| 1. |
- Belavy, D. L., et al.
(författare)
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Characterization of Intervertebral Disc Changes in Asymptomatic Individuals with Distinct Physical Activity Histories Using Three Different Quantitative MRI Techniques
- 2020
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Ingår i: Journal of Clinical Medicine. - : MDPI AG. - 2077-0383. ; 9:6
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Tidskriftsartikel (refereegranskat)abstract
- (1) Background: Assessments of intervertebral disc (IVD) changes, and IVD tissue adaptations due to physical activity, for example, remains challenging. Newer magnetic resonance imaging techniques can quantify detailed features of the IVD, where T2-mapping and T2-weighted (T2w) and Dixon imaging are potential candidates. Yet, their relative utility has not been examined. The performances of these techniques were investigated to characterize IVD differences in asymptomatic individuals with distinct physical activity histories. (2) Methods: In total, 101 participants (54 women) aged 25-35 years with distinct physical activity histories but without histories of spinal disease were included. T11/12 to L5/S1 IVDs were examined with sagittal T2-mapping, T2w and Dixon imaging. (3) Results: T2-mapping differentiated Pfirrmann grade-1 from all other grades (p< 0.001). Most importantly, T2-mapping was able to characterize IVD differences in individuals with different training histories (p< 0.005). Dixon displayed weak correlations with the Pfirrmann scale, but presented significantly higher water content in the IVDs of the long-distance runners (p< 0.005). (4) Conclusions: Findings suggested that T2-mapping best reflects IVD differences in asymptomatic individuals with distinct physical activity histories changes. Dixon characterized new aspects of IVD, probably associated with IVD hypertrophy. This complementary information may help us to better understand the biological function of the disc.
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| 2. |
- Cetinic, Ivan, et al.
(författare)
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Shear wave elastography and shear wave dispersion correlated to biopsy at the scheduled follow-up of pediatric liver grafts
- 2023
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Ingår i: Pediatric Transplantation. - 1397-3142. ; 27:7
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Tidskriftsartikel (refereegranskat)abstract
- Background: It is unknown how shear wave dispersion (SWD) is displayed in pediatric liver transplant recipients and not fully elucidated how ultrasound shear wave elastography (2D-SWE) display within this cohort, which is important to determine to improve noninvasive surveillance of these patients. The study aimed to compare SWE and SWD values with histopathology in pediatric liver recipients.Methods: Forty-eight pediatric liver recipients were examined with SWE in conjunction with an elective liver biopsy (clinically without complication). Additionally, SWD values were measured in 21 children. SWE and SWD values were compared to histologically determined fibrosis graded as none-to-mild (F0-1) and moderate-to-severe (F2-4), and inflammation graded as low (grade 0-1) and high (grade 2-4).Results: Two children were excluded due to SWE IQR/median > 30% kPa. The mean age across 46 included patients was 10.9 years (range 1.4-18). The number of patients and median (range) SWE value (kPa) for each stage of fibrosis were: F0-1 [n = 23; 5.8 (3.2-16.1)], F2 [n = 22; 6.0 (4.5-25.9)], F3 [n = 1; 33.3], and F4 [n = 0]. Significantly higher SWE values and greater variability were registered in F2-4 vs. F0-1 (p = .05). Grade of fibrosis correlated weakly to SWE values (r = .3; p = .05), but not to SWD values (r = .2; p = .27). In patients with low-grade inflammation, median SWD was 13.7 m/s KHz (10.7-17.6). Only one patient had high-grade inflammation.Conclusions: Uncomplicated transplanted liver grafts in a small pediatric cohort revealed slightly increased SWE and SWD values compared to previously reported values in healthy children. This likely reflect both the fibrotic and inflammatory elements in the grafts; however, other confounders impacting the liver's viscoelastic properties are also probable factors.
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| 3. |
- Cetinic, I., et al.
(författare)
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Ultrasound Shear Wave Elastography, Shear Wave Dispersion and Attenuation Imaging of Pediatric Liver Disease with Histological Correlation
- 2022
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Ingår i: Children. - : MDPI AG. - 2227-9067. ; 9:5
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Tidskriftsartikel (refereegranskat)abstract
- Aim: To evaluate the feasibility of multiple ultrasound markers for the non-invasive characterization of fibrosis, inflammation and steatosis in the liver in pediatric patients. Materials and methods: The quantitative ultrasound measures shear wave elastography (SWE), shear wave dispersion (SWD) and attenuation imaging (ATI) were compared and correlated with percutaneous liver biopsies and corresponding measures in a control cohort. Results: The median age of the 32 patients was 12.1 years (range 0.1-17.9), and that of the 15 controls was 11.8 years (range: 2.6-16.6). Results: There was a significant difference in SWE values between histologic grades of fibrosis (p = 0.003), with a positive correlation according to the grade (r = 0.7; p < 0.0001). Overall, a difference in SWD values between grades of inflammation was found (p = 0.009) but with a lack of correlation (r = 0.1; p = 0.67). Comparing inflammation grades 0-1 (median:13.6 m/s kHz [min; max; 8.4; 17.5]) versus grades 2-3 (16.3 m/s kHz [14.6; 24.2]) showed significant differences between the groups (p = 0.003). In the 30 individuals with a steatosis score of 0, ATI was measured in 23 cases with a median value of 0.56 dB/cm/MHz. Conclusion: Comprehensive ultrasound analysis was feasible to apply in children and has the potential to reflect the various components of liver affection non-invasively. Larger studies are necessary to conclude to what extent these image-based markers can classify the grade of fibrosis, inflammation and steatosis.
