Metallic spinal artifacts in magnetic resonance imaging

[Magnetic resonance imaging artefacts and fixed orthodontic attachments]

OBJECTIVES

Orthodontic appliances are often removed before magnetic resonance imaging (MRI) scans because they are known to produce artefacts. The purpose of this study was to find the exact indications for removal of various fixed attachments when imaging four specific areas of the head and neck.

MATERIALS AND METHODS

Sixty patients requiring an MRI scan of the head for medical reasons volunteered for this investigation. One of four different types of fixed attachments (stainless steel brackets, titanium brackets, ceramic brackets with metal slots, and stainless steel retainers) were assigned to a patient. Each patient had two scans at 1.5 T: with an "empty wax jig" and with a wax jig including the attachment. Archwires were not investigated as they are easily removed before a scan. Two radiologists evaluated the scans of each patient and each of the four areas under investigation: maxillary sinus, oral cavity, temporomandibular joints and posterior cerebral fossa.

RESULTS

Stainless steel brackets always caused non-interpretability of all anatomic areas (100 per cent). Titanium brackets, ceramic brackets with metal slots, and stainless steel retainers caused artefact in the oral cavity only (for 20, 16.65, and 86.65 per cent of the subjects).

CONCLUSIONS

Our results show that ceramic brackets with metal slots and titanium brackets do not always have to be removed before MRI scans of the head and neck, depending on the area under investigation. Metal fixed retainers should only be removed if the oral cavity itself is under investigation. Stainless steel brackets should always be removed before MRI scans of the head and neck.

A standardized evaluation of artefacts from metallic compounds during fast MR imaging

OBJECTIVES

Metallic compounds present in the oral and maxillofacial regions (OMRs) cause large artefacts during MR scanning. We quantitatively assessed these artefacts embedded within a phantom according to standards set by the American Society for Testing and Materials (ASTM).

METHODS

Seven metallic dental materials (each of which was a 10-mm³ cube embedded within a phantom) were scanned [i.e. aluminium (Al), silver alloy (Ag), type IV gold alloy (Au), gold-palladium-silver alloy (Au-Pd-Ag), titanium (Ti), nickel-chromium alloy (NC) and cobalt-chromium alloy (CC)] and compared with a reference image. Sequences included gradient echo (GRE), fast spin echo (FSE), gradient recalled acquisition in steady state (GRASS), a spoiled GRASS (SPGR), a fast SPGR (FSPGR), fast imaging employing steady state (FIESTA) and echo planar imaging (EPI; axial/sagittal planes). Artefact areas were determined according to the ASTM-F2119 standard, and artefact volumes were assessed using OsiriX MD software (Pixmeo, Geneva, Switzerland).

RESULTS

Tukey-Kramer post hoc tests were used for statistical comparisons. For most materials, scanning sequences eliciting artefact volumes in the following (ascending) order FSE-T₁/FSE-T₂ < FSPGR/SPGR < GRASS/GRE < FIESTA < EPI. For all scanning sequences, artefact volumes containing Au, Al, Ag and Au-Pd-Ag were significantly smaller than other materials (in which artefact volume size increased, respectively, from Ti < NC < CC). The artefact-specific shape (elicited by the cubic sample) depended on the scanning plane (i.e. a circular pattern for the axial plane and a "clover-like" pattern for the sagittal plane).

CONCLUSIONS

The availability of standardized information on artefact size and configuration during MRI will enhance diagnosis when faced with metallic compounds in the OMR.

The Contribution of Common Surgically Implanted Hardware to Functional MR Imaging Artifacts

BACKGROUND AND PURPOSE

Blood oxygenation level-dependent MR imaging is increasingly used clinically to noninvasively assess cerebrovascular reactivity and/or language and motor function. However, many patients have metallic implants, which will induce susceptibility artifacts, rendering the functional information uninformative. Here, we calculate and interpret blood oxygenation level-dependent MR imaging artifact impact arising from surgically implanted hardware.

MATERIALS AND METHODS

A retrospective analysis of all blood oxygenation level-dependent MRIs (n = 343; B0 = 3T; TE = 35 ms; gradient echo EPI) acquired clinically (year range = 2006-2014) at our hospital was performed. Blood oxygenation level-dependent MRIs were most commonly prescribed for patients with cerebrovascular disease (n = 80) or patients undergoing language or motor localization (n = 263). Artifact volume (cubic centimeters) and its impact on clinical interpretation were determined by a board-certified neuroradiologist.

