shoulder mri for surgeons

AMSTERDAM / THE NETHERLANDS

www.esska-congress.org

Lennard Funk

lenfunk@shoulderdoc.co.uk

• Prof. Waqar Bhatti

• Dr. Jonathan Harris

• Dr. Sarah Jackson

www.esska-congress.org4

QUESTION A

My IDEAL investigation for cuff pathology

a. Ultrasound

b. MRI

c. MR Arthrogram

d. CT Arthrogram

QUESTION B

My IDEAL investigation for Instability is:

a. Ultrasound

b. MRI

c. MR Arthrogram

d. CT Arthrogram

QUESTION 1

Radiologists are better at interpreting MRI scans than surgeons:

a. True

!b. False

QUESTION 2

MRI Sequences:

a. T1 is best for pathology

b. In T2 fat tissue is bright

c. A long TR is shows inflammation

b. STIR is a Fat Suppression sequence

QUESTION 3

MR Arthrogram:

a. ABER improves accuracy

b. Cannot show Bony lesions

c. Is not ideal for fatty infiltration

d. Is 100% accurate for labral tears

AMBIGUOUS REPORTS

“Full width tear”

“Advanced muscle atrophy along with Infraspinatus”

“mild atrophy supraspinatus”

CONFUSING REPORTS

There is a partial full tear of the supraspinatus tendon.

There is a complete partial tear of the supraspinatus tendon.

INADEQUATE SCANS

Grainy Shadows

Movement

CUFF PATHOLOGY IN ASYMPTOMATIC

• 96 MRI’s viewed by 2 radiologists

• 20% PTT; 15% FTT

– Increased with age:

• >60yrs = 55% PTT; 30% FTT

Sher et al. JBJS. 1995

MR ARTHROGRAM V. SCOPE

Sensitivity Specificity Accuracy

SLAP 0.42 0.92 77%

Rotator Cuff Tear 0.50 0.86 83%

Hill Sachs 0.91 0.78 90%

Bankart 0.85 0.83 86%

N Karlson, J Geoghan, L Funk; 2008

RADIOLOGIST LOCALITY

• Nine radiologists - regional & secondary care

• MR diagnostic accuracy is better when surgeon and radiologist work in the same institution.

• Differences between local- and non-local MRA data suggest that diagnostic accuracy is better in the local secondary referral centre.

N Karlson, J Geoghan, L Funk; SECEC 2011

DO NOT RELY ON THE SCAN REPORT

An experienced Shoulder Surgeon better Can correlate with clinical context Experience of reviewing Scopes & Scans

MRI BASICS

• T1 - Fat Bright - Anatomy

• T2 - Water Bright - Pathology

• Standard 3mm thick slices

• Thick slices = more signal & less grainy, but lower spatial resolution (due to volume averaging)

MRI BASICS

• PD = Long TR & Short TE

• T1 = Short TR & Short TE

• T2 = Long TR & Long TE

• TE is always < TR

• Short TR < 500ms

• Long TR > 1500ms

• Short TE < 30ms

• Long TE > 90ms

http://www.imaios.com/en/e-Courses/e-MRI/MRI-signal-contrast/Signal-weighting

MRI BASICS

• Fat Suppression

• PDFS

• T2 Gradient Echo

• STIR

• SPIR

• SPAIR

• Labral Tears

• Bankart

• Perthes

• ALPSA

• SLAP

• GLAD

• GLOM

T1 WI T2 FS

INFLAMMATION

MUSCLE OEDEMA

T1 FS T2 FS

LABRAL TEARS

T1 WI T1 FS

PLAIN MRI SEQUENCES

• Hospital 1:

• Hospital 2:

MRI SEQUENCES

• No universal standards

• Each Hospital has different MRI Protocols

• Each Radiologist has different experience

• Each clinical question demands different approach

PLAIN MRI - PREFERENCES

1. Full Series

!!2. T1 Axial - Bony Bankarts

3. T1 Sag - Bony Bankarts

4. T1 Sag - extend medial to scapula ‘Y’

5. T2 FS Cor - Cuff, ACJ, Bursa

T1 WITH FS SAGITTAL IN GLENOID PLANE

SCAPULA ‘Y’ ON T1WI

ARTEFACT

• Rotator cuff repair

ARTEFACT

• ACJ Metalwork

• Deodorant spray in axilla

MR ARTHROGRAM

• Direct / Indirect

INDIRECT ARTHROGRAM

MR ARTHROGRAM

• Direct / Indirect

SUMMARY

• Beware / Be aware of Reports • Full 6 series • T1 FS Axial - Instability • T2 FS Cor - Rotator Cuff • T1 Sag to Scapula ‘Y’ • MRA:

– Direct – T1 FS in 2 planes (axial; sagittal) – ABER (if able)

RELATIONSHIPS

• Clinical Imaging is a ‘request for consultation to clarify a clinical query’

• NOT ‘ordering’ an investigation

!• Vetting of request should be an MSK Radiologist

• Provide clear clinical info and query

I can see it now !

QUESTION 1

Radiologists are better at interpreting MRI scans than surgeons:

a. True

!b. False

QUESTION 2

MRI Sequences:

a. T1 is best for pathology

b. In T2 fat tissue is bright

c. A long TR is shows inflammation

b. STIR is a Fat Suppression sequence

QUESTION 3

MR Arthrogram:

a. ABER improves accuracy

b. Cannot show Bony lesions

c. Is not ideal for fatty infiltration

d. Is 100% accurate for labral tears

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