Skeletal Imaging

Front 1

Isotopes

Back 1

are different types of atoms (nuclides) of the same atomic element. Isotopes have a different atomic mass number or different atomic neutron number. Isotopes have the same proton number or the same atomic number. For example, Carbon-12, Carbon-13, Carbon 14 are isotopes of the element Carbon.

Front 2

Radioisotopes

Back 2

are pharmaceuticals attached to a radionuclide.
Slang = tagged, trace amounts, emits gamma radiation.

Front 3

Planar

Back 3

Whole Body, Limited, Dynamic ( constant change or activity), Static ( lacking movement or change)

Front 4

SPECT

Back 4

Single Photon Emission Computed Tomography (3D)

Front 5

PET

Back 5

Positron Emission Tomography

Front 6

Gamma Camera

Back 6

CT Fusion

Front 7

Technetium 99m or Tech

Back 7

Is the most common radioisotope used.

Front 8

Geiger Counter

Back 8

Is used to measure traces of contamination of radio activity in and outside the lab.

Front 9

Dose Calibrator

Back 9

Used to measure amounts of radioactivity prior to patient administration.

Front 10

Planar, Static Images

Back 10

Time, distance, resolution & counts. Sequential imaging

Front 11

Whole Body Scan

Back 11

Sweep, Skeletal Imaging, Tumor Localization & Infectious imaging.

Front 12

collimator

Back 12

a device for producing a parallel beam of rays of radiation.

Front 13

Dynamic Acquisition-

Back 13

Flow Study, Skeletal, Cardiac, Gastric Bleed. It shows and demonstrates motion. MUGA, gastric emptying, Hepatobiliary.

Front 14

SPECT

Back 14

Shows 3D dimensional imaging, cross sectional anatomy, transverse, coronal & sagittal.

Front 15

Time Activity Curves

Back 15

For Gastric, Cardiac, hepatic, urinary.

Front 16

Field of View

Back 16

Useful field of view, a circular area within a diameter that is the largest inscribed circle within a collimated field of view.

Front 17

PET

Back 17

PET Imaging, Glucose metabolism, Oncology, Cardiac & Neurology. Cross Section Anatomy

Front 18

Spatial Resolution

Back 18

The ability of a camera to resolve clinical lesions.

Front 19

Matrix

dynamic images

Back 19

64 x 64, 128 x 128

Front 20

static images

Back 20

256 x 256

Front 21

Whole Body Sweep

Back 21

512 x 1024

Front 22

TC99m PYP

Back 22

At two 2 hours approximately 55% of the injected dose has localized in the bone. At 4 hours, 10% remains in the vascular system. Decreasing to 7% after 24 hours.
Reaction- hypersensitivity reactions, itching skin, rashes, hypotension, fever, chills, nausea, vomiting and dizziness.
Imaging = 10-15 mCI 2-4 hours post injection.

Front 23

TC99m HDP

Back 23

At 24 hours post injection, skeletal retention is approximately 50% of the injected dose. 6,4 and 3% remain in the blood at 2,3 and 4 hours post injection.
Imaging- 15 mCi 1-4 hours post injection

Front 24

TC99m MDP-

Back 24

During the initial 24 hours following injection, about 50% of the dose is retained in the skeleton. About 50% is renally excreted. Less then 2% remains in the vascular system. Blood levels fall to 3-5 of the injected dose by 3 hours post injection.
Reaction: Allergic dermatological reactions have been reported. Hypersensitivity reactions - itching, skin rashes, hypotension, chills, nausea, fever and vomiting,

Front 25

Patient Preparation-

Back 25

The patient should be well hydrated, two or more 8oz glasses of water between the time of injection and time of delayed imaging. The patient should be ask to urinate immediately prior to delayed imaging. In order to minimize the radiation dose to the bladder, the patient should be encouraged to increase fluid intake and to void as often as possible after injection and up to 4-6 hours after imaging.
Breast feeding should be discontinued for 24 hours after radiopharmectiucal injection.
Always verify orders and explain procedure. Question females of child bearing age about pregnancy or breast feeding.

