Musculoskeletal Imaging

Musculoskeletal Imaging (21)

The advent of the multidetector CT (MDCT) scanner has increased the applicability of this imaging technique for the assessment of the musculoskeletal system. This technology allows for the acquisition of large data set in the axial plane that can be reconstructed in multiple planes of imaging with the use of multiplanar reconstruction (MPR) algorithm. 


MRI can serve as an adjunct diagnostic tool for CTS when the clinical or neurophysiologic findings are equivocal. The carpal tunnel is a fibro-osseous space with little fat that contains the flexor tendons and the median nerve. The flexor retinaculum composes the volar aspect of the tunnel and normally shows slight palmar bowing. The median nerve courses through the tunnel within its volar and radial aspect, and it can be differentiated from the adjacent tendons because it shows relative higher signal intensity. The carpal tunnel and its contents are best evaluated in the axial plane and should be scrutinized at three standard locations.

  1. Distal radioulnar joint before the median nerves enter the tunnel.
  2. Proximal tunnel, at the level of the pisiform.
  3. Distal tunnel, at the level of the hook of the hamate.

FIGURE 6-13. Normal wrist anatomy as seen on T1-weighted MR images. Axial MR images are at the levels A: of the distal radioulnar joint, B: the proximal and C: the distal carpal tunnel. D: Longitudinal MRI through the median nerve within the carpal tunnel. C, capitate; FDP, flexor digitorum profundus; FDS, flexor digitorum superficialis; FR, flexor retinaculum; H, hamate; L, lunate; MN, median nerve; PDN, palmar digital branches of the median nerve; R, radius; T, trapezium; U, ulna; UA, ulnar artery; UN, ulnar nerve. Note fracture through the base of the hook of the hamate (arrow in B).

There are four universal findings of CTS visible by MRI regardless of etiology (21):

  1. Swelling of the median nerve (i.e., pseudoganglion) in the proximal part of the carpal tunnel at the level of the pisiform. Best evaluated by comparing the size of the median nerve at the level of the distal radioulnar joint with its size at the proximal tunnel.
  2. Increased signal intensity of the edematous median nerve on T2-weighted images.
  3. Palmar bowing of the flexor retinaculum, determined by a bowing ratio of more than 15%. The bowing ratio is calculated by drawing a line from the trapezium to the hook of the hamate on the axial plane. The distance from this line to the flexor retinaculum is divided by the previously calculated length.
  4. Flattening of the median nerve in the distal carpal tunnel at the level of the hamate (Fig. 6-14A–D). MRI also has the potential to establish the cause of CTS. Some of the etiologies visualized by MRI include traumatic tenosynovitis, rheumatoid tenosynovitis, a ganglion cyst of a carpal joint, excessive fat within the carpal tunnel, a hypertrophied adductor pollicis muscle in the floor of the carpal tunnel, and a persistent median artery (23).

FIGURE 6-14. Axial FSE T2-weighted fat suppressed images (A, B, C) and sagittal T1-weighted image in a patient with carpal tunnel syndrome. A, B: There is a normal size to the nerve within the tunnel (arrowheads). C: There is thickening, increased girth and increased signal intensity proximal to the flexor retinaculum (arrowheads). D: Note tapering to the nerve as it approaches the carpal tunnel in the sagittal view (arrowheads).

MRI also provides a means of postoperative evaluation of those patients in whom the symptoms persist, to ensure that the flexor retinaculum has been completely incised and that there are no other complicating postoperative factors producing continuing discomfort. When the flexor retinaculum has been completely incised, the incision site is well documented by MRI and the contents of the carpal tunnel are typically displaced forward (Fig. 6-15A). If the distal part of the flexor retinaculum has been incompletely incised, this can be demonstrated by MRI, and the preoperative MRI findings of CTS will persist (Fig. 6-15B and C).

