Cervical spondylolysis in children. Apropos of 4 cases. Review of the literature

PURPOSE OF THE STUDY: A clinical and radiological study of four cases of spondylolysis in children. Literature review shows the congenital origin of the disorder and how it is to be treated. MATERIAL AND METHODS: We report on four children with cervical spondylolysis. One of the children presented a two-level spondylolysis C5C6. One case was totally asymptomatic and was hazardly discovered. Standard radiographs were used for diagnosis. Conservative treatment was administered in all cases and all patients were immobilized for a few days. DISCUSSION: It has been clearly established that cervical spondylolysis is a congenital disorder often associated with other anomalies: spina bifida, dysplasia of the posterior articular processes. In the child, cervical spondylolysis is only discovered in fifty per cent of Post traumatic cases. The most frequent finding is at C6. A diagnosis can be made based on the radiographs and the CT scan. MRI will only be indicated in spondylolisthesis in order to analyze the disc statement and the degree of canal narrowing. When possible conservative treatment should be adopted. Arthrodesis is reserved for unstable and painful lesions. CONCLUSION: Cervical spondylolysis in the child is a rare congenital disorder. It must be distinguished from the congenital absence of a pedicle and from a pedicle or isthmic fracture. It is a lesion which is normally discovered once the patient has turned adult and is very well long term tolerated.     

Defects of pars interarticularis in athletes: a protocol for nonoperative treatment

The purpose of this study was to report the results of a specific treatment protocol for athletes with spondylolysis or spondylolisthesis of the lumbar spine. A retrospective study with recent follow-up was performed on 82 patients treated with restriction of activity, bracing, and physical therapy. All of the patients were involved in sports at first onset of symptoms. Sixty-six patients were boys and 16 were girls. Activities involving repetitive hyperextension and/or extension rotation of the lumbar spine were described as painful in 98% of the patients. Of the 62 patients with spondylolysis, 53 (85%) had an L5 defect and nine (15%) an L4 defect (90% of these 62 patients' defects were located in the most caudad mobile vertebra). Thirty-seven patients had bilateral pars defects, and 25 had unilateral defects. Eight patients had normal roentgenograms, but these eight had abnormal bone scans. Nine patients with spondylolysis underwent posterolateral fusion. Average follow-up was 4.2 years. Fifty-two (84%) had excellent results, eight had good results, and two had fair results. Twenty patients had a spondylolisthesis: 12 were grade I, six were grade II, and two were grade III. Twelve patients (60%) required surgery; 9 had excellent results, one had good results, one had a fair result, and one had a poor result. Pars defects must be suspected in the differential of low back pain in young athletes. Oblique radiographs are frequently diagnostic; however, if the history and examination are suggestive despite normal plain films, a bone scan should be obtained. Nonoperative management of pars defects is frequently successful.(ABSTRACT TRUNCATED AT 250 WORDS)     

The use of single photon emission computerized tomography in neuropsychiatric SLE: a pilot study

