Imaging Basics PDF

Primary Care Introduction Diagnostic Imaging  Overview Imaging Basics – Radiographs – Computed Tomography – Bone Scintigraphy – Magnetic Resonance Imaging Radiation Exposure – Utilization/Appropriateness Reading/Interpreting Imaging # of skills reportedly practiced “routin...

Primary Care Introduction Diagnostic Imaging  Overview Imaging Basics – Radiographs – Computed Tomography – Bone Scintigraphy – Magnetic Resonance Imaging Radiation Exposure – Utilization/Appropriateness Reading/Interpreting Imaging # of skills reportedly practiced “routinely” – 6.95 Overall – 67% Report practicing 7 or more overall – 28% Report practicing all 9 routinely DIAGNOSTIC ULTRASOUND  Diagnostic Ultrasound Hyperechoic: reflects sound with much energy. Bright. Hypoechoic: reflects sound with little energy. Dark. Anechoic: does not reflect sound at all. Black.  Dx US Certification Alliance for Physician Certification & Advancement (APCA) – Registered in Musculoskeletal sonography (RMSK ®) – Eligible as a DPT – 150 diagnostic studies w/in 36 months – 200 questions 4 hour test – 2-5 year post graduation normal timeline Info available on Blackboard RADIOGRAPHY From McKinnis LN. Fundamentals of Musculoskeletal Imaging  Radiography Benefits – Fast (same day) – Inexpensive: $200 vs. $3000 for MRI https://health.costhelper.com/x-rays.html – Comparably low radiation dose – Radiographs depict a 3-dimentional structure on a 2-dimentional medium Initial imaging modality of choice for most musculoskeletal conditions. A B Mabry LM, et al. Congenital Partial Mabry LM, et al. Diagnostic imaging Aplasia of the Atlas Causing Functional following cervical spine injury. Journal Angular Displacement of the Posterior of Orthopaedic & Sports Physical Arch. Physical Medicine & Stepwards. Fundamentals of X-Ray Studies. https://www.stepwards.com/? page_id=7633 Radiograph/CT Terminology Radiodensity – the ability for a structure to block radiation from passing through it. More Radiodense – Structures will appear comparably lighter on a radiograph/CT (i.e. bones, metal) Less Radiodense – Structures will appear comparably darker on a radiograph/CT (i.e. air, fat) Mabry LM, et al. Congenital Partial Aplasia of the Atlas Causing Functional Angular Displacement of the Posterior Arch. Physical Medicine & Foundations in Radiology. https://quizlet.com/ 419262497/foundations- in-radiology-flash-cards/ https://radiopaedia.org/cases/anterior-cervical-discectomy- and-fusion-acdf-subsidence Re A, et al. Results of the Italian neu_ART project. IOP Conference Series Materials Science and Engineering. 2021:37(1). Radiograph/ CT Terminology Radiolucency – comparably darker area (or less radiodense region) within a structure. May also be referred to as a “lytic” lesion. Radiopacity – comparably brighter area. This term is typically reserved for metal with an opaque presentation. By comparison, slow growing osteoblastic activity within a bone may be called “sclerotic” Epstein J, et al. Myeloma and Bone Schuh A, et al. Symptomatic giant bone Disease: “The Dangerous Tango.” island of the tibia mimicking lesion of Clinical advances in hematology & the medial meniscus. Glob Med Therap. A B Bousson V, et al. Fibrous dysplasia and McCune–Albright syndrome: Imaging for positive and differential diagnoses, prognosis, and follow-up guidelines. Euro J Radiol. 2014;83:1828-1842. Epstein J; Walker R. Myeloma and Bone Schuh A, et al. Symptomatic giant bone Disease: “The Dangerous Tango.” Clinical island of the tibia mimicking lesion of advances in hematology & oncology: H&O. the medial meniscus. Glob Med Therap.  