FIGURE 6-15. Postoperative MR of carpal tunnel syndrome. A: Axial T1-weighted image. There has been release to the flexor retinaculum (short arrow). The median nerve insinuates through the surgical defect. B: Axial T2-weighted fat suppressed image. The median nerve (arrow) has intermediate signal and is better delineated. C: Patient with failed carpal tunnel release. There is a linear area of decreased signal intensity (short arrow) which was found to represent a fibrous band at surgery. The median nerve (long arrow) is flattened underneath the fibrous band. (A and B; courtesy of Zehava Rosenberg, NY. C; courtesy of Mark Kransdorf, FL.) OTHER WRIST ABNORMALITIES

MRI can visualize postincisional neuromas as lobulated masses in the typical location of the palmar cutaneous branches of the median nerve. Other peripheral nerve tumors such as schwanomas (Fig. 6-16) and neurofibromas can be well recognized as well. It can also demonstrate tenosynovitis involving any of the tendons crossing the wrist. MRI also displays marrow abnormalities such as ischemic necrosis of the proximal fragment of a scaphoid fracture and avascular necrosis of the lunate, where the marrow shows reduced signal intensity (24). MRI has the ability to evaluate the integrity of the intrinsic/extrinsic ligaments of the wrist and the triangular fibrocartilage complex (TFCC) (25). The TFCC, scapholunate, and lunotriquetral ligaments are best evaluated with MR arthrography (Fig. 6-17).

FIGURE 6-16. Coronal T2-weighted sequence in a 72-year-old patient with a palpable hypothenar mass. There is a rounded soft tissue mass (arrow) within the ulnar nerve proximal to the retinaculum representing a shwannoma of the ulnar nerve. Courtesy of Dr. Mark Kransdorf, Jacksonville Fla.

FIGURE 6-17. A coronal T1-weighted image of the wrist shows intermediate signal intensity and increased distance to the scapholunate interval (arrow), representing a scapholunate ligament tear.


Source: Physical Medicine and Rehabilitation - Principles and Practice

Plain film radiographic examination of the elbows should be the initialevaluation forpatients withchronicelbowpain. Radiographs can be useful for the assessment of calcium within the joint compartment or periarticular soft tissues. Standard frontal and lateral radiographs are used for the routine evaluation of the elbow joint. Radiographic examination of the elbow has a minimal RRL.

MRI has not been applied to the evaluation of elbow pathology as extensively as it has been to other large joints (17). However, improving imaging techniques and the use of surface coils permit superb visualization of the bony, ligamentous, muscular and neurovascular structures around the elbow. Common elbow injuries evaluated with MRI are usually related to sports (weightlifting, throwing, and racquet sports) or compartmental nerve entrapment.

FIGURE 6-9. Normal elbow as seen on T1-weighted MR images. A: The axial MRI displays the ulna (U), radius (R), annular ligament (AL), radial collateral ligament (RCL), brachial artery (BA), biceps tendon (BT), forearm flexor muscles (FM), forearm extensor muscles (EM), ulnar nerve (UN), and radial nerve (RN). B: The coronal MRI displays the humeroulnar joint (HUJ), humeroradial joint (HRJ), radial collateral ligament (RCL), ulnar collateral ligament (UCL), forearm flexor muscles (FM), and forearm extensor muscles (EM). C: The sagittal MRI through the humeroulnar joint demonstrates the biceps tendon (BT), brachialis (Br), and triceps (T).

Axial MRI views of the elbow region permit good visualization of the biceps, brachialis, triceps, and all the extensor and flexor muscles of the forearm (Fig. 6-9A). High–signalintensity fat planes and low–signal-intensity intermuscular septa permit clear delineation of each muscle and their tendons of insertion or origin. Axial images clearly depict brachial, ulnar, and radial arteries and all the subcutaneous and deep veins. They also allow identification of the ulnar nerve within the cubital tunnel and the radial nerve in the brachioradialisbrachialis interval and under the supinator muscle’s arcade of Frohse, where it is commonly entrapped. The median nerve is visualized at all its common elbow entrapment sites, including under the bicipital aponeurosis, between the heads of the pronator teres, and under the fibrous arch of the flexor digitorum superficialis.

The humeroulnar, humeroradial, and proximal radioulnar joint spaces and articular cartilages are well visualized on both coronal and sagittal MR images (Fig. 6-9B and C). The low–signal-intensity ulnar collateral, radial collateral, and annular ligaments are depicted on both axial and coronal MR images. Sagittal images delineate the anterior and posterior subsynovial fat pads.

