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Chung M, Dahabreh IJ, Hadar N, et al. Emerging MRI Technologies for Imaging Musculoskeletal Disorders Under Loading Stress [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2011 Nov. (Comparative Effectiveness Technical Briefs, No. 7.)

Cover of Emerging MRI Technologies for Imaging Musculoskeletal Disorders Under Loading Stress

Emerging MRI Technologies for Imaging Musculoskeletal Disorders Under Loading Stress [Internet].

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Appendix EComparative Studies of Diagnostic Tests

Author, year [UI]
Country
Center
Enrollment year
N enrolled
Inclusion criteria
Sampling
Mean age [SD/range], yr
(% male)
Weight-bearing MRI
  • Device description
  • Model (manufacturers)
  • Field strength
  • Coil
  • Loading
  • Positioning
  • Configuration
Comparator testOutcomesMain findingsFunding
Comments
Lumbar spine imaging with open, positional MRI
Vitzthum 20001 [10879759]
Germany
nd
nd
50 (patients); 50 (healthy controls)
Cases: Lumbar disc herniation (82%), lateral osteogenic recess stenosis (10%); degenerative spondylolithesis (8%)
Controls: healthy volunteers
Sampling not described.
Patients: 53 [34 to 71]
(60)
Controls: 24.5 [3.4]
(56)
Open, interventional MRI
  • Open MRI
  • Signa SP (GE)
  • 0.5 T
  • nd
  • Sitting
  • Neutral, extension, flexion, rotation (dynamic)
  • Vertically open
Prior MRI finding: decompression of the lumbar nerve roots, which correlated with clinical symptoms
  • Impact on diagnostic thinking
  • Functional patterns based on dynamic exam of flexion-extension, compared to results obtained in healthy controls
  • In 32 (64%) patients dynamic exam of flexion-extension contributed important additional information to the preliminary diagnosis.
  • Patients had characteristics of a Type I functional pattern.
Nonindustry
How controls were selected were not described
Weishaupt, 20002 [10751495]
Switzerland
Single
nd
36 (30 analyzed)
Recruited after MRI of lumbar spine. Low back pain or leg pain for >6 weeks, unresponsiveness to a trial of nonsurgical treatment, surgery not indicated or not urgent on the basis of clinical findings.
Sampling not described.
38 [20 to 50]
(57)
Open, interventional MRI
  • Positional MRI
  • Signa Advanced SP (GE)
  • 0.5 T
  • Flexible transmit-receive wraparound surface coil
  • Sitting
  • Extension, flexion (static)
  • Vertically open
cMRI
  • cMRI
  • Impact Expert (Seimen)
  • 1.0 T
  • Dedicated receive-only spinal coil
  • None
  • Supine neutral
  • Closed
  • Diagnosis of disk abnormalities
  • Impact on diagnostic thinking
  • Pain assessment: a visual analogue scale was used for assessing pain intensity
  • Diagnoses in supine position (cMRI) changed in 4 disks (5%) in seated flexion, and in 7 disks (9%) in seated extension.
  • Positional pain differences are related to position-dependent changes in foraminal size.
nd
Wildermuth, 19983 [9577486]
Switzerland
Single
nd
30
Patients referred for lumbar myelography and agreeing to undergo MR imaging with an open system in another institute
Consecutive
58 [27 to 84]
(43)
Open, interventional MRI
  • Open MRI
  • Advantage SP (GE)
  • 0.5 T
  • Transmit-receive wraparound surface coil
  • Sitting
  • Extension, flexion (static)
  • Vertically open
Lumbar myelography
Radiographs were obtained with fluoroscopic guidance in the lateral decubitus, prone, and left and right posteroanterior oblique projections.
Upright anteroposterior and lateral images were then obtained at flexion and extension.
  • Patient preferences and anxiety during imaging
  • Correlation between MRI and myelographic measurements
  • More patients reported anxiety during myelography than during MRI, and more patients preferred MRI than myelography.
  • Myelography and positional MRI are comparable for quantitative assessment of sagittal dural sac diameters.
Nonindustry
17% patients could not be contacted for preferences and anxiety outcomes.
Zou, 20084 [18317181]
US
nd
2005 to 2006
533
Patients with symptomatic back pain with/without radiculopathy
Selection criteria and sampling were not described.
46.2 [18 to 76]
(42)
Kinetic, upright MRI in extension or flexion position
  • Upright multiposition MRI
  • Upright (Fonar)
  • 0.6 T
  • Quad channel planar coil
  • Standing
  • Extension, flexion (static)
