US/CT fusion imaging and virtual navigation to guide lumbar intradiscal oxygen-ozone therapy: a pilot study.

PURPOSE: To test the feasibility of US/CT fusion imaging to guide lumbar intradiscal O2/O3 therapy to treat discogenic degenerative low back pain due to lumbar disc herniation (LDH). METHODS: We retrospectively included consecutive patients affected by low back pain and/or sciatica due to LDH resistant to conservative therapies, who underwent to lumbar intradiscal O2/O3 injection under CT/US fusion imaging guidance (Fusion Group) and standard CT guidance (Control Group). For each procedure, we collected procedure operative time, room utilization time, number of CT passes, complications, and O2/O3 intradiscal diffusion adequacy. Technical success was defined as the ability to complete the procedure as initially planned to reach the disc. Technical efficacy was based on O2/O3 intradiscal diffusion adequacy, as demonstrated by the last CT scan. RESULTS: Six patients (4 males; mean age: 68 ± 15 years) were included in the Fusion group, six (4 males; mean age: 66 ± 12 years) in Control group. No complications were observed in both groups. In Fusion group we found significantly lower room utilization time (30 ± 6 min vs. 46 ± 10 min, p = 0.008), procedure operative time (14 ± 3 min vs. 24 ± 6 min, p = 0.008), and number of CT passes (2 [2,2] vs. 3 [3,3], p = 0.006) than in Control Group, respectively. Technical success and efficacy were 100% in both Groups. CONCLUSION: CT/US fusion imaging seems to be a feasible and safe guidance for intradiscal O2/O3 injections, allowing decrease of procedure time and number of CT passes.

The Technique of Intradiscal Injection: A Narrative Review.

BACKGROUND: Low back pain (LBP) is one of the most common spine diseases and represents the most frequent cause of absence from work in developed countries. Approximately 40% of chronic LBP is related to discogenic origin. The goal of the study is producing a review of literature to describe analytically the techniques of intradiscal injections. METHODS: PubMed database was searched for clinical studies with the different key terms: "intradiscal", "injection", "steroid" "procedures", "techniques", "CT", "MRI", "fluoroscopy", "fluoroscopic", "guidance", "ozone", "ultrasound", "images". Only studies written in English, French, or Italian in which the intradiscal injection represents the main procedure for the low back discopathy treatment on humans were considered. We excluded the articles that do not mention this procedure; those which indicated that the intradiscal injection had happened accidentally during other treatments; those reporting the patient's pain was determined by other causes than the discopathy (facet joint syndrome, tumor, spondylodiscitis). RESULTS: Thirty-one articles dated from 1969 to 2018 met the criteria. The examined population was 6843 subjects, 52.3% male and 47.7% female, with a mean age of 45.9±10.1 years. The techniques are highly variable in terms of procedure: different operators, needle guidance, injection sites, drugs, tilt angle of the needle). CONCLUSION: The efficacy and the safety of the intradiscal procedures are not easily comparable due to different types of studies and their limited number. Further studies are needed to standardize the intradiscal injection technique/procedure to improve safety, repeatability and effectiveness, and last but not least to reduce peri- and postoperative care and health-care costs.

Position paper on magnetic resonance imaging protocols in the musculoskeletal system (excluding the spine) by the Italian College of Musculoskeletal Radiology.

Magnetic resonance imaging (MRI) is a pivotal radiological examination in clinical practice, being widely applied for musculoskeletal examinations. In this setting, strict adherence to standardized protocol is crucial to increase diagnostic performance and minimize variability among different diagnostic centres and readers. The aim of this paper is to provide standardized technical recommendations for musculoskeletal MRI scans proposed by the Italian College of Musculoskeletal Radiology. These recommendations are designed to give a uniform application of MRI protocols over the national territory, to increase reproducibility and improve diagnostic performance.

Real-time fusion-imaging in low back pain: a new navigation system for facet joint injections.

AIMS AND OBJECTIVES: The aim of the current study is to present our experience in lumbar spine interventional procedures performed with a newly developed multimodal echo-navigator (EcoNav) and to evaluate short-term clinical outcomes of a series of patients affected by facet joint disease (FJD) treated with steroid and anaesthetic injection under fusion-imaging guidance, compared to a cohort of patients that received the same treatment under computed tomography (CT) guidance. METHODS: Sixty-five consecutive patients (34 females; mean age 68.3 ± 12.8 years) with a clinical diagnosis of non-radicular low back pain lasting for more than 6-weeks and magnetic resonance (MR) or CT confirmed FJD were enrolled for image-guided FJI. Twenty-eight patients underwent FJI with fusion-guided technique, while CT-guided procedures were performed in the other cases. Clinical and procedural data were recorded and compared at a mean follow-up of 6.1 ± 2.0 months. RESULTS: A significant improvement in clinical parameters was observed for both fusion-guided and CT-guided group. Comparing both groups, no statistically significant difference could be detected neither at baseline conditions nor during the follow-up period. No significant periprocedural complication occurred in both groups. A satisfaction rate of 92.3 and 81.1% was reported for fusion-guided and CT-guided group, respectively. CONCLUSION: EcoNav fusion-imaging system represents a safe, feasible, effective and reproducible guidance option in FJD infiltration procedures, also avoiding use of ionising radiations.

