Read the article by
Love et al in the journal Radiographics the concept of radionuclear imaging is discussed. Describe one thing that you learned about radionuclear imaging from this article, and how it may relate to a patient you have seen during one of your clinicals!
This article gave me a good, general understanding about radionuclide bone imaging that I was not aware of before. This procedure has been proven to be highly sensitive for diagnosing conditions that I initially thought could not be detected such as RSD and Paget's diesease. I found it interesting that bone scintigraphy itself is rather quick considering the actual process of injection and imaging. I do not recall having a patient describe to me having this exact procedure done, however, there are a few who may have benefited from it. I had a male patient in his early teens who was diagnosed with Legg Calve Perthe's after many tests. I believe the bone scintigraphy would have been a great diagnostic tool to detect the avascular necrosis in this patient earlier. Due to the this procedure's high sensitivity, the LCP could have been ruled in and be considered positive. Although the article does state that MRI is more sensitive than radionuclide imaging, time and expenses must also be considered for each patient case.
ReplyDeleteThis article helped me to better understand the appropriate uses of radionuclear imaging. I learned that this procedure can be used to reveal abnormalities when other imaging results, such as radiographs, appear normal. However, it is important to compare radionuclear imaging reports over time when a patient has undergone hormonal therapy or chemotherapy. The "flare" phenomenon shows healing of the bone and should not be confused with disease progression.
ReplyDeleteIn my clinical rotations, radionuclear imaging was appropriate for a patient I treated with a history of trauma from falls. She was an elderly lady who presented with osteoporosis and a tibial fracture. When radiographs appear negative, bone scintigraphs can be used to detect fractures. Performing the bone scintigraphy at 72 hours post injury can maximize sensitivity.
I learned a lot from this article. I was unaware that Reflex Sympathetic Dystrophy could be visualized with imaging and I found it interesting that it is used in tumor staging and management. Learning that it can identify fractures within 24 hours, I would have liked to see the results of this procedure on a patient that had experienced a traumatic fall. He fell 6 ft with his ribs absorbing the blow on a horizontal bar and an additional 8 ft landing on concrete on his back. Multiple x-rays were taken and were negative, however, this was within 24 hours of his injury. His rib pain was his chief complaint throughout therapy.
ReplyDeleteI was not aware that RSD could be detected on imaging, and I found that to be very interesting. I also found the radiotracer component of radionuclear imaging to be very cool, especially to detect fractures within 24 hours! Comparing radiographs to radionuclear imaging was interesting to note hte differences of how abnormalities present. A few of my patients could have benefited from this procedure. One in particular was a 89 year old woman who fell but did not have the cognitive ability to describe the location or type of pain. this radionuclear bone imaging would have benefited her and all the caregivers greatly!
ReplyDeleteLike others have said, I never knew that RSD could be seen with any kind of imaging. It was my understanding that the only possible diagnostic tool would be some sort of nerve conduction testing. I would be very interested in observing a patient with RSD go through scintigraphic imaging. A patient that I worked with recently was a female in her late teens that had complaints of LBP. She was extremely flexible and did not have a position of comfort. At the same time, she did not have a position of relief (the CI was using a McKenzie treatment method). I think she had enough symptoms to justify imaging for a spondy. With that being said, what is the best way to go about asking the physician for a certain imaging study? Obviously the PT wouldn't just say "This patient needs an x-ray," but if the PT thinks the patient would benefit from a certain procedure, how should you ask?
ReplyDeleteYou pose a great question. In Kansas you as a PT do not have imaging privilages. Some physicians will respect your expertise in musculoskeletal treatment and evaulation of dysfunction and listen to your suggestion of some form of advanced imaging. At this point it would be their decision as to what form of imaging to utilze. In most instances a simple suggestion of some form of advanced imaging due to continued or a change in symptoms will be enough to raise suspicion.
DeleteThis article was very informative and helped me understand all the possible uses for radionuclear imaging. I found it interesting that radionuclear imaging could be used to detect other pathologies besides fracutres resulting from traumas. Radionuclear imaging has been proven to be highly sensitive in detecting pathologies such as RSD, avascular necrosis, metastic diseases and Paget's disease. When using to detect Metastic deseases, it is important to consider the "flare" phenomenon and not confuse healing of bone and disease progression.