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| 4. |
- de Lange, Charlotte, 1963, et al.
(författare)
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Fontan-associated liver disease: Diagnosis, surveillance, and management
- 2023
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Ingår i: Frontiers in Pediatrics. - : Frontiers Media SA. - 2296-2360. ; 11
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Forskningsöversikt (refereegranskat)abstract
- The Fontan operation is a lifesaving procedure for patients with functional single-ventricle congenital heart disease, where hypoplastic left heart syndrome is the most frequent anomaly. Hemodynamic changes following Fontan circulation creation are now increasingly recognized to cause multiorgan affection, where the development of a chronic liver disease, Fontan-associated liver disease (FALD), is one of the most important morbidities. Virtually, all patients with a Fontan circulation develop liver congestion, resulting in fibrosis and cirrhosis, and most patients experience childhood onset. FALD is a distinctive type of congestive hepatopathy, and its pathogenesis is thought to be a multifactorial process driven by increased nonpulsatile central venous pressure and decreased cardiac output, both of which are inherent in the Fontan circulation. In the advanced stage of liver injury, complications of portal hypertension often occur, and there is a risk of developing secondary liver cancer, reported at young age. However, FALD develops with few clinical symptoms, a surprisingly variable degree of severity in liver disease, and with little relation to poor cardiac function. The disease mechanisms and modifying factors of its development are still not fully understood. As one of the more important noncardiac complications of the Fontan circulation, FALD needs to be diagnosed in a timely manner with a structured monitoring scheme of disease development, early detection of malignancy, and determination of the optimal time point for transplantation. There is also a clear need for consensus on the best surveillance strategy for FALD. In this regard, imaging plays an important role together with clinical scoring systems, biochemical workups, and histology. Patients operated on with a Fontan circulation are generally followed up in cardiology units. Ultimately, the resulting multiorgan affection requires a multidisciplinary team of healthcare personnel to address the different organ complications. This article discusses the current concepts, diagnosis, and management of FALD, with special emphasis on the role of different imaging techniques in the diagnosis and monitoring of disease progression, as well as current recommendations for liver disease surveillance.
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| 5. |
- Eriksson, Stefanie, et al.
(författare)
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Texture Analysis of Magnetic Resonance Images Enables Phenotyping of Potentially Painful Annular Fissures.
- 2022
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Ingår i: Spine. - 1528-1159. ; 47:5, s. 430-437
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Tidskriftsartikel (refereegranskat)abstract
- Retrospective analysis of prospectively collected data.To investigate whether intervertebral disc (IVD) image features, extracted from magnetic resonance (MR) images, can depict the extension and width of annular fissures and associate them to pain.Annular fissures are suggested to be associated with low back pain (LBP). Magnetic resonance imaging (MRI) is a sensitive method, yet fissures are sometimes unobservable in T2-weighted MR-images, even though fissure information is present in the image. Image features can mathematically be calculated from MR-images and might reveal fissure characteristics.44 LBP patients who underwent MRI, low-pressure discography (<50psi) and computed tomography (CT) sequentially in one day, were reviewed. After semi-automated segmentation of 126 discs, image features were extracted from the T2-weighted images. The number of image features were reduced with principle component analysis (PCA). CT-discograms were graded and dichotomized regarding extension and width of fissures. IVDs were divided into fissures extending to outer annulus vs. short/no fissures. Fissure width was dichotomized into narrow (<10%) vs. broad fissures (>10%), and into moderately broad (10%-50%) vs. very broad fissures (>50%). Logistic regression was performed to investigate if image features could depict fissure extension to outer annulus and fissure width. As a sub-analysis, the association between image features used to depict fissure characteristics and discography-provoked pain-response were investigated.Fissure extension could be depicted with sensitivity/specificity=0.97/0.77 and area under curve (AUC)=0.97. Corresponding results for width depiction were sensitivity/specificity=0.94/0.39 and 0.85/0.62, and AUC=0.86 and 0.81 for narrow vs. broad and moderately broad vs. very broad fissures respectively. Pain prediction with image features used for depicting fissure characteristics showed sensitivity/specificity=0.90/0.36, 0.88/0.4, 0.93/0.33; AUC=0.69, 0.75 and 0.73 respectively.Standard MR-images contains fissure information associated to pain that can be depicted with image features, enabling non-invasive phenotyping of potentially painful annular fissures.Level of Evidence: 2.
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| 6. |
- Ghassemi Jahani, Shadi A, et al.
(författare)
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Degenerative Changes in the Cervical Spine Are More Common in Middle-Aged Individuals with Thalidomide Embryopathy than in Healthy Controls
- 2016
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Ingår i: Plos One. - : Public Library of Science (PLoS). - 1932-6203. ; 11:5
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Tidskriftsartikel (refereegranskat)abstract
- Background Thalidomide was used as a sedative drug for pregnant women in the 1950-60:s and resulted in children born with thalidomide embryopathy (TE), including upper limb malformations. These may alter the motion pattern of the cervical spine by the use of head/shoulder and mouth grip. To compare degenerative changes in the cervical spine in TE individuals with healthy controls (CTR). Twenty-seven middle-aged TE individuals and 27 age-and gender-matched CTR were examined by cervical spine MRI. The presence of malformations, disc herniation(s), osteophytes, nerve and medullary compression and the degree of disc degeneration (DD) were evaluated. Significantly higher degree of DD was seen in the TE group compared with the controls (p<0.001). Similar frequencies of disc herniation and disc space narrowing were observed in the two groups, but more foraminal narrowing was seen in the TE group (p = 0.002). DD was observed relatively frequently at all cervical levels in the TE group, however, mainly at the two lower levels in the CTR. Middle-aged individuals with TE have a higher frequency of degenerative changes in the cervical spine than controls, possibly caused by an altered load on the cervical spine.
