Dynamic Flexion-Extension Magnetic Resonance Imaging of the Cervical Spine: An Evolutionary Tool for Diagnosis and Management of Cervical Spondylotic Myelopathy.

Dynamic problems need dynamic solutions. High motility of the cervical spine causes a common age-related degenerative condition called cervical spondylotic myelopathy (CSM), manifested by neurological impairments. An accurate and reliable diagnosis of CSM is crucial for determining appropriate management strategies. Traditional static magnetic resonance imaging (MRI) has been the gold standard for imaging CSM; however, it may not fully capture dynamic changes during neck movement. Dynamic flexion-extension (DFE) MRI is an innovative imaging technique that allows for real-time visualization of cervical spine motion. This review article aims to scrutinize the role of DFE MRI in assessing CSM, its added value to clinical implementations, and its limitations. Finally, by addressing the knowledge gaps, this survey sheds light on the road ahead to incorporate DFE MRI into a standard version of the practice.

The uterocervical angle-cervical length ratio: A promising predictor of preterm birth?

OBJECTIVE: To predict spontaneous preterm birth (sPTB) (labor before 37 weeks of pregnancy) in low-risk singleton pregnancies during the second trimester, using ultrasound markers: uterocervical angle (UCA) and cervical length (CL). METHODS: In a prospective observational cohort study, we followed primigravid women with singleton pregnancies without known risk factors for sPTB from 16+0-23+6 weeks of pregnancy until birth. Transvaginal ultrasonography on admission revealed the UCA and CL, and maternal history was obtained from submitted patient profiles. Logistic regression models disclosed significant predictive variables, and receiver operating curves (ROCs) demonstrated optimal cut-offs and test accuracy indices. Predictive functions of variables were compared using positive and negative likelihood ratios. RESULTS: In a sample of 357 participants, 41 (11.5%) experienced sPTB. UCA and CL were significantly associated with sPTB when adjusting for other variables (adjusted odds ratio: UCA 1.05, 95% confidence interval [CI] 1.02-1.07 and CL 0.82, 95% CI 0.75-0.90). Optimal cut-offs were estimated to be 106° and 33 mm for UCA and CL, respectively. We devised the novel index UCA/CL with an area under the ROC of 0.781 (95% CI 0.734-0.823), cut-off = 3.09°/mm, and improved likelihood ratios (positive: 3.18, 2.47, and 4.22; negative: 0.63, 0.52, and 0.51 for UCA, CL, and UCA/CL, respectively). CONCLUSION: The second-trimester UCA/CL was found to be a promising index to predict sPTB in low-risk singleton pregnancies. Further multicenter studies may generalize this conclusion to other gestational ages or risk groups and make it more comprehensive by considering other risk factors.

A transvaginal ultrasound-based diagnostic calculator for uterus post-cesarean scar defect.

BACKGROUND: A cesarean scar defect (CSD) is incomplete healing of the myometrium at the site of a prior cesarean section (CS), complicating more than half of all cesarean sections. While transvaginal ultrasound (TVU) is the most common modality for diagnosing this defect, hysteroscopy remains the gold standard. We aimed to develop an efficient diagnostic tool for CSD among women with abnormal uterine bleeding (AUB) by integrating TVU findings and participants' demographic features. METHODS: A single-center cross-sectional study was conducted on 100 premenopausal and non-pregnant women with a history of CS complaining of AUB without a known systemic or structural etiology. Each participant underwent a hysteroscopy followed by a TVU the next day. The defect dimensions in TVU, patients' age, and the number of previous CSs were integrated into a binary logistic regression model to evaluate their predictive ability for a hysteroscopy-confirmed CSD. RESULTS: Hysteroscopy identified 74 (74%) participants with CSD. The variables age, the number of CSs, defect length, and defect width significantly contributed to the logistic regression model to diagnose CSD with odds ratios of 9.7, 0.7, 2.6, and 1.7, respectively. The developed model exhibited accuracy, sensitivity, and specificity of 88.00%, 91.89%, and 76.92%, respectively. The area under the receiver operating curve was 0.955 (P-value < 0.001). CONCLUSION: Among non-pregnant women suspected of CSD due to AUB, looking at age, the number of previous CSs, and TVU-based defect width and length can efficiently rule CSD out.

Reference values for ductus venosus Doppler velocity indices between 11 and 13+6 weeks of gestation: A single-center prospective study in Iran.

