Correlation between CT imaging and symptom scores in cystic fibrosis associated chronic sinusitis.

PURPOSE: There are limited guidelines for diagnosing and managing chronic rhinosinusitis (CRS) in the cystic fibrosis (CF) population. While CF patients are known to have significant opacification on paranasal computed tomography (CT), limited evidence suggests that CT findings are not indicative of patients' symptom burden and therefore not a reliable indicator for surgical intervention. This provides a diagnostic challenge for otolaryngologists taking care of this patient population. The purpose of this study is to better define the relationship between objective imaging findings and patients' symptom severity in the CF-CRS population with the goal of providing more selective and effective patient care. MATERIALS AND METHODS: In this retrospective cohort study, 67 patients with CF CRS had their CT scans scored according to a modified Lund Mackay CT score (LMCTS), which was compared to their Sinonasal Outcome Test scores (SNOT-22). Total SNOT-22 and individual domains were evaluated. Pearson's correlation was performed. RESULTS: The overall mean SNOT-22 score was 32.3. The mean LMCTS was 17.6. These metrics correlate with relatively low subjective symptom scores in comparison to the high objective presence of sinus disease. While patients had high LMCTS, there was no correlation found between LMCTS and total SNOT-22 or individual SNOT-22 domains. CONCLUSIONS: CT findings in CF CRS patients do not accurately reflect patients' symptom burden and should not be used as a primary driver in the clinical management of these patients.

Influence of Lumbar Stenosis Surgery on Sacroiliac Joint Pain-Long-Term Results.

OBJECTIVE: To investigate whether sacroiliac join (SIJ) pain can be secondary to walking with a flexed posture resulting from stenosis with neurogenic claudication, and resolves spontaneously after lumbar decompression. METHODS: A review of charts from January 1, 2014, through March 3, 2019, was performed to identify consecutive cases of adults 35 years of age or older with surgical spinal stenosis with neurogenic claudication as well as concomitant severe SIJ pain. Posture was considered flexed during walking if self-reported, confirmed by a close companion, or observed directly. SIJ pain was diagnosed clinically ± confirmatory injection. A 10-point visual analog scale was used to assess SIJ pain. The primary endpoint was SIJ pain improvement at a minimum of 24 months' follow-up. SIJ pain improvement at 3 months was used to assess the rate of improvement as a secondary endpoint. RESULTS: Ten patients (3 female) met entry criteria: 4 were treated with decompression alone; 6 with decompression and spinal fusion. Mean SIJ visual analog scale pain score improved by 6.9 ± 2.4 (8.7 ± 1.6-1.8 ± 2.2; P < 0.0005). Results were similar for 20 patients at the secondary endpoint of 3 months. CONCLUSIONS: Sacroiliac joint pain shows robust, rapid, reliable, and durable improvement following lumbar decompressive surgery. The addition of a spinal fusion also leads to a similar improvement in SIJ pain. This study demonstrates the importance of evaluating the specific source of low back pain in patients with stenosis, claudication, and SIJ pain so as to more effectively plan appropriate surgery.

Pelvic Evaluation in Thoracolumbar Corrective Spine Surgery: How I Do It.

Surgeons and radiologists have traditionally focused on frontal radiographs and the measurement of scoliosis curves as important tools in the management of spinal deformity. It has become evident, however, that the management of spinal deformity should use a multidimensional approach with an increased emphasis on standing lateral radiographs and the sagittal position of the spine. Furthermore, they have come to realize the critical role that the pelvis plays in the maintenance of posture. Failure to recognize pelvic compensation can lead to under-treatment and poor postoperative outcomes.

Indirect decompression of lumbar stenosis with transpsoas interbody cages and percutaneous posterior instrumentation.

BACKGROUND: The minimally invasive lateral transpsoas retroperitoneal approach to address lumbar stenosis offers advantages to traditional approaches, including sparing of the AP annulus and longitudinal ligament and less risk to the peritoneal contents and retroperitoneal vascular structures. Few studies have presented longitudinal measures of radiographic indirect decompression and relief of pain and restoration of function using the lateral approach to spine fusion. QUESTION/PURPOSES: We determined (1) whether radiographic measures suggestive of decompression were achieved after surgery and maintained 1 year after surgery, (2) whether the intervention resulted in sustained improvements in patient-reported outcomes scores 1 year after surgery, and (3) the frequency of pseudarthrosis on CT scans at 1 year after surgery in patients with moderate or severe lumbar stenosis treated with the approach. METHODS: Between 2008 and 2012, 158 patients were surgically treated to alleviate symptoms associated with degenerative lumbar stenosis, of whom 60 (38%) were treated with lateral lumbar interbody fusion. Of these 60 patients, 36 (60%) received CT scans preoperatively and at 1-year postoperatively and were available for radiographic analysis. Of the 60 treated patients, 16 (27%) were lost to followup before 12 months, leaving the records of 44 patients available for review of patient-reported improvements in pain and return to function. Radiographic increases in disc height, foraminal area, and canal area were measured by one observer on CT scans postoperatively and at 1 year and compared to preoperative values. Patient-reported scores, including VAS pain score and Oswestry Disability Index (ODI), were collected preoperatively and at 3 and 12 months postoperatively. RESULTS: Increases in disc height (67%, p < 0.001), foraminal area (24%-31%, p < 0.001), and canal area (7%, p = 0.011) measured immediately postoperatively were sustained at 1-year followup. VAS pain score and ODI both improved (p < 0.001) at 3 months and were maintained at 1 year. No pseudarthroses were noted radiographically. CONCLUSIONS: The lateral transpsoas approach to interbody fusion is capable of sustaining indirect decompression of the neural structures and resolving preoperative claudication and radiculopathy. A larger series of patients with longer followup should be studied to substantiate these early clinical results. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

