The Bone Scan

doi:10.1053/j.semnuclmed.2011.07.005

Seminars in Nuclear Medicine

Volume 42, Issue 1, January 2012, Pages 11-26

https://doi.org/10.1053/j.semnuclmed.2011.07.005 Get rights and content

Bone imaging continues to be the second greatest-volume nuclear imaging procedure, offering the advantage of total body examination, low cost, and high sensitivity. Its power rests in the physiological uptake and pathophysiologic behavior of 99m technetium (99m-Tc) diphosphonates. The diagnostic utility, sensitivity, specificity, and predictive value of 99m-Tc bone imaging for benign conditions and tumors was established when only planar imaging was available. Currently, nearly all bone scans are performed as a planar study (whole-body, 3-phase, or regional), with the radiologist often adding single-photon emission computed tomography (SPECT) imaging. Here we review many current indications for planar bone imaging, highlighting indications in which the planar data are often diagnostically sufficient, although diagnosis may be enhanced by SPECT. ¹⁸F sodium fluoride positron emission tomography (PET) is also re-emerging as a bone agent, and had been considered interchangeable with 99m-Tc diphosphonates in the past. In addition to SPECT, new imaging modalities, including ¹⁸F fluorodeoxyglucose, PET/CT, CT, magnetic resonance, and SPECT/CT, have been developed and can aid in evaluating benign and malignant bone disease. Because ¹⁸F fluorodeoxyglucose is taken up by tumor cells and Tc diphosphonates are taken up in osteoblastic activity or osteoblastic healing reaction, both modalities are complementary. CT and magnetic resonance may supplement, but do not replace, bone imaging, which often detects pathology before anatomic changes are appreciated. We also stress the importance of dose reduction by reducing the dose of 99m-Tc diphosphonates and avoiding unnecessary CT acquisitions. In addition, we describe an approach to image interpretation that emphasizes communication with referring colleagues and correlation with appropriate history to significantly improve our impact on patient care.

Section snippets

Physiology

The skeleton is a living, active organ that changes during the normal physiological process of growth and remodeling and in response to pathologic processes.⁵ Bone is constantly changing, with an ongoing level of bone resorption (osteoclastic) and bone formation (osteoblastic). Osteoblasts form an osteoid matrix that is later mineralized with hydroxyapatite crystals. 99m-Tc diphosphonates chemisorb⁶ and bind to the hydroxyapatite crystals in proportion to local blood flow and osteoblastic

Planar Bone Imaging

Bone scans have stood the test of time. After myocardial perfusion studies, they are the second most commonly performed nuclear procedure in the United States. A recent survey showed that the bone scan was the most commonly performed hospital-based procedure, emphasizing its continued importance.¹³ Planar imaging is the cornerstone for all indications for bone scans by offering the advantage of total body examination, low cost, and a high degree of sensitivity. Even with the availability of

Conclusions

The power of bone imaging lies in the physiological uptake and pathophysiologic behavior of 99 m-Tc diphosphonates. Its clinical utility, sensitivity and specificity was established based on planar imaging data. Planar bone imaging data are often sufficient for diagnosis and may be enhanced by SPECT. New imaging modalities, including ¹⁸F-FDG-PET, CT and MR are complementary to 99 -m-Tc bone imaging. ¹⁸F-FDG-PET and 99m-Tc bone imaging reflect different biological processes (FDG uptake by tumor

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