Assessing Diagnostic Accuracy of Four-dimensional CT for Instable Scapholunate Dissociation: The Prospective ACTION Trial

Background Timely treatment of scapholunate instability depends on early identification, but current imaging methods are either intricate or fail to demonstrate the dynamic stages. Purpose To calculate the diagnostic accuracy of four-dimensional (4D) CT for diagnosing instable scapholunate ligament (SLL) tears. Materials and Methods This prospective study enrolled consecutive participants with clinically suspected SLL tears who underwent 4D CT from July 2020 to May 2022. A historical study sample diagnosed at cineradiography served as a comparison, and wrist arthroscopy was the reference standard. Scapholunate joints greater than 3 mm were interpreted as instable at index 4D CT and cineradiography. Diagnostic accuracy was expressed as sensitivity and specificity. Areas under the receiver operating characteristic curve and cutoff values for both index tests were calculated. Intraclass correlation coefficients (ICCs) were computed to compare interrater reliability. Effective radiation doses at 4D CT were measured with thermoluminescent dosimeters. Results The study included 40 participants (mean age, 43 years ± 14 [SD]; 24 male) evaluated at 4D CT and 78 patients (mean age, 45 years ± 11; 50 male) historically evaluated at cineradiography. Four-dimensional CT helped detect instable tears in 26 of 35 participants (sensitivity, 74.3% [95% CI: 56.7, 87.5]. Cineradiography revealed instable tears in 52 of 63 patients (sensitivity, 82.5% [95% CI: 70.9, 91]). Four of five participants with stable scapholunate joints were identified at 4D CT (specificity, 80.0% [95% CI: 28.4, 99.5]), and 12 of 15 patients with stable SLLs were identified at cineradiography (specificity, 80.0% [95% CI: 51.9, 95.7]). Interrater agreement of radiologic measurements on 4D CT scans was good to excellent (ICC range, 0.89-0.96). The effective radiation dose ranged from 67 to 72 mSv at the wrist and was less than 1 mSv at the head. Conclusion Four-dimensional CT results are highly reproducible. Instable scapholunate joints greater than 3 mm were detected with a sensitivity of 74.3% and a specificity of 80% in an exploratory trial. Further evidence from larger randomized trials is warranted. German Register for Clinical Trials no. DRKS00021110 (Universal Trial Number U1111-1249-7884) Published under a CC BY 4.0 license. Supplemental material is available for this article. See also the editorial by Demehri and Ibad in this issue.

Cervical spine fracture detection in computed tomography using convolutional neural networks

OBJECTIVE


In the context of primary in-hospital trauma management timely reading of computed tomography (CT) images is critical. However, assessment of the spine is time consuming, fractures can be very subtle, and the potential for under-diagnosis or delayed diagnosis is relevant. 
Artificial intelligence is increasingly employed to assist radiologists with the detection of spinal fractures and prioritization of cases.
Currently, algorithms focusing on the cervical spine are commercially available.
A common approach is the vertebra-wise classification.
Instead of a classification task, we formulate fracture detection as a segmentation task aiming to find and display all individual fracture locations presented in the image.\\ 
Approach:
Based on 195 CT examinations, 454 cervical spine fractures were identified and annotated by radiologists at a tertiary trauma centre. 
We trained for the detection a U-Net via 4-fold-cross validation to segment spine fractures and the spine via a multi-task loss. 
We further compared advantages of two image reformation approaches - straightened curved planar reformatted (CPR) around the spine and spinal canal aligned volumes of interest (VOI) - to achieve a unified vertebral alignment in comparison to processing the Cartesian data directly.
Main results:
Of the three data versions (Cartesian, reformatted, VOI) the VOI approach showed the best detection rate and a reduced computation time. The proposed algorithm was able to detect 87.2\% of cervical spine fractures at an average number of false positives of 3.5 per case. Evaluation of the method on a public spine dataset resulted in 0.9 false positive detections per cervical spine case. 
Significance:
The display of individual fracture locations as provided with high sensitivity by the proposed voxel classification based fracture detection has the potential to support the trauma CT reading workflow by reducing missed findings. &#xD.

Whole-Body Magnetic Resonance Tomography and Whole-Body Computed Tomography in Pediatric Polytrauma Diagnostics-A Retrospective Long-Term Two-Center Study

Although serious accidents remain the leading cause of pediatric mortality, protocols to orient diagnostic procedures towards a certain type of initial imaging are widely needed. Since 2007, we have performed whole-body magnetic resonance imaging (WBMR) and whole-body computed tomography (WBCT) for diagnoses of severely injured children. We retrospectively reviewed 134 WBMR and 158 WBCT in patients younger than 16 years that were performed at two trauma centers between 2007 and 2018. A higher Injury Severity Score (ISS) was found in WBCT vs. WBMR (10.6 vs. 5.8; p = 0.001), but without any significant difference in mortality. The WBMR was significantly preferred at younger ages (9.6 vs. 12.8 years; p < 0.001). The time between patient's arrival until diagnosis was 2.5 times longer for WBCT (92.1 vs. 37.1 min; p < 0.001). More patients in the CT group received analgesic sedation and/or intubation at 37.3% vs. 21.6% in the MRI group. Of these patients, 86.4% (CT) and 27.6% (MRI) were already preclinically sedated (p < 0.001). Correspondingly, 72.4% of the patients were first sedated in-hospital for MRIs. In conclusion, WBMR is an alternative and radiation-free imaging method for high-energy-traumatized children. Although the selected diagnostics seemed appropriate, limitations regarding longer duration or additional analgesic sedation are present, and further studies are needed.

Superselective Catheter Angiographies of the Wrist (SCAW): Approaches for Vascularized Bone Grafts

Background: This study assesses the variability of the palmar radiocarpal artery (PRCA), dorsal carpal branch of the ulnar artery (DCBUA), and anterior interosseous artery (AIA) in superselective catheter angiographies of the wrist (SCAW). Methods: Secondary analysis of consecutive SCAW (2009-2011). Measurements of the distances of the PRCA to the midface of the radiocarpal joint, the DCBUA to the styloid process of the ulnar, and maximum diameters of PRCA, DCBUA, and AIA. Results: Seven female and ten male patients (mean 35 years) received SCAW. All patients suffered from Kienbock's disease. The mean distance from the PRCA to the radiocarpal joint was 7.9 ± 2.3 mm and the distance from the DCBUA to the styloid process of the ulna was 29.6 ± 13.6 mm. The mean maximum diameter of the PRCA was 0.6 ± 0.2 mm, that of the DCBUA was 1.1 ± 0.4 mm, and that of the AIA 1.2 ± 0.3 mm. In six cases (35%), all three arteries contributed to the PRCA; in eight cases (47%), the radial and AIA; in two cases (12%), the radial and ulnar artery; and in one case (6%), only the radial artery contributed. Conclusions: SCAW are feasible to assist in preoperative planning. Os pisiforme transfer with DCBUA might be the best choice for a vascular bone graft in Kienbock's disease.

Middle Meningeal Artery Embolization Minimizes Burdensome Recurrence Rates After Newly Diagnosed Chronic Subdural Hematoma Evacuation (MEMBRANE): study protocol for a randomized controlled trial

Background

Chronic subdural hematoma (cSDH) is the most common complication of mild traumatic brain injury demanding neurosurgery in high-income countries. If undetected and untreated, cSDH may increase intracranial pressure and cause neurological deficiencies. The first-line intervention of choice is burr hole trepanation and hematoma evacuation. However, any third patient may experience rebleeding, demanding craniotomy with excess morbidity. Adjunct endovascular embolization of the frontal and parietal branches of the middle meningeal artery (MMA) is a promising approach to avoid relapse and revision but was hitherto not studied in a randomized trial.

