Evidence-Based Imaging - part 7 potx

cumulative radiation dose to the breast was 10.8cGy (range, 0–170). Seventy-seven breast cancer deaths were observed compared with 45.6 expected deaths on the basis of United States mortality rates. Women with scoliosis had a 1.7-fold risk of dying of breast cancer (95% CI, 1.3–2.1) when compared with the general population. The data suggested that radiation was the causative factor, with risk increasing significantly with the number of radiographic exposures and the cumulative radiation dose (moderate evidence). Potential confounding was noted because the severity of disease was related to radiation exposure and reproductive history; patients with more severe disease were less likely to become pregnant and had a greater risk of breast cancer. In a large retrospective cohort study of 2039 patients, Levy and col- leagues (75) found an excess lifetime cancer risk of 1% to 2% (12 to 25 cases per 1000 population) among women (moderate evidence). The same group suggested that supplanting the anteroposterior (AP) view with the pos- teroanterior (PA) view would result in a three- to sevenfold reduction in cumulative doses to the thyroid gland and the female breast, three- to four- fold reductions in the lifetime risk of breast cancer, and a halving of the lifetime risk of thyroid cancer (76). The same cohort of women was evalu- ated for adverse reproductive outcomes (77). Of the initial group of 1793 young women evaluated for scoliosis between 1960 and 1979, 1292 women returned questionnaires in 1990. This cohort was compared with a refer- ence group of 1134 women selected randomly from the general population. The adolescent idiopathic scoliosis cohort had a higher risk of spontaneous abortions [odds ratio (OR), 1.35; 95% CI, 1.06–1.73] (moderate evidence). The odds of unsuccessful attempts at pregnancy (OR, 1.33; 95% CI, 0.84–2.13) and of congenital malformations (OR, 1.2; 95% CI, 0.78–1.84) were also higher but not statistically significant (moderate evidence). Digital radiography seems to reduce radiation exposure. The results are varied (78–80), and the technology is evolving (limited evidence). Studies report an 18-fold reduction with some systems (73) versus an almost twofold increase with others (81). VII. What Is the Use of Magnetic Resonance Imaging (MRI) for Severe Idiopathic Scoliosis? Summary of Evidence: There is increasing concern about the association of idiopathic scoliosis with structural abnormalities of the neural axis. Minimal tonsillar ectopia (<5mm) is significantly prevalent in scoliosis and correlates with abnormalities in somatosensory-evoked potentials and with the severity of scoliosis (4) (moderate evidence). Otherwise, a paucity of significant findings on MRI of patients evaluated for idiopathic scolio- sis is noted, even in severe cases (4). Supporting Evidence: Cheng and colleagues (82) studied 36 healthy control subjects, 135 patients with moderately severe adolescent idiopathic scolio- sis (Cobb angle less than 45 degrees), and 29 similar patients with Cobb angles greater than 45 degrees. All of the patients were evaluated pros- pectively with MRI looking specifically for tonsillar ectopia and with somatosensory-evoked potentials. Tonsillar herniation was found in none of the controls versus four of 135 (3%) and eight of 29 (27.6%) of the two scoliotic groups (p < .001) (moderate evidence). Similarly, the percentages 344 L.S. Medina et al. of patients with abnormal somatosensory-evoked potentials were 0%, 11.9%, and 27.6%, respectively. There was a significant association between tonsillar ectopia and abnormal somatosensory function (p < .001; correla- tion coefficient, 0.672) (moderate evidence). Tonsillar ectopia was defined as any inferior displacement of the tonsils, and none of the patients had a displacement greater than 5mm, which is considered the usual threshold for the diagnosis (83–85). Several studies have addressed the prevalence of MR abnormalities in patients with severe idiopathic scoliosis who are otherwise asymptomatic. Do and colleagues (86) studied a consecutive series of 327 patients with idiopathic scoliosis requiring surgical intervention (average preoperative curve of 57 degrees) but without neurologic findings. The patients, aged 10 to 19 years, were evaluated from the base of the skull to the sacrum. Seven patients had abnormal MRI, including two with syrinx, four with Chiari malformation type I, and one with a fatty vertebral body. None of them required specific treatment for these findings (moderate evidence). In four other cases, equivocal MRI findings necessitated additional