Update on Imaging of Spinal Fixation Hardware.

This article discusses instrumented spinal surgeries, the radiologic assessment of spinal fixation hardware, and the potential complications of spinal hardware. Radiography is the standard for the postoperative assessment of spinal hardware. Computed tomography and magnetic resonance imaging play a valuable role in the detection of hardware and postsurgical-related complications such as infection, pseudarthrosis, and malpositioned instrumentation. Familiarity with the normal imaging appearance of implanted spinal hardware along with the expected progression of normal postoperative osseous arthrodesis enables recognition of potential complications and helps facilitate appropriate clinical management.

State medical licensure for telemedicine and teleradiology.

Physician medical licensure is state based for historical and constitutional reasons. It may also provide the best method for guaranteeing patient protection from unqualified, incompetent, impaired, or unprofessional practitioners of medicine. However, a significant cost for physicians practicing telemedicine is having to obtain multiple state medical licenses. There is reasonable likelihood that model legislation for the practice of telemedicine across state boundaries will be passed in the next few years, providing physicians with a simpler process for license reciprocity in multiple states via interstate licensing compacts. Physicians would have to be licensed in the state in which the patient resides. Patient complaints would still be adjudicated by the medical licensing board in the state where the patient resides according applicable state legislation.

University-Based Teleradiology in the United States.

This article reviews the University of Arizona's more than 15 years of experience with teleradiology and provides an overview of university-based teleradiology practice in the United States (U.S.). In the U.S., teleradiology is a major economic enterprise with many private for-profit companies offering national teleradiology services (i.e., professional interpretation of radiologic studies of all types by American Board of Radiology certified radiologists). The initial thrust for teleradiology was for after-hours coverage of radiologic studies, but teleradiology has expanded its venue to include routine full-time or partial coverage for small hospitals, clinics, specialty medical practices, and urgent care centers. It also provides subspecialty radiologic coverage not available at smaller medical centers and clinics. Many U.S. university-based academic departments of radiology provide teleradiology services usually as an additional for-profit business to supplement departmental income. Since academic-based teleradiology providers have to compete in a very demanding marketplace, their success is not guaranteed. They must provide timely, high-quality professional services for a competitive price. Academic practices have the advantage of house officers and fellows who can help with the coverage, and they have excellent subspecialty expertise. The marketplace is constantly shifting, and university-based teleradiology practices have to be nimble and adjust to ever-changing situations.

Factors in the selection of a teleradiology provider in the United States.

Commercial teleradiology is well established in the US. There are many factors to consider when engaging a teleradiology provider. One of the basic questions is what do you expect to gain from it? Do you want a final reading from an attending radiologist (known as a consultant radiologist in many countries) or would you be satisfied with a preliminary reading from a teleradiology provider and a final reading from your own in-house radiologist the following day? Do you simply require after-hours coverage or do you need to supplement the coverage provided by your own internal radiologists during normal working hours? Teleradiology is not without its drawbacks. It can add additional costs, particularly for after-hours coverage. Teleradiology rarely provides in-house coverage for procedures, and the interpreting radiologist may sometimes be difficult to contact for consultation. Choosing a teleradiology vendor requires due diligence. When the contracting entity defines its expectations well and chooses its teleradiology vendor with care, the end result will be satisfactory for all concerned, including the patients.

Humeral avulsion of the inferior glenohumeral ligament in college female volleyball players caused by repetitive microtrauma.

