Diagnostic evaluation of cancer patients with pelvic pain: comparison of scintigraphy, CT, and MR imaging

Pelvic pain in cancer patients can result from several causes. The most appropriate choice of imaging techniques for evaluating such patients has not been established. We evaluated 27 cancer patients with pelvic pain by using radionuclide bone scintigraphy (24 patients), abdominal CT (27 patients), and pelvic MR imaging (27 patients) and used the correlation between symptoms and imaging findings to compare these imaging methods. The study population included 11 patients with Ewing sarcoma, six with other sarcomas, five with colorectal cancers, and five with other tumors. All patients had pelvic pain, and eight had pain radiating to a leg. Twenty-three patients had soft-tissue masses, and 19 had bone metastases; 16 had both. Findings on bone scans explained the symptoms in 17 (71%) of 24 patients, findings on CT in 23 (85%) of 27 patients, and findings on MR imaging in 25 (93%) of 27 patients. The difference between bone scanning and CT or MR was statistically significant (p less than .05); however, the difference between CT and MR imaging was not significant (p greater than .05). MR imaging detected 41 (98%) of 42 relevant lesions, whereas CT detected 31 (74%) of 42, and bone scanning 17 (44%) of 39. We conclude that MR is superior to either bone scanning or CT in the initial evaluation of pelvic pain in cancer patients. Such information can be important in directing the treatment of these patients.     

Bone infarction and fat island appearing as local defects in radionuclide bone marrow imaging

Parallel studies of radionuclide bone marrow imaging and bone scanning are helpful in the early diagnosis of skeletal metastasis. In bone marrow imaging, most lesions are observed as a local defect. We had two cases of nonmetastatic lesions which appeared as local defects in bone marrow imaging. The first case was a male Hodgkin's disease patient, aged 48, who had been treated with frequent chemotherapy, including the administration of a large quantities of steroids. He complained of slight pain in the left shoulder. Without increased uptake in bone scanning, abnormal accumulation of 67Ga-citrate and a local defect in bone marrow imaging appeared, corresponding to localization of the pain. Suspecting bone marrow metastasis, we performed magnetic resonance imaging (MRI). An area of slightly decreased intensity in T1-weighted spin-echo images and lower intensity than fat tissue in T2-weighted images were observed, although it was slightly enhanced by Gd-DTPA. This lesion was diagnosed by biopsy as a bone infarction. The second case was that of a 69-year-old male lung cancer patient. Though no abnormality was revealed by bone scanning or 67Ga-citrate scintigraphy, an apparent defect at the 10th thoracic vertebra was observed in bone marrow imaging. It was not accompanied by pain. MRI was also performed in this case. This was depicted as a clearly defined high intensity area. This was diagnosed as a fat island, and no change has been seen in the seven months of follow up. In conclusion, it is necessary to consider the possibility of nonmetastatic lesions, when local defects appear in bone marrow imaging performed on cancer patients.     

Value of bone scan imaging in predicting pain relief from percutaneous vertebroplasty in osteoporotic vertebral fractures

BACKGROUND AND PURPOSE: Patient selection for percutaneous vertebroplasty is often complicated by the presence of multiple fractures or non-localizing pain. Our purpose was to determine whether increased activity revealed by bone scan imaging is predictive of a positive clinical response to percutaneous vertebroplasty. METHODS: A retrospective chart review conducted at our institution yielded 28 vertebroplasty treatment sessions that had been performed after obtaining bone scan imaging for painful, osteoporotic compression fractures in 27 patients. Thirty-five compression fractures were treated during these 28 treatment sessions. In all cases, increased activity was revealed by bone scan imaging before treatment with vertebroplasty. Positive outcome was defined as subjective decrease in pain severity and/or increased level of patient mobility. RESULTS: Subjective pain relief was noted in 26 (93%) of 28 treatment sessions. In 14 (100%) of 14 cases with quantifiable pain levels, pain improved at least 3 points on a 10-point scale (range of improvement, 3-10 points; mean improvement, 7.4 points). Among the remaining 14 treatment sessions in which patients were unable or unwilling to quantify pain severity, the pain relief was described as complete or excellent pain relief in 11 (78%) of 14 cases. In 14 (100%) of 14 cases for which semiquantitative assessment of mobility was available, mobility improved at least one level (5-point graded scale; range of improvement, 1-4 points; mean improvement, 1.7 points). CONCLUSIONS: Increased activity revealed by bone scan imaging is highly predictive of positive clinical response to percutaneous vertebroplasty.     

