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OBJECTIVES: To assess inter-modality agreement and accuracy for medial temporal lobe atrophy (MTA) ratings across radiologists with varying clinical experience in a non-demented population. METHODS: Four raters (two junior radiologists and two senior neuroradiologists) rated MTA on CT and MRI scans using Scheltens' MTA scale. Ratings were compared to a consensus rating by two experienced neuroradiologists for estimation of true positive and negative rates (TPR and TNR) and over- and underestimation of MTA. Inter-modality agreement expressed as Cohen's κ (dichotomized data), Cohen's κw, and two-way mixed, single measures, consistency ICC (ordinal data) were determined. Adequate agreement was defined as κ/κw ≥ 0.80 and ICC ≥ 0.80 (significance level at 95% CI ≥ 0.65). RESULTS: Forty-nine subjects (median age 72 years, 27% abnormal MTA) with cognitive impairment were included. Only junior radiologists achieved adequate agreement expressed as Cohen's κ. All raters achieved adequate agreement expressed as Cohen's κw and ICC. True positive rates varied from 69 to 100% and TNR varied from 85 to 100%. No under- or overestimation of MTA was observed. Ratings did not differ between radiologists. CONCLUSION: We conclude that radiologists with varying experience achieve adequate inter-modality agreement and similar accuracy when Scheltens' MTA scale is used to rate MTA on a non-demented population. However, TPR varied between radiologists which could be attributed to rating style differences. KEY POINTS: ⢠Radiologists with varying experience achieve adequate inter-modality agreement with similar accuracy when Scheltens' MTA scale is used to rate MTA on a non-demented population. ⢠Differences in rating styles might affect accuracy, this was most evident for senior neuroradiologists, and only junior radiologists achieved adequate agreement on dichotomized (abnormal/normal) ratings. ⢠The use of an MTA scale template might compensate for varying clinical experience which could make it applicable for clinical use.
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Enfermedad de Alzheimer , Disfunción Cognitiva , Anciano , Enfermedad de Alzheimer/patología , Atrofia/patología , Disfunción Cognitiva/patología , Humanos , Imagen por Resonancia Magnética , Radiólogos , Lóbulo Temporal/diagnóstico por imagen , Lóbulo Temporal/patologíaAsunto(s)
Enfermedades del Sistema Nervioso Central/diagnóstico por imagen , Enfermedades de los Pequeños Vasos Cerebrales/diagnóstico por imagen , Sarcoidosis/diagnóstico por imagen , Enfermedades del Sistema Nervioso Central/complicaciones , Enfermedades del Sistema Nervioso Central/tratamiento farmacológico , Enfermedades de los Pequeños Vasos Cerebrales/tratamiento farmacológico , Enfermedades de los Pequeños Vasos Cerebrales/etiología , Humanos , Imagen por Resonancia Magnética , Sarcoidosis/complicaciones , Sarcoidosis/tratamiento farmacológicoRESUMEN
BACKGROUND: Sacroiliac joint pain is increasingly recognized as a cause of low back pain. We compared the safety and effectiveness of minimally invasive sacroiliac joint arthrodesis using triangular titanium implants and conservative management in patients with chronic sacroiliac joint pain. METHODS: This study was a prospective, multicenter randomized controlled trial of adults with chronic sacroiliac joint pain assigned to either conservative management or sacroiliac joint arthrodesis with triangular titanium implants. The study end points included self-rated low back pain (visual analog scale [VAS]), back dysfunction (Oswestry Disability Index [ODI]), and quality of life. Ninety percent of subjects in both groups completed the study. RESULTS: Between June 6, 2013, and May 15, 2015, 103 subjects were randomly assigned to conservative management (n = 51) or sacroiliac joint arthrodesis (n = 52). At 2 years, the mean low back pain improved by 45 points (95% confidence interval [CI], 37 to 54 points) after sacroiliac joint arthrodesis and 11 points (95% CI, 2 to 20 points) after conservative management, with a mean difference between groups of 34 points (p < 0.0001). The mean ODI improved by 26 points (95% CI, 21 to 32 points) after sacroiliac