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Imaging of Osteomyelitis: the Key Is in the Combination

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Imaging of Osteomyelitis: the Key Is in the Combination Special RepoRt Special RepoRt Imaging of osteomyelitis: the key is in the combination An accurate diagnosis of osteomyelitis requires the combination of anatomical and functional imaging techniques. Conventional radiography is the first imaging modality to begin with, as it provides an overview of both the anatomy and the pathologic conditions of the bone. Sonography is most useful in the diagnosis of fluid collections, periosteal involvement and soft tissue abnormalities, and may provide guidance for diagnostic or therapeutic interventions. MRI highlights sites with tissue edema and increased regional perfusion, and provides accurate information of the extent of the infectious process and the tissues involved. To detect osteomyelitis before anatomical changes are present, functional imaging could have some advantages over anatomical imaging. Fluorine-18 fluorodeoxyglucose-PET has the highest diagnostic accuracy for confirming or excluding the diagnosis of chronic osteomyelitis. For both SPECT and PET, specificity improves considerably when the scintigraphic images are fused with computed tomography. Close cooperation between clinicians and imagers remains the key to early and adequate diagnosis when osteomyelitis is suspected or evaluated. †1 KEYWORDS: computed tomography n hybrid systems n imaging n MRI n nuclear Carlos Pineda , medicine n osteomyelitis n ultrasonography Angelica Pena2, Rolando Espinosa2 & Cristina Osteomyelitis is inflammation of the bone that osteomyelitis. The ideal imaging technique Hernández-Díaz1 is usually due to infection. There are different should have a high sensitivity and specificity; 1Musculoskeletal Ultrasound Department, Instituto Nacional de classification systems to categorize osteomyeli- numerous studies have been published con- Rehabilitacion, Avenida tis. Traditionally, it has been labeled as acute, cerning the accuracy of the various modali- Mexico‑Xochimilco No. 289, Arenal de Guadalupe, Tlalpan, Mexico City [2–4] subacute or chronic, depending on its clinical ties in diagnosing chronic osteomyelitis . 14389, Mexico course, histologic findings and disease dura- Confirmation of the presence of osteomyeli- 2Rheumatology Department, Instituto tion, but there is no consensual agreement on tis usually entails a combination of imaging Nacional de Rehabilitacion, Mexico City, Mexico the temporal scale used or specific findings. techniques. Table 1 shows the main pathologic †Author for correspondence: As a result, some researchers have proposed findings of osteomyelitis assessed by diverse Tel.: +52 559 991 000 ext. 13229 more detailed classification systems, such as imaging techniques. [email protected] the Waldvogel classification system based on etiology of the infection (hematogenous spread Conventional radiography of an organism, direct inoculation of an organ- Plain films are usually the first imaging test ism through trauma or contiguous spread from ordered by clinicians [5]. Conventional radio- a soft tissue infection), and Cierny-Mader clas- graphy should not be used to exclude acute sification, a descriptive system that takes into osteomyelitis in a patient who has experienced account both anatomic factors and the host’s symptoms for less than 10 days. Nevertheless, physiologic status [1,2]. deep soft tissue swelling, joint effusion or early An inadequate or late diagnosis increases periosteal changes may be seen within days the degree of complications and morbidity; for after onset of infection. Furthermore, conven- these reasons, imaging techniques are essential tional radiography helps to exclude fracture to confirm the presumed clinical diagnosis and or tumor. to provide information regarding the exact site Destructive bone changes do not occur until and extent of the infection process [1]. 7–10 days after the onset of infection. During the Although a variety of diagnostic imaging first 2–3 days of symptoms, radionuclide bone techniques is available for excluding or con- imaging may be particularly useful in showing firming osteomyelitis, it is often difficult to a well-defined focus of increased uptake on the choose the most appropriate technique to dynamic perfusion, as well as early blood pool conclusively establish the diagnosis of osteo- and delayed images corresponding to the area myelitis. Several imaging modalities have of hyperemia [6]. At this early stage, the main been used in the evaluation of suspected utility of plain film is to provide a global view 10.2217/IJR.10.100 © 2011 Future Medicine Ltd Int. J. Clin. Rheumatol. (2011) 6(1), 25–33 ISSN 1758-4272 25 Special RepoRt Pineda, Pena, Espinosa & Hernández-Díaz Imaging of osteomyelitis: the key is in the combination