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Radionuclide Bone Imaging: An Illustrative Review¹

¹ From the Division of Nuclear Medicine, Long Island Jewish Medical Center, 270-05 76th Ave, New Hyde Park, NY 11040. Presented as an education exhibit at the 2001 RSNA scientific assembly. Received May 28, 2002; revision requested July 24 and received August 19; accepted August 19. Address correspondence to C.L. (e-mail: love@lij.edu).

View larger version (85K): [in a new window]   Figure 1.  Anterior (left) and posterior (right) whole-body bone scintigrams obtained in an adult demonstrate normal anatomy.

View larger version (103K): [in a new window]   Figure 2.  Anterior (left) and posterior (right) whole-body bone scintigrams obtained in a child demonstrate normal anatomy. Note the increased activity in the physes of the long bones and in the hematopoietically active facial bones.

View larger version (106K): [in a new window]   Figure 3a.  (a) Anterior bone scintigram shows discrete focal activity in the left maxilla (arrowhead) due to a dental process and heart-shaped activity in the anterior neck (arrow) representing the thyroid cartilage, both of which are normal variants. (b) Posterior bone scintigram shows focal activity in the right side of the neck (arrow) caused by a cervical osteophyte.

View larger version (134K): [in a new window]   Figure 3b.  (a) Anterior bone scintigram shows discrete focal activity in the left maxilla (arrowhead) due to a dental process and heart-shaped activity in the anterior neck (arrow) representing the thyroid cartilage, both of which are normal variants. (b) Posterior bone scintigram shows focal activity in the right side of the neck (arrow) caused by a cervical osteophyte.

View larger version (80K): [in a new window]   Figure 4.  Extensive osseous metastases from lung carcinoma. Anterior (left) and posterior (right) whole-body bone scintigrams show multiple, randomly distributed foci of abnormal radiotracer uptake. The foci vary in size and intensity.

View larger version (112K): [in a new window]   Figure 5.  Anterior (left) and posterior (right) whole-body scintigrams obtained in a patient who fell demonstrate multiple foci of increased radiotracer uptake. The linearly distributed rib foci and H-shaped sacral activity indicate trauma as the cause of these foci. The increased activity in the right proximal humerus is due to a fracture.

View larger version (66K): [in a new window]   Figure 6.  Bone metastases from gastric carcinoma. Anterior (left) and posterior (right) whole-body scintigrams show diffuse, irregularly increased activity throughout the appendicular and axial skeleton. There is minimal soft-tissue activity and virtually no renal or bladder activity. This pattern is indicative of diffuse bone metastases and is often referred to as a superscan.

View larger version (89K): [in a new window]   Figure 7.  Renal osteodystrophy and secondary hyperparathyroidism. Anterior (left) and posterior (right) whole-body scintigrams demonstrate uniformly increased activity throughout the skeleton that is especially intense in the calvaria. These images show the superscan pattern associated with metabolic bone disease (cf Fig 6).

View larger version (79K): [in a new window]   Figure 8a.  (a) Posterior planar scintigram demonstrates a focus of increased radiotracer uptake in the right side of a lower thoracic vertebra. (b-d) Transaxial (b), coronal (c), and sagittal (d) tomograms demonstrate that this eccentric activity extends from the body of the vertebra into the pedicle, a pattern that is consistent with metastatic disease.

View larger version (110K): [in a new window]   Figure 8b.  (a) Posterior planar scintigram demonstrates a focus of increased radiotracer uptake in the right side of a lower thoracic vertebra. (b-d) Transaxial (b), coronal (c), and sagittal (d) tomograms demonstrate that this eccentric activity extends from the body of the vertebra into the pedicle, a pattern that is consistent with metastatic disease.

View larger version (134K): [in a new window]   Figure 8c.  (a) Posterior planar scintigram demonstrates a focus of increased radiotracer uptake in the right side of a lower thoracic vertebra. (b-d) Transaxial (b), coronal (c), and sagittal (d) tomograms demonstrate that this eccentric activity extends from the body of the vertebra into the pedicle, a pattern that is consistent with metastatic disease.