joint arthrodesis and 8 points (95% CI, 2 to 14 points) after conservative management, with a mean difference between groups of 18 points (p < 0.0001). Parallel improvements were seen in quality of life. In the sacroiliac joint arthrodesis group, the prevalence of opioid use decreased from 56% at baseline to 33% at 2 years (p = 0.009), and no significant change was observed in the conservative management group (47.1% at baseline and 45.7% at 2 years). Subjects in the conservative management group, after crossover to the surgical procedure, showed improvements in all measures similar to those originally assigned to sacroiliac joint arthrodesis. In the first 6 months, the frequency of adverse events did not differ between groups (p = 0.664). By month 24, we observed 39 severe adverse events after sacroiliac joint arthrodesis, including 2 cases of sacroiliac joint pain, 1 case of a postoperative gluteal hematoma, and 1 case of postoperative nerve impingement. The analysis of computed tomographic (CT) imaging at 12 months after sacroiliac joint arthrodesis showed radiolucencies adjacent to 8 implants (4.0% of all implants). CONCLUSIONS: For patients with chronic sacroiliac joint pain due to joint degeneration or disruption, minimally invasive sacroiliac joint arthrodesis with triangular titanium implants was safe and more effective throughout 2 years in improving pain, disability, and quality of life compared with conservative management. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Artrodesis/métodos , Tratamiento Conservador/métodos , Dolor de la Región Lumbar/cirugía , Articulación Sacroiliaca/cirugía , Adulto , Anciano , Artrodesis/efectos adversos , Dolor Crónico , Tratamiento Conservador/efectos adversos , Femenino , Humanos , Dolor de la Región Lumbar/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/etiología , Estudios Prospectivos , Prótesis e Implantes , Articulación Sacroiliaca/diagnóstico por imagen , Resultado del Tratamiento , Adulto JovenRESUMEN
OBJECTIVES: To investigate the accuracy of 3 commonly used neurodynamic tests (slump test, straight-leg raise [SLR] test, femoral neurodynamic test) and 2 clinical assessments to determine radiculopathy (radiculopathy I, 1 neurologic sign; radiculopathy II, 2 neurologic signs corresponding to 1 specific nerve root) in detecting magnetic resonance imaging (MRI) findings (extrusion, subarticular nerve root compression, and foraminal nerve root compression). DESIGN: Validity study. SETTING: Secondary care. PARTICIPANTS: We included subjects (N=99; mean age, 58y; 54% women) referred for epidural steroid injection because of lumbar radicular symptoms who had positive clinical and MRI findings. Positive clinical findings included the slump test (n=67), SLR test (n=50), femoral neurodynamic test (n=7), radiculopathy I (n=70), and radiculopathy II (n=33). Positive MRI findings included extrusion (n=27), subarticular nerve compression (n=14), and foraminal nerve compression (n=25). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Accuracy of clinical tests in detecting MRI findings was evaluated using sensitivity, specificity, and receiver operating characteristics analysis with area under the curve (AUC). RESULTS: The slump test had the highest sensitivity in detecting extrusion (.78) and subarticular nerve compression (1.00), but the respective specificity was low (.36 and .38). Radiculopathy I was most sensitive in detecting foraminal nerve compression (.80) but with low specificity (.34). Only 1 assessment had a concurrent high sensitivity and specificity (ie, radiculopathy II) in detecting subarticular nerve compression (.71 and .73, respectively). The AUC for all tests in detecting extrusion, subarticular nerve compression, and foraminal nerve compression showed ranges of .48 to .60, .63 to .82, and .33 to .57, respectively. CONCLUSIONS: In general, the investigated neurodynamic tests or assessments for radiculopathy lacked diagnostic accuracy. The slump test was the most sensitive test, while radiculopathy II was the most specific test. Most interestingly, no relationship was found between any neurodynamic test and foraminal nerve compression (foraminal stenosis) as visualized on MRI.