  • Vertically open
Kinetic, upright MRI in neutral position
  • Upright multiposition MRI
  • Upright (Fonar)
  • 0.6 T
  • Quad channel planar coil
  • Standing
  • Neutral
  • Vertically open
Missed diagnosis of lumbar disc herniations, comparing flexion or extension to neutral postion: the extent of lumbar disc bulges in neutral, flexed, and extended views were graded by 2 spine surgeons independently without knowing the patients’ history and clinical findings.19.4%, 13.3% 10.6%, and 9.1% missed diagnosis of a disc herniation in patients with grade 1 (0–3 mm), grade 2 (3–5 mm), grade 3 (5–7 mm), and grade 4 (7–9 mm) of lumbar disc bulges, respectively.Nonindustry
Missed diagnosis rates were calculated based on the number of lumbar discs
Lumbar spine imaging with axial-loading MRI
Danielson, 19985 [9817029]
Sweden
Single
1994 to 1996
34
Clinically suspected lumbar spinal canal narrowing which resulted in sciatica and/or neurogenic claudication
Sampling was not described.
50 [25 to 71]
(53)
cMRI with axial loading
  • cMRI with axial loading
  • Magnetom Impact (Siemens)
  • 1.0 T
  • Surface coil
  • Custom-made axial loading compression devicea (300–400 Newtons or ~50% BW)
  • Axial loading of the lumbar spine in extension
  • Closed
Preloaded cMRI exam
  • cMRI (before axial loading)
  • Magnetom Impact (Siemens)
  • 1.0 T
  • Surface coil
  • None
  • PRP
  • Closed
  • Diagnosis of recess and foraminal stenosis: a reduction in the space available to the nerve roots (recess <3 mm) in combination with loss of epidural fat
  • Pain during axial loading
  • 7 patients (21%) had low back pain and 10 (29%) had leg pain in axial loading of the lumbar spine in extension (ACE )
  • 1 recess stenosis was found in 12 patients and a foraminal stenosis was seen in 1 patients.
  • 5 of the patients with leg pain in ACE had a disc herniation and 6 had a recess stenosis.
Industry
Post hoc exclusion of patients from most of the analyses
Based on the enrollment years and data presented in the table, patients were overlapped with Willen, 1997 and Willen, 2001
Hiwatashi, 20046 [14970014]
Sweden
Single
nd
20
Patients with signs and symptoms of spinal stenosis; with detected appreciable difference in the caliber of the dural sac on the routine and the axially loaded MRI.
Sampling was not described.
54 [32 to 75]
(70)
cMRI with axial loading
  • cMRI with axial loading
  • nd
  • 1.0 T
  • Surface coil
  • DynaWell L-Spine: 50% BW
  • Axial loading of the lumbar spine in extension
  • Closed
Preloaded cMRI exam
  • cMRI (before axial loading)
  • nd
  • 1.0 T
  • Surface coil
  • None
  • PRP
  • Closed
  • Additional information gained from the axially loaded images
  • Changes in treatment decisions based on preloaded cMRI, axial loading MRI, and patients’ clinical history: decisions were made by 3 experienced neurosurgeons (who are also the coauthors of this paper)
Additional information gained from axial loading during MRI of the lumbar portion of the spine changed neurosurgeons’ treatment decision from conservative management to decompressive surgery for 5 (25%) patients.nd
Retrospective secondary database analyses.
Selection of patients based on the MRI findings.
Danielson was the 2nd author.
Huang, 20097 [19526378]
Taiwan
nd
nd
32 (29 analyzed)
Patients with diagnoses of degenerative L4–L5 spondylolisthesis, grade 1 or 2 slippage. Patients with degenerative scoliosis were excluded.
Consecutive
nd
(19)
cMRI with axial loading
  • cMRI with axial loading
  • Signa Cvi (Siemens)
  • 1.5 T
  • Phase array spinal coil
  • DynaWell: 50% BW
  • Supine in extension
  • Closed
Preloaded cMRI exam
  • Preloaded MRI exam
  • Signa Cvi (Siemens)
  • 1.5 T
  • Phase array spinal coil
  • None
  • Supine
  • Closed
  • Disability: Oswestry Diability Index (ODI)
  • Physical functioning: Physical Function (PF) scale
After adjustment for sex and age, significant associations were found between ODI, PF and the difference of segmental angulation, and the PF and the post-loaded lumbar lordotic angles (p=0.02)Nonindustry
Patients were excluded from the study after axial loading due to intolerable back pain, numbness or sciatica
Manenti, 20038 [14598603]
Italy
nd
nd
50 (patients); 43 (healthy controls)
Patients with a history of chronic lumbar pain and recurrent movement-induced painful blockages.