Kahoot https://play.kahoot.it/v2/?quizId=719 9a688-0b8e-4e4e-8a18-48054d015e 47 Stepwards. Fundamentals of X-Ray Studies. https://www.stepwards.com/? page_id=7633 Lin N, et al. BMC Anesthesiology. 2015 Richardson & Iglarsh. Clinical Kutchman, et al. Biomed J Sci Orthopaedic Physical Therapy. 1994. Tech Res. 2021. Richardson & Iglarsh. Clinical Orthopaedic Physical Therapy. 1994. Akinyemi OA, et al. Buttock Pain and Sciatica Caused by a Femoral Osteochondroma. Journal of Orthopaedic & Sports Physical Therapy. 2017 Stepwards. Fundamentals of X-Ray Studies. https://www.stepwards.com/? page_id=7633 Fauber TL. Radiographic Imaging and Exposure. Fauber TL. Radiographic Imaging and Exposure. Radiography Statistical Properties Inherently specific but not inherently sensitive. Ability to “rule in” a Specificity pathology Positive finding “rules in” SpIn Negative finding means little Ability to “rule out” a Sensitivity pathology Positive finding means SnOut little A B C Case courtesy of Dr Bruno Di Muzio, te Stroet MAJ, et al. Emergency Radiology. 2010 https://medpix.nlm.nih.gov/case? Radiopaedia.org, rID: 46212 id=3a397cea-e0a5-4bf2-911d- BONE SCAN https://www.verywellhealth.com/what-is-a-bone-scan-for-can  Bone Scan Shows metabolic activity using radioactive tracer – Typically looking for metastases – Stress Fracture – AVN Slow High Radiation Diminishing utility for musculoskeletal medicine Can be “negative” Or “positive” Shikino K, et al. Super bone scan: bone metastases of prostate cancer. Montella M, et al. Diagnosis: BMJ Case Reports. 2014. Osteomalacia secondary to Facnoni’s Syndrome.  Positive Bone Scan Hot Spots: Darker, more metabolic activity (increased radionucleide uptake) – Stress reaction – Chronic Regional Pain Syndrome – Infection – Metastatic cancer – Other inflammatory conditions Cold Spots: Brighter, lower metabolic activity (decreased radionucleide uptake) – TKA – AVN Shikino K, et al. Super bone scan: bone metastases of prostate cancer. BMJ Case Reports. 2014.  Negative Bone Scan Hot Spots: Brighter, more metabolic activity – Stress reaction – Chronic Regional Pain Syndrome – Infection – Metastatic cancer – Other inflammatory conditions Cold Spots: Darker, lower metabolic activity – TKA – AVN Montella M, et al. Diagnosis: Osteomalacia secondary to Facnoni’s Syndrome.  Bone Scan Imaging Inherently very sensitive but not specific. Why? Iwamoto J, et al. Analysis of stress fractures in athletes based on our clinical experience. COMPUTED TOMOGRAPHY https://www.slideshare.net/shekharstar/ct-scan-final-2-63863260  Computed Tomography Primarily used for fracture screening/diagnosis in musculoskeletal medicine Benefits – Fast (potentially same day) Emergencies Involuntary Movements – Better statistical properties than radiographs. Best imaging modality for cortical bone fractures. Otherwise largely statistically inferior to MRI – Metal not contraindicated – May be used for soft tissue imaging when MRI is contraindicated High radiation exposure http://www.bodytrainer.tv/en/page/1/19-74-Body%2BPlanes%2B%252 6%2BTerms Transverse Frontal  Sagittal Coronal Axial Mabry LM, et al. Congenital Partial Aplasia of the Atlas Causing Functional Angular Displacement of the Posterior Arch. Physical Medicine & Rehabilitation. 2018 Dec;10(12):1434-1436.  