: 23-90 years); 67% were male, with an average body mass index of 28.3 (±4.3). A smoking history was reported in 31.2% of patients and 5.2% were diabetic. The partial ruptures were caused by a traumatic mechanism in 57.1% of cases, 23.4% were atraumatic, and 19.5% had an unknown mechanism. The most common injury morphology was a partial LH rupture with an intact SH tendon (33.8%). Isolated complete ruptures of the LH represented the least common injury morphology. Injury morphology was significantly related to mechanism (P < .01). Traumatic ruptures had a higher percentage of SH involvement compared with the atraumatic group (77.3% vs. 37.7%, respectively). In contrast, atraumatic ruptures involved the LH tendon in 89% of cases, with only 37.7% of cases involving the SH tendon. Patients with a history of smoking were more likely to have an atraumatic mechanism (P = .01). A history of diabetes was unrelated to mechanism (P = .20). CONCLUSION: Partial ruptures of the distal biceps brachii tendon represent a spectrum of patterns with varying involvement of the LH and SH tendons. Injury morphology was significantly related to mechanism (P < .01). LH tendon involvement was seen in 88.9% of atraumatic cases, whereas SH tendon involvement was seen in 77.3% of traumatic cases. A more comprehensive understanding of partial rupture patterns is critical to further understand the risk factors that may preclude to worse clinical outcomes, and aid in deciding which patients would benefit from operative vs. nonoperative management.

Imaging of Hip Arthroplasties: Normal Findings and Hardware Complications.

Hip arthroplasty is a common and largely successful surgical procedure, often used for the treatment of advanced osteoarthritis. Imaging plays a key role in routine postoperative imaging surveillance as well as the evaluation of post-arthroplasty pain. Radiographs are the first-line imaging modality and may be followed by computed tomography (CT), ultrasound, and/or magnetic resonance imaging (MRI). Recent advancements in imaging techniques allow for metal artifact reduction on CT and MRI. A variety of complications can arise in the setting of arthroplasty: mechanical loosening, component wear-induced synovitis and osteolysis, adverse local tissue reaction, infection, periprosthetic fracture, implant dislocation and/or component displacement, tendinopathy, and neurovascular injury. This article reviews normal and abnormal imaging findings of hip arthroplasty.

Imaging of Total Ankle Arthroplasty: Normal Imaging Findings and Hardware Complications.

End-stage ankle osteoarthritis often significantly impacts patients' quality of life. This can be managed surgically either by ankle arthrodesis or total ankle arthroplasty (TAA). Although ankle arthrodesis is considered by some as the standard-of-care surgical option for this condition, it restricts range of motion and may lead to accelerated osteoarthritis of neighboring joints. Better understanding of ankle biomechanics, the biological effects of orthopaedic devices, and new surgical techniques have led to significant improvements in the designs of TAAs, and over the last several decades TAA has been used increasingly to treat patients with end-stage tibiotalar osteoarthritis. However, complication and ultimate failure rates remain greater than those seen with total knee and hip arthroplasty, and imaging is often critical in determining whether a prosthesis is beginning to fail. As a result, imagers should be familiar with the basic types of TAAs in clinical use, the normal radiographic appearances, as well as the common complications seen with this procedure.

Update on Imaging of Knee Arthroplasties: Normal Findings and Hardware Complications.

Total knee arthroplasty (TKA) is the most common joint replacement performed. This article reviews the normal appearance of TKA including the most common types of arthroplasties as well as complications. Common complications at the present time are infection, aseptic loosening, and instability. Rarer complications such as polyethylene wear, periprosthetic fracture, and soft tissue pathology are also discussed. Although the mainstay of imaging is radiographs, newer techniques in TKA imaging such as computed tomography and magnetic resonance imaging are also reviewed.

High-resolution ultrasound of the fascia lata iliac crest attachment: anatomy, pathology, and image-guided treatment.

