contemporary bone spect/ct imaging for msk injury
TRANSCRIPT
Contemporary Bone SPECT/CT
imaging for MSK injury
April 12, 2014
Dr Ho Jen
2014 – CANM/ACMN
ANNUAL SCIENTIFIC CONFERENCE/CONFÉRENCE SCIENTIFIQUE ANNUELLE
CONCURRENT D- Part 2-TECHNOLOGISTS’ PROGRAM
Dr. Ho Jen, M.D. FRCPC Nuclear Medicine, FRCPC Radiology
Dept. Diagnostic Imaging, University of Alberta hospitals
Medical Imaging Consultants (MIC)
•Division of nuclear medicine
•MSK subgroup
•Medical Imaging Consultants
•Chair of BMD subgroup, Medical Imaging Consultants
•Medical director, Human Nutrition Research Unit (HNRU), University of
Alberta
No Disclosures
Objectives
• full diagnostic potential of modern bone scintigraphy with SPECT/CT
• concepts from MSK MRI imaging applied to bone SPECT/CT
• Challenge traditional view on what bone scintigraphy can
show
• MSK radiology:
– X-ray, CT, MRI
– Joint and nerve root injections. Bone biopsy.
• Nuclear medicine:
– Bone Scan and other scintigraphy:
– planar and SPECT/CT
– PET/CT
• in hospital departments: UAH, RAH, GNH
• outpatient clinics: Medical Imaging Consultants
• Athletic population:
– Edmonton Oilers, Edmonton Eskimos, U. Of Alberta Varsity athletes, Glen Sather Sports
clinic
• BMD: adult and pediatric
• second opinion diagnostic imaging reviews for MSK injuries – (WCB and med/legal cases)
My Practice
Bull Sh#t medicine ...Prof Emeritus of Surgery, McGill
“You’re going to learn UNclear medicine ?” ...ex MIC radiologist
“What else is there to do after reading Mettler ?...”
...current MIC radiologist, ex Chair of large oncology hospital
“Smeared, Fuzzy black dots Medicine” ...ex MIC radiologist
“Sorry, Ho, there just aren’t enough pixels in those images for my liking...”
...current oncologic radiologist
“What do you mean by LOW probability ? ...” generic E.R. doc
“Why don’t you just do a REAL test ....” ....previous radiology resident
“MIBI ? You mean a MAYBE Scan ?....” ...current MIC radiologist
I don’t get no respect ....
...Rodney Dangerfield, 1967
1985 2001Early 1980’s
2002
1985: Collier et al.
2005
1999
Bone scan of feet – Right ankle (1 mm isotropic voxels)Bone scan of feet – Right ankle (0.33 mm isotropic voxels)
2008
2012, 2013:Strobel et al.
So to all who used to make fun of nuclear medicine:
el
bldR
e
c
Good Planar technique
is still important !
Get the body part as close to the collimator as possible !
When b = 0,
Rc = d
So …….
40 y.o. F with ankle pain
Anatomy
MSK Imaging:
85% anatomy grunt work
the rest is easy !
Location, Location, Location !
Has Van der Wall et al., 2001
CROSS SECTIONAL ANATOMY
on SPECT, adds sensitivity:
Anatomy:SPECT alone without SPECT/CT is sometimes insufficient
Current CT
One year ago
18 y.o. M
Chronic low back pain
Worse x 3 months
? Unilateral ?
BILATERAL spondylolysis !!!!
BILATERAL spondylolysis:
(subacute) RIGHT
Previously unilateral LEFT, now inactive
(chronic) LEFT
Subacute lysis RIGHT
INTRA-ARTICULAR on right
14 y.o. F gymnast with LBP
Right
Left
Bilat syndylolysis
spondylolisthesis and segmental instability
-ve planar
“-ve SPECT”
+ve CT !
Bilat spondylolysis
spondylolisthesis and segmental instability
Right Left
Accelerated Disc degeneration from bilateral spondylolysis
Bone Marrow edema
Bone Marrow edema:contusion
Direct blow ACL injury patellar dislocation
Bone Marrow edema:Reaction to avulsive force
Posterolateral corner
Ulnar collateral lig
LisFranc Lig
MCL
Bone Marrow edema:Bone reaction to altered biomechanics:
e.g., stress response to altered weight bearing.
Advanced OA Early OA Ulnolunate impingement Meniscus tear
Bone Marrow edema:Non specific ?hyperemic ?sympathetic reaction
To adjacent soft tissue pathology
e.g., tendonopathy
Flexor tendonopathy Tibialis Posterior Insertional Achilles tendonpathy
With bone SPECT/CT
imaging, we can see
“bone marrow edema too…
~ 70-80 % concordance
Examples of SPECT-CT of MSK injury
Contemporary approach with emphasis on
•Anatomy
•bone reaction/bme congruence
Much more accurate Fracture dx
With modern SPECT/CT:
# anterior process of Calcaneus
Avulsion injury from attachment of bifurcate ligament
(commonly missed …)
Different Patient:
Obscure fractures more easily seen:
Fracture of lateral Process Talus
aka “Snow Boarder’s fracture” !
When “No Fracture or shin splint is seen….”
We can (possibly) see more….
Osteochondral injury
•Usually easy dx
•SPECT-CT more specific
•Surgical management parameters:
• -size ( < or > 1 cm )
• -evidence of unstable fragment
•
•? Contributory role of nucs uncertain
• ? “hot”
• ? arthrosis
43 y.o. M with bilateral osteochondral injuries of talus
Internal derangement
stress rxn to complex tear of med meniscus or acute contusion
65 y.o. F. Mild OA. ACUTE onset L knee pain 2-3 weeks. No trauma.
