Clinical Imaging 50 (2018) 216–222

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Clinical Imaging
journal homepage: www.elsevier.com/locate/clinimag

Musculoskeletal and Emergency Imaging

Diagnosis of lumbar spinal fractures in emergency department: low-dose T

versus standard-dose CT using model-based iterative reconstruction
⁎
Sun Hwa Leea, Seong Jong Yunb, , Hyeon Hwan Joc, Jae Gwang Songd
a
Department of Emergency Medicine, Sanggye Paik Hospital, Inje University College of Medicine, 1342 Dongil-ro, Nowon-gu, Seoul 01757, Republic of Korea
b
Department of Radiology, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, 892 Dongnam-ro, Gangdong-gu, Seoul 05278, Republic
of Korea
c
Department of Radiology, Aerospace Medical Center, 635 Danjae-ro, Namil-myeon, Cheongwon-gun, Chungcheongbuk-do 363-849, Republic of Korea
d
Department of Orthopedic Surgery, Aerospace Medical Center, 635 Danjae-ro, Namilmyeon, Cheongwon-gun, Chungcheongbuk-do 363-849, Republic of Korea

A R T I C LE I N FO A B S T R A C T

Keywords: Purpose: To compared the diagnostic performance of low-dose (LD) lumbar-spine (L-spine) CT with that of
Lumbar spine standard-dose (SD) L-spine CT.
Fracture Methods: Patients who underwent SD (n = 76) or LD (n = 68) L-spine CT using model-based iterative re-
Radiation dose construction were included. Two reviewers independently analyzed 10 anatomical regions on both CT scans.
Computed tomography
Also, suggested treatment decision between both CT scans was compared.
Iterative reconstruction
Diagnostic performance
Results: LD L-spine CT showed an excellent diagnostic accuracy (98.1–98.2%) that was comparable to that of SD
L-spine CT (98.4–99.1%). The suggested treatment decision was not different between both CT scans.
Conclusion: LD L-spine CT can be used as a potential first-line diagnostic tool.

1. Introduction
1.1. Background
Lumbar spinal (L-spinal) fractures can occur when forces applied to
the lower spinal column exceed the forces that can be countered by the
strength and stability of the spinal column unit. L-spinal trauma has
been reported to represent 15% of all cases of spinal trauma and is less
frequent than cervical spinal trauma (55%). However, L-spinal fractures
are more common than cervical spinal fractures [1]. Most L-spinal
fractures occur in elderly individuals with osteoporosis and young in-
dividuals who have experienced major traumas, such as motor vehicle
and pedestrian accidents [1].
For the diagnosis of L-spinal fractures, L-spine conventional radio-
graphy and L-spine three-dimensional (3D) computed tomography (CT)
are the commonly used initial imaging modalities. Although some L-
spinal fractures can be detected with conventional L-spine radiography,
L-spine CT has been gradually playing an important role in the workup
of L-spinal trauma patients owing to its inherently superior contrast
resolution and ability to aid in surgical decisions/planning by spine
surgeons. Additionally, L-spine CT is useful in the emergency depart-
ment (ED) because it can be performed immediately and provides
thorough and rapid assessment of the anatomy and the disease, while
magnetic resonance imaging (MRI) does not allow rapid assessment [2].
From the start of the 2000s, the number of CT examinations has
significantly increased in ED. Optimization of radiation exposure during
a CT examination is necessary because a high radiation dose during a
CT examination may increase the risk of carcinogenesis [3,4]. Few
studies have concluded that low-dose (LD) L-spine CT can replace L-
spine plain radiography or standard-dose (SD) L-spine CT [5–7]. Ad-
ditionally, few studies [8–10] demonstrated that image quality and
diagnostic efficacy were better with L-spine CT using iterative re-
construction (IR) than using filtered-back projection (FBP) reconstruc-
tion, when diagnosing spinal disorders in non-traumatic patients.
First-generation IR techniques rely on FBP data for primary image
reconstruction, with the final image being produced by computational
iterations of FBP. This approach is widely available through all vendors,
such as adaptive statistical iterative reconstruction (ASIR) and the hy-
brid iterative reconstruction method (e.g. 50% ASIR 50% blended with
50% FBP) [11]. In contrast to ASIR, model-based iterative reconstruc-
tion (MBIR) has recently been introduced as a second-generation
iterative reconstruction technique, and it is a pure iterative re-
construction method. In previous studies [11,12], MBIR showed su-
perior objective noise and dose reduction than those with FBP and
ASIR. Thus, MBIR is an important technique in the ED for reduction of
the radiation dose, as ED patients might undergo repeated CT

