The role of radiography in the study of spinal disorders

Pyogenic Vertebral Osteomyelitis

Vertebral osteomyelitis is a general term for a heterogenous group of spine infections involving the vertebral bone, intervertebral discs, and facet joints. These infections can often spread contiguously to adjacent paraspinal structures, including paravertebral muscles and the epidural space and frequently presents with nonspecific and indolent symptoms, which can delay diagnosis. Treatment can be arduous, requiring prolonged courses of antibiotics often combined with surgical debridement. This review focuses primarily on pyogenic vertebral osteomyelitis in adults, reviewing the pathophysiology, epidemiology, microbiology, diagnosis, and treatment of this infection.

Review Article: Diagnostic Paradigm Shift in Spine Surgery

Meticulous clinical examination is essential for spinal disorders to utilize the diagnostic methods and technologies that strongly support physicians and enhance clinical practice. A significant change in the approach to diagnosing spinal disorders has occurred in the last three decades, which has enhanced a more nuanced understanding of spine pathology. Traditional radiographic methods such as conventional and functional X-rays and CT scans are still the first line in the diagnosis of spinal disorders due to their low cost and accessibility. As more advanced imaging technologies become increasingly available worldwide, there is a constantly increasing trend in MRI scans for detecting spinal pathologies and making treatment decisions. Not only do MRI scans have superior diagnostic capabilities, but they also assist surgeons in performing meticulous preoperative planning, making them currently the most widely used diagnostic tool for spinal disorders. Positron Emission Tomography (PET) can help detect inflammatory lesions, infections, and tumors. Other advanced diagnostic tools such as CT/MRI fusion image, Functional Magnetic Resonance Imaging (fMRI), Upright and Kinetic MRI, magnetic resonance spectroscopy (MRS), diffusion-weighted imaging (DWI), and diffusion tensor imaging (DTI) could play an important role when it comes to detecting more special pathologies. However, some technical difficulties in the daily praxis and their high costs act as obstacles to their further spread. Integrating artificial intelligence and advancements in data analytics and virtual reality promises to enhance spinal procedures' precision, safety, and efficacy. As these technologies continue to develop, they will play a critical role in transforming spinal surgery. This paradigm shift emphasizes the importance of continuous innovation and adaptability in improving the diagnosis and treatment of spinal disorders.

Factors Influencing the Development of Metachronous Fractures in Patients with Osteoporotic Vertebral Fractures Treated with Conservative Management or Vertebroplasty

Objectives: We aimed to analyze potential predictors for the development of metachronous fractures (MFs) after osteoporotic vertebral fractures (OVFs), with particular focus on radiological variables obtained at initial X-rays and computed tomography (CT) examinations, treatment applied (conservative management [CM] versus percutaneous vertebroplasty [PV]), and fractures located at the thoracolumbar junction (T11-L2). Methods: We conducted a two-center, observational retrospective study, including patients with single-level OVFs treated with CM or VP. We collected socio-demographic, radiological and treatment-related variables. We performed descriptive and contrastive bivariate analyses based on the presence of MFs and univariate and multivariate logistic regression analyses to obtain adjusted and crude odds ratios (aOR and cOR, respectively) for predicting MFs. Finally, we performed receiver-operating characteristic (ROC) curve analyses to determine the discriminative power of the models obtained. Results: Of the 90 patients included, 20 (22.2%) developed one or more MFs (15 in CM and 5 in PV groups, respectively; p = 0.037). The treatment group (aOR for PV, 0.087; 95%CI, 0.015-0.379), presence of intravertebral cleft (aOR, 5.62; 95%CI, 1.84-19.2) and difference in posterior height loss between X-rays and CT (aOR, 0.926; 95%CI, 0.856-0.992) were identified as significant predictors for MFs, while Genant's numerical classification showed a trend toward significance (aOR, 1.97; 95%CI, 0.983-4.19; p = 0.064). A multivariate model combining these four variables showed optimal fitting and correctly discriminated over 80% of cases (AUC, 0.828; 95%CI, 0.725-0.930). Factors associated with MFs in thoracolumbar junction OVFs were intravertebral cleft, CM, posterior height loss in CT, and DGOU OF3 fractures. Conclusions: The presence of intravertebral cleft, a difference in posterior height loss between X-rays and CT equal to or lower than 2.4%, higher grades of Genant's numerical classification, and application of CM instead of PV are predictors of MFs. These findings improve our understanding of the factors involved in the development of MFs, but they need to be validated prospectively.

