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Example from the reference examination for grading central canal stenosis. (Left) At the level of the L2 pedicles, the area of the thecal sac measures approximately 241 mm 2. (Right) At the level of the L2–L3 disc space, the area of the thecal sac measures approximately 67 mm 2. The reduction of the thecal sac is greater than two-thirds and was graded as severe stenosis.
Source publication
Background context:
In today's health-care climate, magnetic resonance imaging (MRI) is often perceived as a commodity-a service where there are no meaningful differences in quality and thus an area in which patients can be advised to select a provider based on price and convenience alone. If this prevailing view is correct, then a patient should...
Context in source publication
Context 1
... study ex- aminations had the lowest interpretive miss rate, 10%, with respect to the patient's single instance of anterior spondylo- listhesis, and the highest miss rate, 72.5%, for the patient's four instances of nerve root involvement. The interpretive miss rates for all other pathologies ranged from 30% to 47.5% and are summarized in Table 1. Fig. 3 illustrates an example from the reference exami- nation for grading central canal stenosis. At the level of the L2 pedicles, the area of the thecal sac measures approxi- mately 241 mm 2 , and at the level of the L2-L3 disc space the area of the thecal sac measures approximately 67 mm 2 . The reduction of the thecal sac is greater than ...
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Citations
... In the current study, these parts have shown excellent ICC values for intra-rater (ICC = 0.918, 0.924) and good inter-rater (ICC = 0.845, 0.806) reliability for AVH and PVH, respectively. Hong et al. [20] evaluated AVH to PVH ratio measured by three observers and reported 0.753 for intra-rater and 0.793 for inter-rater agreement. In another study Yao et al. [21] reported excellent reliability coefficients (0.90-0.99) for AVH, PVH, SVBH, AIVDH, and PIVDH. ...
Background
Magnetic resonance imaging (MRI) is increasingly used to estimate the geometric dimensions of lower lumbar vertebrae. While MRI-based measurements have demonstrated good reliability with interclass correlation coefficients (ICCs) of 0.80 or higher, many evaluations focus solely on the comparison of identical MRI images. This approach primarily reflects analyst dexterity and does not assess the reliability of the entire process, including imaging and image selection.
Objective
To evaluate the inter- and intra-rater reliability of the entire process of using MRI to measure biomechanically relevant lumbar spinal characteristics, incorporating imaging, image selection, and analysis. Methods: A dataset of 144 low-back MRI scans was analyzed. Reliability assessments were performed under different conditions: (1) identical scans rated by the same analyst at different times (intra-rater reliability) and (2) distinct scans of the same subject obtained by different MRI operators and analyzed by different analysts (inter-rater reliability). Mean absolute differences in measurements were calculated, and sources of variability, such as breathing artifacts, were noted.
Results
Larger discrepancies were observed when comparing distinct scans analyzed by different MRI operators and analysts. In the “worst-case” scenario, where both the MRI operator and analyst differed, a 4.05% mean absolute difference was noted for anterior endplate measurements. This was higher than the 2.76% difference observed when analysts re-rated their own scans after one month. Despite these discrepancies, the variability in measurements was relatively low and primarily attributed to factors like breathing artifacts.
Conclusion
The process of using MRI to derive biomechanical measures, particularly for bony structures, demonstrates robust reliability. Variability in measurements is minimal even under challenging conditions, supporting the use of MRI for biomechanical assessments.
... Diagnosing spinal disorders and their underlying causes has long posed a substantial challenge, as recently evidenced again by a study that revealed significant discrepancies in diagnoses from different MRI centers based on one single MRI (Herzog et al., 2017). To offer individual prevention strategies, estimate personal risks or plan patient-specific therapies, more information needs to be derived from medical images. ...
Introduction
Biomechanical simulations can enhance our understanding of spinal disorders. Applied to large cohorts, they can reveal complex mechanisms beyond conventional imaging. Therefore, automating the patient-specific modeling process is essential.
Methods
We developed an automated and robust pipeline that generates and simulates biofidelic vertebrae and intervertebral disc finite element method (FEM) models based on automated magnetic resonance imaging (MRI) segmentations. In a first step, anatomically-constrained smoothing approaches were implemented to ensure seamless contact surfaces between vertebrae and discs with shared nodes. Subsequently, surface meshes were filled isotropically with tetrahedral elements. Lastly, simulations were executed. The performance of our pipeline was evaluated using a set of 30 patients from an in-house dataset that comprised an overall of 637 vertebrae and 600 intervertebral discs. We rated mesh quality metrics and processing times.
