Cadaveric study of movement of an unstable atlanto-axial (C1/C2) cervical segment during laryngoscopy and intubation using the Airtraq(®) , Macintosh and McCoy laryngoscopes.

Concern that laryngoscopy and intubation might create or exacerbate a spinal cord injury has generated extensive research into cervical spinal movement during laryngoscopy. We performed a randomised trial on six cadavers, using three different laryngoscopes, before and after creating a type-2 odontoid peg fracture. Our primary outcome measure was the change in the space available for the spinal cord at the C1/2 segment measured by cinefluoroscopy. Tracheal intubation was performed using a minimal view of the glottis, a bougie, and manual in-line stabilisation. In a cadaveric model of type-2 odontoid fracture, the space available for the cord was preserved in maximum flexion and extension, and changed little on laryngoscopy and intubation.

FIESTA: an MR arthrography celebration of shoulder joint anatomy, variants, and their mimics.

Magnetic resonance (MR) arthrography is currently the gold standard radiological investigation for shoulder joint instability. Not only does this investigation allow for identification of important disease processes, but the reduced slice thickness and increased in-plane resolution allowed by the latest imaging sequences also gives excellent demonstration of shoulder joint internal anatomy. This article describes the technique of MR arthrography of the shoulder practiced at our institution, briefly outlining features of the FIESTA (fast imaging employing steady state acquisition) MR sequence employed, including its advantages and limitations. A pictorial review of shoulder MR arthrography performed with this technique is presented, concentrating on normal shoulder joint internal anatomy and anatomical variants that may mimic pathology.

Injuries to the lower back in elite fast bowlers: acute stress changes on MRI predict stress fracture.

In our study, the aims were to describe the changes in the appearance of the lumbar spine on MRI in elite fast bowlers during a follow-up period of one year, and to determine whether these could be used to predict the presence of a stress fracture of the posterior elements. We recruited 28 elite fast bowlers with a mean age of 19 years (16 to 24) who were training and playing competitively at the start of the study. They underwent baseline MRI (season 1) and further scanning (season 2) after one year to assess the appearance of the lumbar intervertebral discs and posterior bony elements. The incidence of low back pain and the amount of playing and training time lost were also recorded. In total, 15 of the 28 participants (53.6%) showed signs of acute bone stress on either the season 1 or season 2 MR scans and there was a strong correlation between these findings and the later development of a stress fracture (p < 0.001). The prevalence of intervertebral disc degeneration was relatively low. There was no relationship between disc degeneration on the season 1 MR scans and subsequent stress fracture. Regular lumbar MR scans of asymptomatic elite fast bowlers may be of value in detecting early changes of bone stress and may allow prompt intervention aimed at preventing a stress fracture and avoiding prolonged absence from cricket.

Undisplaced scaphoid waist fractures: is 4 weeks' immobilisation in a below-elbow cast sufficient if a week 4 CT scan suggests fracture union?

This prospective study investigated a cohort of 59 scaphoid waist fractures which were treated nonoperatively in a below-elbow plaster cast for 4 weeks and then underwent a Week 4 CT scan to assess displacement and progress to union. Forty-three were classed as undisplaced and 37 of these 43 were also classed as 'united'. All the 37 undisplaced and 'united' fractures united with up to 8 weeks' cast immobilisation, including 26 which were taken out of plaster at 4 weeks and mobilised. We conclude that scaphoid waist fractures which appear to be undisplaced and united on a week 4 CT scan will unite, and may not need to be immobilised in a plaster cast for more than 4 weeks. Such a treatment policy may reduce the period of disability and time off work associated with nonoperative treatment.

Magnetic resonance imaging of the lumbar spine in asymptomatic professional fast bowlers in cricket.

Low back injuries account for the greatest loss of playing time for professional fast bowlers in cricket. Previous radiological studies have shown a high prevalence of degeneration of the lumbar discs and stress injuries of the pars interarticularis in elite junior fast bowlers. We have examined MRI appearance of the lumbar spines of 36 asymptomatic professional fast bowlers and 17 active control subjects. The fast bowlers had a relatively high prevalence of multi-level degeneration of the lumbar discs and a unique pattern of stress lesions of the pars interarticularis on the non-dominant side. The systems which have been used to classify the MR appearance of the lumbar discs and pars were found to be reliable. However, the relationship between the radiological findings, pain and dysfunction remains unclear.

