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Paradigm Shift of Spinal Diagnosis and Treatment

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A special issue of Diagnostics (ISSN 2075-4418). This special issue belongs to the section "Medical Imaging and Theranostics".

Deadline for manuscript submissions: closed (5 October 2022) | Viewed by 36356

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Dr. Masato Tanaka

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1. Okayama University Hospital, Okayama, Japan
2. Okayama Rosai Hospital, Okayama, Japan
Interests: navigation; spine; cervical; scoliosis; adult spinal deformity; endoscopic surgery; MIS
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Dear Colleagues,

Recently, new spinal imaging technology and innovative spinal surgery has been emerging. For the imaging technology, dynamic contrast-enhanced (DSC) MR perfusion imaging can differentiate hyper- from hypovascular spinal tumor. Diffusion-weighted imaging (DWI) and diffusion tensor imaging (DTI) are MRI techniques based on measuring the microscopic diffusion of water in living tissues, which is available for spinal intramedullary tumor. Furthermore, 3D-MRI/CT fusion imaging can demonstrate lumbar nerve root compromise.

These imaging technologies, spinal navigation, and robot-assisted surgery, together provide spine surgeons with innovative options for spinal surgery. The advantages of applying robotic technology in spine surgery include the possibility of improving screw accuracy and reducing complications. Spinal navigation surgery has been developing for twenty years. Because of the increase of the aging population around the world, minimally invasive surgery (MIS) such as the endoscopic technique has been in a rapid phase of development since the turn of the 21st century.

With these technological developments, this Special Issue welcomes original research and review articles.

Specific topics of interest include investigations of the human spine that demonstrate the following:

Advances in image acquisition including dual-energy X-ray absorptiometry (DXA); multi-detector computed tomography (MDCT); and the new magnetic resonance imaging (MRI) technique, 3D-MRI/CT fusion imaging.
Novel spinal surgery, which includes new technology or imaging techniques, as well as navigation, robot-assisted surgery, endoscopic surgery.

Dr. Masato Tanaka
Guest Editor

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Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Diagnostics is an international peer-reviewed open access semimonthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 2600 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

artificial intelligence
mixed reality
navigation
emerging technologies (robot-assisted surgery)
functional MRI
fusion image
new innovative diagnostic tools
scoliosis
adult spinal surgery
spinal tumor
spondylodiscitis
minimally invasive surgery (MIS)
aging spine

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Related Special Issue

Paradigm Shift in the Field of Spinal Diagnosis and Treatment in 2025 in Diagnostics

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10 pages, 1376 KiB

Open AccessArticle

Clinical and Imaging Characteristics of Non-Neoplastic Spinal Lesions: A Comparative Study with Intramedullary Tumors

by Keita Kajikawa, Narihito Nagoshi, Osahiko Tsuji, Satoshi Suzuki, Masahiro Ozaki, Yohei Takahashi, Mitsuru Yagi, Morio Matsumoto, Masaya Nakamura and Kota Watanabe

Diagnostics 2022, 12(12), 2969; https://doi.org/10.3390/diagnostics12122969 - 28 Nov 2022

Cited by 2 | Viewed by 1774

Abstract

The features of non-neoplastic lesions are often similar to those of intramedullary tumors, and a differential diagnosis is challenging to obtain in some cases. A surgical biopsy, which is performed on highly invasive tumors, should be avoided in cases of non-neoplastic lesions. Therefore, an accurate diagnosis is important prior to treatment. We evaluated 43 patients suspected of having spinal cord tumors and, finally, were diagnosed with non-neoplastic intramedullary lesions via magnetic resonance imaging. The patients commonly presented with myelitis. The patients with non-neoplastic neurological diseases had a significantly shorter symptom duration than those with intramedullary astrocytomas. The proportion of patients with non-neoplastic neurological diseases who presented with lesions at the cervical spinal level and focal lesions on axial imaging but without a spinal cord enlargement was significantly higher than that of patients with intramedullary astrocytomas. The current study aimed to distinguish spinal cord tumors from non-neoplastic intramedullary lesions based on their distinct features. Full article

(This article belongs to the Special Issue Paradigm Shift of Spinal Diagnosis and Treatment)

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12 pages, 3941 KiB

Open AccessArticle

Computed Tomographic Epidurography in Patients with Low Back Pain and Leg Pain: A Single-Center Observational Study

by Kimiaki Yokosuka, Kimiaki Sato, Kei Yamada, Tatsuhiro Yoshida, Takahiro Shimazaki, Shinji Morito, Kouta Nishida, Atsushi Matsuo, Takuma Fudo and Naoto Shiba