ReplyDeleteI think radionuclear imaging would have been appropriate in a pt. I saw that had fallen in the middle of the night while under the influence of sleeping pills. Traditional radiographs were taken in the ER and revealed a fracture of the Left tibia that was casted, but results of Right LE reported to be unremarkable. Pt. was NWB for 6 weeks on Left LE, but continued to complain of pain in Right LE during transfers and weight bearing activities. Radionuclear imaging may have revealed something that could have altered the course of therapy and ease the pain of the pt. I would have been a good venue to explore.
Bone scintigraphy is a far more versatile tool than I had originally known. Like many others who have posted already, I was surprised to find that this type of imaging has so many indications, including RSD and metastatic disease. One thing that I find interesting; however, is that bone scintigraphy can be used as a method to also diagnose spondylolysis defects in the lumbar spine. Routine radiographs are typically sufficient to diagnose this pathology due to the fact that it can be seen on both lateral and oblique views with high sensitivity and specificity. False negatives are possible; however, in the early acute stage when a fracture is not present.
ReplyDeleteMy patient was a collegiate level basketball player with diffuse low back pain. When we saw this patient his symptoms were present for approximately 3 weeks. He had routine radiographs performed, which were negative. His presentation was consistent with lumbosacral instability. His pain level improved with 2-3 weeks of traditional PT and lumbar stabilization exercises. Approximately 2 weeks later his symptoms were exacerbated by playing a pick-up basketball game at which time he received an MRI. The MRI indicated increased stress in the pars interarticularis without a fracture. A bone scintigraphy scan would have also been appropriate at this time.
After reading through all the available information, the most important tid-bit of information I found that was useful to PT's is the findings of acute fractures within 24 hours. The literature illustrated several other diagnoses that can be ascertained via radionuclide bone imaging such as RSD, and metastatic bone diseases, but I do believe that the most important of these is the ability to recognize a fracture early where other forms of imaging leave doubt to whether or not an acute fracture is present due to many false negatives via simple x-rays.
ReplyDeleteThe reason I believe this is due to two separate patients I have evaluated in the acute setting where they have suffered from a fall which sent them to the hospital. Twice I have seen patients who initially were diagnosed with no bone fractures to the suspected body part, but later after no improvement of pain were re-diagnosed after a subsequent MRI or second X-ray to actually have a recent bone fracture.
I do believe that the other uses of this imaging are important to be aware of and understand, but in my opinion and experience, it would have best served myself and the patient's I cared for to have used this form of imaging for the explicit use of early fracture diagnosis.
I was unaware that bone scintigraphy was such a versatile diagnostic tool with such high sensitivity. It is good to know that certain somewhat radiographically elusive diagnoses (shin splints, stress fractures, plantar fascitis, and RSD) are visible on this type of imaging. I think it's most useful aspect is the ability to identify stress fractures since they are not usually visible on plain film xrays until they begin to calcify.
ReplyDeleteI treated a runner this summer who had a diagnosis of ankle pain with negative ankle xrays. She was training for a marathon and despite PT advice, continued to train during PT. Her symptoms did not improve after 4 weeks of PT. We referred her back to her MD with a recommendation of additional imaging. He ordered foot xrays which displayed a healing stress fracture of the proximal 5th metatarsal. Her treatment could have been modified, including running cessation, and healing better facilitated with an earlier diagnosis using bone scintigraphy.
I found it interesting that bone scintigraphy can be used to detect so many different issues. Most commonly, in our field, it seems that we only learn about its ability to detect stress fractures. I treated a long distance runner who complained of foot pain. His plain film images were negative and he continued to train at a high level. He ended up fracturing his talus. The physician told the patient that a bone scan might have revealed the stress fracture and allowed him to avoid the incredibly long rehabilitation and healing process.
ReplyDeleteI along with all my fellow collegues found the article very interesting and was amazed at the many uses of the bone scintigraphy in diagnosising different pathologies. One area I found particularly intersting were the different scintigrams
ReplyDelete(I am a very visual learner), especially view 28 of the autoinfracted spleen in the patient with sickle cell disease. I acutally had a young patient with this disease and missed several physical therapy appointments due to having kidney dialysis. I also had another patient that was born with all of her organs on the opposite side of her body... since the scintigraphy can also look at the colon, oral and gastric activity, and heart obstruction (which she had), I wonder what her bone scintigraphy would have looked like? INTERESTING!
I thought that this article was very interesting. I had no idea that radionuclide bone imaging could be used for so many diagnoses. I thought diagnosis of RSD using this imaging was especially interesting, as I had no idea that RSD could be diagnosed this way. I, like Kilah, am a visual learner and appreciated all of the example scintigrams that the author provided along with explanations.