View larger version (47K): [in a new window]   Figure 8d.  (a) Posterior planar scintigram demonstrates a focus of increased radiotracer uptake in the right side of a lower thoracic vertebra. (b-d) Transaxial (b), coronal (c), and sagittal (d) tomograms demonstrate that this eccentric activity extends from the body of the vertebra into the pedicle, a pattern that is consistent with metastatic disease.

View larger version (124K): [in a new window]   Figure 9a.  (a) Posterior planar scintigram shows bilateral foci of increased activity in a lower lumbar vertebra. (b-d) Transaxial (b), coronal (c), and sagittal (d) tomograms help confirm that this increased activity is confined to the posterior elements, sparing the pedicles, and therefore does not represent metastatic disease.

View larger version (91K): [in a new window]   Figure 9b.  (a) Posterior planar scintigram shows bilateral foci of increased activity in a lower lumbar vertebra. (b-d) Transaxial (b), coronal (c), and sagittal (d) tomograms help confirm that this increased activity is confined to the posterior elements, sparing the pedicles, and therefore does not represent metastatic disease.

View larger version (110K): [in a new window]   Figure 9c.  (a) Posterior planar scintigram shows bilateral foci of increased activity in a lower lumbar vertebra. (b-d) Transaxial (b), coronal (c), and sagittal (d) tomograms help confirm that this increased activity is confined to the posterior elements, sparing the pedicles, and therefore does not represent metastatic disease.

View larger version (30K): [in a new window]   Figure 9d.  (a) Posterior planar scintigram shows bilateral foci of increased activity in a lower lumbar vertebra. (b-d) Transaxial (b), coronal (c), and sagittal (d) tomograms help confirm that this increased activity is confined to the posterior elements, sparing the pedicles, and therefore does not represent metastatic disease.

View larger version (131K): [in a new window]   Figure 10.  Scintigram shows a bone metastasis in a lower lumbar vertebra (arrow) as an area of decreased rather than increased activity.

View larger version (61K): [in a new window]   Figure 11.  Posterior whole-body scintigram obtained about 1 year after mediastinal radiation therapy shows a sharply demarcated area of uniformly decreased radiotracer accumulation in the upper thoracic spine, a finding that represents the radiation port.

View larger version (100K): [in a new window]   Figure 12.  Bone metastasis from breast carcinoma. Scintigram from the initial bone study (left) demonstrates numerous foci of increased activity. On a scintigram obtained 3 months later (center), the abnormalities are more intense, and new abnormalities have become evident. On a third scintigram obtained yet 3 months later (right), many lesions have resolved, and those that remain have decreased in intensity. No new abnormalities have appeared. The changes present on the second study (center) reflect a response to treatment and the flare phenomenon, not disease progression.

View larger version (108K): [in a new window]   Figure 13a.  Fracture of the femur in an 83-year-old patient who complained of left hip pain after a fall. (a) Radiograph demonstrates normal findings. (b) Anterior (left) and posterior (right) radionuclide bone scans demonstrate foci of increased activity in the left femoral neck, a finding that is consistent with trauma. (c) Computed tomographic (CT) scan helps confirm the presence of a left femoral neck fracture (arrow).

View larger version (98K): [in a new window]   Figure 13b.  Fracture of the femur in an 83-year-old patient who complained of left hip pain after a fall. (a) Radiograph demonstrates normal findings. (b) Anterior (left) and posterior (right) radionuclide bone scans demonstrate foci of increased activity in the left femoral neck, a finding that is consistent with trauma. (c) Computed tomographic (CT) scan helps confirm the presence of a left femoral neck fracture (arrow).

View larger version (88K): [in a new window]   Figure 13c.  Fracture of the femur in an 83-year-old patient who complained of left hip pain after a fall. (a) Radiograph demonstrates normal findings. (b) Anterior (left) and posterior (right) radionuclide bone scans demonstrate foci of increased activity in the left femoral neck, a finding that is consistent with trauma. (c) Computed tomographic (CT) scan helps confirm the presence of a left femoral neck fracture (arrow).