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Desplazamiento del Disco Intervertebral/diagnóstico , Dolor de la Región Lumbar/diagnóstico , Imagen por Resonancia Magnética/estadística & datos numéricos , Examen Neurológico/estadística & datos numéricos , Radiculopatía/diagnóstico , Área Bajo la Curva , Femenino , Humanos , Desplazamiento del Disco Intervertebral/complicaciones , Dolor de la Región Lumbar/etiología , Vértebras Lumbares/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Examen Neurológico/métodos , Curva ROC , Radiculopatía/complicaciones , Reproducibilidad de los Resultados , Sensibilidad y EspecificidadRESUMEN
OBJECTIVE: In patients with chronic radicular pain, we aimed to evaluate subgroup differences in 1-yr response to transforaminal epidural steroid injection. DESIGN: In this longitudinal cohort study of 100 subjects, 170 transforaminal epidural steroid injections were performed for 1 yr. The sample was stratified by type of disc herniation (protrusion n = 57, extrusion n = 27), by location of disc herniation (central/subarticular n = 60, foraminal n = 24), by grade of nerve root compression (low-grade compression n = 61, high-grade subarticular nerve compression n = 14, high-grade foraminal nerve compression n = 25), and by positive Slump test (n = 67). Treatment response was evaluated by visual analogue scale leg pain and self-reported disability (Oswestry Disability Index). Logistic regression was used to analyze the predictive value of baseline characteristics including the stratified subgroups. RESULTS: High-grade subarticular nerve compression predicted the 1-yr improvement in both visual analogue scale leg pain (P = 0.046) and Oswestry Disability Index (P = 0.027). Low age (P < 0.001), short duration of leg pain (P = 0.015), and central/subarticular disc herniation (P = 0.017) predicted improvement in Oswestry Disability Index. CONCLUSIONS: In patients treated with one or several transforaminal epidural steroid injections due to chronic lumbar radicular pain, clinical findings failed to predict the 1-yr treatment response. Low age, short duration of leg pain, central/subarticular disc herniation, and high-grade subarticular nerve compression predicted a favorable 1-yr response to transforaminal epidural steroid injection.
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Dolor Crónico/tratamiento farmacológico , Dolor de la Región Lumbar/tratamiento farmacológico , Radiculopatía/tratamiento farmacológico , Esteroides/administración & dosificación , Factores de Edad , Dolor Crónico/diagnóstico por imagen , Dolor Crónico/etiología , Estudios de Cohortes , Evaluación de la Discapacidad , Femenino , Estudios de Seguimiento , Humanos , Inyecciones Epidurales , Desplazamiento del Disco Intervertebral/complicaciones , Modelos Logísticos , Estudios Longitudinales , Dolor de la Región Lumbar/diagnóstico por imagen , Dolor de la Región Lumbar/etiología , Vértebras Lumbares , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Dimensión del Dolor , Valor Predictivo de las Pruebas , Radiculopatía/diagnóstico por imagen , Radiculopatía/etiología , Suecia , Factores de Tiempo , Resultado del TratamientoRESUMEN
Lumbar spine radiography - unreliable diagnostic accuracy and negligible value for the patients In 2016 140 000 lumbar spine radiographies were performed in Sweden (14 000 per million inhabitants) to a cost of about 85 million SEK (≈8.5 million Euro) and a negligible value for the patients with low back pain. In the work-up of low back pain, when imaging is indicated, lumbar spine radiography should be replaced by limited magnetic resonance imaging including a whole lower body coronal STIR sequence or computed tomography with radiation dose adapted to indication and patient age. Indication for imaging should be restricted to 1) low back pain with more than 3-4 weeks duration in combination with at least one ¼red flag«, 2) radicular pain without improvement on conservative treatment, or 3) low back pain with more than 8 weeks duration in combination with ¼yellow flags«.
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Vértebras Lumbares/diagnóstico por imagen , Radiografía/estadística & datos numéricos , Procedimientos Innecesarios , Humanos , Dolor de la Región Lumbar/diagnóstico por imagen , Imagen por Resonancia Magnética/economía , Imagen por Resonancia Magnética/normas , Masculino , Persona de Mediana Edad , Radiografía/economía , Radiografía/normas , Factores de Tiempo , Tomografía Computarizada por Rayos X/economía , Tomografía Computarizada por Rayos X/normasRESUMEN
BACKGROUND: Transforaminal epidural steroid injection (TESI) is a frequently used intervention for lumbar radicular pain. OBJECTIVE: To evaluate the value of MRI findings, neurologic assessment and the Slump test (neurodynamic test) as predictors of treatment response to TESI. METHOD: One hundred subjects (mean age 58 [SD13], 54% females) were included in this trial. The sample was stratified by location of disc herniaton, grade of nerve root compression, clinically assessed neurologic deficit and positive Slump test.Treatment response was primarily evaluated by Visual Analogue Scale for leg pain after three weeks. Predictive value for each stratum was analyzed using logistic regression after the sample was dichotomized into definite treatment response (≥ 50% reduction of pain) and negative response (≤ 0% reduction) to TESI (the 1-49% reduction group was excluded). RESULTS: The overall definite treatment response rate was 27%. The Slump test was the only predictor of the response to TESI (p= 0.031). The definite treatment response rates for subjects with positive and negative Slump test were 33% and 15%, respectively. CONCLUSION: In patients with chronic low back related leg pain, MRI findings and neurologic assessment results failed to predict treatment response, whereas a positive Slump test predicted the best 3-week response to TESI.
