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Background: MRI is critical for diagnosing lumbar spine disorders but its complexity challenges diagnostic accuracy. This study proposes a BERT-based large language model (LLM) to enhance precision in classifying lumbar spine disorders through the integration of MRI data, textual reports, and numerical measurements., Methods: The segmentation quality of MRI data is evaluated using dice coefficients (cut-off: 0.92) and intersection over union (IoU) metrics (cut-off: 0.88) to ensure precise anatomical feature extraction. The CNN extracts key lumbar spine features, such as lumbar lordotic angle (LLA) and disc heights, which are tokenized as direct scalar values representing positional relationships. A data source of 28,065 patients with various disorders, including degenerative disc disease, spinal stenosis, and spondylolisthesis, is used to establish diagnostic standards. These standards are refined through post-CNN processing of MRI texture features. The BERT-based spinal LLM model integrates these CNN-extracted MRI features and numerical values through early fusion layers., Results: Segmentation analysis illustrate various lumbar spine disorders and their anatomical changes. The model achieved high performance, with all key metrics nearing 0.9, demonstrating its effectiveness in classifying conditions like spondylolisthesis, herniated disc, and spinal stenosis. External validation further confirmed the model's generalizability across different populations. External validation on 514 expert-validated MRI cases further confirms the model's clinical relevance and generalizability. The BERT-based model classifies 61 combinations of lumbar spine disorders., Conclusions: The BERT-based spinal LLM significantly improves the precision of lumbar spine disorder classification, supporting accurate diagnosis and treatment planning., Competing Interests: Declarations Ethics approval and consent to participate The composite dataset of lumbar spine MRI images, accessed on March 2, 2021, is publicly available at https://data.mendeley.com/datasets/k3b363f3vz/2. Since the dataset does not include any identifiable personal information or sensitive medical data that could compromise patient confidentiality, it falls outside the scope of ethical review requirements typically mandated for studies involving human subjects. The focus of this dataset is strictly on clinically relevant spinal measurements and imaging correlations, without involving patient-specific details or interventions that would necessitate ethical oversight. Therefore, the use of this dataset for research purposes is considered exempt from formal ethical approval processes. Consent for publication Not applicable. Competing interests The authors declare no competing interests., (© 2024. The Author(s).)

Background: Chronic nonbacterial osteomyelitis (CNO) is a rare non-infectious inflammatory musculoskeletal disease where imaging plays a key diagnostic role. Vertebral and mandibular lesions are frequent manifestations, meaning their awareness is crucial for the neuroradiologist to avoid delays in diagnosis and treatment., Objective: Characterize vertebral and mandibular CNO lesions on imaging to assist practicing neuroradiologists in better identifying this disease., Materials and Methods: Retrospective review of all CNO patients of our pediatric center, including only patients with vertebral or mandibular lesions. All imaging exams were analyzed to record lesion characteristics., Results: We included 13 patients (six male). The mean age of onset was 12.3 years. Ten patients had only vertebral lesions, two had only mandibular lesions, and one had both. For patients with vertebral lesions, the median number of levels affected was three, 81.8% had multiple levels affected, 90.0% had dorsal spine lesions, 72.7% had platyspondyly, and 81.8% had inflammatory changes. All vertebral lesions had at least partial resolution of inflammatory findings, the mean time of lesion activity was 2.5 years, and recurrence occurred in 27.3%. Three patients had sacral lesions, all with sacroiliitis. In patients with mandibular lesions, all had unilateral lesions involving the mandibular ramus, all had hyperostosis, periosteal reaction, bone edema, and soft tissue inflammation, all had partial resolution on follow-up, and one had recurrence., Conclusion: CNO vertebral lesions are not rare, are often multiple, predominantly affect dorsal levels, and most result in vertebral height loss. Resolution of vertebral inflammatory lesions is frequent, but so is recurrence. Sacral lesions may be present and result in sacroiliitis. The mandible may be a site of unifocal disease, typically affecting the ramus, with prominent bony changes and soft tissue inflammation., Competing Interests: Declarations. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Purpose: Single-shot echo-planar imaging (ss-EPI) has limited application in vertebral column imaging due to numerous artifacts. Therefore, we aimed to compare readout-segmented echo-planar imaging (rs-EPI) to ss-EPI and assess its value in the differential diagnosis of vertebral infectious, tumoral infiltrative, and degenerative disorders., Materials and Methods: Sixty-six adult patients with spondylodiscitis (SD, n = 26), tumoral infiltration (TI, n = 20), or Modic type I degeneration (DE, n = 20) findings on spinal magnetic resonance imaging (MRI) included in this retrospective study. Two radiologists scored images for quality on a 4-point scale (image resolution, degree of geometric distortion, lesion selectivity, and diagnostic reliability) and measured signal intensity (SI), apparent diffusion coefficient (ADC), signal-to-noise ratio (SNR), and contrast-to-noise ratio (CNR). DE and SD groups also united to form the benign group., Results: In all groups, rs-EPI performed better than ss-EPI in image quality, SNR, and CNR (p < 0.05). The difference between mean pathological ADC (ADC P ) in the two sequences was statistically significant (p < 0.05). There was no significant difference between the groups in terms of ADC P in rs-EPI (p = 0.229), unlike ss-EPI (p = .025). Pathological SI (SI P ) and CNR in rs-EPI were significantly higher in the malignant group than benign group (p = 0.002, p < 0.001). In rs-EPI, no significant difference was found between malignant and benign groups' ADC P (p = 0.13)., Conclusion: The rs-EPI is a diffusion-weighted imaging (DWI) method with higher image quality that diminishes motion-induced phase errors and increases resolution through phase corrections. However, the distinction of malignant and benign vertebral bone marrow pathologies is unsatisfactory for rs-EPI compared with ss-EPI., (© 2024 Wiley Periodicals LLC.)

Rationale and Objectives: Edema in the subcutaneous soft tissue of the lumbar spine is a frequent incidental finding in spinal magnetic resonance imaging, however, its exact explanation is yet to be determined. The aim of this paper is to provide a systematic literature review on posterior lumbar subcutaneous edema (LSE)., Materials and Methods: The present systematic literature search was carried out in October 2023 using electronic databases: PubMed, Cochrane library, and Scopus., Results: The current evidence suggests that lumbar edema is correlated with clinical data such as weight and age, and potentially female sex. Moreover, LSE is related to several specific conditions, including both systemic and spinal disorders, such as heart or kidney disorders, as well as low back pain and degenerative and/or inflammatory diseases., Conclusion: It is important to be aware that there is an association between LSE and a variety systemic and spinal disorders., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved.)

