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Appropriateness Criteria

Reference Study Type Patients/Events Study Objective(Purpose of Study) Study Results Study Quality
1. Ramirez N, Flynn JM, Hill BW, et al. Evaluation of a systematic approach to pediatric back pain: the utility of magnetic resonance imaging. Journal of pediatric orthopedics 2015;35:28-32. Observational-Dx 261 patients To (1) describe the prevalence of back pain seen in a pediatric orthopaedic clinic; (2) evaluate the efficacy of a systematic approach dependent on magnetic resonance imaging (MRI) in the diagnosis of pediatric back pain; and (3) analyze sensitivity, specificity, positive predictive value, and negative predictive value of various clinical signs and symptoms. The prevalence of chief complaint of back pain was 8.6% (261/3042 patients). Of the 261 patients, 34% had an identifiable pathology following the systematic approach. In 8.8% of patients, the diagnosis was established with the history, physical examination, and plain radiographs. MRI yielded a definitive diagnosis in another 25% of patients. It is noteworthy that of the 89 patients with a confirmed pathology, 26% were identified with plain radiographs and 74% with MRI. 3
2. Kjaer P, Wedderkopp N, Korsholm L, Leboeuf-Yde C. Prevalence and tracking of back pain from childhood to adolescence. BMC Musculoskelet Disord. 2011;12:98. Review/Other-Dx 771 children To show the prevalence estimates of BP, low back pain (LBP), mid back pain (MBP), neck pain (NP), and care-seeking because of BP at three different ages (9, 13 and 15 years) and how the BP reporting tracks over these age groups over three consecutive surveys. Of the 771 children sampled, 62%, 57%, and 58% participated in the three back surveys and 34% participated in all three. The prevalence estimates for children at the ages of 9, 13, and 15, respectively, were for BP 33%, 28%, and 48%; for LBP 4%, 22%, and 36%; for MBP 20%, 13%, and 35%; and for NP 10%, 7%, and 15%. Seeking care for BP increased from 6% and 8% at the two youngest ages to 34% at the oldest. Only 7% of the children who participated in all three surveys reported BP each time and 30% of these always reported no pain. The patterns of development differed for the three spinal regions and between genders. Status at the previous survey predicted status at the next survey, so that those who had pain before were more likely to report pain again and vice versa. This was most pronounced for care-seeking. 4
3. Shymon SJ, Yaszay B, Dwek JR, Proudfoot JA, Donohue M, Hargens AR. Altered disc compression in children with idiopathic low back pain: an upright magnetic resonance imaging backpack study. Spine 2014;39:243-8. Experimental-Dx Fifteen pediatric and adolescent patients To analyze the lumbar spine's response to backpack loads with upright MRI in children with ILBP to compare their results with previously published normal child data under the same conditions. We hypothesize that typical backpack loads will have a different effect on the lumbar spine of normal children and children with ILBP. The cohort's mean age was 13 +/- 3 years. The 4-kg and 8-kg backpacks only compressed the L5-S1 IVD relative to upright with no load. Subjects experienced increasing pain with increasing load. Load had no effect on lumbar lordosis or lumbar coronal deformity. Compared with normal children, children with ILBP experience significantly less disc compression at T12-L1 to L4-L5, less lumbar lordosis, and more pain with increasing load. 3
4. Bhatia NN, Chow G, Timon SJ, Watts HG. Diagnostic modalities for the evaluation of pediatric back pain: a prospective study. J Pediatr Orthop. 2008;28(2):230-233. Review/Other-Dx 73 patients To prospectively examine the rate of diagnosis for pediatric back pain and the value of various diagnostic studies for this problem. Fifty-seven patients (78.1%) ended with no diagnosis. Of the remaining 16, 9 were diagnosed with spondylolysis with or without spondylolisthesis. Three other patients had abnormal laboratory values but no definitive diagnosis. Other diagnoses included Scheuermann disease (n = 2), osteoid osteoma (n = 1), and a herniated disk (n = 1). 4
5. Feldman DS, Straight JJ, Badra MI, Mohaideen A, Madan SS. Evaluation of an algorithmic approach to pediatric back pain. J Pediatr Orthop. 2006;26(3):353-357. Observational-Dx 87 patients To review an algorithm for the evaluation of pediatric back pain and assesses critical factors in the history and physical examination that are predictive of specific diagnoses. Twenty-one (24%) of 87 patients had positive radiographs and were treated for their specific diagnoses. Nineteen (29%) of 66 patients with negative radiographs had constant pain, night pain, radicular pain, and/or an abnormal neurological examination. Ten of these 19 patients had a specific diagnosis determined by magnetic resonance imaging. Therefore, 31 (36%) of 87 patients had a specific diagnosis. Back pain of other 56 patients was of a nonspecific nature. No specific diagnoses were missed at latest follow-up. Specificity for determining a specific diagnosis was very high for radicular pain (100%), abnormal neurological examination (100%), and night pain (95%). Radicular pain and an abnormal neurological examination also had high positive predictive value (100%). Lumbar pain was the most sensitive (67%) and had the highest negative predictive value (75%). 3