⁎
Corresponding author.
E-mail address: zoomknight@naver.com (S.J. Yun).

https://doi.org/10.1016/j.clinimag.2018.04.007
Received 22 August 2017; Received in revised form 27 March 2018; Accepted 11 April 2018
0899-7071/ © 2018 Elsevier Inc. All rights reserved.
S.H. Lee et al.
examinations [13]. However, there has been no comparison of the di-
agnostic performance of LD L-spine CT using MBIR with that of SD L-
spine CT using MBIR in L-spinal trauma patients. We hypothesized that
the diagnostic reliability would be similar between these approaches
but the effective radiation dose would be lower with LD L-spine CT
using MBIR than with SD L-spine CT using MBIR with regard to all
anatomical structures of the L-spine. To test our hypothesis, the present
study retrospectively compared the diagnostic performance of LD L-
spine CT with that of SD L-spine CT in patients with suspected L-spinal
fractures.
2. Methods
2.1. Study population
Data for this study were obtained from our tertiary hospital in Seoul,
Republic of Korea. We assessed approximately 40,000 emergency visits
made between January 2016 and December 2016. Our institutional
review board approved this retrospective study and waived informed
consent. The inclusion criteria were as follows: 1) adult (≥18 years)
with lumbar spinal trauma, 2) visit to the ED of our hospital between
January 2016 and December 2016, and 3) performance of L-spine 3D
CT. Between January 2016 and December 2016, a total of 172 con-
secutive patients underwent L-spine 3D CT for identification of sus-
pected L-spinal fractures after trauma. Among these patients, 28 were
excluded because of severe metallic artifacts (n = 14), absence of a
radiation dose report (n = 8), and absence of a sagittal or coronal MPR
image of CT (n = 6). Therefore, 144 patients (mean age, 45.3 ± 15.0
[standard deviation] years; range, 18–95 years), including 66 men
(mean age, 41.2 ± 14.1 years; range, 18–81 years) and 78 women
(mean age, 46.6 ± 15.9 years; range, 18–95 years), were ultimately
enrolled in this study. Data collection was performed consecutively by
one coauthor, based on a picture archiving and communication system
(PACS) (Maro-view 5.4, Infinitt, Seoul, Republic of Korea) and elec-
tronic medical records. Body mass index was calculated using available
data from the patient medical records, and each patient was categorized
into one of the following four groups: underweight, normal weight,
overweight, and obese [14]. Of the 144 patients, 76 underwent SD L-
spine CT between January 2016 and June 2016, while the remaining 68
patients underwent LD L-spine CT between July 2016 and October
2016. Before July 2016, the routine protocol of L-spine CT in ED for
evaluating L-spinal fractures in our institution was a SD protocol. Since
July 2016, the protocol of L-spine CT in ED for evaluating L-spinal
fractures was changed to a LD protocol, based on previous LD L-spine
CT studies [8–10].
2.2. Image acquisition
L-spine CT examinations were performed by using a 320-slice
multidetector CT (MDCT) scanner (Aquilion ONE™ dynamic volume CT,
Toshiba Medical Systems Corporation, Otawara, Japan). Scanning was
performed from the upper endplate of T11 to the coccyx. The effective
tube current–time products were generally 200–300 mAs and
80–150 mAs for SD and LD L-spine CT, respectively. Other parameters
for SD and LD L-spine CT were identical as follows: tube voltage,
120 kVp; collimation, 320 × 0.5 mm; matrix, 512 × 512; rotation
speed, 0.35 s; and bone convolution kernel. Image noise was reduced by
reconstructing the image data from each scan with MBIR (Adaptive
Iterative Dose Reduction 3D [AIDR 3D]; Toshiba Medical Systems,
Tokyo, Japan) sequentially using an automatic-programmed process in
the CT console. The actual radiation dose was adjusted according to the
patient's body size and body shape by automatically modulating the x-,