Methods

MEMBRANE is an investigator-initiated, single-center, randomized controlled trial. Male, female, and diverse patients older than 18 years scheduled for surgical evacuation of a first cSDH will be assigned in a 1:1 fashion by block randomization to the intervention (surgery plus endovascular MMA embolization) or the control group (surgery alone). The primary trial endpoint is cSDH recurrence within 3 months of follow-up after surgery. Secondary endpoints comprise neurological deficits assessed by the modified Rankin Scale (mRS) and recurrence- or intervention-associated complications during 3 months of follow-up. Assuming a risk difference of 20% of rebleeding and surgical revision, a power of 80%, and a drop-out rate of 10%, 154 patients will be enrolled onto this trial, employing an adaptive O’Brien-Fleming approach with a planned interim analysis halfway.

Discussion

The MEMBRANE trial will provide first clinical experimental evidence on the effectiveness of endovascular embolization of the MMA as an adjunct to surgery to reduce the risk of recurrence after the evacuation of cSDH.

Trial registration

German Clinical Trials Registry (Deutsches Register Klinischer Studien [DRKS]) DRKS00020465. Registered on 18 Nov 2021. ClinicalTrials.gov NCT05327933. Registered on 13 Apr 2022.

The CRECHE study: testing the urban myth that chocolate Santa Clauses are re-wrapped Easter Bunnies

OBJECTIVE

To test the urban myth that surplus chocolate Easter Bunnies are re-packaged as Santa Clauses for the following Christmas holiday season.

DESIGN

Prospective radiographic cohort study of seasonal chocolate figurines, supplemented by anonymous 5-item questionnaire survey of belief in the re-wrapping myth (Generic Risk Items Noted by Chocolate consumers in Health care settings; GRINCH).

SETTING

Two tertiary referral trauma centres in Germany (Berlin and Duisburg).

PARTICIPANTS

Eighteen chocolate Easter Bunnies and 15 chocolate Santa Clauses from different manufacturers purchased during 2020; 502 randomly selected people passing through the entrance halls of the two hospitals during 16 September - 12 October 2020.

MAIN OUTCOME MEASURES

Whole body computed tomography (WBCT) images of chocolate Easter Bunnies and Santa Clauses assessed by four independent, board-certified radiologists using a visual contour resemblance scale (CRS); survey participants' views on statements related to the re-wrapping myth.

RESULTS

Expert examiners clearly distinguished the WBCT images of chocolate Easter Bunnies and Santa Clauses; the mean difference in CRS was 84.2 points (95% CI, 78.5-90.0 points), with excellent inter-observer agreement (mean intra-class correlation coefficient, 0.99; 95% CI, 0.99-1.00). A total of 214 survey participants (43%) disagreed and 145 (29%) agreed with the proposition that seasonal chocolate figurines are re-packaged and re-sold the following season.

CONCLUSION

Although about one-third of our survey respondents did not rule out the possibility of seasonal sweets being re-used, WBCT imaging found no similarity between chocolate foil-wrapped Easter and Christmas figurines, providing solid evidence against this urban myth. Chocolate Santa Clauses are unlikely to pose a significant threat to hospital food hygiene requirements.

TRIAL REGISTRATION

Current Controlled Trials, ISRCTN16847363 (prospective).

Obstacles and Solutions Driving the Development of a National Teleradiology Network

Background: Teleradiology has the potential to link medical experts and specialties despite geographical separation. In a project report about hospital-based teleradiology, the significance of technical and human factors during the implementation and growth of a teleradiology network are explored. Evaluation: The article identifies major obstacles during the implementation and growth of the teleradiology network of the Berlin Trauma Hospital (BG Unfallkrankenhaus Berlin) between 2004 and 2020 in semi-structured interviews with senior staff members. Quantitative analysis of examination numbers, patient numbers, and profits relates the efforts of the staff members to the monetary benefits and success of the network. Identification of qualitative and quantitative factors for success: Soft and hard facilitators and solutions driving the development of the national teleradiology network are identified. Obstacles were often solved by technical innovations, but the time span between required personal efforts, endurance, and flexibility of local and external team members. The article describes innovations driven by teleradiology and hints at the impact of teleradiology on modern medical care by relating the expansion of the teleradiology network to patient transfers and profits. Conclusion: In addition to technical improvements, interpersonal collaborations were key to the success of the teleradiology network of the Berlin Trauma Hospital and remained a unique feature and selling point of this teleradiology network.

Deep learning algorithm in detecting intracranial hemorrhages on emergency computed tomographies

BACKGROUND

Highly accurate detection of intracranial hemorrhages (ICH) on head computed tomography (HCT) scans can prove challenging at high-volume centers. This study aimed to determine the number of additional ICHs detected by an artificial intelligence (AI) algorithm and to evaluate reasons for erroneous results at a level I trauma center with teleradiology services.

METHODS

In a retrospective multi-center cohort study, consecutive emergency non-contrast HCT scans were analyzed by a commercially available ICH detection software (AIDOC, Tel Aviv, Israel). Discrepancies between AI analysis and initial radiology report (RR) were reviewed by a blinded neuroradiologist to determine the number of additional ICHs detected and evaluate reasons leading to errors.

RESULTS

4946 HCT (05/2020-09/2020) from 18 hospitals were included in the analysis. 205 reports (4.1%) were classified as hemorrhages by both radiology report and AI. Out of a total of 162 (3.3%) discrepant reports, 62 were confirmed as hemorrhages by the reference neuroradiologist. 33 ICHs were identified exclusively via RRs. The AI algorithm detected an additional 29 instances of ICH, missed 12.4% of ICH and overcalled 1.9%; RRs missed 10.9% of ICHs and overcalled 0.2%. Many of the ICHs missed by the AI algorithm were located in the subarachnoid space (42.4%) and under the calvaria (48.5%). 85% of ICHs missed by RRs occurred outside of regular working-hours. Calcifications (39.3%), beam-hardening artifacts (18%), tumors (15.7%), and blood vessels (7.9%) were the most common reasons for AI overcalls. ICH size, image quality, and primary examiner experience were not found to be significantly associated with likelihood of incorrect AI results.

CONCLUSION

Complementing human expertise with AI resulted in a 12.2% increase in ICH detection. The AI algorithm overcalled 1.9% HCT.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS-ID: DRKS00023593).

Comparison of Calculated Skin Doses in Cineradiography and Four Dimensional Kinematic Computed Tomography of the Wrist

Background: Previous studies have discussed the diagnostic value of four dimensional kinematic CT in cases of carpal instabilities. This analysis compares calculated skin doses of 4D CT and conventional cineradiography of the wrist in cases of suspected SLL rupture. Methods: Retrospective calculation and interpolation of skin doses and effective doses for ten consecutive 4D CT examinations and 41 cineradiographies for suspected lesions of the scapholunate ligament. Standardised anterior-posterior and lateral cine sequences using a flat-panel digital subtraction imager and of 4D kinematic CT using a dual-source scanner were acquired and acquisition parameters recorded. We tested if the skin dose of 4D CT is different from cineradiography. Results: Median dose area product (DAP) of cineradiography was 135.34 cGycm² resulting in a calculated median skin dose of 32.6 mSv (confidence interval 26.86-42.90 mSv) and an estimated effective skin dose of 3.26 µSv. CT dose index (CTDI) for 4D examinations was recorded to be 26.79 mGy and the dose-length product (DLP) was 150 mGy × cm. This resulted in an estimated skin dose of 34 mSv, which is covered by the confidence interval of cineradiography, and an effective skin dose of 3.4 µSv. Conclusions: Skin dose calculations are comparable for 2D cineradiography in two plains and 4D kinematic CT of the wrist. Calculated effective doses are < 0.01 mSv.

