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Preoperative Ultrasound-guided Wire Localization of Soft Tissue Masses Within the Musculoskeletal System

Burke, Christopher John; Walter, William R; Gao, Yiming; Hoda, Syed T; Adler, Ronald S
Ultrasound-guided hookwire localization was initially introduced to facilitate the excision of nonpalpable breast lesions by guiding surgical exploration, thereby reducing operative time and morbidity. The same technique has since found utility in a range of other applications outside breast and can be useful within the musculoskeletal system. Despite this, there remains limited literature with respect to its technical aspects and practical utility. We describe our technique and a series of preoperative ultrasound-guided wire localizations in the musculoskeletal system to assist surgical excision of 4 soft tissue masses.
PMID: 33298773
ISSN: 1536-0253
CID: 4721882

Clinical feasibility of 2D dynamic sagittal HASTE flexion-extension imaging of the cervical spine for the assessment of spondylolisthesis and cervical cord impingement

Burke, Christopher J; Samim, Mohammad; Alizai, Hamza; Sanchez, Julien; Kingsbury, Dallas; Babb, James S; Walter, William R
PURPOSE/OBJECTIVE:To assess the utility of a 2D dynamic HASTE sequence in assessment of cervical spine flexion-extension, specifically (1) comparing dynamic spondylolisthesis to radiographs and (2) assessing dynamic contact upon or deformity of the cord. METHODS:Patients with a dynamic flexion-extension sagittal 2D HASTE sequence in addition to routine cervical spine sequences were identified. Static and dynamic listhesis was first determined on flexion-extension radiographs reviewed in consensus. Blinded assessment of the dynamic HASTE sequence was independently performed by 2 radiologists for (1) listhesis and translation during flexion-extension and (2) dynamic spinal cord impingement (cord contact or deformity between neutral, flexion and extension). RESULTS:32 scans in 32 patients (9 males, 23 females) met inclusion criteria acquired on 1.5 T (n = 15) and 3 T (n = 17) scanners. The mean acquisition time was 51.8 s (range 20-95 seconds). Dynamic translation was seen in 14 patients on flexion-extension radiographs compared to 12 (reader 1) and 13 (reader 2) patients on HASTE, with 90.6 % agreement (K = 0.83; p = 0.789). In all cases dynamic listhesis was ≤3 mm translation with one patient showing dynamic listhesis in the range 4-6 mm. Four cases (13 %) demonstrated deformity of the cord between flexion-extension, not present in the neutral position. For cord impingement there was strong inter-reader agreement (K = 0.93) and the paired sample Wilcoxon signed rank test found no significant difference between the impingement scores of the two readers (p = 0.787). CONCLUSIONS:A sagittal dynamic flexion-extension HASTE sequence provides a rapid addition to standard MRI cervical spine protocols, which may useful for assessment of dynamic spondylolisthesis and cord deformity.
PMID: 33307460
ISSN: 1872-7727
CID: 4709532

Pitfalls in MRI of the Developing Pediatric Ankle

Walter, William R; Goldman, Lauren H; Rosenberg, Zehava S
Normal skeletal development in the pediatric ankle is dynamic and often produces variable imaging appearances that are subject to misinterpretation. Radiologists must understand the underlying developmental phenomena, such as endochondral and membranous ossification and physeal fusion, and be familiar with their common and uncommon imaging manifestations unique to the pediatric ankle. This is especially true as the use of MRI in the evaluation of musculoskeletal trauma expands among younger populations. The authors focus on MRI evaluation of the skeletally maturing pediatric ankle and present pearls for accurately distinguishing normal findings and imaging pitfalls from true pathologic findings. The normal but often variable imaging findings of preossification, secondary ossification, and multiple ossification centers, as well as the range of bone marrow signal intensities that can be visualized within ossification centers, are described, along with tips to help differentiate these from true pathologic findings such as contusion, fracture, or tumor. The authors also review dynamic periosteal and physeal contributions to bone growth to highlight helpful distinguishing features and avoid misdiagnosis of common subperiosteal and periphyseal abnormalities. For example, the normal trilaminar appearance of the immature cortex and periosteum should not be mistaken for periosteal reaction, traumatic stripping, or subperiosteal hematoma. In addition, the physis can have several confusing but normal appearances, including normal physeal undulations (eg, Kump bump) or focal periphyseal edema, which should not be mistaken for pathologic findings such as physeal fracture, infection, or bar. ©RSNA, 2020.
PMID: 33216674
ISSN: 1527-1323
CID: 4702252