A survey of bridging bone on chest radiography shows a greater than expected prevalence of marginal syndesmophytes

BACKGROUND

The recognition of thin marginal spinal syndesmophytes is important, in part due to their association with non-traumatic or mildly traumatic vertebral fractures.

PURPOSE

To determine a lower limit on the prevalence of marginal spinal syndesmophytes using chest radiographs.

MATERIAL AND METHODS

We conducted a retrospective analysis of 500 chest radiographs, assessing the prevalence of thin marginal syndesmophytes, bridging or near-bridging osteophytes, and flowing paravertebral ossifications in the thoracic intervertebral discs among individuals aged 16 years and older in a North American city.

RESULTS

Among the 500 participants, we observed that thin vertical marginal syndesmophytes were present in 17 (3.4%) cases, bridging or near-bridging osteophytes were present in 126 (25.2%) cases, and flowing paravertebral ossifications were present in 37 (7.4%) cases. Out of the 17 participants with thin marginal syndesmophytes, 10 exhibited a bamboo-like spine appearance, defined as the presence of ≥4 contiguous levels of bridging marginal syndesmophytes. Analysis of syndesmophyte distribution per vertebral level indicated a higher frequency of involvement in the mid to lower thoracic spine, maximal at T9/10.

CONCLUSIONS

The presence of thin marginal syndesmophytes in the thoracic spine on routine chest radiographs is substantially more prevalent than would be anticipated based on the existing literature. The feasibility of reliably identifying these syndesmophytes in the spine and the impact of this on morbidity should be further investigated due to their association with advanced ankylosing spondylitis and their susceptibility to fractures.

Detection and Localization of Spine Disorders from Plain Radiography

Spine disorders can cause severe functional limitations, including back pain, decreased pulmonary function, and increased mortality risk. Plain radiography is the first-line imaging modality to diagnose suspected spine disorders. Nevertheless, radiographical appearance is not always sufficient due to highly variable patient and imaging parameters, which can lead to misdiagnosis or delayed diagnosis. Employing an accurate automated detection model can alleviate the workload of clinical experts, thereby reducing human errors, facilitating earlier detection, and improving diagnostic accuracy. To this end, deep learning-based computer-aided diagnosis (CAD) tools have significantly outperformed the accuracy of traditional CAD software. Motivated by these observations, we proposed a deep learning-based approach for end-to-end detection and localization of spine disorders from plain radiographs. In doing so, we took the first steps in employing state-of-the-art transformer networks to differentiate images of multiple spine disorders from healthy counterparts and localize the identified disorders, focusing on vertebral compression fractures (VCF) and spondylolisthesis due to their high prevalence and potential severity. The VCF dataset comprised 337 images, with VCFs collected from 138 subjects and 624 normal images collected from 337 subjects. The spondylolisthesis dataset comprised 413 images, with spondylolisthesis collected from 336 subjects and 782 normal images collected from 413 subjects. Transformer-based models exhibited 0.97 Area Under the Receiver Operating Characteristic Curve (AUC) in VCF detection and 0.95 AUC in spondylolisthesis detection. Further, transformers demonstrated significant performance improvements against existing end-to-end approaches by 4-14% AUC (p-values < 10-13) for VCF detection and by 14-20% AUC (p-values < 10-9) for spondylolisthesis detection.

Imaging assessment of spine infection

This article comprehensively reviews current imaging concepts in spinal infection with primary focus on infectious spondylodiscitis (IS) as well as the less common entity of facet joint septic arthritis (FSA). This review encompasses the multimodality imaging appearances (radiographs, CT, MRI, and nuclear imaging) of spinal infection-both at initial presentation and during treatment-to aid the radiologist in guiding diagnosis and successful management. We discuss the pathophysiology of spinal infection in various patient populations (including the non-instrumented and postoperative spine) as well as the role of imaging-guided biopsy. We also highlight several non-infectious entities that can mimic IS (both clinically and radiologically) that should be considered during image interpretation to avoid misdiagnosis. These potential mimics include the following: Modic type 1 degenerative changes, acute Schmorl's node, neuropathic spondyloarthropathy, radiation osteitis, and inflammatory spondyloarthropathy (SAPHO syndrome).