[Alternatives of histological material collection - When and how is histological confirmation by ultrasound (US), computer tomography (CT) or endosonography (EUS) useful?]

Histological classifications of tumorous lesions together with adequate staging are necessary for stage-appropriate and personalized therapies. The indications, technical possibilities, and limitations as well as potential complications of image-guided needle biopsy by ultrasound, computed tomography, and endosonography are described. Which procedure for which organ and which lesion?

Incidence and underreporting of osseous wrist and hand injuries on whole-body computed tomographies at a level 1 trauma center

BACKGROUND

To investigate the incidence of osseous wrist and hand injuries on whole-body computed tomographies (WBCT) at an urban maximum-care trauma center, to report the number of missed cases in primary radiology reports, and to develop an algorithm for improved detection of these injuries.

METHODS

Retrospective analysis reviewing all WBCT for a period of 8 months for osseous wrist and hand injuries. (1) Reconstruction of hands/wrists in three planes (thickness 1-2 mm) and analysis by a blinded musculoskeletal radiologist. (2) Scanning of primary radiology reports and comparison to the re-evaluation. (3) Calculation of the diagnostic accuracy of WBCT during primary reporting. (4) Search for factors potentially influencing the incidence (trauma mechanism, associated injuries, Glasgow Coma Scale, artifacts). (5) Development of an algorithm to improve the detection rate.

RESULTS

Five hundred six WBCT were included between 01/2020 and 08/2020. 59 (11.7%) WBCT showed 92 osseous wrist or hand injuries. Distal intra-articular radius fractures occurred most frequently (n = 24, 26.1%); 22 patients (37.3%) showed multiple injuries. The sensitivity of WBCT in the detection of wrist and hand fractures during primary evaluation was low with 4 positive cases identified correctly (6.8%; 95% CI 1.9 to 16.5), while the specificity was 100% (95% CI 99.2 to 100.0). Forty-three cases (72.9%) were detected on additional imaging after clinical reassessment. Twelve injuries remained undetected (20.3%). Motorcycle accidents were more common in positive cases (22.0% vs. 10.1%, p = 0.006). 98% of positive cases showed additional fractures of the upper and/or lower extremities, whereas 37% of the patients without osseous wrist and hand injuries suffered such fractures (p < 0.001). The remaining investigated factors did not seem to influence the occurrence.

CONCLUSION

Osseous wrist and hand injuries are present in 11.7% on WBCT after polytrauma. 93.2% of injuries were missed primarily, resulting in a very low sensitivity of WBCT during primary reporting. Motorcycle accidents might predispose for these injuries, and they often cause additional fractures of the extremities. Clinical re-evaluation of patients and secondary re-evaluation of WBCT with preparation of dedicated multiplanar reformations are essential in polytrauma cases to detect osseous injuries of wrist and hand reliably.

TRIAL REGISTRATION

The study was registered prospectively on November 17th, 2020, at the German register for clinical trials (DRKS-ID: DRKS00023589 ).

ACTION trial: a prospective study on diagnostic Accuracy of 4D CT for diagnosing Instable ScaphOlunate DissociatioN

Background

Early detection of scapholunate ligament (SLL) tears is essential after minor and major trauma to the wrist. The differentiation between stable and instable injuries determines therapeutic measures which aim to prevent osteoarthritis. Arthroscopy has since been the diagnostic gold standard in suspected SLL tears because non-invasive methods have failed to exclude instable injuries reliably. This prospective study aims to determine the diagnostic accuracy of dynamic, 4D computed tomography (CT) of the wrist for diagnosing instable SLL tears.

Methods

Single center, prospective trial including 40 patients with suspected SLL tears scheduled for arthroscopy. Diagnostic accuracy of 4D CT will be tested against the reference standard arthroscopy. Radiologists will be blinded to the results of arthroscopy and hand surgeons to radiological reports. A historical cohort of 80 patients which was diagnosed using cineradiography before implementation of 4D CT at the study site will serve as a comparative group.

Discussion

Static imaging lacks the ability to detect instable SLL tears after wrist trauma. Dynamic methods such as cineradiography and dynamic magnetic resonance imaging (MRI) are complex and require specific technical infrastructure in specialized centers. Modern super-fast dual source CT scanners are gaining popularity and are being installed gradually in hospitals and ambulances. These scanners enable dynamic imaging in a quick and simple manner. Establishment of dynamic 4D CT of the wrist in patients with suspected SLL tears in in- and outpatient settings could improve early detection rates. Reliable identification of instable injuries through 4D CT scans might reduce the number of unnecessary diagnostic arthroscopies in the future.

Trial registration

This study was registered prospectively at the German Clinical Trials Register (DRKS) DRKS00021110. Universal Trial Number (WHO-UTN): U1111–1249-7884.

What Is the Diagnostic Accuracy of Flat-panel Cone-beam CT Arthrography for Diagnosis of Scapholunate Ligament Tears?

BACKGROUND

Cone beam CT (CBCT) is a widely available technique with possible indications in carpal ligament injuries. The accuracy of CBCT arthrography in diagnosing traumatic tears of the scapholunate ligament has not been reported.

QUESTIONS/PURPOSES

(1) What is the diagnostic accuracy of CBCT and how does it relate to the accuracy of multislice CT arthrography and conventional arthrography in diagnosing scapholunate ligament tears? (2) What is the estimated magnitude of skin radiation doses of each method?

METHODS

This secondary analysis of a previous prospective study included 71 men and women with suspected scapholunate ligament tears and indications for arthroscopy. Preoperative imaging was conventional arthrography and either MSCT arthrography for the first half of patients to be included (n = 36) or flat-panel CBCT arthrography for the remaining patients (n = 35). Index tests identified therapy-relevant SLL tears with dorsal or complete SLL ruptures, and these tears were compared with relevant SLL tears which were determined through arthroscopy as Geissler Stadium III and IV by probing the instable SL joint with a microhook or arthroscope. These injuries were treated by open ligament repair and Kirschner wire fixation. Accuracy values and 95% confidence intervals were calculated. Additional estimates of the radiation skin doses of each CBCT exam and two MSCT protocols were subsequently calculated using dose area products, dose length products, and CT dose indices.

RESULTS

The diagnostic accuracy was high for all imaging methods. 95% CIs were broadly overlapping and therefore did not indicate differences between the diagnostic groups: Sensitivity of CBCT arthrography was 100% (95% CI 77 to 100), specificity was 95% (95% CI 76 to 99.9), positive predictive value was 93% (95% CI 68 to 99.8), and negative predictive value was 100% (95% CI 83 to 100). For MSCT arthrography, the sensitivity was 92% (95% CI 64 to 99.8), specificity was 96% (95% CI 78 to 99.9), positive predictive value was 92% (95% CI 64 to 99.8), and negative predictive value was 96% (95% CI 78 to 99.9). For conventional arthrography, the sensitivity was comparably high: 96% (95% CI 81 to 99.9). Specificity was (81% [95% CI 67 to 92]); the positive predictive value was 77% (95% CI 59 to 89) and negative predictive value was 97% (95% CI 86 to 99.9). Estimated mean (range) radiation skin doses were reported in a descriptive fashion and were 12.9 mSv (4.5 to 24.9) for conventional arthrography, and 3.2 mSv (2.0 to 4.8) for CBCT arthrography. Estimated radiation skin doses were 0.2 mSv and 12 mSv for MSCT arthrography, depending on the protocol.