y-, and z-axis tube currents (SURE Exposure™ 3D Adaptive, Toshiba
Medical Systems Corporation, Otawara, Japan). The adjusted radiation
dose was recorded in terms of dose-length product (DLP).
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Clinical Imaging 50 (2018) 216–222
2.3. Image analysis
All CT images were evaluated by one board-certified emergency
physician and one board-certified radiologist, who were not involved in
patient selection. The two reviewers were unaware of the final clinical
diagnoses and the prevalence of L-spinal fractures. They were also
blinded to patient information, such as name, date of examination, and
clinical symptoms. They performed evaluations in a random order with
respect to the CT studies. They interpreted the MPR images of CT scans
using a PACS in stack mode. The reviewers were permitted to manip-
ulate the window and level of the images. Each reviewer judged whe-
ther L-spinal fracture was present with SD and LD L-spine CT in the
following eight anatomical regions of L1–L5 and two additional regions
(sacrum and coccyx):: (i) vertebral body; (ii) pedicle; (iii) transverse
process; (iv) lamina; (v) superior articular process; (vi) inferior articular
process; (vii) pars interarticularis; (viii) spinous process; (ix) sacrum;
and (x) coccyx. The findings were interpreted by each reader without
knowledge of the findings of other scans, such as L-spine radiography
and L-spine MRI, for the same patient.
2.4. Suggested treatment decisions for L-spine fractures
Based on the interpretations of SD and LD L-spine CT separately, the
emergency physician (reviewer 1) evaluated the suggested treatment
decision (conservative treatment with outpatient clinic follow-up or
immediate consultation with a surgeon for further surgical treatment)
that was considered appropriate. The reviewer was blinded to the
treatment that had actually been used.
2.5. Reference standard
The reference standard was determined by one orthopedic spine
surgeon and one senior board-certified radiologist, who were not in-
volved in patient selection and image analysis. They judged in-
dependently whether L-spinal fracture was present with SD and LD L-
spine CT in the following eight anatomical regions of L1–L5 and two
additional regions (sacrum and coccyx): (i) vertebral body; (ii) pedicle;
(iii) transverse process; (iv) lamina; (v) superior articular process; (vi)
inferior articular process; (vii) pars interarticularis; (viii) spinous pro-
cess; (ix) sacrum; and (x) coccyx. In the case of discrepancy, they
reached agreement by consensus. Chart review and additional image
examinations, such as L-spine MRI, were available for determination of
the reference standard.
To evaluate the appropriateness of the treatment decision by re-
viewer 1, an orthopedic spine surgeon evaluated the suggested treat-
ment decision (conservative treatment with outpatient clinic follow-up
or immediate admission for further surgical treatment).
2.6. Radiation dose analysis
The volume computed tomography dose index (CTDIvol) and DLP
were displayed on the final screen after each examination, and these
were automatically generated by the system. The effective radiation
dose (mSv) was calculated by multiplying the DLP with the conversion
factor of 0.0129 (mSv × mGy−1 × cm−1) [15].
2.7. Statistical analysis
The statistical analysis involved the following components: 1) as-
sessment of the diagnostic accuracy (sensitivity, specificity, accuracy,
positive predictive value, and negative predictive value) of L-spinal
fractures for each reviewer, by using Pearson's chi-square test or Fisher's
exact test for comparison with reference results; 2) comparison of
sensitivity, specificity, and accuracy between SD and LD L-spine CT by
using DeLong's test; and 3) assessment of interobserver agreement by
calculating the kappa value. Interobserver agreement analysis was
S.H. Lee et al. Clinical Imaging 50 (2018) 216–222