Bone Window CT Windows Soft Tissue Window Mabry LM, et al. Congenital Partial Aplasia of the Atlas Anisau A, et al. Omental infarction in the Causing Functional Angular Displacement of the postpartum period. EuroRad. 2018. Posterior Arch. Physical Medicine & Rehabilitation. https://radiopaedia.org/cases/fac et-joint-fracture-treated-with-acd f-and-follow-up?lang=us  Kahoot https://play.kahoot.it/v2/lobby?quizId =4e499097-3b30-4513-9425-fed36b a3735e MAGNETIC RESONANCE IMAGING Magnetic Resonance Imaging Inherently sensitive and specific Ideal for soft tissues and trabecular bone No radiation exposure But… – Irrelevant positive findings are common – Clinical correlation a must!!! De Smet AA, et al. Clinical and MRI findings associated with false-positive knee MR diagnoses of Image courtesy of Magnet is ALWAYS on https:// ressonanciamagneticadobr asil.wordpress.com/ 2014/12/23/international- alert-three-accidents- involving-mri-last- november/  Magnetic Resonance Imaging Key is polarity of Hydrogen – Fat – Water https://biologydictionary.net/polar-mole  MRI Simplified… 1. Magnet aligns H+ 2. Radiofrequency pulse alters H+alignment 3. H+ realigns, releasing energy detected by MRI Farnsworth B. EEG vs. MRI vs. fMRI – What are the Differences?  MRI Properties Very Slow (Motion Artifact) Expensive New/unsecured metal contraindicated Claustrophobia Stadler A, et al. Artifacts in body MR imaging: Their appearance and how to eliminate them. Euro Radiol. 2007. Ross JS, Bell GR. Spine Imaging. https://radiology.ucsf.edu/patient-care/prepare/claustr https://clinicalgate.com/spine-ima  Collier D, et al. Recognition of Cervical Myelopathy via Diagnostic Cluster. MRI Terminology JOSPT Cases; in press. Hyperintense – Structure signal is comparably brighter Hypointense – Structure signal is comparably darker Kutchman, et al. Biomed J Sci Tech https://www.startradiology.com/th e-basics/mri-technique/index.html https://www.fifamedicalnetwork.com/lessons/radiology  MRI Weights T1 Fat Weighted (Fat Bright, Water is dark) T2 Water-Weighted (Water is bright, Fat not quite as bright) Fat Saturated/STIR (Water is bright, Fat appears dark) MRI H2O Fat Weight T1 Dark Bright T2 Bright Bright-ish  Aissiou M. Normalized intervertebral T1 T2 STIR disc MRI signal as a biomarker of pain. J Biomed Sci Engin. 2013  T1 Water Dark Anatomy Fat bright to bright- ish T2 Soft Tissue Pathology Fat Sat Water Bright Pathology Fat dark Bone to very Marrow dark STIR Edema  T1 T2 Case courtesy of Dr Balint Botz, T1 better for Radiopaedia.org, rID: 87940 anatomy T2 better for pathology  STIR/Fat Sat better for bony pathology T2 STIR Case courtesy of Dr Nick Tarasov, Radiopaedia.org, rID:  MR Arthrography MRI with contrast injected into joint Typically for labral tears Unneeded with higher power magnets? Contact ortho/radiologist before ordering. RADIATION EXPOSURE United States Environmental Protection Agency. https://www.epa.gov/radiation/radiation-s ources-and-doses United States Environmental Protection Agency. https://www.epa.gov/radiation/radiation-s ources-and-doses  Mafraji MA. 2023 Imaging Modality Radiation Exposure Radiation Dosage Elevated Risk High Children CT } Cumulative Pregnant WomenLifetime Exposure Bone scan Tissues Low – radiographs Genitals None - MRI Intestines Lymphatics Blood 1 Chest X-Ray = 10 days of naturally occurring background radiation  Sung & Shin. 2013 Radiation Dose Considerations Justification – Appropriateness of Imaging Reduce Unnecessary Imaging (i.e. overutilization) Will this change management of patient