MRI has the capability of directly visualizing degenerative or traumatic abnormalities of the annular and the radial and ulnar collateral ligamentous complexes. A sprain appears in MRI as thickened or thinned ligament with surrounding highT2 signal intensity. The collateral ligaments may show degeneration in association with adjacent epiocondylosis. The affected ligament commonly shows thickening and intermediate signal intensity. Full thickness of avulsion ligamentous tears appears as discontinuities of the low–signal-intensity ligament. The T2-weighted images disclose hyperintense edema and hemorrhage between the torn ends of the ligament extending into the joint interval and adjacent soft tissues. A partial thickness tear appears as high T2 fluid signal intensity within an uninterrupted ligament (Fig. 6-10).

FIGURE 6-10. Coronal MR T1WI with intra-articular contrast in a 22-year-old baseball player with medial elbow pain. There is a partial tear (arrowhead) at the insertion of the ulnar collateral ligament into the coronoid process of the ulna. Note the minimal amount of contrast extending between the bone cortex and the distal ligament attachment.

MRI also provides good visualization of the sites of muscle injury and denervation about the elbow (18) (Fig. 6-11A,B). Acute muscle denervation is demonstrated by increased T2-weighted signal intensity within the specific muscle group supplied by the injured or the affected nerve. Increased intramuscular T2-weighted signal intensity is due to muscle edema. Chronic muscle denervation is demonstrated by increased intramuscular T1-weighted signal intensity, related to muscle atrophy and fatty infiltration. Acute muscle injuries presents with intramuscular edema and hemorrhage. Increased thickening, increased signal intensity, and discontinuity of tendon fibers are the findings commonly observed in tendon tears (Fig. 6-12A,B).

FIGURE 6-11. Impingement to the anterior interosseous branch of the median nerve, Kiloh Nevin Syndrome. Axial STIR (short tau inversion recovery sequence) at the level of the distal forearm. On this fat suppressed sequence there is increased signal intensity to the fibers of the flexor pollicis longus muscle as can be appreciated with acute (stage I) or subacute (stage II) impingement. (Courtesy of Zehava Rosenberg, NY.)

FIGURE 6-12. Sagittal A and axial B FSE T2-weighted fat suppressed images of the distal arm in a patient with a complete biceps tear. A: The tendon free margin is retracted (long arrow in A). B: There is significant edema (arrow- heads) surrounding the retracted tendon (long arrow). B, biceps muscle; Br, brachialis muscle.

MRI has the ability to demonstrate tendinosis involving the common extensor and flexor tendon origins from the lateral and medial aspects of the humerus with findings similar to those described in tendinosis about the shoulder. It also can display abnormalities of the radial and ulnar collateral ligament complexes.


Source: Physical Medicine and Rehabilitation - Principles and Practice

Tendinitis and rupture also can involve the subscapularis, infraspinatus, and teres minor, or biceps tendons, although far less commonly than the supraspinatus. Early tendinitis involves an increased signal intensity area within the tendon. This can progress to frank rupture of the tendon with a high–signalintensity area at the site of the tear on T2-weighted images and may be associated with joint effusion. A complete tear will eventually cause muscle retraction and later atrophy.

Calcific tendinosis (Fig. 6-8) of the supraspinatus is a common clinical entity most commonly affecting middle age persons. It is slightly more common in females and can affect multiple tendons in the body. It is however far more frequently in the supraspinatus. Although the exact etiology is unknown, it is felt to be secondary to chronic ischemia of the tendon fibers.


FIGURE 6-8. Calcific tendinosis of the infraspinatus tendon. A: Axial T1WI and B: coronal oblique T2WI with fat suppression demonstrating a focal area of decreased signal within the fibers of the distal infraspinatus (arrow). Note high–signal-intensity fluid within the posterior joint (*). C: Sagittal oblique T1WI shows the calcification within the posterior fibers of the infraspinatus.

Increased high-intensity fluid about the biceps tendon on T2-weighted MR images can be produced by either a biceps tenosynovitis or a shoulder joint effusion because the tendon sheath normally communicates with the shoulder. Rupture of the biceps tendon is demonstrated by absence of the biceps tendon within the intertubercular sulcus and by distal retraction of the muscle, which is seen on imaging the arm (16). Dislocation of the biceps tendon is identified by medial displacement of the biceps tendon out of the intertubercular sulcus.