Using Deep Learning to Accelerate Knee MRI at 3T: Results of an Interchangeability Study

Recht, Michael P; Zbontar, Jure; Sodickson, Daniel K; Knoll, Florian; Yakubova, Nafissa; Sriram, Anuroop; Murrell, Tullie; Defazio, Aaron; Rabbat, Michael; Rybak, Leon; Kline, Mitchell; Ciavarra, Gina; Alaia, Erin F; Samim, Mohammad; Walter, William R; Lin, Dana; Lui, Yvonne W; Muckley, Matthew; Huang, Zhengnan; Johnson, Patricia; Stern, Ruben; Zitnick, C Lawrence
OBJECTIVE:Deep Learning (DL) image reconstruction has the potential to disrupt the current state of MR imaging by significantly decreasing the time required for MR exams. Our goal was to use DL to accelerate MR imaging in order to allow a 5-minute comprehensive examination of the knee, without compromising image quality or diagnostic accuracy. METHODS:A DL model for image reconstruction using a variational network was optimized. The model was trained using dedicated multi-sequence training, in which a single reconstruction model was trained with data from multiple sequences with different contrast and orientations. Following training, data from 108 patients were retrospectively undersampled in a manner that would correspond with a net 3.49-fold acceleration of fully-sampled data acquisition and 1.88-fold acceleration compared to our standard two-fold accelerated parallel acquisition. An interchangeability study was performed, in which the ability of 6 readers to detect internal derangement of the knee was compared for the clinical and DL-accelerated images. RESULTS:The study demonstrated a high degree of interchangeability between standard and DL-accelerated images. In particular, results showed that interchanging the sequences would result in discordant clinical opinions no more than 4% of the time for any feature evaluated. Moreover, the accelerated sequence was judged by all six readers to have better quality than the clinical sequence. CONCLUSIONS:An optimized DL model allowed for acceleration of knee images which performed interchangeably with standard images for the detection of internal derangement of the knee. Importantly, readers preferred the quality of accelerated images to that of standard clinical images.
PMID: 32755163
ISSN: 1546-3141
CID: 4557132

Ultrasound-guided Therapeutic Injection and Cryoablation of the Medial Plantar Proper Digital Nerve (Joplin's Nerve): Sonographic Findings, Technique, and Clinical Outcomes

Burke, Christopher J; Sanchez, Julien; Walter, William R; Beltran, Luis; Adler, Ronald
RATIONALE AND OBJECTIVES/OBJECTIVE:The medial plantar proper digital nerve, also called Joplin's nerve, arises from the medial plantar nerve, courses along the medial hallux metatarsophalangeal joint, and can be a source of neuropathic pain due to various etiologies, following acute injury including bunion surgery and repetitive microtrauma. We describe our clinical experience with diagnostic ultrasound assessment of Joplin's neuropathy and technique for ultrasound-guided therapeutic intervention including both injection and cryoablation over a 6-year period. MATERIALS AND METHODS/METHODS:Retrospective review of all diagnostic studies performed for Joplin's neuropathy and therapeutic Joplin's nerve ultrasound-guided injections and cryoablations between 2012 and 2018 was performed. Indications for therapeutic injection and cryoablation, were recorded. Studies were assessed for sonographic abnormalities related to the nerve and perineural soft tissues. Post-treatment outcomes including immediate pain scores, clinical follow-up, and periprocedural complications were documented. RESULTS:Twenty-four ultrasound-guided procedures were performed, including 15 perineural injections and nine cryoablations. With respect to sonographic abnormalities, nerve thickening (33%) and perineural hypoechoic scar tissue (27%) were the most common findings. The mean pain severity score prior to the therapeutic injection was 6.4/10 (range 4-10) and 0.25/10 (range 0-2) following the procedure; mean follow-up was 26.2 months (range 3-63 months). All of the cryoablation patients experienced sustained pain relief with a mean length follow-up of 3.75 months (range 0.2-10 months). CONCLUSION/CONCLUSIONS:Therapeutic injection of Joplin's nerve is a safe and easily performed procedure under ultrasound guidance, with high rates of immediate symptom improvement. For those experiencing a relapse or recurrent symptoms, cryoablation offers an effective secondary potential treatment option.
PMID: 31279644
ISSN: 1878-4046
CID: 3976292

