[CT-guided pain management of specific low back pain : Disc impairment vs. osseous degeneration]. / CT-gesteuerte Schmerztherapie des spezifischen Rückenschmerzes : Bandscheibenschädigung vs. ossäre Degeneration.

BACKGROUND: Back pain is common and leads the patient to the radiologist both for diagnosis and in specific cases for therapy. OBJECTIVES: The current study compares the pain-reducing effect of microinvasive computed tomography (CT)-guided pain therapy for specific back pain caused by herniated discs or spondylarthrosis. MATERIALS AND METHODS: Over a period of 3.3 years, a total of 239 patients were included, in whom 686 CT-guided periradicular therapies (PRT) and 264 CT-guided facet joint therapies (FAC) were performed. In all patients, the pain score was determined using a visual analog pain scale (VAS) before the intervention, during the course of treatment and at the end of treatment. Finally, treatment success was correlated to the type of treatment performed and to the morphological changes present. RESULTS: Both groups showed good improvement of pain under treatment (74% of the PRT patients and 60% of the FAC patients). Patients who underwent PRT showed an average improvement in pain score of 3.1, while those who underwent FAC showed an average improvement of 2.1. The efficacy of FAC was dependent on the degree of degenerative changes present. The more extensive the proven degeneration was in the treated segment, the more interventions were necessary for a good treatment response. CONCLUSION: CT-guided PRT and CT-guided FAC both lead to a good reduction of pain symptoms. In comparison, PRT achieves significantly higher pain reduction than FAC.

The physician as a success determining factor in CT-guided pain therapy.

BACKGROUND: Back pain is a common problem and a burden for the patient. MR-morphologically proven pain-causing changes of the spine is often successfully treated utilizing CT-guided pain therapy. The CT-guided execution enables a controlled and reproducible therapy. Nevertheless, treatment results can differ even with the same patient; the physician is a possible influencing factor of the outcome. Accordingly, the present study analyzes the different behaviors and forms of communication of the treating physicians during the course of the intervention as factors influencing the outcome of treatment. METHODS: 67 patients suffering from specific back pain were included in this study. 5 treating physicians (2 female, 3 male) of different age (29-63 years), and experience and a total of 244 CT-guided treatments were included in this study. In every case a psychologist observed the treatment based on a standardized observation protocol. Observed were both the verbal and non-verbal interactions as well as the reaction of patient and physician. The success of the therapy was measured in the course of the treatment using the visual analogue pain scale. The technical comparability of the performed CT-guided periradicular therapy was ensured by the distribution of the drug mixture. RESULTS: The outcome is significantly better if the patient considers the treating physician to be competent (correlation coefficient: 0.24, p < 0.006) and feels understood (correlation coefficient: 0.29, p < 0.001). In addition, the outcome is better when the physician believes that the treatment brings a positive reduction of pain, underlining his belief with positive statements of affirmation before the intervention thus creating a positive atmosphere [correlation coefficient: 0.24 (p < 0.009)]. In contrast, the outcome is worse if the patient complains about pain during the intervention [average pain reduction M = 0.9 (pain group) vs. M = 2.0 (no-pain group)]. CONCLUSION: Our study shows that with comparable implementation of CT-guided periradicular therapy, the outcome of the patient with specific back pain can be significantly improved by certain behavioral patterns of the performing physician and this without side effects and without significant additional time expenditure. Our findings indicate that there is a non-negligible psychological factor linking confidence in therapy to actual therapy success. TRIAL REGISTRATION: The study was designed as an observational study, therefore a trial registration was not necessary.

Diagnostic value of proton MR spectroscopy in peripheral arterial occlusive disease: a prospective evaluation.