Front 26

Normal Scan

Back 26

High degree uptake occurs in sacroiliac joints, hip joints, glenoid fossa, acromioclavicular joints, sternoclavicular joints, ends of long bones, growing epiphyses, vertebral column.

Front 27

Three Phase Bone Scan

Back 27

Flow Study (dynamic acquisition,) Immediate blood pool, Delayed Images (planar)
-Whole Body Scan
Limited bone scan
SPECT

Front 28

Three Phase Bone Scan SPECIFIC

Back 28

Osteomyelitis, Acute fractures, stress fractures, reflex sympathetic dystrophy, prosthetic loosening.

Front 29

Whole Body Scan

Back 29

Tumor evaluation, benign or malignant, increased alkaline phosphatase, hyperparathyroidism, Paget’s Disease

Front 30

Limited Imaging

Back 30

Specific site pain unknown etiology, chronic pain.

Front 31

Static (lacking movement, activity or change.

Back 31

Lateral = axial skeleton, extremities.
Oblique = axial skeleton, deep and swallow, 180 degree configuration, 90 degree configuration, extremities.
Squat
Vertex

Front 32

Advantage of nuclear medicine procedures over most other radiology procedures

Back 32

is that the camera can be angled if the patient can not be moved. Oblique view of the pelvis moves the right thochanteric region away from the pelvis.
Keep in mind that oblique views may now always be helpful, but the attempt at getting pertinent information is critical to the diagnosis.

Front 33

Whole Body Scan of a constricted patient. The attempt of the whole body scan to straighten out the legs was unsuccessful. Area of interest is the right femur. How can a better image be obtained?

Back 33

Oblique view of the pelvis moves the right thochanteric region away from the pelvis.

Front 34

Static Shots are

Back 34

still pictures

Front 35

Lateral shots are side shots say of example

Back 35

of the knees

Front 36

Oblique shots of the side

Back 36

stomach

Front 37

Spot Shots (SNM)

Back 37

500-1m counts axial skeleton
Remaining spots acquired for the same time as the first image.
128 x 128 or 256 x 256 matrix

Front 38

WB Protocol

Back 38

2-5 hr delay
Speed adjustment for minimum 1.5 million counts.
24 hr delay for a 4 phase.

Front 39

Dynamic Flow ( recording movement/activity)

Back 39

30-60 images at 1-3 seconds each.
128 x 128 matrix
Bolus injection
Blood Pool at 500k static image

Front 40

SPECT

Back 40

64 x 64 matrix
10-40 sex/projections
60-120 projections (azimuths)
360

Front 41

Transverse

Back 41

Head to Toes

Front 42

Coronal

Back 42

Front to back or anterior to posterior.

Front 43

Sagittal

Back 43

Right to left

Front 44

For images of the knees,

Back 44

place a 2-3 inch pad between the knees, secure the knees with straps to prevent motion. Secure feet in neutral position to prevent motion. For obese patients both knees may not be in the field of view.

Front 45

For hips and pelvis

Back 45

have patient excrete urine before scan. Position hips symmetrically and secure feet to prevent motion.

Front 46

For lumbar spine

Back 46

keep arms out of the field of view, a pillow under the knees to relieve stress on the back. Patients with back pain will often move during the scan.

Front 47

Pediatrics Patients

Back 47

Will have multiple normal hot spots in the bones due to growing!
Arms should be at side!

Front 48

Physiological increase of bone uptake

Back 48

Growing epiphysis
Sternal officiation centers
Shoulder uptake corresponding to handedness.
Altered bone stress due to limp
Spinal curvature resulting in apparent increase due to differing distances from camera.
Hypertosis interna frontal symmetrical frontal skull uptake.

Front 49

Periosteal Causes

Hypertrophic pulomonary osteoarthropathy

Back 49

Increased concentration along the long bones associated with lung cancer, HPO may be painful and the ling cancer silent. Indications of unexplained leg pain.

Front 50

Periosteal Causes cont.

Back 50

Periostitis secondary to soft tissue tumor or vascular disease (varicose veins)

- Periostitis deformans

Front 51

Benign Neoplastic

Bone Cyst

Back 51

Generally not visualized on bone scans, unless the lesion is large enough to create a photopenic region.