6. Miller R, Beck NA, Sampson NR, Zhu X, Flynn JM, Drummond D. Imaging modalities for low back pain in children: a review of spondyloysis and undiagnosed mechanical back pain. J Pediatr Orthop. 2013;33(3):282-288. Observational-Dx 2846 patients To determine the natural history of low back pain, evaluate the value of radiographic studies in establishing a diagnosis of spondylolysis, and determine the cost and radiation effective doses (EDs) associated with those studies with the associated risks radiation exposure. A total of 2846 patients (63% female) with average age of 14.3 years were identified. A total of 2159 (76%) patients had UMLBP, 61% of that had </=2 follow-up visits. One hundred and ninety-four patients (7.8%) were diagnosed with spondylolysis; 119 (86%) by plain film, 56 (12.5%) by BSs, and 17 (1.5%) by CTs. Most patients (74%) with spondylolysis had a positive plain film study. There was no significant difference between 2-view (anterior-posterior, lateral) and 4-view (anterior-posterior, lateral, right oblique, left oblique) studies in sensitivity (78% vs. 72%, P=0.39). Advanced imaging was pursued in 90/354 (25%) patients with negative plain film studies. The sensitivity of BS for spondylolysis was 84% (73 of 88 BSs were positive). The sensitivity of CT for spondylolysis was 90% (44 of 49 CTs were positive. BSs exposed patients to much more radiation than CTs and plain film studies. 3
7. Khoury NJ, Hourani MH, Arabi MM, Abi-Fakher F, Haddad MC. Imaging of back pain in children and adolescents. Curr Probl Diagn Radiol. 2006;35(6):224-244. Review/Other-Dx N/A To present the imaging findings of the wide spectrum of musculoskeletal diseases causing back pain in children and adolescents. No results stated in abstract. 4
8. Rodriguez DP, Poussaint TY. Imaging of back pain in children. AJNR. American journal of neuroradiology 2010;31:787-802. Review/Other-Dx N/A To describe 1) the epidemiology of back pain in children, 2) the imaging work-up used, and 3) the correlation of imaging findings with disease entities that may cause back pain in the pediatric patient. No results stated in the abstract. 4
9. Sucato DJ, Micheli LJ, Estes AR, Tolo VT. Spine problems in young athletes. Instr Course Lect. 2012;61:499-511. Review/Other-Dx N/A To provide a review on the causes of back pain to be diagnosed and possible treatments so that young athletes can quickly return to sports participation. No results stated in the abstract 4
10. Schlemmer E, Mitchiner JC, Brown M, Wasilevich E. Imaging during low back pain ED visits: a claims-based descriptive analysis. Am J Emerg Med. 2015;33(3):414-418. Review/Other-Dx 14,838 events To determine the frequency and type of nonindicated imaging during LBP ED visits and to describe demographic and prior health care use characteristics among the nonindicated population. Of the 14838 total events, 51.9% (95% CI, 51.1%-52.7%) did not have indications for imaging. Patients without imaging indications were less likely to have had ED visits, hospital stays, LBP, lower back imaging, primary care physician visits, and back-related specialist visits in the past year compared with patients with indications. Among nonindicated patients, 30.1% (95% CI, 29.1%-31.1%) received imaging; of these, 26.2% received advanced imaging (computed tomography or magnetic resonance imaging). Nonindicated patients who received imaging were slightly older than those who did not receive imaging (27.6% [95% CI, 25.8%-29.4%] were ages 55-64 years vs 20.6% [95% CI, 19.6%-21.7%]) and had a higher prevalence of observation/treatment room use (7.3% [95% CI, 6.2%-8.4%] vs 1.2% [95% CI, 0.9%-1.4%]). 4
11. Bernstein RM, Cozen H. Evaluation of back pain in children and adolescents. Am Fam Physician. 2007;76(11):1669-1676. Review/Other-Dx N/A To evaluate back pain in children and adolescents. No results stated in abstract. 4
12. Haidar R, Saad S, Khoury NJ, Musharrafieh U. Practical approach to the child presenting with back pain. European journal of pediatrics 2011;170:149-56. Review/Other-Dx N/A To summarize the most commonly encountered causes of back pain in children and highlight diagnostic approaches that will ensure early diagnosis and intervention for a more favorable outcome. No results stated in abstract 4
13. Kempthorne JT, Pratt C, Smale EL, MacFarlane MR. Ten-year review of extradural spinal abscesses in a New Zealand tertiary referral centre. J Clin Neurosci. 2009;16(8):1038-1042. Review/Other-Dx 42 patients To define the presentation, findings and prognosis of extradural spinal abscess in a New Zealand tertiary referral centre. Staphylococcus aureus was identified in 67% of patients. On presentation, 27/38 patients with back pain were afebrile and 2/37 patients had a normal C-reactive protein (CRP) level in the first 24 hours. Ten patients were discharged with neurological dysfunction and one died. 4