Efficacy of radiofrequency in lumbar facet joint pain: a systematic review and meta-analysis of placebo-controlled randomized controlled trials

BACKGROUND

Lumbar facet joint pain (LFJP) is one of the main causes of chronic low back pain (LBP) and can be treated using radiofrequency (RF) sensory denervation. The aim of this work is to analyze the efficacy of RF in LFJP through a systematic review and meta-analysis of randomized controlled trials (RCTs) with placebo control.

MATERIALS AND METHODS

A systematic search was conducted in the Medline (PubMed), Scopus, Web of Science databases, and the Cochrane Central Register of Controlled Trials (CENTRAL). The variables of interest were pain, functional status, quality of life (QoL), and global perceived effect (GPE) measured at different time intervals: short (< 3 months), medium (> 3 and < 12 months), and long term (> 12 months).

RESULTS

Eight RCTs with placebo control were included. RF showed significant benefits over placebo in pain relief in the short (MD - 1.01; 95% CI - 1.98 to -0.04; p = 0.04), medium (MD - 1.42; 95% CI - 2.41 to - 0.43; p = 0.005), and long term (MD - 1.12; 95% CI - 1.57 to - 0.68; p < 0.001), as well as improvement in functional disability in the short (SMD - 0.94; 95% CI - 1.73 to - 0.14; p = 0.02) and long term (SMD - 0.74; 95% CI - 1.09 to - 0.39; p < 0.001). No statistically significant differences were observed in QoL or quantitative GPE, but benefits for RF were observed in dichotomous GPE in the medium (OR 0.19; 95% CI 0.07-0.52; p = 0.001) and long term (OR 0.22; 95% CI 0.06-0.78; p = 0.02). Subgroup analyses showed more benefits for RF in LBP < 1 year in the short term and in RCTs that did not require performing an MRI for patient selection.

CONCLUSIONS

RF demonstrated significant improvement in pain and functionality, but the benefits in terms of QoL and GPE are inconclusive. Future clinical trials should investigate the long-term effects of RF, its impact on quality of life, and define appropriate criteria for patient selection.

Sagittal Full-Spine vs. Sectional Cervical Lateral Radiographs: Are the Measurements of Cervical Alignment Interchangeable?

(1) Background: This study assessed the relationship between cervical spine parameters taken on standing full-spine lateral radiographic images compared to sectional lateral cervical radiographs. (2) Methods: Full-spine (FS) and sectional lateral cervical (LC) radiographs from four spine treatment facilities across the USA retrospectively provided data collected on 220 persons to assess the comparison of three sagittal cervical radiographic measurements between the two views. The measures included cervical lordosis using the absolute rotation angle from C2-C7, sagittal cervical translation of C2-C7, and atlas plane angle to horizontal. Linear correlation and R2 models were used for statistical comparison of the measures for the two views. (3) Results: The mean values of the three measurements were statistically different from each other: C2-C7 translation (FS = 19.84 ± 11.98 vs. LC = 21.18 ± 11.8), C2-C7 lordosis (FS = -15.3 ± 14.63 vs. LC = -18.32 ± 13.16), and atlas plane (FS = -19.99 ± 8.88 vs. LC = -22.56 ± 8.93), where all values were p < 0.001. Weak-to-moderate-to-strong correlations existed between the full-spine and sectional lateral cervical radiographic variables. The R2 values varied based on the measurement were R2 = 0.768 (p < 0.001) for sagittal cervical translation of C2-C7 (strong), R2 = 0.613 (p < 0.001) for the absolute rotation angle C2-C7 (moderate), and R2 = 0.406 (p < 0.001) for the atlas plane line (weak). Though a linear correlation was identified, there were consistent intra-person differences between the measurements on the full spine versus sectional lateral cervical radiographic views, where the full-spine view consistently underestimated the magnitude of the variables. (4) Conclusion: Key sagittal cervical radiographic measurements on the full spine versus sectional lateral cervical radiographic views show striking intra-person differences. The findings of this study confirm that full spine versus sectional lateral cervical radiographic views provide different biomechanical magnitudes of cervical sagittal alignment, and caution should be exercised by health care providers as these are not interchangeable. We recommend the LC view for measurement of cervical sagittal alignment variables.