BACKGROUND: Humeral avulsion of the inferior glenohumeral ligament is a rare injury resulting from hyperabduction and external rotation, and it is most commonly seen with sports-related injuries, including those from volleyball. The anterior band of the inferior glenohumeral ligament is most commonly injured (93%), whereas the posterior band is infrequently injured. The axillary pouch humeral avulsion of the inferior glenohumeral ligament as a result of repetitive microtrauma has not been yet described in the English literature. HYPOTHESIS: Humeral avulsions of the inferior glenohumeral ligaments are identifiable in volleyball players without acute injuries, and they have a unique pathologic pattern in these athletes. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Four female college volleyball players with pain in their dominant shoulder and with inferior capsular laxity and/or instability­without a known history of trauma or dislocation of the same shoulder­were referred by an experienced sports medicine orthopaedic surgeon for the magnetic resonance arthrogram procedure of the same shoulder. The imaging findings were retrospectively correlated with the initial interpretation and arthroscopic findings. RESULTS: All 4 patients had an axillary pouch humeral avulsion of the inferior glenohumeral ligament. Three had articular surface partial-thickness rotator cuff tear, and 3 had a labral tear. All were outside hitters or middle blockers who consequently performed multiple hitting maneuvers in practice and games. CONCLUSION: Repetitive microtrauma from overhead hitting in volleyball generates forces on the inferior capsule of the shoulder joint that may cause inferior capsular laxity and subsequent failure of the humeral side of the axillary pouch portion of the inferior glenohumeral ligament.

Gender and renal cancer: do variations in clinical presentation and imaging patterns explain observed differences between males and females?

OBJECTIVES: To determine whether gender variations in imaging and healthcare access are contributing to observed differences in renal cancer, we examine the initial events in the diagnosis of renal masses in a cohort of patients and correlate it with detailed data on imaging patterns over the same period. METHODS: A total of 308 patients diagnosed with a renal mass over 11 years were reviewed. Information on symptoms, imaging, diagnosing physician, demographics, and pathology was gathered. Data on imaging for 1 862 485 patients at our institution over the same period were also collected. The data were analyzed for temporal trends, gender variations, and differences between incidental and nonincidental masses. RESULTS: Females presented with smaller masses (4.8 vs 6.0 cm, P = .0064), and were less likely to have clear cell tumors (58.7% vs 63.4%, P = .049). A total of 66.9% of female and 61.1% of male cases were incidental (not significant). In both males and females, primary care physicians were the most common diagnosing physicians (47.4% and 49.6%, respectively). Gynecologic complaints were an uncommon cause of diagnosis for women (5.3%). Computerized tomography was the most common diagnosing modality for both males and females (69.1% and 63.2%, respectively). Ultrasound as the diagnosing modality did not reach statistical significance between males and females (23.4% and 28.6%, respectively). During the 11- year period, women underwent more imaging studies overall than men (19.7% difference), but the difference was lower when only considering studies that can diagnose renal masses (6.4% difference). CONCLUSIONS: Gender variations in imaging rates and presentation for obstetrics/gynecology concerns by females did not lead to a significant difference in incidental diagnosis and do not appear adequate to explain gender differences in renal cancer presentation.

Imaging of musculoskeletal soft tissue infections.

Prompt and appropriate imaging work-up of the various musculoskeletal soft tissue infections aids early diagnosis and treatment and decreases the risk of complications resulting from misdiagnosis or delayed diagnosis. The signs and symptoms of musculoskeletal soft tissue infections can be nonspecific, making it clinically difficult to distinguish between disease processes and the extent of disease. Magnetic resonance imaging (MRI) is the imaging modality of choice in the evaluation of soft tissue infections. Computed tomography (CT), ultrasound, radiography and nuclear medicine studies are considered ancillary. This manuscript illustrates representative images of superficial and deep soft tissue infections such as infectious cellulitis, superficial and deep fasciitis, including the necrotizing fasciitis, pyomyositis/soft tissue abscess, septic bursitis and tenosynovitis on different imaging modalities, with emphasis on MRI. Typical histopathologic findings of soft tissue infections are also presented. The imaging approach described in the manuscript is based on relevant literature and authors' personal experience and everyday practice.

Imaging characteristics of diffuse idiopathic skeletal hyperostosis with an emphasis on acute spinal fractures: review.

OBJECTIVE: The educational objectives of this self-assessment module are for the participant to exercise, self-assess, and improve his or her understanding of the imaging of diffuse idiopathic skeletal hyperostosis (DISH), with emphasis on acute spinal fractures. CONCLUSION: Understanding the pathomechanics of the fractures in the ankylosed spine is important in the differentiation of the acute spinal fractures in DISH and ankylosing spondylitis. This article emphasizes the imaging features of spinal DISH and acute spinal fractures in DISH, distinguishing them specifically from those in ankylosing spondylitis.

