"Whiplash" injury of the cervical spine: value of modern diagnostic imaging

"Whiplash injuries" are frequent sequelae of motor vehicle accidents. While conventional imaging methods such as X-ray, including special and functional lateral projections, continue to be the first-choice evaluation methods, they frequently do not reveal injuries to the soft tissues. Cross-sectional methods such as CT and MRT may therefore be indicated for further workup in given clinical situations. In this paper the role of the entire spectrum of imaging methods is reviewed. Emphasis is placed on so-called functional CT, which allows detection of rotational instabilities of the upper cervical spine. These are difficult to evaluate clinically or by standard imaging studies, yet they may be a frequent cause of chronic whiplash syndrome. Furthermore, some results of morphologic studies of the alar ligaments by MRT are presented. Although experience to date is limited, it is likely that MRT of the occipitocervical junction region due to its potential to reveal exquisite anatomical detail, will gain in importance in the future.     

Patient characteristics associated with diagnostic imaging evaluation of persistent low back problems

STUDY DESIGN: Post hoc analysis of data from the National Low Back Pain Study, a prospective observational multicenter study of patients referred for the evaluation and treatment of persistent low back problems. OBJECTIVE: To identify patient characteristics associated with use of particular diagnostic imaging examinations in patients with persistent low back problems. SUMMARY OF BACKGROUND DATA: The Agency for Health Care Policy and Research clinical practice guidelines on low back problems suggest that the use of particular diagnostic imaging tests for a given patient should be based on specific characteristics of that patient. METHODS: Use of diagnostic imaging examinations in 2,374 patients with persistent low back problems who were enrolled in the National Low Back Pain Study from 1986 to 1991 was analyzed. Stepwise logistic regression was used to identify patient characteristics that distinguish between enrollees who underwent particular imaging studies. RESULTS: Characteristics that distinguished patients who had undergone magnetic resonance imaging from those who had received only lumbo-sacral spine radiographs included higher socioeconomic status, greater resource use in the preceding 12 months, more functional impairment, presence of sciatica, and presence of neurologic signs/symptoms suggestive of nerve root compromise. Suspected soft tissue involvement was characteristic of enrollees who had undergone magnetic resonance imaging, whereas suspected structural involvement characterized patients who received noncontrast computed tomography. Only nonclinical factors, such as higher annual household income, disability compensation, and male gender distinguished enrollees who had undergone both magnetic resonance imaging and computed tomography-myelography from those who received only computed tomography-myelography. CONCLUSION: Particular patient socioeconomic and clinical characteristics are associated with receipt of specific imaging studies in evaluation of persistent low back problems.     

Fast spin-echo imaging of the brain and spine

The recent advent and implementation of rapid spin-echo techniques has allowed increased imaging speed while maintaining spin-echo-like contrast. This review explains the basis of fast spin-echo imaging and attempts to elucidate the etiology of the differences between it and spin-echo imaging. Clinical applications and limitations of fast spin-echo imaging in the brain and spine will also be addressed.     

Clinical and technical assessment of the cervical spine

In analysis of the cervical and cervicobrachial syndrome with or without signs of compression of the nerve root or spinal cord, functional assessment of the cervical spine is of great importance. Comparisons between actively performed and passively induced motion can be verified by using standardized computer-assisted assessment allowing precise documentation of the range of motion and coupled motion. The age-related normal values should be considered. The neurological assessment includes not only the cranial nerves and upper extremities but also lower extremities to avoid overlooking the signs of cervical myelopathy. In patients with compression of nerve roots or the spinal cord neurophysiology might be helpful in identifying or verifying compression. In patients with suspected myelopathy sensory evoked potentials will allow assessment of the function of the ascending spinal pathways and motor evoked potentials, assessment of the function of the descending cortical spinal pathways.     

Computed tomography of the spine as an important diagnostic tool in the management of war missile spinal trauma

Twenty-two patients with spinal injury were evaluated by plain radiography immediately after hospital admission. In 14 patients whose condition was stable, we performed computed tomography (CT) scanning through the involved segments. To provide better planning before neurosurgical management, we divided the vertebral column in thirds. According to this division, we concluded that these injuries are mostly extensive, severely damaging all three thirds of the vertebral column and accompanying neural structures in the majority of cases. The information acquired by Ct concerning bony fragments, bone destruction, dural tear, spinal cord and nerve root compression, and neural damage directly influenced the surgical management. All patients except one underwent surgery while associated injuries of other organs were given priority in management. Injuries of the thoracic and the lumbar spine were the most common ones, frequently found in association with lesions of nearby organs. Penetrating injuries with a dural lesion were present in the majority of cases, while spinal cord injury was obvious in some. They were all well visualized using spinal CT scanning. Our view is that the role of CT is essential in guiding surgical management of war missile injuries to the spine.     