RESULTS

Mean artifact volume associated with intracranial hardware was 4.3 ± 3.2 cm(3) (range = 1.1-9.4 cm(3)). The mean artifact volume from extracranial hardware in patients with cerebrovascular disease was 28.4 ± 14.0 cm(3) (range = 6.1-61.7 cm(3)), and in patients with noncerebrovascular disease undergoing visual or motor functional mapping, it was 39.9 (3)± 27.0 cm(3) (range = 6.9-77.1 cm(3)). The mean artifact volume for ventriculoperitoneal shunts was 95.7 ± 39.3 cm(3) (range = 64.0-139.6 cm(3)). Artifacts had no-to-mild effects on clinical interpretability in all patients with intracranial implants. Extracranial hardware artifacts had no-to-moderate impact on clinical interpretability, with the exception of 1 patient with 12 KLS-Martin maxDrive screws with severe artifacts precluding clinical interpretation. All examined ventriculoperitoneal shunts resulted in moderate-to-severe artifacts, limiting clinical interpretation.

CONCLUSIONS

Blood oxygenation level-dependent MR imaging yields interpretable functional maps in most patients beyond a small (30-40 cm(3)) artifact surrounding the hardware. Exceptions were ventriculoperitoneal shunts, particularly those with programmable valves and siphon gauges, and large numbers of KLS-Martin maxDrive screws.

Magnetic resonance imaging artefacts and fixed orthodontic attachments

BACKGROUND/OBJECTIVES

Orthodontic appliances are often removed before magnetic resonance imaging (MRI) scans because they are known to produce artefacts. The purpose of this study was to find the exact indications for removal of various fixed attachments when imaging four specific areas of the head and neck.

MATERIALS/METHODS

Sixty patients requiring an MRI scan of the head for medical reasons volunteered for this investigation. One of four different types of fixed attachments (stainless steel brackets, titanium brackets, ceramic brackets with metal slots, and stainless steel retainers) were assigned to a patient. Each patient had two scans at 1.5 T: with an 'empty wax jig' and with a wax jig including the attachment. Archwires were not investigated as they are easily removed before a scan. Two radiologists evaluated the scans of each patient and each of the four areas under investigation: maxillary sinus, oral cavity, temporomandibular joints, and posterior cerebral fossa.

RESULTS

Stainless steel brackets always caused non-interpretability of all anatomic areas (100 per cent). Titanium brackets, ceramic brackets with metal slots, and stainless steel retainers caused artefact in the oral cavity only (for 20, 16.65, and 86.65 per cent of the subjects).

CONCLUSIONS/IMPLICATIONS

Our results show that ceramic brackets with metal slots and titanium brackets do not always have to be removed before MRI scans of the head and neck, depending on the area under investigation. Metal fixed retainers should only be removed if the oral cavity itself is under investigation. Stainless steel brackets should always be removed before MRI scans of the head and neck.

Long-term stability after multilevel cervical laminectomy for spinal cord tumor resection in von Hippel-Lindau disease

OBJECT

Despite the frequent multiplicity and development of new spinal cord hemangioblastomas that require multiple resections in patients with von Hippel-Lindau (VHL) disease, the long-term effects of spinal surgery on spinal column stability in this neoplasia disorder are not known. To determine the effect of multilevel cervical laminectomy for spinal cord tumor resection in VHL, the authors analyzed long-term clinical and radiographic outcomes.

METHODS

The authors included consecutive patients enrolled in a prospective VHL disease natural history study who underwent cervical laminectomy(s) for spinal cord hemangioblastoma resection. Serial clinical examinations, neck disability indices, and radiographs (static and dynamic), as well as operative records, were analyzed.