Diagnostics 2022, 12(5), 1267; https://doi.org/10.3390/diagnostics12051267 - 19 May 2022

Cited by 2 | Viewed by 2099

Abstract

This study was conducted to analyze the findings and benefits of computed tomography (CT) epidurography in patients with low back and leg pain and compare these findings with those of magnetic resonance imaging (MRI) images. In total, 495 intervertebral discs from 99 patients with low back and leg pain who underwent percutaneous epidural adhesiolysis (epidural neuroplasty or percutaneous adhesiolysis) were examined. The axial views of CT epidurography were classified into six types to examine each intervertebral disc: round type, ellipse type, spike type, Benz mark, incomplete block, complete block, and non-contrast. MRI images were graded from A to D using the Schizas classification. Notably, 176 images were round-type and ellipse-type axial views, and 138 were spike-type and Benz-mark views; Schizas classification Grades A and B were observed in 272 and 47 MRI images, respectively. The incomplete block and complete block axial images did not significantly differ in CT epidurography and Schizas classification Grades C and D. The images showing Benz marks existed only at the L4/5 and L5/S intervertebral levels and only in 14.7% of patients. The ratio of normal shadows differed between MRI images and CT epidurography. Therefore, CT epidurography may enable a detailed evaluation of the epidural space. Full article

(This article belongs to the Special Issue Paradigm Shift of Spinal Diagnosis and Treatment)

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12 pages, 1252 KiB

Open AccessArticle

The Prevalence and Characteristics of Diffuse Idiopathic Skeletal Hyperostosis (DISH): A Cross-Sectional Study of 1519 Japanese Individuals

by Hisanori Ikuma, Tomohiko Hirose, Dai Nakamura, Kazutaka Yamashita, Masataka Ueda, Kazuhiro Sasaki and Keisuke Kawasaki

Diagnostics 2022, 12(5), 1088; https://doi.org/10.3390/diagnostics12051088 - 27 Apr 2022

Cited by 8 | Viewed by 2676

Abstract

Background: Diffuse idiopathic skeletal hyperostosis (DISH) is a pathology characterized by enthesis ossification, but there have been few reports on epidemiological surveys. This report presents a cross-sectional survey of DISH from thoracic to sacral spine in patients at the tertiary emergency medical center. Methods: The patients were divided into DISH (+) group and DISH (−) group for a retrospective comparative study. The primary outcome measures were the frequency of DISH and the patient demographic data, the secondary outcome measures were the previous medical history (diabetes mellitus, cardiovascular disease), the extent of aortic calcification, the frequency of hyperostosis around the costovertebral joint and the mortality rate within 3 months of the initial examination. Results: This survey examined a total of 1519 patients. There were 265 cases (17.4%) in the DISH (+) group and 1254 cases in DISH (−) group. The prevalence of DISH was concentrated at the thoracolumbar junction, particularly at T9. The mean age, ratio of male and hyperostosis around the costovertebral joint were significantly higher in the DISH (+) group (p < 0.001), but there was no significant difference in other variables. Conclusions: The pathology of DISH might involve the effects of age-related changes or biomechanical effects. Full article

(This article belongs to the Special Issue Paradigm Shift of Spinal Diagnosis and Treatment)

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10 pages, 3155 KiB

Open AccessArticle

Usefulness of 3D CT/MRI Fusion Imaging for the Evaluation of Lumbar Disc Herniation and Kambin’s Triangle

by Masakazu Nagamatsu, Praful Maste, Masato Tanaka, Yoshihiro Fujiwara, Shinya Arataki, Taro Yamauchi, Yoshiyuki Takeshita, Rika Takamoto, Tsukasa Torigoe, Masato Tanaka, Ryosuke Tanaka and Shinsuke Moriue

Diagnostics 2022, 12(4), 956; https://doi.org/10.3390/diagnostics12040956 - 12 Apr 2022