Integrating case management and utilization management

Over the years the utilization review coordinator's role has evolved to more than quality assessment, risk management, and utilization management. Recognizing the need to expand the traditional role, one hospital integrated two positions: case management and utilization management. A 2-mont pilot defining roles, responsibilities, outcomes, and future goals is described.     

The agreement among urological experts on the diagnostic management of patients with common urological problems

OBJECTIVE: To assess the level of agreement among randomly selected international urologists on the diagnostic management of patients with prostate cancer, bladder cancer, urinary stones or lower urinary tract symptoms (LUTS) arising from benign prostatic hyperplasia (BPH). METHODS: A computer program was used to provide an unbiased format of 53 simulated patients, comprising 13 with prostate cancer, 10 with bladder cancer, 10 with stones in the upper urinary tract and 20 with LUTS from BPH. For each case, the history was provided to the user while information from 60 diagnostic tests could be chosen interactively. Thirty-three university-based urologists participated in the study. The probability that a certain test was used by them in a certain patient [P(test)] and the related costs (Swedish 1995 prices) were recorded. The probability that two urologists would agree (relative measure of agreement, RMA) on whether or not to use one particular test in a certain case was RMA(test) = P(test)2 + [1-P(test)]2 and the mean of this RMA(test) for a certain patient [RMA(case)] was used as a measure of the inter-individual agreement among the urologists on the diagnostic management. The significance levels of the generalized kappa statistic, KG, were also calculated. The correlation between the RMA(case) and the diagnostic groups was analysed. RESULTS: The KG was statistically significant for all cases; the RMA(case) was significantly correlated with the diagnostic groups (rs = 0.86). The agreement in the diagnostic management was the strongest for stones, then for bladder cancer and prostate cancer, and the weakest for BPH. The mean cost for the diagnostic evaluation for one case varied from $455 to $1771 (mean 898) and varied in the diagnostic groups, i.e. $1718 for prostate cancer, $947 for bladder cancer, $400 for stones and $594 for BPH. CONCLUSION: The diagnostic management of urological patients varies greatly among urological experts from the industrial world. As a consequence, the related diagnostic costs might vary by about 400% if prices were similar everywhere. The agreement on the diagnostic management of cases is strongly correlated to the diagnosis. LUTS from BPH seems to be managed with the poorest agreement.     

Pediatric management problems. What is your assessment? Scarlet fever

Apocrine hidrocystoma is a cyst from the secretory portion of the apocrine sweat gland and tends to occur as a solitary facial lesion. We report a 66-year-old woman with multiple, cystic lesions on her face. Histopathology revealed cystic spaces lined by a row of secretory cells showing decapitation secretion. We emphasize the multiple character of the case and discuss its distinction from so-called eccrine hidrocystomas.     

An approach to the diagnostic imaging of jaw lesions, dental implants, and the temporomandibular joint

This article is an overview of three complex and often confusing areas of diagnostic imaging. It provides the reader with a starting point and a frame of reference from which to proceed when confronted with either an unknown jaw lesion, evaluating a potential dental implant patient, or a patient with TMJ internal derangement.     

An eight-year follow-up of a management assessment center.

47 individuals evaluated in a management assessment center in 1967 in the marketing organization of a large manufacturing company were followed up 8 yrs later. Both the overall assessment center rating and a general management evaluation of potential derived from personnel files were significantly related to position level attained after 8 yrs for 30 individuals still with the company. The shrunken multiple correlation of these 2 predictors with level attained was .58. Characteristics of aggressiveness, persuasiveness, oral communications, and self-confidence plus test scales of ascendency and self-assurance were most strongly related to level attained 8 yrs later. It is commented that while the validity of this specific assessment center for predicting advancement appears adequate, additional research is desirable to evaluate the ability to predict performance in management. (7 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Pain drawings in the assessment of nerve root compression: a comparative study with lumbar spine magnetic resonance imaging

STUDY DESIGN: Prospective comparative study of pain drawings with findings on lumbar spine magnetic resonance imaging. OBJECTIVES: To assess the ability of the pain drawing to predict the presence of nerve root compression. SUMMARY OF BACKGROUND DATA: Most research work has concentrated on the ability of the pain drawing to act as a screening method for psychological distress with less work directed at the influence the anatomic abnormality has on the pain drawing. METHODS: One hundred thirty-four consecutive outpatients attending for lumbar magnetic resonance imaging in the investigation of back and leg pain completed pain drawings and psychological testing immediately before the examination. The pain drawing was analyzed by previously reported criteria, and the magnetic resonance imaging was assessed independently for the presence of nerve compression by three radiologists. Multivariate stepwise discriminant analysis was used to identify patients with nerve compression on the basis of their pain drawing. RESULTS: Nerve compression was predicted by numbness in the anterolateral aspect of the foot. There was considerable overlap in the appearances of the pain drawings between patients with and without nerve compression, and the pain drawing correctly classified only 58% of patients with nerve compression. CONCLUSIONS: The pain drawing is not a good predictor of nerve compression on magnetic resonance imaging in a group of patients investigated for back and leg pain. It should be interpreted with caution and in light of the full clinical picture.     