Comparison of Outcomes between Single-Level and Double-Level Corpectomy in Thoracolumbar Reconstruction: A Retrospective Study of 16 Patients Using Expandable Cages

BACKGROUND Reconstruction surgery using titanium vertebral body replacements aids in spinal stability after damage. Functional evaluation includes Nurick and ASIA grading systems. This study compares outcomes of single and double-level corpectomy in patients treated with thoracolumbar reconstruction. MATERIAL AND METHODS Records of 16 patients who underwent vertebral reconstruction with expandable cages after single (n=9) and double (n=8) corpectomy were analyzed retrospectively. Thoracal and lumbar cases were approached posteriorly (n=14). Clinical evaluation was performed by neurological examination, Nurick Scale, American Spinal Injury Association (ASIA) Neurological Scores, and Visual Analog Scale (VAS). Preoperative and postoperative 3-month scores were recorded. Radiological evaluation was performed by calculation of regional angulation and postoperative recovery of vertebral body height. RESULTS Preoperatively, 2 patients had no motor or functional sensory deficits (ASIA grade E) and 6 patients were ASIA grade D. Immediately after surgery, 4 of the ASIA grade D patients improved to ASIA grade E, while 2 patients remained ASIA grade D during follow-up. Four patients were ASIA grade A; their conditions showed no improvement postoperatively. Preoperative and postoperative 3-month Nurick grade was statistically significant (P=0.022). Postoperative Cobb angle improved by a mean of 5.4° (P=0.001). Improvement by at least 1 grade in neurological recovery was observed in 6 (38%) of the cases. Pain scores analyzed using the VAS changed from a mean of 7 to a mean of 2.63 (P<0.001). CONCLUSIONS In our experience, expandable cages are useful in the restoration of different pathologies of the thoracolumbar trunk with low complication and revision rates. With expandable cages it is possible to achieve restoration of the Cobb angle, improvement in Nurick Grade and effective pain palliation.

Multidisciplinary and Coordinated Management of Osteoporotic Vertebral Compression Fractures: Current State of the Art

Osteoporotic vertebral compression fractures (OVCFs) present a significant health concern, affecting a substantial portion of the older adult population worldwide. This narrative review explores the prevalence, diagnostic challenges and management strategies for OVCFs. Despite the increasing incidence and impact on morbidity and mortality, existing clinical guidelines lack consistency and clear diagnostic and therapeutic recommendations. The review addresses key questions faced by physicians dealing with older adult patients experiencing acute back pain, offering insights into triage, radiological assessments and classification systems. We propose a comprehensive algorithm for clearing OVCF, considering clinical presentation, radiological findings and morphological aspects. Emphasis is placed on the importance of medically treating osteoporosis alongside OVCF management. The review encompasses relevant literature from 1993 to 2023, provides a detailed discussion on triage issues and incorporates a clinically oriented classification system developed by the German Society for Orthopaedics and Trauma. The Material and Methods section outlines the extensive literature search carried out in PUBMED, encompassing clinical and experimental studies, systematic reviews and meta-analyses. The articles retained focused mainly on answering critical questions regarding radiological assessments, imaging modalities and the presence of a specific classification system for OVCFs. The review emphasises that the evaluation and management of OVCFs necessitates a multidisciplinary approach involving spine specialists and bone disease experts. It also addresses the role of conservative versus surgical treatments, with a focus on percutaneous vertebral augmentation. The conclusion summarises the algorithm derived for use in emergency departments and general practice, aiming to streamline OVCF management, reduce unnecessary examinations and ensure optimal patient care. The algorithm recommends primary diagnosis using computed tomography, with magnetic resonance imaging reserved for specific cases. The review advocates a holistic approach, integrating medical and surgical interventions to address the complex challenges posed by OVCFs in ageing populations.

Plain radiography has a role to play in current clinical practice in Western Switzerland

AIM

The aim of the study was to investigate the current role of conventional radiography examinations in Western Switzerland and the main clinical indications required to justify the use of this imaging examination.

METHODS

Ethical approval was obtained from Vaud Ethics committee (Ref 2020-00311). An online questionnaire was specifically designed and implemented on the data collection tool LimeSurvey composed of two parts: a) to characterise the participants' profile and their institutions and b) 169 projections for the different anatomical area (upper and lower limbs, pelvis, skull, spine, thorax, abdomen) were presented to collect data about the frequency and main clinical indications. Statistical analysis was performed using the software IBM SPSS® (Statistical Package for the Social Sciences) version 26.