Demonstration of the appearance of the paraspinal musculoligamentous structures of the cervical spine using ultrasound.

The application of ultrasound in the imaging of the neck has primarily focussed on anterior structures (e.g., thyroid gland). Structures located on the posterior aspect of the neck have received little attention. This study illustrates the capability of modern ultrasound equipment in visualising the musculoligamentous structures of the neck, particularly the paraspinal musculature. Ten healthy adult volunteers (6 female; 4 male) underwent ultrasound examination of the cervical spine. A standardised technique for transducer placement was adopted and successive images of the neck of each subject were obtained. Spatial compound (extended field of view) images were obtained in subjects using one of two different ultrasound systems. Images of structures produced by ultrasound were compared to those achieved with magnetic resonance imaging in three subjects. Identification of key landmarks aided orientation and identification of structures. The internal architecture of the musculoligamentous structures of the cervical spine, especially the posterior neck muscles, was demonstrated well using ultrasound. Our study showed that modern ultrasound equipment is capable of producing clear images of the posterior cervical spine musculature and certain bony features.

Comparing spondylolysis in cricketers and soccer players.

OBJECTIVE: To determine whether the location of spondylolysis in the lumbar spine of athletes differs with biomechanical factors. METHODS: Single photon emission computerised tomography and reverse gantry computerised tomography were used to investigate 42 cricketers and 28 soccer players with activity related low back pain. Sites of increased scintigraphic uptake in the posterior elements of the lumbar spine and complete or incomplete fracture in the pars interarticularis were compared for these two sports. RESULTS: Thirty seven (90.4%) cricketers and 23 (82.1%) soccer players studied had sites of increased uptake. In cricketers, these sites were on the left of the neural arch of 49 lumbar vertebrae and on the right of 33 vertebrae. In soccer players there was a significantly different proportion, with 17 sites on the left and 28 on the right (difference of 22.0%; 95% confidence interval (CI) 0.04 to 0.38). Lower lumbar levels showed increased scintigraphic uptake more frequently than did higher levels, although the trend was reversed at L3 and L4 in soccer. Forty spondylolyses were identified in the lumbar vertebrae of the cricketers and 35 spondylolyses in the soccer players. These comprised 26 complete and 14 incomplete fractures in the cricketers, and 25 complete and 10 incomplete fractures in the soccer players. Similar numbers of incomplete fractures were found either side of the neural arch in soccer players, but there were more incomplete fractures in the left pars (14) than in the right (2) in cricketers. The proportion of incomplete fractures either side of the neural arch was significantly different between cricket players and soccer players (difference of 37.5%; 95% CI 0.02 to 0.65). Most complete fractures were at L5 (66.7%) and more were found at L3 (15.7%) than L4 (6.9%). However, incomplete fractures were more evenly spread though the lower three lumbar levels with 41.7% at L5, 37.5% at L4, and 20.8% at L3. CONCLUSIONS: Fast bowling in cricket is associated with pars interarticularis bone stress response and with development of incomplete stress fractures that occur more frequently on the left than the right. Playing soccer is associated with a more symmetrical distribution of bone stress response, including stress fracturing. Within cricketers, unilateral spondylolyses tend to arise on the contralateral side to the bowling arm.

The value of combining single photon emission computerised tomography and computerised tomography in the investigation of spondylolysis.

The aim of this study was to assess the diagnostic value of combining single photon emission computerised tomography (SPECT) with reverse gantry computerised tomography (rg-CT) in the investigation of spondylolysis. Patient characteristics and imaging results in 118 patients, aged 8-44 years, with low back pain (LBP) were analysed. SPECT showed increased scintigraphic uptake in 80 patients, and spondylolysis was identified on rg-CT in 53. The Cohen Kappa ratio of 0.362 (95% CI: 0.198-0.526) suggests only fair agreement for the result of increased scintigraphic activity with the finding of spondylolysis on rg-CT. We conclude that these investigations give mutually exclusive information, which leads to four diagnostic categories. When there was increased scintigraphic activity on SPECT, 58.8% (95% CI: 48.0-69.5%) of patients had spondylolysis on rg-CT. With rest from provoking activities, these lesions may heal. We interpret the findings of increased scintigraphic activity, but no spondylolysis demonstrated on rg-CT as indicating a bone stress response. These also require rest from provoking activity to prevent a stress fracture developing. In this study, 84.2% (95% CI: 72.67-95.8%) of those patients without increased activity on SPECT had no spondylolysis identified on rg-CT. These patients may need further investigations such as magnetic resonance imaging (MRI) to diagnose pathology, which typically does not involve the posterior elements--but rest from sport may not be so important. There were five patients in our study, without increased scintigraphic activity, but in whom bilateral chronic-appearing (wide separation, smooth sclerotic bone margins) spondylolyses were identified at L5. These all were anticipated from previous plain radiographs or MRI. This group will almost certainly not heal, and if the spondylolyses are the cause of pain these vertebrae will need stabilisation by surgery if physiotherapy fails.