ReplyDeleteThe diagnosis discussed in the article that I feel is most relevent to my recent clinical experience is avascular necrosis. I had a patient this summer who complained of severe hip pain when standing, with hardly no pain when seated. His plain film radiograph showed possible AVN, but was not conclusive. After not seeing much improvement with therapy, he was sent back to the physician. I don't know what type of treatment or imaging he received from that point on, but feel that a scintigram would have been beneficial for either confirming or ruling out AVN.
As stated by other classmates, I didn't realize that radionuclide bone imaging could be used for such a vast array of diagnosis. I found this to be very interesting. I didn't realize there was a type of imaging that could show results of fractures so quickly after trauma. That is very useful information! I was also unaware that this type of imaging was used in staging of tumors.
ReplyDeleteI treated a patient this last rotation that complained of abdominal spasms and anterior hip pain. Although it was suspected that this was more of a conversion disorder case, the use of this type of bone imaging would have been useful in helping further rule out, or discover new findings of hip pathology since other types of imaging were not significant.
As stated by many of my classmates I was unaware of the wide variety of uses for bone scintigraphy. I have only had one patient who I know to have undergone this type of imaging. She was diagnosed with malignant osteosarcoma of the right distal femur at the age of 11. This was one of the tool that was used in her diagnosis. She underwent a right TKA at the age of 12. She played sports and was a cheerleader in college. I treated her following the revision of her TKA when she was 25. She has a yearly follow up appointment with her Oncologist to undergo a bone scintigraphy to check for recurrence of her osteoscarcoma.
ReplyDeleteI thought the article was informative and interesting. Prior to this article I did not realize the extent for using the radionuclide bone imaging. I also appreciated the figures provided to demonstrate how each diagnosis would present when viewing a bone scintigram.
ReplyDeleteThis is relevant to a patient I worked with who after a fall was told he did not have a fracture but after the pain did not resolve and additional radiographs was found to in fact have a fracture.
I thought it was very interesting that RSD could be diagnosed using radionuclide bone imaging. I was not very familiar with bone scintigraphy at all until now, so this was a great article to help further my knowledge on the subject. I thought that seeing the imaging was very helpful and it is definitely very obvious, which is nice when trying to interpret the images. I wonder if any research has been done to see if bone scintigraphy is easier to interpret compared to other diagnostic imaging and if there are less errors.
ReplyDeleteI had a 50 yr old male patient that had rapid onset of LE weakness and severe back pain over the past 3 weeks, with a history of cancer in the past 10 years. He also had loss of bowel/bladder with approximately the same time of onset. This individual went to his PCP and they told him it was probably just because he was becoming more sedentary, later that evening he had a fall in the bathroom, because his legs just gave out on him. He was on my case load in acute care and he never was able to stand even with a body weight support system. He just could not seem to accept any weight through his legs. My CI and I were very confident that he had a metastatic tumor in his lower vertebra that was affecting the spinal cord. The physician did finally do a CT scan and said it came back clear. He refused to do an MRI or other imaging. We ended up discharging him to a SNF with high possibility of going to a nursing home. I still wonder what happened to him and now I wonder if a bone scintigraphy would have shown anything.
After reading the journal article I was surprised to find that radionuclide bone imaging was sensitive, inexpensive and considered a quick and widely available diagnostic tool for numerous pathological conditions. Of particular interest to me was the ability of scintigraphy and the scintigram to detect RSD.
ReplyDeleteMy niece was diagnosed with RSD several years ago and has done a good deal of research on ways to cope and manage the many symptoms of RSD and has reported that it was a diagnosis of exclusion. Upon reading the article I called her to ask if she ever received a bone scan and mentioned its ability to possibly detect RSD and she stated that she had it done but that it was to rule out cancer as a cause of her constant pain.
My question to you Rob is when this imaging is performed is it usually for a particular focus like ruling out cancer as in her case or will the report include other findings as well?
Additionally I did work with several people diagnosed with plantarfasciitis but they did not have imaging for it. I think it would have been interesting to see if the bone scan would additionally confirm the diagnosis they were given which was based on history, signs and symptoms, and evaluation.
Allison
DeleteI think it can be used as either. To create a diagnosis or rule out a specific pathology. If you so a simple search on Pubmed you see multiple articles that describe multiple uses of Radionuclide bone imaging for multiple pathologies.
I looked specifically at lower extremity and found articles relating findings of Radionuclide imaging with patellofemoral pain patients, joint infections, and bone metastases very quickly.
