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!
I didn't realize that there was any imaging that you were able to identify RSD. this states that with bone scintigraphy, reflex sympathetic dystrophy usually manifests as diffuse, uniformly increased uptake throughout the affected region. I think this would be very beneficial do diagnosis a patient with RSD. I had a pt that had a compound fracture of his tibia and fibula and when he came to therapy his Dr stated that on his X-ray his bones were healing. It turns out they were not healing and he refractured his leg. I think that maybe if they would have done the radionuclear imaging they would have had better results.
ReplyDeleteWith trauma new fractures do not always appear on a traditional radiograph. I wonder why bone scans are not performed more often. I found it interesting that a bone scan can be done within 24 hours of the trauma and if a clear image is not necessarily obtained the scan can be repeated at 72 hours to maximize sensitivity. A patient in the clinic fell and fractured her humerus; she would also come to therapy with complaints of pain and swelling in her wrist. X-ray imaging of the wrist revealed that everything was normal, a few weeks later she convinced the doctor to look at it again and it was determined that she had a fracture in her distal radius. If a bone scan was done I imagine this would have been detected much sooner.
ReplyDeleteLike Chelci, I found it interesting that you could use imaging for RSD. I had a patient that coming to the clinic with RSD and wanted to find ways to manager her pain. It sounded like she had been hurting for quite a while before the actually diagnosed her with RSD. I wish the article described a little more in detail how the imaging can help diagnose RSD vs diagnosing something else. Having something that showed up as diffuse, uniformly increased uptake I would think would be difficult to know that it was RSD and not something else.
ReplyDeleteI am not super familiar with the types of imaging that patients with cancer receive, so it was interesting to learn that cancer patients receive bone imaging. 75% of patients with malignancy and pain have some abnormality in their scintigraphic findings. This is a very high percentage, so I think that bone scintigraphy is most definitely warranted in patients with metastases. I would have liked to see this type of imaging done in a patient I saw last summer who was having extreme pain in her femoral region approximately 1 year after having a rod placed in the upper leg s/p MVA. It ended up that she had gotten a large infection and had to get completely new hardware. What if she had gotten a scintigraph and the infection was caught earlier? She probably wouldn't have lost so much time and would have gotten it taken care of much sooner, and had less pain overall.
ReplyDeleteI agree with what Zach said above. I knew that radiographs like this could show fractures that a x-ray could miss but I didn't know that after the 72 hours it could be more accurate. I have seen patients that had possible stress fractures that had only an traditional x-ray performed. One was a high school athlete that competed in cross country, basketball and track. He was constantly running with no offseason to rest. He was diagnosed with shin splints but his condition didn't respond well to normal shin splint treatments. Due to financial constraints the parents had to stop coming to therapy. I would have been curious to have another form of radiograph to determine a possible stress fracture.
ReplyDeleteLike Chelci and Anne, I was unaware of this imaging option for patients with possible RSD. A pediatric patient of mine initially was diagnosed with avasuclar necrosis in his left hip. He later fractured his femur which was reset and casted. Following the casting, he continues to have limited knee range of motion as well as vascular issues in the entire lower extremity. Several x-rays have been negative providing no suggestion to what is causing his pain and edema. It is possible that this form of imaging could help the doctors and therapists treat his symptoms and condition better.
ReplyDeleteIn the past I have misunderstood the efficacy and benefits of bone scintigraphy in patients who have experienced a trauma - such as a fall. I would expect plain radiographs to show almost fractures, and even if they were negative, to be re-tested if pain was still a problem. For example, we had a 1st grade female who fractured her right wrist when she fell off a skate board. Her left wrist x-ray was negative. About a week later, she continued to complain of pain and so a repeat x-ray was done of the left wrist and it showed a fracture as well. Perhaps this would have shown originally on a bone scan. I like Zach, found it interesting that if a bone scan was performed within 24 hours of an original trauma, that it could be more conclusive and sensitive 72 hours post-trauma.
ReplyDeleteI had also discounted the use of scintigraphy, I assumed that it wasn't used very often due to the length of the time for the scan and that the information attained from the results wasn't anything they couldn't usually get from an x-ray. I had a patient who had one done and it revealed that she the had periositits formation. Intrestingly enough even though she was diagnosed with plantar fasciitis she didn't have any tenderness to be palpated or any other signs or symptoms of plantar fasciitis.
