Clinical Applications

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Understandably, the clinical use of bone scan was much restricted when first introduced in the early 1960s (Fleming et al. 1961). At that time bone scintigraphy was applied to the diagnosis of cancer metastasis (Fig. 1.2) and fracture (Fig. 3.1). Since then, its scope has been enormously expanded, indeed far beyond the scope originally envisaged. This expansion has been made possible basically by the availability of high-technology gamma camera systems and excellent radiopharmaceuticals, and developments in image interpretation science, which have led to ever-increasing clinical demands. Thus, bone scintigraphy has long been established as the most popular nuclear imaging modality, not only for the screening of acute and critical bone and joint disorders but also for standard diagnosis of most skeletal dis

Fig. 3.1A, B One of the first bone scintigraphs made with 85Sr. A Dot photoscan superimposed on the radiograph of the left humerus reveals increased tracer uptake in the proximal metaphysis at the site of cancer metastasis. B Radiograph shows irregular bone destruction (from Fleming et al. 1961)

Fig. 3.1A, B One of the first bone scintigraphs made with 85Sr. A Dot photoscan superimposed on the radiograph of the left humerus reveals increased tracer uptake in the proximal metaphysis at the site of cancer metastasis. B Radiograph shows irregular bone destruction (from Fleming et al. 1961)

Bone infections

Osteomyelitis, osteitis, periostitis, bone abscess

Noninfective osteitides

Osteitis condensans ilii, osteitis pubis, condensing osteitis of the clavicle, Paget's disease, costosternoclavicular hyperostosis

Transient synovitis

Initial diagnosis, posttherapeutic followup


Initial diagnosis, posttherapeutic followup


Regional form, generalized form

Rheumatoid arthritis

Seronegative spondyloarthropathies

Ankylosing spondylitis, Reiter's syndrome, psoriatic arthritis, enteropathic arthritis

Arthropathies related to specific conditions

Systemic lupus erythematosus, Sjogren's syndrome, gouty arthritis, Charcot's joint

Soft-tissue rheumatism disorders

Tendinitis, bursitis, plantar fasciitis, myositis ossificans


Legg-Calve-Perthes disease, Kohler's disease, Friedrich's disease, Freiberg's infraction, Scheuermann's disease, Sever's disease

Osteochondritis dissecans

Vascular bone disorders

Avascular necrosis, infarction, reflex sympathetic dystrophy, transient osteoporosis

Metabolic bone diseases

Senile and postmenopausal osteoporosis, primary and secondary hyperparathyroidism, rickets, iatrogenic portosis

Traumatic and sports injuries

Contusion, stress fracture, enthesopathy, covert fracture, pseudoarthrosis, fracture nonunion

Bone metastases

Malignant and benign primary bone tumors

Osteosarcoma, chondrosarcoma, fibrosarcoma, Ewing's sarcoma, multiple myeloma and osteoid osteoma, enostosis, exostosis, fibrous cortical defect, and simple bone cyst

Table 3.1 Diseases diagnosable by pinhole scintigraphy

Table 3.1 Diseases diagnosable by pinhole scintigraphy orders. Lately, the combined use of nuclear angiography, SPECT, and pinhole techniques has greatly increased its diagnostic potential in terms of both sensitivity and specificity.

Of particular interest, bone scintigraphy augmented with the pinhole technique has been shown to provide important and often unique information that can suggest or establish the specific diagnosis of many skeletal disorders (Bahk 1988, 1992; Bahk et al. 1987, 1992, 1994; Kim et al. 1992, 1993a, 1993b). Thus, pinhole scintigraphy seems a sine qua non in clinical practice and research of muscu-loskeletal disorders. A brief list of these disorders includes: (a) bone infections such as osteomyelitis; (b) noninfective osteitides such as osteitis condensans ilii and Paget's disease of bone; (c) transient synovitis; (d) pyarthritis; (e)

osteoarthritis; (f) rheumatoid arthritis; (g) seronegative spondyloarthropathies such as ankylosing spondylitis and Reiter's syndrome; (h) arthropathies related to specific conditions such as systemic lupus erythematosus and gouty arthritis; (i) soft-tissue rheumatism disorders such as tendonitis and bursitis; (j) osteochondroses such as Legg-Calvé-Perthes disease; (k) osteochondritis dissecans; (l) vascular bone disorders such as avascular necrosis and i n-farction; (m) metabolic bone diseases such as postmenopausal osteoporosis and hyperpara-thyroidism; (n) traumatic and sports injuries; (o) metastases; (p) malignant and benign primary bone tumors; and (q) many other skeletal disorders (Table 3.1). In general, pinhole scintigraphy has been shown to be a highly potent tool for the fine topographic study of diseases in complex anatomical units of the body such as the spine, head and neck, knee, and hip (Bahk et al. 1987).

It appears fully justified, therefore, to explore the utility of this easily and economically performable, yet immensely rewarding scan technique, for the diagnosis of the broad spectrum of skeletal disorders with the eventual goal of establishing a classic piecemeal interpretation system. This attempt might result in systematic upgrading of bone scintigraphic diagnosis through the mediation of an image transition. In this connection, it is fortunate that new pinhole collimators can be economically provided or may already be in available but just laid aside! It must be emphasized again that the time needed for pinhole scanning is, at most, comparable to that for SPECT. With the latest technical modification using 99mTc-labe-led hydroxydiphosphonate (HDP) and optimized pinhole aperture and tracer acquisition, the vast majority of pinhole scans can now be completed in 15-20 min.

What is essential is to realize that the pinhole technique can truly improve the resolution, whereas simulated magnification or SPECT cannot. Basically, SPECT is a technique that deals with contrast and not with resolution. When SPECT is performed with pinhole colli-mation both the resolution and contrast are significantly enhanced. The resolution of pinhole SPECT is almost the same as that of CT. Practically, pinhole SPECT can portray most major anatomical landmarks, for example, in the ankle and hindfoot, including fine structures such as physiologically fortified trabecu-lae in the weight-bearing axes of the talus and calcaneus, the sites of tendinous and ligamen-tous insertion, and intertarsal and tarsometa-tarsal articulations (Fig. 2.8). It can also show characteristic pathological changes in various diseases as presented in Chap. 2.

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