14. Yee DK, Samartzis D, Wong YW, Luk KD, Cheung KM. Infective spondylitis in Southern Chinese: a descriptive and comparative study of ninety-one cases. Spine (Phila Pa 1976). 2010;35(6):635-641. Review/Other-Dx 91 patients To assess the prevalence, risk factors, clinical features, and prognostic outcomes associated with tuberculous spondylitis to that of pyogenic spondylitis in Southern Chinese treated at a single institution. Ninety-one patients were identified. Overall, tuberculous spondylitis and pyogenic spondylitis entailed 22 (24.2%) and 69 (75.8%) cases, respectively. Staphylococcus aureus was the most commonly isolated infective agent associated with pyogenic spondylitis. Individuals with pyogenic spondylitis were significantly much older than those with tuberculous spondylitis (P = 0.001). Intravenous drug addiction was the most commonly noted risk factor followed by diabetes, and found to be more prevalent in pyogenic spondylitis cases. At initial presentation, white cell count and c-reactive protein levels were higher in pyogenic spondylitis cases compared with tuberculous spondylitis (P < 0.05). The occurrence of tuberculous spondylitis cases was predominant in the thoracic region (40.9%) (P < 0.05). Surgical intervention was performed in 54.5% of tuberculous spondylitis and in 24.6% of the pyogenic spondylitis cases (P = 0.009). 4
15. Altaf F, Heran MK, Wilson LF. Back pain in children and adolescents. Bone Joint J. 2014;96-B(6):717-723. Review/Other-Dx N/A To review the important causes of back pain in children and adolescents, of which defects and stress reactions of the pars interarticularis are the most common identifiable problems. No results stated in the abstract 4
16. Summers BN, Singh JP, Manns RA. The radiological reporting of lumbar Scheuermann's disease: an unnecessary source of confusion amongst clinicians and patients. Br J Radiol. 2008;81(965):383-385. Review/Other-Dx 50 reports To investigate how often the diagnosis of Scheuermann's disease was made at a District General Hospital in radiological reports sent to local general practitioners (GPs); to determine the type of "Scheuermann's disease" being described; and to assess what GPs understood by the term "Scheuermann's disease" in the context of a specific clinical presentation. Review of the radiographs revealed that 80% showed features of lumbar Scheuermann's disease and 20% classical Scheuermann's. A questionnaire was issued to local GPs that described a case history of an adult patient with typical mechanical lower back pain for whom a radiological report, describing degenerative changes in the lumbar spine, concluded that some of the features "were consistent with Scheuermann's disease". 86% of GPs stated that they would inform their patients that they had "Scheuermann's disease" (using that exact term), but only 51% understood the meaning of the diagnosis in the context of the case history. 4
17. Hospach T, Langendoerfer M, von Kalle T, Maier J, Dannecker GE. Spinal involvement in chronic recurrent multifocal osteomyelitis (CRMO) in childhood and effect of pamidronate. Eur J Pediatr. 169(9):1105-11, 2010 Sep. Review/Other-Dx 102 children and adolescents To address the frequency and type of spinal involvement in patients with chronic recurrent multifocal osteomyelitis (CRMO) as well as the outcome of these patients treated with pamidronate (PAM). Of 102 children and adolescents with CRMO, 27 (26%) had involvement of the spine. Vertebral deformities were seen in 14 of these 27 patients, scoliosis or kyphosis in 6. After routine whole body MRI, 19 complained of back pain, whereas eight were asymptomatic with spinal lesions detected incidentally. A total of 72 spinal lesions were detected, thoracic vertebrae being the most commonly affected. Seven patients were treated with PAM; all of whom had vertebral deformities and ongoing back pain. Pain resolution was achieved within 3 months of PAM treatment in every case. One patient subsequently developed a pain amplification syndrome. Repeat MRI performed at a mean interval of 13 months revealed partial or complete resolution of vertebral hyperintensities in every patient. Improvement of vertebral height was seen in a total of three vertebrae in two patients. Severe side effects were not observed. 4
18. Bellah RD, Summerville DA, Treves ST, Micheli LJ. Low-back pain in adolescent athletes: detection of stress injury to the pars interarticularis with SPECT. Radiology. 1991;180(2):509-512. Observational-Dx 162 patients To compare the accuracy with which SPECT and planar bone scintigraphy aided in localizing a stress injury to the pars interarticularis, and to evaluate whether SPECT increases the sensitivity of bone scans in detecting this lesion. Planar scintigraphy and SPECT revealed no abnormality in 91 patients (56%). All abnormalities detected on planar images were also detectable with SPECT. SPECT showed an abnormal focus of radiotracer uptake in the lumbar spine in 71 patients (44%). In 32 of these 71 patients, these findings were also evident with planar scintigraphy. In 39 of these 71 patients, use of SPECT. Correlation with contemporaneous radiographs was made in 72 cases (including computed tomography in 10 cases). 3
