Film-free efficiency systems: a new cost-effective approach.

Pressure is on healthcare providers to make their services more affordable. Streamlining operations to improve efficiency is one means of achieving that goal. PACS has been touted as the technology to improve radiologic services. Sold as a way to eliminate lost records and lower operations costs, in reality, PACS has raised costs and slowed work flow in many cases. Perhaps PACS that raise operations costs are more properly named digital overhead generating systems (DOGS). There is an alternative solution--film-free efficiency systems (FFES), defined as the technological tools required to lower radiologic costs and improve services. A new type of image and information management technology and distinct from traditional PACS in a number of ways, film-free efficiency systems are immediately cost effective. They improve personnel efficiency, reduce costs per RVU, provide an alternative to film and exclude the use of any technology that is not cost effective. Implementation of these systems must begin with a clearly stated mission, a leadership statement and financial accountability. To guarantee an immediate financial gain in your department, you'll want to finance the system through material cost savings. Implementation should start with the digital modalities. The next step is to retrain staff and reengineer the workplace, followed by creating the necessary infrastructure of PCs in referring physicians' offices. Lastly, implement CR or digital radiography as prices drop and technologies improve in speed.

Comparison of conventional and computed arthrotomography with MR imaging in the evaluation of the shoulder.

To compare conventional arthrography and computed arthrotomography (CAT) with magnetic resonance (MR) imaging in the evaluation of the shoulder, we studied 18 patients who underwent conventional double contrast arthrography and CAT, and T1-, balanced, and T2-weighted MR imaging. The arthrograms were independently reviewed by two of the authors and the MR images were independently reviewed by three other authors in a systematic fashion with the aid of a prewritten evaluation form. The findings were compared among reviewers and between imaging methods. We found MR comparable to conventional arthrography in the evaluation of the rotator cuff; however, MR also enabled evaluation of tendonitis, which could not be accomplished with conventional arthrography. Because of MR's superior soft tissue imaging capability, we were able to stage the impingement syndrome. Magnetic resonance also allowed evaluation of the glenoid labrum and capsuloligamentous structures and assessment of instability in a fashion similar to CAT. In most cases, information obtained from MR equaled or exceeded that obtained from conventional arthrography and CAT. With refinement in technique and increased experience, we believe that MR may replace arthrography in the evaluation of the shoulder.

Achilles tendon injuries: the role of MR imaging.

Eight magnetic resonance (MR) examinations were performed in seven patients with Achilles tendon injuries and correlated with physical examination and surgical and clinical follow-up. The MR examinations depicted the Achilles tendon in excellent detail and Achilles tendon abnormalities with greater accuracy than physical examination. Of five tendons shown to be at least partially torn on MR, palpable tendinous defects were found in only one, and plantarflexion weakness was found in four. The MR and surgical findings precisely correlated in one case. Magnetic resonance proved valuable in the evaluation of clinically equivocal Achilles tendon tears and may ultimately play a greater role as a research tool in the determination of optimal forms of therapy for specific Achilles tendon injuries.

The painful shoulder: MR imaging of the glenohumeral joint.

We used magnetic resonance imaging in 41 patients with shoulder pain. Magnetic resonance was found useful in depicting the spectrum of rotator cuff abnormalities associated with mechanical impingement including both large and small rotator cuff tears as well as tendinitis. Abnormalities of the capsular mechanism, osseous tumors, osteonecrosis, and injuries to the supporting musculature are also well depicted.

The use of MRI to assist in diagnosis of pigmented villonodular synovitis of the knee joint.

Pigmented villonodular synovitis (PVNS) of the knee joint remains a difficult and elusive entity to define and characterize. This entity most often appears in the young adult knee with nonspecific clinical features, including a painful range of motion and perhaps a sensation of locking. Detection and diagnosis of this localized soft-tissue mass are difficult because plain roentgenograms may be totally within normal limits. The case of a 21-year-old woman illustrates the use of magnetic resonance imaging (MRI) as an effective technique to define and characterize PVNS. Advantages of MRI include high-resolution/high-contrast multiplanar sections that depict bone, marrow, ligaments and tendons, fat, menisci, and articular cartilage in one image. In addition, MRI is noninvasive and requires no ionized radiation. MRI is an excellent clinical tool for the evaluation of intraarticular tumors of the knee joint.

Intraoperative digital subtraction neuroangiography: a diagnostic and therapeutic tool.