Primary obturator pyomyositis: a diagnostic challenge.

Pyomyositis of the obturator muscles is a rare condition, characterised by pain in the hip and features of systemic infection. It may follow minor trauma to the hip, sometimes in the presence of an apparently innocuous infective source. All previously reported cases have been diagnosed conclusively on the initial CT or MR scan. We present a case of obturator pyomyositis in a 21-year-old football player in which the first MR scan was misleading. A radiolabelled, white blood cell scan was also negative and the resultant delay in diagnosis proved dangerous. The crucial importance of careful and repeated clinical examination is emphasised.

Clinical outcome and return to sport after the surgical treatment of spondylolysis in young athletes.

We studied prospectively 22 young athletes who had undergone surgical treatment for lumbar spondylolysis. There were 15 men and seven women with a mean age of 20.2 years (15 to 34). Of these, 13 were professional footballers, four professional cricketers, three hockey players, one a tennis player and one a golfer. Preoperative assessment included plain radiography, single positron-emission CT, planar bone scanning and reverse-gantry CT. In all patients the Oswestry disability index (ODI) and in 19 the Short-Form 36 (SF-36) scores were determined preoperatively, and both were measured again after two years in all patients. Three patients had a Scott's fusion and 19 a Buck's fusion. The mean duration of back pain before surgery was 9.4 months (6 to 36). The mean size of the defect as determined by CT was 3.5 mm (1 to 8) and the mean preoperative and postoperative ODIs were 39.5 (SD 8.7) and 10.7 (SD 12.9), respectively. The mean scores for the physical component of the SF-36 improved from 27.1 (SD 5.1) to 47.8 (SD 7.7). The mean scores for the mental health component of the SF-36 improved from 39.0 (SD 3.9) to 55.4 (SD 6.3) with p < 0.001. After rehabilitation for a mean of seven months (4 to 10) 18 patients (82%) returned to their previous sporting activity.

The role of radiography in primary care patients with low back pain of at least 6 weeks duration: a randomised (unblinded) controlled trial.

OBJECTIVES: To test the hypotheses that: (1) Lumbar spine radiography in primary care patients with low back pain is not associated with improved patient outcomes, including pain, disability, health status, sickness absence, reassurance, and patient satisfaction or belief in the value of radiography. (2) Lumbar spine radiography in primary care patients with low back pain is not associated with changes in patient management, including medication use, and the use of primary and secondary care services, physical therapies and complementary therapies. (3) Participants choosing their treatment group (i.e. radiography or no radiography) do not have better outcomes than those randomised to a treatment group. (4) Lumbar spine radiography is not cost-effective compared with usual care without lumbar spine radiography. DESIGN: A randomised unblinded controlled trial. SETTING: Seventy-three general practices in Nottingham, North Nottinghamshire, Southern Derbyshire, North Lincolnshire and North Leicestershire. Fifty-two practices recruited participants to the trial. SUBJECTS: Randomised arm: 421 participants with low back pain, with median duration of 10 weeks. Patient preference arm: 55 participants with low back pain, with median duration of 11 weeks. INTERVENTION: Lumbar spine radiography and usual care versus usual care without radiography. MAIN OUTCOME MEASURES: Roland adaptation of the Sickness Impact Profile, visual analogue pain scale, health status scale, EuroQol, use of primary and secondary care services, and physical and complementary therapies, sickness absence, medication use, patient satisfaction, reassurance and belief in value of radiography at 3 and 9 months post-randomisation. RESULTS: Participants randomised to receive an X-ray were more likely to report low back pain at 3 months (odds ratio (OR) = 1.56; 95% confidence interval (CI), 1.02 to 2.40) and had a lower overall health status score (p = 0.02). There were no differences in health or functional status at 9 months. A higher proportion of participants consulted the general practitioner (GP) in the 3 months following an X-ray (OR = 2.72; 95% CI, 1.80 to 4.10). There were no differences in use of any other services, medication use or sickness absence at 3 or 9 months. No serious spinal pathology was identified in either group. The commonest X-ray reports were of discovertebral degeneration and normal findings. Many patients did not perceive their information needs were met within the consultation. Satisfaction with care was greater in the group receiving radiography at 9 months. Participants randomised to receive an X-ray were not less worried, or more reassured about serious disease causing their low back pain. Satisfaction was associated with meeting participants' information needs and reduced belief in the necessity for investigations for low back pain, including X-rays and blood tests. In both groups, at 3 and 9 months 80% of participants would choose to have an X-ray if the choice was available. Participants in the patient preference group achieved marginally better outcomes than those randomised to a treatment group, but the clinical significance of these differences is unclear. Lumbar spine radiography was associated with a net economic loss at 3 and 9 months. CONCLUSIONS: Lumbar spine radiography in primary care patients with low back pain of at least 6 weeks duration is not associated with improved functioning, severity of pain or overall health status, and is associated with an increase in GP workload. Participants receiving X-rays are more satisfied with their care, but are not less worried or more reassured about serious disease causing their low back pain. CONCLUSIONS - RECOMMENDATIONS FOR FURTHER RESEARCH: Further work is required to develop and test an educational package that educates patients and GPs about the utility of radiography and provides strategies for identifying and meeting the information needs of patients, and the needs of patients and GPs to be reassured about missing serious disease. Guidelines on the management of low back pain in primary care should be consistent about not recommending lumbar spine radiography in patients with low back pain in the absence of red flags for serious spinal pathology, even if the pain has persisted for at least 6 weeks.