RESULTS

Twenty-five adult patients (16 female, 9 male) with VHL disease underwent 34 operations (mean 1.4 ± 0.7 [± SD]/patient) for the resection of cervical spinal cord hemangioblastomas (mean number of lamina removed/surgery 3.0 ± 1.3). The mean age at surgery was 33.9 ± 11.9 years (range 18-61 years), and the mean follow-up duration was 9.1 ± 5.6 years. At last follow-up, radiographic criteria indicated that 9 patients (36%) had spinal column instability, 13 patients (52%) developed a cervical spinal deformity, 4 patients (16%) developed moderate to severe neck disability, and 3 patients (12%) met the criteria for clinical instability. Removal of the C-2 lamina was associated with the development of clinical instability (p = 0.02, Fisher exact test); older age at surgery was associated with the development of cervical deformity (p = 0.05, logistic regression); and a greater number of operations (suboccipital-T4) were associated with increased neck disability indices (p = 0.01, linear regression).

CONCLUSIONS

Whereas patients with VHL disease will often require multiple laminectomies for cervical spinal cord hemangioblastoma resection, a limited number of patients (12%) will develop clinical instability. Because prophylactic cervical instrumentation confers limited benefit at the time of spinal cord tumor resection for most patients, and because these patients need life-long MR imaging of the spinal cord, the quality of which may be affected by instrumentation, longitudinal clinical and radiological evaluation may be used to determine which patients will require stabilization.

Intervertebral test spacers and postfusion MRI artifacting: A comparative in vitro study of magnesium versus titanium and carbon fiber reinforced polymers as biomaterials

Intervertebral spacers are made of different materials, which can effect the postfusion magnetic imaging (MRI) scans. Susceptibility artifacts specially for metallic implants can decrease the image quality. This study aimed to determine whether magnesium as a lightweight and biocompatible metal is suitable as a biomaterial for spinal implants based on its MRI artifacting behavior. To compare artifacting behaviors, we implanted into one porcine cadaveric spine different test spacers made of magnesium, titanium and CFRP. All test spacers were scanned using 2 T1-TSE MRI sequences. The artifact dimensions were traced on all scans and statistically analyzed. The total artifact volume and median artifact area of the titanium spacers were statistically significantly larger than magnesium spacers (p < 0.001), while magnesium and CFRP spacers produced almost identical artifacting behaviors (p > 0.05). Our results suggest that spinal implants made with magnesium alloys will behave more like CFRP devices in MRI scans.

Magnetic resonance imaging evaluation of intervertebral test spacers: an experimental comparison of magnesium versus titanium and carbon fiber reinforced polymers as biomaterials

INTRODUCTION

Intervertebral spacers are made of different materials, which can affect the postfusion magnetic resonance imaging (MRI) scans. Susceptibility artifacts, especially for metallic implants, can decrease the image quality. This study aimed to determine whether magnesium as a lightweight and biocompatible metal is suitable as a biomaterial for spinal implants based on its MRI artifacting behavior.

MATERIALS AND METHODS

To compare artifacting behaviors, we implanted into one porcine cadaveric spine different test spacers made of magnesium, titanium, and CFRP. All test spacers were scanned using two T1-TSE MRI sequences. The artifact dimensions were traced on all scans and statistically analyzed.

RESULTS

The total artifact volume and median artifact area of the titanium spacers were statistically significantly larger than magnesium spacers (P < 0.001), while magnesium and CFRP spacers produced almost identical artifacting behaviors (P > 0.05).

CONCLUSION

Our results suggest that spinal implants made with magnesium alloys will behave more like CFRP devices in MRI scans.

Artifacts in spine magnetic resonance imaging due to different intervertebral test spacers: an in vitro evaluation of magnesium versus titanium and carbon-fiber-reinforced polymers as biomaterials

Introduction

Intervertebral spacers are made of different materials, which can affect the postfusion magnetic imaging (MRI) scans. Susceptibility artifacts especially for metallic implants can decrease the image quality. This study aimed to determine whether magnesium as a lightweight and biocompatible metal is suitable as a biomaterial for spinal implants based on its MRI artifacting behavior.

Materials and methods

To compare artifacting behaviors, we implanted into one porcine cadaveric spine different test spacers made of magnesium, titanium, and carbon-fiber-reinforced polymers (CFRP). All test spacers were scanned using two T1-TSE MRI sequences. The artifact dimensions were traced on all scans and statistically analyzed.

Results

The total artifact volume and median artifact area of the titanium spacers were statistically significantly larger than magnesium spacers (p < 0.001), while magnesium and CFRP spacers produced almost identical artifacting behaviors (p > 0.05).