Background: This study aimed to investigate reference Doppler velocimetry indices (DVIs) of the fetal ductus venosus (DV) during 11-13 + 6 gestational weeks. Materials and Methods: In a prospective observation over referrals to a single tertiary care center in a 2-year interval, normal singleton pregnancies with fetal crown-rump lengths (CRLs) of 43-80 mm were examined by a single experienced sonographer for their DV pulsatility index (DVPI), DV resistance index (DVRI), and S-wave maximum velocity/A-wave minimum velocity (S/A ratio). Multinomial and quantile regression functions were used to analyze the effect of gestational age (estimated by CRL) on reference values (5th and 95th percentiles of the distribution in each gestational day/week). P < 0.05 was considered significant. Results: Over a sample of 415 participants with a mean/median gestational age of 12 + 1 weeks, no significant correlations were found between the CRL and DVIs using multinomial regression functions (linear model best fitted for all [DVPI: B coefficient = 0.001, P = 0.235] [DVRI: B coefficient = 0.001, P = 0.287] [DV S/A: B coefficient = 0.010, P = 283]). Quantile regression analyses of DVIs' reference values were nonsignificant across the CRL range except for the DVRI ([5th regression line: coefficient = -0.004, P = 0.018] [95th regression line: coefficient = -0.001, P = 0.030]). Conclusion: Reference values for DVPI, DVRI, and DV S/A ratios were established as 0.80-1.39, 0.62-0.88, and 2.57-6.70, respectively. Future meta-analyses and multicenter studies are required to incorporate DV DVIs into an updated universal version of the practice.

Preventing thrombotic events in a case of postpartum ovarian artery aneurysm rupture: clinical challenges and management approaches.

Ovarian artery aneurysm is a rare asymptomatic condition usually diagnosed when it ruptures. It causes massive bleeding, often in the peripartum period of multiparous women, who are already at an increased risk for thromboembolic events. Balancing the bleeding risk against the thrombotic complications remains unexplored in such cases. A 35-year-old woman presented with hemorrhagic shock 3 days after delivering her seventh healthy child. During the emergent exploratory laparotomy, she responded well to the blood transfusion; the stable retroperitoneal hematoma indicated no need to explore it. A subsequent episode of hemodynamic instability necessitated another laparotomy, during which the hematoma was evacuated and both ovarian arteries were ligated. Shortly thereafter, the patient suffered a pulmonary embolism (PE). In multiparous patients presenting with peripartum retroperitoneal hematoma and hemorrhagic shock, exploring the hematoma and ligating the ovarian and uterine arteries may reduce the risk of PE or the need for reoperation.

Thoracolumbar Injury: The Thoracolumbar Injury Classification and Severity Scoring System or Modified Thoracolumbar Injury Classification and Severity?

OBJECTIVE: To compare the Thoracolumbar Injury Classification and Severity (TLICS) scoring system with its modified (mTLICS) version based on their agreement with the surgeon's opinion regarding treatment for patients with thoracolumbar injuries. Moreover, the Posterior Ligamentous Complex health was compared between intraoperative examinations and magnetic resonance imaging (MRI) reports. METHODS: MRI was obtained from 114 patients suffering thoracolumbar spinal trauma; the TLICS and mTLICS scores were measured. Approaches 1 and 2 were designed in both scoring systems based on assuming a total score of 4 as surgery and conservative management indication, respectively. Kappa was used to estimate the agreements between each approach and the surgeon's opinion on treatment. The receiver operating curve calculated the appropriate cut-off scores for the above systems over which surgical management was preferred. A P < 0.05 was considered significant. RESULTS: All the approaches showed moderate agreements with the surgeon's opinion on therapeutic management (TLICS: κapproach1 = 0.557, κapproach2 =0.508; mTLICS: κapproach1 = 0.557, κapproach2 = 0.551; P < 0.001 for each κ). A score >3.5 best illustrated the indication for surgery in both systems. The radiology report agreed stronger with intraoperatively observed ligamentous health when suspicious cases on MRI were reported as injured (κTLICS = 0.830, κmTLICS = 0.704) rather than healthy (κTLICS = 0.620, κmTLICS = 0.620). CONCLUSIONS: The surgeon's treatment plan agreed moderately with suggestions of the TLICS and mTLICS systems; surgery was the preferred management for the patients with a score of 4. Moreover, radiologic suspicion of Posterior Ligamentous Complex injury seemed to indicate a damaged ligament rather than a healthy one.

Evaluation of Skin-Soft Tissue Envelope Thickness by Ultrasonography after Primary and Revision Rhinoplasty.