Imaging characteristics of diffuse idiopathic skeletal hyperostosis with an emphasis on acute spinal fractures: self-assessment module.

The educational objectives for this self-assessment module are for the participant to exercise, self-assess, and improve his or her understanding of the imaging of diffuse idiopathic skeletal hyperostosis (DISH).

Bone marrow edema pattern in advanced hip osteoarthritis: quantitative assessment with magnetic resonance imaging and correlation with clinical examination, radiographic findings, and histopathology.

OBJECTIVE: To correlate the amount of bone marrow edema (BME) calculated by magnetic resonance imaging(MRI) with clinical findings, histopathology, and radiographic findings, in patients with advanced hip osteoarthritis(OA). MATERIALS AND METHODS: The study was approved by The Institutional Human Subject Protection Committee. Coronal MRI of hips was acquired in 19 patients who underwent hip replacement. A spin echo (SE) sequence with four echoes and separate fast spin echo (FSE) proton density (PD)-weighted SE sequences of fat (F) and water (W) were acquired with water and fat suppression, respectively. T2 and water:fat ratio calculations were made for the outlined regions of interest. The calculated MRI values were correlated with the clinical, radiographic, and histopathologic findings. RESULTS: Analyses of variance were done on the MRI data for W/(W + F) and for T2 values (total and focal values) for the symptomatic and contralateral hips. The values were significantly higher in the study group. Statistically significant correlations were found between pain and total W/(W + F), pain and focal T2 values, and the number of microfractures and calculated BME for the focal W/(W + F) in the proximal femora. Statistically significant correlations were found between the radiographic findings and MRI values for total W/(W + F), focal W/(W + F) and focal T2 and among the radiographic findings, pain, and hip movement. On histopathology, only a small amount of BME was seen in eight proximal femora. CONCLUSION: The amount of BME in the OA hip, as measured by MRI, correlates with the severity of pain, radiographic findings, and number of microfractures.

Update on imaging and treatment of Ewing sarcoma family tumors: what the radiologist needs to know.

This review article provides an update on multimodality imaging characteristics of Ewing sarcoma family tumors. Pathology of this tumor and current trends in medical and surgical treatment are briefly discussed.

Sonography and sonoarthrography of the scapholunate and lunotriquetral ligaments and triangular fibrocartilage disk: initial experience and correlation with arthrography and magnetic resonance arthrography.

OBJECTIVE: The purpose of this study was to determine the utility of sonography and sonoarthrography in evaluation of dorsal bands of the scapholunate ligament (SLL), lunotriquetral ligament (LTL), and triangular fibrocartilage (TFC) disk in correlation with arthrography and magnetic resonance arthrography (MRA). METHODS: High-resolution sonography of the SLL, LTL, and TFC disk was performed on symptomatic wrists in 16 patients referred by a hand surgeon for MRA of the symptomatic wrists. All patients then underwent arthrography and an MRA study of the same wrist. After MRA, sonography was repeated. The imaging findings of these different techniques were then compared. Four patients (25%) underwent surgery of their wrists. In these 4 patients, the surgical and imaging findings were correlated. RESULTS: For the SLL, the results were concordant for all imaging modalities in 15 patients (93.75%) and partially concordant in 1 (6.25%). For the LTL, the results were concordant for all imaging modalities in 12 patients (75%), partially concordant in 3 (18.75%), and discordant in 1 (6.25%). For the TFC disk, the results were concordant for all imaging modalities in 13 patients (81.25%), partially concordant in 2 (12.5%), and discordant in 1 (6.25%). The arthroscopic and imaging findings were concordant for 3 SLLs, 3 LTLs, and 3 TFC disks. CONCLUSIONS: Our preliminary results are encouraging. Sonography may be used at least as a screening imaging modality in evaluation of the SLL and TFC disk. Sonoarthrography improves evaluation of the LTL.

Academic radiologists' on-call and late-evening duties.