Conclusion

Our results suggest that spinal implants made with magnesium alloys will behave more like CFRP devices in MRI scans. Given its osseoconductive potential as a metal, implant alloys made with magnesium would combine the advantages to the two principal spacer materials currently used but without their limitations, at least in terms of MRI artifacting.

Postimplantation MRI with cylindric and cubic intervertebral test implants: evaluation of implant shape, material, and volume in MRI artifacting--an in vitro study

BACKGROUND CONTEXT

Interbody spacers for anterior spine fusion are made of different materials, which can affect the postfusion magnetic resonance imaging (MRI) scans. Susceptibility artifacts specially for metallic implants can decrease the image quality.

PURPOSE

This study focused on the influence of determined implant parameters like shape, implant volume, and implant material in MRI artifacting with regard to solid geometrical titanium and carbon test spacers.

STUDY DESIGN/SETTING

A comparative study on an in vitro spine model. The study was performed at a university research facility.

METHODS

In this study we evaluated the postimplantation MRI scans of three determined cuboids and six cylinders, which were made of titanium alloy and carbon fiber reinforced polymer. MRI scans were carried out by using T1 turbo spin echo (TSE) sequences. The total artifact volume (TAV) as well as median artifact area (MAA) were calculated. Additionally the implant volume (IV)/TAV and cross-sectional area (CSA)/MAA relation were determined. Statistical analyses were calculated with the t test and Newman-Keuls test for multiple comparisons.

RESULTS

Considering all test implants with an increasing implant size, the TAV and the MAA became significantly larger (p<.001) with simultaneous reduction of the IV/TAV and CSA/MAA relation. In contrast to the carbon implant group, for titanium cylinders with an implant volume equivalent to the cuboids significant differences in MRI artifacting (p<.05) could be demonstrated.

CONCLUSIONS

Susceptibility artifacts were clearly affected by the implant material, shape, and implant volume. Independent of the implant material, with regard to a more advantageous IV/TAV and CSA/MAA relation, for larger implants the artifact rate was more limited to the implant's direct surroundings. On the basis of a high magnetizability for titanium implants with an equal IV, the range of implant-related susceptibility artifacts was influenced by the material as well as implant shape in favor of cylindric implants. According to the very low MRI artifact rate of carbon implants, the implant shape did not have any significant effect on the artifact behavior.

Implant detectibility of intervertebral disc spacers in post fusion MRI: evaluation of the MRI scan quality by using a scoring system--an in vitro study

INTRODUCTION

Intervertebral spacers for anterior spine fusion are made of different materials, such as titanium and cobalt chromium alloys and carbon fiber-reinforced polymers. Implant-related susceptibility artifacts can decrease the quality of MRI scans. The aim of this cadaveric study was to demonstrate the extent that implant-related MRI artifacting affects the postfusion differentiation of determined regions of interest (ROIs).

METHODS

In six cadaveric porcine spines, we evaluated the postimplantation MRI scans of a titanium, cobalt-chromium and carbon spacer that differed in shape and surface qualities. A spacer made of human cortical bone was used as a control. A defined evaluation unit was divided into ROIs to characterize the spinal canal as well as the intervertebral disc space. Considering 15 different MRI sequences read independently by an interobserver-validated team of specialists the artifact-affected image quality of the median MRI slice was rated on a score of 0-3. A maximum score of 18 points (100%) for the determined ROIs was possible.

RESULTS

Turbo spin echo sequences produced the best scores for all spacers and the control. Only the control achieved a score of 100%. For the determined ROI maximum scores for the cobalt-chromium, titanium and carbon spacers were 24%, 32% and 84%, respectively.

CONCLUSION

By using favored T1 TSE sequences the carbon spacer showed a clear advantage in postfusion spinal imaging. Independent of artifact dimensions, the scoring system used allowed us to create an implant-related ranking of MRI scan quality in reference to the bone control.

