Detect/stage metastatic disease & follow-upEvaluate primary bone neoplasmsEvaluate inflammatory vs. infectious diseasesEvaluate bone pain in pt with normal radiographsInvestigate unexplained, increased alkaline phosphatase levels (enzyme used by osteoblasts to lay down bone matrix)Assess bone graft viability, infarction or aseptic necrosisAssess prosthetic joints for infection or looseningEvaluation of roentgenologically difficult fractures

1. SKELETAL SYSTEM
EXAMINATION

2. The SkeletalSystem
• Axial skeleton
• Skull
• Vertebral column
• Thorax
• Appendicular skeleton
• Shoulder girdle
• Arms
• Pelvic girdle
• Legs
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Review of Skeletal System

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Review of Skeletal System

4. Acetabulum
NMT Program UAB
8 Review of Skeletal System

5. 9
Review of Skeletal System

6. 1. Cranium
(Skull)
3. S.I. Joint
4. Femur
5. Posterior
8. Iliac crest
9. Pubis
10. Clavicle
6. Scapula
11. Humerus
7. Spine
12. Neck of
Femur
13.
Ma ndible
14.
Sternum
15.
Radius
1 6
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Uln
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Tibia
2. Rib
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Review of Skeletal System

7. Terminology
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• Anterior/Posterior
Anterior/Posterior
ANT
POST
R L
L R
Review of Skeletal System

8. Terminology
continued…
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Plantar
• Proximal/Distal
• Lateral/Medial
• Superior/inferior
• Palmar (volar)
• Plantar
Review of Skeletal System

9. Bone
Ultrastructure

10. • Detect/stage metastatic disease & follow-up
• Evaluate primary bone neoplasms
• Evaluate inflammatory vs. infectious diseases
• Evaluate bone pain in pt with normal radiographs
• Investigate unexplained, increased alkaline
phosphatase levels (enzyme used by osteoblasts to
lay down bone matrix)
• Assess bone graft viability, infarction or aseptic
necrosis
• Assess prosthetic joints for infection or loosening
• Evaluation of roentgenologically difficult fractures
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Clinical Indications

11. Radiopharmaceutical used
Generic name Chemical name
• Tc-99m medronate
(technetium)
Methylene
Di Phosphonate
(MDP)
• Tc-99m oxidronate HydroxyMethylene
DiphosPhonate
(HDP or HMDP)
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Mechanism of uptake - Chemisorption

12. • Pediatrics by weight : Recommended
• 0.25 mCi/kg (pediatric dose)
Young’s rule or Webster’s rule for pediatric dosage
calculation:
Age in years + 1
Age in years + 7
Dosage
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Dosage & Administration
X Adult dose
20 – 30 mCi (adult dose) ( 740 –1110 MBq)

13. Administration
• Intravenous (i.v.)
• Straight Stick -
• Butterfly-
-
existing i.v. catheter (with saline flush)
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Dosage & Administration

14. Patient preparation (beforearrival)
Hydration
Frequent voiding
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Technique
Critical Organ - Bladder

15. Patient preparations (afterarrival)
• Identify the patient; verify the
physician’s order; review the clinical
indication for the exam
• Explain exam to patient; obtain
relevant medical history
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Technique

16. Relevant Medical
History
• Bone pain
• Trauma/fracture
• Arthritis
• Medications/dietary
supplements
• Surgery
• Malignancies
• Biopsy/pathology
• Radiation/chemotherapy
• Kidney/bladder problems
• Recent dental work
• Chronic health problems
• Other medical imaging
results
• Pregnancy status
• Lab results
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Technique

17. Patient Preparation
• Radiopharmaceutica
l clearance depends
on several factors,
including:
• Age
• Renal status
• Ideal wait time:
• 2 to 3 hours post inj
• Immediately before
imaging:
-remove attenuating
materials
- patient should void
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Technique

18. Imaging the patient
Use one of the following imaging
techniques:
-Static studies
- Dynamic studies
-Multiphase studies (with 3-phase/
4-phase)
- Tomographic studies (SPECT)
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Technique

19. Static studies
• Time delay post tracer injection
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• Whole body vs limited (“spot” view)
• Preset total counts or time
- Imaging localized concentration of
radiopharmaceutical in the body
Technique

20. Dynamic Studies (Flow)
- Multiple sequential Imaging of
nonlocalized radioactivity in the body
usually yielding functional data
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Technique
(as in imaging blood flow, gastric emptying, kidney filtration, etc)