Surgical Planning Treatment Considerations In some cases, fear reduction. Etc… Optimization – Radiology Clinic Responsibility Right Radiation Dosage Reducing extraneous exposures Shielding sensitive tissues, etc Appropriateness of Imaging Appropriateness – As defined by EBP Guidelines ACR Criteria Meta-analysis (Jenkins, et al) 32-35% of LBP Imaging orders are inappropriate Jenkins HJ, Downie AS, Maher CG, Moloney NA, Magnussen JS, Hancock MJ. Imaging for low back pain: is clinical use consistent with guidelines? A systematic review and meta-analysis.  Jenkins HJ, et al. Spine J. 2018 Dec;18(12):2266-2277. Appropriateness of Imaging Overutilization Meta-analysis 32-35% inappropriate Underutilization Same meta-analysis 61-66% of those with red flag finding/concern for pathology did not receive imaging Appropriateness… Physicians Physical Therapists 61-66% (Jenkins, et al) 100% (Moore, et al) 83.2% (Crowell, et al) 91% (Keil, et al) Utilization Mabry, et al (2020) Primary Care – imaging 1 in 5 encs PT – imaging in 1 in 37 encounters Crowell, et al (2022) Primary Care – no imaging in 82% of encounters PT – no imaging in 97% of encounters We need to change our language from imaging is “overutilized” to imaging is “mis-utilized.” Radiation Exposure Justification “…the potential benefit of a diagnostic test often outweighs the potential harms.” (Mafraji MA) “The inappropriate treatment by neglected or omitted procedures owing to the expected radiation exposure damage may give rise to disastrous consequences.” (Sung & Shin)  Final Kahoot! https://play.kahoot.it/v2/?quizId=bfaf 51ed-1f22-4957-9a29-caf685ed5ec4 Interpretation Orientation, Mnemonics, My Advice Orientation Flipped (patient looking at you) Variable Patient’s right is on the Bone Scintigraphy left of image Radiographs CT scan MRI  Catena L, et al. Multiple Total Hip Arthroplasty Dislocations in a Patient with Radiograph Lumbar Stenosis. Open Journal of Case Reports; 2021 Feb;2(1):120. s Patient is looking “at” you Right is on the left, etc  Mabry LM, et al. Congenital Partial Aplasia of the Atlas Causing Functional Angular Displacement of the Posterior Arch. Physical Medicine & Rehabilitation. 2018 Dec;10(12):1434-1436. Collins JD. Basketball Player with Left Foot Pain. HCP Live. 2014. https://www.hcplive.com/view/basketball-player-with-le ft-foot-pain  Mabry LM, et al. Congenital Partial Aplasia of the Atlas Causing Functional Angular CT/MRI Orientation Displacement of the Posterior Arch. Physical Medicine & Rehabilitation. 2018 Dec;10(12):1434-1436. Patient is looking “at” you Right is on the left, etc R R Mabry LM, et al. Metastatic cancer mimicking mechanical low back pain: a case report. Journal of Manual & Manipulative Therapy. Bone Scan Orientation varies by view Shikino K, et al. Super bone scan: bone metastases of prostate cancer. BMJ Case Radiograph/CT Search Strategy: ABCS Alignme Bone Cartilag Soft nt Density e Space Tissues Overall → Deep → Superficial  https://younglifeyoungwife.w eebly.com/life-with-chronic-p ain/scoliosis Alignment Skeletal Architecture Bone Contour Alignment Beers LR, et al. Osseous fragment in a patient with knee pain. JOSPT.  Bone Density General bone density Local bone density Primary Bone Tumors. Memorang. https://memorang.com/flashcards/157299/Primary+Bone+Tumo rs Keesler R, Dean AJ. Plain http://www.wikiradiography.ne Radiography in the Elderly. t/page/Lateral_Lumbar_Spine_ Ch 11: in Clinical Emergency Cartilage Space Joint Space Subchondral Bone Hahn S. Easy Way Out-Quick Interpretation of Musculoskeletal Radiographs: The Lower Extremity. J Korean Soc Radiol. 