ReplyDeleteRachelle Denman
I am curious as to why bone scintigraphy is not performed first over radiography in certain situations. The reason being that it is quick, extremely sensitive, relatively inexpensive, and widely available. It may be more cost effective to utilize bone scintigraphy first in the case of trauma in order to detect fractures within the first 24-72 hours of occurrence. I worked with a patient, a collegiate soccer player, who had previously been diagnosed with shin splints, then later her diagnosis changed to tibial stress fractures. Her condition has now progressed to anterior compartment syndrome. I believe radionuclide bone imaging should have been used prior to radiography in her case in order to differentiate her tibial stress fractures from the first diagnosed, shin splints. In her case, a quicker diagnosis of tibial stress fractures could have allowed proper treatment and avoid the progression to anterior compartment syndrome.
ReplyDeleteIt was interesting to see that long-standing CHF would show up on a regular bone scintigraphy without using the dynamic, blood-pooling and bone method. I found this article to be clinically relevant because of the number of patients that I treated with multiple metastatic tumors that were identified using this type of imaging. One patient was admitted because his scintigraphy result indicated that he was at an extremely high risk of a pathological proximal femoral fracture. Many of them were being treated with radiation therapy. According to the article those patients will have increased activity due local inflammation as a result of the radiation therapy and not a progression of the disease process. This could prove to be very helpful information that could be disseminated to a worried patient in the future.
ReplyDeleteI found it very interesting that bone scintigraphy is an often used and helpful tool to detect whether or not a painful joint replacement is due to the prosthesis or other factors. I always thought that radiographs were the best and easiest way for a surgeon to assess mal-alignment in a prosthesis. Of course radiographs may not pick up on other factors such as infection. According to Love et al. in their work titled, "Role of Nuclear Medicine in Diagnosis of the Infected Joint Replacement," differentiating infection from aseptic loosening may be done with radionuclide imaging as it is not affected by the presence of metallic hardware as some other "cross-sectional imaging modalities" may be. When they combine leukocyte-marrow imaging with gallium-67 (a nonspecific inflammation-imaging agent) the accuracy of detecting issues with the prosthesis is 90% certain as the test is sensitive to picking up on "neutrophil-mediated inflammations," to tease out simple mal-alignment verses infection. I had a recent patent who was complaining of post TKA pain 5 years after he had a TKA performed on his left knee. According to Love et al, only 2% of TKA's develop post-surgical infection, and out of that 2% only a third occur 1 year post surgery and that by "10 years after implantation, 50% of prostheses demonstrate radiographic evidence of loosening and 30% require revision." However, Love et al also reported that in many of these aseptic (non-infection) cases some of them might be from an inflammatory immune reaction causing the prostheses to loosen and mal-align over time. In my patient's case since his surgery was so long ago, he might simply have a case of aseptic loosening, but bone scintigraphy should be the imaging method of choice to rule out other factors.
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ReplyDeleteLike Jenica, the new piece of information I learned about radionuclear imaging is the how much of a role it plays in the diagnosis and treatment of malignancies. I knew of some of the other more orthopedic uses of it, but I did not know about this use of radionuclear imaging. I found it interesting how they differentiate malignancies from other conditions. Malignancies are usually dispersed at various points with various intensities while multi-trauma activity is usually lined up. Metabolic bone disease activity has more of an even distribution than malignant sites. Also degenerative in the spine is usually differentiated from metastasis by the fact that trauma usually affects the body and facet joints and metastasis usually affects the body and pedicles. Lastly, I learned how they use this technique to identify the effectiveness of their treatment and that healing bone is the main indicator of good treatment outcomes. Like my classmates, I didn't know about the use of radionuclear imaging for RSD, but this imaging technique was actually used on one for my patient's this fall who had an initial working diagnosis of CRPS, medial tibial stress syndrome and chronic exertional compartment syndrome. The imaging technique was done mainly to rule out stress fractures. For this patient the imaging was negative for stress fractures and we were never really informed if it demonstrated any activity typically associated with RSD.