Source: Physical Medicine and Rehabilitation - Principles and Practice

For the assessment of shoulder instability and labral tears, it is imperative that intra-articular contrast medium be injected in order to be able to evaluate the entire articular labrum, glenoid fossa, and capsular mechanism (12). Axial MR images provide the best visualization of the anterior and posterior glenoid labra, capsule, and lower rotator cuff muscles (Fig. 6-1). Anteriorly, the moderate–signal-intensity subscapularis muscle belly and its low–signal-intensity tendon are visualized. The tendon fuses with the low–signal-intensity anterior capsule as it courses to its insertion on the lesser tubercle. The fibrocartilaginous anterior and posterior labra appear as low–signal-intensity triangular or rounded areas attached to the glenoid rim. The higher–signalintensity intra-articular contrast opposed the hyaline cartilage surfaces of the glenoid and humeral head. The posterior capsule is visualized as a low-intensity area blending with the deep surface of infraspinatus and teres minor muscles as they extend to their insertions on the greater tubercle of the humerus. The long tendon of the biceps is demonstrated as a round, low– signal-intensity area within the bicipital groove.

Shoulder instability and the associated disruption of the anterior capsular mechanism can cause chronic shoulder pain and disability. The instability may be caused by an acute traumatic

episode or can occur with no history of a traumatic event. Both recurrent traumatic subluxation and nontraumatic instability are typically associated with disruption of the anterior capsular mechanism. Anteriorly, where most instability occurs, this mechanism includes the subscapularis muscle and tendon, the anterior joint capsule, three underlying glenohumeral ligaments, the synovial lining, and the anterior labrum. With instability, the labrum shows tears, separation from the glenoid rim, or degeneration (13). Also frequently present are medial stripping of the capsule from its normal attachment to the labrum and glenoid rim, an enlarged fluid-filled subscapular bursa secondary to joint effusion, attenuation of the glenohumeral ligaments, and injury or laxity of the subscapularis muscle or tendon.

By MRI, labral tears may be visualized as discrete linear areas of increased signal intensity within the normal signal void of the labrum (Figs. 6-6 and 6-7). These areas show moderate intensity on T1-weighted images and high intensity on T2-weighted images. With recurrent dislocation or subluxation, the labrum can become fragmented or attenuated.

FIGURE 6-6. SLAP lesion and posterior labral tear in a patient with history of posterior instability. A: Coronal oblique T1-weighted fat suppressed MR arthrogram demonstrates increased signal intensity within the BLC extending on the biceps tendon (arrowhead) characteristic of a type IV SLAP lesion. B: Axial T1-weighted MR arthrogram demonstrates increased signal within the posterior labrum (arrowhead ). There is a cyst within the posterior aspect of the spinoglenoid notch with high–signal-intensity contrast extending into the cyst.

FIGURE 6-7. Bankart lesion. A: Axial T1-weighted images of a left shoulder MR arthrogram demonstrate the fibrocartilaginous Bankart lesion of the anterior glenoid labrum (arrow). B: Coronal T1-weighted fat suppression demonstrates the inferior (short arrow) and the superior (long arrow) extensions of the labral tears.

Capsular detachment from the scapula (i.e., stripping) is visualized by T2-weighted MRI as an area of high–signalintensity fluid dissecting medially from the glenoid rim. With trauma to the subscapularis tendon, there can be medial retraction of the muscle-tendon junction when the tendon is completely ruptured. Chronic atrophy of the subscapularis muscle belly is identified by high–signal-intensity fatty replacement. The glenoid marrow underlying a labral detachment may show pathologically decreased signal intensity even before the plain film radiograph shows an osseous Bankart lesion. MRI and CT can be used to visualize Bankart fractures of the anterior glenoid and the Hill-Sachs compression deformity of the posterolateral humeral head (14,15) and are both useful in the assessment of the extent of a Hill-Sachs defect in patients with engaging lesions. Patients with the rarer posterior instability show similar posterior labral, capsular, and muscular defects.


