SPECT/CT Wrist. Wrist pain 3/27/2012
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1 Wrist pain Wrist joint - complicated anatomy complex biomechanics Imaging and management of wrist pain presents a significant challenge Significant economic burden SPECT/CT Wrist HK Mohan GSTT London Intra-capsular Fracture Ligament tear static instability pattern dynamic instability pattern triangular fibrocartilage complex tear Distal radioulnar joint subluxation Arthritis rheumatoid arthritis other connective tissue diseases psoriasis metabolic diseases(gout/pseudogout/ hyperparathyreoidism) infectious diseases (common/atypical agent) Osteoarthritis primary (CMC 1, STT joint) secondary (SLAC) Neoplasm enchondroma osteoid osteoma p igmented villonodular synovitis other (giant cell tumour) Ganglia (extra-osseous/intra-osseous/occult) Avascular necrosis lunate (Kienbock s) scaphoid (Preiser s) Other Osteochondromatosis Carpal boss Carpal coalition Extra-capsular Neuropathy median nerve (carpal tunnel) ulnar nerve (Guyon s canal) distal posterior interosseous nerve syndrome thoracic outlet compression syndrome neuroma Tendinopathy extensor carpi ulnaris tendon subluxation tendovaginitis (De Quervain s) repetitive strain injury Multisystemic disease Infectious 1
2 Algorithm for chronic wrist pain. Bone scintigraphy Highly sensitive Low specificity Radiation exposure van Vugt R M et al. Ann Rheum Dis 1999;58: by BMJ Publishing Group Ltd and European League Against Rheumatism Co-registration of anatomy and function Side by side X-ray + Bone scan with markers Study at GSTT 2001 Mohan HK, Vijayanathan S, Sharp D, et al: Co-registration of plain X-ray and two-phase 99m Tc-MDP bone scans of wrist impact on diagnostic sensitivity and specificity. Nucl Med Commun 23:407, 2002 N=35 In 14/27 patients with positive BS, X-ray coregistration improved specificity. Limitations remain X- ray low sensitivity, 2 Dimensional = lower specificity compared to 3d imaging 2
3 Coregistration of SPECT + CT Hybrid SPECT/CT Groves AM, Bird N, Tabor I, Cheow HK, Balan KK. 16-Detector multislice CT-skeletal scintigraphy image co-registration. Nucl Med Commun Nov;25(11): Problems Scans acquired at different times Patient position Movement Software issues Manual registration Anatomy + Function in a single session Convenient to the patient? cost effective to the system Increasing evidence 961 Articles 110 review articles 3
4 SPECT Collimators: LEHR parallel hole s matrix, Pixel size =f mm. The SPECT scan took approximately 25 minutes. Localisation CT: 120 kv, 100 mas/slice, Pitch = Rotation time = 0.75 s, Collimation = mm. Slice thickness of 1.5 mm. 1 minute to complete. Diagnostic CT: 140 kv, 150 mas/slice, Pitch = Rotation time = 0.75 s, Slice thickness of 0.8 mm. 1 minute to complete. 4
5 Image analysis Nuc med physician + MSK radiologist 5
6 Planar Blood Pool and Delayed views of wrist in a patient with previous trauma and continuing pain in left wrist Coronal view of fused scan. Note a cyst in the scapula below the area of uptake but does not show any uptake. CT of left wrist Multiplanar views shows subluxation of 1 st metacarpal radial to the trapezium as cause of pain Subluxed 1 st metacarpal uptake cyst 6
7 7
8 SPECT/CT in the evaluation of wrist pain 26/31 patients (84%), SPECT-CT provided additional information Accurate localisation in 22 patients (71%) Additional/new abnormalities in 13 patients (42%) The patient management was influenced by the SPECT-CT results in 15/24 (62%). SPECT/CT Vs MRI Recent study from Lucerne SPECT/CT better specificity than MRI MRI more sensitive than SPECT/CT (Huellner MW, et al SPECT/CT versus MRI in patients with nonspecific pain of the hand and wrist - a pilot study. Eur J Nucl Med Mol Imaging 2012 Jan 12. [Epub ahead of print) 8
9 To summarise Imaging wrist pain remains challenging Bone scintigraphy plays an important role SPECT/CT has a major role to play Teamwork core to success Thanks!! Nuclear medicine team at GSTT Dr S Vijayanathan MSK radiologist 9
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