RESULTS

Radiographers from 60% (26/43) of the invited institutions participated in this survey, mainly from Vaud region. The upper and lower limbs were the most commonly examined by using conventional radiography mainly for trauma and degenerative disorders. The thorax was also an anatomical area commonly explored by X-rays, so were the spine (cervical and lumbar lateral). The skull radiographs were rarely performed in clinical practice and some of the projections were not being used, namely Hirtz, Tangential Nose Bones, Worms and Caldwell's views.

CONCLUSIONS

Plain radiography is being used in clinical practice mainly for appendicular skeleton studies and for trauma and degenerative pathologies. Adaptations in radiographers' education and training and other healthcare professionals are needed to provide the judicious use of data that radiographs can give to better manage the patients' imaging pathway.

AC-Faster R-CNN: an improved detection architecture with high precision and sensitivity for abnormality in spine x-ray images

Objective.In clinical medicine, localization and identification of disease on spinal radiographs are difficult and require a high level of expertise in the radiological discipline and extensive clinical experience. The model based on deep learning acquires certain disease recognition abilities through continuous training, thereby assisting clinical physicians in disease diagnosis. This study aims to develop an object detection network that accurately locates and classifies the abnormal parts in spinal x-ray photographs.Approach.This study proposes a deep learning-based automated multi-disease detection architecture called Abnormality Capture-Faster Region-based Convolutional Neural Network (AC-Faster R-CNN), which develops the feature fusion structure Deformable Convolution Feature Pyramid Network and the abnormality capture structure Abnormality Capture Head. Through the combination of dilated and deformable convolutions, the model better captures the multi-scale information of lesions. To further improve the detection performance, the contrast enhancement algorithm Contrast Limited Adaptive Histogram Equalization is used for image preprocessing.Main results.The proposed model is extensively evaluated on a testing set containing 1007 spine x-ray images and the experimental results show that the AC-Faster R-CNN architecture outperforms the baseline model and other advanced detection architectures. The mean Average Precision at Intersection over Union of 50% are 39.8%, the Precision and Sensitivity at the optimal cutoff point of Precision-Recall curve are 48.6% and 46.3%, respectively, reaching the current state-of-the-art detection level.Significance.AC-Faster R-CNN exhibits high precision and sensitivity in abnormality detection tasks of spinal x-ray images, and effectively locates and identifies abnormal areas. Additionally, this study would provide reference and comparison for the further development of medical automatic detection.

Specialty Impact on Patient Outcomes: Paving a Way for an Integrated Approach to Spinal Disorders

Spinal surgical procedures are steadily increasing globally due to broad indications of certain techniques encompassing a wide spectrum of conditions, including degenerative spine disorders, congenital anomalies, spinal metastases, and traumatic spinal fractures. The two specialties, neurosurgery (NS) and orthopedic surgery (OS), both possess the clinical adeptness to perform these procedures. With the advancing focus on comparative effectiveness research, it is vital to compare patient outcomes in spine surgeries performed by orthopedic surgeons and neurosurgeons, given their distinct approaches and training backgrounds to guide hospital programs and physicians to consider surgeon specialty when making informed decisions. Our review of the available literature revealed no significant difference in postoperative outcomes in terms of blood loss, neurological deficit, dural injury, intraoperative complications, and postoperative wound dehiscence in procedures performed by neurosurgeons and orthopedic surgeons. An increase in blood transfusion rates among patients operated by orthopedic surgeons and a longer operative time of procedures performed by neurosurgeons was a consistent finding among several studies. Other findings include a prolonged hospital stay, higher hospital readmission rates, and lower cost of procedures in patients operated on by orthopedic surgeons. A few studies revealed lower sepsis rates unplanned intubation rates and higher incidence of urinary tract infections (UTIs) and pneumonia postoperatively among patient cohorts operated by neurosurgeons. Certain limitations were identified in the studies including the use of large databases with incomplete information related to patient and surgeon demographics. Hence, it is imperative to account for these confounding variables in future studies to alleviate any biases. Nevertheless, it is essential to embrace a multidisciplinary approach integrating the surgical expertise of the two specialties and develop standardized management guidelines and techniques for spinal disorders to mitigate complications and enhance patient outcomes.