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| 7. |
- Hebelka, Hanna, 1977, et al.
(författare)
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Axial Loading during MRI Induces Lumbar Foraminal Area Changes and Has the Potential to Improve Diagnostics of Nerve Root Compromise
- 2022
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Ingår i: Journal of Clinical Medicine. - : MDPI AG. - 2077-0383. ; 11:8
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Tidskriftsartikel (refereegranskat)abstract
- Lumbar foraminal stenosis is a common cause of lumbar radiculopathy and conventionally assessed with magnetic resonance imaging (MRI) in supine-positioned patients. An MRI acquired during spine loading may unmask pathology not otherwise revealed in a relaxed position. Therefore, we investigated how spine loading during MRI affects lumbar foramina. In 89 low-back pain patients’ lumbar, MRIs were performed in a relaxed supine position and during axial loading using a Dynawell® compression device. The smallest area of all intervertebral foramina at levels L3/L4–L5/S1 (534 foramina) was determined using a freehand polygonal tool in parasagittal T2-weighted sequences. The grading system described by Lee et al. was also used to qualitatively assess foraminal stenosis. Overall, a mean reduction of 2.2% (mean −0.89 cm2 and −0.87 cm2, respectively) was observed (p = 0.002), however for individual foramina large variations, with up to about 50% increase or decrease, were seen. Stratified for lumbar level, an area reduction was found for L3/L4 and L4/L5 foramina (mean change −0.03 cm2; p = 0.036; and −0.03 cm2; p = 0.004, respectively) but not for L5/S1. When comparing the measured area changes to qualitative foraminal grading, 22% of the foramina with a measured area decrease were evaluated with a higher grading. Thus, detailed information on foraminal appearance and nerve root affection can be obtained using this method.
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| 8. |
- Hebelka, Hanna, 1977, et al.
(författare)
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Axial loading during MRI induces significant T2 value changes in vertebral endplates-a feasibility study on patients with low back pain
- 2018
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Ingår i: Journal of Orthopaedic Surgery and Research. - : Springer Science and Business Media LLC. - 1749-799X. ; 13:18
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Tidskriftsartikel (refereegranskat)abstract
- Background: The function of the endplate (EP) is the most important factor influencing nutritional supply to the avascular intervertebral disc (IVD). It is desired to have a non-invasive method to assess functional EP characteristics in vivo. Assessment of functional EP characteristics is important in order to understand its relation to IVD degeneration, which in turn might deepen the understanding of the pathophysiology behind low back pain (LBP). It was hypothesized that, by comparing quantitative MRI of EPs performed with conventional supine MRI (unloaded MRI) with axial loading during MRI (alMRI), dynamical properties of the EP can be displayed. The aim was therefore to investigate the feasibility of axial loading during MRI (alMRI) to instantaneously induce quantitative EP changes. Methods: T2 mapping of 55 vertebral EPs (L1-S1) in five LBP patients was performed during conventional supine MRI (unloaded MRI) and subsequent alMRI. With T2 mapping, the cartilaginous EP and bony EP cannot be separated; hence, the visualized EP was termed EP zone (EPZ). Each EPZ was segmented at multiple midsagittal views, generating volumetric regions of interest. EPZs demonstrating signal inhomogeneity and/or adjacent Modic changes (MC) were termed abnormal EPZs. EPZ mean T2 values were compared between unloaded MRI and alMRI, and their relationship with abnormal EPZs was determined. Results: alMRI induced significantly higher (p = 0.01) EPZ mean T2 values compared with unloaded MRI. Significantly higher mean T2 values were seen in inferior EPZs compared with superior EPZs, both with unloaded MRI (35%, p < 0.001) and with alMRI (26%, p = 0.04). Significant difference between unloaded MRI and alMRI was seen in normal (p = 0.02), but not in abnormal EPZs (p = 0.5; n = 12). Conclusions: alMRI induces changes in human EPZ characteristics in vivo. The T2 value significantly increased in normal EPZs, with lack of such in abnormal EPZs. Combining T2 mapping with alMRI provides a clinical feasible, non-invasive method with potential to reveal biochemical behavioral patterns, thus adding another dimension of the EPZs characteristics compared with information obtained with solely unloaded MRI.
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| 9. |
- Hebelka, Hanna, 1977, et al.
(författare)
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Axial loading during MRI reveals deviant characteristics within posterior IVD regions between low back pain patients and controls
- 2018
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Ingår i: European Spine Journal. - : Springer Science and Business Media LLC. - 0940-6719 .- 1432-0932. ; 27:11, s. 2840-2846
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Tidskriftsartikel (refereegranskat)abstract
- Purpose To investigate differences in functional intervertebral disk (IVD) characteristics between low back pain (LBP) patients and controls using T2-mapping with axial loading during MRI (alMRI). Methods In total, 120 IVDs in 24 LBP patients (mean age 39years, range 25-69) were examined with T2-mapping without loading of the spine (uMRI) and with alMRI (DynaWell((R)) loading device) and compared with 60 IVDs in 12 controls (mean age 38 years, range 25-63). The IVD T2-value was acquired after 20-min loading in five regions of interests (ROI), ROI1-5 from anterior to posterior. T2-values were compared between loading states and cohorts with adjustment for Pfirrmann grade. Results In LBP patients, mean T2-value of the entire IVD was 64 ms for uMRI and 66 ms for alMRI (p = 0.03) and, in controls, 65 ms and 65 ms (p = 0.5). Load-induced T2-differences (alMRI-uMRI) were seen in all ROIs in both patients (0.001>p<0.005) and controls (0.0001>p<0.03). In patients, alMRI induced an increase in T2-value for ROI1-3 (23%, 18% and 5%) and a decrease for ROI4 (3%) and ROI5 (24%). More pronounced load-induced decrease was detected in ROI4 in controls (9%/p=0.03), while a higher absolute T2-value was found for ROI5 during alMRI in patients (38 ms) compared to controls (33 ms) (p = 0.04). Conclusion The alMRI-induced differences in T2-value in ROI4 and ROI5 between patients and controls most probably indicate biomechanical impairment in the posterior IVD regions. Hence, alMRI combined with T2-mapping offers an objective and clinical feasible tool for biomechanical IVD characterization that may deepen the knowledge regarding how LBP is related to altered IVD matrix composition.