OBJECTIVE: The objective of the present study was to determine the detectability of metabolic alterations in patients with peripheral arterial occlusive disease (PAOD) using proton MR spectroscopy (hydrogen-1 MR spectroscopy). SUBJECTS AND METHODS: Twenty-seven people were included in this study: 10 patients with PAOD and a pain-free walking distance of less than 200 m served as the patient group and 17 young healthy subjects served as a control group. Hydrogen-1 MR spectroscopy was performed on a 1.5-T scanner using an extremity coil and a point-resolved spectroscopy (PRESS) sequence (TR/TE, 1,500/30; 256 repetitions). For the patient group, a voxel was localized in the gastrocnemius muscle of the diseased leg. The data were processed using standard 1H MR spectroscopy tools. The identification of resonances detected on all MR spectra was made: intramyocellular lipids at 1.2 ppm, extramyocellular lipids at 1.6 ppm, lactate at 4.1 ppm, glucose with two main peaks at 3.4 and 3.8 ppm, choline at 3.2 ppm, and creatine at 3.0 and 3.9 ppm. To avoid operator bias, three spectral intensities were measured after correcting baseline and phase of MR spectra each time. The creatine signal was used as an internal reference; thus, all spectra were scaled relative to creatine. We compared the resultant intensity ratios between the two groups using the Mann-Whitney U test. RESULTS: The lactate-creatine quotient was higher in the patient group, with a ratio of 1.6, than in the control group, with a ratio of 0.6. The glutamate-creatine ratio was higher in the patient group than in the control group (1.3 vs 0.8, respectively). All other ratios were higher in the control group. The best ratio for differentiating between healthy subjects and patients with PAOD was the glucose-lactate ratio. The patient group had a glucose-lactate quotient of 5.4, whereas the control group had a glucose-lactate quotient of 21.5 (p = 0.001). CONCLUSION: Proton MR spectroscopy has the potential to allow identification of patients who have PAOD on the basis of altered muscle metabolism.

Multi-detector CT in the evaluation of patients with recurrence of rectal cancer.

The advantages of multiplanar reconstruction in rectal cancer recurrence diagnostics using medium resolution multi-detector CT are evaluated. We included 40 patients after a rectal cancer operation in this study. During follow-up ten patients developed a recurrence. All patients received a minimum of two CT-examinations in their follow-up program. A total of 131 CT-scans were evaluated. Each examination was reviewed by two experienced radiologists in respect to recurrence. Each examination was presented in axial reconstruction with a slice thickness of 8mm with an increment of 7 mm and a slice thickness of 3 mm with an increment of 2 mm. The thin slices were used for the multi-planar reconstruction. Multi-planar reconstructions showed better results for the detection of recurrence than axial reconstruction. A reduced slice thickness did not lead to better results in axial reconstruction. Multi-planar reconstruction showed a sensitivity of 0.88, a specificity of 1.0 and an accuracy of 0.97. Our axial reconstruction results were: 0.86, 0.96, and 0.93, respectively. Sensitivity and accuracy showed a significant increase after the first and second examinations. Multi-planar reconstructions allow for better detection of rectal cancer recurrence when compared to axial reconstructions. Thinner axial slice thickness shows no diagnostic advantage.

Multislice computed tomography angiography of the abdominal arteries: comparison between computed tomography angiography and digital subtraction angiography findings in 52 cases.

Since the introduction of multislice CT scanners, CT angiography (CTA) has become a powerful tool for imaging the vascular system. We compare conventional angiography to CTA in the diagnosis of morphological changes in the abdominal aorta and its branches. A retrospective analysis of 52 patients who underwent both multislice CT angiography (MSCTA) and digital subtraction angiography before surgical treatment is presented. All CT examinations were performed after administration of 100 mL contrast medium with a collimation of 4 x 1 mm and a pitch of 7. A standardized evaluation of the axial, multiplanar and 3D reconstructions was performed by two experienced radiologists. Stenoses were classified as high-grade and low-grade, and aneurysms, occlusions and arteriosclerosis were evaluated. The CTA findings were compared with conventional angiography. All aneurysms, occlusions, stenoses and calcifications were diagnosed correctly by CTA in axial and multiplanar projections (sensitivity 1.0; specificity 1.0). The degree of stenosis was overestimated in three cases when using axial projections. Three-dimensional volume-rendered CTA showed a sensitivity of 0.91 for aneurysms, 0.82 for stenoses, 0.75 for occlusions and 0.77 for calcifications. The specificity was 1.0 in all cases. Multislice CT angiography seems to be similar to conventional digital subtraction angiography for abdominal vessels if multiplanar projections are used.