19. Masci L, Pike J, Malara F, Phillips B, Bennell K, Brukner P. Use of the one-legged hyperextension test and magnetic resonance imaging in the diagnosis of active spondylolysis. Br J Sports Med. 2006;40(11):940-946; discussion 946. Observational-Dx 71 subjects To evaluate whether the one-legged hyperextension test can assist in the clinical detection of active spondylolysis and to determine whether magnetic resonance imaging (MRI) is equivalent to the clinical gold standard of bone scintigraphy and computed tomography in the radiological diagnosis of this condition. Seventy one subjects were recruited. Fifty pars interarticulares in 39 subjects (55%) had evidence of active spondylolysis as defined by bone scintigraphy (with SPECT). Of these, 19 pars interarticulares in 14 subjects showed a fracture on computed tomography. The one-legged hyperextension test was neither sensitive nor specific for the detection of active spondylolysis. MRI revealed bone stress in 40 of the 50 pars interarticulares in which it was detected by bone scintigraphy (with SPECT), indicating reduced sensitivity in detecting bone stress compared with bone scintigraphy (p = 0.001). Conversely, MRI revealed 18 of the 19 pars interarticularis fractures detected by computed tomography, indicating concordance between imaging modalities (p = 0.345). There was a significant difference between MRI and the combination of bone scintigraphy (with SPECT)/computed tomography in the radiological visualisation of active spondylolysis (p = 0.002). 2
20. Sanpera I, Jr., Beguiristain-Gurpide JL. Bone scan as a screening tool in children and adolescents with back pain. Journal of pediatric orthopedics 2006;26:221-5. Observational-Dx 142 patients To review bone scan as a screening tool in children and adolescents with back pain The sensitivity of the bone scan was low, 0.613 (95% CI: 0.549-0.654), although it proved to be highly specific, 0.91 (95% CI: 0.83-0.95). 3
21. Auerbach JD, Ahn J, Zgonis MH, Reddy SC, Ecker ML, Flynn JM. Streamlining the evaluation of low back pain in children. Clin Orthop Relat Res. 2008;466(8):1971-1977. Observational-Dx 873 consecutive patients To analyze the value of information gained from clinical examination and imaging studies (plain radiography, MRI, and SPECT) in reaching a diagnosis in children who present with isolated low back pain. Our tangible goals from this analysis included (1) identification of the imaging modality or combinations of modalities best able to rule out a serious diagnosis (negative predictive value) and least likely to miss a serious diagnosis (sensitivity); (2) development of guidelines based on this identification to streamline evaluation (reduce imaging, cost, time, radiation, and sedation); and (3) contributing to a framework on which an evidence-based approach to evaluating back pain in children can be developed. Fifty-seven children had negative radiographs, SPECT, and MRI and no identified organic diagnosis; they were assigned to Group I, MBP. The diagnoses that led to assignment of patients in Group II, OBP, were spondylolysis (21% [21 of 100]), spondylolisthesis (6%), herniated nucleus pulposus (4%), and other rare causes (12%, spina bifida occulta, Bertolotti’s syndrome, lumbar Scheuermann’s, pathologic compression fracture, osteomyelitis, L4 pedicle stress reaction, large Schmorl’s node). The examination findings common to both groups included tenderness to palpation of the lower back, hyperextension pain of the lumbar spine, and hamstring tightness. Evaluation of the use of imaging alone in distinguishing between Groups I and II revealed that all three modalities (radiography, SPECT, MRI) were able to discriminate between the two groups (p\0.001). Magnetic resonance imaging was the most useful with an overall NPV (predicting MBP) of 0.79 compared with 0.75 for SPECT and 0.68 for radiographs. The overall sensitivity (identification of OBP) of MRI alone in detecting patients with Group II diagnoses was 0.65, which was superior to SPECT (0.56) and radiographs (0.38). All combinations of anteroposterior, lateral, and oblique plain film radiography (routinely the first imaging obtained in evaluation) with either SPECT or MRI showed the ability to distinguish between Groups I and II (p\0.001) with high NPV and Sens values. The most useful combination of imaging and physical examination findings was MRI in conjunction with radiography and hyperextension testing, NPV and Sens of 1.0. Combining any imaging modality alone with hyperextension pain or hamstring tightness resulted in lower NPV and Sens values. A stepwise analysis showed a significant association between SPECT use (NPV and Sens) and time less than or equal to 6 weeks (p\0.001). A SPECT scan performed within the first 6 weeks of symptom duration (n = 6), regardless of physical examination findings, had a NPV and Sens of 1.0. After 6 weeks, there was a significant dropoff in both values. To validate this finding in a small population, we rescreened our initial population of 873 for all patients with a SPECT scan. Among 220 such patients, we again found a NPV and Sens of 1.0 (n = 29). In contrast, the use of MRI scans did not show time dependence (p[0.05). No child who received a bone scan required sedation (zero of 63). In contrast, 685 (49.1%) of the 1394 patients (1516 MRIs) who had MRI at our institution during the same period required sedation. 3