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| 10. |
- Hebelka, Hanna, 1977, et al.
(författare)
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Clinical outcome and MRI appearance in a group of chronic low back pain patients more than 10 years after discography evaluation and consideration for surgery
- 2023
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Ingår i: BMC Musculoskeletal Disorders. - : Springer Science and Business Media LLC. - 1471-2474. ; 24:1
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Tidskriftsartikel (refereegranskat)abstract
- BackgroundIt is an ongoing debate whether fusion surgery is superior to non-operative treatment for non-specific low back pain (LBP) in terms of patient outcome. Further, the evidence for how signs of intervertebral disc (IVD) degeneration on magnetic resonance imaging (MRI) correlate with patient outcome is insufficient. Longitudinal studies of low back pain (LBP) patients are thus of interest for increased knowledge. The aim of this study was to investigate long-term MRI appearance in LBP patients 11-14 years after discography.MethodsIn 2021, 30 LBP patients who had same-day discography and MRI in 2007-2010 were asked to undergo MRI (Th12/L1-L5/S1), complete visual analog scale (VAS), Oswestry Disability Index (ODI) and EuroQol-5 Dimension (EQ5D) questionnaires. Patients who had fusion surgery before the follow-up were compared with those without such surgery. MRIs were evaluated on Pfirrmann grade, endplate classification score (EPS), and High Intensity Zones (HIZ). For each disk it was noted if injected at baseline or not.ResultsOf 17 participants (6 male;mean age 58.5 years, range 49-72), 10 (27 disks) had undergone fusion surgery before the follow-up. No differences in VAS, ODI, or EQ5D scores were found between patients with and without surgery (mean 51/32/0.54 vs. 50/37/0.40, respectively; 0.77 > p < 0.65). Other than more segments with EPS >= 4 in the surgery group (p < 0.05), no between-group differences were found in longitudinal change in MRI parameters. Of 75 non-fused disks, 30 were injected at baseline. Differences were found between injected and non-injected disks at both baseline and follow-up for Pfirrmann grade and HIZ, and at follow-up for EPS (0.04 > p < 0.001), but none for progression over time (0.09 > p < 0.82).ConclusionsOther than more endplate changes in the surgery group, no differences in longitudinal change of MRI parameters were established between LBP patients treated with or without fusion surgery in the studied cohort. The study also highlights the limited progress of degenerative changes, which may be seen over a decade, despite needle puncture and chronic LBP.
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| 11. |
- Hebelka, Hanna, 1977, et al.
(författare)
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Coexistence of Vertebral and Intervertebral Disc Changes in Low Back Pain Patients—In Depth Characterization with Same Day MRI and CT Discography
- 2023
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Ingår i: Diagnostics. - 2075-4418. ; 13:23
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Tidskriftsartikel (refereegranskat)abstract
- The aim of this study was to investigate to what extent annular fissures, vertebral and endplate changes, and Modic changes (MCs), coexist in low back pain (LBP) patients by using multiple imaging modalities. Sixty-two LBP patients (mean age 45 years, range 24–63, 53% men) were examined with same-day CT-discography and MRI. Intervertebral discs punctured for discography (n = 204) were evaluated on MRI [Pfirrmann grade, High-Intensity Zone (HIZ)] and on CT-discograms [Modified Dallas Discogram Score (DDS)]. DDS≥ 1, i.e., disc fissures involving the outer annulus were further digitomized into delimitable fissuring (<50% of annulus affected) or non-delimitable annular fissuring. Using both MRI and CT, adjacent vertebrae and endplates were assessed for MC, vertebral sclerosis, and a modified endplate defect score (EPS). In 194 discs the contrast agent was adequately injected during discography, of which 160 (83%) displayed outer annular fissures, with 91 (47%) of the latter being delimitable fissures. Most discs with delimitable fissures were moderately degenerated; 68% Pfirrmann grade ≤3, 71% EPS ≤ 2, and 12% displayed MC. The majority (76%) of MCs were associated with advanced adjacent disc degeneration; 84% Pfirrmann grade ≥4, 76% with non-delimitable annular fissuring, 59% EPS≥ 4, and 34% EPS of 3. A total 95 HIZ (47%) were found, of which 54 had delimitable fissuring, while the remainder displayed non-delimitable fissuring. Vertebral sclerosis was commonly observed (26%), both with MCs (73%) and without MCs (27%), and not specifically linked to MC type 3. A total of 97% of segments with vertebral sclerosis displayed outer annular fissures. These findings were significant (0.046 > p > 0.0001), except between HIZ and adjacent sclerosis (p = 0.303). To conclude, the present study confirmed a close interplay between the disc and adjacent vertebra and endplates. The fact that a majority of discs with delimitable annular fissures did not coexist with pronounced endplate changes and/or MCs, however, supports the theory that disc fissuring is an early event in the degenerative cascade. This was further supported by the fact that MCs were strongly linked to extensive disc fissuring and to advanced endplate damage. Further, vertebral sclerosis was common also in vertebra without MCs and strongly associated to annular fissuring, indicating that sclerosis is a previously underestimated feature of a general degenerative process.