CONCLUSION

Flat-panel CBCT arthrography can be recommended as an accurate technique to diagnose scapholunate ligament injuries after wrist trauma. Estimated skin doses are low for CBCT arthrography and adapted MSCT arthrography protocols.

LEVEL OF EVIDENCE

Level III, diagnostic study.

Association of Low-Dose Whole-Body Computed Tomography With Missed Injury Diagnoses and Radiation Exposure in Patients With Blunt Multiple Trauma

Question

Is low-dose whole-body computed tomography with statistical image reconstruction associated with similar rates of missed injuries and accuracy but reduced radiation exposure compared with standard-dose whole-body computed tomography in the primary diagnostic workup of blunt multiple trauma?

Findings

In this quasi-experimental cohort study of 971 patients with suspected blunt multiple trauma, participants in the standard-dose and low-dose whole-body computed tomography groups had the same risk of missed injury diagnoses. Low-dose scanning markedly reduced exposure to radiation, improved the contrast-to-noise ratio, and showed similar diagnostic accuracy among the investigated anatomical areas and organs when compared with standard-dose scanning.

Meaning

These findings suggest that low-dose whole-body computed tomography may safely replace standard-dose scanning in the primary diagnostic workup of blunt multiple trauma.

Importance

Initial whole-body computed tomography (WBCT) for screening patients with suspected blunt multiple trauma remains controversial and a source of excess radiation exposure.

Objective

To determine whether low-dose WBCT scanning using an iterative reconstruction algorithm does not increase the rate of missed injury diagnoses at the point of care compared with standard-dose WBCT with the benefit of less radiation exposure.

Design, Setting, and Participants

This quasi-experimental, prospective time-series cohort study recruited 1074 consecutive patients admitted for suspected blunt multiple trauma to an academic metropolitan trauma center in Germany from September 3, 2014, through July 26, 2015, for the standard-dose protocol, and from August 7, 2015, through August 20, 2016, for the low-dose protocol. Five hundred sixty-five patients with suspected blunt multiple trauma prospectively received standard-dose WBCT, followed by 509 patients who underwent low-dose WBCT. Confounding was controlled by segmented regression analysis and a secondary multivariate logistic regression model. Data were analyzed from January 16, 2017, through October 14, 2019.

Interventions

Standard- or low-dose WBCT.

Main Outcomes and Measures

The primary outcome was the incidence of missed injury diagnoses at the point of care, using a synopsis of clinical, surgical, and radiological findings as an independent reference test. The secondary outcome was radiation exposure with either imaging strategy.

Results

Of 1074 eligible patients, 971 (mean [SD] age, 52.7 [19.5] years; 649 men [66.8%]) completed the study. A total of 114 patients (11.7%) had multiple trauma, as defined by an Injury Severity Score of 16 or greater. The proportion of patients with any missed injury diagnosis at the point of care was 109 of 468 (23.3%) in the standard-dose and 107 of 503 (21.3%) in the low-dose WBCT groups (risk difference, −2.0% [95% CI, −7.3% to 3.2%]; unadjusted odds ratio, 0.89 [95% CI, 0.66-1.20]; P = .45). Adjustments for autocorrelation and multiple confounding variables did not alter the results. Radiation exposure, measured by the volume computed tomography dose index, was lowered from a median of 11.7 (interquartile range, 11.7-17.6) mGy in the standard-dose WBCT group to 5.9 (interquartile range, 5.9-8.8) mGy in the low-dose WBCT group (P < .001).

Conclusions and Relevance

Low-dose WBCT using iterative image reconstruction does not appear to increase the risk of missed injury diagnoses at the point of care compared with standard-dose protocols while almost halving the exposure to diagnostic radiation.

Unique Indications for Covered Stent Grafts in Neuroradiology Departments of Level 1 Trauma Centers

OBJECTIVE

 To describe unique indications for covered stent grafts in trauma-associated cerebrovascular injuries.

PATIENTS

 Between 2006 and 2018, five patients with cerebrovascular injuries were treated with a covered stent graft. We present a retrospective analysis of technique and outcomes.

RESULTS

 In all cases stent deployment was successful. Endoleaks occurred in two cases requiring additional transvenous embolization of a carotid cavernous fistula (CCF) in one patient. Two cases of in-stent thrombosis were observed during intervention and 2 days postintervention in a patient with a long-segment dissection of the internal carotid artery (ICA) and another patient with a contained ICA rupture, both of which could not be prepared with dual antiplatelet therapy. Intravenous heparin and intra-arterial tirofiban dissolved in-stent thrombosis efficiently. One CCF and an iatrogenic vertebral artery injury were covered adequately with GraftMaster stent grafts.

CONCLUSION

 Patient selection with regard to individual anatomy and the site of vascular lesions is essential for an uncomplicated deployment of covered stent grafts and the success of therapy. Management of dual antiplatelet therapy, anticoagulation, and an escalation of medication in cases of in-stent thrombosis require expertise, a strict therapeutic regime, and an evaluation of individual risks in polytraumatized patients.

Retrospective Analysis and Systematic Review of Isolated Traumatic Dissections of the Celiac Artery

BACKGROUND

Isolated dissections of the celiac artery (CA) after blunt trauma are rarely described. This retrospective analysis and systematic review analyzes epidemiology, radiologic examinations, patterns of injuries, therapeutic measures, clinical courses, and outcomes.

METHODS

Retrospective analysis of polytraumatized patients admitted between 1997 and 2012 to a trauma center level I. Systematic literature search was carried out on pubmed.gov, eurorad.org, and google.com.

RESULTS

Isolated traumatic dissections of the CA had an incidence of 0.17% in a retrospective collective (n = 9). Mean age was 31.7 years in 6 male (66.7%) and 3 female (33.3%) patients. Systematic literature search identified 12 primary sources describing 13 males (100%) with a mean age of 41.3 years. Traffic accidents and falls were the most common causes of injury. An intimal flap (77.7%) and a thrombosed false lumen (59.1%) were the most common computed tomographic findings. Twenty-two patients were analyzed, and 16 patients were treated conservatively. The CA was bypassed in 2 symptomatic patients. One patient was treated with a stent. Two patients died because of massive bleeding, and 1 patient died because of liver failure. About 19 discharged patients were asymptomatic on follow-up. Long-term follow-up with magnetic resonance angiography showed stable dissections (n = 1), medium stenosis (n = 1), resolution of the dissection (n = 2), high-grade stenosis of the CA combined with a small pseudoaneurysm (n = 1), or occlusion of the CA with sufficient collateralization (n = 3). Pharmaceutical treatment was individualized with low-molecular-weight heparin, heparin, or warfarin, and acetylicsalicylic acid.

CONCLUSIONS

Traumatic CA dissections are mostly caused by traffic accidents and falls. Visceral perfusion should be monitored clinically and radiologically. Beginning visceral ischemia requires early invasive treatment. Endovascular and open surgery are possible options. Benefits of specific pharmaceuticals are still up for debate. Follow-up via magnetic resonance imaging or computed tomography angiography is essential to rule out vascular complications.

LEVEL OF EVIDENCE

III (Retrospective therapeutic study and systematic literature review).

Stapes piston insertion depth and clinical correlations

Background: The insertion of the stapes piston within the vestibule provides the physical basis for a successful stapedotomy. An insertion depth of 0.5 mm is recommended to avoid the dislocation of the stapes prosthesis (e.g. sneezing). Aims: The objective of this study is to analyze the depth of stapes prosthesis insertion and its correlation with clinical outcome. Material and methods: We observed in a retrospective case series 39 otosclerosis patients after a stapedotomy and a postoperative performed flat panel tomography/cone beam CT. The evaluation included the radiologically found depth of prosthesis insertion within the vestibule, the vestibule depth, and the correlation with the bone conduction (BC) threshold, vertigo, and tinnitus. Results: Insertion depth varied between 0.2 and 1.6 mm (mean 0.74 mm). The ratio of insertion depth versus the vestibule depth was between 8% and 59% (mean 26.6%). We observed no correlation between the insertion depth, the length of the prosthesis, the ratio of insertion depth/vestibule depth, postoperative BC, appearance of vertigo, or tinnitus. Conclusions and significance: In our group, we observed no significant relation between insertion depth of the stapes piston, postoperative vertigo, tinnitus, or decrease of the BC.