Groin pain in footballers: the association between preseason clinical and pubic bone magnetic resonance imaging findings and athlete outcome

BACKGROUND: Groin pain and tenderness are common in athletes from a variety of codes of football, but little attention has been directed to the influence of magnetic resonance imaging and such clinical findings on athlete participation. HYPOTHESIS: Preseason groin pain, tenderness, and magnetic resonance imaging findings such as pubic bone marrow edema are associated with restricted training capacity and missed games. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Fifty-two Australian footballers in the national competition were recruited. Preseason groin pain and focal tenderness were recorded, and magnetic resonance imaging of the groin was performed within 1 week of examination. Training restriction and games missed owing to groin pain were documented during the subsequent season. RESULTS: Magnetic resonance imaging showed pubic bone marrow edema in 19 of 52 (37%) footballers and linear parasymphyseal T2 hyperintensity in 16 of 52 (31%) footballers. Groin pain restricted training during the season in 22 of 52 (42%) footballers, and 9 of 52 (17%) footballers missed at least 1 game. Preseason pain (P = .0004), pubic bone tenderness (P = .02), and linear parasymphyseal T2 hyperintensity (P = .01) were associated with restricted training capacity during the subsequent season. Preseason groin pain (P = .03) was associated with missed games, but magnetic resonance imaging findings were not. CONCLUSION: Preseason pubic bone marrow edema, groin pain, and linear parasymphyseal T2 hyperintensity were associated with training restriction, but only preseason groin pain was associated with missed games.     

Isolated injury of the cuboid bone

The purpose of this study was to describe isolated injury of the cuboid bone as a potentially radiographically occult cause of foot pain. The imaging studies of 17 patients, 13 women and 4 men aged 17–79 years (average 45 years), who presented with pain over the lateral aspect of the midfoot were retrospectively reviewed. Frontal, lateral, and inversion-oblique radiographs were available for all patients. In addition, MR imaging was performed in eight patients, CT in two, conventional tomography in two, and bone scan in one. Conventional radiographs revealed cuboid fracture in seven patients. Of the remaining ten, eight underwent MR imaging which demonstrated four fractures, three bone bruises, and one stress reaction, and two had tomography, CT, and/or bone scan, all of which documented an isolated cuboid fracture. Isolated fracture of the cuboid may be radiographically occult. Other imaging modalities, particularly MR imaging, can document this injury as the source of pain. Electronic Publication     

Carpal avascular necrosis: MR imaging

The authors evaluated the use of magnetic resonance (MR) imaging in diagnosis of avascular necrosis (AVN) of carpal bones by examining 21 patients with wrist pain and two healthy volunteers. MR images were compared with conventional radiographs in every case and with bone scintigrams in 18 cases. MR imaging was slightly less sensitive than bone scintigraphy in depicting AVN, but in patients who were imaged with long repetition time (TR)/long echo time (TE) sequences in addition to short TR/short TE sequences, MR imaging was found to be more specific. While the authors believe that bone scintigraphy remains the screening test of choice for patients with wrist pain and normal plain radiographs, MR imaging promises to add significant diagnostic information in cases in which bone scans are abnormal.     

放射性核素骨显像在腰腿痛患者中的应用价值

目的:探讨放射性核素全身骨显像在腰腿痛患者中的应用价值。方法:对我院以腰腿痛为主要症状、X线、CT检查结果完整的患者417例进行了全身骨显像,并按患者有无肿瘤病史将其分为两组,其中肿瘤病史组165例,非肿瘤病史组252例。分别观察了核素骨显像在这两组患者中的应用情况。结果:肿瘤病史组165例检出肿瘤骨转移68例,占39.4%,非肿瘤病史组252例检出肿瘤骨转移28例,占11.1%。核素骨显像对椎体退行性变、椎间盘突出、椎管狭窄等常导致腰腿痛的疾病没有特异性图像表现。结论:对有肿瘤病史的腰腿痛患者应首选核素全身骨显像检查。对于无肿瘤病史的腰腿痛患者,只对查不出确切病因或对症治疗无效的患者,加做全身骨显像以排除有无肿瘤骨转移。     