It has many unique uses and works very well for certain pathologies. I think the article by Love et al was an excellent educational manuscript.
I had no idea the versatility of bone scintigraphy. It makes since now after reading the article, but I didn't realize all the different issues that could be seen such as RSD, CHF, and even metastases. This was a very informative article giving great insight into an imaging technique I knew little about. I do wonder however about the safety/side effects of these procedures.
ReplyDeleteDuring my last rotation there was a lady who was about 3 months post labral repair who was doing very well, but started complaining of varying degrees of N/T in ulnar distribution down to her 5th and 4th digits. She also had pain at the lateral aspect of her arm at the deltoid tuberosity. The doctor decided to do imaging (plain and MRI) of the pts neck, which came back negative. Eventually they took a CT scan of her arm, which showed a large bone mass lateral to her humerus. Not exactly sure what they are doing at this point, but I know the doctor was reluctant to do surgery as the bone mass was embeded in her muscles. I wonder if bone scintigraphy would have been a quicker less expensive option, or is there a time frame for when bone scintigraphy can be used for something like heterotopic ossification.
I, like most people have stated, was unaware of the various uses of bone scintigraphy. I was amazed that it could be used to view RSD, venous obstructions, Paget's disease, ext. I only knew of its used for fractures. The article taught me a great deal about the procedure and what it can do. Like Steve had mentioned in his post, I was wondering about any side effects from the procedure.
ReplyDeleteA patient of mine that could have used bone scintigraphy was a young soccer player who had been diagnosed with shin splints. Xrays had been performed but came back negative. The patient continued to complain of lower tibial pain for weeks, and more xrays were taken but again they came back negative. Perhaps bone scintigraphy could have been used in this instance to get a better image of the tibia to check for fractures that were not showing up on the xray.
Indeed, the versatility of radionuclide bone imaging for diagnostic purposes is amazing. It was interesting to learn that delayed bone imaging differentiation between focal fusiform uptake of shin splints and the cortical, longitudinal linear uptake of tibial stress fracture can lead to prompt and appropriate treatment by enabling accurate diagnosis.
ReplyDeleteThe parent of a six month old pediatric patient with birth diagnosis of craniosynostosis received recent imaging results reversing the previous diagnosis. The way she talked about the procedure made me curious if bone scintigraphy was the method used.
This article was very helpful in teaching me a lot about radionuclear imaging, as I was not very familiar with it. There were several interesting points in this article including being able to view a fracture in 24 hours and observing problems such as RSD, shin splints, and plantar fasciitis. The part I was most interested in, however, was the section on metastatic disease. It was surprising to me how specific this imaging can be when dealing with cancer. For instance, when it stated that radiotracer accumulation in the vertebral body and pedicles typically points to metastatic disease, but accumulation in the vertebral bodies and facets that do not involve the pedicles are benign. The fact that one is able to interpret a “simple” image and tell if something is metastatic or benign at a pinpointed spot amazes me. I have always thought you had to look at a broader, more general area to tell if it was metastatic, I didn’t realize you could know by something as simple as if it involved a tiny pedicle or not. Another part to the metastatic disease section that caught my attention was the “flare” phenomenon and how an increase or the appearance of new abnormalities between bone scans on a cancer patient does not always indicate disease progression, but may actually be healing. Though when still present and increasing past 6 months, there is a good chance of the disease progressing.
ReplyDeleteDuring my first clinical rotation I helped treat a patient who had had this type of imaging. He was a boy in his late teens that had been diagnosed with osteosarcoma a few years prior. The cancer had affected one knee and he ended up having a total knee replacement and then a revision (which is what I was treating him for). It would have been interesting to see the images that he had done at various times following his cancer.
Like many others I was amazed at the diversity of conditions that could be diagnosed with the help of bone scintigraphy. I had no idea that RSD was visible on this form of imaging. I also found the images of plantar fascitis from bone scintigraphy interesting
ReplyDeleteBone scintigraphy would have been helpful in developing a treatment plan for a cross-country runner that I treated during my last rotation. It was pretty much the classic shin splints vs. stress fracture case. Evaluation data suggested shin splints and treatment for this condition was initiated and client was progressing well at the conclusion of my rotation. However, it would have been beneficial to have imaging to help confirm this diagnosis and treatment plan.
I, like many of my classmates had never heard of Radionuclide bone imaging before but found it extremely interesting that one form of imaging could be used to diagnose so many different pathologies. I especially liked the part where they explained the how radionuclide imaging could differentiate between tibial stress fractures and shin splints. I also found it interesting that this form of imaging is used to diagnose RSD. I also found the images to be very helpful and surprisingly easy to interpret.