OBJECTIVE: To test the sensitivity of single photon emission computerized tomography (SPECT) in detecting brain abnormalities in cases of definite active neuropsychiatric systemic lupus erythematosus (NPSLE) in a blinded, prospective pilot study. METHODS: Fourteen patients fulfilling at least 4 of the American College of Rheumatology criteria for the classification of SLE plus positive serology manifested by either elevated DNA binding or decreased serum complement and a recent neuropsychiatric event were evaluated with cerebral SPECT using hexa-methyl-propylene-amine-oxime labeled 99Tc. Secondary causes such as infection, uremia, hypertension, drugs, and metabolic abnormalities were excluded. Patients underwent brain scan and electroencephalogram (EEG) for comparison. When clinically indicated, CT scan, magnetic resonance imaging, angiography, and lumbar puncture were performed. RESULTS: SPECT scan abnormalities were noted in 12/14 patients and brain scan was abnormal in 12/14 patients. SPECT and brain scan were in accordance in 12/14 patients (11 patients both positive and 1 both negative) and the combination of SPECT and brain scan yielded 13/14 positive results. In the 3 patients with headache, SPECT scan was negative in 2/3, despite positive EEG and one with a positive brain scan. The positive SPECT in the patient with headache showed an old cerebrovascular accident (CVA), which was confirmed by CT scan. The most consistent CT finding was cortical atrophy; however, SPECT identified a lesion in the occipital cortex in a patient with seizure, and a lesion in the basal ganglia in a patient with ataxia. CONCLUSION: In clinically and serologically active NPSLE, SPECT is a sensitive diagnostic tool. When further stratifying NPSLE into focal (seizure, ataxia, CVA) and diffuse (headache, organic brain syndrome, psychosis), SPECT appeared to be sensitive for focal disease and for most diffuse manifestations, with the exception of headache. The high sensitivity of SPECT in patients with true, positive NPSLE merits further controlled studies in unselected patients with SLE.     

Treatment of spondylolysis and spondylolisthesis in children and adolescents

The treatment of spondylolysis and spondylolisthesis in children depends on the severity of clinical symptoms, pathologic anatomy, and prognosis. Simple spondylolysis can be cured by immobilization alone in selected cases, or by surgery when it remains symptomatic and resistant to nonoperative treatment. The majority of cases are asymptomatic and require no treatment. Spondylolisthesis is classified into 2 types based on the magnitude of the lumbosacral angle: spondylolisthesis with a horizontal sacrum (lumbosacral angle > or = 100 degrees), which seldom requires surgical treatment, usually responds to orthotic management, and generally shows little progression; spondylolisthesis with a vertical sacrum (lumbosacral angle < 100 degrees) which is always progressive, can produce neurologic impairment and cosmetic and functional disability, and requires surgical treatment. In 17 cases the author has reduced the latter deformity by gradual traction in hyperextension followed by cast immobilization, then stabilized the reduction by posterolateral fusion performed through the cast without instrumentation and without opening the spinal canal. When the lumbosacral angle is not improved to 100 degrees or more by hyperextension and traction, an anterior console interbody fusion is added before the posterolateral fusion.     

Single-photon emission-computed tomography in the diagnosis of cerebrovascular diseases

BACKGROUND: SPECT-HM-PAO allows to detect the regional cerebral blood flow and total diminution of the brain perfusion still before morphological substrate evolution in CT scan, without invasive technologies. SEARCH GOAL: The authors have analyzed data obtained by SPECT-99mTc HM-PAO in the group of 46 patients suffering from cerebrovascular disorders and they have compared them with results aimed by CT scans. Both, the SPECT-99mTc HM-PAO and CT scan were performed within 48 hours or later after the onset of the stroke; some of CT scans were repeatedly performed. RESULTS: They discovered 40 positive and 6 negative SPECT-HM-PAO findings, 26 positive and 20 negative CT scans. SPECT investigation more frequently discovers circulatory failures in the clinically altered hemisphere than the CT scan does in a substrate; SPECT discloses hypoperfusion of the clinically unaltered hemisphere if silent hypoperfusion is present. The ipsilateral foci of CT substrates were significantly less frequently observed (p < 0.001) than some ipsilateral regional hypoperfusions. Not only the number, but also size and extent of hypoperfusional foci searched by SPECT are significantly higher and wider than the numbers and dimensions of substrates observed by CT (p < 0.001). CONCLUSION: CT scan diagnostic possibilities are restricted by the time factor (CT examinations performed within 48 hours since the onset of the stroke are significantly less frequently positive than those performed later-p < 0.001). SPECT examination has not such a limiting time factor (p > 0.05). MEANING: Hence SPECT-HM-PAO renders early, long lasting and wide information on the restriction of the overall and regional perfusion, independently of the fact as to whether the reduction of cerebral perfusion is, or is not going to result in ischemic necrosis and/or ischemic sclerosis. SPECT renders correlation of the perfusion disorder earlier, wider in space, and more frequently than the CT scan, and therefore it is a prerequisite to the disclosure of the mentioned silent focal blood flow reductions. (Graph 12, Fig. 3, Ref. 4.)     