ReplyDeleteI have always thought of bone scans as only for stress fractures and osteoporosis. I did not realize that they can be so helpful in the diagnosis (and evaluation of treatment) of so many non-orthopedic pathologies. It makes sense that I they would be good for detecting bone cancer but I didn't realize that they were able to accurately detect other cancers, RsD/ CPRS, plantar fasciitis, infections, and venous obstruction. I had a patient on a rotation who was having trouble with his. TKA. My CI thought it was because the doctor that did his surgery "puts in a very tight joint" but I was never quite convinced. He was 8 weeks post TKA and still having lots of pain and swelling and his knee was always warm. He did not have any s/s of a systemic infection or infection at the knee other than the swelling and warmth. I left the rotation before he was discharged and I think he ended up doing alright but if that is something that persisted it may have been a good idea to use a bone scan to make sure his prosthesis was not infected.
ReplyDeleteLike many have stated above, it is truly a wonder why bone scans are not being done initially, particularly in those who have suffered trauma. Melissa mentioned above all of the perks of utilizing a bone scans such as being cost effective and the ability to detect fractures within a short amount of time from the trauma. I worked with a patient this past rotation who fell off of a roof. He had some fractures of the ribs, pelvis and femur. Perhaps it was because of all his other injuries that nothing was noticed about his fractures clavicle. It wasn't until PT saw him 2 days post trauma for an initial evaluation when the patient's aunt spoke up and asked why his shoulder on one side was sagging versus the other one. There was a noticeable difference in the two. At first it was hard to tell whether it was a fractured distal clavicle or a dislocated shoulder that had popped out of the socket. The attending physician was notified and imaging was obtained later that afternoon with the results being a fractured distal clavicle. Had the ER docs obtained a full bone scintigraphy, perhaps this would have saved the patient another trip to imaging and had it taken care of 2 days ago.
ReplyDeleteI believe that a bone scan would be benificial for a variety of cases but I would have truly loved to have it for a patient that I believed to have RSD. I discussed this with my CI on the clinical and he stated that she was overreacting. She came in post knee scope c and eval and tx for the low back as well. Due to her being in so much pain there was little I could do with her before she started screaming when I touched. Yes she could have calmed it down a little but I truly believed she was in a lot of pain and it would have beneficial to see if it was down to an overflow of the sympathetic NS.
ReplyDeleteI learned several interesting things that may have been helpful in my rotations had I read this before I saw some of my patients. The trauma section really intrigued me as I had a few patients during my last rotation who had received regular radiographs from the ER post trauma that looked fairly normal, but continued to have pain/symptoms of fractures. One was a nurse who had her hand smashed between a shelf and a patient. When x-rays were performed the next morning, they were unremarkable, but when we sent her back for further imaging 2 weeks later, they found a scaphoid fracture! Maybe if the hospital would have performed a bone scan right away, it would have detected the fracture earlier. We also had a high school cross country runner who had terrible shin splints that would resolve and then return again each time he began running. This same young man had pain in the bottom of his feet when he ran. I think he would have been a really good case for a bone scan as it would have helped confirm that he only had shin splints rather than a stress fracture and it also would have detected plantar fasciitis if he had persistent problems! The radiographs that were taken of his shins showed shin splints the very first time he came in with the problem, but they were taken at a very acute stage, so it makes me wonder now if he would have had different results from a bone scan 72 hours post injury.
ReplyDeleteLike many of my fellow classmates, I did not know bone scans could be beneficial to patients with RSD. During this last clinical I saw many children with both an amplified pain diagnosis or ones that were suspected to have. This would be beneficial to help diagnose those who were not yet so that they may be seen in Children's Mercy's amplified pain clinic that encompasses both physical and psychological aspects of this diagnosis. With children, the psychological aspect can be very important as well as having the diagnosis explained in greater detail and how the different treatments will help the patient so that they as well as their parents will "buy into" everything and be compliant. I also did not know about the "flare" phenomenon that is seen ad indicates healing if the increased intensity is seen within 3 months of starting radiation or chemotherapy. I feel this could been beneficial when working with patients who are going through these treatments to be able to explain that this is a positive if seen during this time as well as when reading radiography reports.