Background: There is increasing interest in forecasting postoperative complications using bone density metrics. Vertebral Hounsfield unit measurements obtained from CT scans performed for surgical planning or other purposes, known as opportunistic CTs, have shown promise for their ease of measurement and the ability to target density measurement to a particular region of interest. Concomitant with the rising interest in prognostic bone density measurement use has been the increasing adoption of intraoperative advanced imaging techniques. Despite the interest in both outcome prognostication and intraoperative advanced imaging, there is little information regarding the use of CT-based intraoperative imaging as a means to measure bone density., Questions/purposes: (1) Can vertebral Hounsfield units be reliably measured by physician reviewers from CT scans obtained intraoperatively? (2) Do Hounsfield units measured from intraoperative studies correlate with values measured from preoperative CT scans?, Methods: To be eligible for this retrospective study, patients had to have been treated with the use of an intraoperative CT scan for instrumented spinal fusion for either degenerative conditions or traumatic injuries between January 2015 and December 2022. Importantly, patients without a preoperative CT scan of the fused levels within 180 days before surgery or who were indicated for surgery because of infection, metastatic disease, or who were having revision surgery after prior instrumentation were excluded from the query. Of the 285 patients meeting these inclusion criteria, 53% (151) were initially excluded for the following reasons: 36% (102) had intraoperative CT scans obtained after placement of instrumentation, 16% (47) had undergone intraoperative CT scans but the studies were not accessible for Hounsfield unit measurement, and 0.7% (2) had prior kyphoplasty wherein the cement prevented Hounsfield unit measurement. Finally, an additional 19% (53) of patients were excluded because the preoperative CT and intraoperative CT were obtained at different peak voltages, which can influence Hounsfield unit measurement. This yielded a final population of 81 patients from whom 276 preoperative and 276 intraoperative vertebral Hounsfield unit measurements were taken. Hounsfield unit data were abstracted from the same vertebra(e) from both preoperative and intraoperative studies by two physician reviewers (one PGY3 and one PGY5 orthopaedic surgery resident, both pursuing spine surgery fellowships). For a small, representative subset of patients, measurements were taken by both reviewers. The feasibility and reliability of Hounsfield unit measurement were then assessed with interrater reliability of values measured from the same vertebra by the two different reviewers. To compare Hounsfield unit values from intraoperative CT scans with preoperative CT studies, an intraclass correlation using a two-way random effects, absolute agreement testing technique was employed. Because the data were formatted as multiple measurements from the same vertebra at different times, a repeated measures correlation was used to assess the relationship between preoperative and intraoperative Hounsfield unit values. Finally, a linear mixed model with patients handled as a random effect was used to control for different patient and clinical factors (age, BMI, use of bone density modifying agents, American Society of Anesthesiologists [ASA] classification, smoking status, and total Charlson comorbidity index [CCI] score)., Results: We found that Hounsfield units can be reliably measured from intraoperative CT scans by human raters with good concordance. Hounsfield unit measurements of 31 vertebrae from a representative sample of 10 patients, measured by both reviewers, demonstrated a correlation value of 0.82 (95% CI 0.66 to 0.91), indicating good correlation. With regard to the relationship between preoperative and intraoperative measurements of the same vertebra, repeated measures correlation testing demonstrated no correlation between preoperative and intraoperative measurements (r = 0.01 [95% CI -0.13 to 0.15]; p = 0.84). When controlling for patient and clinical factors, we continued to observe no relationship between preoperative and intraoperative Hounsfield unit measurements., Conclusion: As intraoperative CT and measurement of vertebral Hounsfield units both become increasingly popular, it would be a natural extension for spine surgeons to try to extract Hounsfield unit data from intraoperative CTs. However, we found that although it is feasible to measure Hounsfield data from intraoperative CT scans, the obtained values do not have any predictable relationship with values obtained from preoperative studies, and thus, these values should not be used interchangeably. With this knowledge, future studies should explore the prognostic value of intraoperative Hounsfield unit measurements as a distinct entity from preoperative measurements., Level of Evidence: Level III, diagnostic study., Competing Interests: Each author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2024 by the Association of Bone and Joint Surgeons.)

Background: Chronic recurrent multifocal osteomyelitis (CRMO) is an inflammatory disorder of bone, typically arising adjacent to the physes of long bones but also seen throughout the skeleton. For patients with spinal involvement, CRMO lesions can cause compression deformities with a range of severity from minimal anterior wedging to circumferential height loss, known as vertebra plana. This study examines a large cohort of CRMO patients to determine the prevalence of spine involvement and vertebral deformity., Methods: This is a retrospective review of all patients with a diagnosis of CRMO seen at our institution between January 2003 and December 2020. These patients were identified through a prospectively maintained database of all CRMO patients seen at the institution. A retrospective review was undertaken to identify all patients with spinal involvement and determine the prevalence of CRMO in the spine and its effects on vertebral height and deformity., Results: Of 170 patients included in this study, 48 (28.2%) were found to have spinal involvement. Among patients with spinal involvement, vertebral body lesions were identified in 27 (56.3%) patients. The remaining lesions were in the sacrum or posterior elements. Radiographic evidence of the vertebral body height loss was noted in 23 of these 27 patients., Conclusions: This cohort of CRMO patients demonstrates that 28% of patients have spinal involvement, and 48% of those patients have vertebral body height loss. While the ideal treatment for spinal CRMO has yet to be determined, imaging studies, including whole-body MRI and spine-specific MRI, are useful in identifying vertebral lesions and deformities. Identification and surveillance of these lesions are important as the disorder has a relapsing and remitting course, and patients can develop significant vertebral body height loss. Once deformity has developed, we have seen no evidence of reconstitution of the height of the collapsed vertebra. Bisphosphonates have been successful in preventing the progression of vertebral body height loss., Level of Evidence: Level II: Retrospective study investigating spinal involvement and prevalence of vertebral body deformity in patients diagnosed with CRMO., Competing Interests: C.D.J. is a paid consultant for Zimmer. This consultancy has no relevance to this work. The remaining authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Lumbar spine disorders often cause lower back pain, lower limb radiating pain, restricted movement, and neurological dysfunction, which seriously affect the quality of life of middle-aged and older people. It has been found that pathological changes in the spine often cause changes in the morphology and function of the paraspinal muscles (PSMs). Fatty infiltration (FI) in PSMs is closely associated with disc degeneration and Modic changes. And FI causes inflammatory responses that exacerbate the progression of lumbar spine disease and disrupt postoperative recovery. Magnetic resonance imaging can better distinguish between fat and muscle tissue with the threshold technique. Three-dimensional magnetic resonance imaging multi-echo imaging techniques such as water-fat separation and proton density are currently popular for studying FI. Muscle fat content obtained based on these imaging sequences has greater accuracy, visualization, acquisition speed, and utility. The proton density fat fraction calculated from these techniques has been shown to evaluate more subtle changes in PSMs. Magnetic resonance spectroscopy can accurately reflect the relationship between FI and the degeneration of PSMs by measuring intracellular and extracellular lipid values to quantify muscle fat. We have pooled and analyzed published studies and found that patients with spinal disorders often exhibit FI in PSMs. Some studies suggest an association between FI and adverse surgical outcomes, although conflicting results exist. These suggest that clinicians should consider FI when assessing surgical risks and outcomes. Future studies should focus on understanding the biological mechanisms underlying FI and its predictive value in spinal surgery, providing valuable insights for clinical decision-making., (Copyright © 2024 Elsevier Inc. All rights reserved.)

This article comprehensively reviews current imaging concepts in spinal infection with primary focus on infectious spondylodiscitis (IS) as well as the less common entity of facet joint septic arthritis (FSA). This review encompasses the multimodality imaging appearances (radiographs, CT, MRI, and nuclear imaging) of spinal infection-both at initial presentation and during treatment-to aid the radiologist in guiding diagnosis and successful management. We discuss the pathophysiology of spinal infection in various patient populations (including the non-instrumented and postoperative spine) as well as the role of imaging-guided biopsy. We also highlight several non-infectious entities that can mimic IS (both clinically and radiologically) that should be considered during image interpretation to avoid misdiagnosis. These potential mimics include the following: Modic type 1 degenerative changes, acute Schmorl's node, neuropathic spondyloarthropathy, radiation osteitis, and inflammatory spondyloarthropathy (SAPHO syndrome)., (© 2024. The Author(s), under exclusive licence to International Skeletal Society (ISS).)

Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Objectives: This study aims to assess the effectiveness of super-resolution deep-learning-based reconstruction (SR-DLR), which leverages k-space data, on the image quality of lumbar spine magnetic resonance (MR) bone imaging using a 3D multi-echo in-phase sequence., Materials and Methods: In this retrospective study, 29 patients who underwent lumbar spine MRI, including an MR bone imaging sequence between January and April 2023, were analyzed. Images were reconstructed with and without SR-DLR (Matrix sizes: 960 × 960 and 320 × 320, respectively). The signal-to-noise ratio (SNR) of the vertebral body and spinal canal and the contrast and contrast-to-noise ratio (CNR) between the vertebral body and spinal canal were quantitatively evaluated. Furthermore, the slope at half-peak points of the profile curve drawn across the posterior border of the vertebral body was calculated. Two radiologists independently assessed image noise, contrast, artifacts, sharpness, and overall image quality of both image types using a 4-point scale. Interobserver agreement was evaluated using weighted kappa coefficients, and quantitative and qualitative scores were compared via the Wilcoxon signed-rank test., Results: SNRs of the vertebral body and spinal canal were notably improved in images with SR-DLR (p < 0.001). Contrast and CNR were significantly enhanced with SR-DLR compared to those without SR-DLR (p = 0.023 and p = 0.022, respectively). The slope of the profile curve at half-peak points across the posterior border of the vertebral body and spinal canal was markedly higher with SR-DLR (p < 0.001). Qualitative scores (noise: p < 0.001, contrast: p < 0.001, artifact p = 0.042, sharpness: p < 0.001, overall image quality: p < 0.001) were superior in images with SR-DLR compared to those without. Kappa analysis indicated moderate to good agreement (noise: κ = 0.56, contrast: κ = 0.51, artifact: κ = 0.46, sharpness: κ = 0.76, overall image quality: κ = 0.44)., Conclusion: SR-DLR, which is based on k-space data, has the potential to enhance the image quality of lumbar spine MR bone imaging utilizing a 3D gradient echo in-phase sequence., Clinical Relevance Statement: The application of SR-DLR can lead to improvements in lumbar spine MR bone imaging quality., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Purpose: To assess the image quality and impact on acquisition time of a novel deep learning based T2 Dixon sequence (T2 DL ) of the spine., Methods: This prospective, single center study included n = 44 consecutive patients with a clinical indication for lumbar MRI at our university radiology department between September 2022 and March 2023. MRI examinations were performed on 1.5-T and 3-T scanners (MAGNETOM Aera and Vida; Siemens Healthineers, Erlangen, Germany) using dedicated spine coils. The MR study protocol consisted of our standard clinical protocol, including a T2 weighted standard Dixon sequence (T2 std ) and an additional T2 DL acquisition. The latter used a conventional sampling pattern with a higher parallel acceleration factor. The individual contrasts acquired for Dixon water-fat separation were then reconstructed using a dedicated research application. After reconstruction of the contrast images from k-space data, a conventional water-fat separation was performed to provide derived water images. Two readers with 6 and 4 years of experience in interpreting MSK imaging, respectively, analyzed the images in a randomized fashion. Regarding overall image quality, banding artifacts, artifacts, sharpness, noise, and diagnostic confidence were analyzed using a 5-point Likert scale (from 1 = non-diagnostic to 5 = excellent image quality). Statistical analyses included the Wilcoxon signed-rank test and weighted Cohen's kappa statistics., Results: Forty-four patients (mean age 53 years (±18), male sex: 39 %) were prospectively included. Thirty-one examinations were performed on 1.5 T and 13 examinations on 3 T scanners. A sequence was successfully acquired in all patients. The total acquisition time of T2 DL was 93 s at 1.5-T and 86 s at 3-T, compared to 235 s, and 257 s, respectively for T2 std (reduction of acquisition time: 60.4 % at 1.5-T, and 66.5 % at 3-T; p < 0.01). Overall image quality was rated equal for both sequences (median T2 DL : 5[3 -5], and median T2 std : 5 [2 -5]; p = 0.57). T2 DL showed significantly reduced noise levels compared to T2 std (5 [4 -5] versus 4 [3 -4]; p < 0.001). In addition, sharpness was rated to be significantly higher in T2 DL (5 [4 -5] versus 4 [3 -5]; p < 0.001). Although T2 DL displayed significantly more banding artifacts (5 [2 -5] versus 5 [4 -5]; p < 0.001), no significant impact on readers diagnostic confidence between sequences was noted (T2 std : 5 [2 -5], and T2 DL : 5 [3 -5]; p = 0.61). Substantial inter-reader and intrareader agreement was observed for T2 DL overall image quality (κ: 0.77, and κ: 0.8, respectively)., Conclusion: T2 DL is feasible, yields an image quality comparable to the reference standard while substantially reducing the acquisition time., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier B.V.)

Optimal management paradigms of spinal pathologies in the octogenarian population are controversial given the higher incidence of comorbidities with concern for poor prognosis and fear of increased complications associated with surgical management. In this narrative review, we aim to detail the complex clinical considerations when approaching odontoid screw fixation/instrumented fusion, spinal decompression, and spinal fusion in the octogenarian. Literature review was conducted via Google Scholar and PubMed databases, with literature selected based on statistical power and clinical relevance to the following pathologies/surgical techniques: odontoid fracture, surgical decompression, and surgical fusion in the octogenarian. The aforementioned pathologies were selected based on prevalence in the advanced-age population in which surgical screening techniques and management remain nonuniform. Preoperative evaluation of the octogenarian patient increasingly includes frailty, sarcopenia, and osteopenia/osteoporosis assessments. In cases of odontoid fracture, conservative management appears to provide beneficial clinical outcomes with lower rates of complication compared to surgery; however, rates of radiographic odontoid fusion are far lower in conservatively managed patients. Regarding surgical decompression and fusion, the presence of comorbidities may be more predictive of outcome rather than age status, with the advent of minimally invasive techniques providing safety and efficacy in the surgical management of this age cohort. Age status may be less pertinent than previously thought in the decision to pursue spinal surgery for odontoid fracture, spinal decompression, or spinal fusion; however, each of these procedures has respective risks and benefits that must be considered within the context of each patient's comorbidity profile., (© 2024. The Author(s), under exclusive licence to American Aging Association.)

Pathologies affecting the spinal epidural space (SES) comprise various abnormalities. However, they all have the potential to cause thecal sac narrowing or spinal cord compression. In this review, we group these pathologies into degenerative, infective, neoplastic, vascular, traumatic, and others, focusing on their imaging features. Degenerative pathologies of the SES range from disc to facet disease, with a particular emphasis on the less common degenerative pathologies in this review. Infective pathologies affecting the epidural space include spondylodiscitis and associated epidural phlegmon and abscess. Neoplasms arising from typical SES components include neurofibroma, hemangioma, and liposarcoma. MRI is the best modality to assess the anatomy and abnormalities of the epidural space. MRI, combined with computed tomography, or a radiograph, is useful for the evaluation of bones or radiopaque foreign bodies., (Copyright © 2024. Published by Elsevier Inc.)

Purpose: Baastrup's disease is characterized by abnormal contact between adjacent spinous processes. Our study is the first to systematically incorporate the STIR sequence, recognized for its heightened sensitivity to fluid and edema, into the MRI protocol for diagnosing Baastrup's disease in symptomatic individuals. The objective is to determine its prevalence and association with lumbar spinal degenerative changes., Materials and Methods: Lumbar spinal MRI examinations of 375 patients performed between January 2021 and 2022 were retrospectively reviewed by two radiologists. Baastrup's disease was diagnosed based on meeting any of the following criteria: lumbar interspinous bursitis, hyperintense signal changes in adjacent spinous processes, and ligaments on the STIR sequence. The study also investigated the presence of degenerative changes and interreader agreement among radiologists., Results: Baastrup's disease was found in 141 of 375 individuals (37.8%). It correlated significantly with degenerative lumbar changes such as bulging (P = 0.0012), herniation (P = 0.0033), disc degeneration (P = 0.0013), Modic changes (P = 0.034), facet osteoarthritis (P = 0.0041), spinal stenosis (P = 0.005), and anterolisthesis (P = 0.0049). No significant associations were observed with gender (P = 0.468) or retrolisthesis (P = 0.167). Its occurrence increased gradually, peaking at 87.5% in individuals aged 80 and above. Radiologists showed complete agreement with Baastrup's diagnoses., Conclusion: Baastrup's disease is more commonly observed than being considered rare, displaying an incremental occurrence with increasing age in symptomatic individuals notably discernible on the STIR sequence. Using the STIR sequence seems to promote a consensus among radiologists, irrespective of their experience levels., (© 2024. The Author(s).)