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| 12. |
- Hebelka, Hanna, 1977, et al.
(författare)
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Comparison between pain at discography and morphological disc changes at axial loaded MRI in patients with low back pain.
- 2014
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Ingår i: European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society. - : Springer Science and Business Media LLC. - 1432-0932. ; 23:10, s. 2075-82
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Tidskriftsartikel (refereegranskat)abstract
- Discogenic pain is induced by axial load, but there are no studies evaluating the influence of dynamic MRI in relation to provoked pain at discography. The aim of this study was to investigate the relationship between discography-induced pain and morphological disc changes, occurring during axial loaded MRI (alMRI). A secondary aim was to compare and register the frequency of provoked concordant pain at alMRI and discography.
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| 13. |
- Hebelka, Hanna, 1977
(författare)
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Discogenic pain - A diagnostic challenge
- 2014
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Low back pain (LBP) is a common health complaint with a lifetime prevalence up to 80%. Patients with discogenic pain constitute a minority of all with LBP but represent an important group with substantial personal consequences and high demands on health-care and social systems. In spite of debated validity discography remains frequently used in the diagnosis of discogenic pain. A concordant pain provocation at discography is an indication of a painful disc. Discography is questioned, especially due to inconclusiveness regarding the rate of false positive responses. The primary aim of this thesis was to investigate a potential validity issue; whether a pressure increase is induced in adjacent discs during discography. Further it aimed to investigate the relationship between discography-induced pain and morphological disc changes, occurring during axial loaded MRI (alMRI) and if such axial load increase the detection of High Intensity Zones (HIZ). These aims were investigated in experimental in vivo studies and in clinical discography patients. Study I-III: Discography was performed in nine healthy porcine lumbar spines (33 discs), in ten degenerated porcine spines (28 discs) and in nine patients (22 discs) with discogenic pain. During contrast injection disc pressure was recorded simultaneously in the injected and in one adjacent disc. All 33 adjacent discs in the healthy porcine spines displayed increased pressure of a mean of 16% (range 3-37) above baseline pressure. In the degenerated porcine spines 16 (57%) of the discs adjacent to the discograms revealed a pressure increase averaging 3 psi (range 2-8), corresponding to a mean increase above baseline of 11%. When including pressure reactions up to 15 minutes after injection increased pressure was recorded in 89% of the adjacent discs. In the clinical study 12 (55%) of the discs adjacent to the discograms displayed a pressure increase of a mean of 13 psi (range 3-42), corresponding to an increase of 62%. This induced pressure increase in adjacent discs (potentially inducing pain) constitutes a potential major source of false positive responses, questioning the validity of discography. Study IV: 41 patients referred for discography underwent pressure controlled discography (PCD), CT, MRI and alMRI within 24 hours. 35 patients completed all MRI sequences (140 discs) and PCD was performed in 119 of the discs examined at MRI. The detection of HIZ was compared between conventional MRI and alMRI without significant differences. No significant correlation between HIZ and pain provoked at PCD was found. With PCD discogenic pain can neither be confirmed in discs with HIZ (PPV 39%) nor ruled out in discs without (NPV 76%). Quantification of HIZ at conventional and alMRI are needed to fully rule out any dynamic component of HIZ. Study V: 41 patients referred for discography underwent PCD (119 discs), MRI and alMRI within 24 hours. Provoked pain at both discography and at alMRI was classified as concordant or discordant with daily pain as reference. Relationships between concordant pain at discography and morphological disc measures (degeneration, height, bulge, angle, area, and circumference) at MRI/alMRI were investigated. 98% of the patients experienced concordant pain at discography compared with 78% at the alMRI. No significant, clinically useful, differences between concordant and discordant discograms in terms of morphological MRI characteristics at either conventional MRI, alMRI or changes between these two were found. Alternative or more sensitive diagnostic methods are needed to understand the load-induced discogenic pain. Conclusions: The validity of discography must be questioned due to induced pressure increase (potentially inducing pain) in adjacent discs. The detection of HIZ is not influenced by axial load. HIZ cannot be used as a reliable clinical predictor of painful discs. Loading of the spine, alMRI, revealed no specific clinically useful morphological characteristics in discs with concordant discograms.
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| 14. |
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| 15. |
- Hebelka, Hanna, 1977, et al.
(författare)
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Loading of the Spine in Low Back Pain Patients Does Not Induce MRI Changes in Modic Lesions: A Prospective Clinical Study
- 2022
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Ingår i: Diagnostics (Basel). - : MDPI AG. - 2075-4418. ; 12:8
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Tidskriftsartikel (refereegranskat)abstract
- Modic changes (MCs) are gaining increased interest as potential generators of low back pain (LBP). The current aim was to investigate possible spinal loading effects on the MRI signal in MCs in patients with LBP. Supine lumbar MRIs were performed and immediately repeated with axial loading in 100 LBP patients. A total of 43 patients (23 male, mean age 45.7 years) had MCs. Each Modic was outlined on all sagittal T2-weighted images (>25% affected vertebrae). For reference, regions of interest were placed in both vertebrae without Modic and in Modic-free tissue in vertebrae with Modic. The Modic signal intensity, normalized to cerebrospinal fluid, and Modic volume were compared between MRIs with and without spinal loading. Of the 94 MCs, 36.2% (n = 34) were type I, 58.5% (n = 55) were type II, and 5.3% (n = 5) were type III. No differences in Modic volume (mean 0.046 cm3; p = 0.25) between the MRIs with and without spinal loading were found. In addition, no significant changes in Modic signal were induced by loading (mean 1.5% difference; p = 0.308). Loading increased the signal in the reference regions of interest in vertebrae both with Modic (mean 5.5%; p = 0.002) and without (mean 3.5%; SD 0.09; p = 0.02). To conclude, MRIs performed with and without spinal loading showed no change in either volume or signal of MCs, suggesting that most MCs are not instantaneously influenced by biomechanical load.