workup. In a similar prospective double-blinded study of 140 patients eval- uated preoperatively, Winter et al. (87) found four patients with abnor- malities, three with Chiari I malformations, and one with a small syrinx, none of whom required treatment. In another study of MRI examinations performed preoperatively, Maiocco et al. (88) found two of 45 patients with syrinx, one requiring decompression (moderate evidence). To study whether the severity of the curve increased the risk of associ- ated abnormalities, O’Brien et al. (89) performed MR evaluation on 33 con- secutive patients with adolescent idiopathic scoliosis and Cobb angles greater than 70 degrees. No neural axis abnormalities were found (limited evidence). VIII. What Is the Use of MRI for High-Risk Subgroups of Scoliosis? Summary of Evidence: Unlike adolescent idiopathic scoliosis, juvenile and infantile idiopathic scoliosis and congenital scoliosis have a high incidence of neural axis abnormalities (limited evidence). Increased incidence of neural axis abnormalities have been seen with atypical idiopathic scoliosis and left (levoconvex) thoracic scoliosis (Figs. 18.3 and 18.4) (4) (limited evidence). Supporting Evidence: Several studies have shown that, with scoliosis types that are different from the typical adolescent idiopathic form, there is a high prevalence of neural abnormalities (4). Of 30 consecutive children with congenital scoliosis studied by Prahinski and colleagues (90), nine had syringomyelia. Of these children, one required release of the tethered cord and one correction of a diastematomyelia (limited evidence). Two studies of prepubertal children suggest a high incidence of neural abnormalities in juvenile and infantile scoliosis. In a study of 26 consecutive children aged less than 11 years, Lewonowski and colleagues (91) found five (19.2%) with abnormalities of the cord. Three required surgical intervention, two with hydromyelia and one with a mass (91) (limited evidence). Gupta and colleagues (92) found that six of 34 patients under 10 years of age studied prospectively had neural axis abnormalities, including two patients with Chapter 18 Imaging of Spine Disorders in Children 345 syrinx requiring syringopleural shunting (one with a Chiari I malforma- tion). Other abnormalities included dural ectasia, tethered cord, and a brainstem astrocytoma (limited evidence). In a retrospective review of 95 patients with idiopathic scoliosis who had been studied for various indications, Schwend and colleagues (93) found that 12 had a syrinx, one a cord astrocytoma, and one dural ectasia (limited evidence). Left thoracic scoliosis was the most important predictor of abnormality (10 abnormalities in 43 patients). Mejia et al. (94) then per- formed a prospective study (level II) of 29 consecutive patients with idio- pathic left thoracic scoliosis, finding only two with syrinx and no other abnormalities (limited evidence). Barnes and colleagues (37) retrospec- tively analyzed 30 patients with atypical idiopathic scoliosis and found 17 abnormalities in 11 patients, including seven cases of syringohydromyelia and five Chiari I malformations (limited evidence). Take-Home Data How Should Physicians Evaluate Newborns with Suspected Occult Spinal Dysraphism? The decision tree in Figure 18.5 reinforces the primary importance of a careful acquisition of a medical history and performance of a thorough examination in newborns with suspected spinal dysraphism (30). For those patients in the high-risk group, imaging of the spine with MRI is recom- mended. For those patients in the intermediate-risk group, imaging of the spine with MRI or ultrasound is suggested, while in the low-risk group the strategies of ultrasound or no imaging may be indicated. Selection between 346 L.S. Medina et al. Figure 18.5. Suggested decision tree for use in newborns with suspected occult spinal dysraphism. For those patients in the high-risk group MRI is recommended. For patients in the intermediate-risk group ultrasound (US) or MRI is the strategy of choice, while for the low-risk group ultrasound or no imaging is recommended. For patients with negative imaging studies close clinical follow-up with periodic reassessment is recommended. [Source: Medina et al. (30), with permission.] these two strategies per risk group may be based on individual and insti- tutional diagnostic performance and cost per test. In newborns with sus- pected occult dysraphism, appropriate selection of patients for imaging based on these risk groups may maximize health outcomes for patients and improve health care resource allocation. How Should Scoliosis Be