ReplyDeleteAlong with my classmates, I wonder why this type of imaging is not utilized more often. Especially when it "is quick, relatively inexpensive, widely available, and exquisitely sensitive." In my last clinical, we had a pt who had tripped while walking down the stairs. She went to the doctor the next day who ordered x-rays but it was reported as negative. Because of this, the pt tried to "tough it out" since she was told everything looked ok, but continued to experience pain and was unable to run, which was a huge hobby of hers. After a month of continued pain, she went back to the doctor who ordered a follow up x-ray which revealed an x-ray along the lateral malleoli. She was then put in a boot for a month before she started PT. The patient was very frustrated to have "wasted" that month which was also another month of no running. I wonder if the timeline of treatment/recovery would have been different if she would have had a bone scan instead of the x-ray initially. I assume it might after reading that "Most fractures are scintigraphically detectable within 24 hours of their occurrence."
ReplyDeleteGreat comments. Some of the reasons that bone scans are not used initially are the amount of radiation that is needed for the scan is significantly more than for standard radiograph. Additionally the nuclear material used is placed internally.
ReplyDeleteHowever, as with all imaging procedures, when the benefit for this imaging does justify the procedure, then the radiation exposure (the amount of radiation given to the patient) should be kept as low as reasonably practicable. For a initial assessesment of a lot of pathology a standard radiograph is probably reasonable in most instances.
Keep up the great comments and examples!
I was unaware that a bone scan could be used to identify osseous metastases brought on from various forms of carcinoma. I think it's interesting that a bone scan can identify osseous metastases in patients that are asymptomatic, but I wonder just how often doctors are ordering a bone scan for patients that don't present with any skeletal pain. I was also surprised to learn that it is fairly easy to distinguish metastatic disease from other diagnoses like fracture, arthritis, and osteoporosis. I had a patient that was exposed to too much radiation for her cancer treatment and has a result she had to have a total shoulder replacement, which I had never seen before. I wonder if bone scans were more routine on cancer patients, especially asymptomatic cancer patients, if something like her deteriorating shoulder complex would have been identified earlier and perhaps saved her from having to have a total shoulder replacement.
ReplyDeleteLike many of my classmates have already mentioned, I did not know that a bone scan could be used to detect so many different pathologies. I think that this article shows that it is a very valuable form of imaging and it's very interesting that it can be used to detect various malignancies and that it can distinguish metastatic disease from other pathologies by the patterns of distribution that are seen on a scan. I also think it's interesting that bone scans aren't used more frequently with trauma as they are likely able to find a fracture within 24 hours of the injury. With it being so accurate and inexpensive I don't understand why it is not used initially to decrease the use (and expense) of other forms of imaging/repeated imaging. I had a patient that was a college soccer player that had severe shin pain and the radiographs were unremarkable and she was told she had splints. She was positive for other forms of testing for a stress fractures such as vibration, but was cleared to play. After weeks of playing and repeated radiographs she was finally diagnosed with a stress fracture and was put into a boot. If they would have initially ordered a bone scan I wonder if they would have caught this injury before she put more stress on it by playing in multiple games.
ReplyDeleteI can recall several patient's and many former athletes that could have potentially benefited from further imaging to differentiate exactly what is discussed in the trauma section of this article. One such patient was an 80 year old lady who was convinced she was suffering from shin splints following a weekend of shopping. with her grandchildren. She was being treated at our clinic for this condition with soft tissue mobilization, stretching, modalities for pain, and minor strengthening activities. It's possible that she would have benefited from further testing to rule out the possibility of stress fractures in her tibia. Like many of my classmates I found the application of this imaging for diagnosis of RSD very interesting, the image presented in this article makes a very clear distinction of involvement in the upper extremities. I was not aware that imaging would be useful for this diagnosis.
ReplyDeleteTwo patients that I have I think could have benefited from bone scintigraphy. One patient we were seeing for back pain kept complaining of pain in her knee after a TKA that happened over a 6 months ago. Even after her back pain resolved she continued to have localized pain in the knee. Regular radiographs appeared to be normal so the surgeon would tell her that nothing was wrong in her knee. Bone scinitigraphy could have also benefited a second patient of mine that had scoliosis. As we were working on her I suspected she may have unilateral spondyloysis however regular radiographs were negative. I treated her conservatively; however, a SPECT of the thoracolumbar spine would have been of great value.