View larger version (50K): [in a new window]   Figure 14.  Plantar fasciitis. Radionuclide scans demonstrate foci of increased activity on the plantar surface of the right calcaneus (arrow), where the plantar fascia attaches to the calcaneal tuberosity.

View larger version (104K): [in a new window]   Figure 15a.  (a) Anterior (left) and posterior (right) scintigrams obtained in a young woman with stress fractures of the right tibia show focal, intense activity in the proximal portion of the bone. (Case courtesy of Lawrence Davis, MD, Department of Radiology, Long Island Jewish Hospital, New Hyde Park, NY.) (b) On anterior (left) and posterior (right) scintigrams obtained in a patient with bilateral shin splints, the tibial activity is linear, longitudinally oriented, and mild in intensity.

View larger version (87K): [in a new window]   Figure 15b.  (a) Anterior (left) and posterior (right) scintigrams obtained in a young woman with stress fractures of the right tibia show focal, intense activity in the proximal portion of the bone. (Case courtesy of Lawrence Davis, MD, Department of Radiology, Long Island Jewish Hospital, New Hyde Park, NY.) (b) On anterior (left) and posterior (right) scintigrams obtained in a patient with bilateral shin splints, the tibial activity is linear, longitudinally oriented, and mild in intensity.

View larger version (27K): [in a new window]   Figure 16.  Osteomyelitis. Dynamic (left), blood pool (center), and bone (right) images from a three-phase bone scan demonstrate focal hyperperfusion, focal hyperemia, and foci of increased bone uptake, respectively, in the right great toe.

View larger version (43K): [in a new window]   Figure 17.  Paget disease. Whole-body scintigram demonstrates increased radiotracer accumulation in the proximal right femur and in the deformed and enlarged tibias.

View larger version (68K): [in a new window]   Figure 18.  Lung carcinoma with hypertrophic osteoarthropathy. Anterior (left) and posterior (right) whole-body scintigrams demonstrate pericortical stripes of activity (tramline sign) in the lower extremities. Hypertrophic osteoarthropathy is also present in the bones of the forearms.

View larger version (90K): [in a new window]   Figure 19.  Reflex sympathetic dystrophy. Scintigram shows diffusely increased uptake in the distal right upper extremity.

View larger version (79K): [in a new window]   Figure 20.  Avascular necrosis in a patient with sickle cell disease who complained of left hip pain. Radiograph from an initial study (top left) shows normal findings. The corresponding scintigram (bottom left) demonstrates an abnormality with a photopenic defect in the left femoral head. Radiograph obtained 1 year later (top center) shows deformity of the left femoral head. The corresponding scintigram (bottom center) reveals increased radiotracer uptake, a finding that represents the reparative phase of avascular necrosis. Radiograph obtained 2 years after the initial study (top right) shows evidence of progressive destruction and deformity of the left femoral head. The corresponding scintigram (bottom right) depicts a small, deformed left femoral head.

View larger version (57K): [in a new window]   Figure 21.  Spontaneous osteonecrosis. Dynamic (left), blood pool (center), and bone (right) images show focal hyperperfusion, hyperemia, and bone activity, respectively, in the intercondylar region of the tibia and medial femoral condyle.

View larger version (46K): [in a new window]   Figure 22a.  Bilateral spondylolysis. (a) Posterior whole-body scintigram shows minimally increased activity in the lower lumbar spine. (b) Coronal (top) and transverse (bottom) SPECT images clearly show bilateral foci of intense activity in the posterior elements of L4 (arrows). (c) CT scan helps confirm the presence of bilateral spondylolysis (arrows).

View larger version (63K): [in a new window]   Figure 22b.  Bilateral spondylolysis. (a) Posterior whole-body scintigram shows minimally increased activity in the lower lumbar spine. (b) Coronal (top) and transverse (bottom) SPECT images clearly show bilateral foci of intense activity in the posterior elements of L4 (arrows). (c) CT scan helps confirm the presence of bilateral spondylolysis (arrows).