Results
With an average number of 21 vertebrae and 20 IVDs per subject, the average processing time was 4.4 min for a vertebra and 31 s for an IVD. The average percentage of poor quality elements stayed below 2% in all generated FEM models, measured by their aspect ratio. Ten vertebra and seven IVD FE simulations failed to converge.
Discussion
The main goal of our work was to automate the modeling and FEM simulation of both patient-specific vertebrae and intervertebral discs with shared-node surfaces directly from MRI segmentations. The biofidelity, robustness and time-efficacy of our pipeline marks an important step towards investigating large patient cohorts for statistically relevant, biomechanical insight.
... Severe symptom progression in a child, especially confusion, fever, and focal neurological deficits following a viral infection, fits the ADEM profile. Characteristic MRI findings included multifocal hyperintense lesions within the white matter and deep gray matter structures typical for ADEM, thus distinguishing it from other demyelinating disorders like multiple sclerosis, which usually presents with distinctive lesion patterns and is often associated with oligoclonal bands in the CSF (Herzog et al., 2017). Oligoclonal bands were not present in the cerebrospinal fluid. ...
... Interpretation of Findings ADEM is an uncommon but serious "inflammatory demyelinating disease of the central nervous system," which primarily has been reported to affect children either following viral infections or, less commonly, vaccinations. Thus, this case falls under an expanding spectrum of ADEM, representing hallmarks such as rapid onset of neurological symptoms following infection, good response to corticosteroid therapy, and typical MRI findings (Herzog et al., 2017). However, it also emphasizes the need to consider atypical presentations in pediatric ADEM cases since early and accurate diagnosis is a significant determinant of good clinical outcomes. ...
... These are commonly affected in ADEM since they show dense myelination and are susceptible to inflammatory demyelination. When there is involvement of lesions in both the basal ganglia and thalamus, it can sometimes blur the diagnostic line with ADEM and other demyelinating disorders of "multiple sclerosis or neuromyelitis optica spectrum disorders (NMOSD)" (Herzog et al., 2017). Unlike MS, which usually has the presentation of new lesions over time, ADEM typically consists of a one-phase attack without recurrence. ...
Acute disseminated encephalomyelitis, or ADEM, “is an acute, immune-mediated disorder affecting the central nervous system.” Viral infection is usually the cause that initiates this rare inflammatory neurological disease, which mainly presents with fever, changes in the state of consciousness, and neurological deficits related to one area of the body. Though the disease usually precipitates with typical symptoms, the atypicality of presentation complicates diagnosis, especially in children. This report will describe the clinical features, diagnosis, and treatment response of an atypically presenting case of ADEM following a viral infection in a 7-year-old boy. He initially presented with high fever, confusion, and weakness on the left side of her body, along with disturbances in vision. Examination revealed a change in mental status with left-sided weakness, hyperreflexia, and features of multifocal lesions consistent with ADEM in magnetic resonance imaging (MRI) studies. Corticosteroid treatment was thus initiated, given the recent viral illness. The patient showed remarkable improvement over several weeks, with complete cognitive and motor recovery during follow-up. The case emphasizes the need to heighten clinical awareness of the atypical presentations of ADEM, on which the success of early recognition and timely treatment depends. The report reviews the complexities of the diagnosis such cases present, including differentiating ADEM from other neurological diseases. It suggests including ADEM in the differential diagnosis of every pediatric patient with unexplained neurological symptoms following a viral infection. The review of existing literature underlines the variability in ADEM presentations and reiterates the importance of early intervention. This case adds to the broad understanding of ADEM and should increase the clinician's high suspicion index, while further research in diverse presentations and their management strategies is encouraged.
... Traditionally, the analysis of MRI scans has relied heavily on manual processing by radiologists. They visually inspect the scans to identify and diagnose conditions, a task that can vary in accuracy among professionals [9], and requires significant expertise. Even when converting MRI data to computational models for automatic processing, manual intervention is necessary to identify, segment, mark, and measure regions of interest, processes which are timeconsuming and prone to human error. ...
... Upper crossed syndrome causes extensive changes in the upper body, including abnormal head posture and scapular protraction, leading to an imbalance in head alignment. This can result in breathing difficulties, altered oral breathing patterns, and chronic neck pain (9). Additionally, it increases the likelihood of developing osteoarthritis in the TMJ, leading to inflammation and referred pains (10,11). ...