On-call and late-evening duties have increased dramatically for radiologists, be they in private practice, at academic medical centers, or at state or federal government health care facilities. Most busy medical centers in North America require around-the-clock radiology interpretations for emergent or urgent patients, particularly if they are level 1 trauma centers. Coverage by attending radiologists around the clock is expensive and difficult to implement. In this study, an e-mail questionnaire was sent to 83 members of the Society of Chairmen of Academic Radiology Departments concerning general radiologists' on-call and after-hours duties. Detailed replies were received from 29 academic medical centers, all of which were university owned or affiliated. There was complex variation on how academic radiology departments approached their after-hours commitments, but only 10% of academic institutions (3 of 29) answering the survey had 24-hour in-house coverage by general radiologists. Coverage by attending radiologists around the clock at academic medical centers is not the current standard of practice at most academic medical centers.

Granulocyte-Stimulating Factor-Induced Bone Marrow Reconversion Simulating Neuroblastoma Metastases on MRI: Case Report and Literature Review.

Granulocyte colony-stimulating factor (GCSF), often used as an adjunct to chemotherapy, can pose a dilemma in differentiating the associated bone marrow changes from metastatic disease on magnetic resonance imaging. The phenomenon has been previously reported in children undergoing treatment for primary musculoskeletal malignancies [1, 2]. We present a case of GCSF-induced marrow reconversion simulating neuroblastoma metastases on MR imaging. An interesting observation in our case was intense abnormal signal in a pattern of metaphyseal bands, which, to our knowledge, was not previously reported in the English literature to be associated with GCSF-induced marrow reconversion.

Misplaced devices in the chest, abdomen, and pelvis: Part I.

Numerous medical devices are used in the chest and fewer in the abdomen and pelvis. They are frequently seen on various radiological studies in daily practice. Knowing the specific name of the device is not important. However, knowing the proper positioning and function of the device is necessary. It is a duty of the reporting radiologist to recognize the malpositioning or breakage of a medical device and to inform the responsible physician promptly, since these complications can have undesirable consequences and sometimes a fatal outcome.

Misplaced devices in the chest, abdomen, and pelvis: Part II.

Numerous medical devices are used in the chest and fewer in the abdomen and pelvis. They are frequently seen on various radiological studies in daily practice. Knowing the specific name of the device is not important. However, knowing the proper positioning and function of the device is necessary. It is a duty of the reporting radiologist to recognize the malpositioning or breakage of a medical device and to inform the responsible physician promptly, since these complications can have undesirable consequences and sometimes a fatal outcome.

Gallery of medical devices: part 2: devices of the head, neck, spine, chest, and abdomen.

This gallery of medical devices illustrates a multitude of common devices in the head, neck, spine, chest, and abdomen that are found in daily radiologic practice (orthopedic devices for the extremities and pelvis were illustrated in Part 1). All these medical devices have been more thoroughly discussed in the previous articles in this medical devices series and in other detailed references. The present article is a comprehensive overview of these devices and provides a quick reference for identifying an unfamiliar device. It is intended to allow the reader to identify a device generically and to understand its purpose. It is important to recognize the presence of a device, understand its purpose and proper function, and recognize the complications associated with its use. Knowing the specific or proper brand name of every device is not important and frequently not possible. New devices are constantly being introduced, although most of them are variations of a previous device. Sometimes, so many devices are used in a patient's treatment that they obscure important anatomy and pathologic conditions (Fig 1). Herein, we present an overview of the many medical devices frequently used in the head, neck, and spine, including a halo device, aneurysm clips, spinal fusion devices, deep brain electrodes, sacral nerve stimulator, and vertebroplasty (Figs 2-9). We also illustrate numerous chest medical devices that are seen daily by almost all radiologists. These devices include a multitude of extrathoracic and intrathoracic apparatus, ranging from intravenous catheters to oxygen tubing and electrocardiographic leads, central venous catheters, chest tubes, endotracheal and feeding tubes, cardiac valves, coronary artery bypass stents, pacemakers, internal cardiac defibrillators, ventricular assist devices, and total artificial hearts (the latter two devices are frequently encountered in many large medical centers) (Figs 10-26). We also present medical devices of the abdomen and pelvis, which can be grouped into four major categories: intestinal tubes, genitourinary apparatus, postoperative apparatus, and vascular devices (Figs 27-47). For a detailed discussion of a particular device, the reader should refer to the appropriate references cited.