View larger version (122K): [in a new window]   Figure 22c.  Bilateral spondylolysis. (a) Posterior whole-body scintigram shows minimally increased activity in the lower lumbar spine. (b) Coronal (top) and transverse (bottom) SPECT images clearly show bilateral foci of intense activity in the posterior elements of L4 (arrows). (c) CT scan helps confirm the presence of bilateral spondylolysis (arrows).

View larger version (59K): [in a new window]   Figure 23.  Lung carcinoma with superior vena caval obstruction. Dynamic-phase radionuclide images obtained 3 (left), 6 (center), and 9 (right) seconds after injection show dilated major vessels and collateral vessels.

View larger version (34K): [in a new window]   Figure 24.  Myocardial uptake in a patient with long-standing congestive heart failure. Whole-body scintigram shows myocardial uptake and abdominal ascites.

View larger version (103K): [in a new window]   Figure 25.  Hepatic metastasis from colon carcinoma. Scintigram shows areas of increased radiotracer uptake (arrows), findings that represent metastases to the liver.

View larger version (140K): [in a new window]   Figure 26.  Rhabdomyolysis. Scintigram shows intense skeletal muscle uptake in the anterior portion of the left upper thorax.

View larger version (140K): [in a new window]   Figure 27a.  Heterotopic ossification in a patient with a history of fracture of the left hip. (a) Scintigram shows intense radiotracer activity around the left hip. (b) Radiograph helps confirm the presence of heterotopic ossification.

View larger version (140K): [in a new window]   Figure 27b.  Heterotopic ossification in a patient with a history of fracture of the left hip. (a) Scintigram shows intense radiotracer activity around the left hip. (b) Radiograph helps confirm the presence of heterotopic ossification.

View larger version (114K): [in a new window]   Figure 28.  Autoinfarcted spleen in a patient with sickle cell disease. Posterior scintigram shows left suprarenal activity in the spleen (arrow).

View larger version (34K): [in a new window]   Figure 29.  Extraosseous uptake. Anterior whole-body scintigram demonstrates poor bone detail and intense oral and gastric activity. These findings are caused by the introduction of air into the vial or syringe containing the radiotracer, which results in oxidation of the compound and the liberation of free pertechnetate.

View larger version (42K): [in a new window]   Figure 30.  Extraosseous uptake. Anterior whole-body scintigram demonstrates colonic activity due to previous myocardial perfusion imaging with Tc-99m sestamibi.

View larger version (128K): [in a new window]   Figure 31a.  Artifact from an implanted defibrillator. (a) Planar scintigram shows an apparent photopenic defect in the lower lumbar spine (arrow). (b) Coronal SPECT image does not demonstrate any bone abnormality. (c) Scout CT scan reveals that the cause of the defect is an implanted defibrillator. (d) Transaxial CT scan shows the defibrillator in the left anterior abdominal wall (arrow).

View larger version (105K): [in a new window]   Figure 31b.  Artifact from an implanted defibrillator. (a) Planar scintigram shows an apparent photopenic defect in the lower lumbar spine (arrow). (b) Coronal SPECT image does not demonstrate any bone abnormality. (c) Scout CT scan reveals that the cause of the defect is an implanted defibrillator. (d) Transaxial CT scan shows the defibrillator in the left anterior abdominal wall (arrow).

View larger version (127K): [in a new window]   Figure 31c.  Artifact from an implanted defibrillator. (a) Planar scintigram shows an apparent photopenic defect in the lower lumbar spine (arrow). (b) Coronal SPECT image does not demonstrate any bone abnormality. (c) Scout CT scan reveals that the cause of the defect is an implanted defibrillator. (d) Transaxial CT scan shows the defibrillator in the left anterior abdominal wall (arrow).

View larger version (113K): [in a new window]   Figure 31d.  Artifact from an implanted defibrillator. (a) Planar scintigram shows an apparent photopenic defect in the lower lumbar spine (arrow). (b) Coronal SPECT image does not demonstrate any bone abnormality. (c) Scout CT scan reveals that the cause of the defect is an implanted defibrillator. (d) Transaxial CT scan shows the defibrillator in the left anterior abdominal wall (arrow).