A 3D MRI sequence for computer assisted surgery of the lumbar spine.

The aim of this research was to develop a magnetic resonance (MR) sequence capable of producing images suitable for use with computer assisted surgery (CAS) of the lumbar spine. These images needed good tissue contrast between bone and soft tissue to allow for image segmentation and generation of a 3D-surface model of the bone for surface registration. A 3D double echo fast gradient echo sequence was designed. Images were filtered for noise and non-uniformity and combined into a single data set. Registration experiments were carried out to directly compare segmentation of MR and computed tomography (CT) images using a physical model of a spine. These experiments showed the MR data produced adequate surface registration in 90% of the experiments compared to 100% with CT data. The MR images acquired using the sequence and processing described in this article are suitable to be used with CAS of the spine.

Radiography of the lumbar spine in primary care patients with low back pain: randomised controlled trial.

OBJECTIVE: To test the hypothesis that radiography of the lumbar spine in patients with low back pain is not associated with improved clinical outcomes or satisfaction with care. DESIGN: Randomised unblinded controlled trial. SETTING: 73 general practices in Nottingham, north Nottinghamshire, southern Derbyshire, north Lincolnshire, and north Leicestershire. 52 practices recruited participants to the trial. SUBJECTS: 421 patients with low back pain of a median duration of 10 weeks. INTERVENTION: Radiography of the lumbar spine. MAIN OUTCOME MEASURES: Roland adaptation of the sickness impact profile, visual analogue scale for pain, health status, EuroQol, satisfaction with care, use of primary and secondary care services, and reporting of low back pain at three and nine months after randomisation. RESULTS: The intervention group were more likely to report low back pain at three months (relative risk 1.26, 95% confidence interval 1.00 to 1.60) and had a lower overall health status score and borderline higher Roland and pain scores. A higher proportion of participants consulted their doctor in the three months after radiography (1.62, 1.33 to 1.97). Satisfaction with care was greater in the group receiving radiography at nine but not three months after randomisation. Overall, 80% of participants in both groups at three and nine months would have radiography if the choice was available. An abnormal finding on radiography made no difference to the outcome, as measured by the Roland score. CONCLUSIONS: Radiography of the lumbar spine in primary care patients with low back pain of at least six weeks' duration is not associated with improved patient functioning, severity of pain, or overall health status but is associated with an increase in doctor workload. Guidelines on the management of low back pain in primary care should be consistent about not recommending radiography of the lumbar spine in patients with low back pain in the absence of indicators for serious spinal disease, even if it has persisted for at least six weeks. Patients receiving radiography are more satisfied with the care they received. The challenge for primary care is to increase satisfaction without recourse to radiography.