Imaging of low-energy vertebral fractures

Low-energy vertebral fractures pose a diagnostic challenge for the radiologist due to their often-inadvertent nature and often subtle imaging semiology. However, the diagnosis of this type of fractures can be decisive, not only because it allows targeted treatment to prevent complications, but also because of the possibility of diagnosing systemic pathologies such as osteoporosis or metastatic disease. Pharmacological treatment in the first case has been shown to prevent the development of other fractures and complications, while percutaneous treatments and various oncological therapies can be an alternative in the second case. Therefore, it is necessary to know the epidemiology and typical imaging findings of this type of fractures. The objective of this work is to review the imaging diagnosis of low-energy fractures, with special emphasis on the characteristics that should be outlined in the radiological report to guide a specific diagnosis that favours and optimizes the treatment of patients suffering of low energy fractures.

The change of Roussouly classification after posterior lumbar fusion surgery

Background

Roussouly classification is an important morphologic classification which can help to determine high local stress zones of the spine. Different lumbar morphologies of Roussouly type suggest different biomechanics leading to degenerative evolution. This study aimed both to describe the change of the Roussouly classification of the human spine after posterior lumbar fusion surgery and to explore the influencing factors of postoperative Roussouly type.

Methods

The study is a retrospective case-control study on preoperative and postoperative Roussouly types. A total of 167 patients with lumbar degenerative disease who had undergone short-level transforaminal lumbar interbody fusion surgery between January 2014 and December 2017 in the Department of Orthopedic Surgery, First Affiliated Hospital, Air Force Medical University, were recruited. Preoperative and postoperative general data including gender, age, follow-up time, Oswestry disability index (ODI) score, visual analogue scale (VAS) score, diagnosis, and surgical segment were recorded. Clinical parameters including pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), lumbar lordosis (LL), thoracic kyphosis (TK), and sagittal vertical axis (SVA) were measured using Surgimap software, and the Roussouly classification was assessed.

Results

This study included 86 male patients and 81 female patients with a mean age of 52.0±12.4 [14-88] years. The mean follow-up time for these patients was 11.5±6.9 months. The value of sagittal alignment parameters changed after the posterior lumbar fusion surgery, except for the PI value (P=0.591). Roussouly classification changed after surgery. The preoperative Roussouly values of preoperative PI, SS, and LL were significantly different in patients of 4 postoperative Roussouly types.

Conclusions

The Roussouly classification changes after posterior lumbar fusion surgery. This change is independent of gender, age, follow-up time, and the number of surgical segments. The preoperative Roussouly type and PI value are essential in predicting one's postoperative Roussouly type.

The value of magnetic resonance imaging and computed tomography in the study of spinal disorders

Computed tomography (CT) and magnetic resonance imaging (MRI) have replaced conventional radiography in the study of many spinal conditions, it is essential to know when these techniques are indicated instead of or as complementary tests to radiography, which findings can be expected in different clinical settings, and their significance in the diagnosis of different spinal conditions. Proper use of CT and MRI in spinal disorders may facilitate diagnosis and management of spinal conditions. An adequate clinical approach, a good understanding of the pathological manifestations demonstrated by these imaging techniques and a comprehensive report based on a universally accepted nomenclature represent the indispensable tools to improve the diagnostic approach and the decision-making process in patients with spinal pain. Several guidelines are available to assist clinicians in ordering appropriate imaging techniques to achieve an accurate diagnosis and to ensure appropriate medical care that meets the efficacy and safety needs of patients. This article reviews the clinical indications of CT and MRI in different pathologic conditions affecting the spine, including congenital, traumatic, degenerative, inflammatory, infectious and tumor disorders, as well as their main imaging features. It is intended to be a pictorial guide to clinicians involved in the diagnosis and treatment of spinal disorders.

Real-world study for identifying the predictive factors of surgical intervention and the value of magnetic resonance imaging in patients with low back pain

BACKGROUND

Low back pain (LBP) is a prevalent disease and can be disabling. Currently, many patients with LBP with or without radiculopathy commonly undergo magnetic resonance imaging (MRI) for diagnosis and therapeutic assessment, yet the final intervention is mainly centered around nonoperative treatment. This study's aim was to identify the predictive factors of surgical treatment and the value of MRI in patients with LBP with or without radiculopathy.

METHODS

The study included a training cohort that consisted of 461 patients with MRI from January 2014 to December 2018. Demographic characteristics and MRI findings were collected from our medical records. We developed and validated 2 nomograms to predict the possibility of receiving surgical treatment in LBP patients, based on multivariable logistic regression analysis. The performance of the 2 nomograms was assessed in terms of their calibration, discrimination, and clinical usefulness. An independent validation cohort containing 163 patients was comparatively analyzed.