Healthy controls were selected by matching weight, age, sex and job
Patients: 46 [19]
(56)
Controls: matching age and sex
cMRI with axial loading
  • Axial loading MRI
  • Gyroscan Intera (Phillips)
  • 1.5 T
  • Flexible surface coil
  • Axial compressor (MIKAI manufacturing, Genoa, Italy): 65% BW
  • Supine in extension
  • Closed
Preloaded cMRI exam
  • Neutral unloaded routine MRI
  • Gyroscan Intera (Phillips)
  • 1.5 T
  • Flexible surface coil
  • None
  • PRP
  • Closed
Diagnosis of discal degeneration or protrusion: 3 radiologists evaluated the mages through the compilation of an apposite questionnaire on the modifications occurring from the neutral to the loaded acquisitions.Relative to the control group, 43 patients were studied for a total of 129 discal levels. 31 presented discal degeneration at 56 (43%) of the studied discal levels.
Diagnosis of discal protrusion was made at 19 discal levels in 12 patients.
Nonindustry
Willen, 19979 [9431634]
Sweden
Single
1994 to 1995
34 (80 sites)
Patients selection criteria were not described.
Sampling was not described.
53 [25 to 74]
(53)
cMRI with axial loading
  • cMRI with axial loading
  • Magnetom Impact (Siemens)
  • 1.0 T
  • Surface coil
  • Custom-made axial loading harnessa (~50% BW)
  • Axial loading of the lumbar spine in extension
  • Closed
Preloaded cMRI exam
  • cMRI (before axial loading)
  • Magnetom Impact (Siemens)
  • 1.0 T
  • Surface coil
  • None
  • PRP
  • Closed
Diagnosis of disc abnormalities (e.g.,disc herniation, lateral recess or formaminal stenosis, or a intraspinal synovial cyst at PRP changing to obvious manifestation at ACE)
  • In 11 patients (16 sites), stenosis was found in one or two sites.
  • Narrowing of the lateral recess was noted in 13 sites.
nd
Post hoc exclusion of patients from most of the analyses
Based on the enrollment years and data presented in the table, patients were overlapped with subsequent publications.
Willen, 200110 [11725243]
Sweden
Single
1994 to 1998
122
Patients were selected according to their symptoms (low back pain, sciatica, or neurogenic claudication).
Sampling was not described.
50 [14 to 80]
(52)
cMRI with axial loading
  • cMRI with axial loading
  • Magnetom Impact (Siemens)
  • 1.0 T
  • Surface coil
  • DynaWell L-Spine: 40% BW (never >50% BW)
  • Axial loading of the lumbar spine in extension
  • Closed
Preloaded cMRI exam
Protocol same as Willen, 1997
Impact on diagnostic thinking: AVI was defined as 1) a sig. reduction of the DCSA (>15 mm2) to areas <75 mm2 (borderline value for canal stenosis) from PRP to ACE, or 2) a suspected disc herniation, lateral recess or formaminal stenosis, or a intraspinal synovial cyst at PRP changing to obvious manifestation at ACE
  • AVI was found by the axially loaded MRI in 30% patients overall (in patients with sciatica or neurogenic claudication only).
  • No AVI was found in patients with low back pain.
Industry
Post hoc exclusion of patients from most of the analyses
Based on the enrollment years and data presented in the table, patients were overlapped with the prior publication.
Willen, 200811 [18277859]
Sweden
Single
1996 to 2002
250
Patients with clinical signs of neurogenic claudication and/or sciatica.
Sampling was not described.
ndcMRI with axial loading
  • cMRI with axial loading
  • nd
  • 1.0 T
  • Surface coil
  • DynaWell L-Spine: 40% BW (never >50% BW)
  • Axial loading of the lumbar supine in extension
  • Closed
Preloaded cMRI exam
Protocol same as Willen, 1997 and Willen, 2001
  • Impact on diagnostic thinking: AVI (same definition as Willen, 2001)
  • Patient outcomes after surgery
  • In 24 patients, a hidden stenosis was disclosed in 1 to 3 disc levels, whereas no stenosis was detected at the unloaded exam.
  • At 1–6 year after surgery, majority of the 24 patients had much improved or improved leg or back pain, and subjective walking ability.
Industry
Probably some overlaps with Willen, 2001
Outcome data were from the Swedish Spine Register 2005.
Based on the enrollment years and data presented in the table, patients were overlapped with the prior publications
Knee joints imaging
Boxheimer 200612 [16373770]
Switzerland
Single
2002 to 2003
42
Patients suspected of having a meniscal tear; diagnosis of meniscal tears based on cMRI and confirmed by arthroscopy.
Sampling was not described.
37 [18 to 60]
(71)
Open, interventional MRI
