Musculo-skeletal Clinical Imaging Guidelines PDF

Musculo-skeletal clinical imaging guidelines Maj Gen Prof.Hany Hafez Lofty Head of radiology departments, Maadi Armed Forces compound Armed Forces Collage of Medicine Assistant secretary general Egyptian society of radiology and...

Musculo-skeletal clinical imaging guidelines Maj Gen Prof.Hany Hafez Lofty Head of radiology departments, Maadi Armed Forces compound Armed Forces Collage of Medicine Assistant secretary general Egyptian society of radiology and nuclear medicine  Imaging Modalities 1. X-ray ( conventional, CR, DR ) 2. Ultrasound(US) 3. Computed Tomography(CT) 4. Magnetic Resonance Imaging (MRI) 5. Nuclear medicine (Planner - SPECT – PET) 6. Hybrid imaging (SPECT-CT / PET-CT / PET-MRI) 7. Imaging guided Intervention (diagnostic/therapeutic). Radiology 1895 Radiology 2020  Soft t soft t Bony bone lesions lesions lesions marrow Superficial underlying lesions bone US MRI CT MRI 1. x-ray ( conventional-CR- DR ) Plain Radiographs – 2 views Posterior Dislocation 1- Plain X-ray The proper views are at least 2 views. 2- CT You should mention that you need coronal & sagittal reformatting as well as 3D reconstruction almost there is not absolute contraindications for use of contrast media if there is no alternative. 3- MRI detailed clinical data leave for radiologist the choice of Protocol Discs or block Numerous names of sequences by companies  Conventional x-rays (screen/film radiography) are attenuated within the body and activate the film to emit light rays and image is produced. Computed Radiography (CR): film receptor is replaced by reusable plate. Digital radiology (DR) replaced by transistors. Displayed on a monitor to be evaluated before patient leave then printed No dark room or chemicals - no need for a space to store films – no need to change your old x-ray machine. 2- Ultrasound  US -ADVANTAGES High resolution for superficial structure and Doppler Scanning Real-time = Interactive No radiation to patient or provider Exam of contralateral side for comparison Portable Relatively inexpensive Educational facility (anatomy , technique , interpretation)  MSK US Advantages High resolution with Doppler Scanning Ability to image in real-time = hands-on, dynamic, fast Interactive –allows feedback from patient Generally unaffected by metal artifacts No radiation to patient or provider Exam of contralateral limb for comparison Real-time guidance for interventional procedures Portable Relatively inexpensive. Hip US for DDH (less than 6 months,need a special skill.  MSK US-Indications Superficial lesions Tendon or ligament pathology. Joint effusion (small) , synovitis, or crystal deposition disease. Nerve entrapment, injury, neuropathy, masses, or subluxation. Evaluation of soft tissue masses, swelling, or fluid collections. Detection of foreign bodies in the superficial soft tissues. Planning and guiding an invasive procedure.  US – disadvantages Limited field of view. Detailed picture of relatively small area ( probe) Limited penetration. Lower resolution at greater depths Operator dependent (expert) Cannot penetrate mature adult bone and air 3- Computed Tomography (X-RAY)  CT Advantages: ✓Relatively quick imaging procedures. ✓Requires minimal patient cooperation. ✓Offers excellent anatomic details. ✓CT has high sensitivity for detection of different densities (Air -400 / fat -200 / water 0 / thick fluid 10 /soft tissue 40 /blood 70 / contrast medium 100 /bone 200) Disadvantages: Exposes the patient to a relatively large amount of ionizing radiation. Risk of contrast induced nephropathy and allergic reaction.  CT EVOLUTIONS (7 GENERATIONS) 1970 1995 Conventional Multi-slice 1 2nd st 1990 Spiral 3rd 4th  CONVENTIONAL CT After each rotation the scanner must stop and rotate in the opposite direction and the table transit to the next position. LIMITATIONS ◼ Slow scan time, that prone to artifact caused by movement or breathing. ◼ Poor ability to reformat images in different planes. ◼ No dynamic contrast studies are less accurate. ◼ Small lesions can be missed due to slice thickness and variable inspiratory effort.  