Cited by 3 | Viewed by 2425

Abstract

Study design: Prospective study. Objective: The aim of this study is to visualize the morphology of a lumbar herniated disc and Kambin’s triangle in three dimensions (3D) based on preoperative CT/MRI fusion images. Methods: CT/MRI fusion images of 23 patients (10 males and 13 females; mean age 58.2 years) were used to evaluate Kambin’s triangle, which is created between the superior articular process (SAP), exiting nerve root (ENR), inferiorly by the superior endplate of the lower lumbar vertebra and dural canal medially at 60 degree and 45 degree endoscopic approach angles. The percentage of the safe usage of transforaminal endoscopic approach was evaluated to utilize a 5 mm dilater without partial facet resection in the fusion image. The 3D lumbar nerve root sleeve angulation (3DNRA), which is the angle between the axis of the thecal sac and the nerve root sleeve, was calculated. The herniated discs were also visualized in the CT/MRI fusion image. Results: The 3DNRA became smaller from L2 to S1. The L2 3DNRA was statistically larger than those of the other root, and the S1 3DNRA was significantly smaller than the others (p < 0.05). (L2, 41.0°; L3, 35.6°; L4, 36.4°; L5, 33.9°; and S1, 23.2°). The SAP-ENR distance at 60° was greatest at L4/5 (5.9 mm). Possible needle passages at 60° to each disc level were 89.1% at L2/3, 87.0% at L3/4 and 84.8% at L4/5. However, the safe 5 mm dilater passage at 60° without bony resection to each disc level were 8.7% at L2/3, 28.3% at L3/4 and 37.0% at L4/5. The 60° corridor at L2/3 was the narrowest (p < 0.01). All herniated discs were visualized in the fusion image and the root compression site was clearly demonstrated especially with foraminal/extraforaminal herniations. Conclusion: The 3D lumbar CT/MRI fusion image enabled a combined nerve-bony assessment of Kambin’s triangle and herniated disc. A fully endoscopic 5 mm dilater may retract the exiting nerve root in more than 60% of total cases. This new imaging technique could prove to be very useful for the safety of endoscopic lumbar disc surgery. Full article

(This article belongs to the Special Issue Paradigm Shift of Spinal Diagnosis and Treatment)

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17 pages, 6634 KiB

Open AccessArticle

Remodeling Pattern of Spinal Canal after Full Endoscopic Uniportal Lumbar Endoscopic Unilateral Laminotomy for Bilateral Decompression: One Year Repetitive MRI and Clinical Follow-Up Evaluation

by Hyeun-Sung Kim, Pang-Hung Wu, Giovanni Grasso, Jin-Woo An, Myeonghun Kim, Inkyung Lee, Jong-Seon Park, Jun-Hyoung Lee, Sangsoo Kang, Jeongshik Lee, Yeonjin Yi, Jun-Hyung Lee, Jun-Hwan Park, Jae-Hyeon Lim and Il-Tae Jang

Diagnostics 2022, 12(4), 793; https://doi.org/10.3390/diagnostics12040793 - 24 Mar 2022

Cited by 2 | Viewed by 2449

Abstract

Objective: There is limited literature on repetitive postoperative MRI and clinical evaluation after Uniportal Lumbar Endoscopic Unilateral Laminotomy for Bilateral Decompression. Methods: Clinical visual analog scale, Oswestry Disability Index, McNab’s criteria evaluation and MRI evaluation of the axial cut spinal canal area of the upper end plate, mid disc and lower end plate were performed for patients who underwent single-level Uniportal Lumbar Endoscopic Unilateral Laminotomy for Bilateral Decompression. From the evaluation of the axial cut MRI, four types of patterns of remodeling were identified: type A: continuous expanded spinal canal, type B: restenosis with delayed expansion, type C: progressive expansion and type D: restenosis. Result: A total of 126 patients with single-level Uniportal Lumbar Endoscopic Unilateral Laminotomy for Bilateral Decompression were recruited with a minimum follow-up of 26 months. Thirty-six type A, fifty type B, thirty type C and ten type D patterns of spinal canal remodeling were observed. All four types of patterns of remodeling had statistically significant improvement in VAS at final follow-up compared to the preoperative state with type A (5.59 ± 1.58), B (5.58 ± 1.71), C (5.58 ± 1.71) and D (5.27 ± 1.68), p < 0.05. ODI was significantly improved at final follow-up with type A (49.19 ± 10.51), B (50.00 ± 11.29), C (45.60 ± 10.58) and D (45.60 ± 10.58), p < 0.05. A significant MRI axial cut increment of the spinal canal area was found at the upper endplate at postoperative day one and one year with type A (39.16 ± 22.73; 28.00 ± 42.57) mm², B (47.42 ± 18.77; 42.38 ± 19.29) mm², C (51.45 ± 18.16; 49.49 ± 18.41) mm² and D (49.10 ± 23.05; 38.18 ± 18.94) mm², respectively, p < 0.05. Similar significant increment was found at the mid-disc at postoperative day one, 6 months and one year with type A (55.16 ± 27.51; 37.23 ± 25.88; 44.86 ± 25.73) mm², B (72.83 ± 23.87; 49.79 ± 21.93; 62.94 ± 24.43) mm², C (66.85 ± 34.48; 54.92 ± 30.70; 64.33 ± 31.82) mm² and D (71.65 ± 16.87; 41.55 ± 12.92; 49.83 ± 13.31) mm² and the lower endplate at postoperative day one and one year with type A (49.89 ± 34.50; 41.04 ± 28.56) mm², B (63.63 ± 23.70; 54.72 ± 24.29) mm², C (58.50 ± 24.27; 55.32 ± 22.49) mm² and D (81.43 ± 16.81; 58.40 ± 18.05) mm² at postoperative day one and one year, respectively, p < 0.05. Conclusions: After full endoscopic lumbar decompression, despite achieving sufficient decompression immediately postoperatively, varying severity of asymptomatic restenosis was found in postoperative six months MRI without clinical significance. Further remodeling with a varying degree of increment of the spinal canal area occurs at postoperative one year with overall good clinical outcomes. Full article