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| 16. |
- Hebelka, Hanna, 1977, et al.
(författare)
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Lumbar vertebral T2-relaxation time investigated with T2-mapping at multiple time points in a day demonstrate large individual variations
- 2022
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Ingår i: Diagnostic and Interventional Radiology. - : Galenos Yayinevi. - 1305-3825. ; 28:1, s. 92-97
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Tidskriftsartikel (refereegranskat)abstract
- PURPOSE The increasing interest of endplate and Modic changes as potential pain generators in low back pain (LBP), along with advancement of functional quantitative magnetic resonance imaging (MRI) techniques, makes it important to characterize the vertebral dynamic behavior in detail. This study aims to perform characterization of the dynamic behavior of the vertebral bodies (VB) by investigating the VB diurnal variation in T2-relaxation time in a cross-sectional asymptomatic group of individuals. METHODS T2-mapping of 30 VBs (L1-L5) in six healthy volunteers (mean age, 40 years; range, 29-65 years) was performed with a 1.5 Tesla MRI at three time points over the day (7 am, 12 am, 5 pm). Volumetric regions of interest were segmented manually to determine VB T2-relaxation time, which was compared between the three time points. RESULTS On a group level only small and not significant diurnal VB variation was detected (all P >.10), with median T2 (ms) (quartiles; Q1, Q3) at the three time points 88.7 (84.1, 99.1), 87.3 (85.0, 96.1) and 87.8 (84.4, 99.2). However, in some VBs up to 7% increase respectively 9% decrease in T2-relaxation time was found during the day. Further, there was a relatively large variation between the individuals in absolute VB T2-relaxation times (range 73.2-108.3 ms), but small differences between the VBs within an individual. CONCLUSION This first T2-mapping study of the VB signal dynamics, in repeated investigations during one day, display variation in T2-relaxation time in specific individual VBs but were negligible on a group level. The result may be of importance when evaluating patients with spinal pathologies and suggest further examinations of dynamic changes not only of the disc but also vertebrae. © Turkish Society of Radiology 2021.
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| 17. |
- Hebelka, Hanna, 1977, et al.
(författare)
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Pressure Increase in Adjacent Discs During Clinical Discography, Questions the Methods Validity.
- 2014
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Ingår i: Spine. - 1528-1159. ; 39:11, s. 893-899
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Tidskriftsartikel (refereegranskat)abstract
- Study Design. Observational in vivo clinical studyObjective. To investigate whether intradiscal pressure is transferred to adjacent discs during clinical discography in subjects with discogenic painSummary of Background Data. Despite the introduction of pressure registration in discography, the validity of the method remains controversial. Discography in vivo in anesthetized pigs has shown that the pressure increase during disc injection is transmitted to adjacent discs. If pressure transmission is confirmed in human spines, it could be a potential source of false positive discography responses.Methods. 25 discograms were performed in nine consecutive patients. A pressure sensor was introduced through a 22 G needle into the nucleus pulposus in two adjacent discs. Contrast was injected with a manometer (approx. 0.03 ml/s) into one of the discs, while intradiscal pressure was measured simultaneously in both discs. The injection continued until one of the endpoints was reached - concordant pain with an intensity of ≥ 5/10, intradiscal pressure of 80 psi (absolute pressure) and/or 3.5 ml contrast volume.Results. Intradiscal pressure was successfully measured in 22 adjacent discs of which seven were not filled with contrast and 15 were pre-filled from the previous discogram. A mean pressure increase of 13 psi (range 3-42) was recorded in 54% (12) of the adjacent discs, corresponding to an increase of 62% above baseline. Of discograms inducing pressure transmission, all had Pfirrmann degeneration grade of ≥ 3 and, of adjacent discs with increased pressure, 75% had degeneration of ≥ 3. Maximum pressure in injected discs averaged 35 psi above opening pressure (range 10-69).Conclusion. Clinical discography induces a pressure increase in adjacent discs. The induced pressure increase was of a clinically relevant magnitude and was evident despite low absolute pressures in the injected disc. Pressure transmission during discography constitutes a potential major source of false positive responses, questioning the ability of discography to provoke pain at just a single disc level.
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| 18. |
- Hebelka, Hanna, 1977, et al.
(författare)
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Radiology and Degenerative Spondylolisthesis
- 2018
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Ingår i: Lumbar Spine Online Textbook.. - : International Society for the Study of the Lumbar Spine.
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Bokkapitel (refereegranskat)
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| 19. |
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| 20. |
- Hebelka, Hanna, 1977, et al.