Source: Physical Medicine and Rehabilitation - Principles and Practice

The MRI findings of shoulder impingement syndrome and its associated supraspinatus injury are best seen on oblique coronal MR images that visualize the full length of the supraspinatus muscle belly and tendon (Fig. 6-1B). The normal muscle belly displays moderately low signal intensity. The tendon is visualized as an intermediate–signalintensity structure that blends with the low signal intensity of the superior capsule as it courses to its insertion on the greater tubercle of the humerus. The tendon demonstrates smooth tapering from medial to lateral into its insertion in the greater tuberosity. The inferior aspect of the tendon is delimited below by the moderate signal intensity of the hyaline cartilage on the superior aspect of the humeral head. The superior aspects of both the muscle belly and tendon are delimited by a high–signal-intensity subacromial and subdeltoid fat plane. The normal subacromial-subdeltoid bursa is not specifically visualized because its walls are separated only by monomolecular layers of a synovial-type fluid, but it is situated between the supraspinatus tendon and the fat plane. Above the fat plane, the clavicle, acromioclavicular joint, acromion, and deltoid muscle are demonstrated on different oblique coronal sections.

Although rotator cuff impingement is a clinical diagnosis, MRI can provide direct visualization of the constituents to the coracoacromial arch and their relationship to the supraspinatus (Fig. 6-2A and B). Downward slanting of the acromion in the coronal or the sagittal plane, a thickened coracoacromial ligament or inferior osteophytosis within the acromioclavicular joint can exert mass effect upon the supraspinatus. This has been implied as being in part responsible for chronic tears of the supraspinatus.


FIGURE 6-2. A: Coronal oblique T2-weighted pulse sequence with fat suppression demonstrates downward slanting to the acromion (long arrow ), which is against the supraspinatus tendon (*). Note focal area of increased signal at the myotendinous junction of the SsT (short arrow ). B: Sagittal oblique T2WI with fat suppression demonstrates to a better advantage the inferior slanting to the acromion against the SsT (short arrow ). Note focal tendinosis (long arrow ).


FIGURE 6-3. A: T1-weighted MRI of focal supraspinatus tendinosis demonstrating focal thickening and slight increase signal intensity to the tendon (arrow ). B: CoronalobliqueT2-weightedfat suppressed sequence with increased signal intensity within the area of tendinosis (arrowhead ). There is fluid within the adjacent subdeltoid bursa (long arrow ). C: Sagittal oblique T2-weighted fat suppressed image demonstrates the area of increased signal to be within the anterior superior portion of the rotator cuff representing fibers of the supraspinatus tendon (short arrow ).

Neer stated that 95% of rotator cuff tears are associated with chronic impingement syndrome (7) and described three stages in the progression of rotator cuff injury. These can be visualized by MRI (6–10). Stage 1 is characterized by edema and hemorrhage within the supraspinatus tendon characteristic of an early tendinitis. On MRI, there is focal tendon thickening and diffuse moderate increase in signal intensity within the tendon (Fig. 6-3A–C). In stage 2, Neer described both inflammation and fibrosis within the tendon. MRI shows this as thinning and irregularity of the tendon. Stage 3 is a frank tear of the supraspinatus tendon. On MRI, complete tears are noted by a discontinuity of the tendon with a well-defined focus of high signal intensity on T2-weighted images (Fig. 6-4). The most susceptible area is the critical zone of hypovascularity, located about 1 cm from the insertion (11). With small or partial tears, there is no retraction of the muscle-tendon junction, the subacromial-subdeltoid fat plane is commonly obliterated, and fluid may accumulate in the subacromial-subdeltoid bursa, which becomes hyper- intense on T2-weighted images. There also may be effusion of the shoulder joint, which may extend inferiorly along the tendon sheath about the long head of the biceps. With a complete supraspinatus tendon tear, the muscle belly may retract medially, and atrophy may occur as the tear becomes chronic (Fig. 6-5A,B). Muscle atrophy appears as areas of high signal intensity because of fatty replacement within the muscle belly and decreased muscle mass. Finally, the acromiohumeral interval narrows as the humeral head migrates superiorly, because of the loss of supraspinatus restraint to the deltoid’s tendency to sublux the humerus superiorly during abduction.

FIGURE 6-4. Complete rupture of the supraspinatus tendon is seen in a T2-weighted MRI. There is fluid filling the gap (arrow) and there is retraction to the tendon fibers underneath the acromion.