Delayed union stress fractures of the anterior tibia: conservative management.

INTRODUCTION: A conservative method of treating four delayed union stress fractures of the anterior mid-tibia is described, with an illustrative case history. METHODS: Once diagnosed each of the patients was treated in a pneumatic lower leg brace with modified rest. The mean (range) age of the patients was 28 (24-32) years and all were involved in professional or amateur sports. The mean (range) duration of symptoms before diagnosis and definitive treatment of the four fractures was 9 (3-14) months. RESULTS: Use of this technique avoided the need for surgery in this group of patients and allowed return to unrestricted activity an average of 12 months from presentation. CONCLUSION: The treatment is cost effective and avoids the often uncertain results and morbidity associated with surgery for these difficult stress fractures.

Injury to the spinal cord without radiological abnormality (SCIWORA) in adults.

Injury to the spinal cord without radiological abnormality often occurs in the skeletally immature cervical and thoracic spine. We describe four adult patients with this diagnosis involving the cervical spine with resultant quadriparesis. The relevant literature is reviewed. The implications for initial management of the injury, the role of MRI and the need for a high index of suspicion are highlighted.

CT imaging and three-dimensional reconstructions of shoulders with anterior glenohumeral instability.

Glenohumeral instability is a common occurrence following anterior dislocation of the shoulder joint, particularly in young men. The bony abnormalities encountered in patients with glenohumeral instability can be difficult to detect with conventional radiography, even with special views. The aim of our study was to evaluate the bony abnormalities associated with glenohumeral instability using CT imaging with 3-D reconstruction images. We scanned 11 patients with glenohumeral instability, one with bilateral symptoms; 10 were male, one female, and their ages ranged from 18-66 years. Contiguous 3 mm axial slices of the glenohumeral joint were taken at 2 mm intervals using a Siemens Somatom CT scanner. In the 12 shoulders imaged, we identified four main abnormalities. A humeral-head defect or Hill-Sachs deformity was seen in 83% cases, fractures of the anterior glenoid rim in 50%, periosteal new bone formation secondary to capsular stripping in 42%, and loose bone fragments in 25%. Manipulation of the 3-D images enabled the abnormalities to be well seen in all cases, giving a graphic visualization of the joint, and only two 3-D images were needed to demonstrate all the necessary information. We feel that CT is the imaging modality most likely to show all the bone abnormalities associated with glenohumeral instability. These bony changes may lead to the correct inference of soft tissue abnormalities making more invasive examinations such as arthrography unnecessary.

Assessment of 3-dimensional magnetic resonance imaging fast low angle shot images for computer assisted spinal surgery.

The objective of this research was to determine whether a fast 3-dimensional (3-D) gradient echo magnetic resonance imaging (MRI) sequence could be used to acquire images suitable for image guided surgery of the spine. The main difficulty with MRI is that inhomogeneities in the static magnetic field lead to geometric distortions in the images. We used a very fast 3-D MRI sequence with a wide bandwidth and short echo time (TE) to minimize these distortions. Fiducial markers that could be localized in MRI and computed tomography (CT) images and in physical space were attached to a phantom in order to assess the accuracy of a landmark based registration method. The effect of varying the MRI parameters on image contrast was also investigated. The results demonstrate that the registration can be undertaken with an accuracy of 0.4 mm using the 3-D MRI. This is comparable to the accuracy of 0.3 mm obtained with CT and is a significant improvement over the accuracy of the 2-D MRI techniques (> 1.0 mm). In vivo images demonstrating good contrast between the spine and surrounding soft tissues such as fat, intervertebral disks, and cerebrospinal fluid were obtained. The MRI acquired using the sequence described in this article shows promise for use in computer assisted surgery of the spine.

Vertebral osteomyelitis as a complication of Crohn's disease.

Vertebral osteomyelitis arising from an enteric fistula in patients with inflammatory bowel disease is rare. We report on a patient with Crohn's disease who developed an enteric fistula, resulting in a presacral abscess and vertebral osteomyelitis involving the L4 and L5 vertebral bodies and related disc spaces. This was managed by a defunctioning colostomy with drainage of the pre-sacral abscess. The vertebral lesion was successfully managed non-operatively.

Atlanto-axial dislocation without fracture: case report of an ejection injury.

We describe an unusual injury to the upper cervical spine sustained during ejection from an aircraft. MRI provided an accurate and direct diagnosis of the severe ligamentous injuries.