Study for Reliability of Interpretation of the Three Phase Bone Scintigraphy in Patients with Post-traumatic Complex Regional Pain Syndrome / 핵의학분자영상

PURPOSE: We performed this study to evaluate reliability on interpretation of three phase bone scintigraphy (TPBS) in patients with post-traumatic complex regional pain syndrome (PT-CRPS). METHODS: Based on International Association for the Study of Pain guideline in 1994, 34 patients with PT-CRPS were selected for this study. Two nuclear medicine physicians evaluated identical TPBS according to the uptake pattern, extent and intensity of the lesion, and their agreements (kappa values) were analysed. The final diagnosis based on arbitrary criteria of each physician were compared with those obtained by the criteria for PT-CRPS established in this study, which are hyperactivity on all phases (criteria 1), hyperactivity of whole joints on delayed phase (criteria 2), and hyperactivity of either whole or focal joints on delayed phase (criteria 3). RESULTS: Intra-observer agreements were good for uptake pattern, intensity, and extent on TPBS. Inter-observer agreements were also good, except extent on blood pool phase (0.55). The inter-observer agreements on final diagnosis improved when criteria 1-3 were applied (0.77-0.88), compared to when physician's own criteria were used (0.63). Those also improved from 0.29 to 0.47-0.82 for acute stage, and from 0.37 to 1.0 for chronic stage. The sensitivities of chronic stage were relatively lower to those of acute stage. CONCLUSIONS: Inter-observer's variations in diagnosis of the patients with PT-CRPS using TPBS were observed. These results were attributed to different criteria set by observers. In order to improve agreement on interpretation of TPBS, common positive criteria should be established, especially considering uptake pattern and clinical stages.

The Comparative Analysis between Digital Infrared Thermography Imaging and Three-phase Bone Scintigraphy in the Post-hemiplegic Complex Regional Pain Syndrome

OBJECTIVE: To evaluate the benefit of digital infrared thermography imaging (DITI) and three-phase bone scintigraphy (TPBS) for detecting the post-hemiplegic complex regional pain syndrome (CRPS). METHOD: DITI and TPBS were done in 26 patients with post-hemiplegic CRPS clinically and 14 hemiplegic patients without CRPS as controls. Positive findings were interpreted when the affected hands were 1.0degrees C higher than those of unaffected hands in DITI system and pathological uptake in the regions of interest (hands without fingers-carpal bones, metacarpal bones and metacarpopharyngeal joints) in delayed phase of the TPBS. RESULTS: The sensitivities of DITI and TPBS to detect CRPS were the same to each other as 46.2%, and specificities were 85.7% and 100% respectively. Nineteen of 26 patients (sensitivity=73.1%) were interpreted as abnormal when at least one test showed a positive finding. As a result, an increased diagnostic strength was achieved. CONCLUSION: These findings suggest that the combination of TPBS and DITI can improve the diagnostic strength of post- hemiplegic CRPS.

Shoulder Uptake in the Bone Scintigraphy in Patients with Hemiplegic Reflex Sympathetic Dystrophy Syndrome / 대한핵의학회잡지

PURPOSE: Increased uptake of wrist and hand joints in three phase bone scintigraphy (TPBS) have been used in the detection of reflex sympathetic dystrophy syndrome (RSDS). TPBS frequently shows increased shoulder uptake in the hemiplegic RSDS patients. We investigated the significance of the shoulder uptake in the detection of these patients. MATERIALS AND METHODS: Twenty three patients who had hemiplegia due to brain stroke and diagnosed as RSD were enrolled in this study (M: F=16: 7, R: L=11: 12). The mean age was 63 +/- 10 yrs. Ten normal volunteer (mean age: 60 +/- 5, M: F=1: 9) data was used as control group. TPBS was performed 59 +/- 32 days after stoke (acute stage). We obtained the count ratios of bilateral hands by drawing a region of interest (ROI) in three phase images and compared to the count ratios of shoulders in the delayed image. Hand ROI included an ipsilateral wrist. Sensitivity of detecting the affected limb was defined using the right/left count ratio of normal control. RESULTS: Sensitivities using count ratios of hand blood flow, blood pool and delayed image were 45%, 76% and 78%, respectively. Sensitivity of shoulder count ratio was 74%. Log of right/left counts of hand delayed image and that of shoulder delayed image were correlated well with statistical significance (Spearman's R=0.824, p< 0.001). CONCLUSION: Shoulder uptake showed good correlation with hand uptake in the delayed image of TPBS. Shoulder uptake maybe helpful in the diagnosis of reflex sympathetic dystrophy syndrome in patients with hemiplegia.

Therapeutic Effect of Oral Corticosteroids in Post-Stroke Reflex Sympathetic Dystrophy: Semiquantitative evaluation of three-phase bone scintigraphy

In 12 Reflex Sympathetic Dystrophy(RSD) patients(13 cases) after the acute stroke, Three- phase Bone Scintigraphy(TBS) was performed to evaluate whether the amount of radioisotope reflects the disease activity of RSD. The diagnosis of RSD was based on Kozin's criteria(definite or probable group) and scintigraphic findings(increased radioisotope uptake in all three phases). Initial TBS was performed within 10 days after the onset of clinical symptoms and it was followed up within 5days after the short term steroids therapy. Before and after the steroids therapy, patients were evaluated with respect to pain, swelling and allodynia. Radioisotope uptake of ROI(Regions Of Interest) of all three images was calculated semiquantitatively in initial and follow up scintigraphy. Pain, swelling and allodynia of the affected hand were improved in all patients after short-term oral corticosteroids therapy. Radioisotope uptake in blood flow image(11 patients, 12 cases) and blood pool image(11 patients, 12 cases) were decreased(p0.05). We concluded that radioisotope uptake in blood flow and blood pool images could reflect disease activity of RSD. It was suggested that decreased capillary vascular permeability by corticosteroids resulted in decreased blood flow and blood pool. The semiquantitative evaluation of TBS may be useful for monitoring the response to therapeutic intervention. The role of inflammatory mediators in RSD and pharmacologic effect of corticosteroids were also discussed.