ACR appropriateness criteria management of vertebral compression fractures.

This is an updated review of management of vertebral compression fracture for both benign osteoporotic and malignant causes. Vertebral compression fracture radiologic imaging evaluation is discussed. A literature review is provided of current indications for vertebral augmentation with percutaneous vertebroplasty and kyphoplasty as well as medical management. Limitations and potential benefits of these procedures are discussed. Variant tables describing various clinical situations are also provided to assist in determining appropriate use of these treatments for patient care. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to formulate recommendations for imaging or treatment.

Magnetic resonance imaging of abdominal versus vaginal prolapse surgery with mesh.

INTRODUCTION AND HYPOTHESIS: We compared two surgical approaches in patients with symptomatic prolapse of the vaginal apex with normal controls by analyzing pelvic landmark relationships measured using magnetic resonance imaging (MRI) before and after surgery. METHODS: In this prospective multicenter pilot study involving 16 participants, nulliparous controls (n = 6) were compared with ten parous (3.0 ± 1.0) women with uterine apical prolapse equal to or greater than stage 2. Group A (n = 5) underwent abdominal sacral colpopexy with monofilament polypropylene mesh and group B (n = 5) with vaginal mesh kit repair (Total ProLift). Subtotal hysterectomy was performed in all group A and no group B women. All patients underwent preoperative and 3-month postoperative Pelvic Organ Prolapse Quantification (POP-Q) and dynamic MRI. Comparison of MRI pelvic angles and distances was performed and analyzed by Mann-Whitney rank sum test and chi-square test. RESULTS: Vaginal apical support is similar at 3 months for abdominal sacral colpopexy (ASCP) and ProLift by POP-Q examination and MRI analysis. In both treatment groups, the postoperative POP-Q point C and MRI parameters were similar to nulliparous controls at 3 months. CONCLUSIONS: Anatomic outcomes for ASCP compared with ProLift were similar at 3 months in terms of vaginal apical support by POP-Q and MRI analysis. Continued comparative analysis of postoperative support with objective imaging seems warranted.

ACR appropriateness criteria(®) acute trauma to the knee.

There are more than 1 million visits to the ER annually in the United States for acute knee trauma. Many of these are twisting injuries in young patients who can walk and bear weight, and emergent radiography is not required. Several clinical decision rules have been devised that can considerably reduce the number of radiographic studies ordered without missing a clinically significant fracture. Although fractures are seen on only 5% of emergency department knee radiographs, 86% of knee fractures result from blunt trauma. In patients with falls or twisting injuries who have focal tenderness, effusion, or inability to bear weight, radiography should be the first imaging study performed. If radiography shows no fracture, MRI is best for evaluating for a suspected meniscal or ligament tear or patellar dislocation. Patients with knee dislocation should undergo radiography and MRI, as well as fluoroscopic angiography, CT angiography, or MR angiography. The ACR Appropriateness Criteria(®) are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

ACR Appropriateness Criteria® on acute shoulder pain.

The shoulder joint is a complex array of muscles, tendons, and capsuloligamentous structures that has the greatest freedom of motion of any joint in the body. Acute (<2 weeks) shoulder pain can be attributable to structures related to the glenohumeral articulation and joint capsule, rotator cuff, acromioclavicular joint, and scapula. The foundation for investigation of acute shoulder pain is radiography. Magnetic resonance imaging is the procedure of choice for the evaluation of occult fractures and the shoulder soft tissues. Ultrasound, with appropriate local expertise, is an excellent evaluation of the rotator cuff, long head of the biceps tendon, and interventional procedures. Fluoroscopy is an excellent modality to guide interventional procedures. Computed tomography is an excellent modality for characterizing complex shoulder fractures. Computed tomographic arthrography or fluoroscopic arthrography may be alternatives in patients for whom MR arthrography is contraindicated. A multimodal approach may be required to accurately assess shoulder pathology. The ACR Appropriateness Criteria(®) are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

MRI pelvic landmark angles in the assessment of apical pelvic organ prolapse.

