Scintigraphy Presented by M.A. Kaeser, D.C Spring 2009

Definition A nuclear medicine procedure, such as a bone scan. The term is derived from the decay of the radionuclide and its resultant gamma radiation or scintillations. The number of scintillations corresponds to the concentration of the isotope. A nuclear medicine procedure, such as a bone scan. The term is derived from the decay of the radionuclide and its resultant gamma radiation or scintillations. The number of scintillations corresponds to the concentration of the isotope.

Nuclear Medicine Images are generated as the uptake and distribution of administered radiopharmaceuticals are detected Images are generated as the uptake and distribution of administered radiopharmaceuticals are detected Provides vital information regarding tissue perfusion, physiology, and biochemistry Provides vital information regarding tissue perfusion, physiology, and biochemistry Physiologic and metabolic changes often precede gross structural alteration of diseased tissue by hours, days or even weeks Physiologic and metabolic changes often precede gross structural alteration of diseased tissue by hours, days or even weeks Key factor in determining early diagnosis and proper treatment protocols and in establishing an accurate prognosis Key factor in determining early diagnosis and proper treatment protocols and in establishing an accurate prognosis

Radionuclide Bone Scanning Most frequently performed nuclear medicine technique (50%) Most frequently performed nuclear medicine technique (50%) Used to evaluate soft tissue, bone and joint disorders Used to evaluate soft tissue, bone and joint disorders Fractures, infections, arthritides, tumors and osteonecrosisFractures, infections, arthritides, tumors and osteonecrosis

History Skeletal scintigraphy radiopharmaceuticals were first introduced in the early 1960s Skeletal scintigraphy radiopharmaceuticals were first introduced in the early 1960s 1971 Technitium 99-MDP polyphosphate compounds were introduced 1971 Technitium 99-MDP polyphosphate compounds were introduced Today we use diphosphonates which have faster blood clearance and higher skeletal uptake Today we use diphosphonates which have faster blood clearance and higher skeletal uptake

Examination Procedure Three phases which represent the distribution of the tracer over the course of time Three phases which represent the distribution of the tracer over the course of time Phase 1 – Flow phase or radionuclide angiogram - tracer is intravascular – images are obtained every 2-3 seconds for 30 secondsPhase 1 – Flow phase or radionuclide angiogram - tracer is intravascular – images are obtained every 2-3 seconds for 30 seconds Phase 2 – Blood pool phase – the tracer is located in the extravascular space – the body is imaged 5 minutes after injectionPhase 2 – Blood pool phase – the tracer is located in the extravascular space – the body is imaged 5 minutes after injection Phase 3 – Bone scan phase – 2-4 hours after injection – represents clearance of the tracer from the vessels and soft tissues and concentration into the skeletonPhase 3 – Bone scan phase – 2-4 hours after injection – represents clearance of the tracer from the vessels and soft tissues and concentration into the skeleton

Blood Flow Phase Show radionuclide in the arterial, capillary, and venous phases Show radionuclide in the arterial, capillary, and venous phases Variations may occur in the blood flow to the extremities depending on the vascular status and activity Variations may occur in the blood flow to the extremities depending on the vascular status and activity

Blood Pool Phase Shows radionuclide in the extravascular space Shows radionuclide in the extravascular space Vascular structures such as kidneys, liver, spleen and uterus are seen and should not be mistaken for sites of abnormality Vascular structures such as kidneys, liver, spleen and uterus are seen and should not be mistaken for sites of abnormality

Bone Scan Phase Show radionuclide in the skeleton and soft tissue Show radionuclide in the skeleton and soft tissue Metaphyseal regions of long bones show higher uptake than diaphyses – due to higher bone turnover rate in the metaphyses Metaphyseal regions of long bones show higher uptake than diaphyses – due to higher bone turnover rate in the metaphyses Areas of highest uptake are the sternum and SI joints Areas of highest uptake are the sternum and SI joints The anterior wings of the iliac bones and the coracoid processes normally show considerable uptake of the radionuclide The anterior wings of the iliac bones and the coracoid processes normally show considerable uptake of the radionuclide Scoliosis – the concave side of the spine appears hotter than the convex Scoliosis – the concave side of the spine appears hotter than the convex

Patient Presentation Children have high diffuse bone uptake and prominent uptake around the growth plates Children have high diffuse bone uptake and prominent uptake around the growth plates Elderly patients tend to have poor-quality bone scans Elderly patients tend to have poor-quality bone scans Heavy patients have poor quality bone scans owing to the greater amount of soft tissue, which causes more scatter and higher attenuation of the photons in the soft tissues because of the greater distance of the detectors from the skeleton Heavy patients have poor quality bone scans owing to the greater amount of soft tissue, which causes more scatter and higher attenuation of the photons in the soft tissues because of the greater distance of the detectors from the skeleton Poor hydration prevents optimal clearance of the radionuclide from the soft tissues Poor hydration prevents optimal clearance of the radionuclide from the soft tissues Renal failure prevents good soft tissue clearance Renal failure prevents good soft tissue clearance Corticosteroids may produce generalized decreased skeletal uptake Corticosteroids may produce generalized decreased skeletal uptake