FIGURE 6-5. Complete rotator cuff tear. A: Coronal oblique T1-weighted image. There is intermediate signal intensity (*) from the inflammatory reaction replacing the normal low signal to the SS tendon. B: The edge (arrow) to the retracted tendon is at the level of the superior labrum. There is increased signal intensity filling the gap of the retracted tendon (long arrow).


Source: Physical Medicine and Rehabilitation - Principles and Practice

Plain film radiographic evaluation of the shoulder should include frontal examinations with internal and external humeral rotation. If there is a question of instability or dislocation, an axillary view, a scapular Y view, or both should be obtained. There have been several reports that recommend the use of a 30-degree caudad-angled radiograph or a suprascapular outlet view for the assessment of the anterior acromion in cases of suspected shoulder impingement. Since these are special views, they must be ordered as routine shoulder radiographs do not include axillary or suprascapular outlet views. The RRL for plain film radiographic examinations of the shoulder is less than 0.1 mSv, which is considered minimal.

MRI has become valuable in evaluating a host of shoulder abnormalities very familiar to the physiatrist. These include impingement syndrome, other rotator cuff abnormalities, instability syndrome, and bicipital tendon abnormalities. It is also useful in demonstrating arthritic changes, occult fractures, ischemic necrosis, and intra-articular bodies. MRI with intra- articular contrast is now considered the modality of choice for the evaluation of labral and capsular pathology. The use of MRI for shoulder evaluation avoids radiation exposure to the nearby thyroid gland, which can occur with CT examinations.The excellent visualization of marrow by MRI permits early diagnosis of ischemic necrosis, infection, and primary or metastatic tumors.

Because of the oblique orientation of the scapula on the chest wall and the consequent anterolateral facing direction of the glenoid, the direct multiplanar imaging capability of MRI provides optimal visualization of all the important shoulder structures. An oblique coronal image parallel to the plane of the scapula provide full-length views of the rotator cuff musculature, especially the supraspinatus and is the best plane for the evaluation of injuries to the biceps-labral complex (BLC) (Fig. 6-1A and B). Coronal oblique images can also provide information about the presence of impingement upon the supraspinatus by the acromion and osteophytes in the presence of acromioclavicular joint osteoarthritis. Oblique sagittal imaging planes parallel to the glenoid provide cross-sectional views of the rotator cuff apparatus and evaluates the anatomical configuration of the coracoacromial arch and the presence of impingement (Fig. 6-1D). Axial imaging planes provide good visualization of the anterior and posterior capsular apparatus, glenoid labrum, bony glenoid rim, and humeral head (Fig. 6-1C).

FIGURE 6-1. Normal shoulder MR images. A: An axial scout film with cursors displays the oblique coronal planes parallel to the plane of the scapula, which allow optimal visualization of the supraspinatus. B: An oblique coronal image demonstrates the supraspinatus muscle belly (SsB), supraspinatus tendon (SsT), subacromial-subdeltoid fat plane (FP), acromioclavicular joint (ACJ), deltoid muscle (D), articular cartilage of humeral head and glenoid (AC), glenoid (G), and humeral head (H). C: An axial image displays humeral head (H), glenoid (G), glenoid labrum (L), the inferior glenohumeral ligament (IGL), deltoid muscle (D), subscapsularis tendon (ScT), and biceps tendon (BT). D: A sagittal section demonstrates good resolution of the coracoacromial ligament (CAL) extending from the coracoid process (CP) to the acromion; coracoid process (CP), supraspinatus (SS), infraspinatus (IS).


Source: Physical Medicine and Rehabilitation - Principles and Practice

The advent of the multidetector CT (MDCT) scanner has increased the applicability of this imaging technique for the assessment of the musculoskeletal system. This technology allows for the acquisition of large data set in the axial plane that can be reconstructed in multiple planes of imaging with the use of multiplanar reconstruction (MPR) algorithm.

Any anatomical part in the human body can now be scanned in the axial plane and the anatomical information can later be reconstructed in the sagittal, coronal, or any orthogonal plane desired in order to better assess complex anatomical structures such as the joints of the axial skeleton and the spine (1).