22. Cohen E, Stuecker RD. Magnetic resonance imaging in diagnosis and follow-up of impending spondylolysis in children and adolescents: early treatment may prevent pars defects. J Pediatr Orthop B. 2005;14(2):63-67. Review/Other-Dx 14 children To evaluate the role of MRI in early diagnosis of spondylolysis. The lumbar spine was assessed by magnetic resonance imaging (MRI) in 14 children (mean age 12.4 years) with unspecific activity-related low back pain for more than 3 weeks presenting with normal plain radiographs. Impending spondylolysis was diagnosed when typical signal abnormalities were confined to the pars interarticularis without signs of thinning or fragmentation. After brace treatment for 3 months, follow-up MRI was performed 3 and 6 months after treatment. MRI signals returned to normal after 3 months in six patients and after 6 months in one patient. 4
23. Goda Y, Sakai T, Sakamaki T, Takata Y, Higashino K, Sairyo K. Analysis of MRI signal changes in the adjacent pedicle of adolescent patients with fresh lumbar spondylolysis. Eur Spine J. 2014;23(9):1892-1895. Observational-Dx 98 adolescent patients To investigate a discrepancy between MRI and computed tomography (CT) findings in the spinal level distribution of spondylolysis. MRI signal changes were detected in 150 adjacent pedicles of 101 vertebrae. Of these vertebrae, MRI signal changes in only 67 (66.3%) corresponded to L5, while changes in 34 (33.7%) corresponded to L3 or L4. In our follow-up study, the bone-healing rate with no vertebral defect was 100% at L3, 97.1% at L4, and 84.4% at L5. In addition, 11 of 34 (32.4%) vertebrae with signal changes at L3 or L4 occurred with L5 terminal-stage spondylolysis (no MRI signal change). 3
24. Kobayashi A, Kobayashi T, Kato K, Higuchi H, Takagishi K. Diagnosis of radiographically occult lumbar spondylolysis in young athletes by magnetic resonance imaging. Am J Sports Med. 2013;41(1):169-176. Observational-Dx 200 consecutive young athletes To evaluate the usefulness of MRI in diagnosing active spondylolysis early and in determining the prevalence of active spondylolysis in cases where findings were not detected on plain radiography. In addition, specific clinical features to aid in the early detection of active spondylolysis were evaluated. Ninety-seven (48.5%) patients showed evidence of active spondylolysis on MRI, findings that had been missed by plain radiography. These pars defects were organized into the following categories based on CT findings: nonlysis stage, 52; very early stage, 37; late early stage, 22; progressive stage, 10; and terminal stage, 0. No significant physical examination factors were identified that could assist in the early detection of active spondylolysis. 3
25. Kjaer P, Leboeuf-Yde C, Sorensen JS, Bendix T. An epidemiologic study of MRI and low back pain in 13-year-old children. Spine (Phila Pa 1976). 2005;30(7):798-806. Observational-Dx 439 children To describe associations between "abnormal" lumbar magnetic resonance imaging (MRI) findings and low back pain (LBP) in 13-year old children. Signs of disc degeneration were noted in approximately 1/3 of the subjects. Reduced signal intensity and irregular nucleus shape in the upper 3 lumbar discs were significantly associated with LBP within the last month (OR, 2.5-3.6), whereas reduced signal intensity and disc protrusion at L5-NS1 were associated with seeking care (OR, 2.8 and 7.7, respectively). Endplate changes in relation to the L3 discs were associated with LBP month and seeking care (OR, between 9.7 and 22.2). Anterolisthesis at L5 was associated with seeking care (OR, 4.3). There were obvious differences between genders: degenerative disc changes in the upper lumbar spine were more strongly associated with LBP in boys, while disc abnormalities in the lower lumbar spine were more strongly associated with seeking care in girls. 2
26. Ozgen S, Konya D, Toktas OZ, Dagcinar A, Ozek MM. Lumbar disc herniation in adolescence. Pediatr Neurosurg. 2007;43(2):77-81. Review/Other-Tx 17 adolescents To assess the radiological, clinical and surgical features and case outcomes for adolescents with lumbar disc herniation, and to compare with adult cases. The collected histories revealed that 14 (82%) of the 17 cases involved trauma or intense sports activity. Low back pain was the most common complaint (15 cases, 88%). None of the 17 patients had major symptoms during follow-up, and most were engaged in intense sports or heavy work-related activities during this period. The main features of lumbar disc herniation in adolescents are different from those seen in adults. 4
27. Garg S, Dormans JP. Tumors and tumor-like conditions of the spine in children. The Journal of the American Academy of Orthopaedic Surgeons 2005;13:372-81. Review/Other-Dx N/A To review tumors and tumor-like conditions of the spine in children No results stated in abstract 4
28. Huisman TA. Pediatric tumors of the spine. Cancer imaging : the official publication of the International Cancer Imaging Society 2009;9 Spec No A:S45-8. Review/Other-Dx N/A To provide a review of pediatric tumors of the spine. No results stated the abstract. 4