Table 1 1 and 2 (p = 0.82 and 0.21, respectively). Additionally, the accuracy,

Patient demographic characteristics. sensitivity, and specificity in each anatomical region showed no sig-
Demographic characteristic Standard-dose CT Low-dose CT p-value nificant difference in both reviewers 1 and 2 (reviewer 1, p = 0.15–1.0;
(n = 76) (n = 68) reviewer 2, p = 0.12–1.0) (Table 3).
The treatment for L-spinal fractures based on SD and LD L-spine CT
Male-to-female ratioa 31:45 35:33 0.26
results did not differ in any patient between reviewer 1 and the or-
Age (y) 45.9 ± 15.4 44.8 ± 14.7 0.66
Male 41.4 ± 14.7 40.5 ± 13.8 0.71
thopedic spine surgeon.
Female 47.5 ± 16.0 46.0 ± 15.8 0.57
Body mass indexa 3.3. Interobserver agreements
Underweight (< 18.5 kg/m2) 2 2 0.69
Normal weight (18.5–24.9 kg/m2) 41 35 0.90
Agreement with the reference standard for all 10 anatomical regions
Overweight (25–29.9 kg/m2) 28 28 0.71
Obese (≥30 kg/m2) 5 3 0.83 was excellent on SD and LD L-spine CT (reviewer 1, k = 0.949 and
0.933, respectively; reviewer 2, k = 0.952 and 0.949, respectively).
Unless otherwise specified, data are means ± standard deviations. Agreement with the reference standard for each of the 10 anatomical
a
Data are numbers of patients. regions was excellent or good on SD and LD L-spine CT (reviewer 1,
k = 0.844–1.000 and 0.785–1.000; reviewer 2, k = 0.846–1.000 and
0.785–1.000, respectively). Good agreement was seen in the pars in-
performed by calculating the kappa value with 95% confidence in- terarticularis in both reviewers and sacrum in reviewer 1 on LD L-spine
terval. The kappa values were defined as follows: 0–0.20, poor agree- CT. Agreement for all 10 anatomical regions was excellent in both re-
ment; 0.21–0.40, fair agreement; 0.41–0.60, moderate agreement; viewers 1 and 2 (k = 0.959 and 0.964, respectively). Additionally,
0.61–0.80, good agreement; and 0.81–1.00, excellent agreement [16]. agreement for each of the 10 anatomical regions was excellent or good
All statistical analyses were performed using MedCalc software (Ver- in both reviewers 1 and 2 (reviewer 1, k = 0.850–1.000; reviewer 2,
sion 12.3.0, Mariakerke, Belgium). A p value < 0.05 was considered k = 0.785–1.000). Good agreement was seen only in the pars inter-
statistically significant. articularis on LD L-spine CT (Table 2).

