Nuclear Medicine Imaging in Rheumatic Diseases

The rapid development of medical imaging technologies has greatly enhanced the utility of nuclear medicine imaging modalities over the last decade. Hybrid imaging technology merging computed tomography (CT) with single-photon emission computed tomography (SPECT) or positron emission tomography (PET) allows superimposing the physiologic data obtained by SPECT or PET on the detailed anatomy of CT, yielding a better understanding of the disease status and improving diagnostic performance. However, the conventional whole body bone scan and three phase bone scan still have their own distinct role as diagnostic imaging, reflecting the changes of bone metabolism in benign and malignant diseases, including rheumatic diseases. A review of each nuclear medicine imaging technique and clinical applications in various conditions of rheumatic diseases will be presented in this article.

Whole Body Bone Scan for Detecting Missed Bone Injuries in Multiple Trauma Patients

PURPOSE: Patients with multiple traumas often experience multiple fractures that are missed or overlooked, despite the use of imaging, careful history taking, and physical examinations. This study aimed to evaluate the usefulness of whole body bone scan (WBBS) for detecting missed bone injuries in patients with multiple traumas. METHODS: We evaluated 30 patients with multiple traumas who underwent WBBS at single tertiary referral center between March 2008 and February 2016. We assessed the association of patient demographics with WBBS uptake as a binomial outcome variable. RESULTS: There were no significant differences in patient demographics by WBBS. The mean injury severity score did not differ by WBBS (18.1 in the WBBS-negative group vs. 18.4 in the WBBS-positive group), and duration from admission to the evaluation of the WBBS was similar (5.4 days in both groups). The most common uptake site in the WBBS was the ribs (n=7), followed by the tibia (n=3), skull (n=2), ankle (n=1), and sternum (n=1). None of the missed injuries required further treatment, such as manual reduction or surgery. CONCLUSION: WBBS was useful for detecting missed bone injuries in patients with multiple trauma.

Bone Scintigraphy in the Diagnosis of Rheumatoid Arthritis: Is There Additional Value of Bone Scintigraphy with Blood Pool Phase over Conventional Bone Scintigraphy?

We aimed to investigate the value of bone scintigraphy with additional blood pool phase (BSBP), compared with conventional bone scintigraphy (CBS), in the assessment of rheumatoid arthritis (RA). A total of 242 patients (43 males, 199 females; 14-78 years) with arthralgia, and underwent BSBP were retrospectively analyzed. On the first physical examination, active arthritis was found in 128 of the 242 patients. Clinical diagnosis was made by a rheumatologist on the basis of the 1987 American College of Rheumatology (ACR) criteria, which are considered to be the gold standard. The diagnostic performances and prognostic value of BSBP and CBS were analyzed in the total patients with arthralgia and in the patients with arthritis. The sensitivity of BSBP (84.2%, 80/95) were significantly higher than that of CBS (74.8%, 72/95) in the patients with arthralgia (P = 0.039). When BSBP was interpreted with the results of elevated/positive anti-CCP antibody, its accuracy over CBS also became significantly higher (86.0%, 208/242 vs. 83.1%, 201/242 respectively, P = 0.021). The diagnostic odds ratio of BSBP positivity was higher than CBS positivity in the patients with arthralgia (26.0, 12.9-52.4 vs. 21.1, 10.8-41.3) and with arthritis (12.0, 4.9-29.4 vs. 10.0, 4.2-23.4). Both BSBP and CBS appear to provide acceptable accuracy and comparable diagnostic performance for diagnosis of RA. However, in the patients with arthralgia, BSBP was found to be more sensitive than CBS and more accurate when interpreted with the result of anti-CCP antibody. This could help physicians diagnose RA in daily clinical practice.

Analysis of Missed Fractures in Polytrauma Patients

PURPOSE: The purpose of this study is to determine the frequency of missed fractures in severe multiple trauma patients and to analyze any differences in treatment plan, after whole body bone scan. MATERIALS AND METHODS: From September 2012 to December 2013, 49 patients were confirmed to have multiple trauma with an injury severity score (ISS) of 16 or higher. Whole body bone scan was performed at an average of 15.7 days (7-25) after injury. Missed fractures were diagnosed according to physical examination and additional radiologic reports. Locations and patterns of missed fractures were analyzed. We evaluated any differences in treatment plan after the diagnosis of missed fractures. RESULTS: Missed fractures were diagnosed in 14 patients (16 cases) on the whole body bone scan. The most frequent location was the knee (three cases), followed by rib, clavicle, carpal bone, and foot. Seven cases were occult fractures, five cases were undisplaced fractures and four cases were displaced fractures. Conservative treatment was administered in 15 patients and surgery was necessary in one patient. CONCLUSION: Delayed or missed diagnosis of fractures occurred frequently in patients of multiple trauma with a high ISS. Whole body bone scan appears to be effective in finding missed fractures in the whole body. Definitive assessment should be supplemented after initial trauma care in order to reduce the rate of missed fractures.