Spinal magnetic resonance (MR) scans are a vital tool for diagnosing the cause of back pain for many diseases and conditions. However, interpreting clinically useful information from these scans can be challenging, time-consuming and hard to reproduce across different radiologists. In this paper, we alleviate these problems by introducing a multi-stage automated pipeline for analysing spinal MR scans. This pipeline first detects and labels vertebral bodies across several commonly used sequences (e.g. T1w, T2w and STIR) and fields of view (e.g. lumbar, cervical, whole spine). Using these detections it then performs automated diagnosis for several spinal disorders, including intervertebral disc degenerative changes in T1w and T2w lumbar scans, and spinal metastases, cord compression and vertebral fractures. To achieve this, we propose a new method of vertebrae detection and labelling, using vector fields to group together detected vertebral landmarks and a language-modelling inspired beam search to determine the corresponding levels of the detections. We also employ a new transformer-based architecture to perform radiological grading which incorporates context from multiple vertebrae and sequences, as a real radiologist would. The performance of each stage of the pipeline is tested in isolation on several clinical datasets, each consisting of 66 to 421 scans. The outputs are compared to manual annotations of expert radiologists, demonstrating accurate vertebrae detection across a range of scan parameters. Similarly, the model's grading predictions for various types of disc degeneration and detection of spinal metastases closely match those of an expert radiologist. To aid future research, our code and trained models are made publicly available., (© 2024. The Author(s).)

Aneurysmal bone cysts are benign neoplastic lesions that are extensively vascularized and can occasionally exhibit destructive and expanding activity. They typically affect young people, with a small predilection toward females, and most frequently arise during the second decade of life. Aneurysmal bone cysts account for about 1% of all bone tumors and usually develop in long tubular bones, with the spine being much less commonly affected., (This is an open access article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Radiography is commonly used in the assessment of spinal disorders, despite a lack of high-quality evidence demonstrating improved clinical outcomes or additional benefit to the patient. There is disagreement amongst chiropractors regarding the appropriate use of radiography for clinical management. This study aims to qualitatively explore chiropractors' perceptions on the use of spinal radiographs in clinical practice with respect to how they determine when to order radiographs; and how they use radiographs to inform clinical management., Methods: Online qualitative semi-structured interviews were conducted with 17 Australian chiropractors who currently manage patients with spinal disorders. Convienence, snowball, and purposive sampling strategies were used to ensure an appropriate breadth and depth of participant characterisitcs and beliefs. Interview data were recorded, transcribed and analysed using framework analysis., Results: Three themes were developed to describe how chiropractors determined when to order radiographs. These themes included specific findings from the clinical encounter that may inform clinical management, their perceptions of radiation risk, and the influence of clinical experience/intuition. Three themes and four subthemes were developed for how chiropractors use radiographs to inform their management. These themes explored the use of radiography for the application of chiropractic technique, as well as the role of radiographs in predicting patient prognosis, and as an educational tool to provide reassurance., Conclusion: Australian chiropractors' decision-making around spinal radiography is diverse and can be influenced by a number of clinical and external factors. Previously unexplored uses of spinal radiography in clinical practice were highlighted. Some chiropractors reported potential benefits of radiography that are currently not supported by research evidence. Future research should address how radiographic findings are reported to patients with spinal disorders and how this could be optimised to improve patient outcomes., (© 2024. The Author(s).)

Background: We compared magnetic resonance imaging (MRI) turbo spin-echo images reconstructed using a deep learning technique (TSE-DL) with standard turbo spin-echo (TSE-SD) images of the lumbar spine regarding image quality and detection performance of common degenerative pathologies., Methods: This prospective, single-center study included 31 patients (15 males and 16 females; aged 51 ± 16 years (mean ± standard deviation)) who underwent lumbar spine exams with both TSE-SD and TSE-DL acquisitions for degenerative spine diseases. Images were analyzed by two radiologists and assessed for qualitative image quality using a 4-point Likert scale, quantitative signal-to-noise ratio (SNR) of anatomic landmarks, and detection of common pathologies. Paired-sample t, Wilcoxon, and McNemar tests, unweighted/linearly weighted Cohen κ statistics, and intraclass correlation coefficients were used., Results: Scan time for TSE-DL and TSE-SD protocols was 2:55 and 5:17 min:s, respectively. The overall image quality was either significantly higher for TSE-DL or not significantly different between TSE-SD and TSE-DL. TSE-DL demonstrated higher SNR and subject noise scores than TSE-SD. For pathology detection, the interreader agreement was substantial to almost perfect for TSE-DL, with κ values ranging from 0.61 to 1.00; the interprotocol agreement was almost perfect for both readers, with κ values ranging from 0.84 to 1.00. There was no significant difference in the diagnostic confidence or detection rate of common pathologies between the two sequences (p ≥ 0.081)., Conclusions: TSE-DL allowed for a 45% reduction in scan time over TSE-SD in lumbar spine MRI without compromising the overall image quality and showed comparable detection performance of common pathologies in the evaluation of degenerative lumbar spine changes., Relevance Statement: Deep learning-reconstructed lumbar spine MRI protocol enabled a 45% reduction in scan time compared with conventional reconstruction, with comparable image quality and detection performance of common degenerative pathologies., Key Points: • Lumbar spine MRI with deep learning reconstruction has broad application prospects. • Deep learning reconstruction of lumbar spine MRI saved 45% scan time without compromising overall image quality. • When compared with standard sequences, deep learning reconstruction showed similar detection performance of common degenerative lumbar spine pathologies., (© 2024. The Author(s).)

Purpose: To compare image quality, assess inter-reader variability, and evaluate the diagnostic efficacy of routine clinical lumbar spine sequences at 0.55T compared with those collected at 1.5/3T to assess common spine pathology., Methods: 665 image series across 70 studies, collected at 0.55T and 1.5/3T, were assessed by two neuroradiology fellows for overall imaging quality (OIQ), artifacts, and accurate visualization of anatomical features (intervertebral discs, neural foramina, spinal cord, bone marrow, and conus / cauda equina nerve roots) using a 4-point Likert scale (1 = non-diagnostic to 4 = excellent). For the 0.55T scans, the most appropriate diagnosis(es) from a picklist of common spine pathologies was selected. The mean ± SD of all scores for all features for each sequence and reader at 0.55T and 1.5/3T were calculated. Paired t-tests (p ≤ 0.05) were used to compare ratings between field strengths. The inter-reader agreement was calculated using linear-weighted Cohen's Kappa coefficient (p ≤ 0.05). Unpaired VCG analysis for OIQ was additionally employed to represent differences between 0.55T and 1.5/3T (95 % CI)., Results: All sequences at 0.55T were rated as acceptable (≥2) for diagnostic use by both readers despite significantly lower scores for some compared to those at 1.5/3T. While there was low inter-reader agreement on individual scores, the agreement on the diagnosis was high, demonstrating the potential of this system for detecting routine spine pathology., Conclusions: Clinical lumbar spine imaging at 0.55T produces diagnostic-quality images demonstrating the feasibility of its use in diagnosing spinal pathology, including osteomyelitis/discitis, post-surgical changes with complications, and metastatic disease., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier B.V.)