3. Results 4. Discussion

3.1. Patient characteristics
The patient characteristics are described in Table 1. There were no
significant differences in sex, age, and BMI between the SD and LD L-
spine CT groups. The mean effective doses in the SD and LD L-spine CT
groups were 5.4 ± 1.1 mSv (range, 4.1–8.5 mSv) and 2.1 ± 0.8 mSv
(range, 1.1–3.0 mSv), respectively.
The causes of injury in the 144 study patients included slipping in
44 (30.6%), falls in 38 (26.4%), motor vehicle collision in 24 (16.7%),
blunt injury in 22 (15.3%), and pedestrian accident in 16 (11.1%). The
time interval between trauma and CT scanning was 1.2 ± 0.7 days
(range, 0–3 days).
Based on the reference standard, 140 patients (97.2%; SD L-spine
CT, 74 patients; LD L-spine CT, 66 patients) showed L-spinal fractures.
No fracture was noted in four patients (2.8%; SD L-spine CT, two pa-
tients; LD L-spine CT, two patients). A total of 566 fractures in the 140
patients (mean, 4.0 ± 2.1 fractures; range, 1–8 fractures) were diag-
nosed on SD and LD L-spine CT. Table 2 summarizes the number of
detected fractures for the reference standard and the reviewers between
SD and LD L-spine CT. Reviewer 1 detected 304 fractures in 74 patients
and 250 fractures in 66 patients with SD and LD L-spine CT, respec-
tively. Reviewer 2 detected 312 fractures in 74 patients and 260 frac-
tures in 66 patients with SD and LD L-spine CT, respectively.
3.2. Diagnostic performances of SD and LD L-spine CT
Table 3 summarizes the diagnostic performances of SD and LD L-
spine CT according to the two reviewers. In both reviewers 1 and 2, LD
L-spine CT showed excellent diagnostic performance (accuracy, 98.2%
and 98.1%; sensitivity, 94.9% and 97.3%; specificity, 99% and 98.5%,
respectively), which was comparable to that of SD L-spine CT (accu-
racy, 98.4% and 99.1%; sensitivity, 95% and 96.5%; specificity, 98.6%
and 99.6%, respectively) (Fig. 1). On LD L-spine CT, the lowest accu-
racy was seen in the right transverse process and left lamina (94.4%).
For all other areas, the accuracies were above 95%.
Although fractures tended to be more apparent on SD L-spine CT
than on LD L-spine CT, the accuracy, sensitivity, and specificity for all
10 anatomical regions were not significantly different in both reviewers
We did not find an overall perceptible difference in diagnostic
performance between SD and LD L-spine CT. Additionally, objectively
calculated fracture detection rates in each of the 10 anatomical regions
were not different between the reviewers. When viewed in terms of
treatment, there was no benefit of SD L-spine CT. Compared with the
treatment of choice identified by the orthopedic spine surgeon, the
treatment selected by reviewer 1 was not different on both SD and LD L-
spine CT. This indicates that LD L-spine CT provided acceptable value to
diagnose L-spinal fractures during work-up (Fig. 2) and plan patient
management.
With the increase in the number of CT examinations, radiation dose
in CT examinations is considered as one of the most important safety
concerns in the modern era. An increase in the radiation dose can in-
crease the potential risk of carcinogenesis [3,4]. Additionally, a recent
cohort study concluded that an increase in the radiation dose increased
the incidence of leukemia and brain tumors in adults who received
more than a certain dose of radiation during CT [17]. Thus, the LD
protocol in CT is recommended on the basis of the “first do no harm”
principle and the “as low as reasonably achievable (ALARA)” concept
[18,19]. A previous study by Lee et al. [20] reported that only 9% of
physicians were aware of the increased risk of cancer associated with
increased radiation dose. According to a recently published report [21],
this proportion has increased to 16%; however, the perceptions re-
garding radiation dose in ED still appear to be insufficient [21,22].
Although the decrease in the number of CT examinations is one solu-
tion, it is still debated due to the accurate diagnosis and patient's sa-
tisfaction [23,24]. Thus, we speculated LD protocol CT would be the
best choice for accurate diagnosis with reducing radiation dose in ED.
Studies have compared the feasibility of the LD protocol with that of
the SD protocol in abdominopelvic CT for acute appendicitis or urinary
stones and chest CT for lung nodule evaluation [25–27]. Moreover, LD
protocol abdomen and pelvis CT with MBIR is recommended in ED
setting [28]. In terms of L-spine, few studies concluded that LD L-spine
CT using IR was appropriate for the evaluation of the intervertebral disc
and disc herniation, by comparing this imaging technique with plain
radiography [6,7] and SD L-spine CT using FBP [8,9]. However, no
previous study has focused on traumatic patients with low back pain.
To our knowledge, the present study is the first to evaluate the