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Inyecciones Epidurales , Dolor de la Región Lumbar/complicaciones , Radiculopatía/tratamiento farmacológico , Radiculopatía/etiología , Anciano , Anestésicos Locales/uso terapéutico , Antiinflamatorios/uso terapéutico , Bupivacaína/uso terapéutico , Femenino , Humanos , Desplazamiento del Disco Intervertebral/complicaciones , Imagen por Resonancia Magnética , Masculino , Metilprednisolona/análogos & derivados , Metilprednisolona/uso terapéutico , Acetato de Metilprednisolona , Persona de Mediana Edad , Examen Neurológico , Estudios Prospectivos , Radiculopatía/complicaciones , Escala Visual AnalógicaRESUMEN
OBJECTIVE: To evaluate clinical usefulness of cerebrospinal fluid stroke volume (SV) assessed in the cerebral aqueduct, via cine phase-contrast magnetic resonance imaging, for predicting outcome after shunt surgery in suspected normal pressure hydrocephalus. METHODS: Thirty-eight patients with suspected normal pressure hydrocephalus were included. SV was assessed using cine phase-contrast magnetic resonance imaging, and the results were kept blinded until postoperative follow-up after 7 +/- 5.8 months (mean +/- standard deviation). Selection to surgery was based on a positive lumbar infusion test or cerebrospinal fluid tap test, and outcome was evaluated with objective tests. RESULTS: Six patients were excluded from SV measurements because of technical difficulties. Eight patients were not operated (negative lumbar infusion test and cerebrospinal fluid tap test). SV in the not operated patients (mean, 66 +/- 53 microl) did not differ from the operated patients (95 +/- 78 microl; P = 0.335). Operated patients showed statistically significant improvements in walk (P = 0.020), reaction time (P = 0.006), and memory (P = 0.001) tests. Patients were divided into three groups according to SV range: low (0-50 microl), middle (51-100 microl), and high (>100 microl). No statistically significant (P > 0.05) improvements in any of the objective tests were found in any of the SV ranges. The numbers of individually improved patients were similar in the different SV ranges: six out of seven in the low, nine out of nine in the middle, and five out of eight in the high range. Weak correlations were found between SV and the initial pulse amplitude (Rs = 0.043; P = 0.014) as well as the plateau pulse amplitude (Rs = 0.043; P = 0.014) as measured with the lumbar infusion test. CONCLUSION: The data from this study show no evidence that cine phase-contrast magnetic resonance imaging measurements of SV in the cerebral aqueduct are useful for selecting patients with normal pressure hydrocephalus symptoms to shunt surgery.
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Acueducto del Mesencéfalo/fisiología , Derivaciones del Líquido Cefalorraquídeo , Hidrocéfalo Normotenso/fisiopatología , Hidrocéfalo Normotenso/cirugía , Imagen por Resonancia Cinemagnética/métodos , Volumen Sistólico/fisiología , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Resultado del TratamientoRESUMEN
Steroid injections are often employed as an alternative treatment for radicular pain in patients with degenerative spinal disorders. Prospective randomised studies of the lumbar spine reveal contradictory results and non-randomised and most often retrospective studies of the cervical spine indicate pain reduction from steroid injections. No prospective randomised study on transforaminal steroid injections for the treatment of radicular pain in the cervical spine focusing on short-term results has been performed. Forty consecutive patients were employed for the study. The inclusion criteria were one-sided cervical radiculopathy with radicular distribution of arm pain distal to the elbow and corresponding significant degenerative pathology of the cervical spine at one or two levels on the same side as the radicular pain and visualised by MRI. A transforaminal technique was used for all injections. A positive response to a diagnostic selective nerve root block at one or two nerve roots was mandatory for all patients. The patients were randomised for treatment with steroids/local anaesthetics or saline/local anaesthetic. Only the neuroradiologist performing the blocks was aware of the content of the injection; all other persons involved in the study were blinded. Follow up was made 3 weeks after the randomised treatment by a clinical investigation and with a questionnaire focusing on the subjective effects from the injections. At follow up, there were no differences in treatment results in the two patient groups. Statistical analysis of the results confirmed the lack of difference in treatment effect. Further studies have to be performed before excluding steroids in such treatment and for evaluating the influence of local anaesthetics on radiculopathy in transforaminal injections.