2017. http://www.svuhradiology.ie/case-study/osteoar thritis-hip/ Freeman S. Blood biomarker panel studies aim to predict knee osteoarthritis, Soft Tissues Tonarelli JM, et al. Diagnostic Imaging of an Achilles Tendon Rupture. JOSPT. 2011 MRI Search Strategy ABCDs Alignment Bone Signal Cartilage eDema Soft Tissue McKinnis L. Fundamentals of Musculoskeletal Imaging. My Recommendation Stage 1 Read Radiologist interpretation on every relevant image on every patient you see. Identify the significant findings on the images themselves. Once you are quickly/easily able to identify the findings (~ 6 months), go to stage 2 Stage 2 Do NOT initially look at radiologist interpretation Look at the images and identify what you think is important Compare it to the radiologist interpretation Review the images to identify if there are discrepancies.  Review Imaging Basics – Radiographs – Computed Tomography – Bone Scintigraphy – Magnetic Resonance Imaging Radiation Exposure – Utilization/Appropriateness Reading/Interpreting Imaging  References Aissiou, M., Périé, D., & Mac-Thiong, J. M. (2013). Normalized intervertebral disc MRI signal as a biomarker of pain. Journal of Biomedical Science and Engineering, 06(03), 372–380. https://doi.org/10.4236/jbise.2013.63a047 Akinyemi, O. A., Mabry, L. M., & Dardenelle, S. I. (2017). Buttock Pain and Sciatica Caused by a Femoral Osteochondroma. Journal of Orthopaedic & Sports Physical Therapy, 47(6), 442. https://doi.org/10.2519/jospt.2017.6877 Anisau, A., Petre, C., Kindt, K., Desimpel, J., & Vanhoenacker, F. (2018). Omental infarction in the postpartum period. Eurorad. Published. https://doi.org/10.1594/EURORAD/CASE.15420 Arndt, S. (n.d.). Body Planes & Terms - Exercise Guide | bodytrainer.tv. Bodytrainer.Tv. Retrieved December 1, 2021, from http://www.bodytrainer.tv/en/page/1/19-74- Body %2BPlanes%2B%2526%2BTerms BD Editors. (2017, April 29). Polar Molecule. Biology Dictionary. Retrieved December 1, 2021, from https://biologydictionary.net/polar-molecule/ Beers, L. R., Mabry, L. M., & Sullivan, R. T. (2015). Osseous Fragment in a Patient With Knee Pain. Journal of Orthopaedic & Sports Physical Therapy, 45(4), 323. https://doi.org/10.2519/jospt.2015.0404 Botz, B. (2021). Lumbar disc herniation and spinal canal stenosis | Radiology Case | Radiopaedia.org. Radiopaedia. 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The value of a CT scan compared to plain radiographs for the classification and treatment plan in tibial plateau fractures. Emergency Radiology, 18(4), 279–283. https://doi.org/10.1007/s10140-010-0932-5 Tonarelli, J. M., Mabry, L. M., & Ross, M. D. (2011). Diagnostic Imaging of an Achilles Tendon Rupture. Journal of Orthopaedic & Sports Physical Therapy, 41(11), 904. https://doi.org/10.2519/jospt.2011.0422 UCSF Department of Radiology & Biomedical Imaging. (2018, November 15). Claustrophobia and MRI. UCSF Radiology. Retrieved December 1, 2021, from https://radiology.ucsf.edu/patient- care/prepare/claustrophobia-mri United States Environmental Protection Agency. (2021, November 5). Radiation Sources and Doses. US EPA. Retrieved December 1, 2021, from https://www.epa.gov/radiation/radiation- sources-and-doses van der Plas, A. (2016). MRI technique - Startradiology. StartRadiology. Retrieved December 1, 2021, from https://www.startradiology.com/the-basics/mri-technique/index.html