Pathology of the fascia lata attachment at the iliac crest (FLAIC) is an under-recognized and often misdiagnosed cause of lateral hip pain. The fascia lata has a broad attachment at the lateral iliac crest with contributions from the tensor fascia lata muscle, the iliotibial band, and the gluteal aponeurosis. The FLAIC is susceptible to overuse injuries, acute traumatic injuries, and degeneration. There is a paucity of literature regarding imaging and image-guided treatment of the FLAIC. We review anatomy and pathology of the FLAIC, presenting novel high-resolution (18-24 MHz) ultrasound images including ultrasound guidance for targeted therapeutic treatment.

Initial experience with dual-energy computed tomography-guided bone biopsies of bone lesions that are occult on monoenergetic CT.

OBJECTIVE: Our purpose was to determine whether dual-energy CT (DECT), specifically the bone marrow setting of the virtual noncalcium (VNCa) algorithm, could be used to identify and accurately biopsy suspected bone malignancies that were visible on magnetic resonance imaging (MRI), nuclear bone scintigraphy, or positron-emission tomography/computed tomography (PET/CT), but occult on monoenergetic computed tomography (CT) by virtue of being either isodense or nearly isodense to surrounding normal bone. MATERIALS AND METHODS: We present 4 cases in which DECT was used to detect various malignant bone lesions and was successfully used to direct percutaneous DECT-guided bone biopsies. RESULTS: Two of the lesions were solid tumor metastases (breast and prostate carcinoma), whereas two others were hematological malignancies (leukemia and lymphoma). This technique enabled us to confidently and accurately direct the biopsy needle into the target lesion. CONCLUSION: The authors demonstrate that the DECT VNCa bone marrow algorithm may be helpful in identifying isodense bone lesions of various histologies and may be used to guide percutaneous bone biopsies. This technique may help to maximize diagnostic yield, minimize the number of passes into the region of concern, and prevent patients from undergoing repeat biopsy.

Correction to: Sonographic evaluation of uncommonly assessed upper extremity peripheral nerves: anatomy, technique, and clinical syndromes.

The original version of this article unfortunately contained mistake. Fig. 13a (Anatomy of the Ulnar Digital nerve of the Thumb) as originally published erroneously depicts the ulnar digital nerve of the thumb as a branch of the ulnar nerve.

Sonographic evaluation of uncommonly assessed upper extremity peripheral nerves: anatomy, technique, and clinical syndromes.

Targeted ultrasound of the median, ulnar, and radial nerves is a well-established technique for suspected upper extremity peripheral neuropathy. However, sonographic imaging of the brachial plexus and smaller peripheral nerve branches is more technically difficult and the anatomy is less familiar to many radiologists. As imaging techniques improve, many clinicians refer patients for imaging of previously less-familiar structures. In addition, some patients may present with injuries that could involve local neurovascular structures. Finally, patients presenting with isolated peripheral neuropathies may be referred for perineural injections with local anesthetic for diagnostic purposes, or steroid for therapeutic reasons. This requires sonologists to have a firm understanding of the courses of these nerves and the surrounding anatomic landmarks that can be used to accurately identify and characterize them. We discuss clinical syndromes referable to specific peripheral nerve branches in the upper extremity, the relevant anatomy, and sonographic technique.

Imaging of Postoperative Infection at the Knee Joint.

Postoperative infections of the knee are uncommon but may occur with joint arthroplasties, fracture fixation, or after arthroscopic procedures. The ultimate diagnosis is made by joint aspiration or tissue sampling. Joint aspiration and tissue sampling can be performed under imaging guidance or intraoperatively. Imaging is an important adjunct to clinical and laboratory findings and should start with radiographs. Cross-sectional imaging including magnetic resonance (MR) imaging, computed tomography (CT), nuclear studies, and ultrasound (US) are frequently used if the diagnosis is in doubt and to evaluate the extent of disease. We discuss the current algorithm in the diagnosis of various postoperative infections of the knee joint. The article addresses the utility of radiography, MR imaging, CT, US, and the most commonly used nuclear studies in the diagnosis of various postoperative knee infections and the imaging appearances of these infections on each of these diagnostic modalities.