Accurate and efficient segmenting of vertebral bodies, muscles, and discs is crucial for analyzing various spinal diseases. However, traditional methods are either laborious and time-consuming (manual segmentation) or require extensive training data (fully automatic segmentation). FastCleverSeg, our proposed semi-automatic segmentation approach, addresses those limitations by significantly reducing user interaction while maintaining high accuracy. First, we reduce user interaction by requiring the manual annotation of only two or three slices. Next, we automatically Estimate the Annotation on Intermediary Slices (EANIS) using traditional computer vision/graphics concepts. Finally, our proposed method leverages improved voxel weight balancing to achieve fast and precise volumetric segmentation in the segmentation process. Experimental evaluations on our assembled diverse MRI databases comprising 179 patients (60 male, 119 female), demonstrate a remarkable 25 ms (30 ms standard deviation) processing time and a significant reduction in user interaction compared to existing approaches. Importantly, FastCleverSeg maintains or surpasses the segmentation quality of competing methods, achieving a Dice score of 94%. This invaluable tool empowers physicians to efficiently generate reliable ground truths, expediting the segmentation process and paving the way for future integration with deep learning approaches. In turn, this opens exciting possibilities for future fully automated spine segmentation., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background and Purpose: Deep learning (DL) accelerated MR techniques have emerged as a promising approach to accelerate routine MR exams. While prior studies explored DL acceleration for specific lumbar MRI sequences, a gap remains in comprehending the impact of a fully DL-based MRI protocol on scan time and diagnostic quality for routine lumbar spine MRI. To address this, we assessed the image quality and diagnostic performance of a DL-accelerated lumbar spine MRI protocol in comparison to a conventional protocol., Methods: We prospectively evaluated 36 consecutive outpatients undergoing non-contrast enhanced lumbar spine MRIs. Both protocols included sagittal T1, T2, STIR, and axial T2-weighted images. Two blinded neuroradiologists independently reviewed images for foraminal stenosis, spinal canal stenosis, nerve root compression, and facet arthropathy. Grading comparison employed the Wilcoxon signed rank test. For the head-to-head comparison, a 5-point Likert scale to assess image quality, considering artifacts, signal-to-noise ratio (SNR), anatomical structure visualization, and overall diagnostic quality. We applied a 15% noninferiority margin to determine whether the DL-accelerated protocol was noninferior., Results: No significant differences existed between protocols when evaluating foraminal and spinal canal stenosis, nerve compression, or facet arthropathy (all p > .05). The DL-spine protocol was noninferior for overall diagnostic quality and visualization of the cord, CSF, intervertebral disc, and nerve roots. However, it exhibited reduced SNR and increased artifact perception. Interobserver reproducibility ranged from moderate to substantial (κ = 0.50-0.76)., Conclusion: Our study indicates that DL reconstruction in spine imaging effectively reduces acquisition times while maintaining comparable diagnostic quality to conventional MRI., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Magnetic resonance imaging (MRI) and clinicopathological tools have led to the identification of a wide spectrum of autoimmune entities that involve the spine. A clearer understanding of the unique imaging features of these disorders, along with their clinical presentations, will prove invaluable to clinicians and potentially limit the need for more invasive procedures such as tissue biopsies. Here, we review various autoimmune diseases affecting the spine and highlight salient imaging features that distinguish them radiologically from other disease entities., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

This study aims to (1) clinically and radiographically characterize a series of unifocal (single-system single-site) and multifocal (single-system multiple-site) langerhans cell histiocytosis (LCH) lesions in the vertebra and (2) determine the success and recurrence rates with different treatment modalities in a pediatric population at a tertiary children's hospital. Patients younger than 18 years old with a diagnosis of LCH before 1 June 2021 at our institution were reviewed. The inclusion criteria were a unifocal or multifocal vertebral lesion without systemic disease. Clinical presentations, lesion sites, radiographic findings, treatments, complications, recurrence rates, and length of follow-up were reviewed and recorded. Thirty-nine patients had unifocal (36%) or multifocal (64%) vertebral lesions. 44% of patients had vertebral lesions only. The most common clinical presentation was neck or back pain (51%) and difficulty or inability to ambulate (15%). 70 vertebrae were involved in total; 59% cervical, 62% thoracic, 49% lumbar, and 10% sacral. 88% of multifocal patients underwent chemotherapy compared to 60% of unifocal patients. The recurrence rate in the entire cohort was 10%. The median length of follow-up was 5.2 years (0.6-16.8). Chemotherapy is often utilized as a treatment for vertebral LCH lesions regardless of unifocal or multifocal osseous presentation, with good outcomes and low recurrence rates. However other treatments such as observation only and steroid injections may be a better option with smaller and less widespread lesions due to side effects and length of treatment with chemotherapy. Determination of more invasive treatments including surgical excision or fixation will need to be considered on a case-by-case basis. Level of evidence: IV., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Butterfly vertebra (BV) is a rare congenital spinal anomaly for which there is a paucity of large-scale retrospective studies and established guidelines for treatment. The objective of this study was to elucidate the clinical characteristics, imaging findings, and therapeutic approaches for BV., Methods: We conducted a retrospective analysis of 30 patients diagnosed with BV at our hospital from 2009 to 2023, examining clinical data, imaging findings, and clinical interventions., Results: The analysis comprised a cohort of 30 patients, consisting of 15 males and 15 females, with a mean age of 27.63 ± 19.84 years. Imaging studies indicated that the majority of vertebral bodies affected by BV were single-segmented (63.3%, 19/30) and less commonly multi-segmented (36.7%, 11/30). These findings frequently coexisted with other medical conditions, most notably spinal scoliosis (76.7%, 23/30). Furthermore, the study identified a range of spinal abnormalities among patients, including hemivertebral deformity (30.0%, 9/30), spinal cleft (10.0%, 3/30), lumbar disc protrusion or herniation (10.0%, 3/30), vertebral slippage (10.0%, 3/30), thoracic kyphosis deformity (6.67%, 2/30), vertebral fusion deformity (6.67%, 2/30), compressive fractures (3.3%, 1/30), and vertebral developmental anomalies (3.3%, 1/30). Clinical intervention resulted in symptom relief for 23 nonsurgical patients through lifestyle modifications, analgesic use, and physical therapy. Seven surgical patients underwent appropriate surgical procedures, leading to satisfaction and adherence to regular postoperative follow-up appointments., Conclusions: BV is a rare vertebral anomaly that can be easily misdiagnosed due to its similarity to other diseases. Consequently, it is imperative to enhance vigilance in the differential diagnosis process in order to promptly recognize BV. Furthermore, in cases where patients present with additional associated radiographic findings, a thorough evaluation is typically warranted and timely measures should be taken for treatment., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Competing Interests: The author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.