(This article belongs to the Special Issue Paradigm Shift of Spinal Diagnosis and Treatment)

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13 pages, 1637 KiB

Open AccessArticle

Treatment Effect of CT-Guided Periradicular Injections in Context of Different Contrast Agent Distribution Patterns

by Vera Reuschel, Cordula Scherlach, Christian Pfeifle, Matthias Krause, Manuel Florian Struck, Karl-Titus Hoffmann and Stefan Schob

Diagnostics 2022, 12(4), 787; https://doi.org/10.3390/diagnostics12040787 - 23 Mar 2022

Viewed by 2965

Abstract

Acutely manifesting radicular pain syndromes associated with degenerations of the lower spine are frequent ailments with a high rate of recurrence. Part of the conservative management are periradicular infiltrations of analgesics and steroids. The purpose of this study is to evaluate the dependence of the clinical efficacy of CT-guided periradicular injections on the pattern of contrast distribution and to identify the best distribution pattern that is associated with the most effective pain relief. Using a prospective study design, 161 patients were included in this study, ensuring ethical standards. Statistical analysis was performed, with the level of statistical significance set at p = 0.05. A total of 37.9% of patients experienced significant but not long-lasting (four weeks on average) complete pain relief. A total of 44.1% of patients experienced prolonged, subjectively satisfying pain relief of more than four weeks to three months. A total of 18% of patients had complete and sustained relief for more than six months. A significant correlation exists between circumferential, large area contrast distribution including the zone of action between the disc and affected nerve root contrast distribution pattern with excellent pain relief. Our results support the value of CT-guided contrast injection for achieving a good efficacy, and, if necessary, indicative repositioning of the needle to ensure a circumferential distribution pattern of corticosteroids for the sufficient treatment of radicular pain in degenerative spine disease. Full article

(This article belongs to the Special Issue Paradigm Shift of Spinal Diagnosis and Treatment)

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13 pages, 5768 KiB

Open AccessArticle

Associations between Patient Report of Pain and Intervertebral Foramina Changes Visible on Axial-Loaded Lumbar Magnetic Resonance Imaging

by Tomasz Lorenc, Marek Gołębiowski, Dariusz Syganiec and Wojciech M. Glinkowski

Diagnostics 2022, 12(3), 563; https://doi.org/10.3390/diagnostics12030563 - 23 Feb 2022

Cited by 1 | Viewed by 7412

Abstract

The intervertebral foramen may influence spinal nerve roots and, therefore, be related to the corresponding dermatomal pain. In vivo evaluation of the intervertebral foramen–dermatome relationship is essential for understanding low back pain (LBP) pathophysiology. The study aimed to correlate the lumbar MRI unloaded-loaded foraminal area changes with dermatomal pain in the patient’s pain drawings. Dynamic changes of the dermatomal pain distribution related to the intervertebral foramen area changes between quantitative conventional supine MRI (unloaded MRI) and axial-loading MRI (alMRI) were analyzed. The MRI axial-loading intervertebral foramen area changes were observed, and the most significant effect of reducing the foraminal area (−6.9%) was reported at levels of L2–L3. The incidence of pain in the dermatomes increases linearly with the spine level, from 15.6% at L1 to 63.3% at L5 on the right and from 18.9% at L1 to 76.7% at L5 on the left. No statistically significant effect of changes in the intervertebral foramen area on the odds of pain along the respective dermatomes was confirmed. Changes in the foraminal area were observed between the unloaded and loaded phases, but differences in area changes between foramen assigned to painful dermatomes and foramen assigned to non-painful dermatomes were not significant. Full article

(This article belongs to the Special Issue Paradigm Shift of Spinal Diagnosis and Treatment)