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S.H. Lee et al. Clinical Imaging 50 (2018) 216–222

Table 2
Fractures on standard-dose (SD) and low-dose (LD) lumbar spine computed tomography (L-spine CT).
Anatomical region SD L-spine CT ka LD L-spine CT ka

RS R1 R2 RS R1 R2

Vertebral body 38 (12.2) 36 (11.8) 38 (12.2) 0.844–0.939 34 (13.4) 34 (13.6) 34 (13.1) 1.0
Right pedicle 16 (5.1) 14 (4.6) 16 (5.1) 0.850–0.930 13 (5.1) 12 (4.8) 15 (5.8) 0.864–0.957
Left pedicle 28 (9.0) 26 (8.6) 28 (9.0) 0.959–1.0 23 (9.1) 23(9.2) 23 (8.8) 1.0
Right transverse process 28 (9.0) 26 (8.6) 28 (9.0) 0.959–1.0 29 (11.4) 29 (11.6) 29 (11.2) 0.885–1.0
Left transverse process 38 (12.2) 38 (12.5) 42 (13.5) 0.878–0.942 25 (9.8) 27 (10.8) 28 (10.8) 0.911–0.971
Right lamina 24 (7.7) 22 (7.2) 18 (5.8) 0.846–0.953 28 (11.0) 26 (10.4) 27 (10.4) 0.941–0.971
Left lamina 36 (11.5) 34 (11.2) 34 (10.9) 0.933–0.967 28 (11.0) 24 (9.6) 26 (10.0) 0.880–0.939
Right superior articular process 16 (5.1) 12 (3.9) 16 (5.1) 0.850–1.0 12 (4.7) 10 (4.8) 12 (4.6) 0.893–1.0
Left superior articular process 22 (7.1) 24 (7.9) 24 (7.7) 0.858–0.901 12 (4.7) 14 (5.6) 15 (5.8) 0.864–0.957
Right inferior articular process 16 (5.1) 20 (6.6) 16 (5.1) 0.863–0.881 7 (2.8) 7 (2.8) 7 (2.7) 1.0
Left inferior articular process 12 (3.8) 12 (3.9) 14 (4.5) 0.919–1.0 12 (4.7) 12 (4.8) 12 (4.6) 1.0
Pars interarticularis 8 (2.6) 10 (3.3) 8 (2.6) 0.885–1.0 5 (2.0) 5 (2.0) 5 (1.9) 0.785
Spinous process 18 (5.8) 18 (5.9) 18 (5.8) 1.0 23 (9.1) 24 (9.6) 23 (8.8) 0.968–1.0
Sacrum 10 (3.2) 10 (3.3) 10 (3.2) 1.0 2 (0.8) 2 (0.8) 3 (1.2) 0.793–1.0
Coccyx 2 (0.6) 2 (0.7) 2 (0.6) 1.0 1 (0.4) 1 (0.4) 1 (0.4) 1.0
Total 312 (100) 304 (100) 312 (100) 0.949–0.959 254 (100) 250 (100) 260 (100) 0.933–0.964

Data are numbers of fractures, with percentages in parentheses. RS = reference standard; R1 = reviewer 1; R2 = reviewer 2; k = kappa values.
a
Interobserver agreements among RS, R1, and R2.