Magnetic resonance imaging of microstructure transition in stainless steel

Magnetic resonance images are prone to artifacts caused by metallic objects. Such artifacts may not only hamper image interpretation, but also have been shown to provide information about the magnetic properties of the substances involved. In this work, we aim to explore the potential of MRI to detect, localize and characterize changes in magnetic properties that may occur when certain alloys have been exposed to a thermomechanical stress. For this purpose, stainless steel 304 L wires were drawn to induce a change from paramagnetic austenitic into ferromagnetic martensitic microstructure. The changes in magnetic behavior were quantified by analyzing the geometric distortion in spin echo and the geometric distortion and intravoxel dephasing in gradient echo images at 0.5, 1.5 and 3 T. The results of both imaging strategies were in agreement and in accordance with independent measurements with a vibrating sample magnetometer. Drawing wire to 2% of its cross-sectional area was found to increase the volume fraction of the ferromagnetic martensite from 0.3% to 80% and to enhance the magnetization up to two or three orders of magnitude. The results demonstrate the potential of MRI to locate and quantify stress-induced changes in the magnetic properties of alloys in a completely noninvasive and nondestructive way.

The interobserver-validated relevance of intervertebral spacer materials in MRI artifacting

Intervertebral spacers for anterior spine fusion are made of different materials, such as titanium, carbon or cobalt-chrome, which can affect the post-fusion MRI scans. Implant-related susceptibility artifacts can decrease the quality of MRI scans, thwarting proper evaluation. This cadaver study aimed to demonstrate the extent that implant-related MRI artifacting affects the post-fusion evaluation of intervertebral spacers. In a cadaveric porcine spine, we evaluated the post-implantation MRI scans of three intervertebral spacers that differed in shape, material, surface qualities and implantation technique. A spacer made of human cortical bone was used as a control. The median sagittal MRI slice was divided into 12 regions of interest (ROI). No significant differences were found on 15 different MRI sequences read independently by an interobserver-validated team of specialists (P>0.05). Artifact-affected image quality was rated on a score of 0-1-2. A maximum score of 24 points (100%) was possible. Turbo spin echo sequences produced the best scores for all spacers and the control. Only the control achieved a score of 100%. The carbon, titanium and cobalt-chrome spacers scored 83.3, 62.5 and 50%, respectively. Our scoring system allowed us to create an implant-related ranking of MRI scan quality in reference to the control that was independent of artifact dimensions. The carbon spacer had the lowest percentage of susceptibility artifacts. Even with turbo spin echo sequences, the susceptibility artifacts produced by the metallic spacers showed a high degree of variability. Despite optimum sequencing, implant design and material are relevant factors in MRI artifacting.

Acute evaluation and management of pediatric spinal cord injury

BACKGROUND/OBJECTIVE

Of new spinal cord injuries (SCIs) throughout North America, up to 14% occur in children younger than 15 years of age. The purpose of this paper is to present several aspects unique to the evaluation and treatment of a child with SCI.

EVALUATION

Vital signs may be absent along with minimal blood loss, indicating upper cervical spine injury that is common in children. Lap belt injuries are more prevalent in children, especially since 1984, when seat belt laws were enacted, and more children began using a lap belt but no shoulder harness. Of children with lap belt injuries, 4% to 39% have significant neurologic injuries, and 30% to 50% have associated retroperitoneal injuries. Radiographic evaluation is more challenging in children because of the presence of normal variants such as C2-C3 pseudosubluxation, which occurs in 9% of children younger than 7 years. SCI without radiographic abnormality (SCIWORA) is common in children under 10 years of age and is associated with more complete neurologic injuries than in cases where the injuries can be seen on radiograph.

MANAGEMENT

For transportation of children and infants younger than 6 years of age, the cervical spine needs to be in a neutral position, and spine boards need to be modified to allow for the larger head-to-torso ratio that is present in children. Cervical traction with Crutchfield tongs in children <12 years of age is associated with dural leaks, and therefore, the use of halo traction with modified pin placements is recommended. Indications for surgery are generally the same as those for adults in regard to decompression and alignment. The length of a spinal fusion for stabilization should be minimized in the thoracolumbar spine because of the potential for premature arrest of spinal growth.

SUMMARY

The differences between children and adults with acute SCI are significant enough that caregivers cannot evaluate and treat a child with SCI as they would a small adult.