Risk factors for the spine: nursing assessment and care

The present work aimed at studying risk factor that affect people with back pain, identifying them and implementing an intervention proposal of a health education program based on self-care teaching, existential humanist philosophical projects and stress equalization approach line, skeletal-muscle reintegration activities, basic techniques on stress equalization and massage. It has been developed for a population of 42 (forty-two) clients. Two instruments which integrate nursing consultation protocol have been used in data collection. The results showed the existence of associated risk factors which are changeable according to health education programs. The assessment process has contributed for therapeutic measures focus, using non-conventional care methods for this approach providing an improvement to these clients life quality.     

Magnetic resonance imaging of the musculoskeletal system: the spine

Magnetic resonance imaging in the patient who has had surgery is discussed. The most common indication for postoperative imaging is in the distinction between postoperative fibrosis and recurrent disc herniation. Magnetic resonance imaging is invaluable in the assessment of potential causes of failed back surgery syndrome such as postoperative infection, arachnoiditis and adjacent segment degeneration. Magnetic resonance imaging assumes a less important role in postoperative patients with metal hardware owing to image degradation secondary to metal artifact. Magnetic resonance imaging has a complementary role with computed tomography evaluation of spinal trauma. It excels at the noninvasive evaluation of spinal deformities and neoplasms.     

Serendipity in diagnostic imaging: magnetic resonance imaging of the breast

BACKGROUND: Magnetic resonance imaging (MRI) of the breast has been proposed as a noninvasive diagnostic test for evaluation of suspicious ("index") lesions noted on mammography and/or clinical breast examination (CBE). However, women may have incidental ("serendipitous") lesions detected by MRI that are not found on mammography or CBE. To understand better whether or not biopsy procedures should be performed to evaluate serendipitous lesions, we estimated the breast cancer risk for women with this type of lesion. METHODS: A decision analysis model was used to estimate the positive predictive value (i.e., the chance that a woman with a serendipitous lesion has cancer) of MRI for serendipitous lesions in women who had an abnormal mammogram and/or CBE suspicious for cancer (where a biopsy procedure is recommended). We restricted the analysis to data from women whose index lesions were noncancerous and used meta-analysis of published medical literature to determine the likelihood ratios (measures of how test results change the probability of having cancer) for MRI and the combination of CBE and mammography. The positive predictive value of MRI was calculated using the U.S. population prevalence of cancer (derived from registry data) and the likelihood ratios of the diagnostic tests. RESULTS: Under a wide variety of assumptions, the positive predictive value of MRI was extremely low for serendipitous lesions. For instance, assuming sensitivity and specificity values for MRI of 95.6% and 68.6%, respectively, approximately four of 1000 55- to 59-year-old women with serendipitous lesions would be expected to have cancer (positive predictive value = 0.44%, 95% confidence interval = 0.24%-0.67%). CONCLUSION: In women with a suspicious lesion discovered by mammography and/or CBE that is found to be benign, serendipitous breast lesions detected by MRI are extremely unlikely to represent invasive breast cancer. Immediate biopsy of such serendipitous lesions may, therefore, not be required.     

An overview of Spanish studies on appropriateness of hospital use

A long-acting depot formulation of octreotide (Sandostatin LAR, Sandoz LTD) has been recently developed. Preliminary studies indicated that, in acromegalic patients previously controlled by Sandostatin 300-600 micrograms/day in 2-3 sc injections, the intramuscular administration of 20-30 mg of Sandostatin LAR achieved, during one month a similar control of GH hypersecretion. In the present study, the variations of plasma levels of octreotide, GH and IGF1 were followed during 2 months in acromegalic patients receiving a unique injection of 20 mg (n = 4) or 30 mg (n = 4) of Sandostatin LAR. Following Sandostatin LAR 20 mg i.m, the baseline values of GH (8.1 +/- 2.5 micrograms/l) and IGF1 (684 +/- 92 micrograms/l) were normalized after 2 weeks and remained into the normal range during the 28 following days. Similar results were obtained, after a 30 mg i.m administration of Sandostatin LAR. In this later case, the maximal inhibition of GH and IGF1 (1.3 +/- 1.0 micrograms/l and 392 +/- 266 micrograms/l respectively) lasted 2 months. These data showed that a monthly injection of Sandostatin LAR (20-30 mg) allowed a correct control of GH hypersecretion in this series of acromegalic patients.