Bel ağrısı hastalarında lumbosakral transisyonel vertebra saptanmasında lomber BT ve rutin lomber MRG sekanslarının karşılaştırılması ve MRG incelemelerinde koronal STIR sekansının değeri

Abstract

Amaç: Bu çalışmanın amacı, koronal sekans kullanılmadan yapılan rutin lomber MRG incelemelerinde LSTV (lumbosakral transisyonel vertebra) ve alt tiplerinin saptanma oranlarını, bu konuda altın standart yöntem olan lomber BT ile karşılaştırmaktır. Gereç ve yöntem: Bu retrospektif çalışmada, Şubat 2016 ile Nisan 2024 arasında kliniğe "bel ağrısı" nedeniyle başvuran ve hem lomber MRG hem de BT görüntüleri bulunan 1.560 hasta değerlendirildi. BT'de LSTV varyasyonu olan toplam 105 hasta belirlendi ve bu hastaların MRG görüntüleri, LSTV’nin tespiti, Castellvi sınıflamasına göre alt tip belirlenmesi, foraminal stenoz değerlendirilmesi ve varsa psödoartikülasyon düzeyindeki ödem tespiti için iki gözlemci tarafından bağımsız olarak incelendi. Bulgular: 1,446 hastanın %9,16'sında LSTV saptanmıştır. Hastaların yaş ortalaması 60 olup, %72,4'ü kadın hastadır. MRG değerlendirmesinde 64 hastada (%61) LSTV saptandı. İki gözlemci arasında LSTV tespiti konusunda yüksek düzeyde uyum gözlenmiştir (κ=0,795, p<0,001); ancak alt tip sınıflandırmasında anlamlı uyumsuzluk bulunmuştur (κ=0,0, p=0,755). BT ve MRI sonuçları karşılaştırıldığında, MRG'nin LSTV tiplerini sınıflandırmadaki doğruluğu oldukça düşük kalmıştır (κ=0,192, p<0,001). Psödoartikulasyon seviyesinde ödem, her iki gözlemci tarafından benzer şekilde tespit edilmiştir (κ=0.9576, p<0,001). BT'de 20 hastada, MRG'de ise 16 hastada foraminal stenoz saptanmış olup gözlemciler arasında yüksek düzeyde uyum gözlenmiştir (κ=0,926, p<0,001). Sonuç: Rutin MRG protokollerinde disk patolojilerine odaklanılması nedeniyle LSTV sıkça gözden kaçmaktadır. Koronal planda STIR sekansının eklenmesi, LSTV’nin saptanması ve bu düzeydeki inflamasyon ve stenozun erken dönemde fark edilmesi açısından önemlidir.

Keywords

• Lumbosakral transisyonel vertebra
• manyetik rezonans görüntüleme
• STIR
• psödoartikülasyon
• bel ağrısı

Comparison of lumbar CT and routine lumbar MRI sequences in detecting lumbosacral transitional vertebrae in patients with low back pain and the value of coronal STIR sequence on MRI

Abstract

Purpose: This study aims to compare the detection rates of LSTV (lumbosacral transitional vertebrae) and its subtypes in routine lumbar MRI performed without a coronal sequence with those of lumbar spine CT, which is the gold-standard method in this regard. Materials and methods: This retrospective study evaluated 1,560 patients who presented with "back pain" between February 2016 and April 2024 and had both lumbar MRI and CT images recorded. A total of 105 patients with LSTV on CT were identified, and two observers independently reviewed the MRI images of these patients for LSTV detection, Castellvi subtype classification, extraforaminal stenosis, and detection of edema at the pseudoarticular level. Results: LSTV was identified in 9.16% of the 1.446 patients. The mean age of the patients was 60, and 72.4% were female. The MRI evaluation revealed LSTV in 64 patients (61%). A high level of agreement was observed between the observers for LSTV detection (κ=0.795, p<0.001); however, a significant discrepancy appeared in subtype classification (κ=0.0, p=0.755). When comparing CT and MRI results, the accuracy of MRI in classifying LSTV types remained low (κ=0.192, p<0.001). Both observers similarly detected edema at the pseudoarticulation level (κ=0.9576, p<0.001). Extraforaminal stenosis was identified in 20 patients on CT and 16 patients on MRI, with a high degree of agreement between the observers (κ=0.926, p<0.001). Conclusion: LSTV is often overlooked in routine MRI protocols because the focus is on disc pathology. A coronal STIR sequence is essential for detecting LSTV and identifying inflammation and stenosis at this level.