Purpose: In recent years, the field of medical imaging has witnessed remarkable advancements, with innovative technologies which revolutionized the visualization and analysis of the human spine. Among the groundbreaking developments in medical imaging, Generative Adversarial Networks (GANs) have emerged as a transformative tool, offering unprecedented possibilities in enhancing spinal imaging techniques and diagnostic outcomes. This review paper aims to provide a comprehensive overview of the use of GANs in spinal imaging, and to emphasize their potential to improve the diagnosis and treatment of spine-related disorders. A specific review focusing on Generative Adversarial Networks (GANs) in the context of medical spine imaging is needed to provide a comprehensive and specialized analysis of the unique challenges, applications, and advancements within this specific domain, which might not be fully addressed in broader reviews covering GANs in general medical imaging. Such a review can offer insights into the tailored solutions and innovations that GANs bring to the field of spinal medical imaging., Methods: An extensive literature search from 2017 until July 2023, was conducted using the most important search engines and identified studies that used GANs in spinal imaging., Results: The implementations include generating fat suppressed T2-weighted (fsT2W) images from T1 and T2-weighted sequences, to reduce scan time. The generated images had a significantly better image quality than true fsT2W images and could improve diagnostic accuracy for certain pathologies. GANs were also utilized in generating virtual thin-slice images of intervertebral spaces, creating digital twins of human vertebrae, and predicting fracture response. Lastly, they could be applied to convert CT to MRI images, with the potential to generate near-MR images from CT without MRI., Conclusions: GANs have promising applications in personalized medicine, image augmentation, and improved diagnostic accuracy. However, limitations such as small databases and misalignment in CT-MRI pairs, must be considered., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Disorders affecting the neurological and musculoskeletal systems represent international health burdens. A significant impediment to progress with interventional trials is the absence of responsive, objective, and valid outcome measures sensitive to early disease or disorder change. A key finding in individuals with spinal disorders is compositional changes to the paraspinal muscle and soft tissue (e.g., intervertebral disc, facet joint capsule, and ligamentous) structure. Quantification of paraspinal muscle composition by MRI has emerged as a sensitive marker for the severity of these conditions; however, little is known about the composition of muscles across the lifespan. Knowledge of what is "typical" age-related muscle composition is essential in order to accurately identify and evaluate "atypical," with a potential impact being improvements in pre- and postsurgical plan and measurement of surgical implants, exoskeletons, and care on a patient-by-patient basis., (© 2024. The Author(s), under exclusive license to Springer Nature Switzerland AG.)

Objective: Response of pyogenic spine infection to antibiotic therapy is usually based on nonspecific symptoms and inflammation markers. Abnormalities on MRI persist too long to influence therapy. Is FDG-PET/CT a timely and robust predictor of successful therapy?, Materials and Methods: Retrospective study. Sequential FDG-PET/CTs done to assess treatment response over a 4-year period. Recurrence of infection after stopping treatment was the endpoint., Results: One hundred seven patients enrolled. First treatment response scan showed no signs of infection in 69 patients (low risk). Twenty-four additional patients underwent additional treatment after an initial positive scan with low-risk pattern on follow-up imaging. After stopping antibiotics, none had clinical recurrence of infection. One had positive cultures at surgery for negative predictive value of 0.99. Thirty-eight patients had evidence of residual infection. Abnormalities in 28 were comparable to what is seen with untreated infection (high-risk). Twenty-seven received additional treatment until resolution. Antibiotics were stopped in 1 who suffered recurrence. Ten had low-grade/localized abnormalities consistent with infection (intermediate-risk). Signs of infection resolved in 3 after additional treatment. Of the remaining 7 patients who had minor residual abnormalities when antibiotics were stopped, 1 had recurrent infection for a positive predictive value of 0.14., Conclusion: Risk stratification proposed: A low-risk scan with only inflammation at a destroyed joint indicates negligible risk of recurrence. Unexplained activity in bone, soft tissue or spinal canal indicates high risk with further antibiotics recommended. Most patients with subtle or localized findings (intermediate risk) did not experience recurrence. Stopping therapy could be considered under careful observation., (© 2023. The Author(s), under exclusive licence to International Skeletal Society (ISS).)

Tarlov cysts were thought to be anatomic variants of uncertain etiology and clinical significance when initially described over 80 years ago. They are often detected in routine lumbosacral imaging and generally not reported in a differential diagnosis. There is increasing evidence that at least some Tarlov cysts are symptomatic and can have a significant adverse impact on patients' health and well-being. Women are disproportionately affected with this condition, often presenting with long-standing pain and neurological dysfunctions. Significant gender bias has been a concern in the management of these patients. Unfortunately, there is no consensus on patient selection or management approaches for symptomatic Tarlov cysts. This review article updates information on the prevalence, diagnosis, clinical significance, and treatments of these cysts. Based on these findings and experience with over 1000 patient referrals, a treatment decision algorithm for symptomatic Tarlov cysts was constructed to provide guidance for appropriate management of patients with these complex cysts., (© 2023. The Author(s).)

Background: Compared with Caucasians, East Asians have a lower incident of back pain, lower prevalence and severity of osteoporotic vertebral fracture and lumbar spine degeneration., Aim: This study compares radiographic spine degeneration features of older Chinese women (as an example of East Asians) and older Italian women (as an example of Caucasians) with a focus on the thoracic spine., Methods: From two population-based epidemiological studies conducted in Hong Kong, China and Rome, Italy, 297 pairs (mean age: 73.6 years) age-matched older community women's lateral spine radiographs were sampled. Existence (or absence) of seven degeneration features were assessed including: (1) hyper-kyphosis, (2) disc space narrowing (T3/T4 ~ T11/T12), (3) osteoarthritic (OA) wedging (T4 ~ T12), (4) generalised osteophyte formation (T4 ~ T12); (5) acquired short vertebrae (T4 ~ T12), (6) Schmorl node (T4 - L5), (7) disc calcification (T4-L5)., Results: Italian women were more likely to have hyper-kyphosis (53.4% vs 25.6%), disc space narrowing (34.4% vs. 17.2%), OA wedging (6.4% vs. 0.67%), Schmorl node (19.5% vs. 4.4%, all P < 0.001). However, there was no statistically significant difference in osteophyte formation (7.7% vs. 9.4%, P > 0.1) and acquired short vertebrae (8.0% vs. 10.4%, P > 0.1). Disc calcification was uncommon among both Chinese and Italians., Discussion and Conclusion: For the first time, this study documented a lower prevalence of a number of thoracic spine degeneration features among Chinese. This study further affirms the concept of a generally healthier spine in older Chinese relative to older Caucasians. The observed differences may reflect a foundational background influence of genetic predisposition that represents an important line of future research., (© 2023. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Background: A different utilization of health care services due to socioeconomic status on the same health plan contradicts the principle of equal treatment. We investigated the presence and magnitude of socioeconomic differences in utilization of diagnostic imaging and non-pharmaceutical conservative therapies for patients with spinal diseases., Methods: The cohort study based on routine healthcare data from Germany with 11.7 million patient-years between 2012 and 2016 for patients with physician-confirmed spinal diseases (ICD-10: M40-M54), occupation and age 20 to 64 years. A Poisson model estimated the effects of the socioeconomic status (school education, professional education and occupational position) for the risk ratio of receiving diagnostic imaging (radiography, computed tomography, magnetic resonance imaging) and non-pharmaceutical conservative therapies (physical therapy including exercise therapy, manual therapy and massage, spinal manipulative therapy, acupuncture)., Results: Patients received diagnostic imaging in 26%, physical therapy in 32%, spinal manipulative therapy in 25%, and acupuncture in 4% of all patient-years. Similar to previous survey-based studies higher rates of utilization were associated with higher socioeconomic status. These differences were most pronounced for manual therapy, exercise therapy, and magnetic resonance imaging., Conclusions: The observed differences in health care utilization were highly related to socioeconomic status. Socioeconomic differences were higher for more expensive health services. Further research is necessary to identify barriers to equitable access to health services and to take appropriate action to decrease existing social disparities., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Background and Objectives: Three-dimensional imaging-based navigation in spine surgery is mostly applied for pedicle screw placement. However, its potential reaches beyond. In this study, we analyzed the incorporation of spinal navigation for lateral instrumentation of the thoracolumbar spine in clinical routine at a high-volume spine center., Methods: Patients scheduled for lateral instrumentation were prospectively enrolled. A reference array was attached to the pelvis, and a computed tomography scan was acquired intraoperatively. A control computed tomography scan was routinely performed after final cage placement, replacing conventional 2-dimensional X-ray imaging., Results: 145 cases were enrolled from April to October 2021 with a median of 1 (1-4) level being instrumented. Indications for surgery were trauma (35.9%), spinal infection (31.7%), primary and secondary tumors of the spine (17.2%), and degenerative spine disease (15.2%). The duration of surgery after the first scan was 98 ± 41 (20-342) minutes. In total, 190 cages were implanted (94 expandable cages for vertebral body replacement (49.5%) and 96 cages for interbody fusion [50.5%]). Navigation was successfully performed in 139 cases (95.9%). The intraoperative mental load was rated on a scale from 0 to 150 (maximal effort) by the surgeons, showing a moderate effort (median 30 [10-120])., Conclusion: Three-dimensional imaging-based spinal navigation can easily be incorporated in clinical routine and serves as a reliable tool to achieve precise implant placement in lateral instrumentation of the spine. It helps to minimize radiation exposure to the surgical staff., (Copyright © Congress of Neurological Surgeons 2023. All rights reserved.)