Background: Upper crossed syndrome is a muscular imbalance disorder associated with various referred pains, especially jaw discomfort. Complications like temporomandibular joint (TMJ) osteoarthritis may link to forward head posture and mechanical head pains resulting from this syndrome. Objectives: The objective of this study was to compare the impact of corrective exercise on pain of TMJ in elderly women with upper cross syndrome. Methods: A total of 30 elderly women with upper crossed syndrome were enrolled at the Kahrizak Elderly Care Center and randomly assigned to either a corrective exercise group or a control group. The experiment group underwent an eight-week training program. Pain levels and neck range of motion were assessed using a pain ruler and goniometer, respectively. In order to measure neck extension, the mean difference and effect size were determined using paired t-test and Cohen’s d, respectively. Referred pain ratings were analyzed using Mann-Whitney U and Wilcoxon signed-rank tests, with effect size calculations, to further understand the intervention’s effect on pain perception. Results: Both groups demonstrated significant changes in referred pain perceptions (P = 0.0441) post-intervention. However, regarding neck extension, neither the control nor the experiment group exhibited statistically significant alterations in neck extension (P = 0.4309) Conclusions: These findings indicate that corrective exercises have a positive effect on alleviating referred pain in the jaw joint caused by muscle imbalance. Given the merits of corrective exercises as a non-pharmacological intervention, they are recommended as an effective approach for improving referred pain in the jaw.
... These tests are particularly useful when conservative measures prove ineffective, surgery is being considered, or severe progressive neurological signs and symptoms are present. It is worth noting that reported MRI findings for spine disorders can vary significantly [53], leading many physicians to independently verify the reported findings to determine the most appropriate treatment plan. The estimated prevalence of radiculopathy is approximately 10 cases per 1000 individuals [54,55]. ...
Neuropathic pain, traditionally considered a chronic condition, is increasingly encountered in the emergency department (ED), accounting for approximately 20% of patients presenting with pain. Understanding the physiology and key clinical presentations of neuropathic pain is crucial for ED physicians to provide optimal treatment. While diagnosing neuropathic pain can be challenging, emphasis should be placed on obtaining a comprehensive medical history and conducting a thorough clinical examination. Patients often describe neuropathic pain as a burning or shock-like sensation, leading them to seek care in the ED after ineffective relief from common analgesics such as paracetamol and NSAIDs. Collaboration between emergency medicine specialists, neurologists, and pain management experts can contribute to the development of evidence-based guidelines specifically tailored for the emergency department setting. This article provides a concise overview of the common clinical manifestations of neuropathic pain that may prompt patients to seek emergency care.
... We eliminated typographical errors in this study by using a script to automatically extract kidney volume measurements into our research database, but for routine clinical reporting of kidney volume measurements, the possibility of transcription error should be considered. Finally, there is an error introduced by using a variety of MRI scanners with different software and calibrations [26]. Although this was not specifically investigated here, we noted the coefficient of intersequence variation varied from 3.5% to 5.2% among the seven types of MRI scanners used for acquiring images in this study (Supplementary Figure S5). ...
Total kidney volume measured on MRI is an important biomarker for assessing the progression of autosomal dominant polycystic kidney disease and response to treatment. However, we have noticed that there can be substantial differences in the kidney volume measurements obtained from the various pulse sequences commonly included in an MRI exam. Here we examine kidney volume measurement variability among five commonly acquired MRI pulse sequences in abdominal MRI exams in 105 patients with ADPKD. Right and left kidney volumes were independently measured by three expert observers using model-assisted segmentation for axial T2, coronal T2, axial single-shot fast spin echo (SSFP), coronal SSFP, and axial 3D T1 images obtained on a single MRI from ADPKD patients. Outlier measurements were analyzed for data acquisition errors. Most of the outlier values (88%) were due to breathing during scanning causing slice misregistration with gaps or duplication of imaging slices (n = 35), slice misregistration from using multiple breath holds during acquisition (n = 25), composing of two overlapping acquisitions (n = 17), or kidneys not entirely within the field of view (n = 4). After excluding outlier measurements, the coefficient of variation among the five measurements decreased from 4.6% pre to 3.2%. Compared to the average of all sequences without errors, TKV measured on axial and coronal T2 weighted imaging were 1.2% and 1.8% greater, axial SSFP was 0.4% greater, coronal SSFP was 1.7% lower and axial T1 was 1.5% lower than the mean, indicating intrinsic measurement biases related to the different MRI contrast mechanisms. In conclusion, MRI data acquisition errors are common but can be identified using outlier analysis and excluded to improve organ volume measurement consistency. Bias toward larger volume measurements on T2 sequences and smaller volumes on axial T1 sequences can also be mitigated by averaging data from all error-free sequences acquired.