ReplyDeleteSome pieces of information that I gained by reading this article is that bone scans can be utilized for many different pathologies, also that many patients with osteoporosis, kyphosis and an H-shaped sacral fracture.
ReplyDeleteIn regards to my last clinical I would have liked to have a bone scan performed on two to three patients that had a variety of random symptoms that didn’t fit any usual disease profile (stomach pain, back pain upon rising and after eating, pain in bilateral hands with no cervical symptoms) to screen for some type of cancer. While neither my CI were sure if any of these patients had cancer it would have been reassuring if they had been screened at least.
It does seem interesting that the bone scan is able to see any fractures or abnormalities in 24 hrs since an accident and if not truly definitive it can be done again 72 hours later. It would almost seem as if it should be required to attempt the bone imaging initially and if nothing is found make sure to schedule again to ensure nothing is missed. Although the article states it is less expensive I wonder what insurance costs might be and if you have to obtain the test twice what that does to overall cost. I had a patient complaining of neck pain and numbness/tingling down into right hand and fingers who suffered a MVA. The initial X ray that was done found nothing but after working with this patient for two weeks with no significant improvement I feel that bone imaging might be a perfect solution to see exactly what is going on in the cervical spine. This patient would benefit from traction but due to the uncertainty of the patients condition I feel having bone imaging done prior to make sure nothing is fractured would be a good and safe choice.
ReplyDeleteI used to think that bone scans were mainly used to check for bone mass index for osteoporotic patients. It's interesting to know that it is actually used for a variety of other things including: detecting infections, staging cancer, looking for AVN, looking for fractures, etc. This article shows that the amount and location of radiotracer uptake in the spine can determine what pathologies are occurring. Radiotracer accumulation in both the vertebral body and the pedicles are usually indicates metastatic disease, whereas abnormalities that involve the vertebral body and facets but spare the pedicles are usually benign. Activity that is confined to the vertebral body can be due to tumor, trauma, or infection. I was working with a patient long ago who was a hemiplegic due to a bullet piercing his spinal cord. He was always in and out of the hospital and getting sick. Later at the end of my rotation, we found out he had osteomyelitis. I think he could have benefited from bone scintigraphy. They could have identified the infection sooner and treated it before it got worse.
ReplyDeleteLike many of my classmates have already stated, the big pick-up from me from this article was the ability of radionuclide bone imaging to detect the possibility of RSD through its manifestation of as diffuse, uniformly increased uptake throughout the affected region. During this last rotation, I had the opportunity to work with a mid-20's patient that was very active. She developed compartment syndrome which was alleviated via surgical decompression. The patient experienced relief for ~1 month before developing what has finally been diagnosed as RSD. The patient was beginning to grow frustrated due to her inability to find relief or answers to her pain. This week, she was going in for an EMG but after reading this article, I feel that radionuclide bone imaging would be a good supplemental diagnostic test for her for maximized sensitivity.
ReplyDeleteOne of the things that I found interesting while reading this article was the ability of the radionuclide bone imaging to differentiate between tibial stress fractures and shin splints. Shin splints are often a common complaint of athletes (particularly those that run/jump on harder surfaces) and the use of proper imaging to rule in/out such diagnosis should be utilized in order for the person to receive the appropriate care. A couple weeks ago we received a referral from a family physician regarding a 17 year-old boy for which she diagnosed as having shin splints. The patient stated that imaging was not performed during his appointment with the physician. I was skeptical of the physician's decision to forgo imaging during our evaluation because of the sudden onset of symptoms that were experienced by the patient. Now, however, after reading this article I feel like the patient would have greatly benefit from bone imaging and its ability to distinguish fractures from periostitis.
ReplyDeleteIt is fascinating to know that Bone scintigraphy can be used for that many medical conditions with a good sensitivity. One thing mentioned in the article: some metastatic diseases may manifest as areas of decreased activities. From the previous knowledge: I was always looking for a structural change or a darker spot in bone scan for the problem, but now I’d surely pay attention to those decreased activates areas because they may be the problem too. The accuracy for the three-phased bone scan is over 90%, that is really high and reliable and a negative study is strong evidence that the prosthesis is not the source of the patient’s discomfort, that is relevant to a lot of the patients we had for out-patient gait training with prosthesis, some reported it just don’t feel right , I always tell them that it may take couple month to adapt to it and unable to tell if that pain is from the body or the prosthesis, with that in mind I could communicate with other professional to rule in/out the fitting problems and focus on other possible sources of the pain or discomfort. I wonder is the procedure different from one to another for all the conditions? Or it is the reading make a difference?