The spine is often difficult to evaluate clinically in children, increasing the importance of diagnostic imaging to detect a wide variety of spinal disorders ranging from congenital abnormalities to severe infections. Clinical history and physical examination can help determine whether imaging is needed and which imaging technique would be best. The most common cause for back pain, even in children, is muscular strain/spasm that does not require any imaging. However, red flags such as pain at age < 5 years, constant pain, night pain, radicular pain, pain lasting > 4 weeks, or an abnormal neurologic examination may require further investigation. Imaging can be of great value for diagnosis but must be interpreted along with the clinical history, physical examination, and laboratory findings to achieve an accurate diagnosis. We discuss imaging for the most common and/or important spine pathologies in children: congenital and developmental pathologies, trauma, infectious processes, inflammatory causes, and tumors., Competing Interests: None declared., (Thieme. All rights reserved.)

Cancer is a leading cause of death, with the spine being the most common site for skeletal metastasis. The spine is also a site for primary malignancy, such as sarcoma and chordoma, as well as non-neoplastic pathologies. An accurate diagnosis of spinal neoplastic diseases is crucial in determining appropriate management. With the advent of personalised oncology, the need to establish a definitive histopathologic diagnosis to guide management is more important than ever. Percutaneous biopsy has proven to be safe and efficient in establishing a reliable histopathologic diagnosis. The spine, however, can be a challenging site to biopsy, due to the proximity of critical neurovascular, respiratory, and gastrointestinal structures. Successful spine biopsy depends on several factors: suspected diagnosis, size of the lesion, location within the spine, modality for best imaging guidance, operator experience, technical equipment considerations, and desired approach and associated limitations. The specimen must also be obtained with a biopsy route amenable to any future surgical intervention, with surgical input often sought, frequently in a multidisciplinary setting, to confirm procedure-specific goals and expectations. Knowledge of the requisite local anatomy, procedural and patient-specific indications, and contraindications and various approaches that may be used to access different segments of the spine, potential complications, and how to address these are keys to a successful percutaneous spinal biopsy, even in the most challenging of circumstances., (© 2022. The Author(s), under exclusive licence to International Skeletal Society (ISS).)

Objectives: Computed tomography (CT) is employed to evaluate surgical outcome after spinal interventions. Here, we investigate the potential of multispectral photon-counting computed tomography (PC-CT) on image quality, diagnostic confidence, and radiation dose compared to an energy-integrating CT (EID-CT)., Methods: In this prospective study, 32 patients underwent PC-CT of the spine. Data was reconstructed in two ways: (1) standard bone kernel with 65-keV (PC-CT std ) and (2) 130-keV monoenergetic images (PC-CT 130 keV ). Prior EID-CT was available for 17 patients; for the remaining 15, an age-, sex-, and body mass index-matched EID-CT cohort was identified. Image quality (5-point Likert scales on overall, sharpness, artifacts, noise, diagnostic confidence) of PC-CT std and EID-CT was assessed by four radiologists independently. If metallic implants were present (n = 10), PC-CT std and PC-CT 130 keV images were again assessed by 5-point Likert scales by the same radiologists. Hounsfield units (HU) were measured within metallic artifact and compared between PC-CT std and PC-CT 130 keV . Finally, the radiation dose (CTDI vol ) was evaluated., Results: Sharpness was rated significantly higher (p = 0.009) and noise significantly lower (p < 0.001) in PC-CTstd vs. EID-CT. In the subset of patients with metallic implants, reading scores for PC-CT 130 keV revealed superior ratings vs. PC-CT std for image quality, artifacts, noise, and diagnostic confidence (all p < 0.001) accompanied by a significant increase of HU values within the artifact (p < 0.001). Radiation dose was significantly lower for PC-CT vs. EID-CT (mean CTDI vol : 8.83 vs. 15.7 mGy; p < 0.001)., Conclusions: PC-CT of the spine with high-kiloelectronvolt reconstructions provides sharper images, higher diagnostic confidence, and lower radiation dose in patients with metallic implants., Key Points: • Compared to energy-integrating CT, photon-counting CT of the spine had significantly higher sharpness and lower image noise while radiation dose was reduced by 45%. • In patients with metallic implants, virtual monochromatic photon-counting images at 130 keV were superior to standard reconstruction at 65 keV in terms of image quality, artifacts, noise, and diagnostic confidence., (© 2023. The Author(s).)

Objective: At certain institutions and radiology practices, a routine lumbar radiographic exam may include 3 views: AP, lateral, and coned-down lateral of the lumbosacral junction. The purpose of this study is to determine whether the third coned-down-lateral view adds significant diagnostic information regarding pathology at the L4-L5 and L5-S1 levels., Materials and Methods: This retrospective study includes patients (n = 74) who had a 3-view radiographic exam of the lumbar spine, as well as a CT or MRI within six months. The AP and lateral views were reviewed by three radiologists, both with and without the use of the third, coned-lateral view. Subsequently, the CT and MRI performed within 6 months was reviewed, and the results compared. The primary outcome was detection of abnormal alignment and disc disease at the L4-L5 and L5-S1 levels., Results: For the combined findings of alignment and disc disease at each L4-L5 and L5-S1, there was disagreement between the 2-view and 3-view exams on 18 (of 296) evaluations. Of these 18, the 2-view and the 3-view exam each made positive findings on 9. By the binomial test, there is no evidence that either the 2-view or the 3-view exam tends to make more findings than the other (p = 1). Compared to CT/MRI, the 2-view exam agrees on 74.7 % of evaluations and the 3-view exam agrees on 75.3 %. There is therefore no evidence that the 3-view exam is more accurate than the 2-view exam., Conclusion: Elimination of the coned-down lateral view could reduce radiation exposure and imaging-related costs while maintaining diagnostic quality., Competing Interests: Declaration of competing interest The authors declare that they have no competing interests/conflicts of interest., (Copyright © 2023 Elsevier Inc. All rights reserved.)

The growing spine is under excessive stresses during pubertal growth. There are specific pathologies, such as posterior ring apophyseal fractures, spondylolysis, and Hirayama's disease, which are primarily encountered in this subset of patients. Pain and deformity remain the common clinical presentations of these disorders. Imaging plays a vital role in elucidating the radiological manifestations of these unusual pathologies and in their subsequent management., (Copyright © 2023. Published by Elsevier Ltd.)

Case: This report describes 3 cases of Langerhans cell histiocytosis (LCH) of the cervical and thoracic spine in patients aged 4 to 10 years. Each patient had painful lytic spinal lesions with vertebral body collapse and posterior involvement suggesting instability requiring corpectomy, grafting, and fusion. All 3 patients were doing well at their most recent follow-up without pain or recurrence., Conclusion: Although LCH of the pediatric spine is usually successfully treated non-operatively, we recommend corpectomy and fusion when there is instability of the spinal column and/or severe stenosis. Posterior element involvement occurred in all 3 cases and may lead to instability., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/C131)., (Copyright © 2023 by The Journal of Bone and Joint Surgery, Incorporated.)