Real-time dynamic 3-T MRI assessment of spine kinematics: a feasibility study utilizing three different fast pulse sequences

Walter, William R; Alizai, Hamza; Bruno, Mary; Portugal, Salvador; Burke, Christopher J
PMID: 32233646
ISSN: 1600-0455
CID: 4370282

Cartilage Imaging in Osteoarthritis

Alizai, Hamza; Walter, William; Khodarahmi, Iman; Burke, Christopher J
Osteoarthritis (OA) is the most common joint disease in the United States. The prevalence of OA is rising due to an aging population and increasing rates of obesity. Magnetic resonance imaging (MRI) allows an incomparable noninvasive assessment of all joint structures. Irreversible and progressive degradation of the articular cartilage remains the hallmark feature of OA. To date, attempts at developing disease-modifying drugs or biomechanical interventions for treating OA have proven unsuccessful. MRI-based cartilage imaging techniques have continued to advance, however, and will likely play a central role in the development of these joint preservation methods of the future. In this narrative review, we describe clinical MR image acquisition and assessment of cartilage. We discuss the semiquantitative cartilage scoring methods used in research. Lastly, we review the quantitative MRI techniques that allow assessment of changes in the biochemical composition of cartilage, even before the morphological changes are evident.
PMID: 31556090
ISSN: 1098-898x
CID: 4105582

MRI Assessment of Subspine Impingement: Features beyond the Anterior Inferior Iliac Spine Morphology

Samim, Mohammad; Walter, William; Gyftopoulos, Soterios; Poultsides, Lazaros; Youm, Thomas
Background The MRI manifestations of subspine impingement (SSI) other than morphologic features of anterior inferior iliac spine (AIIS) have not been extensively explored and validated. Purpose To determine the MRI findings associated with SSI, including AIIS morphologic features, femoral distal cam, and associated soft-tissue injuries. Materials and Methods This is a retrospective study of symptomatic patients who underwent arthroscopic treatment for femoroacetabular impingement between December 2014 and March 2017, with preoperative MRI within 6 months before surgery. The SSI group included patients with clinical and intraoperative findings of SSI; the remaining patients comprised the non-SSI group. Preoperative MRI findings were independently assessed by two radiologists who were blinded to clinical information. Interreader agreement was assessed, and multivariable logistic regression was also used. Results A total of 62 patients (mean age ± standard deviation, 42.1 years ± 11.9; 38 women) were included. SSI was diagnosed in 20 of the 62 patients (32%) (mean age, 43 years ± 12); 42 patients (68%) did not have SSI (mean age, 41 years ± 10). Reader 1 detected distal cam in 16 of the 20 patients with SSI (80%) and eight of the 42 patients without SSI (19%), and reader 2 detected distal cam in 15 of the 20 patients with SSI (75%) and eight of the 42 patients without SSI (19%) (P < .001 for both). Reader 1 detected signs of impingement on the distal femoral neck (IDFN) in 18 of the 20 patients with SSI (90%) and seven of the 42 patients without SSI (16%), and reader 2 detected signs of IDFN in 13 of the 20 patients with SSI (65%) and nine of the 42 patients without SSI (21%) (P < .001 and P = .001, respectively). Reader 1 detected superior capsular edema in 15 of 20 patients with SSI (75%) and three of 42 patients without SSI (7%), and reader 2 detected superior capsular edema in 17 of 20 patients with SSI (85%) and 22 of 42 patients without SSI (52%) (P < .001 and P = .02, respectively). Distal cam was a predictor of SSI after adjustment for IDFN. Interreader agreement was substantial for distal cam (κ = 0.80) and moderate for IDFN (κ = 0.50). Conclusion Soft-tissue injuries and osseous findings other than morphologic features of the anterior inferior iliac spine were associated with subspine impingement. © RSNA, 2019 See also the editorial by Guermazi in this issue.
PMID: 31549946
ISSN: 1527-1315
CID: 4105422

Real-Time Assessment of Femoroacetabular Motion Using Radial Gradient Echo Magnetic Resonance Arthrography at 3 Tesla in Routine Clinical Practice: A Pilot Study