Evaluation of posterior cruciate ligament healing: a study using magnetic resonance imaging and stress radiography.

PURPOSE: To review a series of tears of the posterior cruciate ligament (PCL) in order to understand its healing process, as well as to identify prognostic factors. TYPE OF STUDY: Prospective study. METHODS: Eighteen patients with isolated or combined PCL tears were evaluated and followed-up for 1 year after their initial injury. Magnetic resonance imaging (MRI) scans and stress radiographs were obtained serially at the time of injury, at 6 months, and at 12 months. RESULTS: Twelve of 18 PCL tears were found to have regained continuity at the 1-year follow-up. These patients complained of an isolated or combined PCL/medial collateral ligament injury at time 0 and all presented a posterior subluxation of less than 8 mm, detected with stress radiographs. The remaining 6 patients had posterior subluxations greater than 12 mm and presented with combined posterolateral corner injuries. CONCLUSIONS: This study underlines the importance of a complete MRI evaluation used in combination with stress radiography to adequately assess the healing process. The results obtained suggest that complete PCL tears with greater than 12 mm of posterior subluxation, as well as combined PLC injuries, are less likely to heal completely. These factors could further aid the surgeon in deciding the need and timing for surgical intervention in the acute setting of a PCL tear. LEVEL OF EVIDENCE: Level II.

Bone mineral density of the proximal metaphysis of tibia: clinical relevance in posterior cruciate ligament reconstruction.

The objective of this study was to evaluate the bone mineral density (BMD) of the proximal tibia in the area adjacent to the fixation of the posterior cruciate ligament (PCL) and compare with the BMD in a similar area at the ideal site for anterior cruciate ligament fixation. Twenty healthy male subjects, undertaking similar daily physical activity were enrolled for this study. The mean age of the subjects was 22 years (range 20-24 years). The bone mineral density (BMD) at the proximal tibia was calculated using a quantitative CT scan of the dominant knee, and the data were recorded in Hounsfield units (HU). Two circular regions of interest, anterior and posterior, of identical diameters (10 mm) and thicknesses (5 mm) were studied. The results showed a significantly higher BMD in the anterior region (162.4 +/- 33.8 HU) than in the posterior one (104 +/- 24.6 HU) with a statistically significant difference (p=0.0001). The clinical implication of this finding is that the fixation should provide a firm construct for PCL reconstructions and be specifically designed for working in low bone quality areas such as the posterior proximal tibia.

Serial magnetic resonance imaging evaluation of the patellar tendon after posterior cruciate ligament reconstruction.

PURPOSE: Our purpose was to prospectively analyze serial changes in magnetic resonance imaging (MRI) signal of the bone-patellar tendon-bone autograft when used for posterior cruciate ligament (PCL) reconstruction and to retrospectively determine at mid-term follow-up the relationship between MRI graft appearance and clinical stability in patients who have undergone arthroscopic PCL reconstruction with a bone-patellar tendon-bone autograft. TYPE OF STUDY: One prospective serial blinded study and 1 retrospective blinded study. METHODS: The first part of the study focused on MRI scans obtained at 3, 6, 9, and 12 months postoperatively in a case series of 10 consecutive patients who underwent arthroscopically assisted PCL reconstruction (group A), and of 10 patients who underwent combined ACL-PCL arthroscopic reconstruction (group B). For the second part of the study, MRI scans were obtained in a retrospective series of 10 patients at mid-term follow-up after PCL arthroscopic reconstruction (group C). Signal intensity of 3 zones, corresponding to the proximal, middle, and distal intra-articular graft zones, was evaluated according to the Howell et al. classification. Fiber continuity assessment was performed using a modified Kühne et al. score. The signal intensity of the 3 zones was independently scored. Knee stability was clinically and instrumentally graded according to the IKDC evaluation form (group 4). A multivariance analysis and grouped t test were used for statistical evaluation. RESULTS: In group A, the average MRI evaluation score was 7.65 +/- 1.6 at 3 months, 3.8 +/- 0.6 at 6 months, 4.75 +/- 1 at 9 months and 6.25 +/- 1.2 at 1 year. The portion of graft exiting the femoral tunnel exhibited increased signal and faster maturation than the tibial tunnel. In group B (combined ACL-PCL reconstruction), the graft showed slower graft healing with an average MRI score of 4.85 +/- 0.7 at 3 months, 1.9 +/- 0.7 at 6 months, 3.9 +/- 0.9 at 9 months, and 5.3 +/- 1.1 at 1 year. At 1 year follow-up, there was no correlation between MRI appearance and stability in group A, even with MRI findings of fiber continuity. However, at long-term evaluation (group C), a strict correlation between MRI appearance and achieved stability was found. CONCLUSIONS: The patellar tendon when used for PCL reconstruction requires more than 1 year to achieve a low-signal intensity over its entire course, and the distal zone near the tibial tunnel shows a slower healing process. MRI graft assessment is useful only 1 year or more following PCL reconstruction.