  • kinematic MRI
  • Signa SP (GE)
  • 0.5 T
  • Flexible transmit-receive surface coil
  • Standing (allowing arms on a support frame)
  • Upright
Vertically open
Supine position in open, interventional MRI
  • kinematic MRI
  • Signa SP (GE)
  • 0.5 T
  • Flexible transmit-receive surface coil
  • None
  • Supine, or supine 90° flexion with rotation
Vertically open
  • Diagnosis of meniscal displacement: a meniscal movement of 3 mm or more between weight-bearing and supine positions.
Assessment of pain intensity: a visual analog scale was used.
  • 58% menisci with tears did not reveal any displacement between the different knee positions.
  • Patients with displaceable meniscal tears reported significantly more pain in all three knee positions than did patients with nondisplaceable meniscal tear (P<0.05)
nd
Shellock, 199313 [8327718]
US
Single
nd
17 (patients); 5 (healthy controls)
how controls were selected were not described
Patients: 31 [17 to 48]
(39)
Controls: nd
cMRI with kinetic resistance loading
  • 64 MHz MR imager
  • nd
  • 1.5 T
  • Transmit-and-receive quadrature body coil
  • Nonferromagnetic positioning device with a force of 30 ft-lb/sec (resistance)
  • Prone position with joints movement from ~45° to extension
  • Closed
cMRI without loading
  • 64 MHz MR imager
  • nd
  • 1.5 T
  • Transmit-and-receive quadrature body coil
  • Nonferromagnetic positioning device without load
  • Prone position with joints movement from ~45° to extension
  • Closed
Missed diagnosis of patellofemoral joint abnormalities in alignment and tracking (diagnosis was made by two radiologists in blinded fashion)
  • In symptomatic patients, the unloaded kinematic MRI showed 41% normal findings, while loaded kinematic MRI showed 5.9% normal findings.
  • The severity of abnormalities was qualitatively the same with both techniques (9 cases) or greater with the loaded technique (7 cases)
Industry
Foot imaging
Sutera, 201014 [20177977]
Italy
Single
2009
20 (patients); 20 (healthy controls)
Two groups of individuals underwent MRI with a dedicated system were included.
Convenience sample
Patients: 36 [24 to 45]
(80)
Controls: 33 [20 to 41]
(70)
Tilting MRI in upright position
  • Dedicated upright MRI
  • G scan (Esaote)
  • 0.25 T
  • Dedicated platform-shaped receiver coil
  • Standing (~82°)
  • Neutral
  • Laterally open
Tilting MRI in supine position
  • Dedicated upright MRI
  • G scan (Esaote)
  • 0.25 T
  • Dedicated platform-shaped receiver coil
  • Conventional supine
  • Neutral
  • Laterally open
Clinical diagnosis of plantar fasciitis: presence of perifascial oedema or both of fascia thickening and abnormal signal intensity (consensus by 3 radiologists blinded to patients’ groups, history and clinical findings)
  • Both supine and upright positions enabled identification of plantar fasciitis in 15/20 cases (75%) in patient group.
  • None of controls had a diagnosis of plantar fasciitis or abnormal MRI findings in either upright or supine position.
Nonindustry
Weishaupt, 200315 [12601213]
Single
2000 to 2001
18
Patients suspected of having Morton’s neuroma and underwent cMRI of their symptomatic forefoot in the prone position. Only those who had presence of >1 Morton’s neuroma 5 mm or larger in its transverse diameter were included.
Referred by foot surgeons or orthopedic foot surgeons
50 [25 to 72]
(6)
Weight-bearing MRI
  • Weight-bearing MRI
  • Signa Advanced SP (GE)
  • 0.5 T
  • Flexible transmit-receive wraparound surface coil
  • Sitting
  • Extension, flexion (static)
  • Vertically open
cMRI
  • cMRI
  • Impact Expert (Seimen)
  • 1.0 T
  • Send-receive extremity coil
  • None
  • Prone position
  • Closed
Supine MRI in open scanner
  • Supine MRI
  • Signa Advanced SP (GE)
  • 0.5 T
  • Flexible transmit-receive wraparound surface coil
  • None
  • Supine
  • Vertically open
Change in diagnosis of Morton’s neuroma: <5 mm in transverse diameter, measurements were performed by 1 of the authors at a separate workstation using software
  • No additional Morton’s neuroma was found on any of the MR images.
  • Visibility of Morton’s neuroma was significantly better in cMRI in the prone position compared with that in the supine position.
nd
Only included patients with successful imaging in all three
Only included patients with a Morton’s neuroma in the prone position.