We report our experience with intraoperative digital subtraction neuroangiography to demonstrate its application as a diagnostic and therapeutic technique. Intraoperative neuroangiography was performed on 53 occasions in 43 patients using a portable imaging system. Thirty-two procedures were performed for diagnostic purposes after resection of arteriovenous malformations, clipping of aneurysms, or carotid endarterectomy. Unexpected problems were disclosed in seven cases and were surgically remedied immediately in four. In addition, angiography was used as a therapeutic tool in 21 cases to facilitate intraoperative embolization of a vascular lesion or to enable the angioplasty of a vessel inaccessible without direct surgical exposure. We found that by allowing a combined interventional neuroangiographic and neurosurgical approach, intraoperative angiography opened new avenues for treatment of intracranial vascular abnormalities.

Asymptomatic degenerative disk disease and spondylosis of the cervical spine: MR imaging.

Evidence on magnetic resonance (MR) images of disk degeneration and herniation, as well as of cord and root impingement, may be regarded either as normal, age-related changes or as causative of symptoms. Individuals referred for MR examinations of the larynx without symptoms referable to the cervical spine were studied retrospectively (35 patients) or prospectively (65 patients) over a 2-year period. With a solenoid surface coil, 5-mm-thick sections were acquired in sagittal, axial, and coronal planes with T1-weighted spin-echo pulsing sequences. Disk protrusion (herniation/bulge) was seen in five of 25 (20%) patients aged 45-54 and 24 of 42 (57%) patients older than 64 years of age. Posterolateral protrusions were seen in only nine of 100 patients and occurred with greatest frequency in patients over 64 years of age. In no patient was obliteration of the intraforaminal fat seen. Spinal cord impingement was observed in nine of 58 (16%) patients under 64 years of age, and in 11 of 42 (26%) patients over 64 years of age. Cord compression was observed in seven of 100 patients and occurred solely secondary to disk protrusion in all cases. The percentage of cord area reduction never exceeded 16% and averaged approximately 7%.

Partially thrombosed giant aneurysm simulating an arteriovenous malformation on MR imaging.

A case of a partially thrombosed giant intracranial aneurysm with a magnetic resonance appearance simulating an arteriovenous malformation is presented. Causes for the similarity in signal pattern are discussed.

MR imaging of the knee. Part I. Traumatic disorders.

One hundred thirty patients with a diversity of knee joint injuries were evaluated with a high-resolution magnetic resonance (MR) imaging technique. The authors report the accuracy of this technique in the evaluation of 105 patients with suspected meniscal tears, 26 patients with suspected cruciate ligament tears, and eight patients with suspected patellar tendon injuries. Of those menisci rated as definitely or probably torn on MR imaging, 80% were found to be torn at subsequent arthroscopy. The predictive value of negative MR imaging results was 100%. MR imaging was 92% accurate in predicting the clinical outcome in patients with suspected meniscal tears who did not undergo surgery. MR permitted complete disruption of the patellar tendon to be differentiated from partial tears, ligamentous inflammation, and localized effusion of the infrapatellar bursa. Injuries to the anterior and posterior cruciate ligaments were identified on MR images, and the status of synthetic grafts of the anterior cruciate ligament was ascertained.

MR imaging of the knee. Part II. Chronic disorders.

Sixty patients with symptoms of chronic disease of the knee joint were evaluated with high-resolution, thin-section magnetic resonance (MR) imaging. MR imaging depicted a wide variety of knee joint abnormalities including osteochondritis dissecans, medullary infarcts, epiphyseal osteonecrosis, intraarticular osteochondral fragments, synovial cysts, joint effusions, intraarticular soft-tissue tumors, synovial disease, leukemic infiltration of bone marrow, Osgood-Schlatter disease, and nonossifying fibroma. In two cases MR imaging depicted bone infarcts not seen on both radionuclide bone scans and standard radiographs. The highly detailed depiction of the articular cartilage was of particular importance in predicting arthroscopic findings in cases of osteochondritis dissecans. In two cases, a soft-tissue mass (pigmented villonodular synovitis) and a large osteochondral fragment undetected at arthroscopy were accurately localized with MR imaging. The results indicate that MR imaging is capable of providing information that might otherwise require multiple, sometimes invasive diagnostic procedures.

MR imaging of the lumbar spine: anatomic correlations and the effects of technical variations.

A correlative anatomic study, a retrospective review of MR images performed in 35 patients, and a series of tests of the effectiveness of various MR scanning techniques were performed in order to improve comprehension of lumbar spine anatomy depicted on MR images, and thereby facilitate development of an optimal scanning protocol. Correlation of MR images with cryomicrotomed cadaver specimens enhanced understanding of the MR depiction of the intervertebral disks, ligamentum flavum, nerve roots, epidural fat, and epidural veins. Experiments were performed to assess the efficacy of a surface coil applied to the back, a solenoidal surface coil, a standard body coil, and an abdominal compression device in optimizing image quality. Experiments were also performed to determine the effect of alterations in the pulse sequence and variations of the phase-encoding axis. Based on these results, a protocol is proposed for routine imaging of the lumbar spine that yields high-resolution sagittal and oblique images and that does not require a surface coil. The recommended protocol employs heavily T1-weighted images with phase encoding along the z axis for sagittal images and along the x axis for axial images. This protocol yields multiple sagittal and oblique axial images through each of the lumbar disks, a larger field of view than obtained with surface coils, and a reduction of total imaging time to as little as 10 min.