Keywords

• Lumbosacral transitional vertebra
• magnetic resonance imaging
• STIR
• pseudoarticulation
• back pain

References

1. Alonzo F, Cobar A, Cahueque M, Prieto JA. Bertolotti's syndrome: an underdiagnosed cause for lower back pain. J Surg Case Rep. 2018;2018(10):rjy276. Published 2018 Oct 17. doi:10.1093/jscr/rjy276
2. Jancuska JM, Spivak JM, Bendo JA. A Review of Symptomatic Lumbosacral Transitional Vertebrae: Bertolotti's Syndrome. Int J Spine Surg. 2015;9:42. Published 2015 Jul 29. doi:10.14444/2042
3. Miller AE, Zhang A. Bertolotti Syndrome. In: StatPearls. Treasure Island (FL): StatPearls Publishing; July 25, 2023.
4. Castellvi AE, Goldstein LA, Chan DP. Lumbosacral transitional vertebrae and their relationship with lumbar extradural defects. Spine (Phila Pa 1976). 1984;9(5):493-495. doi:10.1097/00007632-198407000-00014
5. Tini PG, Wieser C, Zinn WM. The transitional vertebra of the lumbosacral spine: its radiological classification, incidence, prevalence, and clinical significance. Rheumatol Rehabil. 1977;16(3):180-185. doi:10.1093/rheumatology/16.3.180
6. Farshad Amacker NA, Lurie B, Herzog RJ, Farshad M. Interreader and intermodality reliability of standard anteroposterior radiograph and magnetic resonance imaging in detection and classification of lumbosacral transitional vertebra. Spine J. 2014;14(8):1470-1475. doi:10.1016/j.spinee.2013.08.048
7. McGrath K, Schmidt E, Rabah N, Abubakr M, Steinmetz M. Clinical assessment and management of Bertolotti Syndrome: a review of the literature. Spine J. 2021;21(8):1286-1296. doi:10.1016/j.spinee.2021.02.023
8. Farshad Amacker NA, Herzog RJ, Hughes AP, Aichmair A, Farshad M. Associations between lumbosacral transitional anatomy types and degeneration at the transitional and adjacent segments. Spine J. 2015;15(6):1210-1216. doi:10.1016/j.spinee.2013.10.029