Superselective angiography of the wrist in patients with Kienböck's disease

BACKGROUND

Microvascular problems like increased intraosseous pressure or venous congestion may influence the development of Kienböck's disease. We examined if wrist position modifies the blood flow in the nutrient vessels.

METHODS

Retrospective analysis of 17 patients with Kienböck's disease who had a superselective microangiography of the radial, ulnar and interosseous artery in different wrist positions under general anaesthesia. We analysed the data with Fisher's exact and Wilcoxon-test.

RESULTS

We found vessels that entered the bone, that ended at the bone edge, and that supplied a vascular plexus. The origins were the anterior interosseous artery in 10 of 17 cases, the radial artery in seven cases, and the ulnar artery in five cases. Movement of the wrist could reduce or stop the blood flow. Type of lunate configuration showed no significant influence on the blood supply in neutral position.

CONCLUSION

The radial, ulnar, and anterior interosseous artery contribute to the vascular supply of the lunate bone in different combinations. Wrist movement can reduce blood flow to the lunate bone.

Stapes Prosthesis Length: One Size Fits All?

BACKGROUND

The insertion of the stapes piston into the vestibule provides the physical basis for a successful stapedotomy. In routine clinical practice, two different ways to handle prosthesis length are performed: (1) an individualized measurement of the stapes prosthesis length or (2) a standard prosthesis length for all cases.

OBJECTIVE

The objective of this study was to compare both ways of handling prosthesis length and the effect of these methods on insertional prosthesis depth.

MATERIAL AND METHOD

We retrospectively evaluated 39 patients after performing a stapedotomy for radiologically estimated vestibular stapes prosthesis insertion depth. The individual measured length data were hypothetically changed to a standard length of 4.75, 5, 5.25, and 5.5 mm, and the insertion depths were compared.

RESULTS

The individually measured prosthesis lengths led to an insertion depth between 0.2 and 1.6 mm (mean 0.74 mm). The ratio of insertion depth/vestibular depth was between 8 and 59.1% (mean 26.6%). The different assumed standard lengths led to different rates of the vestibulum positions and possible bony contacts at the vestibulum floor.

CONCLUSION

The individual measurement led to a zero rate of the vestibulum positions of stapes prosthesis pistons with a low insertion depth/vestibular depth ratio.

Postoperative imaging of the internal auditory canal : Visualization of active auditory implants

BACKGROUND

Assessment of the internal auditory canal (IAC) and cochlea is of central importance in neurotology. The artefacts and visibility of active auditory implants on magnetic resonance imaging (MRI) vary because of their specific magnetic components. Knowledge of the size of MRI artefacts and the options for handling them is important for the auditory rehabilitation of specific diseases (e. g., vestibular schwannoma).

METHODS

The current article is a literature review.

RESULTS

MRI assessment of the IAC and cochlea after surgical placement of an active auditory implant is feasible only with a percutaneous bone-anchored hearing aid (BAHA, Ponto). When specific factors (implant position and MRI sequence) are taken into consideration, these structures can be visualized even after cochlear implantation. Complications such as magnet dislocation and pain may occur.

CONCLUSION

The possibility of assessing the IAC and cochlea by MRI is an important aspect that needs to be taken into consideration when planning the auditory rehabilitation of patients after acoustic neuroma surgery.

Point-of-care ultrasonography for diagnosing thoracoabdominal injuries in patients with blunt trauma

BACKGROUND

Point-of-care sonography (POCS) has emerged as the screening modality of choice for suspected body trauma in many emergency departments worldwide. Its best known application is FAST (focused abdominal sonography for trauma). The technology is almost ubiquitously available, can be performed during resuscitation, and does not expose patients or staff to radiation. While many authors have stressed the high specificity of POCS, its sensitivity varied markedly across studies. This review aimed to compile the current best evidence about the diagnostic accuracy of POCS imaging protocols in the setting of blunt thoracoabdominal trauma.

OBJECTIVES

To determine the diagnostic accuracy of POCS for detecting and excluding free fluid, organ injuries, vascular lesions, and other injuries (e.g. pneumothorax) compared to a diagnostic reference standard (i.e. computed tomography (CT), magnetic resonance imaging (MRI), thoracoscopy or thoracotomy, laparoscopy or laparotomy, autopsy, or any combination of these) in patients with blunt trauma.

SEARCH METHODS

We searched Ovid MEDLINE (1946 to July 2017) and Ovid Embase (1974 to July 2017), as well as PubMed (1947 to July 2017), employing a prospectively defined literature and data retrieval strategy. We also screened the Cochrane Library, Google Scholar, and BIOSIS for potentially relevant citations, and scanned the reference lists of full-text papers for articles missed by the electronic search. We performed a top-up search on 6 December 2018, and identified eight new studies which may be incorporated into the first update of this review.

SELECTION CRITERIA

We assessed studies for eligibility using predefined inclusion and exclusion criteria. We included either prospective or retrospective diagnostic cohort studies that enrolled patients of any age and gender who sustained any type of blunt injury in a civilian scenario. Eligible studies had to provide sufficient information to construct a 2 x 2 table of diagnostic accuracy to allow for calculating sensitivity, specificity, and other indices of diagnostic test accuracy.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles, abstracts, and full texts of reports using a prespecified data extraction form. Methodological quality of individual studies was rated by the QUADAS-2 instrument (the revised and updated version of the original Quality Assessment of Diagnostic Accuracy Studies list of items). We calculated sensitivity and specificity with 95% confidence intervals (CI), tabulated the pairs of sensitivity and specificity with CI, and depicted these estimates by coupled forest plots using Review Manager 5 (RevMan 5). For pooling summary estimates of sensitivity and specificity, and investigating heterogeneity across studies, we fitted a bivariate model using Stata 14.0.

MAIN RESULTS

We included 34 studies with 8635 participants in this review. Summary estimates of sensitivity and specificity were 0.74 (95% CI 0.65 to 0.81) and 0.96 (95% CI 0.94 to 0.98). Pooled positive and negative likelihood ratios were estimated at 18.5 (95% CI 10.8 to 40.5) and 0.27 (95% CI 0.19 to 0.37), respectively. There was substantial heterogeneity across studies, and the reported accuracy of POCS strongly depended on the population and affected body area. In children, pooled sensitivity of POCS was 0.63 (95% CI 0.46 to 0.77), as compared to 0.78 (95% CI 0.69 to 0.84) in an adult or mixed population. Associated specificity in children was 0.91 (95% CI 0.81 to 0.96) and in an adult or mixed population 0.97 (95% CI 0.96 to 0.99). For abdominal trauma, POCS had a sensitivity of 0.68 (95% CI 0.59 to 0.75) and a specificity of 0.95 (95% CI 0.92 to 0.97). For chest injuries, sensitivity and specificity were calculated at 0.96 (95% CI 0.88 to 0.99) and 0.99 (95% CI 0.97 to 1.00). If we consider the results of all 34 included studies in a virtual population of 1000 patients, based on the observed median prevalence (pretest probability) of thoracoabdominal trauma of 28%, POCS would miss 73 patients with injuries and falsely suggest the presence of injuries in another 29 patients. Furthermore, in a virtual population of 1000 children, based on the observed median prevalence (pretest probability) of thoracoabdominal trauma of 31%, POCS would miss 118 children with injuries and falsely suggest the presence of injuries in another 62 children.