Burke, Christopher J; Walter, William R; Gyftopoulos, Soterios; Pham, Hien; Baron, Samuel; Gonzalez-Lomas, Guillem; Vigdorchik, Jonathan M; Youm, Thomas
PURPOSE/OBJECTIVE:To compare femoroacetabular motion in a series of consecutive symptomatic patients with hip pain throughout the range of motion of the hip using a real-time radial gradient echo (GRE) sequence in addition to the routine hip protocol sequences for magnetic resonance (MR) arthrographic assessment of patients with and without clinical femoroacetabular impingement (FAI) syndrome. In particular, we sought to assess whether the additional dynamic sequence could differentiate between patients with and without a positive physical exam maneuver for FAI syndrome. METHODS:Patients with hip pain referred for conventional hip MR arthrogram including those with and without a positive physical exam maneuver for FAI syndrome were imaged using routine hip MR arthrogram protocol and an additional real-time radial 2-dimensional GRE acquisition at 3 Tesla in an axial oblique plane with continuous scanning of a 9 mm thick slice through the center of the femoral head-neck axis. Patients who were unable to move through the range of motion were excluded (n = 3). Patients with acetabular dysplasia (defined by a lateral center-edge angle [CEA] of 20°) were also excluded, as were patients had Kellgren and Lawrence scores of > 0. The real-time cine sequence was acquired with the patient actively moving through neutral, flexion, flexion-abduction external-rotation, and flexion-adduction internal rotation (FADIR) positions aiming for 40° of abduction, then 25° of adduction at 80° to 90° flexion. Due to the placement of the coil over the hip, a true FADIR was precluded. Images were evaluated independently by 2 musculoskeletal radiologists measuring the joint space in the anterior, central, and posterior positions at each point during range of motion for femoroacetabular cortical space (FACS). Anterior FACS narrowing was calculated as the ratio of joint space in FADIR:neutral position, with lower ratios indicating greater narrowing. Static metrics including alpha angle, CEA, grade of cartilage loss according the Outerbridge classification, and patient demographics were also recorded. RESULTS:Twenty-two painful hips in 22 patients (11 males and 11 females) with mean age 36 years (range, 15-67) were included. Twelve patients had a positive physical exam maneuver for FAI syndrome. The time to perform the dynamic sequence was 3 to 6 minutes. Interobserver agreement was strong, with intraclass correlation 0.91 and concordance correlation 0.90. According to results from both readers, patients with impingement on clinical exam had significantly lower anterior FACS ratios compared with those without clinical impingement (reader 1: 0.39 ± 0.10 vs 0.69 ± 0.20, P = .001; reader 2: 0.36 ± 0.07 vs 0.70 ± 0.17, P < .001). Decreased anterior FACS ratio was found to be significantly correlated to increased alpha angle by both readers (reader 1: R = -0.63, P = .002; reader 2: R = -0.67, P = .001) but not significantly correlated to CEA (reader 1: R = 0.13, P = .561; reader 2: R = 0.20, P = .378) or cartilage loss (reader 1: R = 0.03, P = .885; reader 2: R = -0.06, P = .784). Both readers found patients with an anterior FACS ratio of 1/2 to have significantly higher mean alpha angle (reader 1: 62.88 vs 52.79, P = .038; reader 2: 63.50 vs 50.58, P = .006); however, there were no significant differences in cartilage loss (reader 1: P = .133; reader 2: P = .882) or CEA (reader 1: P = .340; reader 2: P = .307). CONCLUSIONS:A dynamic radial 2-dimensional-GRE sequence can be added to standard hip MR arthrogram protocols in <6 minutes, allowing assessment of dynamic femoroacetabular motion with strong interreader agreement. Patients with impingement on clinical exam had significantly lower anterior FACS ratios between FADIR and neutral positions, compared with those without clinical impingement. LEVEL OF EVIDENCE/METHODS:Level III, comparative diagnostic investigation.
PMID: 31395172
ISSN: 1526-3231
CID: 4033502

Ultrasound-Guided Therapeutic Scapulothoracic Interval Injections

Walter, William R; Burke, Christopher J; Adler, Ronald S
Scapulothoracic pain is a common ailment, but the underlying cause can be difficult to diagnose in a timely manner, and treatment options are limited. We retrospectively review our experience using ultrasound-guided therapeutic scapulothoracic interval steroid injections to treat scapulothoracic pain and review correlative magnetic resonance imaging findings over a 5-year period. Although a variety of structural causes are known to cause scapulothoracic pain, in our experience, most cases lack correlative imaging findings. Ultrasound-guided scapulothoracic interval injections provide a safe, easily performed diagnostic and therapeutic tool for treating patients with periscapular pain, providing at least short-term symptom relief.
PMID: 30472731
ISSN: 1550-9613
CID: 3500992