ReplyDeleteAt the clinic I was at, we saw a patient who was diagnosed with RSD. The patient did not have any imaging performed, and this was what the Dr. was thinking it was. The patient displayed all signs of RSD and was very sensitive to light touch. I had no clue that RSD could be diagnosed by bone scintigraphy. Its amazing how it is able to see uniform increased uptake throughout the affected area. I think bone scinctigraphy would have helped to diagnose this patient accurately with RSD. Would it have helped to treat this patient any differently? This is a good question to ask. I'm not sure it would have changed anything differently. I also didn't know that radionuclide bone imaging plays an integral part in tumor staging and management. Its amazing that 75% of patients with malignancy and pain can be detected by this imaging.
ReplyDeleteAs many of you had said, I find it very interesting that bone scintigraphy can help identify those individuals who suffer from reflex sympathetic dystrophy as shown in (fig. 19) where the patients right arm/hand has shown diffuse, uniformly increased uptake which presents as darker areas when compared to the non-affected extremity. This could have benefited several of our patients I have seen over the past few clinical rotations, especially those patients who have all the s/s of RSD, but are unclear whether or not that's exactly the problem. I agree with Brian in that even if we know from imaging, whether or not it is actually RSD, is that going to change our treatment approach?
ReplyDeleteIt is extremely useful to understand what a normal view of this imaging looks like. If we do not know what is considered to be normal imaging when we are viewing the imaging we do not have justification to convey opinions about what is being seen. The article states that with age a person typically with continue to have persistently increased symmetric uptake, such as the acromial and coracoid processes of the scapulae, the medial ends of the clavicles, the junction of the body and manubrium of the sternum (angle of Louis), and the sacral alae. So if we note increases in uptake at these locations then we should be more inclined to dismiss these findings as insignificant, especially since it is so sensitive to bone abnormalities. It would likely then be wise of the person assessing the imaging to follow the general concept of “The presence of multiple, randomly distributed areas of increased uptake of varying size, shape, and intensity is highly suggestive of bone metastases”. Obviously there are always unique instances that are all listed towards end of the article where this may be false. It provides a good starting point for assessing imaging.
ReplyDeleteI found it very interesting that radionuclear imaging is sensitive for such a wide range of pathologies. In particular, RSD. I wasn’t aware that there was any type of imaging that helped diagnosis this. On my last rotation we saw a patient who had a venous malformation present from birth. He was functioning with normal development until he broke his leg at the age of 10. His knee became contracted and extremely sensitive to touch. Even with a brace, intense stretching and PT, no progress was made with him. My CI and I wondered if he might have RSD due to his extreme sensitivity. When I finished my rotation he and his parents were considering amputation of his LE. I wish he would have gotten a bone scintigraphy, and maybe we and his doctors could have better understood what was going on to provide him with a better treatment plan or more options.
ReplyDeleteReading this article, I was very interested in radionuclear imaging being able to differentially diagnose a tibial stress fracture versus shin splints. (Although all of the different types of pathologies radionuclear imaging can be used for diagnostic purposes is incredible.) When looking at the definition of shin splints being caused by great exertion of the tibialis and soleus muscles which causes inflammation at the tibial insertions of these muscles, it can be understood that the imaging of shin splits would look a certain way, but it would look different from a stress fracture. Shin splints would show up more diffuse where a stress fracture would show up more intense and local. Many track (or running/jumping) athletes suffer from shin splints and radionuclide imaging would be a great way to make sure the shin splint was not a more serious stress fracture. I can think of one particular patient I was seeing for hip pain, but they were also complaining of shin pain. (This patient was a cheerleader tumbler and was in the middle of her season.) Looking back it would have been good to have radionuclear imaging performed to see if the way she was treating her shin pain was appropriate or not.