diagnostic efficacy of LD L-spine CT in traumatic patients with low back
pain.
In terms of the reconstruction method, the traditional reconstruc-
tion method of FBP has been replaced by IR methods, such as ASIR,
which generate images of high quality and with low image noise by
forming iterations between raw data and the image space, allowing a
40–50% CT dose reduction [29]. More recently, a complex iterative
reconstruction technique called MBIR, which is an algorithm that re-
constructs the features of the projection data more accurately based on
the noise system (photon statistics and electronic noise) and geometry
of the machine, has become clinically available. In addition, MBIR
enables further dose reduction than that with ASIR, with preserved
image quality [29,30]. Therefore, MBIR use is essential for radiation
dose reduction in the ED, particularly among patient who might
undergo repeated CT examinations and are thus at a greater risk of
cancer development owing to relatively high cumulative doses [13,28].
Therefore, our study is more meaningful with regard to MBIR use.
L-spine MRI is considered the most accurate modality for spinal
imaging without ionizing radiation. Bone marrow edema change or a
medullary infiltrating lesion has been reported to be better visualized
using L-spine MRI than L-spine CT [6,7]. However, L-spine MRI is not
commonly performed in patients with suspected L-spinal fracture in the
ED owing to its high cost and long examination duration [6,7]. Ad-
ditionally, L-spine MRI has some absolute/relative contraindications,
such as presence of a cardiac pacemaker. These factors may influence
the selection of the initial tool for spinal imaging in the ED.
The present study has several limitations. First, although intra-in-
dividual comparison is the best approach, we did not compare LD and

Table 3
Diagnostic performances of standard-dose (SD) and low-dose (LD) lumbar spine computed tomography (L-spine CT) for each reviewer
Anatomical region Reviewer 1 pa Reviewer 2 pa

SD LD SD LD

Vertebral body 96.5 (89.5, 98.4) 100 (100, 100) 0.15–0.58 98.6 (94.7, 99.2) 100 (100, 100) 0.19–1.0
Right pedicle 99.3 97.2 0.68–1.0 100 98.6 0.98–1.0
(87.5, 100) (85.7, 100) (100, 100) (100, 98.3)
Left pedicle 99.3 (92.9, 100) 100 (100, 100) 0.49–1.0 100 (100, 100) 100 (100, 100) 1.0
Right transverse process 99.3 94.4 0.22–0.62 100 94.4 0.12–0.49
(92.9, 100) (93.1, 95.3) (100, 100) (93.1, 95.3)
Left transverse process 97.2 97.2 0.25–0.95 98.6 95.8 0.60–1.0
(89.5, 98.4) (100, 95.7) (100, 98.4) (100, 93.6)
Right lamina 99.3 97.2 0.68–1.0 97.9 98.6 0.75–1.0
(91.7, 100) (92.9, 100) (92.9, 100) (96.4, 100)
Left lamina 99.3 94.4 0.22–1.0 99.3 94.4 0.22–0.93
(94.4, 100) (85.7, 100) (94.4, 100) (89.3, 97.7)
Right superior articular process 98.6 97.2 0.95–1.0 100 100 1.0
(75, 100) (83.3, 100) (100, 100) (100, 100)
Left superior articular process 97.9 97.2 0.66–0.99 97.9 95.8 0.62–0.81
(90.9, 98.5) (100, 96.7) (90.9, 98.5) (100, 95)
Right inferior articular process 97.2 (87.5, 97.7) 100 (100, 100) 0.48–0.86 98.6 (87.5, 99.2) 100 (100, 100) 0.46–1.0
Left inferior articular process 100 (100, 100) 100 (100, 100) 1.0 93.3 (100, 93.3) 100 (100, 100) 0.14–1.0
Pars interarticularis 100 (100, 100) 97.2 (80, 98.5) 0.46–0.97 100 (100, 100) 97.2 (80, 98.5) 0.46–0.97
Spinous process 100 (100, 100) 98.6 (100, 98) 1.0 100 (100, 100) 100 (100, 100) 1.0
Sacrum 100 (100, 100) 100 (100, 100) 1.0 100 (100, 100) 98.6 (100, 98.6) 0.94–1.0
Coccyx 100 (100, 100) 100 (100, 100) 1.0 100 (100, 100) 100 (100, 100) 1.0
Total 98.4 98.1 0.51–0.89 99.1 98.2 0.18–0.76
(95.0, 99.6) (94.9, 99.0) (96.5, 99.6) (97.3, 98.5)

Data are accuracies, with sensitivities and specificities in parentheses, respectively.

a
Comparison of diagnostic performance (sensitivity, specificity, and accuracy) of SD and LD L-spine CT.