Dec 4, 2013
Dec 19, 2013
Tendonopathy
57 M. Chronic heel pain
Achilles non-insertional tenopathy
(mostly tendonosis), with low grade tear
static Blood pool
lat
Blood pool
plantar
58 F. Left lat ankle pain. No injury. XR Normal. No improvement with physioRx.
R lat ant post L lat
IMPRESSION: (bone scan, 07 Jun 2013)
Low-grade focal uptake involving the posterior aspect of the left lateral malleolus
associated with a bony spur and findings of peroneal tendinopathy. Further
evaluation with an MRI of the left ankle is recommended to better assess the peroneal
tendons.
MRI ankle (20 Jul 2013),
Hx: Chronic left ankle pain. Bone scan suggesting peroneal tendinopathy.
Extensive longitudinal split tear of
Peroneus brevis tendon with
Reactive tenosynovitis
Peroneus Brevis t
Peroneus Brevis t
72 F. Chronic med ankle pain/swelling
ImmediateR medial
antPost Plantar
Impression (bone scan Dec 19, 2013):
•Medial hyperemia
•Med malleolus bone rxn (to soft tiss pathology).
•Prominent post tib spur (not reported)
•? Tibialis posterior tendonpathy
•Suggest MRI
MRI (Jan 10 2014):
Reason for Exam:
SEVERE MEDIAL MALLEOLAR AND FOOT PAIN FOR MONTHS.
NO IMAGING IN LAST FEW YEARS !!!!!!
MRI (Jan 10 2014) Conclusion:
after IGNORING bone scan report:
tendinosis and longitudinal splitting of the tibialis posterior
Surrounding tenosynovitis
Secondary bone marrow edema in posterior aspect of medial malleolus
38 M. Chronic ?posterior ankle pain,
-ve XR r/o occult fracture
Avulsion of
Posterior-inferior
Tibial-fibular
Ligament !
called “stress fracture” (by myself) …
wrong !
40 M. Chronic RIGHT high lateral ankle pain
U/S report:
osseous irregularity of the fibula in the insertion of the high ankle ligaments.
? stress induced osseous change.
No corresponding osseous abnormality is apparent on the radiographs
Left lat
malleolusRight lat
malleolus
PITF lig
ant post plantar R lat
Chronic stress rxn @ attachment of post tib-fib ligament
Cystic change = intra ossesous ganglion or cortical desmoid formation
? PITF lig
Impingement syndromes
•Can be BONY or SOFT Tissue etiology
•Probably ALL visible now, with modern SPECT/CT
•More/most will gradually show up in nucmed literature
•Prognosis and Rx different from arthritis
43 F. Chronic post ankle pain. ? OCD
immediate Post immediate
Post delayeddelayed
called synovitis and
+ve for OLT … incorrectly !
Posterior Impingement !(Mostly non-osseous)
No OC injury
52 F, Multiple prior trauma and surgery to R ankle.
chronic ant-medial ankle pain. Distinctly localizable.
Ant immediate
initially
Reported as
“osteoarthritis”
Med/lat Lat/med
No OA, on XR
No OA, on
CT arthrogram
Anteromedial
IMPINGEMENT !
Well-known in MSK literature
Due to trauma to the (superficial) deltoid ligament,
•with subsequent (soft tissue and osseous) hypertrophic change
Bone Scan confirms functionally active impingement !
Degenerative change, Osteoarthritis, Impingement,
What’s the difference ? Who cares ?
Rx for ankle OA:
-steroid injection
-arthroplasty (rarely done !)
-surgical fusion
-poor prognosis
Rx for impingement:
-initially, steroid injection
-arthroscopy, and resection of spurs, hypertrophic tissue, etc.
-very good prognosis, in the absence of true OA !!! - van Dijk CN, et al (1997)
Yes, it does matter !
64 y.o. F with Chronic bilateral ankle/hindfoot pain, much worse on the L side
ant post plantar L lat R lat
Different pt. - mild Different pt. - severe patient
Patients with Pes Planus
Get Subtalar Impingement
22 M chronic bilat hip pain R > L
Bone scan describes
bilateral stress # of femoral necks
No SPECT/CT
MRI shows
NO FRACTURE
NO edema
typical bone contour for CAM type femoral acetabular impingement
Femoral Acetabular Impingement – CAM type
XR Shows:
Poor head/neck offset
“dysplastic bump”/Synovial pits
Femoral Acetabular Impingement:
The presence of bone reaction at impingement site on bone scan is
a strong predictor for
The development of full FAI, preceding the required diagnostic soft tissue damage
A Hypothesis:
Plantar
46 F. Lateral midfoot pain
Dorsal
SPECT/CT (28-10-2013):
Intraosseous ganglion in peroneal groove with bone reaction
Pathology (? Inflamation) in Peroneus longus tendon
F/U MRI (28-11-2013):
Intraosseous ganglion in peroneal groove with bone marrow edema
Inflamation in peroneal groove
Peritendonous Inflamation in Peroneus longus tendon
No acute bone injury
Summary:
With SPECT/CT, modern day bone scintigraphy can now diagnose
far more MSK pathology, than previously possible with
traditional planar or conventional SPECT imaging.
“bone marrow edema” is usually (70-80%) visible on bone
scintigraphy as a bone reaction. There is an effective
congruence between them which is diagnostically useful.
Analogous to bme on MRI, the specific anatomic location
and distribution of bone reaction can be used to strongly
suggest soft tissue injury/pathology.
Many “new” syndromes well known to the general MSK imaging
literature will soon be introduced to the nuclear medicine bone
scintigraphy literature.
Thank you !