BACKGROUND: Excessive nasal edema is among the complications after rhinoplasty translating into Skin-Soft Tissue Envelope (SSTE) thickening and disruption in the nasal framework's definition. Revision rhinoplasties are suspected of causing even more nasal edema. The objective postoperative SSTE thickness between revisionary and primary rhinoplasties is compared in this study. METHODS: A study was conducted over a recorded database of eligible candidates who had attended the senior author's private clinic in a 12-month period and underwent primary and revisionary open-approach rhinoplasties. The SSTE thickness was measured by ultrasonography in each nasion, rhinion, supratip, and tip region at months 1, 3, 6, and 12 after each episode of rhinoplasty. Paired T-test was used for pairwise comparisons of the corresponding region-time thicknesses between primary and revisionary rhinoplasties. Repeated measure ANOVA tests were used to assess mean thickness changes over time after each surgery-P < 0.05 indicated significance. RESULTS: Of the 36 participants analyzed, the SSTE was significantly thicker after revisionary surgery in all the follow-up sessions and nasal regions, except for the 1-month follow-up in the nasion (p = 0.273) and 12-month follow-up in the rhinion (p = 0.050). Mean nasal SSTE thickness showed decreasing trends in each region after either primary or revisionary surgery, with a lower level of resolution in the nasion region after revision rhinoplasty (p < 0.001). CONCLUSIONS: The nasal SSTE had been significantly thicker in most regions after revisionary procedures than primary ones, and the swelling had subsided slightly slower. Surgeons are recommended to consider revisionary rhinoplasties based on these findings cautiously. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Association between patellofemoral osteoarthritis with demographic features and anatomical variants of the knee in non-traumatic patients.

BACKGROUND: Patellofemoral osteoarthritis (PFOA) is a common cause of knee discomfort and impairment, particularly among athletes. The development of PFOA has been associated with anatomical knee variations, such as trochlear dysplasia and patella alta. However, the relationship between these anatomical variants and the development of PFOA remains poorly understood. This study aimed to investigate the association between PFOA and knee anatomical variants in a cohort of patients. METHODS: The study included 200 patients with PFOA and 200 healthy controls. In this study, we investigate the relationship of osteoarthritis with both anatomical variants and demographic characteristics. The participants underwent Magnetic resonance imaging (MRI) evaluation of the knee, and anatomical variants including trochlear dysplasia and patella alta were assessed. The severity of PFOA was also graded based on cartilage area and depth, as well as the bone marrow involvement and presence of osteophytes. RESULTS: Statistically significant differences were observed between the two groups in terms of Tibial tuberosity-trochlear groove (TT-TG) distance, patella position, trochlear dysplasia, and Insall-Salvati ratio. The mean TT-TG distance, prevalence of alta patella position, and Insall-Salvati ratio were significantly higher in cases (P<0.001 for all), and cases had a higher incidence of trochlear dysplasia (P<0.001). There were no significant differences between cases and controls regarding patella baja. CONCLUSION: Anatomical knee variants, including the TT-TG distance, trochlear dysplasia, and Insall-Salvati ratio, are significant risk factors for PFOA progression. The results also indicate that higher BMI and older age are significantly associated with more measures of MRI Osteoarthritis Knee Score (MOAKS) than demographic information. Among anatomical variants, a higher TT-TG distance and an increased grade of trochlear dysplasia show a significant relationship with more measures of MOAKS. Understanding the relationship between these factors has important clinical and research implications and can help inform the development of new treatments.

Coronary artery calcification-does it predict the CAD-RADS category?

PURPOSE: Coronary calcium scores (CCSs) in cardiac-gated computed tomography (CCT) are diagnostic for coronary artery disease (CAD). This study aims to investigate if CCSs can foretell CAD-reporting and data system (CAD-RADS) without performing computed tomography angiography (CTA). METHODS: Profiles of 544 patients were studied who had gone through CCT and CTA; the number of calcified regions of interest (ROIs), the Agatston, area, volume, and mass CCSs were calculated. Among the CAD-RADS categories (1 to 5), the mean values were compared for each CCS separately. A cut-offfor each CCS was declared using ROC curve analysis, more than which could predict significant CAD (CAD-RADS 3 to 5). Also, logistic regression models indicated the most probable CAD-RADS category based on the CCSs. P < 0.05 was considered significant. RESULTS: Among 53% male and 47% female participants with a mean (SD) age of 62.57 (0.84) years, numbers of calcified ROIs were significantly different between each pair of CAD-RADS categories. While other CCSs did not show a significant difference between CAD-RADS 1 and 2 or 2 and 3. All CCSs were significantly different between the non-significant and significant CAD groups; cut-offs for the number of calcified ROIs, the Agatston, area, volume, and mass scores were 9, 128, 44mm2, 111mm3, and 22 mg, respectively. Formulae A and B predicted the most probable CAD-RADS category (accuracy: 79%) and the probability of significant/non-significant CAD (accuracy: 81%), respectively. CONCLUSION: CCSs could predict CAD-RADS with an accuracy of 80%. Further studies are needed to introduce more predictive calcium indices.