Correlations between abnormalities on brain SPECT scan and interictal EEG-foci in children with 'intractable' partial epilepsy

SPECT scanning with Tc99mHM-PAO was performed on 40 children with 'intractable' partial epilepsy; 27 patients had abnormalities on SPECT images consisting of areas of decreased cerebral blood flow. In 18 of these 27 subjects there was a good correlation between site of the abnormalities on SPECT scan and interictal EEG foci. 12 patients with regionally decreased CBF had also neuroimaging (C.T. and/or R.M.I.) abnormalities. The brain SPECT provides more precise detection of epileptogenic foci, when used to complement EEG, also in childhood-onset epilepsy.     

99mTc-HMPAO SPECT of the brain in mild to moderate traumatic brain injury patients: compared with CT--a prospective study

Single photon emission computed tomography (SPECT) with Technetium-99m hexamethyl propylenamine oxime (Tc-99m-HMPAO) was used in 20 patients with mild to moderate traumatic brain injury (TBI) to evaluate the effects of brain trauma on regional cerebral blood flow (rCBF). SPECT scan was compared with CT scan in 16 patients. SPECT showed intraparenchymal differences in rCBF more often than lesions diagnosed with CT scans (87.5% vs. 37.5%). In five of six patients with lesions in both modalities, the area of involvement was relatively larger on SPECT scans than on CT scans. Contrecoup changes were seen in five patients on SPECT alone, two patients with CT alone and one patient had contrecoup lesions on CT and SPECT. Of the eight patients (50%) with skull fractures, seven (43.7%) had rCBF findings on SPECT scan and five (31.3%) demonstrated decrease in rCBF in brain underlying the fracture. All these patients with fractures had normal brain on CT scans. Conversely, extra-axial lesions and fractures evident on CT did not visualize on SPECT, but SPECT demonstrated associated changes in rCBF. Although there is still lack of clinical and pathological correlation, SPECT appears to be a promising method for a more sensitive evaluation of axial lesions in patients with mild to moderate TBI.     

Spondylolysis and spondylolisthesis and sports

Spondylolysis and spondylolisthesis occur predominantly in the lower lumbar spine. Besides congenital defects such as predisposition of spondylolysis the correlation between competitive sports activities and an increased incidence of spondylolysis is proved. In early stages, complete healing can be achieved by conservative treatment (abstinence from sports activities for 3 months, orthesis). Persistence of pain, neurologic symptoms and progression of vertebral slipping are indications for operative treatment (reconstruction of the isthmus, dorso-ventral spondylodesis). The exercise tolerance depends on the extent of instability, progression of vertebral slipping and clinical symptoms. The limits of exercise tolerance vary among the individual athletes and require the decision of the physician. Backstroke swimming, abdominal and back muscle strengthening exercises, and types of sport involving smooth movements are advisable. Sports education in school is possible without restriction in patients with stable spondylolysis and in those with spondylolisthesis without unfavourable concomitant factors.     

Incremental value of prognostic testing in patients with known or suspected ischemic heart disease: a basis for optimal utilization of exercise technetium-99m sestamibi myocardial perfusion single-photon emission computed tomography

