Basics of musculoskeletal nuclear medicine

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Scintigraphy is a functional imaging modality which uses radioactive isotopes. These are usually tagged to a pharmaceutical to create a radiopharmaceutical which mimics specific physiological processes within the body. Skeletal scintigraphy is capable of identifying areas of active bone turnover with very high sensitivity. However, it has low specificity; that is, areas of increased bone uptake can be due to a variety of physiological and disease processes. This chapter explores the indications for and value of nuclear medicine compared with other imaging techniques; equipment; restraint and patient preparation; examination method; and principles of image interpretation.

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5.1 Lateral view of the left tibia, tarsus and pes of a 12-year-old mixed-breed dog undergoing bone phase scintigraphy. Note the linear area of IRU caudal to the tibia, corresponding to retention of radiopharmaceutical in the intravenous saphenous vein catheter.
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5.2 Soft tissue phase scintigraphy in a normal dog. (a) Right and (b) left shoulders (arrowed). Note the symmetrical pattern of uptake and lack of significant bone localization.
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5.3 Composite bone phase right lateral image of the entire skeleton of a 7-month-old Akita using Tc-HDP. Notice the IRU at the level of the physes and metaphyses, a normal finding for a young animal. The rectangular photopenic area in the caudal abdomen represents a lead shield used to block the urinary bladder.
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5.4 Bone phase lateral image of the right femur in an 11-year-old female spayed Husky obtained using Tc-MDP. There is marked IRU along the diaphysis of the femur, more intense along the cortical margin; the final diagnosis was femoral osteosarcoma. Notice normal activity in the urinary bladder, the normal route of excretion for bone-seeking radiopharmaceuticals.
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5.5 Bone phase lateral images of the (a) right and (b) left scapulae, humeri and elbows of the same dog as in Figure 5.4 . There are focal areas of marked IRU at the level of the proximal diaphysis of both humeri: radiographs only revealed mildly increased medullary opacity at these levels. Both sites were confirmed to be osteosarcoma metastases.
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5.6 Bone phase images of the elbows of a 12-month-old male neutered Labrador Retriever with waxing and waning multiple limb lameness. (a) Lateral and (b) caudal views of both elbows. There is IRU in the proximal left radius/ulna (right side of (a)). It has a semilunar shape which differs from the pattern of uptake at the level of the normal right proximal radial physis. On the caudal view, the left limb IRU (left side of (b)) is more intense medially. The final diagnosis was disease of the medial coronoid process of the left elbow.
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5.7 Lymphoscintigraphy using Tc-SC in a 4-year-old Irish Wolfhound with a 2-month history of left pelvic limb swelling. Lateral images of (a) the right and (b) the left pelvic limbs. Radioactive Co markers (‘string of pearls’ appearance) placed near the body were used to identify key anatomical locations (tarsus, ischium, popliteal lymph node (PLN)). There is normal uptake of radiopharmaceutical in (a) the right pelvic limb, with normal visualization of the PLN in the last two (i.e. 25- and 30-minute) images. In the left pelvic limb (b) absorption is abnormal, with lack of visualization of normal lymphatic channels to the level of the PLN, and abundant interstitial activity. The popliteal and medial iliac lymph nodes are visible on both sides. The final diagnosis was secondary lymphoedema of unknown cause.
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