Evaluated? Figure 18.6 summarizes the decision tree for patients with suspected scoliosis. Imaging Case Study of Spinal Dysraphism This imaging case study illustrates a child with skin stigmata (Fig. 18.1) who has an occult dysraphic lesion of the intradural lipoma type (Fig. 18.2). Imaging Case Study of Scoliosis This imaging case study illustrates a child with atypical levoconvex tho- racic scoliosis (Fig. 18.3) who has neurofibromatosis type 1 with underly- ing plexiform neurofibromas (Fig. 18.4). Chapter 18 Imaging of Spine Disorders in Children 347 Figure 18.6. Suggested decision tree for use in patients with suspected scoliosis. Decision tree emphasizes importance of clinical history, physical exam, and radiographs in determining the need for MRI. Suggested Imaging Protocols for Spinal Dysraphism Spinal Ultrasound Spinal ultrasound should be performed in patients before the age of 3 months to avoid the limited acoustic window from mineralization of the posterior elements. An experienced operator should perform the study using a high-frequency, 5- to 15-MHz linear array transducer (52). Entire Spine MRI A retrospective case-control study including 101 patients (moderate evi- dence) suspected of having occult lumbosacral dysraphism demonstrated that conventional three-plane T1-weighted lumbosacral MRI in children and young adults provided better diagnostic information than a fast screening two-plane T1-weighted MRI because of its higher specificity and interobserver agreement (20). T2-weighted images in the axial and sagittal plane are often added to the protocol to assess intrinsic cord abnormali- ties. Intravenous paramagnetic contrast is not routinely used, unless the patient has a communicating dorsal dermal sinus tract or clinical concerns of underlying infection. Suggested Imaging Protocols for Scoliosis Scoliosis Radiographs Radiographs should be performed only when clinically indicated. Using the posteroanterior projection greatly reduces exposure, and some digital systems also decrease radiation (4,73). Entire Spine MRI Patients with scoliosis may represent an imaging challenge. In patients with scoliosis being evaluated with MRI, the entire spine should be covered. Three plain T1- and T2-weighted images should be obtained with different obliquities to optimize imaging information. Another approach is to obtain three-dimensional fast spin echo (FSE) volumetric imaging. Weinberger and colleagues (95) recommend using a TR of 500 ms, TE eff of 21ms, echo train length (ETL) of 8, 20- to 38-cm field of view, 256 ¥ 256 in plane matrix, 1-mm sagittal partition thickness, one excitation, and 16kHz of receive bandwidth. Intravenous paramagnetic contrast is important in the evaluation of intramedullary and extramedullary neoplasm. Future Research • Formal cost-effectiveness analysis of imaging in children with scoliosis. • Further development of low or no radiation imaging techniques for patients with scoliosis. References 1. Pacheco-Jacome E, Ballesteros MC, Jayakar P, Morrison G, Ragheb J, Medina LS. Neuroimag Clin North Am 2003;13:327–334. 348 L.S. Medina et al. 2. Soonawala N, Overweg-Plandsoen WCG, Brouwer OF. Clin Neurol Neurosurg 1999;101:11–14. 3. Tortori-Donati P, Cama A, Rosa ML, Andreussi L, Taccone A. Neuroradiology 1990;31:512–522. 4. Jaramillo D, Poussaint TY, Grottkau BE. Neuroimag Clin North Am 2003;13: 335–341. 5. 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What is the appropriate use of coronary artery computed tomogra- phy and magnetic resonance? 352 Issues ᭿ A strong recommendation can be made for initial coronary angiogra- phy among high-risk patients and those who are post–myocardial infarction (MI) that was transmural or with ischemic symptoms (strong evidence). ᭿ A strong recommendation can be made for performing a noninvasive imaging examination [e.g., single photon emission computed tomo- graphy (SPECT) or stress echo] prior to coronary angiography in low-risk patients and those who have had a non–Q-wave MI (strong evidence). ᭿ Aside from coronary angiography, the appropriate usage of cardiac imaging studies remains unclear, and more research is required to evaluate the outcomes, as well as the cost-effectiveness of the afore- mentioned modalities (insufficient evidence). ᭿ Coronary artery calcium scoring has been shown in asymptomatic patients to be predictive of coronary artery disease; however, there have been no data to support the position of added predictive value over and above the clinical Framingham model (insufficient evidence). Key Points Definition and Pathophysiology The etiology of coronary artery disease (CAD) is multifactorial