RESULTS

The baseline model incorporated 6 clinicopathological variables, while the MRI model consisted of 9 variables including several MRI findings. Internal validation revealed the good performance of the 2 nomograms in discrimination and calibration, with a concordance index (C-index) of 0.799 (95% CI: 0.743-0.855) for the baseline model and 0.834 (95% CI: 0.783-0.884) for the MRI model, which showed that the addition of MRI findings to the nomogram failed to achieve better prognostic value (Z statistic =-1.509; P=0.131). Application of the 2 models in the validation cohort also showed good discrimination (baseline model: C-index 0.75, 95% CI: 0.671-0.829; MRI model: C-index 0.777, 95% CI: 0.696-0.857) and calibration. No significant predictive benefit was found in the MRI model in the validation cohort (Z statistic =-0.588; P=0.557).

CONCLUSIONS

This study showed that clinical demographic characteristics provide good prognostic value to determine whether LBP patients with or without radiculopathy require surgical treatment. The addition of MRI findings yielded no significantly incremental prognostic value.

Radiographic diagnosis of osteoporotic vertebral fractures. An updated review

The radiological diagnosis of osteoporotic vertebral fractures (OVFs) is of major importance considering its therapeutic and prognostic implications. Both radiologists and clinicians have the opportunity to diagnose OVFs in daily clinical practice due to the widespread use of spine and chest radiography. However, several studies have reported an under-diagnosis of OVFs, particularly by a lack of consensus on the diagnostic criteria. Therefore, up-to-date knowledge of the most relevant approaches for the diagnosis of OVFs is necessary for many physicians. This article aims to review the most commonly used classification systems in the diagnosis of OVFs based on conventional radiography. We discuss their rationale, advantages and limitations, as well as their utility according to the context. This review will provide a concise yet useful understanding of the typology of OVFs, their clinical significance and prognosis. Finally, we include anatomical variations that can be confused with OVFs by non-experts.

Imaging features of spinal fractures in ankylosing spondylitis and the diagnostic value of different imaging methods

Background

Our study aimed to characterize the imaging appearance of spinal fractures in ankylosing spondylitis (AS) and identify situations in which the use of magnetic resonance imaging (MRI) is necessary.

Methods

A total of 70 cases of spinal fractures associated with AS were retrospectively enrolled. Two radiologists independently reviewed the preoperative images. The location, type, ligament injury, neurological injury, and epidural hematoma following spinal fractures were assessed.

Results

Only one patient had a vertebral compression fracture, and 69 patients had 77 transverse fractures involving three columns. The most frequent injuries in AS patients were type B3 (N=32, 43.8%) spine fractures, followed by type C (N= 20, 27.4%) spine fractures. There were significant differences in fracture types of the different spine regions (H=14.1, P<0.0001). Most type C spine fractures were located in the lower cervical spine, while most of the type B2 spine fractures were located in the thoracic spine. Transverse fractures were classified as shear or stress type fractures. In total, there were 62 shear fractures and 15 stress fractures. All of the transverse fractures were detected by computed tomography (CT). The accuracy of CT in the diagnosis of the exact anatomic involvement of transverse fractures was significantly higher than that of MRI (χ²=8.36, P=0.014). The anterior longitudinal ligament (ALL) was the most frequently torn ligament. Tears of ossified ligaments were best visualized by sagittal reformatted CT. Lower cervical fractures were more likely to be associated with neurological injury compared with fractures to other regions of the spine (χ²=7.24, P=0.025). There were six epidural hematoma cases, which were only detected by MRI, were found to have fractures of the lower cervical spine.

Conclusions

We recommend a whole-spine CT examination with three-dimensional reconstruction for detecting a suspected fracture in AS patients. In cases with neurological injury, MRI examinations are always mandatory. AS patients with lower cervical spine fractures require further investigation by MRI. Patients with non-lower cervical spine fractures without any neurological deficits do not need to undergo an immediate MRI.

Association between spinal alignment and biochemical composition of lumbar intervertebral discs assessed by quantitative magnetic resonance imaging

Background

To evaluate potential associations between spinopelvic parameters and the biochemical composition of lumbar intervertebral discs using quantitative magnetic resonance imaging in asymptomatic young adults.