New techniques in lumbar spinal instrumentation: what the radiologist needs to know.

Lumbar spinal fusion is a commonly performed procedure, and, despite changes in cage types and fixation hardware, radiologists have, over the years, become familiar with the imaging features of typical spinal fusion and many of the complications seen in patients after surgery, including pseudoarthrosis, hardware loosening, and recurrent or residual disk herniation. Recently, however, novel approaches and devices have been developed, including advances in minimally invasive surgery, the increasing use of osteoinductive materials, and a wide variety of motion-preserving devices. These new approaches and devices manifest with characteristic imaging features and the potential for unusual and unexpected complications. Several of these devices and approaches are experimental, but many, including those devices used in lateral approaches to fusion, as well as the use of bone morphogenic protein, disk arthroplasty, and interspinous spacers, are seen with increasing frequency in daily clinical practice. Given the recent advances in spinal fusion surgery, it is important that radiologists have a basic understanding of the rationale behind these procedures, the common imaging features of the devices, and the complications associated with their use.

Diffusion tensor imaging tractography in patients with intramedullary tumors: comparison with intraoperative findings and value for prediction of tumor resectability.

OBJECT: The aim of this retrospective study was to evaluate the predictive value of diffusion tensor (DT) imaging with respect to resectability of intramedullary spinal cord tumors and to determine the concordance of this method with intraoperative surgical findings. METHODS: Diffusion tensor imaging was performed in 14 patients with intramedullary lesions of the spinal cord at different levels using a 3-T magnet. Routine MR imaging scans were also obtained, including unenhanced and enhanced T1-weighted images and T2-weighted images. Patients were classified according to the fiber course with respect to the lesion and their lesions were rated as resectable or nonresectable. These results were compared with the surgical findings (existence vs absence of cleavage plane). The interrater reliability was calculated using the kappa coefficient of Cohen. RESULTS: Of the 14 patients (7 male, 7 female; mean age 49.2 +/- 15.5 years), 13 had tumors (8 ependymomas, 2 lymphomas, and 3 astrocytoma). One lesion was proven to be a multiple sclerosis plaque during further diagnostic workup. The lesions could be classified into 3 types according to the fiber course. In Type 1 (5 cases) fibers did not pass through the solid lesion. In Type 2 (3 cases) some fibers crossed the lesion, but most of the lesion volume did not contain fibers. In Type 3 (6 cases) the fibers were completely encased by tumor. Based on these results, 6 tumors were considered resectable, 7 were not. During surgery, 7 tumors showed a good cleavage plane, 6 did not. The interrater reliability (Cohen kappa) was calculated as 0.83 (p < 0.003), which is considered to represent substantial agreement. The mean duration of follow-up was 12.0 +/- 2.9. The median McCormick grade at the end of follow-up was II. CONCLUSIONS: These preliminary data suggest that DT imaging in patients with spinal cord tumors is capable of predicting the resectability of the lesion. A further prospective study is needed to confirm these results and any effect on patient outcome.

Normal and abnormal imaging findings in lumbar total disk replacement: devices and complications.

Fusion, with or without laminectomy, is the standard treatment for symptomatic lumbar degenerative disk disease when conservative management has failed. Yet even radiographically verified solid fusion may be accompanied by considerable long-term problems, including recurrent low back pain, spinal stenosis, hypertrophic facet disease, pseudarthrosis, and spondylolysis and spondylolisthesis at adjacent levels. Several studies have shown a relationship between solid fusion and the development of adjacent-level disk disease, which is thought to result from increased stress on, or hypermobility of, adjacent segments. Total disk replacement (TDR) was developed as a way to restore normal mobility of the diseased segments and improve clinical outcomes by decreasing the risk of adjacent-level degenerative disease and related complications. However, like fusion, TDR is associated with various complications; some of these (eg, migration, subsidence) may occur regardless of the device used, whereas others (eg, extrusion of the polyethylene inlay, vertical fractures) are device specific. Facet arthrosis, device wear, particle disease, adjacent-level degeneration, and heterotopic ossification also have been observed after TDR, but the frequency and importance of these findings remain uncertain. Given the increasing use of lumbar TDR to treat degenerative disk disease, it is important that radiologists be familiar with the most commonly used devices and the potential complications of their use.