CT provides poor contrast resolution to evaluate the musculoskeletal system. Since the relative soft-tissue density of cartilage, tendons, and muscle is similar, we cannot resolve adequate soft-tissue differences between these structures. For example the articular cartilage can only be assessed with CT after a positive contrast is introduced in the joint space such as is the case with CT arthrography. CT however provides a superb spatial resolution that allows for the accurate evaluation of fine soft-tissue and bone trabecular details.

CT images may be displayed with various windows suitable to resolve different structures. Bone window images provide the highest resolution of compact and cancellous bone. Soft- tissue window offers moderate resolution of muscle, tendon, ligament, fat, cartilage, and neural structures.

The good resolution and enhanced contrast of MRI for soft-tissue structures, together with its direct multiplanar imaging capability, make it a superb modality for evaluating all the principal constituents of the musculoskeletal system. Although a technical discussion of the physics of MRI is beyond the scope of this chapter, the physiatrist should know the normal and abnormal MRI appearance of various tissues to be able to look at an MR image with confidence and explain the findings to a patient. The MRI signal intensity of any tissue primarily reflects its proton density, its T1 relaxation time, and its T2 relaxation time. Various techniques, including manipulating the repetition time (TR) between the application of radiofrequency pulses or the echo time (TE) between the radiofrequency pulse and the recording of a signal (i.e., echo) produced by the tissue, can emphasize the proton density, T1 relaxation time, or T2 relaxation time features of any tissue (2). The TR and TE are expressed in milliseconds. The most commonly used technique is spin echo, in which short TR and TE will emphasize the T1 relaxation time of a tissue, the so- called T1-weighted image. In general, an image is said to be T1 weighted if TR is less than 1,000 ms and TE is less than 30 ms (e.g., TR = 500 ms, TE = 20 ms). A T2-weighted image generally is accomplished with a TR longer than 1,500 ms and a TE greater than 60 ms (e.g., TR = 2,000 ms, TE = 85 ms). Proton density images are obtained with a long TR and a short TE (e.g., TR = 2,000 ms, TE = 20 ms).

FIGURE 6-1. Normal shoulder MR images. A: An axial scout film with cursors displays the oblique coronal planes parallel to the plane of the scapula, which allow optimal visualization of the supraspinatus. B: An oblique coronal image demonstrates the supraspinatus muscle belly (SsB), supraspinatus tendon (SsT), subacromial-subdeltoid fat plane (FP), acromioclavicular joint (ACJ), deltoid muscle (D), articular cartilage of humeral head and glenoid (AC), glenoid (G), and humeral head (H). C: An axial image displays humeral head (H), glenoid (G), glenoid labrum (L), the inferior glenohumeral ligament (IGL), deltoid muscle (D), subscapsularis tendon (ScT), and biceps tendon (BT). D: A sagittal section demonstrates good resolution of the coracoacromial ligament (CAL) extending from the coracoid process (CP) to the acromion; coracoid process (CP), supraspinatus (SS), infraspinatus (IS).

Most normal tissues demonstrate similar signal intensities on both T1- and T2-weighted images. Compact bone, fibrocartilage, ligament, tendon, and the rapidly flowing blood within the blood vessel typically produce very low signal intensity, referred to as a signal void, and appear black both on T1 and T2 (Fig. 6-1). Muscle demonstrates moderately low signal intensity and appears dark gray. Peripheral nerves demonstrate slightly higher signal intensity than muscle because of the fat content of their myelinated fibers. Hyaline cartilage produces

moderate signal intensity and appears light gray. Fat produces very high signal intensity and appears bright on T1 and T2. Because fat is frequently situated adjacent to ligaments and tendons, it can provide a high-contrast interface for evaluating the integrity of these structures. Adult bone marrow also shows high signal intensity because of its high fat content. Most normal body fluids that are not flowing show low signal intensity on T1-weighted images and high signal intensity on T2-weighted images.

Pathologic processes such as tumor, infection, and abnormal fluids (e.g., edema, joint effusion) show intermediate signal intensity on T1-weighted images and become very hyperintense on T2-weighted images. Pathologic calcifications demonstrate very low signal intensity on both T1-and T2-weighted images.

The direct multiplanar imaging capability of MRI is particularly useful in evaluating obliquely oriented musculoskeletal structures such as the supraspinatus tendon, the cruciate ligaments, and the lateral collateral ligaments of the ankle.