Methods

Our study group comprised 93 asymptomatic volunteers aged 20-40 years (49 women and 44 men). Lumbar spine T2-weighted images and T2 relaxometry were acquired on a 1.5T MRI scanner. Spinopelvic parameters including sacral slope, pelvic tilt, pelvic incidence, lumbar lordosis, thoracic kyphosis, thoracolumbar alignment, sagittal vertical axis, spinosacral angle, C2 pelvic angle, and T1S1 and L1S1 length were measured on panoramic spine radiographs.

Results

Lumbar lordosis decrease correlates with discrete dehydration of nucleus pulposus at all lumbar levels. Also low values of sacral slope, pelvic tilt, pelvic incidence, thoracic kyphosis and spinosacral angle were associated with decrease of T2 relaxation times on annulus fibrosus.

Conclusions

In conclusion, spinopelvic parameters presented a discrete association with lumbar disc composition and water content.

Improving osteoporotic vertebral deformity detection on chest frontal view radiograph by adjusted X-ray beam positioning

Purpose

In clinics, chest frontal view radiograph (CFR) is often taken for patients suspected of respiratory diseases and for assessing the heart and big vessels. CFR can be utilised to opportunistically detect osteoporotic vertebral fracture (OVF). However, for standard CFR, the site of highest OVF prevalence, i.e., the thoracolumbar junction, is usually 'off-centre' to the X-ray beam focus. This study tested the hypothesis that, if a CRF is taken with approximately two vertebrae lower than the standard X-ray beam positioning, the visualization of thoraco-lumbar junction can be much improved.

Materials

Four hospitals (A, B, C, D) provided 101 elderly women's digital CFRs with standard filming (28, 20, 24, and 21 cases respectively). Eighty four elderly female patients were prospectively recruited from hospitals-A and B, who were consecutive patients referred for chest radiograph with indications other than spine disorders. For theses prospective CFRs, the focus of X-ray beam was adjusted from towards vertebra T6 to towards T8, and standard lateral radiographs were obtained for reference. Visibility of spine and detectability of OVF were assessed on the CFRs. OVF was diagnosed based on chest lateral radiograph (CLR) after excluding other potential causes both radiographically and clinically.

Results

For standardly filmed CFR, spine readability was similar among those from Hospitals-A, B, and C, while performed less well for those from Hospital-D. With the prospective cases from Hospitals-A and B, spines readable to vertebra L1 level or lower increased from 48.2% for standard filming to 80.7% for adjusted filming. Spines with 'blurry' labelling decreased from 35.7% for standard filming to 15.7% for adjusted filming. For the 84 prospective cases, 42.9% (36/84) of the patients had OVF, and 26 cases of CLR positive cases were detected as having vertebral deformity on CFR. For minimal OVF cases (<20% height loss), 38% (5/13) were detected on CFR. Among 22 cases with apparent OVF (≥20% height loss), two cases were missed on CFR. False positivity was labelled in five cases, among them four cases had 'burry' spines.

Conclusion

CFR can help opportunistically detect OVF, which can be further improved if X-ray beam is adjusted to towards vertebra T8 instead of towards vertebra T6.

The translational potential of this article

This study confirms that CFR can help detect OVF opportunistically, and the visibility of the mid/lower thoracic spine and thoracolumbar junction can be much improved after minor adjustment of X-ray beam positioning. This study also suggests high positive rate of OVF in elderly Chinese female patients indicated for chest radiograph. Radiologists should be trained and sensitized in vertebral deformity identification on CFR as the clinical management can be improved by opportunistic detection of OVF.

Interpretation of osteoporotic vertebral deformity on frontal view radiographs of the chest and abdomen: a pictorial review

Osteoporotic vertebral fracture (OVF) has high prevalence in the elderly population. It affects at least one-fourth of all postmenopausal women and is commonly seen among women approximately one decade after menopause. A vertebral fracture, after minor trauma, is a hallmark of osteoporosis. Many fractures and associated complications, including secondary fractures and mortality, can be prevented by routine osteoporosis screening in older people and timely treatment initiation in at-risk individuals. Depending on the technical condition of the radiographs, a substantial portion of moderate to severe grades OVFs in mid-thoracic and lower thoracic spine as well as lumbar spine can be detected on a frontal view digital radiograph of the chest or abdomen. Radiologists should pay attention to the potential existence of an OVF while reading chest and abdominal radiographs of elderly female subjects. In this pictorial review, we describe our experience in evaluating the normal shaped and deformed vertebrae on chest and abdominal radiographs.