Special RepoRt Table 1. Imaging abnormalities in osteomyelitis. Technique Main findings Acute Chronic Conventional Radiolucent areas associated with periostitis Single or multiple radiolucent radiography Cortical resorption identified as endosteal scalloping, abscesses (Brodie’s abscess) intracortical lucent regions or tunneling Cortical sequestration Lytic lesions New bone apposition Focal osteopenia Loss of trabecular architecture Computed Blurring of fat planes Periosteal thickening tomography Increased density of fatty bone marrow sequestra, Cortical erosion or involucra and intraosseous gas destruction Ultrasonography Soft tissue abscess (if present) Elevated periosteum Surrounding fluid collection Fistulous tracts Cortical discontinuity MRI T1-weighted: low signal intensity medullary space T1- and T2-weighted: low T2-weighted: high signal intensity contiguous to signal intensity areas of inflammatory processes and edema devascularized fibrotic Gadolinium: enhances areas of necrosis scarring in the bone marrow Subacute: Evidence of Brodie’s abscess, single or multiple radiolucent abscesses T1-weighted: central abscess cavity with low signal intensity T2-weighted: high signal intensity of granulation tissue surrounded by low signal intensity band of bone sclerosis (double-line effect) of the suspect part of the skeleton and to provide does not exhibit the osteopenia of the adjacent information regarding differential diagnosis in a living bone. A wide scope of bone lesions may patient complaining of pain. present with an image suggestive of sequestrum Structural bony changes and periosteal reac- including osteoid osteoma, e osinophilic granu- tion consist first of subperiosteal resorption or loma and primary lymphoma [7]. scalloping, which creates radiolucencies within A lucent circumscribed lesion (Brodie’s cortical bone that may progress to irregular abscess) in the metaphyses of long bones pre- destruction with areas of periosteal new bone dominantly abutting the growth plate with formation. However, hematogenous osteo- well-defined dense margins is commonly seen myelitis in children typically arises within can- in the tibia and femur of children with subacute cellous bone, mostly in the vicinity of physeal osteomyelitis. plates, and s econdarily involves cortical bone Periostitis, involucrum formation and sinus and periosteum. tracts are due to a subperiosteal abscess with In general, osteopenia becomes evident lifting of the periosteum, new bone formation on conventional radiographs after the loss of and soft tissue fistulas. All of these findings approximately 30–50% of bone mineraliza- are indicative of the protracted nature of the tion. Follow-up radiographs may be normal i nfection process. if therapy is successful, or in some instances periosteal new bone formation may be apparent. nSpecial situations The search for sequestra is a common and Diabetic foot important diagnostic challenge in chronic In a recent meta-ana lysis of the accuracy of osteomyelitis. The presence of a sequestrum diagnostic tests for osteomyelitis in diabetic may lead to a decision of surgery. A bone seques- patients with foot ulcers, the sensitivity of trum manifests on conventional radiographs as plain radiography for diagnosis of osteomyeli- a piece of calcified tissue within a lucent lesion. tis was highly variable, ranging from 0.28 to The increased density of the sequestrum rela- 0.75. The wide variation may be attributable tive to the surrounding bone is a consequence to the timing of performance of the radiograph of its absence of blood supply. As a result of this in relation to the chronicity of the ulcer. The devascularization, the sequestrum does not par- pooled sensitivity was 0.54 and the pooled ticipate in the reactive hyperemia and therefore specificity was 0.68. The diagnostic odds ratio 26 Int. J. Clin. Rheumatol. (2011) 6(1) future science group Special RepoRt Pineda, Pena, Espinosa & Hernández-Díaz Imaging of osteomyelitis: the key is in the combination Special RepoRt (OR) for radiography was 2.84 (the value of defines the course and extent of the sinus tract a diagnostic OR ranges from 0 to infinity; and its possible communications with neighbor- higher values indicate better discriminatory ing structures. Sinography or fistulography may test p erformance) [5]. be combined with CT for better delineation of In summary, plain radiography is helpful as the anatomical relationships of the contrast- a first step, as it is widely available and may filled track[8] . Sinography is not widely used in reveal soft tissue changes and alternative diag- clinical practice. noses (e.g., bone metastases or a fracture) can be made; however, it is not a sensitive test for Ultrasonography acute osteomyelitis. Radiographs, when posi- During recent years, ultrasonography has had an tive, are helpful, but negative
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