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11 pages, 623 KiB

Open AccessArticle

Predictive Factors for Successful Treatment of Deep Incisional Surgical Site Infections following Instrumented Spinal Surgeries: Retrospective Review of 1832 Cases

by Masahiro Kuroiwa, Jordy Schol, Daisuke Sakai, Natsumi Horikita, Akihiko Hiyama, Hiroyuki Katoh, Yukihiro Yamamoto, Masato Sato and Masahiko Watanabe

Diagnostics 2022, 12(2), 551; https://doi.org/10.3390/diagnostics12020551 - 21 Feb 2022

Cited by 4 | Viewed by 2697

Abstract

Background: Surgical site infection (SSI) is a major complication in spinal instrumentation that is often difficult to treat. The purpose of this study was to identify and determine prognostic indicators for successful treatment of spine instrumentation SSI. Methods: Retrospectively, spine surgery cases were examined on SSI diagnosis. Post-instrumentation SSI patients were categorized as “Successful” if SSI subsided after single debridement. Patients in whom SSI did not subsided and/or required removal of instrumentation were classified as “Challenging”. We investigated the relation of treatment outcomes to patients and treatment factors. Results: A total of 1832 spinal instrumentation cases were recognized with 44 (2.40%) SSI cases. White blood cell count, C-reactive protein (CRP) levels, causative bacteria (i.e., S. Aureus or MRSA), trauma injury, and early-stage antimicrobial agent sensitivity correlated with treatment prognosis. Multivariate analysis highlighted CRP levels and applying early-stage sensitive antibiotics as potential impactful predictive factors for successful treatment. Conclusions: Our results demonstrated that early selection of sensitive antimicrobial agents is critical and emphasizes the potential for early-stage classification methods such as Gram staining. Additionally, S. Aureus and MRSA SSI formed significantly more challenging infections to treat, thus requiring consideration when deciding on instrumentation retention. These factors offer promising aspects for further large-scale studies. Full article

(This article belongs to the Special Issue Paradigm Shift of Spinal Diagnosis and Treatment)

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Review

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10 pages, 1115 KiB

Open AccessReview

An Evolution Gaining Momentum—The Growing Role of Artificial Intelligence in the Diagnosis and Treatment of Spinal Diseases

by Andre Wirries, Florian Geiger, Ludwig Oberkircher and Samir Jabari

Diagnostics 2022, 12(4), 836; https://doi.org/10.3390/diagnostics12040836 - 29 Mar 2022

Cited by 5 | Viewed by 2461

Abstract

In recent years, applications using artificial intelligence have been gaining importance in the diagnosis and treatment of spinal diseases. In our review, we describe the basic features of artificial intelligence which are currently applied in the field of spine diagnosis and treatment, and we provide an orientation of the recent technical developments and their applications. Furthermore, we point out the possible limitations and challenges in dealing with such technological advances. Despite the momentary limitations in practical application, artificial intelligence is gaining ground in the field of spine treatment. As an applying physician, it is therefore necessary to engage with it in order to benefit from those advances in the interest of the patient and to prevent these applications being misused by non-medical partners. Full article

(This article belongs to the Special Issue Paradigm Shift of Spinal Diagnosis and Treatment)

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16 pages, 2647 KiB

Open AccessReview

Imaging Evaluation of Intervertebral Disc Degeneration and Painful Discs—Advances and Challenges in Quantitative MRI

by Shota Tamagawa, Daisuke Sakai, Hidetoshi Nojiri, Masato Sato, Muneaki Ishijima and Masahiko Watanabe

Diagnostics 2022, 12(3), 707; https://doi.org/10.3390/diagnostics12030707 - 14 Mar 2022

Cited by 21 | Viewed by 8004

Abstract

In recent years, various quantitative and functional magnetic resonance imaging (MRI) sequences have been developed and used in clinical practice for the diagnosis of patients with low back pain (LBP). Until now, T2-weighted imaging (T2WI), a visual qualitative evaluation method, has been used to diagnose intervertebral disc (IVD) degeneration. However, this method has limitations in terms of reproducibility and inter-observer agreement. Moreover, T2WI observations do not directly relate with LBP. Therefore, new sequences such as T2 mapping, T1ρ mapping, and MR spectroscopy have been developed as alternative quantitative evaluation methods. These new quantitative MRIs can evaluate the anatomical and physiological changes of IVD degeneration in more detail than conventional T2WI. However, the values obtained from these quantitative MRIs still do not directly correlate with LBP, and there is a need for more widespread use of techniques that are more specific to clinical symptoms such as pain. In this paper, we review the state-of-the-art methodologies and future challenges of quantitative MRI as an imaging diagnostic tool for IVD degeneration and painful discs. Full article

(This article belongs to the Special Issue Paradigm Shift of Spinal Diagnosis and Treatment)

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