Musculoskeletal imaging: current and future trends
- 2.1k Downloads
Advances in imaging technology and the increasing role of interventional procedures in musculoskeletal imaging have continued to stimulate research over recent years. This review summarises some recent articles on musculoskeletal radiology topics and looks forward to potential future developments in this exciting sub-speciality.
KeywordsMusculoskeletal imaging Trends MRI Vertebroplasty Cost-effectiveness
Table illustrating the most commonly encountered musculoskeletal topics published in European Radiology from January 2008 to July 2010
Topics published in European Radiology
Number of articles published (%)
Tumours and tumour-like lesions
Cartilage imaging and imaging of the knee
Myeloma, bone marrow and skeletal metastases
Vertebroplasty and other spinal interventional procedures
Imaging of the shoulder
Imaging of tumours and tumour-like lesions
In the article by Alyas and Saifuddin , the authors have focused on a well recognised MRI appearance (fluid-fluid levels) and used this sign in an attempt to further characterise whether a benign or malignant process is being encountered. They retrospectively evaluated 214 patients with fluid-fluid levels and assessed the diagnostic relevance of relative signal intensity of the superior and inferior layer of fluid-fluid levels. They found that low/high signal on T1WI was significantly associated with benign disease whilst, high/low signal intensity on T1WI was more commonly associated with malignant lesions. In contrast, the high/low signal intensity pattern on T2WI was identified as a non-specific pattern. These findings may therefore help to differentiate benign versus malignant bone tumours.
Singh and co-workers  performed a multicentre retrospective analysis of patellar lesions in four European bone tumour registries producing the largest published series of primary patellar lesions. The authors identified 59 lesions in the patella of which: 46% were non-neoplastic, 39% were benign and 15% were malignant. The most common benign lesions were giant cell tumours. Lesions in patients younger than 40 years of age included giant cell tumour, chondroblastoma, aneurysmal bone cyst, osteomyelitis, osteoid osteoma and solitary bone cyst. In patients older than 40 years, intra-osseous gout, metastasis and intra-osseous ganglion were common lesions. This study has therefore enhanced our understanding of the nature of patellar lesions.
Radiologically-guided interventional treatment for certain bone tumours has gained in popularity. Percutaneous interventional therapy for instance has established itself as the treatment of choice for osteoid-osteoma. However, radiologically-guided treatment of osteoid-osteoma of the hands and feet has been thought difficult due to the close proximity of neurovascular bundles and skin, and the small size of bones involved. Zouari et al. published their experience of 15 patients with osteoid osteomas of the hands and feet who were treated with CT-guided percutaneous laser photocoagulation . In their retrospective analysis, the procedure was successful in all patients and no complications were observed, demonstrating the efficacy of CT-guided percutaneous laser photocoagulation in the treatment of osteoid-osteomas of the hands and feet.
Ultrasound has become one of the most rapidly expanding imaging techniques in musculoskeletal imaging. However, our knowledge and understanding of the sonographic appearance of certain anatomical structures is still evolving.
Recent anatomical studies have demonstrated that the distal biceps brachii tendon consists of two separate tendons rather than a single tendon as previously thought. Tagliafico and co-workers assessed the sonographic appearance of the distal biceps tendon bifurcation in healthy volunteers and in patients with tear of the distal biceps tendon and correlated the sonographic findings with MRI . In their study, ultrasound demonstrated the two separate tendons of the distal biceps tendon in all volunteers and patients and was able to differentiate between complete tendon rupture, partial tear of the short and long head of the biceps tendon. Interestingly, isolated long head of distal biceps tendon tear clinically mimicked complete tears. In their series, ultrasound changed the management in patients with isolated tears of the long head of distal biceps tendon as these patients were treated conservatively.
Another interesting concept discussed in this journal was “tenomalacia”. Khoury and Cardinal  assessed tendon compressibility in eight patients suffering from unilateral lateral epicondylitis and compared the findings with the asymptomatic contralateral site. They found, amongst other signs of tendinosis, increased compressibility of the common extensor tendon on the painful side compared to the asymptomatic side. The authors therefore concluded that increased compressibility indicative of tendon softening or “tenomalacia” is a new sign of common extensor tendinosis.
3.0-Tesla MRI is increasingly used in the assessment of the knee due to the increased signal-to-noise ratio when compared to lower field strengths. However, few studies have evaluated the diagnostic efficacy of 3.0-T MRI-imaging of the knee compared to 1.5 T. Schoth et al. evaluated 20 knees imaged at 1.5 and 3.0 T . They found that imaging at 3.0 T was faster and resulted in improved subjective visibility of smaller structures such as the transverse ligament and the articular cartilage.
In times of anticipated decreased public sector spending, the cost effectiveness of radiological investigations is likely to become more important than ever. Oei et al. assessed the cost effectiveness of selective short MRI in patients with acute knee injury in the absence of a fracture on radiography . Patients were randomized between radiography only and radiography plus MRI. The authors found that mean total costs were lowest for the selective MRI-group and quality of life proxies (e.g. time off work) were better in the MRI group. These findings emphasize the cost-effectiveness of MRI in acute knee injury in the absence of radiographic fractures. Moreover, the findings may represent a strong argument for the expansion of musculoskeletal radiology services despite anticipated cutbacks in public sector spending.
