Diagnostic treatment-level discrepancies in patients with lumbosacral radicular pain and lumbar spine anomalies

BackgroundLumbosacral transitional vertebra can result in an anomalous number of lumbar vertebrae associated with wrong level treatment. The primary aim of this study was to characterize discrepancies between reported referring levels and levels from MRI reports with treated levels. The secondary aim was to analyze interobserver variability between a pain physician and a radiologist when determining levels and classifying lumbosacral transitional vertebrae.MethodsBetween February 2016 and October 2019, a retrospective case series of prospectively collected data of the affected levels mentioned in referrals, MRI reports and treated levels was performed. The counting process, level determination, classification of lumbosacral transitional vertebrae and a secondary control were carried out by independent researchers using a standard methodology.ResultsOf the 2443 referrals, 143 patients had an anomalous number of lumbar vertebrae; of these, 114 were included for analysis. The vertebral level noted in the patient’s file, in the referral, and the reported level of treatment differed in 40% of these cases. The vertebral level between the MRI reports and treatment differed in 46% of cases. The interobserver reliability (radiologist vs pain physician) for classifying a transitional vertebra was fair ((κ=0.40) and was substantial (κ=0.70) when counting the vertebrae.ConclusionIn the presence of lumbar spine anomalies, we report a high prevalence of discrepancies between referral levels and MRI pathological findings with treatment levels. Further research is needed to better understand clinical implications.

Minimising Radiation Dose in Computerised Tomography in the Investigation of Renal Stone Disease: A Teaching Hospital Audit

Background: CTKUB is a commonly performed scan as the gold standard investigation for renal stone disease. However, CT exposes a patient to ionising radiation. The radiation delivered to the patient increases in importance given the young demographic and often need for interval imaging. To minimise exposure, low dose scanning techniques are employed, and image field is reduced to only scan relevant anatomy. A common starting point for CT KUB is often the T10 vertebra however many scans are performed starting at higher levels exposing the patient to unnecessary radiation. Methods: A list of 100 patients who underwent CTKUB for renal stone disease at a teaching hospital was created. Following exclusion of duplicates and application of exclusion criteria 51 scans were included. Each scan was individually analysed to assess vertebral level of upper limit of kidney and vertebral level at which the CTKUB scan was started. Percentage overshoot was calculated as number of axial slices cranial to the upper aspect of the kidneys. Results: 22% of scans included in the study were started proximal to T10, these scans had a mean percentage overshoot of 19.6% exposing the patient to excess radiation. Of the CT KUB scans started at T10 or below mean percentage overshoot was improved to 8.6%. At the level of T10 all analysed scans would avoid undershooting. Conclusions: Implementation of a CTKUB imaging protocol which starts at T10 will minimise ionising radiation exposure whilst allowing visualisation of the complete renal tract. Keywords: CT KUB, Radiation safety, Minimise radiation

Computed Tomography Osteoabsorptiometry Evaluation of Cervical Endplate Subchondral Bone Mineral Density

Study Design Basic Science. Objective Poor subchondral bone mineral density (sBMD) has been linked with subsidence of cervical interbody devices or grafts, which are traditionally placed centrally on the endplates. Considering that sBMD reflects long-term stress distributions, we hypothesize that the cervical uncovertebral joints are denser than the central endplate region. This study sought to investigate density distributions using computed tomography osteoabsorptiometry (CT-OAM). Methods Twelve human cervical spines from C3–C7 (60 vertebrae, 120 endplates) were imaged with CT and segmented to create 3D reconstructions. The superior and inferior endplates were isolated, and the sBMD of the whole endplate, endplate center, and uncus was evaluated using CT-OAM. Density distributions were compared across the subaxial cervical spine. Results The uncinate region of the inferior and superior endplates was significantly denser than the central endplate across all vertebral levels ( P < .01). When comparing sBMD of the whole inferior and superior endplates, the superior endplate was significantly denser than the inferior endplate ( P < .0001). However, the inferior uncus was denser than the superior uncus ( P = .035). When assessing sBMD by vertebral level, peak densities were observed at C4 and C5, while C7 was, on average, significantly less dense than all other vertebrae. Conclusion The subchondral bone of the cervical uncovertebral joints is significantly denser than the central endplates. While the superior endplate in its entirety is denser than the inferior endplate, the inverse was true for the uncovertebral joints. This study serves as a basis for future investigations of new implant designs and their implications on subsidence.

Bifurcation of Common Carotid Artery in Relation to Vertebral Level in Nepalese: A Cadaveric Study

The principal arterial supply of the head and neck are the two Common Carotid Arteries (CCA), they ascend in the neck and each divides into two branches, the External Carotid Artery (ECA) supplying the exterior of the head, neck and the Internal Carotid Artery (ICA) supplying the cranial and orbital cavities. Atherosclerosis of the carotid arteries is a major cause of stroke and transient ischemic attack and it increases with age. The present study was observational based descriptive type, conducted to identify the CCA bifurcation in relation to cervical vertebral level. A total number of 18 cadavers (16 males and 2 females), right and left side of cadavers were studied by dissection method in the Department of Anatomy, NMCTH from February 2020 to February 2021. The ethical approval was taken from NMC- IRC (Ref no- 026-076/077). In present study the frequency of CCA bifurcation in sixteen male Nepalese cadavers (32 samples) on the right and left side was observed and found high level of bifurcation on 31.25% and 37.5% respectively and normal/ standard on the right and left on 68.75% and 62.5% and there were no findings of low bifurcation of CCA. In two female cadavers (4 observations) the level of bifurcation was same on both the side at the level of C3-C4. The Carotid artery injury is possible in different neurological and head and neck surgery. Therefore, the knowledge of variation in level of bifurcation of CCA in different population will be referential to reduce the iatrogenic injury.