9. Konin GP, Walz DM. Lumbosacral transitional vertebrae: classification, imaging findings, and clinical relevance. Am J Neuroradiol. 2010;31(10):1778-1786. doi:10.3174/ajnr.A2036
10. Hou L, Bai X, Li H, et al. Lumbar plain radiograph is not reliable to identify lumbosacral transitional vertebra types according to Castellvi classification principle. BMC Musculoskelet Disord. 2020;21(1):333. Published 2020 May 29. doi:10.1186/s12891-020-03358-3
11. Hashimoto M, Watanabe O, Hirano H. Extraforaminal stenosis in the lumbosacral spine. Efficacy of MR imaging in the coronal plane. Acta Radiol. 1996;37(5):610-613. doi:10.1177/02841851960373P238
12. Neelakantan S, Anandarajan R, Shyam K, Philip B. Multimodality imaging in Bertolotti's syndrome: an important cause of low back pain in young adults. BMJ Case Rep. 2016;2016:bcr2016217121. Published 2016 Nov 14. doi:10.1136/bcr-2016-217121
13. White AA 3rd, Gordon SL. Synopsis: workshop on idiopathic low-back pain. Spine (Phila Pa 1976). 1982;7(2):141-149. doi:10.1097/00007632-198203000-00009
14. Lakadamyali H, Tarhan NC, Ergun T, Cakir B, Agildere AM. STIR sequence for depiction of degenerative changes in posterior stabilizing elements in patients with lower back pain. AJR Am J Roentgenol. 2008;191(4):973-979. doi:10.2214/AJR.07.2829
15. Lee IS, Kim HJ, Lee JS, Moon TY, Jeon UB. Extraforaminal with or without foraminal disk herniation: reliable MRI findings. AJR Am J Roentgenol. 2009;192(5):1392-1396. doi:10.2214/AJR.08.1035
16. Sollmann N, Fields AJ, O'Neill C, et al. Magnetic Resonance Imaging of the Lumbar Spine: Recommendations for Acquisition and Image Evaluation from the BACPAC Spine Imaging Working Group. Pain Med. 2023;24(Suppl 1):S81-S94. doi:10.1093/pm/pnac130
17. Sayah A, Jay AK, Toaff JS, Makariou EV, Berkowitz F. Effectiveness of a Rapid Lumbar Spine MRI Protocol Using 3D T2-Weighted SPACE Imaging Versus a Standard Protocol for Evaluation of Degenerative Changes of the Lumbar Spine. AJR Am J Roentgenol. 2016;207(3):614-620. doi:10.2214/AJR.15.15764
18. Ghasemi A, Luna R, Kheterpal A, Debs P, Fayad L. Axial T1-weighted imaging of the lumbar spine: a redundancy or an asset?. Skeletal Radiol. 2024;53(6):1061-1070. doi:10.1007/s00256-023-04522-1
19. Zerunian M, Pucciarelli F, Caruso D, et al. Fast high-quality MRI protocol of the lumbar spine with deep learning-based algorithm: an image quality and scanning time comparison with standard protocol. Skeletal Radiol. 2024;53(1):151-159. doi:10.1007/s00256-023-04390-9
20. Wassenaar M, van Rijn RM, van Tulder MW, et al. Magnetic resonance imaging for diagnosing lumbar spinal pathology in adult patients with low back pain or sciatica: a diagnostic systematic review. Eur Spine J. 2012;21(2):220-227. doi:10.1007/s00586-011-2019-8
21. Chalian M, Soldatos T, Carrino JA, Belzberg AJ, Khanna J, Chhabra A. Prediction of transitional lumbosacral anatomy on magnetic resonance imaging of the lumbar spine. World J Radiol. 2012;4(3):97-101. doi:10.4329/wjr.v4.i3.97
22. Apaydin M, Uluc ME, Sezgin G. Lumbosacral transitional vertebra in the young men population with low back pain: anatomical considerations and degenerations (transitional vertebra types in the young men population with low back pain). Radiol Med. 2019;124(5):375-381. doi:10.1007/s11547-018-0974-4
23. D'Aprile P, Nasuto M, Tarantino A, Cornacchia S, Guglielmi G, Jinkins JR. Magnetic Resonance Imaging in degenerative disease of the lumbar spine: Fat Saturation technique and contrast medium. Acta Biomed. 2018;89(1-S):208-219. Published 2018 Jan 19. doi:10.23750/abm.v89i1-S.7024
24. Laporte C, Albert JD, Duvauferrier R, Bertaud V, Gouillou M, Guillin R. MRI investigation of radiating pain in the lower limbs: value of an additional sequence dedicated to the lumbosacral plexus and pelvic girdle. AJR Am J Roentgenol. 2014;203(6):1280-1285. doi:10.2214/AJR.13.11884
25. Borg B, Modic MT, Obuchowski N, Cheah G. Pedicle marrow signal hyperintensity on short tau inversion recovery- and t2-weighted images: prevalence and relationship to clinical symptoms. AJNR Am J Neuroradiol. 2011;32(9):1624-1631. doi:10.3174/ajnr.A2588
26. Nevalainen MT, McCarthy E, Morrison WB, Zoga AC, Roedl JB. Lumbosacral transitional vertebrae: significance of local bone marrow edema at the transverse processes. Skeletal Radiol. 2018;47(8):1145-1149. doi:10.1007/s00256-018-2900-1
27. Porter NA, Lalam RK, Tins BJ, Tyrrell PN, Singh J, Cassar-Pullicino VN. Prevalence of extraforaminal nerve root compression below lumbosacral transitional vertebrae. Skeletal Radiol. 2014;43(1):55-60. doi:10.1007/s00256-013-1750-0
28. Kanematsu R, Hanakita J, Takahashi T, Minami M, Tomita Y, Honda F. Extraforaminal entrapment of the fifth lumbar spinal nerve by nearthrosis in patients with lumbosacral transitional vertebrae. Eur Spine J. 2020;29(9):2215-2221. doi:10.1007/s00586-020-06460-1
29. Bezuidenhout AF, Lotz JW. Lumbosacral transitional vertebra and S1 radiculopathy: the value of coronal MR imaging. Neuroradiology. 2014;56(6):453-457. doi:10.1007/s00234-014-1361-z