Absorbed Patient Dose Exact dose is difficult to determine Exact dose is difficult to determine Influenced by: Influenced by: Tracer biodistributionTracer biodistribution Organ pathologyOrgan pathology Renal functionRenal function

Dose Approximately 50% of the injected dose is taken up by the skeleton within 2-6 hours Approximately 50% of the injected dose is taken up by the skeleton within 2-6 hours Normal renal excretion results in 50-60% of the tracer eliminated within 24 hours of injection Normal renal excretion results in 50-60% of the tracer eliminated within 24 hours of injection Bladder receives the highest dose Bladder receives the highest dose May be reduced by pre-examination hydration and frequent voiding after exam May be reduced by pre-examination hydration and frequent voiding after exam Whole-body dose is approximately 0.13 rad (average dose for CT scan of the L/S is 3-5 rad. Whole-body dose is approximately 0.13 rad (average dose for CT scan of the L/S is 3-5 rad.

Contraindications Pregnancy because transplacental transmission of radiopharmaceuticals is possible Pregnancy because transplacental transmission of radiopharmaceuticals is possible Breast milk will carry isotope activity for several days after the study Breast milk will carry isotope activity for several days after the study

Image generation Radiopharmaceutical emits gamma rays that are detected by an instrument and transformed into electrical signals that ultimately generate a computer image of the tracer agent activity and concentration Radiopharmaceutical emits gamma rays that are detected by an instrument and transformed into electrical signals that ultimately generate a computer image of the tracer agent activity and concentration

Radiopharmaceutical Agents Dozens are employed Dozens are employed Most widely used – Technitium 99 – MDP Most widely used – Technitium 99 – MDP 6 hour half-life6 hour half-life Principal photon energy of 140 keVPrincipal photon energy of 140 keV

Several Bone Scan Uses Insufficiency fractures in metabolic disease Insufficiency fractures in metabolic disease Trauma Trauma Metastatic Disease Metastatic Disease Disuse osteoporosis Disuse osteoporosis Osteomalacia Osteomalacia Osteonecrosis Osteonecrosis Osteomyelitis Osteomyelitis

Insufficiency fractures in metabolic disease Pubic rami Pubic rami Femoral necks Femoral necks Femoral condyles Femoral condyles Metaphyses of the proximal and distal portions of the tibias, sacrum and calcaneus Metaphyses of the proximal and distal portions of the tibias, sacrum and calcaneus Tend to be bilaterally symmetric and occur in the metaphyses of long bones of the lower extremities Tend to be bilaterally symmetric and occur in the metaphyses of long bones of the lower extremities

Trauma Increased blood flow associated with bone repair results in marked radiopharmaceutical accumulation Increased blood flow associated with bone repair results in marked radiopharmaceutical accumulation Occult fractures demonstrate an increased perfusion Occult fractures demonstrate an increased perfusion Important for follow up to assess for fracture non-union Important for follow up to assess for fracture non-union Compression fractures of the spine reveal a horizontal band of increased tracer activity, typically affecting the superior endplate Compression fractures of the spine reveal a horizontal band of increased tracer activity, typically affecting the superior endplate

Metastatic Disease Random pattern of areas of increased uptake Random pattern of areas of increased uptake Predominantly in the axial and proximal appendicular skeleton Predominantly in the axial and proximal appendicular skeleton

Disuse Osteoporosis Increased bone turnover and increased uptake on a bone scan Increased bone turnover and increased uptake on a bone scan

Osteomalacia Hot spots in adjacent ribs on both sides with no history of trauma Hot spots in adjacent ribs on both sides with no history of trauma Hot spots in the inferior tips of the scapulae Hot spots in the inferior tips of the scapulae

Osteonecrosis Early osteonecrosis shows decreased or absent uptake Early osteonecrosis shows decreased or absent uptake When bone becomes revascularized and begins to remodel, increased radiotracer uptake is identified When bone becomes revascularized and begins to remodel, increased radiotracer uptake is identified Necrotic process defined by collapse, deformity and flattening of the joint is characterized by a rim of increaed radiopharmaceutical uptake surrounding a photopenic zone (double line sign) Necrotic process defined by collapse, deformity and flattening of the joint is characterized by a rim of increaed radiopharmaceutical uptake surrounding a photopenic zone (double line sign)

Scintigraphy Cases