29. Dietrich A, Vaccarezza H, Vaccaro CA. Iliopsoas abscess: presentation, management, and outcomes. Surg Laparosc Endosc Percutan Tech. 2013;23(1):45-48. Observational-Tx 34 consecutive patients To analyze presentation, treatment, and outcomes in a series of patients with diagnosis of pyogenic iliopsoas abscess (PIPA). Primary and secondary abscess occurred in 20.6% and 79.4%, respectively. The leading cause of PIPA was spondylodiscitis (38%) and computed tomography was the preferred diagnostic modality (87%). Most common presentation was left unilateral abscess in 66% of patients and most frequent isolated bacteria were Staphylococcus aureus. Fifteen patients (44%) received antibiotics as initial treatment with an initial failure rate of 80%; 11 of 15 patients required a second treatment. Sixteen patients (47%) underwent percutaneous drainage (PD) as first line treatment with a success rate of 50%. However, success rate of PD, increased to 100% after 2 drainages. Three patients were surgically drained without success (0 of 3 patients). Compared with the rest of the population, PD showed a lower hospital stay (25 vs. 14 d, respectively, P = 0.08) whereas surgery had a higher mortality rate (8% vs. 22%, respectively, P = 0.03). 3
30. Gregory PL, Batt ME, Kerslake RW, Scammell BE, Webb JF. The value of combining single photon emission computerised tomography and computerised tomography in the investigation of spondylolysis. Eur Spine J. 2004;13(6):503-509. Observational-Dx 118 patients The aim of this study was to assess the diagnostic value of combining single photon emission computerised tomography (SPECT) with reverse gantry computerised tomography (rg-CT) in the investigation of spondylolysis. SPECT showed increased scintigraphic uptake in 80 patients, and spondylolysis was identified on rg-CT in 53. The Cohen Kappa ratio of 0.362 (95% CI: 0.198-0.526) suggests only fair agreement for the result of increased scintigraphic activity with the finding of spondylolysis on rg-CT. We conclude that these investigations give mutually exclusive information, which leads to four diagnostic categories. When there was increased scintigraphic activity on SPECT, 58.8% (95% CI: 48.0-69.5%) of patients had spondylolysis on rg-CT. With rest from provoking activities, these lesions may heal. We interpret the findings of increased scintigraphic activity, but no spondylolysis demonstrated on rg-CT as indicating a bone stress response. These also require rest from provoking activity to prevent a stress fracture developing. In this study, 84.2% (95% CI: 72.67-95.8%) of those patients without increased activity on SPECT had no spondylolysis identified on rg-CT. 3
31. DePalma MJ, Bhargava A. Nonspondylolytic etiologies of lumbar pain in the young athlete. Curr Sports Med Rep. 2006;5(1):44-49. Review/Other-Dx N/A To review nonspondylolytic etiologies of lumbar pain in the young athlete. No results stated in the abstract 4
32. Wang H, Cheng J, Xiao H, Li C, Zhou Y. Adolescent lumbar disc herniation: experience from a large minimally invasive treatment centre for lumbar degenerative disease in Chongqing, China. Clin Neurol Neurosurg. 2013;115(8):1415-1419. Observational-Tx 120 adolescent patients To discuss the aetiology, medical history, physical examination, imaging characteristics and treatment modalities relevant to this entity aiming to increase awareness among paediatricians regarding LDH (lumbar disc herniation) in young children. The present retrospective analysis was performed on 121 adolescent patients (2.6%, 121/4695 cases with LDH operations) with LDH. One hundred and thirteen patients (93.4%) presented with low back pain with or without radiculopathy, and 12 patients (9.9%) presented with leg pain as the first symptom. Only 60 patients (49.6%) were diagnosed with LDH as their first outpatient diagnosis. Thirty-eight patients (31.4%) had a history of trauma before the onset of their symptoms. The most common segments were L4/5 (61, 50.4%), L5/S1 (42, 34.7%) and L4/5+L5/S1 (13, 10.7%). Disc herniation was centrolateral in 77.7% (n=94) and central in 35.5% (n=43). Eighty patients were treated by MED (microendoscopy discectomy), 25 by PELD (percutaneous endoscopic lumbar discectomy) and 16 by OLD (open lumbar discectomy). The rate of operative complications was 3.8%, 4.0% and 6.3% in MED, PELD and OLD, respectively. Through the ordinal regression analysis, we found that the patients with central disc herniation had much better outcomes than the patients with centrolateral disc herniation (P=0.046). 3
33. Vendhan K, Sen D, Fisher C, Ioannou Y, Hall-Craggs MA. Inflammatory changes of the lumbar spine in children and adolescents with enthesitis-related arthritis: magnetic resonance imaging findings. Arthritis care & research. 66(1):40-6, 2014 Jan. Observational-Dx 79 patients To describe and profile abnormalities of the lumbar spine in a cohort of patients with enthesitis-related arthritis (ERA) as compared to a control group of adolescents with mechanical back pain. The contrast agent used was gadoterate meglumine, which was administered as an intravenous bolus at a dose of 0.2 mmoles/kg. One or more abnormalities of the lumbar spine were found in 39 (67%) of 58 cases and sacroiliitis was present in 45 (78%) of the cases. Apophyseal joint synovitis was seen in 22 (38%) cases and in 1 (5%) control patient. This difference was highly significant (P = 0.004). Inflammatory changes in the interspinous ligaments were seen in a higher percentage of cases than controls and this observation was of statistical significance (P = 0.04). 2