Front 52

Osteoid Osteoma

Back 52

In young males in tibia, femur of vertebral body, marked by concentration of tracer due to reactive bone formation. Most common tumor of the spine.

Front 53

Benign osteoblastoma

Back 53

Larger (>1.5cm) than osteoma, commonly less painful and have a history of progressive growth.

Front 54

Osteochondroma

Back 54

Most common of the benign tumors of the bone, characterized by cartilage capped bony growths that project from the surface of the affected bone.

Front 55

Non-ossifying fibroma

Back 55

In young adults slight increased concentration surrounding lesions, caused by reactive bone formation.

Front 56

Fibrous dysplasia

Back 56

Benign growth of fibrous tissue, sites are hyper metabolic.

Front 57

There are no classical scintigraphic =

Back 57

technique in which a scintillation counter or similar detector is used with a radioactive tracer to obtain an image of a bodily organ or a record of its functioning

Front 58

There are no scintigraphic findings to

Back 58

allow one to differentiate between a benign or a malignant process.

Front 59

Benign boney tumors usually

Back 59

present with marked
uptake (as in this case) include Aneurysmal
bone cyst, Chondroblastoma, Fibrous dysplasia, Osteoblastoma and Osteoid
osteoma.

Front 60

Malignant bony tumors usually

Back 60

Osteogenic sarcoma, Ewing’s sarcoma and Chondrosarcoma are the ones more commonly seen.

Front 61

The differential diagnosis for the three areas of increased uptake in the left femur includes

Back 61

neoplasm (benign or malignant), dysplasias, multiple fractures, or multifocal infection.

Front 62

The patient denied pain in her left hip, and had no significant trauma history.

Back 62

Therefore, fractures or infections are highly unlikely.

Front 63

The most concerning possibility in the differential
is osteosarcoma. Possible benign neoplasms
include osteochondromas, chondroblastomas,
and enchondromas

Back 63

Bone dysplasias
demonstrating increased uptake include fibrous
dysplasia, osteogenesis imperfecta,
osteopetrosis, progressive diaphyseal dysplasia,
hereditary multiple diaphyseal sclerosis, and melorrheostosis.

Front 64

Malignant Neoplastic

Metastases

Back 64

From breast, lung, prostate, kidney, colon. Increased deposition of bone agents is in itself not diagnostic of a neoplastic process, nor does a positive bone scan differentiate between malignant and benign tumors.Advantage over MRI, and radiography is the ability for WB
scans, multiple images, SPECT.

Front 65

Prostate

Back 65

mets rare in patients with a PSA under 8-10ng/mL. 50 % of patients with PSA over 20 have mets.

Front 66

Bone Palliation

Back 66

required prior to administration of Sm-153 or Sr-89.

Front 67

Myeloma

Back 67

Usually a purely osteoclastic disease which is better seen on radiography, unless fractures occur.Multiple myeloma occur with little
reparative bone formation to be detected by bone scans.

Front 68

Diffuse Skeletal Metastases

Superscan

Back 68

Flare response is usually a good indicator that a tumor has been checked by therapy.
- Lack of visible renal activity.

Front 69

There is heterogeneous increased uptake throughout the axial and appendicular skeleton....

Back 69

consistent with
disseminated active osseous metastatic disease.

Front 70

Faint bilateral renal activity is noted, consistent with a near "super scan"

Back 70

appearance of widespread osseous metastatic disease.

Front 71

Metabolic staging of soft tissues and osseous structures with

Back 71

PET imaging is suggested.

Front 72

Sarcoidosis

Back 72

There are multiple focal areas of increased radiotracer activity seen within the hands and feet in an asymmetric pattern. Specifically, within the hands, the activity is located within the metacarpophalangeal joints and interphalangeal joints with a single focus involving the carpometacarpal region of the right hand. Activity within the feet is located throughout the tarsal, metatarsal, and phalangeal regions. Increased activity is
seen within the elbows, as well as the left knee. The activity seen in the
nasopharangeal region is more than what is normally seen.