AUTHORS' CONCLUSIONS

In patients with suspected blunt thoracoabdominal trauma, positive POCS findings are helpful for guiding treatment decisions. However, with regard to abdominal trauma, a negative POCS exam does not rule out injuries and must be verified by a reference test such as CT. This is of particular importance in paediatric trauma, where the sensitivity of POCS is poor. Based on a small number of studies in a mixed population, POCS may have a higher sensitivity in chest injuries. This warrants larger, confirmatory trials to affirm the accuracy of POCS for diagnosing thoracic trauma.

Superior Canal Dehiscence: A Comparative Postmortem Multislice Computed Tomography Study

Objective

Superior canal dehiscence is defined by missing bony coverage of the superior canal against the middle cranial fossa. The gold standard in diagnosis is high-resolution computed tomography (CT). A false-positive CT scan, identifying a dehiscence when one is not present, could lead to unnecessary surgical therapy. This study aims to compare postmortem CT scans with autopsy findings with regard to superior canal dehiscence.

Study Design

Postmortem study.

Setting

Tertiary referral center.

Subjects and Methods

Twenty-two nontraumatic death cases within a 3-month period (January to March 2017) were included with 44 temporal bones. Each body underwent postmortem head CT prior to medicolegal autopsy. The middle fossa floor was exposed, and if present, the superior semicircular canal dehiscence was identified and measured. In each case, 3 comparable photographs were taken during the autopsy (left temporal bone, right temporal bone, overview).

Results

Autopsy findings revealed bony dehiscences in 11% of the temporal bones, whereas CT scan revealed bony dehiscences in 16%. The length of the dehiscences were longer when measured by CT imaging.

Conclusion

The diagnosis of superior canal dehiscence syndrome requires high-resolution CT with clinical symptoms and physiologic evidence of a third mobile window. Our study underlines a mismatch between multislice CT imaging in the coronal plane and the presence of a dehiscence on autopsy.

Cochlear implants and 1.5 T MRI scans: the effect of diametrically bipolar magnets and screw fixation on pain

Background

The probability that a patient will need an MRI scan at least once in a lifetime is high. However, MRI scanning in cochlear implantees is associated with side effects. Moreover, MRI scan-related artifacts, dislodging magnets, and pain are often the most frequent complications. The aim of this study was to evaluate the occurrence of pain in patients with cochlear implant systems using 1.5T MRI scans.

Methods

In a prospective case study of 10 implantees, an MRI scan was performed and the degree of pain was evaluated by a visual analog scale. Scans were performed firstly with and depending on the degree of discomfort/pain, without a headband. Four of the cochlear implants contained a screw fixation. Six cochlear implants contained an internal diametrically bipolar magnet. MRI observations were performed with a 1.5 T scanner.

Results

MRI scans were performed on all patients without causing any degree of pain, even without the use of a headband.

Conclusion

Patients undergoing 1.5 T MRIs with devices including a diametrically bipolar magnet or a rigid implant screw fixation, experienced no pain, even without headbands.

Radiological and NRT-Ratio-Based Estimation of Slim Straight Cochlear Implant Electrode Positions: A Multicenter Study

OBJECTIVES

An intraoperative neural response telemetry-ratio (NRT-ratio) was established, which can provide information about the intraoperative intracochlear electrode array position for perimodiolar electrodes.

METHODS

In a retrospective controlled study in 2 tertiary referral centers, the electrophysiological data sets of 50 patients with measured intraoperative auto-NRTs and postoperative radiological examinations were evaluated. All patients were implanted with Nucleus slim straight electrodes. The NRT-ratio was calculated by dividing the average auto-NRT data from electrodes 16 to 18 with the average from electrodes 5 to 7. Using a flat panel tomography system or a computed tomography, the position of the electrode array was certified radiological.

RESULTS

Radiologically, 2 out of 50 patients were identified with an electrode translocated from the scala tympani into the scala vestibuli. The radiologically estimated electrodes indicating a scalar change showed a regular NRT-ratio but nonspecific NRT-level changes at the localization of translocation.

Emergency ultrasound-based algorithms for diagnosing blunt abdominal trauma

BACKGROUND

Ultrasonography (performed by means of a four-quadrant, focused assessment of sonography for trauma (FAST)) is regarded as a key instrument for the initial assessment of patients with suspected blunt abdominal and thoraco-abdominal trauma in the emergency department setting. FAST has a high specificity but low sensitivity in detecting and excluding visceral injuries. Proponents of FAST argue that ultrasound-based clinical pathways enhance the speed of primary trauma assessment, reduce the number of unnecessary multi-detector computed tomography (MDCT) scans, and enable quicker triage to surgical and non-surgical care. Given the proven accuracy, increasing availability of, and indication for, MDCT among patients with blunt abdominal and multiple injuries, we aimed to compile the best available evidence of the use of FAST-based assessment compared with other primary trauma assessment protocols.

OBJECTIVES

To assess the effects of diagnostic algorithms using ultrasonography including in FAST examinations in the emergency department in relation to the early, late, and overall mortality of patients with suspected blunt abdominal trauma.

SEARCH METHODS

The most recent search was run on 30th June 2015. We searched the Cochrane Injuries Group Specialised Register, The Cochrane Library, MEDLINE (OvidSP), EMBASE (OvidSP), ISI Web of Science (SCI-EXPANDED, SSCI, CPCI-S, and CPSI-SSH), clinical trials registers, and screened reference lists. Trial authors were contacted for further information and individual patient data.

SELECTION CRITERIA

We included randomised controlled trials (RCTs). Participants were patients with blunt torso, abdominal, or multiple trauma undergoing diagnostic investigations for abdominal organ injury. The intervention was diagnostic algorithms comprising emergency ultrasonography (US). The control was diagnostic algorithms without US examinations (for example, primary computed tomography (CT) or diagnostic peritoneal lavage (DPL)). Outcomes were mortality, use of CT or invasive procedures (DPL, laparoscopy, laparotomy), and cost-effectiveness.

DATA COLLECTION AND ANALYSIS

Two authors (DS and CG) independently selected trials for inclusion, assessed methodological quality, and extracted data. Methodological quality was assessed using the Cochrane Collaboration risk of bias tool. Where possible, data were pooled and relative risks (RRs), risk differences (RDs), and weighted mean differences, each with 95% confidence intervals (CIs), were calculated by fixed-effect or random-effects models as appropriate.

MAIN RESULTS

We identified four studies meeting our inclusion criteria. Overall, trials were of poor to moderate methodological quality. Few trial authors responded to our written inquiries seeking to resolve controversial issues and to obtain individual patient data. Strong heterogeneity amongst the trials prompted discussion between the review authors as to whether the data should or should not be pooled; we decided in favour of a quantitative synthesis to provide a rough impression about the effect sizes achievable with US-based triage algorithms. We pooled mortality data from three trials involving 1254 patients; the RR in favour of the FAST arm was 1.00 (95% CI 0.50 to 2.00). FAST-based pathways reduced the number of CT scans (random-effects model RD -0.52, 95% CI -0.83 to -0.21), but the meaning of this result was unclear.