Spiral (Volumetric) multi-slice ct Scanning Continuous data acquisition ( exposure) and table displacement at constant speed BENEFITS Alter Slice Thickness retrospectively without Rescanning Reduced Examination time (Single breath-hold acquisition): No lesion missed, 94% of patients can hold their breath for 30 sec Good control of delay between injection and scan: Multi-phasic studies and efficient use of contrast media Longer Scans (Full Organ Coverage - Trauma whole body - Long Vascular Run off) 4- Magnetic Resonance Imaging  MRI Advantages: ✓ No irradiation ✓ Variable sequences. ✓ Direct multiple planes ( without reformatting ) ✓ Excellent for chest wall soft tissue and bone marrow imaging ✓ characterize mediastinal lesions ✓ Angiography could be done without contrast injection Disadvantages: ✓Longer time not suitable for uncontrolled, paediatrics, claustrophobic patients. Might be general anaesthesia ✓Less availability ✓High cost Bone Marrow  High-Field MRI scanners are usually closed or tube or tunnel like due to their use of stronger magnets ranging from at least 1.5T up to 3.0T. it provides a really great quality image. There is also an ultra-high field scanner strength of 13.0T. It is not widely available and is typically used for research. Low-Field MRI scanners are typically identified as open MRI scanners and have a magnet range of 0.23T-0.3T. useful for people who are claustrophobic or unable to have a closed MRI scan due to weight or size. Low-field MRI scanners have decreased image quality and require a longer scan times yet resolution is good for most of MSK exams.  Standing or Sitting MRI Scans allow patients to stand or sit while having their exams done. While these machines help with patient comfort, In the future these machines will hopefully improve in many aspects which will make them much more useful. Right now they are only useful in very specific circumstances.  Dis-advantages One exam = one body part Average exam time 15:30 minutes. NOT patient friendly- Claustrophobia High Cost Many sequences (T1,T2,PD,STIR,Gradient…etc. Non-standardized imaging techniques. Metallic or electronic objectives. occult tibial plateau fracture T1 STIR MRI- Lipoma  MRI-Absolute Contraindications ▪ Cardiac Pacemakers ▪ Electronic stimulators ▪ Aneurysm clips ▪ Metallic foreign bodies N.B : Titanium plates are accepted  5-Nuclear medicine imaging (molecular imaging) ( scintigraphy )  Scintigraphy (molecular imaging) : 1. Planner isotope scanning 2. Single positron emission computed tomography (SPECT) 3. positron emission tomography (PET) 4. Others  Nuclear medicine is a Functional imaging modality detecting metabolic activity. SPECT provides true 3D reformatting. This information is typically presented as cross-sectional slices through the patient, but can be freely reformatted or manipulated as required. POSITRON EMISSION TOMOGRAPHY(PET) Tracer emits positrons which combine with electrons to produce gamma rays detected by 1 scanner then recorded by computer program to reconstruct 3D images FDG is commonly used to detect cancer Naf (bone formation) - H2o (blood flow) PET is expensive and not used alone now Advantages ✓Differentiate Necrotic tissue, scar tissue, and inflammatory changes from malignancy which are not differentiated based on anatomic imaging alone. ✓Detect Lymph nodes which are not pathologically enlarged by size criteria alone when using traditional cross-sectional imaging but are harboring malignant cells ✓ High negative predictive value (exclude malignancy) Dis-Advantages ✓ less spatial resolution. ✓ High percentage of false positive. PET ✓ High cost and radiation dose (pediatrics and pregnancy). ✓ Diabetics may undergo a PET under certain precautions  Nuclear Imaging (Functional) PET provides imaging of the whole body distribution of FDG, thus highlighting the markedly increased metabolic activity of tumor cells. 6-hYBRID imaging (spect-ct/pet-ct/PET-mri) It is fusion of nuclear medicine with Cross sectional anatomical imaging to produce special views , These views allow the information from two different exams to be correlated and interpreted on one image, leading to more precise information and accurate diagnoses.  7-IMAGING- GUDIED Intervention (diagnostic/therapeutic)  Image-guided MSK intervention Diagnostic: -Biopsy, fluid aspiration, nerve block, arthrogram, discograms…etc. Therapeutic: -Intra-articular steroid injection -dry-needling tendons, Autologous blood injection, -vertebroplasty, -ostiod osteoma ablation.  Diagnostic intervention Discogram Athrogram SA/SD Bursal Infiltration Supra-spinatus barbotage Vertebroplasty