Clinical consequences of posttraumatic bone bruise in the knee

BACKGROUND: Bone bruise is often seen in posttraumatic knees, but the clinical relevance is unclear. HYPOTHESIS: The presence of bone bruise is associated with increased pain severity in patients with sustained knee trauma. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: We collected prospective data of 132 patients visiting their general practitioner after sustained knee trauma. Patients with bone bruise underwent a magnetic resonance imaging follow-up study that was discontinued when the bone bruise could no longer be discerned or after 1 year of follow-up. Bone bruise was assessed on magnetic resonance imaging, and pain severity was scored on a numeric rating scale (0-10) at baseline, and at 3, 6, and 12 months after trauma. The presence of bone bruise and pain severity (over time) were compared using linear regression analyses for repeated measurements. Adjustment was made for possible confounders: presence of meniscal tears, cruciate or collateral ligament ruptures, severe effusion, osteoarthritis, obesity, age, gender, work load, and sports load. RESULTS: At baseline as well as during follow-up, bone bruise was associated with a slightly higher pain score. The differences, however, were very small (adjusted difference in pain severity 0.34 or less) and not statistically significant nor clinically relevant. CONCLUSION: There is no statistically significant relationship, nor a clinically relevant relationship, between the presence of bone bruise and pain severity in patients with sustained knee injury in general practice.     

Imaging of posterior element axial pain generators: facet joints, pedicles, spinous processes, sacroiliac joints, and transitional segments

The role of the posterior elements in generating axial back and neck pain is well established; the imaging detection of posterior element pain generators remains problematic. Morphologic imaging findings have proved to be nonspecific and are frequently present in asymptomatic patients. Edema, inflammation, and hypervascularity are more specific for sites of pain generation, but are often overlooked by imagers if physiologic imaging techniques such as fat-suppressed T2 or contrast-enhanced T1-weighted magnetic resonance imaging, radionuclide bone scanning with single-photon emission computed tomography (CT), or (18)F-fluorodeoxyglucose positron emission tomography combined with CT are not used.     

Painful bipartite patella following injury: a case report

Bipartite patella is a normal variation in ossification development. This variation is usually asymptomatic but can cause persistent and debilitating anterior knee pain with an injury.We report the case of a 56-year-old man complaining of persistent anterior left knee pain following trauma.Standard knee radiographs show a bilateral Bipartite Patella appearance, and magnetic resonance imaging shows discrete bony edema of the cancellous bone of the accessory bone and about the synchondrosis explaining the anterior knee pain, associated with a crack in the posterior compartment of the medial meniscus.Conservative care including medical treatment with non-steroidal anti-inflammatory drugs, physical therapy was used.Magnetic resonance imaging is the most valuable diagnostic tool for evaluating detailed morphologic and pathologic changes in patients with the bipartite patella.     

Percutaneous Cryoablation and Vertebroplasty: A Case Report

A 70-year-old man with a painful vertebral metastasis was treated with combined percutaneous cryoablation and vertebroplasty therapy (CVT) in one session. The patient was suffering from diffuse visceral metastasized cholangiocarcinoma. After several weeks of back pain, magnetic resonance imaging documented a single L2 bone metastasis. In consultation with the oncologists, palliative combined CVT was administered with the aim of obtaining pain relief and bone stabilization. In our experience this combined treatment is safe and effective for immediate pain relief in painful bone metastases when other standard palliative treatments have failed.     

Acute nontraumatic adult knee pain: the role of MR imaging

Acute nontraumatic pain in the adult knee can be seen in many settings, such as transient bone marrow oedema syndrome (TBMOS), regional migratory osteoporosis (RMO), spontaneous osteonecrosis (SONK) and insufficiency fractures. Early differentiation among them is crucial to avoid unnecessary treatment. TBMOS and RMO are considered to be self-limiting conditions without longterm sequelae. On the other hand, the clinical course of SONK is thought to be dependent on the size of osteonecrosis. Recent data suggest the term SONK is misleading one and should be replaced. Insufficiency fractures may demonstrate a similar clinical syndrome without a history of a single traumatic injury. The imaging pathway for knee pain has evolved considerably with the advent of magnetic resonance (MR) imaging, which is very sensitive in the early depiction of bone marrow oedema. Therefore, in patients with acute nontraumatic knee pain whose radiographs are negative or inconclusive, MR imaging is the method of choice for further evaluation. This article discusses the potential aetiologies and reviews MR imaging findings of the most common disorders afflicting the subchondral knee-joint area.     