ReplyDeleteOne thing I learned that I didn't realize is that radionuclear imaging could be used for reflex sympathetic dystrophy. Towards the end of my last clinical I had a young girl come in with a diagnosis of complex regional pain syndrome which is also known as reflex sympathetic dystrophy. This young girl was about 12 years old and was having very exaggerated global shoulder pain with numbness and tingling in the hand. She was hardly using that arm for any functional activities and used it very seldomly due to the pain. Even a minor touch to the arm or having a sheet over her arm while sleeping would exacerbate her pain. Now the interesting thing to me was that she also was diagnosed with scoliosis around age 6 and currently wears a TLSO to help correct the deformity. She has taken x-rays, but did have any radionuclear imaging done. This may have been helpful because I was almost curious if something with her scoliosis was also a reason for the pain and maybe scintigraphy could have overruled that and shown increased uptake throughout the her UE. After reading this article it is definitely apparent the widespread use of scintigraphy. Also scintigraphy can have a vital role in screening for various pathologies warranting for more conclusive studies to be performed.
ReplyDeleteAs I look back at some of my classmates comments I didn't realize that RSD was so common! This young girl was the only one I had. It is definitely apparent as my classmates have said that scintigraphy should be utilized more often!
ReplyDeleteThis article was very interesting. I too, did not realize that radionuclide bone imaging could be done for RSD. I also did not know how beneficial it could be in diagnosis of metastatic disease. I can see though, as Rob stated, that the amount of radiation that the patient is exposed to with a scan like this could decrease its use. I have not had many patients that I feel would have benefited from a scan like this versus the imaging they had, but I did have the opportunity to work briefly with a patient that suffered from shin splints that had nearly halted her running. I only saw her for 2 sessions but from the history that I saw from her other therapists it seemed that she was not progressing as quickly as they had hoped. I wonder if a radionuclide scan would have possibly revealed a condition worse than just shin splints.
ReplyDeleteI did not know what an osteoporosis circumscripta pattern was when talking about Paget disease. I guess that I did not realize that Paget disease can affect the skull too. I have seen a patient with Paget disease in the hospital. Paget disease was listed in the past medical history but nothing about how it affected the patient. When asked, the patient reported pain in legs and pelvis and had significant bilateral genu varus. At the time I was most concerned with making sure the patient did not fall during ambulation because of the increased risk for fractures. I guess the legs were more obviously deformed due to added stresses during ambulation, but it did not cross my mind that the skull would be constantly remodeling also.
ReplyDeleteI was not aware of the multiple uses of a radionuclide bone image. The first thing that stuck out to me after reading this article was that this imaging could be used to stage a malignancy. I was also not aware that 75% of patients that have a malignancy also have abnormal bone scintigraphic images, and 25%-45% of them have the malignancy metastasis to their bones. The second interesting fact of this article was the use of a bone scintigraph with infections. The scan is taken in three phases. The first phase indicates the amount of blood flow to the area. The second phase depicts the amount of blood flow to the tissues around the area. The final phase depicts the rate of bone turnover. This bone scan gives an accuracy of over 90% for osteomyelitis. Also the fact that you could use a bone scan to identify reflex sympathetic dystrophy is extremely interesting. I have had two pervious patients that had RSD and this could have helped confirm and indicate where it was manifesting the symptoms. Another area where this article was insightful was bone scintigraphs and patients with CHF, MI, and unstable angina. It would have been nice to know that the bone scans could show myocardial uptake in these patients and help confirm their diagnoses. Stacey Smith
ReplyDeleteI find the bone scintigraphy very interesting in that it is very inexpensive, easily accessible and yet able to help in diagnosis such a wide variety of conditions. I can see simple scan can save many lives. I had at least two patients during my rotation at ViaChristi St. Francis where a patient had metastatic tumors in their bone. Both of them had the CA spread to their spine and were now presenting with spinal cord deficits with bilateral LE paralysis, paresthesia, and loss of bowel and bladder. One patient was significantly worse than the other but either way having a scan that is very good at detecting metastatic malignancies earlier in their progression and without surgery. Being from more on an orthopedic back ground I like that they are looking into using the bone scintigraphy to determine total joint replacement chronic pain cases to help rule in or out the prosthesis and bone involvement. This can help cut down on the number of unnecessary surgeries. I also like how it is a good screening process for various different metabolic bone conditions that might otherwise be very difficult to diagnose.
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