34. Joseph RN, Batty R, Raghavan A, Sinha S, Griffiths PD, Connolly DJ. Management of isolated syringomyelia in the paediatric population--a review of imaging and follow-up in a single centre. Br J Neurosurg. 2013;27(5):683-686. Review/Other-Dx 39 patients To assess the natural history of isolated syringomyelia in children. Thirty-nine patients were included with a mean age at diagnosis of 10.6 years. The average syrinx AP diameter was 3.30 mm. The rostrocaudal length of the syringes varied between 2 and 19 vertebral bodies. Twenty-seven out of 39 syringes were thoracic in origin. There were 3 and 6 syringes involving the cervicothoracic and thoracolumbar regions, respectively, with 3 involving the cervical area only. Eleven out of 39 (Group I) patients were found "incidentally" during work-up for adolescent idiopathic scoliosis and these were considered as a separate group. These patients did not have any significant symptoms and were discharged following their scoliosis correction surgery. Syrinx was incidental in 14 further patients (Group II). Of the 14 patients, 11 remained asymptomatic with no change in syrinx morphology throughout follow up. Of the 14 patients, 3 were lost to follow-up. Of the 39 patients, 14 (Group III) presented with progressive back pain without any obvious clinical cause. Of the 14, 10 either improved or remained the same. Of the 14 patients, 3 underwent lumbar puncture, 1/14 having myelography. All 4/14 patients reported significant pain reduction on follow up following intervention. 4
35. Lohani S, Rodriguez DP, Lidov HG, Scott RM, Proctor MR. Intrasacral meningocele in the pediatric population. Journal of neurosurgery. Pediatrics 2013;11:615-22. Review/Other-Dx 13 pediatric patients To categorize the clinical presentation, radiological appearance, surgical anatomy, and operative results in pediatric patients undergoing operation for intrasacral meningocele. There were 13 patients (11 boys and 2 girls) who underwent operation for intrasacral meningocele. The median age was 8 years (range 5 months-16 years). The most common presenting symptom was back pain (in 5) often described as deep tail bone pain, followed by urinary incontinence (3) and constipation (2). Three patients had evidence of associated tethered cord on MRI studies. Four patients were asymptomatic and their diagnosis was made following imaging for other reasons; they were surgically treated because of the increasing size of the lesion or association with other congenital lesions. Most patients had symptomatic improvement after surgery. 4
36. Lehman VT, Murphy RC, Maus TP. 99mTc-MDP SPECT/CT of the spine and sacrum at a multispecialty institution: clinical use, findings, and impact on patient management. Nuclear Medicine Communications. 34(11):1097-106, 2013 Nov. Review/Other-Dx 212 99mTc-MDP SPECT/CT examinations To assess the optimal clinical role and true clinical impact of the technetium-99m methylene diphosphonate single-photon emission tomography/computed tomography (99mTc-MDP SPECT/CT) of the spine and sacrum Of the 212 99mTc-MDP SPECT/CT examinations of the spine and sacrum identified, 191 (90%) were for pain evaluation, 14 (7%) were to assess infection, and seven (3%) were to evaluate a potential malignancy. The most common specific indication was evaluation of facet joint pain in 70/191 (37%) patients, and the most common finding was facet joint activity in 106/212 (50%) patients. Several findings were reported, although facet joint activity was the most frequent. The other findings included costovertebral joint activity, pars interarticularis defects, an osteoid osteoma, a lumbosacral pseudoarticulation, and a postoperative pseudoarthrosis. A resultant change in clinical management was documented in 168/212 (79%) patients. Ninety-two of the 212 (44%) patients had undergone an MRI of the same region for any indication within +/-6 months. 4
37. Borg B, Modic MT, Obuchowski N, Cheah G. Pedicle marrow signal hyperintensity on short tau inversion recovery- and t2-weighted images: prevalence and relationship to clinical symptoms. AJNR Am J Neuroradiol. 2011;32(9):1624-1631. Review/Other-Dx 446 patients, both prospective and retrospective To assess type 1 pedicle marrow signal intensity changes and their behavior within the pedicle are associated with clinical symptoms and may be similar to and behave like type 1 pedicle marrow signal intensity chnages in the vertebral body. The prevalence of pedicle marrow hyperintensity on T2 and STIR-weighted sequences was 1.7%. Associated morphologic abnormalities were pars interarticularis and pedicle fractures and degenerative facets. In the longitudinal study, pedicle marrow signal hyperintensity on T2- and STIR-weighted images resolved in 17 patients and persisted in 5 patients. The extent, intensity, and resolution of signal intensity changes significantly related to the degree of functional limitation (P = .01). 4
38. Kim HJ, Green DW. Spondylolysis in the adolescent athlete. [Review]. Curr Opin Pediatr. 23(1):68-72, 2011 Feb. Review/Other-Dx N/A To review the typical presentation of spondylolysis in the adolescent with specific focus on the adolescent athlete. The optimal algorithm for diagnostic imaging is controversial. Single positron emission computerized tomography can provide good sensitivity but poor specificity for spondylolysis. Computerized tomography can be useful as a follow-up exam to visualize the bony anatomy and osseous healing but has the concern of high radiation exposure. MRI may be a useful tool for diagnosis and follow-up examination, which may have significant advantages over traditional imaging techniques. Brace use is controversial and most likely functions as an adjunct for limiting motion to promote activity restrictions. 4