Diagnostic Accuracy of Bone Scan Compared to Computed Tomography of Thorax Fractures of Chest Trauma Patients

PURPOSE: Thorax computed tomography (CT) is the diagnostic test for chest trauma patients in the emergency department. Thorax CT has high diagnostic accuracy for rib, sternum fractures. However, rib, sternum fractures are often missed by thorax CT. In this study, the accuracy of thorax CT as a diagnostic test of rib, sternum fractures was examined by comparing the diagnosis of rib, sternum fractures by bone scan. METHODS: A total of 112 patients who had visited the emergency department due to chest trauma and who had undergone both thorax CT and bone scan from January 1, 2010, to June, 30, 2013 were examined. We examined the patients'characteristics, vital signs and cause of trauma through a retrospective analysis of medical records, and thorax CT and bone scan were read by a radiologist and a nuclear medicine specialist. RESULTS: Among 112 patients, 62 patients (55.3%) were male, 50 patients (44.7%) were female, and mean age was 56. There were 59 patients who had no fracture on thorax CT and were regarded as contusion. In 59 patients, 28 patients (47.5%) were diagnosis rib, sternum fractures detected by bone scan. Sex (p=0.188), age (p=0.624), and cause of trauma (p=0.389) were not significant predictors for rib, sternum fractures. However, combined fracture (p=0.043) showed significant correlation. In this study, the sensitivity, specificity, positive predictive value, and negative predictive value of thorax CT in diagnosis of rib, sternum fractures were 64.5%, 93.9%, 96.2%, and 52.5%. CONCLUSION: Thorax CT has low sensitivity (64.5%) and low negative predictive value (52.5%) in detection of rib, sternum fractures. Although thorax CT shows no thorax fracture, when patients have persistent pain or they need accurate diagnosis, we may recommend bone scan for detection of rib, sternum fractures and accurate diagnosis.

The Value of Preoperative MRI and Bone Scan in Percutaneous Vertebroplasty for Osteoporotic Vertebral Compression Fractures

OBJECTIVE: Percutaneous vertebroplasty is often complicated by the presence of multiple fractures or non-localizing pain in the patients with osteoporotic vertebral fractures. The purpose of this study is to estimate the value of preoperative radiologic studies in the localization of symptomatic vertebrae and to determine the factors which can influence on the clinical results. MATERIALS AND METHODS: We retrospectively reviewed the clinical and radiologic data of 57 vertebrae in 30 patients underwent percutaneous vertebroplasty for osteoporotic vertebral compression fractures. Inclusion criteria was severe pain(McGill-Melzack score 3, 4 or 5) associated with the acute vertebral fractures and absence of spinal nerve root or cord compression sign. Acute symptomatic vertebral fracture was determined by the presence of signal change on MR images or increased uptake on whole body bone scan. RESULTS: Pain improvement was obtained immediately in all patients and favorable result was sustained in 26 patients(86.7%) during the mean follow-up duration of 4.7 months(5 complete pain relief, 21 marked pain relief). Those who underwent vertebroplasty for all acute symptomatic vertebrae had significantly better clinical result than those who did not. Further vertebral collapse and eventual bursting fracture occurred in 1 vertebra which showed intradiskal leakage of bone cement and disruption of cortical endplate on postoperative CT scan. CONCLUSION: Preoperative MR imaging and whole body bone scan are very useful in determining the symptomatic vertebrae, especially in the patients with multiple osteoporotic vertebral fractures. To obtain favorable clinical result, the careful radiologic evaluation as well as clinical assessment is required. Control of PMMA volume seems to be the most critical point for avoiding complications.

Significance of Whole Body bone Scan in bone and Joint Tuberculosis / 대한정형외과학회잡지

For confirmative diagnosis of bone and joint tuberculosis, it is made by culture method, inoculation to guinea pig, or histological examination of the specimen obtained from a lesion site. But plain reontgenogram is not valuable for early detection of the disease because specific, abnormal finding is not found in early stage and only found in late stage as progressive destruction of bone and joint. Many reports were made thst whole body bone scan, as diagnostic tool, was valuable in other orthopedic disease, but report for its diagnostic value in bone and joint tuberculosis is very rare. The study was carried out on 35 patients of bone and joint tuberculosis who whole body bone scan was performed before operation from Janusry, 1978 to December, 1987 in Depaartment of Orthopedic Surgery, Yonsei University college of Medicine. The following results were obtained. 1. Value of early detection of tuberculosis is not much as pyogenic infection. Intensity of uptake was decreased in tuberculosis than acute pyogenic osteomyelitis and arthritis, but increased than chronic osteomyelitis. 2. Intensity of uptake was decreased in female than male, and also increased in age. group under 10 and over 60 than other age group. 3. The longer duration of the disease, the more decreased intensity of uptake. 4. Intensity of uptake is increased in joint tuberculosis than bone, snd also increased in tuberculosis of spine than long bone. 5. Multifocal disease was detected in 14.3% by whole body bone scan.

The Role of Whole Body Bone Scan in Bronchogenic Carcinoma

One hundred and sixty patients having bronchogenic carcinoma were evaluated for bone metastasis by means of 99mTc-monodiphosphate bone scanning, correlative radiographic bone survey and their clinical findings. In all patients, diagnosis was histologically proved. Bone scan demonstrated the possible evidence of bone metastasis in 75 patients (46.9%) and radiography, in 29 patients (18.1%). False negative was noted in 1 patient-Bone scan correlated with radiography in 37.3%, and with accompanying bone pain in 52% of the patients. But there was no correlation with the level of serum calcium, inorganic phos- phorus and alkaline phosphatase. In connection with their clinical stages before scanning, bone scans were positive in 33.3% of clinical stage I, 10.8% of clinica1 stage II and 54.1% of clinical stage III. Our Study suggests that bone scanning with 99m-monodiphosphate detected early bone metastasis in patients with bronchogenic carcinoma before their lesions became evident clinically or radiographically, and also important to determine operability.