Accuracy and Reliability of MRI Reports in Diagnosing the Symptomatic Knee in Patients Who Had Bilateral MRI.

Background: Newly symptomatic chronic musculoskeletal illness is often misinterpreted as new pathology, particularly when symptoms are first noticed after an event. In this study, we were interested in the accuracy and reliability of identifying the symptomatic knee based on bilateral MRI reports. Methods: We selected a consecutive sample of 30 occupational injury claimants, presenting with unilateral knee symptoms who had bilateral MRI on the same date. A group of blinded musculoskeletal radiologists dictated diagnostic reports, and all members of the Science of Variation Group (SOVG) were asked to indicate the symptomatic side based on the blinded reports. We compared diagnostic accuracy in a multilevel mixed-effects logistic regression model, and calculated interobserver agreement using Fleiss' kappa. Results: Seventy-six surgeons completed the survey. The sensitivity of diagnosing the symptomatic side was 63%, the specificity was 58%, the positive predictive value was 70%, and the negative predictive value was 51%. There was slight agreement among observers (kappa= 0.17). Case descriptions did not improve diagnostic accuracy (Odds Ratio: 1.04; 95% CI: 0.87 to 1.3; P=0.65). Conclusion: Identifying the more symptomatic knee in adults based on MRI is unreliable and has limited accuracy, with or without information about demographics and mechanism of injury. When there is a dispute concerning the extent of the injury to a knee in a litigious, medico-legal setting such as Workers' Compensation, consideration should be given to obtaining a comparison MRI of the uninjured, asymptomatic extremity.

Linguistic tones in MRI reports correlate with severity of pathology for rotator cuff tendinopathy.

BACKGROUND: Written communication can convey one's emotions, personality, and sentiments. Radiology reports employ medical jargon and serve to document a patients' condition. Patients might misinterpret this medical jargon in a way that increases their anxiety and makes them feel unwell. We were interested whether linguistic tones in MRI reports vary between radiologists and correlate with the severity of pathology. QUESTIONS/PURPOSES: (1) Is there variation in linguistic tones among different radiologists reporting MRI results for rotator cuff tendinopathy? (2) Is the retraction of the supraspinatus tendon in millimeters associated with linguistic tones? METHODS: Two hundred twenty consecutive MRI reports of patients with full-thickness rotator cuff defects were collected. Supraspinatus retraction was measured on the MRI using viewer tools. Using Kruskal-Wallis H tests, we measured variation between 11 radiologists for the following tones: positive emotion, negative emotion, analytical thinking, cause, insight, tentativeness, certainty, and informal speech. We also measured the correlation of tones and the degree of tendon retraction. Multilevel mixed-effects linear regression models were constructed, seeking factors associated with the tone, accounting for retraction, the presence of prior imaging, and for the effects of each radiologist (nesting). RESULTS: There were statistically significant differences for all of the tones by radiologist. In bivariate analysis, greater retraction of the supraspinatus muscle in millimeters was associated with more negative emotion and certainty, and with less tentativeness. In multilevel mixed-effects linear regression, more negative tones were associated with greater retraction and absence of prior imaging. Greater tentativeness was associated with the absence of prior imaging, but not with retraction. CONCLUSIONS: Radiology reports have emotional content that is relatively negative, varies by radiologist and is affected by pathology. Strategies for more hopeful, positive, optimistic descriptions of pathology have the potential to help patients feel better without introducing inaccuracies even if unlikely. LEVEL OF EVIDENCE: Level III, Diagnostic.

Surgeons' Recommendations for Neurodiagnostic Testing With High Pretest Probability of Idiopathic Median Neuropathy at the Carpal Tunnel.

PURPOSE: The utility of electrodiagnostic tests (EDx) for patients with a high pretest probability of idiopathic median neuropathy at the carpal tunnel (IMNCT) based on characteristic symptoms and signs is debated. Decision-making and care strategies could be informed by a better understanding of factors associated with surgeon recommendations for electrodiagnostic testing. METHODS: Ninety-one upper-extremity surgeons participated in an online, survey-based experiment. Participants viewed 7 vignettes of patients with carpal tunnel syndrome, with the following factors randomized in each vignette: patient age, gender, magnitude of incapability, symptom intensity and the presence of nocturnal symptoms, palmar abduction weakness, and positive provocative tests results. We sought patient and surgeon factors associated with ordering EDx and surgeon-rated comfort with performing carpal tunnel release (CTR) without EDx. RESULTS: Surgeons recommended EDx for over half of the patient vignettes, with notable variation (median, 57%; interquartile range, 14-100), and felt relatively neutral, on average, offering CTR without EDx. Twenty-six (29%) out of 91 surgeons ordered EDx for all patient scenarios, and 18 surgeons (20%) did not order testing for any scenario. A lower likelihood of EDx was associated with older age and positive provocative tests results. Greater surgeon comfort offering CTR without EDx was associated with older patients, the presence of nocturnal symptoms, palmar abduction weakness, and positive provocative tests results. CONCLUSIONS: Upper-extremity surgeons are neutral regarding diagnosing IMNCT based on electrodiagnostic evidence of pathology and are relatively more comfortable offering surgery without EDx in older patients that present with key aspects of carpal tunnel syndrome. There is notable variation in care, with half of all surgeons always or never ordering EDx. CLINICAL RELEVANCE: Future studies can investigate whether a treatment strategy offering surgery to patients with a high pretest probability of IMNCT and only using EDx in intermediate probability scenarios can limit use of testing without affecting patient health.

Restrained Differential Growth: The Initiating Event of Adolescent Idiopathic Scoliosis?

STUDY DESIGN: An experimental model study and a short review of literature. OBJECTIVE: The purpose of this study was to explore a new hypothesis suggesting that the curvatures seen in adolescent idiopathic scoliosis (AIS) originate from restrained differential growth between the vertebral column and the surrounding musculo-ligamentary structures. SUMMARY OF BACKGROUND DATA: Despite decades of research, there is no generally accepted theory on the physical origin of the severe spinal deformations seen in AIS. The prevailing theories tend to focus on left-right asymmetry, rotational instability, or the sagittal spinal profile in idiopathic scoliosis. METHODS: We test our hypothesis with a physical model of the spine that simulates growth, counteracted by ligaments and muscles, modeled by tethers and springs. Growth of the spine is further restrained by an anterior band representing the thorax, the linea alba, and abdominal musculature. We also explore literature in search of molecular mechanisms that may induce differential growth. RESULTS: Differential growth in the restrained spine model first induces hypokyphosis and mild lateral bending of the thoracic spine, but then suddenly escalates into a scoliotic deformity, consistent with clinical observations of AIS. The band simulating the ventral structures of the body had a pivotal effect on sagittal curvature and the initiation of lateral bending and rotation. In literature, several molecular mechanisms were found that may explain the occurrence of differential growth between the spine and the musculo-ligamentary structures. CONCLUSION: While AIS is a three-dimensional deformation of the spine, it appears that restrained differential growth in the sagittal plane can result in lateral bending and rotation without a pre-existing left-right asymmetry. This supports the concept that AIS may result from a growth imbalance rather than a local anatomical defect. LEVEL OF EVIDENCE: N/A.