Front 73

Sarcoidosis:

Back 73

Osseous involvement in sarcoidosis occurs in approximately 5% to 15% of cases and is usually seen in advanced disease. The hands are the most common sites of involvement, followed by the feet.

Front 74

Sacroma

Back 74

osteogenic (Ewings, fibro)

Front 75

Ewings

Back 75

tumor in children with femur being a common site. Bone images are positive early, probably because of periosteal new bone formation.

Front 76

Sarcoma

Back 76

increased concentration may be larger than size of tumor because of adjacent vascularity.

Front 77

Giant cell tumor

Back 77

Lymphoma, Leukemia

Front 78

Inflammatory

Osteomyelitis

Back 78

acute and chronic – Increased uptake in 3 phases for bone infection. Due to increased vascularity and new bone formation. Bone image remains during repair phase which may last for months or years (chronic)

Front 79

Osteitis

Back 79

Osteitis fibrosa cystica - Caused by hyperparathyroidism, most
common manifestation of renal osteodystrophy

Front 80

Spondylosis

Back 80

Use SPECT for stress fracture of the pas interarticularis that
results in spondylosis, a condition that may be difficult to assess.

Front 81

Spondylolysis

Back 81

s a defect in the pars
interarticularis commonly found in the
lumbar spine at L4 and L5. Frequently,
the etiology for this defect is a stress
fracture, although, there may be a
congenital weakness in the osseous
matrix of pars interarticularis that
predisposes some individuals to the
development of spondylolysis.
Individuals commonly affected are
young athletes presenting with back
and radicular pain, however, some
patients are asymptomatic.
Spondylothisthesis or slippage of a
vertebral body onto another can be
associated.

Front 82

Arthritis

osteoarthritis

Back 82

Increased concentration at the diseased joints. Synovitis with increased blood flow or direct involvement may account for increased uptake. Can not really differentiate different types of arthritis.
Rheumatoid arthritis
Gout

Front 83

Vascular

Avascular necrosis =

Back 83

Vascularity of the head or
metaphysis of long bones may occur spontaneously or
may be acquired secondary to fracture, sickle-cell
disease, alcoholism, steroid use. Initially there is an
absence of tracer uptake in the avascular and infarcted
bone. Later a healing phase of bone repair with
activation of osteoblasts there is an increase in tracer
uptake. Increased uptake may also be seen around the
site of AVN.

Front 84

Bone infarct =

Back 84

Increased uptake in infarcted tissue.

Front 85

Paget's Disease

Back 85

Positive scan when metabolically
active. Chronic disease causing enlargement and
deformity of bones. Pelvis, tibia, skull, scapula
frequently involved. Positive in nuclear imaging before x-
ray changes occur, however there may be a late or
metabolically inactive phase with little or no increased
uptake on imaging.

Front 86

Paget's usually an incidental finding when

Back 86

when alkaline phosphatase levels are increased

Front 87

Paget's Disease

Back 87

Positive scan when
metabolically active. Chronic disease causing
enlargement and deformity of bones. Pelvis,
tibia, skull, scapula frequently involved. Positive
in nuclear imaging before x-ray changes occur,
however there may be a late or metabolically
inactive phase with little or no increased uptake
on imaging.

Front 88

Trauma

Fracture- stress fracture

Back 88

Three phase bone scan shows increased uptake in the left lower extremity, as compared to the right. The blood pool phase is basically equal in uptake.

Front 89

Trauma

Fracture- stress fracture

Back 89

Whole body and static images of the
left lower extremity demonstrate an
increased uptake in the distal left
tibia. To a lesser extent there is a
faint increased uptake in the more
proximal shaft in the right tibia.
These areas of abnormality are
consistent with stress fracture.

Front 90

Trauma

Back 90

Prosthesis, bone graft, reflex sympathetic dystrophy, child abuse

Front 91

Stress Fracture/shin splints

Back 91

The dynamic blood flow study and immediate post injection images demonstrate a minimally increased vascularity corresponding to abnormal bone tracer uptake in the right and left femora, consistent with stress fractures.