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Corticoesteroides/uso terapéutico , Radiculopatía/tratamiento farmacológico , Corticoesteroides/administración & dosificación , Adulto , Anciano , Dolor de Espalda/tratamiento farmacológico , Femenino , Humanos , Inyecciones Espinales , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Resultado del TratamientoRESUMEN
Transforaminal injections are sometimes used for the diagnosis and treatment of painful conditions in the lumbar and to a lesser degree in the cervical spine. The technique is most often used when investigating/treating radiculopathy caused by degenerative disease. But how selective are the nerve root blocks? What possible structures other than the intended nerve root are affected from such injections? This study was undertaken in order to try to answer these questions, as no study focusing on the possible spread from the transforaminal selective nerve root blocks in the cervical spine has been performed earlier. In three groups of patients, each group including three patients, we injected three different volumes (0.6, 1.1 and 1.7 ml) with a transforaminal technique in the cervical spine. In all the injections, a small amount of contrast media was added. The spread of the injections were then investigated using multi-slice computed tomography with reconstructions. The imaging revealed a possible effect on other nerve roots than the intended ones when a larger volume was used for the root blocks. The spread was related to the injected volume as well as to local anatomy (size of foraminal area). In this study, only 0.6-ml injections could be accepted for being selective enough for diagnostic investigations.
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Corticoesteroides/administración & dosificación , Anestésicos Locales/administración & dosificación , Vértebras Cervicales/diagnóstico por imagen , Medios de Contraste/administración & dosificación , Bloqueo Nervioso/métodos , Adulto , Femenino , Humanos , Inyecciones Espinales , Disco Intervertebral/patología , Masculino , Persona de Mediana Edad , Radiculopatía/tratamiento farmacológico , Enfermedades de la Columna Vertebral/tratamiento farmacológico , Tomografía Computarizada por Rayos XRESUMEN
In patients with radiculopathy due to degenerative disease in the cervical spine, surgical outcome is still presenting with moderate results. The preoperative investigations consist of clinical investigation, careful history and most often magnetic resonance imaging (MRI) of the cervical spine. When MRI shows multilevel degeneration, different strategies are used for indicating which nerve root/roots are affected. Some authors use selective diagnostic nerve root blocks (SNRB) for segregating pain mediating nerve roots from non-pain mediators in such patients. The aim of the present study is to assess the ability of transforaminal SNRB to correlate clinical symptoms with MRI findings in patients with cervical radiculopathy and a two-level MRI degeneration, on the same side as the radicular pain. Thirty consecutive patients with cervical radiculopathy and two levels MRI pathology on the same side as the radicular pain were studied with SNRBs at both levels. All patients underwent clinical investigation and neck and arm pain assessment with visual analogue scales (VAS) before and after the blocks. The results from the SNRBs were compared to the clinical findings from neurological investigation as well as the MRI pathology and treatment results. Correlation between SNRB results and the level with most severe degree of MRI degeneration were 60% and correlation between SNRB results and levels decided by neurological deficits/dermatome radicular pain distribution were 28%. Twenty-two of the 30 patients underwent treatment guided by the SNRB results and 18 reported good/excellent outcome results. We conclude that the degree of MRI pathology, neurological investigation and the pain distribution in the arm are not reliable parameters enough when deciding the affected nerve root/roots in patients with cervical radiculopathy and a two-level degenerative disease in the cervical spine. SNRB might be a helpful tool together with clinical findings/history and MRI of the cervical spine when performing preoperative investigations in patients with two or more level of degeneration presenting with radicular pain that can be attributed to the degenerative findings.
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Bloqueo Nervioso , Radiculopatía/diagnóstico , Enfermedades de la Columna Vertebral/diagnóstico , Adulto , Anciano , Vértebras Cervicales , Femenino , Humanos , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Dimensión del Dolor , Estudios Prospectivos , Radiculopatía/fisiopatología , Enfermedades de la Columna Vertebral/fisiopatologíaRESUMEN
Sudden idiopathic unilateral loss of vestibular function without other signs or symptoms is called acute vestibular neuritis. It has been suggested that reactivation of human herpes simplex virus 1 could cause vestibular neuritis, Bell palsy, and sudden unilateral hearing loss. Enhancement of the facial nerve on gadolinium-enhanced magnetic resonance imaging (MRI) is a common finding in Bell palsy, but enhancement of the vestibular nerve has never been reported in acute vestibular neuritis. We present 2 consecutive cases of acute vestibular neuritis where high-field-strength MRI (3.0 T) with high-dose (0.3 mmol/kg of body weight) gadolinium-pentetic acid showed isolated enhancement of the vestibular nerve on the affected side only. These findings support the hypothesis of a viral and inflammatory cause of acute vestibular neuritis and might have implications for its treatment.