The Effect of Oblique Magnetic Resonance Imaging on Surgical Decision Making for Patients Undergoing an Anterior Cervical Discectomy and Fusion for Cervical Radiculopathy.

BACKGROUND: The purpose of this study was to determine if oblique magnetic resonance imaging (MRI) sequences affect the surgical treatment recommendations for patients with cervical radiculopathy. METHODS: In this cohort study consecutive clinical cases of persistent cervical radiculopathy requiring surgical intervention were randomized, blinded, and reviewed by 6 surgeons. Initially each surgeon recommended treatment based on the history, physical examination, and axial, coronal and sagittal preoperative magnetic resonance (MR) images; when reviewing the cases the second time, the surgeons were provided oblique MR images. This entire process was then repeated after 2 months. Change in surgical recommendation, interobserver and intraobserver reliability and the average number of levels fused was determined. RESULTS: The addition of the oblique images resulted in the surgical recommendation being altered in 49.2% (59/120) of cases; however, the addition of oblique images did not substantially improve the interobserver reliability of the treatment recommendation (κ = .57 versus.57). Similarly, the overall intraobserver reliability using only traditional MRI sequences (κ = .64) was only slightly improved by the addition of oblique images (κ = .66). Lastly, the addition of oblique images did not change the average number of levels fused (traditional MRI = 1.38, oblique MRI = 1.41, P = .53), or the total number of 3-level fusions recommended (6 versus 6, P = 1.00). CONCLUSIONS: The additional oblique images resulted in a change to the surgical plan in almost 50% of cases; however, it had no substantial effect on the reliability of surgical decision making. Further studies are needed to see if this alteration in treatment affects clinical outcomes. LEVEL OF EVIDENCE: 3.

Calcium pyrophosphate dihydrate crystal deposition disease (pseudogout) of lumbar spine mimicking osteomyelitis-discitis with epidural phlegmon.

Calcium pyrophosphate dihydrate crystal deposition disease (pseudogout) of the axial spine is rare. To our knowledge, there are few reports of the disease presenting with a presumed diagnosis of infection in the lumbar spine. As reported here, the diagnosis of osteomyelitis-discitis with epidural phlegmon was presumed before intervention. We present the case of a 60-year-old man with radiographic imaging and worsening clinical presentation at 2 consecutive hospitalizations. Axial magnetic resonance imaging originally showed increased signal intensity at the L5-S1 disk, which suggested an infectious rather than inflammatory process. Aspiration and biopsy at the time were nondiagnostic and showed no evidence of organisms. Two months after conservative treatment, the patient was readmitted with intractable low back pain and radiating bilateral leg pain. Repeat imaging showed increased interval signal in the L5-S1 disk, as well as enhancing soft-tissues that now extended to adjacent levels with extensive erosive changes. After surgical intervention for suspected infection, all cultures and stains for organisms were negative. Final pathology showed granulation tissue with focal inflammatory changes and calcium pyrophosphate crystal deposition. Although pseudogout is rare, physicians should add the disorder to the differential diagnosis for low back pain with radiculopathy and presumed infection.