OBJECTIVES: This study assessed the incremental prognostic implications of normal and equivocal exercise technetium-99m (Tc-99m) sestamibi single-photon emission computed tomography (SPECT) and sought to determine its incremental prognostic value, impact on patient management and cost implications. BACKGROUND: The prognostic implications of Tc-99m sestamibi SPECT are not well defined, and risk stratification using this test has not been explored. METHODS: We studied 1,702 patients referred for exercise Tc-99m sestamibi SPECT who were followed up for a mean (+/- SD) of 20 +/- 5 months. Patients with previous percutaneous transluminal coronary angioplasty or coronary artery bypass surgery were excluded. The SPECT studies were assessed using semiquantitative visual analysis. Cardiac death and myocardial infarction were considered "hard" events, and coronary angioplasty and bypass surgery > 60 days after testing were considered "soft" events. RESULTS: Of the 1,702 patients studied, 1,131 had normal or equivocal scan results. A total of 10 events occurred in this group (1 cardiac death and 1 myocardial infarction [0.2% hard events]; 4 coronary angioplasty and 4 bypass surgery procedures [0.7% soft events]). The rates of hard events and referral to catheterization after SPECT were similarly low in patients with a low (< 0.15), intermediate (0.15 to 0.85) and high (> 0.85) post-exercise treadmill test (ETT) likelihood of coronary artery disease. With respect to scan type, patients with normal, probably normal or equivocal scan results had similarly low hard event rates. In the 571 patients with abnormal scan results, there were 43 hard events (7.5%) and 42 soft events (7.4%) (p < 0.001 vs. 1,131 patients with normal scan results for both). When the complete spectrum of scan responses was considered, SPECT provided incremental prognostic value in all patient subgroups analyzed. However, the nuclear scan was cost-effective only in patients with interpretable exercise ECG responses and an intermediate to high post-ETT likelihood of coronary artery disease and in those with uninterpretable exercise ECG responses and an intermediate to high pre-ETT likelihood of coronary artery disease. CONCLUSIONS: Normal or equivocal exercise Tc-99m sestamibi study results are associated with a benign prognosis, even in patients with a high likelihood of coronary artery disease. Although incremental prognostic value is added by nuclear testing in all patient subgroups, a testing strategy incorporating nuclear testing proved to be cost-effective only in the groups with an intermediate to high likelihood of coronary artery disease before scanning.     

Evaluation of specific stabilizing exercise in the treatment of chronic low back pain with radiologic diagnosis of spondylolysis or spondylolisthesis

STUDY DESIGN: A randomized, controlled trial, test--retest design, with a 3-, 6-, and 30-month postal questionnaire follow-up. OBJECTIVE: To determine the efficacy of a specific exercise intervention in the treatment of patients with chronic low back pain and a radiologic diagnosis of spondylolysis or spondylolisthesis. SUMMARY OF BACKGROUND DATA: A recent focus in the physiotherapy management of patients with back pain has been the specific training of muscles surrounding the spine (deep abdominal muscles and lumbar multifidus), considered to provide dynamic stability and fine control to the lumbar spine. In no study have researchers evaluated the efficacy of this intervention in a population with chronic low back pain where the anatomic stability of the spine was compromised. METHODS: Forty-four patients with this condition were assigned randomly to two treatment groups. The first group underwent a 10-week specific exercise treatment program involving the specific training of the deep abdominal muscles, with co-activation of the lumbar multifidus proximal to the pars defects. The activation of these muscles was incorporated into previously aggravating static postures and functional tasks. The control group underwent treatment as directed by their treating practitioner. RESULTS: After intervention, the specific exercise group showed a statistically significant reduction in pain intensity and functional disability levels, which was maintained at a 30-month follow-up. The control group showed no significant change in these parameters after intervention or at follow-up. SUMMARY: A "specific exercise" treatment approach appears more effective than other commonly prescribed conservative treatment programs in patients with chronically symptomatic spondylolysis or spondylolisthesis.     