39. Bennett DL, Nassar L, DeLano MC. Lumbar spine MRI in the elite-level female gymnast with low back pain. Skeletal Radiol. 35(7):503-9, 2006 Jul. Observational-Dx 19 Olympic-Level female gymnasts To assess that MRI will demonstrate the same types of abnormalities in both the symptomatic and asymptomatic gymnasts. Anterior ring apophyseal injuries (9/19) and degenerative disk disease (12/19) were common. Spondylolysis (3/19) and spondylolisthesis (3/19) were found. Focal bone-marrow edema was found in both L3 pedicles in one gymnast. History and physical exam revealed four gymnasts with current low back pain at the time of imaging. There were findings confined to those athletes with current low back pain: spondylolisthesis, spondylolysis, bilateral pedicle bone-marrow edema, and muscle strain. 1
40. Sairyo K, Sakai T, Amari R, Yasui N. Causes of radiculopathy in young athletes with spondylolysis. Am J Sports Med. 2010;38(2):357-362. Review/Other-Dx 10 patients To assess the causes of radiculopathy in young athletes with spondylolysis The pathomechanism was classified into nonspondylolytic radiculopathy (3 cases) and spondylolytic radiculopathy (7 cases). In the nonspondylolytic group, 1 patient had a juxta-facet cyst at L4-5 and 2 patients had a herniated nucleus pulposus. In the other group, spondylolytic-related factors caused radiculopathy, and spondylolysis was in the early or progressive stage in all 7 patients. Radiologic findings indicated that radiculopathy was caused by extraosseous hematoma or edema in the vicinity of the fracture site. The radiculopathy disappeared within a month of nonoperative management, and radiologic abnormalities disappeared 3 to 6 months later. 4
41. Fadell MF, Gralla J, Bercha I, et al. CT outperforms radiographs at a comparable radiation dose in the assessment for spondylolysis. Pediatr Radiol. 2015;45(7):1026-1030. Observational-Dx 62 patients To provide a definitive diagnosis of fractures of the pars interarticularis at comparable or lower radiation dose than commonly performed lumbar spine radiographs CT provided a significantly higher level of agreement among raters than radiographs (P < 0.001). The overall Kappa for rater agreement with radiographs was 0.24, 0.34 and 0.40 for 2, 3 or 4 views, respectively, and 0.88 with CT. 3
42. Yang J, Servaes S, Edwards K, Zhuang H. Prevalence of stress reaction in the pars interarticularis in pediatric patients with new-onset lower back pain. Clinical nuclear medicine 2013;38:110-4. Observational-Dx 63 consecutive pediatric patients To determine the prevalence of stress reaction in pars interarticularis in pediatric patients presenting new-onset back pain using both bone SPECT and CT. Among the cohort of 63 patients who had both bone SPECT and thin-slice CT of the lumbar spine, there was a total of 56 positive SPECT results indicating stress injuries in the pars interarticularis. Spondylolysis was shown on both bone SPECT and thin-slice CT in 45 patients. In 11 patients, stress reaction was shown. In 7 patients, no abnormality was detected by either SPECT or thin-slice CT. 3
43. Spencer HT, Sokol LO, Glotzbecker MP, et al. Detection of pars injury by SPECT in patients younger than age 10 with low back pain. J Pediatr Orthop. 33(4):383-8, 2013 Jun. Observational-Dx 107 consecutive skeletal Tc-99m MDP SPECT scans To detect pars injury by SPECT in patients younger than age 10 with low back pain Of the 72 SPECT studies, 35 (49%) identified a focal area in the spine of abnormal increased uptake, with 17 in the region of the pars interarticularis. With additional imaging, 1 case was demonstrated not to be a pars injury (computed tomography showed a transverse process fracture) and 2 patients with negative SPECT scans were shown to have pars injuries that SPECT scan had not detected, for a total of 18 pars injuries (25%) in this cohort. Reported participation in gymnastics or football was related to pars injury (odds ratio 4.3, P=0.04). 3
44. Takemitsu M, El Rassi G, Woratanarat P, Shah SA. Low back pain in pediatric athletes with unilateral tracer uptake at the pars interarticularis on single photon emission computed tomography. Spine. 31(8):909-14, 2006 Apr 15. Review/Other-Dx 22 pediatric athletes To study the clinical characteristics and outcome of pediatric athletes with low back pain and unilateral tracer uptake on single photon emission computed tomography (SPECT) at the pars interarticularis but no defect on radiographs. The average age was 12.3 +/- 2.5 years. The male-to-female ratio was 1.2:1. The average duration of symptoms was 21 +/- 23 weeks. Nineteen (86%) had increased uptake at L5. Six (27%) had spina bifida occulta and 8 (36%) had scoliosis. Eighteen (82%) patients showed an excellent outcome. The patients who presented with a longer history of symptoms or a concomitant spina bifida occulta had an increased risk of having occasional aching with vigorous activity when compared with the patients who did not (P < 0.05). 4
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