Magnetic resonance imaging as a tool for evaluation of traumatic knee injuries. Anatomical and pathoanatomical correlations.

Traumatic injury to the knee remains a diagnostic and therapeutic challenge. Magnetic resonance imaging (MRI) has been applied to musculoskeletal pathoanatomy and has been shown to be an effective tool for definition and characterization of knee pathology. A systematic approach is taken to establish anatomical and pathoanatomical correlations, as well as the role of MRI in the management of knee injuries. Imaging was performed at the UCLA Medical Center using a permanent magnet system and a combination of solenoidal surface coils and thin-section, high-resolution scanning techniques. Images depict structural anatomical and spatial details of the knee that correlate well with corresponding cadaveric cryosections. To determine pathoanatomical correlations and the efficacy of MRI, 105 patients with preoperative diagnoses of meniscal tears, anterior and posterior cruciate ligament tears, tibial plateau fracture, and patella and quadriceps injuries were imaged. Results indicated that for the medial meniscus MRI demonstrated a 95.7% sensitivity, 81.8% specificity, 90% accuracy, 88.2% positive predictive value (PPV), and 93.1% negative predictive value (NPV). Imaging of the lateral meniscus demonstrated a 75% sensitivity, 95% specificity, 91% accuracy, 80% PPV, and 94% NPV. MRI of the ACL revealed 100% sensitivity, specificity, accuracy, positive and negative predictive values. MRI is a noninvasive tool which uses no ionizing radiation and can accurately define and characterize anatomy and pathoanatomy. This study indicates that MRI in conjunction with clinical evaluation can contribute to treatment decision-making processes and assist in preoperative planning. An algorithm demonstrating the potential clinical use of MRI is presented.

Pneumosinus dilatans of the sphenoid sinus.

Four cases of pneumosinus dilatans of the sphenoid sinus are reported, supplementing the eight cases previously reported in the literature. This rare entity is characterized by expansion of a paranasal sinus that contains only air. In one patient, severe visual loss due to compression of the optic canal by the adjacent enlarged sinus was seen. Galactorrhea occurred in one patient, and three of the four patients reported headaches. There was dehiscence of the sinus roof in two cases, which apparently resulted in a cerebrospinal fluid fistula in one. Previous reports of this entity are reviewed, and the radiographic findings and clinical presentations are discussed. It is proposed that the term "pneumosinus dilatans" be used to describe all dilated, air-filled sinuses with outwardly bulging walls when the primary cause is uncertain.

Multiple-angle, variable-interval, nonorthogonal MRI.

Multiple-angle, variable-interval, nonorthogonal (MAVIN) MRI is a new, time-saving technique that allows for the independent choice of slice angle and position for each slice in a multiangle pulse sequence. By appropriate adjustment of the slice-select radiofrequency pulse and the slice-select and readout magnetic-field gradients, the interval and angle of each slice may be individually chosen. MAVIN can reduce examination time in studies of the lumbar spine, orbits, knees, and heart, where nonparallel oblique scanning may be necessary and would otherwise require the use of additional pulse sequences. Loss of signal in the region of intersection of multiple planes due to local changes in effective repetition time is a practical limitation. For this reason, scan planes are chosen so that the intersection does not overlie the region of interest.

Meniscal injuries: detection using MR imaging.

Both retrospective and blinded analyses of thin-section, high-resolution magnetic resonance (MR) images of the knee joint, produced using a solenoid surface coil, indicate that MR imaging is an effective technique for evaluating meniscal injuries. Images of 49 patients were evaluated, and the results were correlated with those of subsequent arthroscopy. A grading scale was developed to rate the index of suspicion of a meniscal tear based on the MR images. Overall, approximately 80% of menisci rated grade 4 (definite tear) or 3 (probable tear) were found to have corresponding tears at arthroscopy. In many other patients with a grade 4 or 3 meniscus in whom a corresponding tear was not found arthroscopically, meniscal tears at other sites or other abnormalities were correctly diagnosed using MR. A majority of the false-positive MR images involved the posterior horns of the menisci, the sites of most false-negative arthroscopic diagnoses. The predictive value of a negative MR image was almost 100%. Even in patients with moderate-to-large effusions, the menisci were accurately evaluated. The results imply that MR imaging is useful in the preoperative evaluation of suspected meniscal tears.