Beta-blockers: a time for reappraisal

Recent studies have shown that SPECT bone scintigraphy is valuable to detect meniscal tears of the knee. This has not been formally assessed in a prospective study, and no substantive study has compared bone SPECT with other noninvasive diagnostic methods. One hundred consecutive patients referred to an orthopedic surgeon with undiagnosed knee pain were assessed by clinical examination, MRI, SPECT bone scintigraphy, and arthroscopy. The MRI and SPECT bone scan findings were reported blinded to other information. Using arthroscopy as a gold standard, both MRI and SPECT showed high diagnostic ability to detect meniscal tears, with respective sensitivity rate, specificity rates, and positive and negative predictive accuracies of 80%, 71%, 84%, and 71% for MRI and 84%, 80%, 88%, and 76% for SPECT. Some meniscal tears were detected by MRI alone (n = 5) or SPECT alone (n = 8). SPECT bone scintigraphy is a suitable alternative to MRI to detect meniscal tears. The comparable diagnostic ability of SPECT bone scintigraphy implies that it can be used successfully when MRI is unavailable or unsuitable.     

Spondylolisthesis in children and adolescents

A study of spondylolysis and spondylolisthesis in 142 children and adolescents is reported. In twelve of the seventy-nine patients followed for over a year the affected vertebra slipped further by 10 per cent or more. Increasing slip occurred mainly during the adolescent growth spurt, and was greater when spinal bifida or other vertebral anomalies were present. If at presentation the slip is less than 30 per cent then further slip beyond 30 per cent is unlikely. Decompression posteriorly is advised when signs of nerve pressure are present. Indications for spinal fusion are suggested; the intertransverse method of fusion was used in sixty-nine patients.     

Clinical examination on localization-related epilepsies with elementary visual seizures--clinical, electroencephalographic and imaging diagnostic studies

The clinical, electroencephalographic and Imaging diagnostic features of the 45 patients of Localization-related Epilepsy who had elementary visual symptoms at seizure onset were investigated. There were 24 males and 21 females aged 19 to 78. Their ages at seizure onset ranged from 1 to 55 with a mean of 15.4. The patients were divided into 3 groups based on the pattern of elementary visual symptoms: Group 1; 23 patients (51%) with only elementary positive visual symptoms, Group 2; 9 patients (20%) with only elementary negative visual symptoms, Group 3; 13 patients (29%) with others. It came to our notice that 8 (18%) patients in Group 3 had positive + negative (P*N) visual seizures such as scintillation scotoma. It was quite difficult to draw a distinction between the P*N seizures and scintillation scotoma in migrainous patients in quality. Therefore, a question arises whether similarities between them are ascribed to the same underlying mechanism. It is possible that the mechanism of the P*N seizures is different from that of the scintillation scotoma, but the both produce the same condition. However, we are not competent to discuss this hypothesis. Further work along this line is necessary. In addition to the elementary visual symptoms, autonomic (69%), focal motor (29%), illusion (29%), vertiginous (22%) manifestations, etc. were also observed. These manifestations suggest that epileptic ictal discharges spread into many different brain areas. Regarding Group 1-3, occurrence of illusional seizures was more common in Group 2. In this group, in only one patient, occipital interictal discharges were observed. The subjects were subclassified into two groups depending on whether the seizures were well controlled (good outcome) or poorly controlled (poor outcome group). On these groups, comparative studies were performed. The poportion of the patients with a family history of convulsive disorder was higher in the latter than that in the former. To the contrary, the poportion of the patients with a etiologic episode was higher in the former than that in the latter. With respect to the imaging study, regardless of localizations, abnormal findings were detected in 25% on CT scan, in 29% on MRI, and in 71% on SPECT. Whether or not these abnormal findings completely or partially agreed with presumed epileptogenic brain region (occipital lobes) was investigated. CT scan was positive (correspondent) in 8%, MRI was positive in 13%, and SPECT was positive in 54%. The incidence of SPECT abnormalities was higher in the poor outcome group (70 %) than that in the good outcome one (43%). We may, therefore, conclude that SPECT seems to be useful for the detection of epileptogenic region, especially in intractable cases. But the incidence of these imaging studies' abnormalities located in occipital lobe was not so high, therefore, there seems to be no doubt that clinical symptoms and EEG findings are most important for diagnosis.     