AUTHORS' CONCLUSIONS

The experimental evidence justifying FAST-based clinical pathways in diagnosing patients with suspected abdominal or multiple blunt trauma remains poor. Because of strong heterogeneity between the trial results, the quantitative information provided by this review may only be used in an exploratory fashion. It is unlikely that FAST will ever be investigated by means of a confirmatory, large-scale RCT in the future. Thus, this Cochrane Review may be regarded as a review which provides the best available evidence for clinical practice guidelines and management recommendations. It can only be concluded from the few head-to-head studies that negative US scans are likely to reduce the incidence of MDCT scans which, given the low sensitivity of FAST (or reliability of negative results), may adversely affect the diagnostic yield of the trauma survey. At best, US has no negative impact on mortality or morbidity. Assuming that major blunt abdominal or multiple trauma is associated with 15% mortality and a CT-based diagnostic work-up is considered the current standard of care, 874, 3495, or 21,838 patients are needed per intervention group to demonstrate non-inferiority of FAST to CT-based algorithms with non-inferiority margins of 5%, 2.5%, and 1%, power of 90%, and a type-I error alpha of 5%.

Electrode Migration in Patients with Perimodiolar Cochlear Implant Electrodes

Migration of a cochlear implant electrode is a hitherto uncommon complication. So far, array migration has only been observed in lateral wall electrodes. Between 1999 and 2014, a total of 27 patients received bilateral perimodiolar electrode arrays at our institution. The insertion depth angle was estimated on the initial postoperative scans and compared with the insertion depth angle of the postoperative scans performed after contralateral cochlear implantation. Seven (25.93%) patients were found to have an electrode array migration of more than 15°. Electrode migration in perimodiolar electrodes seems to be less frequent and to occur to a lower extent than in lateral wall electrodes. Electrode migration was clinically asymptomatic in all cases.

Relationship between intracochlear electrode position and tinnitus in cochlear implantees

CONCLUSION

Cochlear implant electrode position has an impact on the rate of tinnitus suppression and generation.

OBJECTIVE

Suppression of pre-operative tinnitus or a generation of a new tinnitus in cochlear implantees is a known effect of cochlear implantation. The aim of the current study was to evaluate different cochlear implant electrode positions and their relationship with tinnitus suppression and tinnitus generation.

METHOD

This study retrospectively evaluated four groups of CI recipients with radiologically evaluated electrode positions in relation to their subjective tinnitus quality, as evaluated by an analogue loudness scale (ALS) and a questionnaire. Group 1 consisted of 19 patients with a scalar change of the electrode position. Group 2 consisted of 18 patients with a scala tympani position and a perimodiolar electrode. Group 3 consisted of 10 patients with a scala tympani position and a lateral wall electrode. Group 4 consisted of eight patients with a scala vestibuli position.

RESULTS

An overall tinnitus suppression rate of 45.9% and a generation of a new tinnitus or the deterioration of an existing one of 5.6% were observed. A significant difference in tinnitus suppression was found between groups 1 and groups 2, 3, and 4 in tinnitus suppression and tinnitus generation.

[Obligation to operate splenic injuries in polytrauma patients using MS-CT criteria]

PURPOSE

The aim of this study is to evaluate the validity of multi-slice computed tomography (MS-CT) in predicting the need to operate on spleen injuries in polytrauma patients using selected grading systems; the Thompson screening test (TST) and the extended TST (ETST).

PATIENTS AND METHODS

A retrospective evaluation of 2791 patients who presented spleen injuries in polytrauma MS-CTs in the period between 12/2002 and 06/2010 was undertaken. On the basis of CT morphology, and by using the above mentioned grading systems, the probability of the need to operate on a splenic injury was defined.

RESULTS

From a sample of 2791 patients, an MS-CT polytrauma scan was used to identify 139 splenic injuries. In correlation with the actual interventions carried out on the spleen, the applied grading systems showed sensitivities of 91 % (TST) and 69 % (ETST) as well as specificities of 78 % (TST) and 93 % (ETST). Regarding interventions on a splenic injury, positive predictive values were 57 % (TST) and 76 % (ETST), and the accordant negative predictive values were 96 % (TST) and 91 % (ETST). Thereby we ascertained significantly lower results than Thompson et al.

CONCLUSION

The applied grading systems based on the findings of MS-CT do not reliably predict the need to operate on spleen injuries in polytrauma patients.

Accuracy of single-pass whole-body computed tomography for detection of injuries in patients with major blunt trauma

BACKGROUND

Contrast-enhanced whole-body computed tomography (also called "pan-scanning") is considered to be a conclusive diagnostic tool for major trauma. We sought to determine the accuracy of this method, focusing on the reliability of negative results.

METHODS

Between July 2006 and December 2008, a total of 982 patients with suspected severe injuries underwent single-pass pan-scanning at a metropolitan trauma centre. The findings of the scan were independently evaluated by two reviewers who analyzed the injuries to five body regions and compared the results to a synopsis of hospital charts, subsequent imaging and interventional procedures. We calculated the sensitivity and specificity of the pan-scan for each body region, and we assessed the residual risk of missed injuries that required surgery or critical care.

RESULTS

A total of 1756 injuries were detected in the 982 patients scanned. Of these, 360 patients had an Injury Severity Score greater than 15. The median length of follow-up was 39 (interquartile range 7-490) days, and 474 patients underwent a definitive reference test. The sensitivity of the initial pan-scan was 84.6% for head and neck injuries, 79.6% for facial injuries, 86.7% for thoracic injuries, 85.7% for abdominal injuries and 86.2% for pelvic injuries. Specificity was 98.9% for head and neck injuries, 99.1% for facial injuries, 98.9% for thoracic injuries, 97.5% for abdominal injuries and 99.8% for pelvic injuries. In total, 62 patients had 70 missed injuries, indicating a residual risk of 6.3% (95% confidence interval 4.9%-8.0%).

INTERPRETATION

We found that the positive results of trauma pan-scans are conclusive but negative results require subsequent confirmation. The pan-scan algorithms reduce, but do not eliminate, the risk of missed injuries, and they should not replace close monitoring and clinical follow-up of patients with major trauma.

Accuracy of single-pass whole-body computed tomography for detection of injuries in patients with major blunt trauma

BACKGROUND

Contrast-enhanced whole-body computed tomography (also called "pan-scanning") is considered to be a conclusive diagnostic tool for major trauma. We sought to determine the accuracy of this method, focusing on the reliability of negative results.

METHODS

Between July 2006 and December 2008, a total of 982 patients with suspected severe injuries underwent single-pass pan-scanning at a metropolitan trauma centre. The findings of the scan were independently evaluated by two reviewers who analyzed the injuries to five body regions and compared the results to a synopsis of hospital charts, subsequent imaging and interventional procedures. We calculated the sensitivity and specificity of the pan-scan for each body region, and we assessed the residual risk of missed injuries that required surgery or critical care.

RESULTS

A total of 1756 injuries were detected in the 982 patients scanned. Of these, 360 patients had an Injury Severity Score greater than 15. The median length of follow-up was 39 (interquartile range 7-490) days, and 474 patients underwent a definitive reference test. The sensitivity of the initial pan-scan was 84.6% for head and neck injuries, 79.6% for facial injuries, 86.7% for thoracic injuries, 85.7% for abdominal injuries and 86.2% for pelvic injuries. Specificity was 98.9% for head and neck injuries, 99.1% for facial injuries, 98.9% for thoracic injuries, 97.5% for abdominal injuries and 99.8% for pelvic injuries. In total, 62 patients had 70 missed injuries, indicating a residual risk of 6.3% (95% confidence interval 4.9%-8.0%).

INTERPRETATION

We found that the positive results of trauma pan-scans are conclusive but negative results require subsequent confirmation. The pan-scan algorithms reduce, but do not eliminate, the risk of missed injuries, and they should not replace close monitoring and clinical follow-up of patients with major trauma.