... One study reported degenerate discs in 96% MRIs from 80 + year olds, who were not experiencing back pain [20]. There is high inter-rater variation between intervertebral disc pathology diagnoses and gradings [21][22][23]. The Pfirrmann scale only has moderate interrater agreement [24,25] and can be difficult to use, with failures to distinguish early signs of degeneration [26]. ...
Introduction:
Low back pain is the leading contributor to disability burden globally. It is commonly due to degeneration of the lumbar intervertebral discs (LDD). Magnetic resonance imaging (MRI) is the current best tool to visualize and diagnose LDD, but places high time demands on clinical radiologists. Automated reading of spine MRIs could improve speed, accuracy, reliability and cost effectiveness in radiology departments. The aim of this review and meta-analysis was to determine if current machine learning algorithms perform well identifying disc degeneration, herniation, bulge and Modic change compared to radiologists.
Methods:
A PRISMA systematic review protocol was developed and four electronic databases and reference lists were searched. Strict inclusion and exclusion criteria were defined. A PROBAST risk of bias and applicability analysis was performed.
Results:
1350 articles were extracted. Duplicates were removed and title and abstract searching identified original research articles that used machine learning (ML) algorithms to identify disc degeneration, herniation, bulge and Modic change from MRIs. 27 studies were included in the review; 25 and 14 studies were included multi-variate and bivariate meta-analysis, respectively. Studies used machine learning algorithms to assess LDD, disc herniation, bulge and Modic change. Models using deep learning, support vector machine, k-nearest neighbors, random forest and naïve Bayes algorithms were included. Meta-analyses found no differences in algorithm or classification performance. When algorithms were tested in replication or external validation studies, they did not perform as well as when assessed in developmental studies. Data augmentation improved algorithm performance when compared to models used with smaller datasets, there were no performance differences between augmented data and large datasets.
Discussion:
This review highlights several shortcomings of current approaches, including few validation attempts or use of large sample sizes. To the best of the authors' knowledge, this is the first systematic review to explore this topic. We suggest the utilization of deep learning coupled with semi- or unsupervised learning approaches. Use of all information contained in MRI data will improve accuracy. Clear and complete reporting of study design, statistics and results will improve the reliability and quality of published literature.
... The conclusion of the study was that there was poor overall agreement on interpretive findings. The true positive rate (sensitivity) was 56.4% and the miss rate (false negative) was 43.6% [6]. Do we really know how to use the MRI spine effectively? ...
... Second opinions might be particularly useful for people recommended surgery for their back pain as surgery has at best a limited role in the management of back pain [10,11]. Reasons to consider a second opinion might include substantial variability in diagnoses given to people with back pain [12], indications for surgery, and risks associated with some surgical procedures that have unclear benefits (e.g. spinal fusion) [13]. ...
Background
Second opinions have the goal of clarifying uncertainties around diagnosis or management, particularly when healthcare decisions are complex, unpleasant, and carry considerable risks. Second opinions might be particularly useful for people recommended surgery for their back pain as surgery has at best a limited role in the management of back pain.
Methods
We conducted a scoping review. Two independent researchers screened PubMed, EMBASE, Cochrane CENTRAL and CINAHL from inception to May 6th, 2021. Studies of any design published in any language were eligible provided they described a second opinion intervention for people with spinal pain (low back or neck pain with or without radicular pain) either considering surgery or to whom surgery had been recommended. We assessed the methodological quality with the Downs & Black scale. Outcomes were: i) characteristics of second opinion services for people considering or who have been recommended spinal surgery, ii) agreement between first and second opinions in terms of diagnoses, need for surgery and type of surgery, iii) whether they reduce surgery and improve patient outcomes; and iv) the costs and healthcare use associated with these services. Outcomes were presented descriptively.
Results
We screened 6341 records, read 27 full-texts, and included 12 studies (all observational; 11 had poor methodological quality; one had fair). Studies described patient, doctor, and insurance-initiated second opinion services. Diagnostic agreement between first and second opinions varied from 53 to 96%. Agreement for need for surgery between first and second opinions ranged from 0 to 83%. Second opinion services may reduce surgery rates in the short-term, but it is unclear whether these reductions are sustained in the long-term or if patients only delay surgery. Second opinion services may reduce costs and healthcare use (e.g. imaging), but might increase others (e.g. injections).
Conclusions
Second opinion services typically recommend less surgical treatments compared to first opinions and may reduce surgery rates in the short-term, but it is unclear whether these reductions are sustained in the long-term or if patients only delay surgery. There is a need for high-quality randomised trials to determine the value of second opinion services for reducing spinal surgery.