ACE=axial loading of the lumbar spine in extension; AVI=additional valuable information; BW=body weight; cMRI=conventional MRI; CT=computed tomography; DCSA=dural sac cross-sectional area; PRP=psoas-relaxed position; SD=standard deviation

a

This custom-made axial loading harness later became commercialized under the brand name of DynaWell L-Spine.

References to Comparative Studies

1.
Vitzthum HE, Konig A, Seifert V. Dynamic examination of the lumbar spine by using vertical, open magnetic resonance imaging. Journal of Neurosurgery. 2000;93:Suppl-64. [PubMed: 10879759]
2.
Weishaupt D, Schmid MR, Zanetti M, et al. Positional MR imaging of the lumbar spine: does it demonstrate nerve root compromise not visible at conventional MR imaging? Radiology. 2000;215:247–53. [PubMed: 10751495]
3.
Wildermuth S, Zanetti M, Duewell S, et al. Lumbar spine: quantitative and qualitative assessment of positional (upright flexion and extension) MR imaging and myelography. Radiology. 1998;207:391–8. [erratum appears in Radiology 1998 Sep;208(3):834] [PubMed: 9577486]
4.
Zou J, Yang H, Miyazaki M, et al. Missed lumbar disc herniations diagnosed with kinetic magnetic resonance imaging. Spine. 2008;33:E140–4. [PubMed: 18317181]
5.
Danielson BI, Willen J, Gaulitz A, et al. Axial loading of the spine during CT and MR in patients with suspected lumbar spinal stenosis. Acta Radiologica. 1998;39:604–11. [PubMed: 9817029]
6.
Hiwatashi A, Danielson B, Moritani T, et al. Axial loading during MR imaging can influence treatment decision for symptomatic spinal stenosis. AJNR Am J Neuroradiol. 2004;25:170–4. [PubMed: 14970014]
7.
Huang KY, Lin RM, Lee YL, et al. Factors affecting disability and physical function in degenerative lumbar spondylolisthesis of L4–5: evaluation with axially loaded MRI. European Spine Journal. 2009;18:1851–7. [PMC free article: PMC2899437] [PubMed: 19526378]
8.
Manenti G, Liccardo G, Sergiacomi G, et al. Axial loading MRI of the lumbar spine. In Vivo. 2003;17:413–20. [PubMed: 14598603]
9.
Willen J, Danielson B, Gaulitz A, et al. Dynamic effects on the lumbar spinal canal: axially loaded CT-myelography and MRI in patients with sciatica and/or neurogenic claudication. Spine (Phila Pa 1976 ). 1997;22:2968–76. [PubMed: 9431634]
10.
Willen J, Danielson B. The diagnostic effect from axial loading of the lumbar spine during computed tomography and magnetic resonance imaging in patients with degenerative disorders. Spine. 2001;26:2607–14. [PubMed: 11725243]
11.
Willen J, Wessberg PJ, Danielsson B. Surgical results in hidden lumbar spinal stenosis detected by axial loaded computed tomography and magnetic resonance imaging: an outcome study. Spine. 2008;33:E109–15. [PubMed: 18277859]
12.
Boxheimer L, Lutz AM, Zanetti M, et al. Characteristics of displaceable and nondisplaceable meniscal tears at kinematic MR imaging of the knee. Radiology. 2006;238:221–31. [PubMed: 16373770]
13.
Shellock FG, Mink JH, Deutsch AL, et al. Patellofemoral joint: identification of abnormalities with active-movement, “unloaded” versus “loaded” kinematic MR imaging techniques. Radiology. 1993;188:575–8. [PubMed: 8327718]
14.
Sutera R, Iovane A, Sorrentino F, et al. Plantar fascia evaluation with a dedicated magnetic resonance scanner in weight-bearing position: our experience in patients with plantar fasciitis and in healthy volunteers. Radiologia Medica. 2010;115:246–60. [PubMed: 20177977]
15.
Weishaupt D, Treiber K, Kundert HP, et al. Morton neuroma: MR imaging in prone, supine, and upright weight-bearing body positions. Radiology. 2003;226:849–56. [PubMed: 12601213]

This custom-made axial loading harness later became commercialized under the brand name of DynaWell L-Spine.

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