involving both interaction of lifestyle and genetic predispositions. While some factors are not modifiable, those risks that may be altered are often neglected until there evidence of disease. As a result, a multitude of tests and clinical Chapter 19 Cardiac Evaluation: The Current Status of Outcomes-Based Imaging 353 assessment tools have been developed to risk stratify patients in order to direct short- and long-term treatments. The modifiable risk factors (e.g., hypertension, hyperlipidemia, and diabetes) have been on the rise over the past decade (1,2); therefore, a greater urgency has arisen to identify patients with CAD. Coronary artery disease begins as fatty streaks in the coronary arteries that may begin as early as 3 years of age. The fatty streaks are composed of large cells with intracellular lipids (foam cells) that are located in the suben- dothelial region. As patients age, the fatty streaks develop into fibrous plaques that narrow the vessel lumen, reducing blood flow. The fibrous plaques over time may calcify, reducing vessel compliance and increasing fragility. This further reduces blood flow and increases the chance of the plaque rupturing, resulting in an acute coronary artery occlusion. Epidemiology Coronary artery disease is a nationwide epidemic involving 6.4% of the entire population (3,4) and is the largest cause of mortality, accounting for one in every five deaths (4). This translates into a death rate of 177.8 per 100,000 (based on 2001 estimates) (4). In the United States, over 1.5 million people will have a myocardial infarction, and the majority of the patients will initially present with symptoms in their 50s and 60s. A large volume of literature has been generated investigating these modalities, but little has focused on the impact the modalities have on the patient outcomes even though there has been a steady increase in the use of costly diagnostic testing and treatment (5). This chapter reviews the literature on the outcomes research of cardiac imaging, and makes recommendations concerning the utilization of the techniques in patient management. Overall Cost to Society In the United States, the estimated 2004 cost of heart disease to society is $238 billion, with over half secondary to CAD ($133 billion) (4,6). The cost of heart disease is substantial in comparison to other disease processes, such as cancers ($189 billion) and AIDS ($29 billion) (4,6). The costs of CAD include direct health care of $66 billion, and $67 billion in indirect costs (e.g., loss of productivity secondary to morbidity and mortality) (4,6). The expenditures for health care are consistently increasing, because of new technologies and the current medicolegal environment. An ever- declining budget results in a need for clinicians to incorporate cost- effective strategies in patient evaluations. However, cost-effective does not mean withholding evaluations or always ordering the seemingly least expensive test, but rather understanding what is most efficient with respect to a specific clinical situation, based on current research. The purpose of this approach is to direct a finite amount of resources and limit costs to society without affecting the quality of health care. This chapter reviews the cost-effectiveness and outcomes of various imaging modalities of heart disease, and makes recommendations concerning these techniques in patient care. Specifically, coronary artery calcification scoring, myocardial SPECT, angiography, stress echocardiography, and cardiac magnetic reso- [...]... 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Current Status of Outcomes-Based Imaging Figure 19.4 Continued 361 362 A.J Bierhals and P.K Woodard Figure 19.5 Kaplan-Meier analysis of the probability of survival according to strategy group during 12 to 44 months of follow-up Death from any cause was included in this analysis The Cox proportional-hazards ratio for the conservative as compared with the invasive strategy was 0 .72 (95% confidence interval, . Neuroradiology. Philadelphia: Lippincott-Raven, 19 97: 7 17 77 8. 20. Medina LS, Al-Orfali M, Zurakowski D, Poussaint TY, DiCanzio J, Barnes PD. Radiology 1999;211 :76 7 77 1. 21. Appignani BA, Jaramillo D,. ed. Philadel- phia: Lippincott Williams & Wilkins, 2000: 677 74 0. 33. Rogala EJ, Drummond DS, Gurr J. J Bone Joint Surg Am 1 978 ;60(2): 173 – 176 . 34. Al-Arjani AM, Al-Sebai MW, Al-Khawashki HM,. 1998; 23(5):551–555. 71 . Loder RT, Urquhart A, Steen H, et al. J Bone Joint Surg Br 1995 ;77 (5) :76 8 77 0. 72 . Crockett HC, Wright JM, Burke S, Boachie-Adjei O. 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