(författare)
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The importance of level stratification for quantitative MR studies of lumbar intervertebral discs: a cross-sectional analysis in 101 healthy adults
- 2019
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Ingår i: European Spine Journal. - : Springer Science and Business Media LLC. - 0940-6719 .- 1432-0932. ; 28:9, s. 2153-2161
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Tidskriftsartikel (refereegranskat)abstract
- Purpose: To investigate whether quantitative T2-times depend on lumbar intervertebral disc (IVD) level. Methods: The lumbar spine (Th12/L1–L5/S1) of 101 participants (53.5% female, 30.0[± 3.6]years, 173.5[± 9.6]cm and 69.9[± 13.4]kg), without history of back pain, was examined on a 3T scanner with sagittal T2-mapping. All IVDs were stratified according to Pfirrmann grade and lumbar level, with mean T2-time determined for the entire IVD volume and in five subregions of interests. Results: Significant level-dependent T2-time differences were detected, both for the entire IVD volume and its subregions. For the entire IVD volume, Pfirrmann grade 2 IVDs displayed 9–18% higher T2-times in Th12/L1 IVDs compared to L2/L3–L5/S1 IVDs (0.001 > p < 0.004) and significantly different T2-times in L1/L2–L2/L3 IVDs compared to most of the IVDs in the lower lumbar spine. In Pfirrmann grades 1, 3 and 4 IVDs, no significant level-dependent T2-time differences were observed for the entire IVD. More pronounced results were observed when comparing IVD subregions, with significant level-dependent differences also within Pfirrmann grade 1 and grade 3 IVDs. For example, in posterior IVD subregions mean T2-time was 80–82% higher in Th12/L1 compared to L3/L4–L4/L5 Pfirrmann grade 1 IVDs (p < 0.05) and 10–14% higher in L5/S1 compared to L3/L4–L4/L5 Pfirrmann grade 3 IVDs (0.02 > p < 0.001). Discussion: Significant level-dependent T2-time differences within several Pfirrmann grades, both for the entire IVD volume and for multiple IVD subregions, were shown in this large cohort study. The T2-time differences between levels existed in both non-degenerated and degenerated IVDs. These findings show the importance of stratifying for lumbar level when quantitative IVD studies are performed using T2-mapping. Graphic abstract: These slides can be retrieved under Electronic Supplementary Material.[Figure not available: see fulltext.]. © 2019, The Author(s).
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| 21. |
- Hebelka, Hanna, 1977, et al.
(författare)
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The transfer of disc pressure to adjacent discs in discography: a specificity problem?
- 2010
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Ingår i: Spine. - 0362-2436. ; 35:20
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Tidskriftsartikel (refereegranskat)abstract
- STUDY DESIGN: In vivo experimental study. OBJECTIVE: The primary objective of the study was to investigate pressure transmission to adjacent discs during discography. A secondary objective was to quantify the transmitted pressure, both in contrast injected and noninjected porcine intervertebral discs. SUMMARY OF BACKGROUND DATA: Discography is used to before surgery identify painful discs. A pain response during discography that is concordant with the patient's experienced back pain is regarded as an indication that the injected disc is the source of pain. However, the sensitivity and specificity of discography are matters of debate. Pressure-controlled discographies have been reported to reduce the number of false-positive discs using low pressure criteria. Preliminary data indicated a transfer of pressure from an injected to an adjacent disc during discography. Pressure transmission in vivo during lumbar discography, not reported before might, if clinically present, contribute to a false-positive diagnosis. METHODS: Thirty-six lumbar discs in 9 adolescent pigs were investigated. Intradiscal pressure was recorded during contrast injection, using a 0.36/0.25 mm fiber-optic pressure transducer inserted into the nucleus pulposus via a 22 G needle. The pressure was measured simultaneously in 2 adjacent discs during contrast injection into 1 of the discs at pressures up to 8 bar. Transmitted pressure was recorded both in noninjected discs and in discs that were prefilled with contrast. RESULTS: Thirty-three discs were successfully examined. During contrast injection, there was an intradiscal pressure rise in the adjacent disc with a median value of 16.0% (range, 3.2-37.0) over baseline pressure. There was no significant difference in pressure increase between the noninjected and prefilled discs (P < 0.68). CONCLUSION: Discography of porcine discs induces a pressure increase in adjacent discs. A similar pressure transfer during human clinical discography might elicit false-positive pain reactions.
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| 22. |
- Hedelin, Henrik, 1975, et al.
(författare)
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Innominate salter osteotomy using resorbable screws: A retrospective case series and presentation of a new concept for fixation
- 2019
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Ingår i: Journal of Children's Orthopaedics. - : SAGE Publications. - 1863-2521 .- 1863-2548. ; 13:3, s. 310-317
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Tidskriftsartikel (refereegranskat)abstract
- © 2019, British Editorial Society of Bone and Joint Surgery. All rights reserved. Purpose The Salter innominate osteotomy (SIO) in children is traditionally stabilized by Kirschner-wires, which have issues regarding stability, infection and the need to be extracted. To counter these disadvantages, we present a surgical method to stabilize SIO with modern resorbable poly lactic-co-glycolic acid screws. Using a case series of 21 patients treated with SIO for developmental dysplasia of the hip or Legg-Calvé- Perthes disease we evaluate the feasibility of the method. Methods The integrity of the osteotomy was interpreted by radiological measurements of acetabular index, centre-edge angle and Reimer’s index. Perioperative and postoperative complications were evaluated. Results Radiographic evaluation revealed a stable osteotomy and favourable development in all measured parameters with the exception of one patient who fell out of bed the first day postoperatively. No other perioperative surgical complications were observed and there were no local reactions to the resorbable screws. Conclusion Modern resorbable screws carry multiple benefits both for the patient and the surgeon. In our case series the implants provided sufficient stability and the implants caused no local reactions. The use of resorbable implants gave the surgeon a wider range of possible screw placements and avoided the need for implant removal.
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| 23. |
- Hedelin, Henrik, 1975, et al.
