What Imaging Study What Imaging Study Should I Should I Order for …? Order for …? Approach to Imaging for Approach to Imaging for Optimal Clinical Optimal Clinical Diagnosis: Diagnosis: Musculoskeletal Musculoskeletal Disorders Disorders Darius Biskup M.D. Darius Biskup M.D.
What Imaging Study Should I Order for …? Approach to Imaging for Optimal Clinical Diagnosis: Musculoskeletal Disorders. Darius Biskup M.D. Disclosures. No financial disclosures. Objectives:. Review common musculoskeletal imaging modalities - PowerPoint PPT Presentation
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What Imaging Study What Imaging Study Should I Should I Order for …?Order for …?
Approach to Imaging for Approach to Imaging for Optimal Clinical Optimal Clinical
Abnormal xray/ normal xrayAbnormal xray/ normal xray If it can be normal, why order it?If it can be normal, why order it?
Can aid in assessment of mass – calcifications, bone Can aid in assessment of mass – calcifications, bone involvementinvolvement
What to order next?What to order next? MRIMRI How to order it? How to order it? MRI w/ & w/o contrast tumor/mass protocolMRI w/ & w/o contrast tumor/mass protocol
e.g. MRI right lower extremity tumor/mass e.g. MRI right lower extremity tumor/mass protocol w & w/o contrast protocol w & w/o contrast
Capsule marker Capsule marker placed around placed around massmass If mass not initially If mass not initially
found by patient, found by patient, show exact location show exact location so the can so the can reproduce site for reproduce site for examexam
Identifies target Identifies target mass vs. additional mass vs. additional not clinically not clinically detected lesionsdetected lesions
Fall, back pain, age Fall, back pain, age indeterminate compression indeterminate compression
fracture on xrayfracture on xray
What if patient has pacemaker and What if patient has pacemaker and there is a compression fracture there is a compression fracture deformity?deformity? Bone scan Bone scan
Imaging of spineImaging of spine
Back painBack pain Xray Xray
initial best testinitial best test
Imaging of spineImaging of spine
CT spine– no IV CT spine– no IV contastcontast Limited in assessment Limited in assessment
of spinal stenosisof spinal stenosis MRI spine w/oMRI spine w/o
most routine work for most routine work for LBP, radiculopathy LBP, radiculopathy
MRI spine w/ & w/oMRI spine w/ & w/o Post op follow upPost op follow up OncologyOncology
Can’t do MRI, but I Can’t do MRI, but I suspect central suspect central canal stenosiscanal stenosis CT myelogramCT myelogram
Low back pain, Low back pain, radiculopathyradiculopathy
CT myelogramCT myelogram
Good option Good option when can’t do when can’t do MRIMRI PacemakerPacemaker Post op metalPost op metal
InvasiveInvasive Contrast Contrast
injected into injected into thecal sacthecal sac
Nuclear Isotope StudiesNuclear Isotope Studies
Bone scan – infections, Bone scan – infections, osteomyeltits, stress/insufficiency osteomyeltits, stress/insufficiency fx “ diffuse bone pain”fx “ diffuse bone pain”
Limited spatial resolution – Limited spatial resolution – compliment with plain filmscompliment with plain films
Indium/sulfur colloid – infectionsIndium/sulfur colloid – infections esp with hardwareesp with hardware
Gallium- infectionsGallium- infections
I want to assess for I want to assess for osteomyeltis but my patient osteomyeltis but my patient
has a pacemakerhas a pacemaker No hardwareNo hardware Plain filmPlain film 3 phase bone scan3 phase bone scan Indium scanIndium scan (gallium in spine)(gallium in spine)
Hardware Hardware Plain filmPlain film 3 phase bone3 phase bone Induim/sulfur Induim/sulfur
colloid scancolloid scan Marrow Marrow
displacementdisplacement
I want to assess for I want to assess for hardware loosening vs hardware loosening vs
infectioninfection Plain filmPlain film 3 phase bone scan3 phase bone scan Induim/sulfur Induim/sulfur
colloid scancolloid scan Marrow Marrow
displacementdisplacement
Objectives:Objectives:
Review common musculoskeletal Review common musculoskeletal imaging modalities imaging modalities
Discuss advantages and Discuss advantages and disadvantages of imaging testsdisadvantages of imaging tests
Discuss use of contrast agentsDiscuss use of contrast agents Discuss imaging test approach to Discuss imaging test approach to
optimize clinical diagnosis of optimize clinical diagnosis of musculoskeletal disordersmusculoskeletal disorders
Take away pearlsTake away pearls Knowing what a Knowing what a
test can and can test can and can not assess will help not assess will help in optimal test in optimal test orderingordering
Xray most useful Xray most useful initial imaging initial imaging modalitymodality
MRI’s best done if MRI’s best done if targeted – soft tissue targeted – soft tissue mass, joint, limbmass, joint, limb Protocols differProtocols differ
Many exams can be Many exams can be substituted to get a substituted to get a diagnosis if a diagnosis if a condition prevents a condition prevents a desired examdesired exam Talk to your Talk to your
radiologistradiologist
Do I Need Contrast?Do I Need Contrast? Optimal forOptimal for Mass/oncology Mass/oncology ““Itis” –infection, Itis” –infection,
abscessabscess Post op Lumbar spinePost op Lumbar spine
Not neededNot needed MRI/CT of joints MRI/CT of joints
(not suspecting (not suspecting infection or mass)infection or mass)
When in doubt, let When in doubt, let the radiologist the radiologist figure it outfigure it out Talk to your Talk to your