Front 92

Stress Fracture/shin splints 2

Back 92

Mildly increased tracer uptake is also noted in the proximal 2/3 portion of both tibiae, suggested of shin splints.

Front 93

Stress Fracture/shin splints 3

Back 93

A focal abnormal tracer is noted in the right knee corresponding to the posterior medial tibial plateau area, suggestive of bone or joint lesion.

Front 94

Prosthesis

Back 94

To determine loosening of the prosthetic device

Front 95

Prosthesis cont.

Back 95

to determine extent of infection.
-Delayed images there is an intense increased uptake in the
midshaft of the right femur and medial femoral condylar portion
of the right knee prostheses, and in the tibia at the tip of the prosthesis on the left tibial plateau.

Front 96

Prosthesis cont. 2

Back 96

This uptake around the right knee prosthesis is suggested of the possibility of loosening of the prosthesis.

Front 97

Bilateral hip replacement

Back 97

determination of fracture or loosening of prosthetic devices.

Front 98

Healing Fracture

Back 98

Fractures may be visible for up to 1 year after the original incident

Front 99

Reflex sympathetic dystrophy

Back 99

RSDS has readily identifiable signs and symptoms and is treatable if recognized early; however, the syndrome may become disabling if unrecognized.

Front 100

Reflex sympathetic dystrophy cont.

Back 100

the patient experiences intense burning pain in one or more extremities.

Front 101

mildly diffusely increased activity throughout the right lower extremity in the osseous structures and soft tissues.

Back 101

A variant of reflex sympathetic dystrophy might be considered, but the patient has a history of specific trauma, and the typical appearance of increased activity
in the small joints peripherally is not present.

Front 102

Metabolic

Back 102

Osteoporosis, osteomalcia, hyperparathyroidism, renal osteodysrophy

Front 103

Incidental Findings

Back 103

Pitfalls in imaging (artifacts)

Front 104

Free Tc

Back 104

Kit breakdown

Front 105

Effects of collimation on the resolution of planar bone scans:

Back 105

(A) Low energy high resolution (LEHR)
(B) Low energy general purpose (LEGP) low energy all purpose (LEAP)
(C) Medium energy

Front 106

Effect of distance from the patient to the detector

Back 106

Anatomic detail progressively decreases as the distance increases.
See P.P

Front 107

Effect of Count Density

Back 107

Traditionally lumbar spine would be imaged for 500k-750k
- 350k would be used for head and extremities.

Front 108

Non-osseous uptake (non skeletal)

Back 108

metastases, renal, lung, cardiac, calcifications
Artifact
Contamination, Radiopharmaceutical = not tagged properly
extravasation = does not injected properly

Front 109

Pulmonary Uptake

Back 109

Idopathic pulomonary hemoisderosis
Improper radiopharmaceutical preparation resulting in particles large enough to lodge in the lungs.
Malignant pleural effusion
Metastatic calcifications

Front 110

Cardiac Uptake

Back 110

Hyperparathyroidism
Myocardial contusion
Myocardial infarct
Tc 99m PYP

Front 111

Calcifications

Back 111

Costal cartilage, scar tissue, breast normal variant.There was soft tissue uptake in the area of the left breast, which was consistent with post surgical swelling of this particular area. There was also
extensive uptake of bone tracer in the right breast, which is non-
specific and may represent calcification.

Front 112

Drug Interaction

Back 112

MDP drug interactions are most
closely associated with potassium
phosphates, potassium and sodium
phosphates and sodium phosphates,
all of which may cause saturation of
the bone binding sites by the
phosphorus ions in the medication,
causing decreased bone uptake of
Tc99m MDP. Renal function
impairment will also cause decreased
clearance of Tc99m MDP from the
blood and soft tissue, decreasing
visualization of lower bone to
background ratio resulting in
increased circulatory activity.

Front 113

Name some side effects of Succinylcholine?

Back 113

Fasciculations
Hyperkalemia
Bradyc. ( seen in children)
Increased ICP
Malignant Hyperthermia (MH)
Increased Intraocular Pressure (IOP)