123I-metaiodobenzylguanidine (MIBG) scintigraphy for the staging of neuroblastoma

Nineteen children with neuroblastoma (aged 2 w.-7 y.o.) were studied to evaluate the optimal scan conditions for Iodine-123-Metaiodobenzylguanidine (MIBG) scintigraphy for accurate staging at the time of diagnosis. Six and 24 hours after an injection of 123I-MIBG, whole body image and truncal spot and SPECT images were obtained. Compared with other studies (CT or MRI and bone scintigraphy), each 123I-MIBG image was evaluated visually to investigate which image can demonstrate the extent of neuroblastoma most exactly. MIBG images demonstrated primary tumors in all patients, and metastatic lymphadenopathy in 8 of 9 patients. Twenty-four hour SPECT images gave us the most detailed information about the extent of abnormal accumulation. As to bone and bone marrow lesions, 6 hour images were superior to 24 hour images in detectability. Moreover, MIBG showed many more lesions and more extended accumulation than the bone scan. 123I-MIBG scintigraphy was very useful in detecting neuroblastomas. In order to get the most valuable information, both delayed SPECT and early whole body planar images should be obtained.     

Are the results of thallium scintigraphy and coronary angiography equivalent? An evaluation of thallium scintigraphies performed at Vestfold Central Hospital

The value of exercise-redistribution thallium-201 perfusion scintigraphy (SPECT; single photon emission computed tomography) in the diagnosis of coronary artery disease was evaluated in 23 patients (one patient tested twice) who were subsequently submitted to coronary angiography. Reversible perfusion defects indicating myocardial ischemia were found in 22 patients, of whom 18 had angiographically significant coronary artery stenoses. Two patients had negative thallium scans, one had a normal angiogram and one had single vessel disease. Thus 18 of 19 patients with angiographically verified coronary heart disease had a positive thallium scan. The majority of patients with left main stenosis and triple vessel disease had scintigraphic evidence of double or triple vessel disease. The scintigraphic method identified the correct anatomical localization in 73% of the angiographically verified coronary artery stenoses. In conclusion, a positive exercise-redistribution thallium scan had a high predictive value in the diagnosis of coronary artery disease, whereas its value in estimating the number and localization of stenoses was more limited.     

Mechanism of action of a new component of the Ca(2+)-dependent proteolytic system in rat brain: the calpain activator

OBJECTIVE: Using single photon emission computed tomography (SPECT) we evaluated the presence and evolution of changes in brain perfusion in juvenile systemic lupus erythematosus (JSLE). METHODS: SPECT was performed in 14 patients with active JSLE divided in 2 groups: the first included 7 patients without central nervous system (CNS) involvement and the second 7 patients with minor neuropsychiatric symptoms (headache, reactive depression, cognitive impairment, mood swing). SPECT findings were compared to seroimmunological and magnetic resonance imaging (MRI) data. After 6 month followup, a second SPECT scan was performed in 12 of 14 patients. RESULTS: At baseline, SPECT showed perfusion defects in 2 patients without neuropsychiatric symptoms and in 5 patients with CNS involvement. In one of the 7 patients with altered SPECT, MRI showed focal hyperintensities. MRI alterations were observed in another patient who had a normal SPECT scan. Cortical atrophy was present in 5 of 14 patients. Correlation between neuropsychiatric manifestations and SPECT findings was not clearly evident because the major part of JSLE patients with CNS involvement and with SPECT alterations had multiple symptoms, but showed focal hypoperfusion on SPECT imaging. No significant association was found between seroimmunological data and SPECT findings. At followup, improvement of perfusion alterations was observed in 6 of 7 patients with altered SPECT and, in 3 of them, findings might be attributed to changes in steroid treatment. CONCLUSION: Perfusion abnormalities in SLE may represent reversible lesions or subclinical CNS involvement. Moreover, SPECT imaging appears to be useful in detecting and monitoring CNS involvement in SLE.     