Comparing an accelerated 3D fast spin-echo sequence (CS-SPACE) for knee 3-T magnetic resonance imaging with traditional 3D fast spin-echo (SPACE) and routine 2D sequences.

PURPOSE: To compare a faster, new, high-resolution accelerated 3D-fast-spin-echo (3D-FSE) acquisition sequence (CS-SPACE) to traditional 2D and high-resolution 3D sequences for knee 3-T magnetic resonance imaging (MRI). MATERIALS AND METHODS: Twenty patients received knee MRIs that included routine 2D (T1, PD ± FS, T2-FS; 0.5 × 0.5 × 3 mm3; ∼10 min), traditional 3D FSE (SPACE-PD-FS; 0.5 × 0.5 × 0.5 mm3; ∼7.5 min), and accelerated 3D-FSE prototype (CS-SPACE-PD-FS; 0.5 × 0.5 × 0.5 mm3; ∼5 min) acquisitions on a 3-T MRI system (Siemens MAGNETOM Skyra). Three musculoskeletal radiologists (MSKRs) prospectively and independently reviewed the studies with graded surveys comparing image and diagnostic quality. Tissue-specific signal-to-noise ratios (SNR) and contrast-to-noise ratios (CNR) were also compared. RESULTS: MSKR-perceived diagnostic quality of cartilage was significantly higher for CS-SPACE than for SPACE and 2D sequences (p < 0.001). Assessment of diagnostic quality of menisci and synovial fluid was higher for CS-SPACE than for SPACE (p < 0.001). CS-SPACE was not significantly different from SPACE but had lower assessments than 2D sequences for evaluation of bones, ligaments, muscles, and fat (p ≤ 0.004). 3D sequences had higher spatial resolution, but lower overall assessed contrast (p < 0.001). Overall image quality from CS-SPACE was assessed as higher than SPACE (p = 0.007), but lower than 2D sequences (p < 0.001). Compared to SPACE, CS-SPACE had higher fluid SNR and CNR against all other tissues (all p < 0.001). CONCLUSIONS: The CS-SPACE prototype allows for faster isotropic acquisitions of knee MRIs over currently used protocols. High fluid-to-cartilage CNR and higher spatial resolution over routine 2D sequences may present a valuable role for CS-SPACE in the evaluation of cartilage and menisci.

Sonographic evaluation of common peroneal neuropathy in patients with foot drop.

The common peroneal nerve arises from the sciatic nerve and is subject to a variety of abnormalities. Although diagnosis is often is based on the clinical findings and electrodiagnostic tests, high-resolution sonography has an increasing role in determining the type and location of common peroneal nerve abnormalities and other peripheral nerve disorders. This article reviews the normal sonographic appearance of the common peroneal nerve and the findings in 21 patients with foot drop related to common peroneal neuropathy.

Evaluation of the tarsometatarsal joint using conventional radiography, CT, and MR imaging.

The tarsometatarsal, or Lisfranc, joint complex provides stability to the midfoot and forefoot through intricate osseous relationships between the distal tarsal bones and metatarsal bases and their connections with stabilizing ligamentous support structures. Lisfranc joint injuries are relatively uncommon, and their imaging findings can be subtle. These injuries have typically been divided into high-impact fracture-displacements, which are often seen after motor vehicle collisions, and low-impact midfoot sprains, which are more commonly seen in athletes. The injury mechanism often influences the imaging findings, and classification systems based primarily on imaging features have been developed to help diagnose and treat these injuries. Patients may have significant regional swelling and pain that prevent thorough physical examination or may have other more critical injuries at initial posttrauma evaluation. These factors may cause diagnostic delays and lead to subsequent morbidities, such as midfoot instability, deformity, and debilitating osteoarthritis. Missed Lisfranc ligament injuries are among the most common causes of litigation against radiologists and emergency department physicians. Radiologists must understand the pathophysiology of these injuries and the patterns of imaging findings seen at conventional radiography, computed tomography, and magnetic resonance imaging to improve injury detection and obtain additional information for referring physicians that may affect the selection of the injury classification system, treatment, and prognosis.