(författare)
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Minimal training sufficient to diagnose pediatric wrist fractures with ultrasound
- 2017
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Ingår i: Critical Ultrasound Journal. - : Springer Science and Business Media LLC. - 2036-3176 .- 2036-7902. ; 9:11
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Tidskriftsartikel (refereegranskat)abstract
- Background: In children, non-fractured wrists generally need no treatment and those that are fractured may only require a 3-week cast without any clinical follow-up. The ability to perform a point-of-care triage decision if radiographs are needed could improve patient flow and decrease unnecessary radiographs. The aim of this study was to evaluate the role of ultrasound (US) as a point-of-care triage tool for pediatric wrist injuries with limited training. Methods: Physicians with no previous US experience attended a 1.5 h course in the use of US to diagnose distal radius fractures at the Emergency Department (ED). The physicians firstly used US to diagnose a potential fracture and, if the patient had a fracture, grouped the patient according to how they wanted him/her to be treated based on US. The physician then interpreted the subsequent radiographs and decided on a treatment based on this information. Consultant traumatologists and a senior radiologist established a gold standard for correct treatment and radiological diagnosis, respectively. Results: One hundred and sixteen injuries in 115 patients were included. The ED physician identified 75 fractures on radiographs. With the exception of a minimal buckle fracture, all were identified on US. US had a tendency to interpret complete fractures on radiographs as incomplete (n = 7) leading to incorrect treatment decisions. Conclusions: In the hands of an US novice, US examination is comparable with radiographs as a point-of-care tool to distinguish a fractured wrist from a non-fractured one. US is not, however, as good as radiographs for placing fractured wrists into the correct treatment group.
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| 24. |
- Hedelin, Henrik, 1975, et al.
(författare)
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MRI evaluation of resorbable poly lactic-co-glycolic acid (PLGA) screws used in pelvic osteotomies in children—a retrospective case series. : Hedelin H, Hebelka H, Brisby H, Laine T.
- 2020
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Ingår i: Journal of Orthopaedic Surgery and Research. - : Springer Science and Business Media LLC. - 1749-799X. ; 15:1
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Tidskriftsartikel (refereegranskat)abstract
- Purpose: The orthopaedic use of resorbable poly lactic-co-glycolic acid (PLGA) implants carries multiple potential benefits. To our knowledge, only one publication exists regarding the use of PLGA implants in pelvic osteotomies in children, and data regarding resorption and potential side effects are lacking for resorbable pelvic screws in children. The aim of this study is to present an MRI-based evaluation of the resorption pattern and local tissue reactions in a paediatric case series after pelvic osteotomies fixated with PLGA screws. Methods: Twelve children who had undergone a Salter or triple pelvic osteotomy fixated with 4.5 mm PLGA screws were included. A total of 18 MRIs was performed 0.5-4.5 years after surgery and were retrospectively analysed. Eight parameters relating to screw resorption, local reactions and re-formation of bone were interpreted. Results: The screw canals were > 90% replaced with solid bone after 2-4.5 years in all cases but one, where the canals were only partly replaced with bone. There were no major soft tissue reactions but small (< 12 mm) bone cysts were observed in 3 of the 18 MRIs and discrete fatty patches in the adjacent bone were common. Conclusion: PLGA screws in the paediatric pelvis appear to be resorbed and replaced with solid bone in most cases but this process takes at least 2 years. Minor reactions could be seen in the adjacent bone but were judged to be of no clinical significance.
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| 25. |
- Hedelin, Henrik, 1975, et al.
(författare)
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Stability in Pelvic Triple Osteotomies in Children Using Resorbable PLGA Screws for Fixation
- 2021
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Ingår i: Journal of Pediatric Orthopaedics. - : Ovid Technologies (Wolters Kluwer Health). - 0271-6798. ; 41:9
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Tidskriftsartikel (refereegranskat)abstract
- Background: The triple pelvic osteotomy (TPO) is a major redirectional osteotomy used to improve the acetabular coverage of the femoral head in selected pediatric patients with hip disorders. Traditionally the iliac osteotomy is stabilized by metal screws that require a second surgery for removal. Despite favorable results for both adults and children in related pelvic osteotomies, resorbable implants have not previously been used for TPOs. This study aims to suggest a novel modified TPO surgical method in children using resorbable poly lactic-co-glycolic acid (PLGA) screws for fixation and to radiographically evaluate the postoperative stability achieved by these implants in a case series. Methods: All patients (n=11) with dysplasia of the hip (2), Perthe disease (5), or Down syndrome (4), who underwent primary TPO surgery during 2013 to 2019, using resorbable PLGA screws for fixation were included. The stability of the osteotomy was evaluated in the postoperative radiograph series using the acetabular index, migration percentage, Sharp's angle and the center-edge angle. The osteotomy angle was introduced as a parameter to confirm the postoperative integrity of the achieved correction. All cases were evaluated until radiographic healing of the iliac osteotomy. Hospital notes were analyzed for complications or local reactions in relation to the implants. Results: In all studied hips, the overall achieved correction was well maintained. The mean (SD) correction achieved, from the preoperative images to the last measurable postoperative image, was a 16.7 degrees decrease for Sharp angle, a 20.9 degrees decrease in acetabular index and a 24.7 degrees increase for the center-edge angle, respectively. There were no complications related to the bioabsorption of the implants. Conclusion: The present findings suggest that the modified TPO method, using resorbable PLGA screws, provides sufficient stability and appears to be a promising alternative to traditional TPO. Avoiding implant removal is a major benefit in a pediatric population. Resorbable screws enable the surgeon to place implants with more degrees of freedom since later implant removal is not a limiting factor.
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