MRI has proved useful in evaluating traumatic, degenerative, inflammatory, and neoplastic pathology of the limbs and spine. It is useful in detecting acute or chronic traumatic injuries and degenerative conditions involving bones, muscles, tendons, ligaments, fibrocartilage, and nerves. Bone pathology, particularly well detected by MRI, includes contusions, osteochondral injuries, stress fractures, marrow replacement by neoplastic cells, and ischemic necrosis. Muscle lesions that MRI is especially sensitive at identifying include strain or contusion, complete rupture, compartment syndrome, myopathies, and atrophy (3). Tendon conditions well depicted by MRI include partial and complete tear, tendinitis, and tenosynovitis. MRI is also very sensitive for detecting partial or complete ligament tears. Fibrocartilaginous injuries or diseases well delineated by MRI include pathology of the menisci, the glenoid labrum, the triangular fibrocartilage of the wrist, and the intervertebral disc. Nerve entrapments well visualized by MRI include spinal nerve encroachment by disc disease or spinal stenosis and carpal tunnel syndrome (CTS) or other entrapment syndromes. Enhanced imaging of normal and injured peripheral nerves can be obtained using a short-tau inversion recovery (STIR) excitation-emission sequence due to the increased sensitivity to free water content associated with tissue edema using this MR recording protocol. The increased signal generated by injured nerves using STIR pulse sequences probably reflects an increase in free water content of the nerve due to altered axoplasmic flow, axonal and/or myelin degeneration, and endoneurial or perineurial edema due to a breakdown in the blood-nerve barrier (4). MRI imaging of denervated skeletal muscle shows increased MR signal using the STIR protocol when there is significant muscular weakness and well-defined changes indicating muscle denervation on needle electromyography (5).

Osteomyelitis causes a reduction in bone marrow signal intensity on T1-weighted images because of the replacement of normal fatty marrow by inflammatory exudate. In T2-weighted images, these areas of active infection become hyperintense.

MRI has particular value in evaluating both bone and soft-tissue neoplasms. Most of them demonstrate moderately low signal intensity on T1-weighted images and very high signal intensity on T2-weighted images.

Emphasis will now be directed to the application of imaging modalities to common regional pathologic conditions of the musculoskeletal system. Particular focus will be given to MRI because of its superb soft-tissue imaging capabilities and its rapidly expanding diagnostic applications.

The important role played by radiology in the diagnosis of diseases has come at the expense of increased radiation exposure to the general population. With the advent of new technology, such as Positron Emission Tomography (PET) studies and MDCT technology, there has been a sharp increase in the number of radiographic examinations performed to the general population and as a consequence an increase in the cumulative radiation dose to the individual patient and the general population. It is an expected outcome for increase in radiation exposure to lead to an increased rate of malignancy. Therefore, increased awareness is needed in issues concerning radiation safety.

Ionizing radiation, especially at high doses, is known to increase the risk of developing cancer. It is estimated that medical exposure might be responsible for 1% of cancer diagnosis in the United States. This rate is expected to increase in the coming years due to the increased number of examinations performed today.

The scientific measurement for the effective dose of radiation is the millisievert (mSv). The background radiation dose for the average person in the United States is about 3 mSv. This is secondary to cosmic radiation and naturally occurring radioactive materials. By comparison, the effective radiation dose for a spinal CT is equivalent to 6 mSv or 2 years of natural background radiation. Radiation exposure is particularly important in pregnant women and pediatric patients due to the cumulative life effect of radiation exposure at a younger age. In nuclear medicine examinations, special precautions are needed. Some of the radiopharmaceuticals used in nuclear medicine can pass into the milk of lactating women (6).

The relative radiation level (RRL) is a radiation measurements used to calculate effective dose. This is the dose used to estimate population total radiation risk associated to an imaging procedure. This takes into account the sensitivity of different body organs and tissues. This estimate cannot assess the specific risk of an individual patient.

Every effort should be made to order examination, which is best indicated to address the clinical concern of the patient. To aid in this regard, the American College of Radiology (acr. org) has established guidelines for the appropriate use of imaging to answer specific clinical questions. The appropriateness criteria can be of help when deciding which imaging study to order to answer a clinical question.


Source: Physical Medicine and Rehabilitation - Principles and Practice
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