Reduction and stabilization without laminectomy for unstable degenerative spondylolisthesis: a preliminary report

Fifty-two patients with unstable degenerative spondylolisthesis treated with the "AO internal fixator" and posterolateral fusion were reviewed. The major purpose of this study is to observe whether this pedicle fixation system could adequately decompress the nervous system tissue by the restoration of the spinal canal and, hence, replace the conventional decompressive laminectomy for the treatment of this disease entity. The results were satisfactory, showing that 92% of the patients with radicular pain, 89% of the patients with low back pain, and 86% of the patients with intermittent claudication improved postoperatively. Observing the results, only two groups of patients with unstable degenerative spondylolisthesis are not suitable for this treatment modality. The first group consists of those patients who have a spondylolisthesis with borderline instability. The second group consists of those patients who have a positive Lasèque's sign.     

HMPAO brain SPECT in acute carbon monoxide poisoning

Technetium-99m-hexamethylpropylene amine oxime (HMPAO) brain images with fanbeam SPECT, in combination with surface three-dimensional display, were used to detect basal ganglion and cerebral cortex anomalies in the acute phase of carbon monoxide (CO) poisoning. METHODS: Ten patients, aged 16-29 yr, with acute CO poisoning and no past history of neurologic disorders were enrolled in this study. After oxygen treatment, all 10 patients were investigated using 99mTc-HMPAO brain images with fanbeam SPECT and surface three-dimensional display. Meanwhile, 6 of 10 patients also received a brain CT scan. RESULTS: CT scan findings were negative in all 6 patients. Fanbeam SPECT demonstrated unilateral or bilateral hypoactivity of basal ganglia in 6 patients. Local hypoactivity anomalies were found in the brain cortex of 7 patients, using surface three-dimensional display of the brain. Only 2 of 10 patients had normal 99mTc-HMPAO brain images. CONCLUSION: This study suggests that, in comparison with traditional brain imaging techniques, 99mTc-HMPAO brain imaging with fanbeam SPECT in combination with surface three-dimensional display is a better tool for early detection of regional cerebral anomalies in acute CO poisoning.     

The relationship between the serum level of prostate specific antigen and bone and CT scans in the staging of the primary carcinoma of the prostate

OBJECTIVE: To determine the relationship between the serum level of prostate-specific antigen (PSA) and the presence of abnormalities in a skeletal or CT scan in patients with primary carcinoma of the prostate. DESIGN: Retrospective. SETTING: Academic Medical Centre, Amsterdam. PATIENTS AND METHODS: The serum PSA levels were compared with the findings in the skeletal and CT scans of 440 patients with carcinoma of the prostate without clinical signs of metastases, seen in the period from January 1990 to December 1994 in the outpatient clinics for Urology of the Academic Medical Centre (AMC) in Amsterdam, Hospital Gooi-Noord in Blaricum and Hospital De Heel in Zaandam. CT scan data were analysed only from the AMC and Hospital Gooi-Noord. RESULTS: There were 76 patients with a positive bone scan (17.3%) and 31 (out of 337; 9.2%) with a positive CT scan. Higher PSA serum levels went together with increasing risk of abnormalities in bone or CT scan. Of 85 patients with PSA values < 10 micrograms/l, none had a positive bone scan and one (out of 73; 1%) a positive CT scan; of the 180 patients with PSA levels < 20 micrograms/l, 4 (2.2%) had a positive bone scan and 2 (out of 154; 1.3%) a positive CT scan. The T stage, the histological grading and the serum alkaline phosphatase activity appeared not to have any supplementary value. CONCLUSION: In view of the low frequency of abnormalities in a bone or CT scan in patients with low PSA levels, it appears justified no longer to recommend bone or CT scanning for staging of patients for a clinically non-metastasized carcinoma of the prostate and serum PSA levels < 20 micrograms/l.