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 !