Artifacts from dental casting alloys in magnetic resonance imaging

The potential advantage of magnetic resonance imaging (MRI) has been limited by artifacts due to the presence of metallic materials. For quantitative evaluation of the magnitude of artifacts from dental casting alloys and implant materials in MR imaging, 11 dental casting or implant materials were imaged by means of 1.5 T MRI apparatus with three different sequences. Mean and standard deviation of water signal intensity (SI) around the sample in the region of interest (1200 mm(2)) were determined, and the coefficient of variation was compared for evaluation of the homogeneity of the SI. A variety of artifacts with different magnitudes was observed. Only one of the samples, composed mainly of Pd, In, and Sb, showed no artifacts in all imaging sequences. We concluded that selection of specific dental casting alloys according to their elemental compositions could minimize the metal artifacts in MRI; however, titanium alloys currently pose a problem with respect to causing MRI artifacts.

Role of onlay grafting with minimal internal fixation for occipitocervical fusion in oncologic patients

The choice of fixation for occipitocervical arthrodesis remains controversial, especially in oncologic patients who need further radiographic evaluation or postoperative radiotherapy. We studied the long-term outcome of 20 patients who underwent occipitocervical fusions using onlay corticocancellous bone graft and wiring, with postoperative halo vest immobilization. Eight of these patients had postoperative radiotherapy for spinal tumors (group I), and 12 patients had occipitocervical fusions for other pathologies that did not require postoperative radiotherapy (group II). All patients had solid arthrodeses; however, there was a difference in the average time to fusion between patients who received pre- or postoperative radiotherapy and those who did not (p = 0.11). At an average follow-up of 54.5 months (range 24-92 months) 15 of 20 patients (75%) had excellent or good outcomes. A high fusion rate can be expected with reasonable intraoperative or postoperative complications.

Effect of interference of metallic objects on interpretation of T1-weighted magnetic resonance images in the maxillofacial region

PURPOSE

Metallic objects produce artifacts on magnetic resonance (MR) images. However, studies on typical dental materials in this area are scant. This study was conducted to describe and measure the magnitude of such artifacts.

MATERIALS AND METHODS

Samples of various dental materials (dental gold, amalgam, stainless steel, titanium, silver-palladium, and vitallium) were embedded in bovine muscle and then subjected to T1-weighted MR imaging. The materials were of the typical morphology and composition encountered in routine maxillofacial practice. The MR artifacts were measured and compared with the original specimen measurements.

RESULTS

All metallic objects were found to produce artifacts and to interfere with the interpretation of MR images. Artifacts were most pronounced in the central plane of the object. Gold produced the greatest artifact, and amalgam produced the least.

CONCLUSION

Because metals commonly used in the maxillofacial region all produce artifacts on MR images, avoidance measures should be used to minimize the effect of these artifacts.

Metallic artifacts in magnetic resonance imaging of patients with spinal fusion. A comparison of implant materials and imaging sequences

STUDY DESIGN

Devices for spinal fusion were compared with respect to their influence on magnetic resonance images. In addition, different magnetic resonance pulse sequences were evaluated to elicit their susceptibility to imaging artifacts.

OBJECTIVES

To determine the implants with the least imaging artifacts as a recommendation for the spine surgeon and to assess the best imaging strategy for the radiologist.

SUMMARY OF BACKGROUND DATA

For patients who have had surgical spinal fusion with instrumentation, magnetic resonance imaging is the most favorable diagnostic method. Unfortunately, metallic implants lead to severe degradation of image quality. These artifacts depend on the material of the implant and on the choice of the pulse sequence.

METHODS

The fusion devices were mounted on a simple plastic phantom in various combinations and were imaged on 1.5-T magnetic resonance units. Frequently used types of plates and screws made of titanium or steel in various alloys were examined on the phantom with routinely used pulse sequences. The results of these examinations were compared with those in patient studies involving the same implants as well as the same pulse sequences.

RESULTS

The least imaging artifacts were caused by titanium implants, especially when using shorter screws, wider screw placement, and thinner titanium plates. Nevertheless, there were distinct image distortions that could lead to erroneous image interpretation. The best images were acquired by spin echo (T1), turbo spin echo (T1, T2), and half Fourier single shot turbo spin echo (HASTE) sequences. Sequences containing any gradient echo components (gradient echo or turbo gradient and spin echo sequence or frequency-selective fat saturation techniques) resulted in the highest amount of image degradation.

CONCLUSION

By choosing appropriate spinal fusion devices as well as pulse sequences, postoperative magnetic resonance imaging examinations can give acceptable results, in spite of the presence of metallic implants.