PURPOSE: The aim of the study was to evaluate the utility of magnetic resonance imaging (MRI) pelvic landmark angles and lines in the assessment of apical vault prolapse. METHODS: Seventeen women were evaluated as part of a prospective surgical trial. Baseline data are presented as a pilot study of the utility of MRI in addition to this evaluation of 6 nulliparous volunteers without prolapse and 11 parous women with symptomatic ≥ stage II uterine prolapse. Each patient underwent assessment for pelvic organ prolapse quantification (POPQ) and pelvic MRI. Pelvic landmark angles and lines were measured. Mann-Whitney Rank sum test and Spearman's Rank order correlation test were used to assess agreement. RESULTS: Women with prolapse had a significantly larger h angle, g angle, and e angle at rest than those without prolapse. Correlation between apical vault descent was measured clinically by POPQ point C with MRI measurements: h angle (r = 0.61, p = 0.01), g angle (r = 0.64, p = 0.005), and e angle (r = 0.62, p = 0.007). CONCLUSION: MRI measurements of pelvic landmark angles reliably differentiate between women with and without uterine prolapse and correlate best with POPQ point C.

Catastrophic polyethylene failure diagnosed with magnetic resonance imaging in a painful total knee arthroplasty.

Determining the etiology of a painful knee after arthroplasty can be extremely challenging. Traditionally, orthopedists relied mainly on physical examination, laboratory results, serial radiographs, and 3-phase bone or indium-labeled white blood cell scans; however, recent advances in magnetic resonance imaging (MRI) software have given orthopedists another powerful tool in their diagnostic armamentarium. We provide the MRI software modification technique for metallic artifact reduction as well as present a novel case in which MRI was used to diagnose catastrophic polyethylene postfailure in a posterior cruciate ligament substituting knee. Although the role for MRI in the postarthroplasty knee has yet to be clearly defined, its utility in working up a painful arthroplasty when history, physical examination, and other diagnostic utilities fail to provide answers is clearly demonstrated in this case.

ACR appropriateness criteria on metastatic bone disease.

Appropriate imaging modalities for screening, staging, and surveillance of patients with suspected and documented metastatic disease to bone include (99m)Tc bone scanning, MRI, CT, radiography, and 2-[(18)F]fluoro-2-deoxyglucose-PET. Clinical scenarios reviewed include asymptomatic stage 1 breast carcinoma, symptomatic stage 2 breast carcinoma, abnormal bone scan results with breast carcinoma, pathologic fracture with known metastatic breast carcinoma, asymptomatic well-differentiated and poorly differentiated prostate carcinoma, vertebral fracture with history of malignancy, non-small-cell lung carcinoma staging, symptomatic multiple myeloma, osteosarcoma staging and surveillance, and suspected bone metastasis in a pregnant patient. No single imaging modality is consistently best for the assessment of metastatic bone disease across all tumor types and clinical situations. In some cases, no imaging is indicated. The recommendations contained herein are the result of evidence-based consensus by the ACR Appropriateness Criteria((R)) Expert Panel on Musculoskeletal Radiology.

Sonographic contrast effect of combined steroid and anesthetic injections: in vitro analysis.

OBJECTIVE: The purpose of this study was to investigate the extent and duration of the sonographic contrast effect during guided steroid-anesthetic injections and to propose a potential mechanism based on mixture immiscibility and density differences. METHODS: A steroid-anesthetic mixture was injected into cyst phantoms under sonographic visualization, and time-dependent data were acquired. Regions of interest were drawn within each cyst, and measured mean pixel intensities were compared with a gel phantom background that served as a control. Two test tubes were also prepared similarly with the steroid-anesthetic mixture and saline in one test tube and synovial fluid in the other; these were observed to estimate separation time to form a fluid-fluid level. RESULTS: There was a substantial contrast effect after injection of the steroid-anesthetic suspension into a cyst phantom containing saline. The background levels remained constant during the period of observation. The contrast effect decreased as a function of time to 4 (94% decrease from the time of injection) in the upper half and to 34 (64% decrease from the time of injection) in the lower half throughout the course of the experiment. The test tube containing the injected material in saline achieved separation in approximately 15 minutes, whereas in the synovial fluid, separation was achieved in 48 hours. CONCLUSIONS: We have verified, in vitro, an apparent clinically observed contrast effect noted during sonographically guided therapeutic injections of cortisone-anesthetic mixtures. We have shown that this effect relates to differences in acoustic impedance and immiscibility, differences in density of the mixture, or both.

Haglund's syndrome: diagnosis and treatment using sonography.