ReplyDeleteThis summer I was treating a patient with an ankle injury. He had injured it in Iraq and was sent home early from his tour as a result. He had severe decreased ROM, some swelling, and warmth, and was extremely sensitive to light touch. We concluded that he had some s/s of RSD(CRPS). It would have been interesting to use radionuclide bone imaging to conclude if this was the correct diagnosis and what areas of the ankle were most affected in order to improve our POC.
I found this article to be beneficial and interesting in many ways. Not only was I unaware of how the process of bone scintigraphy truly worked but what I found most interesting is its ability to differentiate the malignancy of metastatic cancer from trauma or degenerative changes. Looking at the different scans on given in the article had me very intrigued throughout the article and I found myself going back several times to look at them.
ReplyDeleteThis spring we were seeing a patient who had a hip replacement but was still having lots of pain on her surgical side. This scan would have been helpful to see if an infection or some degeneration could have potentially been causing her pain.
- Darci E. -
This article provided me good insight of what exactly bone scintigraphy is and what all it is capable of detecting. After reading the article, and finding out its high sensitivity and relatively low costs, I was surprised that I have not seen this type of imaging more often. I was impressed at the imaging photographs and the variable details and the ability of imaging to detect bone metastasis and RSD.
ReplyDeleteIn the pediatric setting, I had a patient with an unknown genetic diagnoses. He presented a lot like Paget's but had a number of other complications. He had severe bony deformities in his lower extremities and demonstrated a bony end-feel into extension. I believe that this type of imagining would have been ideal.
Jessica Scram
It sounds like scintigraphy is a good diagnostic tool to differintiate between many possible pathological conditions. The fact that it is relatively inexpensive makes it seem like a good option to go with. The article mentioned that a low dose gamma ray was used to make the image, and the fact that a radiolucent chemical is injected into your body doesn't sound very appealing to me. The article did not mention the risks involved with the procedure although it seems they would be similar to ordinary radiographs. If I had the option to go with an uninvasive and gamma ray lacking MRI, and new that it could do the job, I'm going with the MRI. I've got good insurance. For the purpose of diagnosing bone cancer, scintigraphy sounds like a very good option to go with as it can easily differintiate this from other conditions.
ReplyDeleteI've had many patients with disc fusions that require extreme caution for many months following surgery. Some with little pain who made great progress, and some who had persistent pain and minimal progress. It would have been interesting to compare results from scintigraphies to explain differences in patient progress.
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DeleteI have learned that bone scans, contrary to their name, are utilized to confirm diagnosis of tumors more so than for purely bone-related conditions (e.g. fractures, spondylolysis). The ability to remove activity on the image around the site to better differentiate between metastatic and degenerative changes is astounding.
ReplyDeleteI had one patient in particular who might have benefited from scintigraphy. This particular patient had radiating pain down his right arm and prominent forward head and rounded shoulder. Mechanical traction, stretching, and strengthening of scapular rectractors and neck extensors did little to modify the patient's pain: sometimes it would help, but it would be at the same intensity a few days later despite treatment. Scintigraphy may have helped provide information based on the location of a possible apical right lung tumor or cervical facet degeneration.
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DeleteI, like many of you, had no idea that bone scans could be used for RSD as well as some other diagnoses that were mentioned such as CHF w/ ascites, differentiation between metastatic & benign cancer, and I probably should have known this but I haven't heard of using it for plantar fasciitis. I learned a lot that I didn't know about bone scans. I didn't realize that they were cheap and that the bone could uptake the disphosphonates that quickly. It was also fascinating how it was used in avascular necrosis to show areas of no bone growth.
ReplyDeleteThe fact that it could be used for RSD was very interesting to me because I had a patient that this would have been perfect for diagnosing. My patient was a pre-adolescent with a knee injury to his patella that upon radiograph was at first thought to be an occult fracture of the patella, but then with subsequent XR's, the doctor felt it was likely not a fracture. That was approximately 2 to 3 months before he came to PT. He came to PT because he still had intense pain and severely limited ROM plus disuse atrophy. He responded to exam with no apparent reason for still having the pain or swelling. My CI and I thought it was likely he had RSD because even a very light touch was extremely painful for him and his skin showed temperature changes and mottling. A bone scan would have helped in determining this much earlier, since RSD responds best to early treatment. It's too bad that it wasn't ordered earlier. But, the patient still improved despite this.