Skeletal scintigraphy with 18F-NaF PET for the evaluation of bone pain in children

OBJECTIVE: Although not commonly used in current clinical practice, the PET agent (18)F-NaF provides an excellent alternative to the standard tracers used for radionuclide bone scintigraphy. This article illustrates the use and appearance of (18)F-NaF PET and shows examples of its utility in the assessment of bone pain in children. CONCLUSION: Skeletal imaging with (18)F-NaF harnesses both the superior imaging characteristics of PET and the improved biodistribution of the fluoride tracer in comparison with standard nuclear techniques, resulting in excellent-quality images that can effectively be used to investigate the cause of bone pain in children.     

Recent developments in understanding temporomandibular joint disorders. Part 1: Bone marrow abnormalities of the mandibular condyle

Improvements in diagnostic imaging of the temporomandibular joint in the past 20 years have shown that disk displacement is the most frequent abnormality in patients with joint pain and dysfunction. The aetiology of the pain is poorly understood. Recent studies with magnetic resonance imaging have demonstrated a number of other changes in the TMJ. In this paper I review the possible significance of alterations in the condylar bone marrow and its relationship to osteonecrosis.     

Diffuse increase in renal uptake of technetium 99m methylene diphosphonate in association with disseminated cholangiocarcinoma

A 48-year-old woman presented with disseminated cholangiocarcinoma and diffuse joint pain. A technetium 99m methylene diphosphonate bone scan revealed no bony abnormality, but intense bilateral renal uptake was seen. There was temporary renal impairment following imaging, but the cause of this is uncertain. An association between cholangiocarcinoma and 'hot kidneys' on bone imaging scanning has not been previously reported.     

Nuclear Medicine in Pediatric Musculoskeletal Imaging

The pediatric skeleton is a dynamic structure. Bone scintigraphy depends on bone metabolism and therefore is particularly applicable to changes occurring in the physes (growth-plates). A knowledge of the physiologic changes in the growing skeleton as well as the disease processes affecting the different pediatric age brackets are necessary to accurately solve clinical diagnostic problems with bone scintigraphy. Bone scintigraphy is a readily available, low-radiation imaging procedure. In this article, the common pediatric skeletal aberrations (appendicular growth alterations, hip pain, back pain, some aspects of trauma, inflammatory and infectious processes, and some common benign neoplastic occurrences) that can be addressed by nuclear imaging are discussed.     

Imaging of painful solitary lesions of the sacrum

In patients with sacral pain, the painful symptoms may be caused by a variety of bony and soft tissue lesions. Benign lesions include giant cell tumour, neurogenic tumour, insufficiency fracture, infection and giant bone island. Malignant lesions include primary bone tumours, Ewing sarcoma, plasmacytoma, lymphoma and chordoma. Soft tissue tumours adjacent to or involving the sacrum may cause painful symptoms. A multimodality approach to imaging is required for full assessment of these lesions. This pictorial essay describes a range of common solitary sacral lesions that may cause pain, with emphasis on imaging features.     

Pain and knee function in relation to degree of bone bruise after acute anterior cruciate ligament rupture

It is unknown whether the bone bruise that occurs in connection with acute anterior cruciate ligament (ACL) rupture is causing pain and dysfunction. We followed prospectively 17 patients [10 men, seven women, mean age 28 years (range 23-34)] with acute ACL rupture for 2 months. A magnetic resonance imaging (MRI) scan was performed shortly after the injury, and at 2 weeks, 1 month and 2 months. The patients reported the level of pain every day and filled in a Knee injury and Osteoarthritis Outcome Score sheet in connection with MRI. For every MRI of the knee, volume of bone bruise was calculated, and intensity was visually graded. Our study showed a reduction of the pain to 50% approximately 2 weeks after the injury, at which time the bone bruise was at maximum. There was a significant relationship between pain and the volume and intensity of the bone bruise in the medial tibia condyle, as well as pain and the bone bruise volume of the lateral femoral condyle. Patients with bone bruise of the medial tibia and patients with meniscal lesions had more pain. It is suggested that pain and decreased function after acute ACL injury most likely is related to soft tissue and cartilage injury and not to bone bruise.