Butterfly vertebras are an abnormal embryological formation of the spinal bodies that occur because of a lack of fusion of the chondrification centers of the vertebral bodies. Langerhans cell histiocytosis is an entity that frequently involves vertebral bodies resulting in flat vertebras, and recovery of the vertebral body height is a very unusual finding. We present a case report of a pediatric patient with a thoracic acquired butterfly vertebra which occurred secondary to a Langerhans cell histiocytosis involvement. It is extremely rare to find vertebra plana that regains its complete height but is even more infrequent to evidence of a butterfly vertebra deformity that is not congenital., (© 2022. The Author(s), under exclusive licence to International Skeletal Society (ISS).)

The Occipito (O) -C2 angle reflects the correct craniocervical spine alignment; however, the poor image quality of standard intraoperative fluoroscopy at times lead to inaccurate measurements. Herein, we preliminarily investigated the relationship between the O-C2 angle and the Gonion-C2 distance, which is based on the positioning of the mandible and the cervical spine. We enrolled patients who underwent cervical spine radiography in neutral, flexion, and extension positions from January 2020 to October 2020. The difference by posture changes for each parameter was defined as the Δ value, and the Spearman's rank correlation coefficient was determined. Furthermore, we determined the cutoff value of the ΔGonion-C2 distance to predict a decrease of > 10° in the ΔO-C2 angle, which is reported to be related to dysphagia and dyspnea. Seventy-four patients were included. Spearman's rank correlations for the neutral, flexion, and extension positions were 0.630 (P < 0.001), 0.471 (P < 0.001), and 0.625 (P < 0.001), respectively, while the cutoff values of the ΔGonion-C2 distance for predicting > 10° in the ΔO-C2 angle were 9.3 mm for the neutral flexion change (sensitivity: 0.435, specificity: 0.882) and 8.3 mm for the extension-neutral change (sensitivity: 0.712, specificity: 0.909). The O-C2 angle and Gonion-C2 distances correlated; however, this correlation was weaker in the flexed position. Nevertheless, the ΔGonion-C2 distance can be used as a warning sign for postoperative complications after posterior occipital bone fusion surgery, because a decrease of > 10° in the ΔO-C2 angle can be predicted with high specificity.

Hydatid disease of the central nervous system is relatively rare and comprises about 2-3% of all the hydatid cyst cases reported in the world. Spinal hydatid disease is an even rarer entity. It is endemic in sheep and cattle-raising regions, seen mainly in Mediterranean countries including Turkey and Syria. Pediatric neurosurgeons in non-endemic countries face a challenge when they encounter children with hydatid cysts of the central nervous system, mostly due to lack of awareness and the ensuing diagnostic dilemmas. It is also a significant socioeconomic problem in developing countries, due to improper hygiene and lack of dedicated veterinary practice. The clinical features are largely nonspecific and very according to location and severity of disease. However, with the advent of advances in MR imaging, the diagnostic accuracy of hydatic disease involving the brain and spine has increased. Intact removal of the cyst/s, without causing any spillage, and appropriate antihelminthic therapy is the goal and key to cure and prevention of recurrence. In this manuscript, the current literature on hydatid cyst of the brain and spine is reviewed to better understand the epidemiology, pathophysiology, diagnostic accuracy, and advances in therapeutic options. A heightened clinical suspicion, awareness of MR imaging features, improved surgical strategies, and options for prevention are discussed., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objective: To develop an automatic diagnostic tool based on deep learning for lumbar spine stability and validate diagnostic accuracy., Methods: Preoperative lumbar hyper-flexion and hyper-extension X-ray films were collected from 153 patients with lumbar disease. The following 5 key points were marked by 3 orthopedic surgeons: L 4 posteroinferior, anterior inferior angles as well as L 5 posterosuperior, anterior superior, and posterior inferior angles. The labeling results of each surgeon were preserved independently, and a total of three sets of labeling results were obtained. A total of 306 lumbar X-ray films were randomly divided into training ( n =156), validation ( n =50), and test ( n =100) sets in a ratio of 3∶1∶2. A new neural network architecture, Swin-PGNet was proposed, which was trained using annotated radiograph images to automatically locate the lumbar vertebral key points and calculate L 4, 5 intervertebral Cobb angle and L 4 lumbar sliding distance through the predicted key points. The mean error and intra-class correlation coefficient ( ICC ) were used as an evaluation index, to compare the differences between surgeons' annotations and Swin-PGNet on the three tasks (key point positioning, Cobb angle measurement, and lumbar sliding distance measurement). Meanwhile, the change of Cobb angle more than 11° was taken as the criterion of lumbar instability, and the lumbar sliding distance more than 3 mm was taken as the criterion of lumbar spondylolisthesis. The accuracy of surgeon annotation and Swin-PGNet in judging lumbar instability was compared., Results: ① Key point: The mean error of key point location by Swin-PGNet was (1.407±0.939) mm, and by different surgeons was (3.034±2.612) mm. ② Cobb angle: The mean error of Swin-PGNet was (2.062±1.352)° and the mean error of surgeons was (3.580±2.338)°. There was no significant difference between Swin-PGNet and surgeons ( P >0.05), but there was a significant difference between different surgeons ( P <0.05). ③ Lumbar sliding distance: The mean error of Swin-PGNet was (1.656±0.878) mm and the mean error of surgeons was (1.884±1.612) mm. There was no significant difference between Swin-PGNet and surgeons and between different surgeons ( P >0.05). The accuracy of lumbar instability diagnosed by surgeons and Swin-PGNet was 75.3% and 84.0%, respectively. The accuracy of lumbar spondylolisthesis diagnosed by surgeons and Swin-PGNet was 70.7% and 71.3%, respectively. There was no significant difference between Swin-PGNet and surgeons, as well as between different surgeons ( P >0.05). ④ Consistency of lumbar stability diagnosis: The ICC of Cobb angle among different surgeons was 0.913 [95% CI (0.898, 0.934)] ( P <0.05), and the ICC of lumbar sliding distance was 0.741 [95% CI (0.729, 0.796)] ( P <0.05). The result showed that the annotating of the three surgeons were consistent. The ICC of Cobb angle between Swin-PGNet and surgeons was 0.922 [95% CI (0.891, 0.938)] ( P <0.05), and the ICC of lumbar sliding distance was 0.748 [95% CI (0.726, 0.783)] ( P <0.05). The result showed that the annotating of Swin-PGNet were consistent with those of surgeons., Conclusion: The automatic diagnostic tool for lumbar instability constructed based on deep learning can realize the automatic identification of lumbar instability and spondylolisthesis accurately and conveniently, which can effectively assist clinical diagnosis.

Back pain is a common health complaint that contributes globally to medical burden and costs, particularly in elderly populations. Nuclear medicine techniques using PET tracers offer diagnostic information about various spine disorders, including malignant, degenerative, inflammatory, and infectious diseases. Herein, the authors briefly review applications of PET in the evaluation of spine disorders in elderly patients., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Interpretation of the morphology and characteristics of soft tissues, such as paravertebral muscles and fat, has always been a "relative blind spot" in the spine. The imaging features of the non-bony structures of the spine have been studied and reinterpreted, and changes in the non-bony structure are associated with spinal disease. Soft tissue parameters such as, the "paraspinal muscle cross-sectional area," "subcutaneous fat thickness," and the "paraspinal muscle fat infiltration rate" on computed tomography, magnetic resonance imaging and other imaging techniques are reproducible in the diagnosis, treatment and prognosis of spinal disorders and have the potential for clinical application. In addition, focus on the association between sarcopenia and spinal epidural lipomatosis with spinal disorders is increasing. Currently, there is no summary of studies on fat and muscle in the spinal region. Given this, within the context of recent research trends, this article provides a synthesis of research on adipose and muscle tissue in the spine, discusses advances in the study of the imaging manifestations of these structures in spinal disorders, and expands the perspectives., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)