Haglund's syndrome is a cause of retrocalcaneal pain. The clinical diagnosis of Haglund's syndrome is often confusing as the clinical picture may mimic other causes of hindfoot pain such as isolated retrocalcaneal bursitis or hindfoot involvement from more systemic arthropathies such as Reiter's syndrome or rheumatoid arthritis. With the increasing frequency of employing sonography as a diagnostic tool in the evaluation of foot and ankle pathology, recognition of the sonographic appearance of Haglund's complex is important. We report a case of Haglund's syndrome diagnosed and treated with sonography.

Radiology-Pathology Conference: carcinosarcoma of the colon.

Carcinosarcomas are very uncommon tumors, which are comprised of both malignant epithelial and mesenchymal elements. They occur most commonly in the head and neck, respiratory tract, and female reproductive organs. In the gastrointestinal tract, they are most often found in the oropharynx, esophagus, and, to a lesser extent, in the stomach. Carcinosarcomas rarely originate from the colon, but when they do, they are extremely aggressive malignancies. We report the radiologic and pathologic findings of a patient with a carcinosarcoma believed to have arisen from the colon and which involved the adjacent mesentery and omentum.

Radiation safety during spine interventions.

Image-guided spine interventions are being performed by radiologists and other physicians with increased frequency. This article assesses the use of several techniques and devices that can mitigate radiation exposure during interventional procedures. Measurements were obtained on a humanoid phantom with use of various shielding methods. Significant radiation dose reductions as great as 98.7% can be achieved with use of a combination of stationary and mobile lead barriers and operator position. The application of basic radiation physics in combination with prudent radiographic technique can significantly reduce radiation exposure to the operator and other personnel during spine interventions.

Can a state-of-the-art D-dimer test be used to determine the need for CT imaging in patients suspected of having pulmonary embolism?

RATIONALE AND OBJECTIVES: The purpose of this study was to determine whether a simple rapid blood test can obviate computed tomography (CT) in a sizable percentage of patients suspected of having pulmonary embolism, based on the hypothesis that negative D-dimer results could eliminate any further search for pulmonary embolism. MATERIALS AND METHODS: At the authors' institution, 2,121 sequential patients underwent a whole-blood antibody agglutination test for cross-linked fibrin degradation products (D-dimer). Of these patients, 844 had positive test results and were not further considered. A retrospective review included reports of all multisection combined CT venographic and pulmonary angiographic studies obtained within 48 hours of the D-dimer assay for the 1,277 patients with negative D-dimer results; 229 (18%) of these 1,277 patients underwent combined CT venography and pulmonary angiography, usually within 24 hours. RESULTS: Retrospective review of the imaging examinations that were discrepant with the D-dimer results revealed only three false-negative D-dimer results. Of the 229 patients in whom combined CT venography and pulmonary angiography was performed for suspected pulmonary embolism, 226 (98.7%) had no evidence of acute pulmonary embolism or deep venous thrombosis. The negative predictive value of a negative D-dimer result was therefore 98.7% (confidence interval, 96.2%-99.7%). CONCLUSION: The D-dimer assay is a simple rapid blood test that is sensitive to the presence of acute thrombosis. Very few patients with negative results have acute deep venous thrombosis or pulmonary embolism, with combined CT venography and pulmonary angiography used as the reference standard.

Utility of hematuria testing in patients with suspected renal colic: correlation with unenhanced helical CT results.

OBJECTIVES: To determine the utility of hematuria testing in a large series of patients with suspected renal colic using unenhanced helical computed tomography (CT) as the reference standard. METHODS: A retrospective review of the CT reports of all patients who underwent unenhanced helical CT for suspected renal colic at one institution during a 3.5-year period and who also underwent a formal microscopic urinalysis within 24 hours of the CT study was conducted. The sensitivity, specificity, positive predictive value, and negative predictive value of the presence of any blood on the urinalysis for renal colic were calculated. RESULTS: Urolithiasis was present in 587 (62%) of the 950 patients, and 363 patients had negative examinations for renal colic, including 69 with significant alternative diagnoses in the latter group. Of the urinalyses, 492 were true-positive, 174 were true-negative, 189 were false-positive, and 95 were false-negative, yielding a sensitivity, specificity, positive predictive value, and negative predictive value of 84%, 48%, 72%, and 65%, respectively. Forty-six percent of the urinalysis results were negative for blood in the subset of patients with significant alternative diagnoses. CONCLUSIONS: The sensitivity of hematuria on microscopic urinalysis for renal colic using unenhanced CT as the reference standard was 84%, and the specificity and negative predictive value was low. The presence or absence of blood on urinalysis cannot be used to reliably determine which patients actually have ureteral stones.