Future Challenges and Critical Approach to Metrology in Patients with Axial Spondyloarthritis

Axial spondyloarthritis (axSpA) is a rheumatic inflammatory chronic disease that mainly affects the spine, producing inflammation and structural damage at the vertebral level (erosions, syndesmophytes, and bony bridges) [...]

Duplication of Inferior Vena Cava with Left Inferior Vena Cava Draining into Right Inferior Vena Cava - A Case Report

Double inferior vena cava is a rare anomaly with incidence rate of 0.2 - 3 %. It occurs due to non-regression of both right and left supracardinal veins during embryonic development. Here, we present a case with double inferior vena cava diagnosed in a patient who underwent routine computed tomography for abdominal pain. In our case, both right and left inferior vena cava are of same caliber and we believe that duplication of IVC in our case was a result of nonregression of anastomosis between left supra subcardinal, posterior subcardinal and intersubcardinal veins resulting in persistence of left subcardinal vein. The knowledge of this anatomical variation is clinically important during retroperitoneal surgeries and vascular and radiological interventional procedures. Inferior vena cava anomalies are rare and incidentally found in asymptomatic patients who undergo radiological imaging for some other diseases. The reported incidence of duplicated inferior vena cava is 0.2 to 3 %. Among all the inferior vena cava anomalies, inferior vena cava duplication and left inferior vena cava are most commonly found. 1,2 Vascular anomalies often get encountered in computed tomography (CT) scans of abdomen and pelvis obtained with contrast injection. Familiarity with these variations is essential for correct interpretation.3 Here, we present a case of duplication of inferior vena cava with left IVC draining into right IVC at upper border of L2 vertebral level.

Difficulty factors of adrenal venous sampling based on patient characteristics and imaging findings

Background Primary aldosteronism is one of the most common causes of secondary hypertension. Unilateral primary aldosteronism can be treated with adrenalectomy; therefore, determining laterality is essential, for which adrenal venous sampling is considered the gold standard. However, as catheter insertion and sampling at an appropriate venous point is occasionally difficult, it is a time-consuming procedure. Purpose To evaluate the patient characteristics and imaging findings that influence the adrenal venous sampling procedure. Material and Methods A total of 69 patients who underwent adrenal venous sampling between January 2013 and December 2017 were retrospectively analyzed. The procedure was considered difficult if the duration was > 142 min (mean ± standard deviation [SD] of procedure time in this study) and/or proper sampling failed. Anatomical factors such as belly diameter, presence of adrenal nodules, diameter of the right adrenal vein and inferior vena cava, ratio of the diameters of the right adrenal vein to diameter of the inferior vena cava, vertical direction of the right adrenal vein, and vertebral level of the right adrenal vein were evaluated as predictive factors on computed tomography. Results Fifteen patients (21.7%) were considered difficult cases. The factors associated with difficulty were the long transverse diameter of the belly ( P = 0.004) and high vertebral level of the right adrenal vein ( P = 0.032). No statistical differences were observed in any other factors. Conclusion The long transverse diameter of the belly and high vertebral level of the right adrenal vein may prevent completion of the adrenal venous sampling procedure.

Chiropractic Spinal Manipulation Prevents Secondary Hyperalgesia Induced by Topical Capsaicin in Healthy Individuals

Background and Aims: Spinal manipulation (SM) is currently recommended for the management of back pain. Experimental studies indicate that the hypoalgesic mechanisms of SM may rely on inhibition of segmental processes related to temporal summation of pain and, possibly, on central sensitization, although this remains unclear. The aim of this study was to determine whether experimental back pain, secondary hyperalgesia, and pain-related brain activity induced by capsaicin are decreased by segmental SM.Methods: Seventy-three healthy volunteers were randomly allocated to one of four experimental groups: SM at T5 vertebral level (segmental), SM at T9 vertebral level (heterosegmental), placebo intervention at T5 vertebral level, or no intervention. Topical capsaicin was applied to the area of T5 vertebra for 40 min. After 20 min, the interventions were administered. Pressure pain thresholds (PPTs) were assessed outside the area of capsaicin application at 0 and 40 min to examine secondary hyperalgesia. Capsaicin pain intensity and unpleasantness were reported every 4 min. Frontal high-gamma oscillations were also measured with electroencephalography.Results: Pain ratings and brain activity were not significantly different between groups over time (p &gt; 0.5). However, PPTs were significantly decreased in the placebo and control groups (p &lt; 0.01), indicative of secondary hyperalgesia, while no hyperalgesia was observed for groups receiving SM (p = 1.0). This effect was independent of expectations and greater than placebo for segmental (p &lt; 0.01) but not heterosegmental SM (p = 1.0).Conclusions: These results indicate that segmental SM can prevent secondary hyperalgesia, independently of expectations. This has implications for the management of back pain, particularly when central sensitization is involved.