Imaging of myeloma, bone marrow and skeletal metastases
Vertebroplasty and other spinal interventions
Despite the recent controversy surrounding the efficacy of vertebroplasty in the treatment of osteoporotic fractures, vertebroplasty remains a widely used treatment option in patients who do not respond to conservative therapy [12, 13, 14, 15, 16]. Numerous cohort studies on the efficacy of vertebroplasty have been published amongst them the paper by Masala et al. . They evaluated the effectiveness of vertebroplasty in 624 patients with 1,253 compression fractures who underwent vertebroplasty for a number of indications. The authors reported a significant reduction in pain at 1 week, 3, 6 and 12 months after treatment. However, the role of vertebroplasty in the treatment of osteoporotic fractures has been called into question recently by two well publicised randomized controlled trials published in the New England journal of medicine [12, 13]. Although these randomized controlled trials were heavily criticized in the radiological literature because of various reasons such as patient selection and the set up of the sham procedure in the control group, they remain the only level 1 evidence available to date. Results from other randomized controlled trials with a more stringent patient selection such as VERTOS II are therefore eagerly awaited in order to establish the efficacy of vertebroplasty in the treatment of osteoporotic fractures .
Increasingly, navigation and tracking systems are being evaluated for spinal interventional procedures which allow more accurate needle placement. Spinal phantom-and animal-studies using navigation systems for facet joint injections and intervertebral disc punctures have been promising . However, further clinical studies are required to assess the benefit of these novel techniques in clinical practice.
Imaging of osteoporosis
It is essential to diagnose osteoporotic fractures accurately as pre-existing osteoporotic fractures increase the risk of future fractures significantly leading to increased morbidity and mortality. Multidetector CT (MD-CT) provides thin-section images of the chest and abdomen therefore allowing high-resolution sagittal reconstructions. In daily clinical practice, MD-CT is routinely used in a wide variety of patients for clinical indications which are unrelated to osteoporotic fractures. Müller et al. assessed, amongst other questions, osteoporotic vertebral fractures on sagittal reformations of routine MD-CT-scans of the chest and/or abdomen in 112 postmenopausal women . The authors discovered osteoporotic fractures in 27 patients of which none were mentioned in the radiology report; only six of these osteoporotic fractures were identifiable on routine axial CT images. The authors therefore concluded that sagittal reformations increase the depiction of osteoporotic fractures when compared to axial images and should therefore be obtained in all patients at risk of osteoporosis who undergo routine MDCT.
Imaging of the shoulder
Both ultrasound and MRI are frequently used imaging modalities in the assessment of rotator cuff tears. However the role of ultrasound in comparison to MRI in the diagnosis of rotator cuff tears remains equivocal. Rutten et al. retrospectively evaluated the need for additional MRI/MRA in 5,216 patients who underwent ultrasound of the shoulder for suspected rotator cuff tear . Furthermore, they compared the accuracy of ultrasound and MRI/MRA for the detection of partial-and full-thickness tears with surgical findings. They found that MRI or MRA of the shoulder in addition to ultrasound was performed in only 5.2%. Both ultrasound and MRI depicted partial and full-thickness tear with a high accuracy. MRI was of additional value in the detection of intra-articular lesions. The authors therefore concluded that after ultrasound of the shoulder by an experienced radiologist, MRI offers little additional value in the detection of rotator cuff tears.
This review demonstrates that research in musculoskeletal imaging is alive and well. Recent years have shown increased research activity in musculoskeletal oncology, expansion of musculoskeletal ultrasound and exciting advances in novel imaging techniques. 3 T imaging is now firmly established in clinical practise and the availability and use of this higher field strength is only likely to increase. The future is also likely to see an increasing role of PET/CT and other forms of molecular imaging and the introduction of whole-body MRI into daily clinical practice. We also look forward to ongoing research about the role of novel imaging techniques and the clarification of the role vertebroplasty in the treatment of osteoporotic fractures.
- 7.De Marchi A, Brach Del Prever EM, Linari A, Pozza S, Verga L, Albertini U, Forni M, Gino GC, Comandone A, Brach Del Prever AM, Piana R, Faletti C, Piedmont Sarcoma Group (2010) Accuracy of core-needle biopsy after contrast-enhanced ultrasound in soft-tissue tumours. Eur Radiol 20:2740–2748, Epub 2010 Jun 27CrossRefPubMedGoogle Scholar
- 13.Kallmes DF, Comstock BA, Heagerty PJ, Turner JA, Wilson DJ, Diamond TH, Edwards R, Gray LA, Stout L, Owen S, Hollingworth W, Ghdoke B, Annesley-Williams DJ, Ralston SH, Jarvik JG (2009) A randomized trial of vertebroplasty for osteoporotic spinal fractures. N Engl J Med 361:569–579CrossRefPubMedGoogle Scholar
- 18.Klazen CA, Verhaar HJ, Lampmann LE, Juttmann JR, Blonk MC, Jansen FH, Tielbeek AV, Schoemaker MC, Buskens E, van der Graaf Y, Janssens X, Fransen H, van Everdingen KJ, Muller AF, Mali WP, Lohle PN (2007) VERTOS II: percutaneous vertebroplasty versus conservative therapy in patients with painful osteoporotic vertebral compression fractures; rationale, objectives and design of a multicenter randomized controlled trial. Trials 8:33CrossRefPubMedGoogle Scholar