21. Multiphase Studies
• 3-Phase Study
Imaging in the following sequence:
1) Immediate flow dynamic images
2) Early (5-15min) static image(s)
3) Delayed (3-4hr) static image(s)
• 4-Phase Study: 3-phase study plus a 24 hour
delayed image
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Technique

22. 1st Phase (Perfusion)
2nd Phase (BloodP ool)
3rd Phase (Delaye
3-Phase bone scintigraphy
Technique
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Technique
Bone SPECT
(single photon emission computed tomography)
• Multiple planar images taken around
the body (projections)
Planar vs. Tomograp hic
Mathematically reconstructs 3-D volume from
projection data using a computer

24. Bone SPECT
(continued..)
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Transverse Slices (Top -> Bottom)
Sagittal Slices (Right -> Left)
Coronal Slices (Front -> Back)
Technique
The projection images are used
to reconstruct slices in 3
different planes using computer

25. Bone SPECTContinued…
Advantages & Disadvantages
• Improves lesion detection
• Better localizes abnormality suspected in
planar images
• Most valuable in complex bony structures
• Time consuming
• Patient discomfort
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Technique

26. NormalAdult
• Symmetry
• Increased tracer
concentration in the
following areas:
• nasopharynx
• sternum
• shoulder joints
• anterior iliac crests
• Posterior S.I. Joints
• Visualization of
kidneys/bladder
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The Normal Scan

27. “Super Scan”
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There is minimal soft-tissue
activity and virtually no renal
or bladder activity. This
pattern is indicative of
diffuse bone metastases
and is often referred to as a
superscan.
Also associated with:
-certain metabolic bone
diseases
- abnormally extended delay
before imaging
Radiographics. 2003;23:341-358

28. Normal Child
• Tracer distribution is
age dependent
• In addition to areas listed
for adults, increased activity
also noted in areas of bone
growth:
– epiphyseal plates
– costochondral
junctions
The Normal Scan
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29. Bone Scintigraphy – Sensitivity
vs. Specificity
Nuclear medicine bone imaging is very sensitive to
pathologic changes in bone physiology (eg., bone
destruction, changes in perfusion), but it is not
specific for a particular disease.
Greater specificity is achieved by gathering more data
about the patient such as clinical symptoms or the
results of other diagnostic tests.
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The Abnormal Scan

30. Bone uptakeprinciples
• Recall that the skeleton undergoes constant
remodeling
• Radiopharmaceutical uptake in the bone is
proportional to blood flow, bone mass, and
metabolic activity
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The Abnormal Scan
Pathology: - Increased tracer uptake (“hot spots”)
- Decreased tracer uptake (“cold spots”
or photopenia)

31. Pathology Manifestations
Pathological conditions
causing Increased Uptake
Neoplastic disease
Trauma sites
Metabolic bone disease
Degenerative bone
disease
Inflammatory bone
disease
Pathological conditions
causing Decreased Uptake
Radiation injury
Avascular necrosis
Cyst
Multiple myeloma
Fluid collections
The Abnormal Scan
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32. Extraosseous
Activity
• Renal anatomy & abnormalities
• Acute myocardial infarction
• Soft tissue inflammation
• Neoplastic soft tissue tumors
• Normal female breasts
• Amyloidosis
SPECT image shows pedicle uptake to
be more superficial in overlying soft
tissue (arrow). Patient had received
injections of antiinflammatory drugs at
this site a few weeks before scan.
Artifacts & Pitfalls
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33. Artifacts
• Attenuating objects
• “Free” pertechnetate
• Tracer infiltration
• Urine contamination
• Arterial injection
Urine contamination (A)
disappeared after patient
removed cloths (B)
Artifact from an implanted
defibrillator.
Artifacts & Pitfalls
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34. Evaluate images for technical quality
Urine contamination
Attenuation artifacts
Patient positioning
Tracer extravasation (infiltration)
Other artifacts (radiopharmaceutical, equipment, patient)
Artifacts & Pitfalls
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Was image acquired at correct time
following tracer administration?
• Check radiopharmaceutical distribution
• Look for soft tissue/bloodclearance
Is the radiopharmaceutical distribution
as expected?
• Normal biodistribution
• Pathology
• Patient preparation
Does the image include all relevant
anatomy?
• Patient/camera positioning
Was the patient positioned correctly?
• Relevant anatomy
• Correct positioning
Were the correct acquisition parameters
used?
• Collimator
• Static vs dynamic
• Total counts, time or framing rate
• Acquisition matrix (spatial resolution)
Are the images displayed and labeled
correctly?
• Format
• Media (film, laser paper, workstation monitor)
Are there any artifacts that need to be explained
or removed (require image to be repeated)?