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S.H. Lee et al.
SD L-spine CT in the same participant because of the obvious ethical
reason of excessive radiation associated with two scanning procedures.
Second, LD and SD L-spine CT were not compared in terms of image
quality. However, our comparison of the diagnostic performances of LD
and SD L-spine CT revealed no significant difference, which suggests
that any differences in image quality did not have an influence on the
diagnostic performance. Third, we excluded patients who had pre-
viously undergone surgery; thus, the effect of metallic artifact reduction
using MBIR in the LD protocol was beyond the scope of this study.
Fourth, we did not include thoracolumbar spine CT because the scan
range of thoracolumbar spine CT considerably varies depending on the
focus lesion, which physicians try to visualize. However, according to
our result, we can speculate the diagnostic accuracy of LD thor-
acolumbar spine CT may be comparable to that of LD L-spine CT. Fifth,
the incidence of L-spine fracture was high, at 97.2% among the patients
included in the study. This may be the reason for obtaining plain
radiographs initially in trauma patients in the study period. L-spine CT
was not performed when a fracture was not seen or suspected on plain
radiography. According to our results, we plan to change the protocol
for trauma patients by performing LD L-spine CT using MBIR for initial
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Clinical Imaging 50 (2018) 216–222
Fig. 1. Examples of the standard-dose (SD) and low-
dose (LD) lumbar spine computed tomography (L-
spine CT) with model-based iterative reconstruction.
(A–C), Images in a 46-year-old man with a history of
falls. Arrows indicate fractures. Images from SD
(effective tube current–time products, 300 mAs; ef-
fective radiation dose 5.1 mSv) sagittal (A) and axial
(B, C) L-spine CT images show fractures in the L2
body (burst fracture), right lamina of L2, spinous
processes, and both transverse processes of L1 and
L2. Both reviewers detected fractures correctly.
L2 = second lumbar vertebral body; L1 = first
lumbar vertebral body.
(D–F), Images in a 48-year-old woman with a history
of slipping. Arrows indicate fractures. Images from
LD (effective tube current–time products, 100 mAs;
effective radiation dose, 1.5 mSv) sagittal (D) and
axial (E, F) L-spine CT images show fractures in the
L3 body (burst fracture), left lamina, right transverse
process, and spinous process of L3. Although more
noise is present in LD L-spine CT images when
compared to the noise in SD L-spine CT images, both
reviewers detected fractures correctly. L3 = third
lumbar vertebral body.
assessment. Finally, the anatomical border between some regions was
unclear, which resulted in different fracture detection rates between
reviewers and the reference standard and between both reviewers in
our study. It is necessary to clarify the anatomical borders to allow for
clear and transparent communication between clinicians and radi-
ologists.
5. Conclusion
In conclusion, the diagnostic performance of LD L-spine CT using
MBIR is similar to that of SD L-spine CT. Our results support the
adoption of LD L-spine CT using MBIR as a potential first-line diagnostic
tool in the ED for patients with trauma, without fear of underdiagnosis
of L-spinal fractures or inappropriate patient management.
Disclosure
The authors have no financial disclosures to report.
S.H. Lee et al.
Fig. 2. Flow diagram for ED patients with spinal trauma. ED = emergency department; L-spine = lumbar spine; LD = low dose; CT = computed tomography;
MBIR = model-based iterative reconstruction; MRI = magnetic resonance imaging.
Meetings
None.
Grant or other financial support
None.
Conflicts of interest
All authors declare that they have no conflict of interest.
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