Minimally invasive spinal surgery using nucleoplasty and the Dekompressor tool: a comparison of two methods in a one year follow-up

OBJECT

The Disc Dekompressor and Nucleoplasty are 2 different, minimally invasive, percutaneous methods in the therapy for chronic discogenic low back pain. The aim of this study is to compare the effectiveness of both methods concerning the outcome one year after surgery.

METHODS

We included patients with MRI-proven disc protrusion suffering from low back pain and/or radiating pain in the lower extremities. The pain perception of the patients was documented using the visual analogue pain scale (VAS). Furthermore, the patients were queried about analgesic consumption, disability in daily life and ability to work. Percutaneous minimally invasive nucleotomy using the Nucleoplasty or the Disc Dekompressor was carried out under fluoroscopic and CT-guidance. We carried out a follow-up examination at 6 and 12 months after the operation.

RESULTS

From April 2005 to November 2007 a total of 126 patients underwent percutaneous minimally invasive nucleotomy using Nucleoplasty (April 2005 - December 2006) or the Disk Dekompressor (February 2006 - November 2007) and were followed up after 6 and 12 months. In the Nucleoplasty group the mean age of the 27 females (39%) and 42 males (61%) was 42 years (range: 18-74). In the Disc Dekompressor group the mean age of the 22 females (39%) and 35 males (61%) was 44 years (range: 16-76). The mean duration of symptoms in the Nucleoplasty group was 30.5 months (range: 1-120), and in the Disc Dekompressor group 16.3 months (range: 1-72). Statistically significant postoperative improvement concerning the VAS score was evident in both groups. Whereas the VAS score slightly increased in the Nucleoplasty group comparing the early postoperative score and the score after 12 months, the VAS score stayed on a low level in the Disc Dekompressor group. A statistically significant reduction in analgesic consumption, disability and occupational incapacitation was observed in the Nuceloplasty group and the Disc Dekompressor group.

CONCLUSIONS

Both Nucleoplasty and Disc Dekompressor are effective therapies for chronic, discogenic back pain. Regardless of the different mechanism no significant differences in the outcomes were found. Both techniques result in significant reductions in levels of disability and incapacity for work as well as decreased analgesic consumption.

Primary pan-computed tomography for blunt multiple trauma: can the whole be better than its parts?

Single-pass, whole-body computed tomography (pan-CT) was proposed in the late 1990s as a new concept for the diagnostic work-up of severely injured patients. Since its introduction, it has led to considerable debate among clinicians and scientists, triggered by concerns about its immediate safety, questionable therapeutic advantages and exposure to radiation. However, it was recently shown that pan-CT scanning may be associated with a reduction in trauma mortality. In this article, we provide an overview of current knowledge of the value of this compelling concept. The diagnostic accuracy of multidetector row CT (MDCT) for clearing various anatomical regions in trauma patients is, at best, unclear. Little is known about the accuracy of pan-CT as a whole, which weakens statements about its effectiveness and prevents inferences about survival advantages. This last point may be explained by a stage-migration or "Will Rogers" phenomenon: Pan-CT increases injury severity by detecting lesions that would not have been recognized by conventional methods but still do not affect treatment decisions, thus artificially lowering the ratio of observed to expected deaths. In order to maintain the credibility of pan-CT technology for trauma, a rigorous, large-scale evaluation of its accuracy is required. Such an evaluation requires consensus about the definition of true and false positive and negative findings in the setting of blunt multiple trauma. In addition, triage criteria need to be refined to increase specificity and reduce the number of unnecessary scans.

Functional outcomes and health-related quality of life after robot-assisted anterior cruciate ligament reconstruction with patellar tendon grafts

During a short period of time, surgical robots had been propagated for automated tunnel placement in anterior cruciate ligament (ACL) reconstruction. Clinical outcome data are currently unavailable. Between 2000 and 2003, 152 patients underwent ACL replacement with the assistance of the Computer Assisted Surgical Planning and Robotics system (CASPAR, OrtoMaquet, Germany) at our hospital. After minimal invasive pin placement in both the tibia and femur, computed tomography was used to register anatomical landmarks and to plan graft tunnel alignment. The robot was used to drill tibial and femoral tunnels in an outside-in fashion according to pre-operative planning. There was one procedure-specific Serious Adverse Event (i.e., an intraoperative transection of the posterior cruciate ligament). After IRB approval, all patients were invited for a follow-up examination. Data from 100 patients (35 women, 65 men, mean age 35 [SD 11] years, median follow-up 61 [range 42-77] months) form the basis of this report. Side-to-side differences in anterior laxity were measured with the KT-1000 arthrometer. Patient-centered outcomes included the Lysholm-Score, the lower extremity functional scale (LEFS), and the Short Form 36 (SF36). The mean KT-1000 side-to-side difference was 0.89 [95% confidence interval (CI) 0.52-1.26] mm. Eight and five patients had a positive Lachman and pivot shift test, respectively. The Lysholm-Score averaged 86 (95% CI 83-89) points. Excellent, good, fair, and poor outcomes were reported by 38, 32, 20, and 10 patients. The LEFS averaged 85 (95% CI 82-88) points. The mean SF36 Physical Component Score was 48.4 (95% CI 46.5-50.3), indicating residual deficits compared to the population norm. All tibial graft tunnels did not cross the Blumensaat line, but were placed slightly anterior to the optimal center of 42% reported in previous studies. Compared to literature data, robot-assisted ACL reconstruction with BTB grafts may lead to higher knee stability, but poorer functional outcomes. The immense additional efforts with the procedure did not pay off in a benefit to patients.

Diagnostic accuracy of plain radiographs and cineradiography in diagnosing traumatic scapholunate dissociation

OBJECTIVE

Missed tears of the scapholunate ligament (SLL) and scapholunate dissociation (SLD) after wrist injuries pose a high risk of post-traumatic osteoarthritis of the carpus. Plain X-rays and dynamic radiographic studies are frequently used for initial diagnostic work-up. Given the limited evidence of their accuracy, we retrospectively compared the radiographic findings of patients with suspected traumatic SLD with wrist arthroscopy as the accepted reference standard.

DESIGN AND METHODS

During a 6-year period, plain radiographs and DSA cineradiography scans were obtained from 198 patients who had sustained a hyperextension injury to their hand. Of those, 102 (72 men, 30 women, mean age of 42+/-12 years) subsequently underwent diagnostic arthroscopy. Digital images were reevaluated by experienced radiologists unaware of the arthroscopic findings for the presence or absence of SLD. We calculated the sensitivity (SN) and specificity (SP) with 95% confidence intervals (CI), and computed areas under the receiver operating characteristic curves (AUC/ROC).

RESULTS

Arthroscopy revealed 42 SLL ruptures, 13, 10, and 19 of which were classified as grade I (partial), II (complete with dynamic instability), or III (complete with static instability) respectively. Plain radiographs correctly identified 24 injuries (SN 57.1%, 95% CI 41.0-72.3%), and produced 1 false-positive result (SP 98.3%, 95% CI 91.1-100.0%). The scapholunate distance and the SL angle contributed independently to the diagnostic variance, with an AUC/ROC of 85.7% (95% CI 76.8-92.2%). Cineradiography had a sensitivity of 36 out of 42 (85.7%, 95% CI 71.5-94.6%), and a specificity of 57 out of 60 (95.0%, 95% CI 86.1-99.0%).

CONCLUSION

Pathological results on plain radiographs and cineradiography reliably indicate the presence of SLD after wrist trauma. Although non-conclusive, a negative dynamic study markedly reduces the pre-test probability of disease. Both methods remain key elements of primary diagnostic strategies for suspected traumatic SLD, and may facilitate the selection of additional tests.