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Shoulder MRI

Shoulder MRI

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Published by BILLYBAT
Clinical Magnetic Resonance Imaging, 3rd Edition (Sample Book Chapter)
Clinical Magnetic Resonance Imaging, 3rd Edition (Sample Book Chapter)

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Published by: BILLYBAT on Jan 17, 2010
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01/16/2013

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99
INTRODUCTION
The shoulder is a joint capable of great freedom andmotion.It is therefore both inherently unstable and sub- ject to injury.Shoulder pain is thus a common clinicalproblem.It has a number of different etiologies,includ-ing subacromial and other forms of impingement leadingto rotator cuff tendon failure,and various forms of glenohumeral joint instability.These diseases may bemisdiagnosed clinically or dismissed with nonspecificdiagnoses,including bursitis or synovitis.In the absenceof a precise diagnosis,treatment may fail to relieve thesymptoms,resulting in chronic limitation of motion,atrophy,and persistent pain.MRI is accepted as the imaging modality of choice inpatients with shoulder pain.It is a useful and accuratetechnique in noninvasively diagnosing many shoulder disorders,particularly those due to rotator cuff diseaseand shoulder instability.This chapter will review currentexperience with this modality and discuss relevant tech-nical,anatomic,and pathologic issues.
TECHNICAL FACTORSLocal Coils
Local radiofrequency coils are critical to MRI of joints,
1
including the shoulder,as they provide greater diag-nostic capability through an increase in signal-to-noiseratio (SNR).Since noise is inherent in the tissue beingimaged,it is important that a radiofrequency coiladequately covers the area of interest,but covers as littleunwanted tissue as possible.In general,larger coils havelower SNR;therefore,it is important to use the smallestcoil feasible to adequately encompass the area of interest.Linear coils which consist of a single loop arelimited as the homogeneity of the image and SNR degrade sharply away from the center of the loop,producing suboptimal image quality for diagnosis of deeper structures such as the labrum.Helmholtz coils,consisting of two parallel loops with the anatomy of interest sandwiched between them,provide better homogeneity than a linear loop coil.The SNR perform-ance is somewhat less than at the center of a loop.Flexible coils are used commonly by some manufac-turers.They consist of one or more linear loops that wrap (once) around the area of interest.While flexiblecoils offer good patient comfort and reasonablediagnostic capability,their performance is easily sur-passed by quadrature or array coils designed specifically for imaging the shoulder.Quadrature (circularly polarized,CP) coils provide significant improvementsinimage quality over linear loop coils,with good SNR and homogeneity available over the entire joint.Someflexible coils may have a quadrature design.Flexiblequadrature coils have the “flexible”positioning optionsof flex coils,but with superior SNR performance. A multicoil (also known as phased) array consists of two or more resonating loops.The output signal of each loop is fed into an independent channel of the MRIsystem.Since each channel is independent from theothers,the coil receivers do not share noise as long as
C H A P T E R 
99
S
HOULDER 
Michael B. Zlatkin
INTRODUCTION
3204
TECHNICAL FACTORS
3204
Local Coils
3204
Pulse Sequences andParameters
3205
MRI Arthrography 
3206
Imaging Protocols
3207
General Shoulder Anatomy 
3207
MRI Anatomy 
3214
ROTATOR CUFF DISEASE
3222
Pathophysiology 
3222
Classification, Location, and IncidenceofRotator Cuff Tears
3226
Magnetic Resonance Imaging
3227
SHOULDER INSTABILITY 
3245
General Features
3245
 Anterior Instability 
3246
Posterior Instability 
3250
POSTOPERATIVE SHOULDER
3259
Impingement and Rotator Cuff Disease
3260
Deltoid Detachment
3262
Biceps Tendon Rupture
3262
Shoulder Instability 
3262
OTHER DISORDERS
3266
Occult Fractures
3266
Muscle Injuries
3267
Inflammatory and Degenerative JointProcesses
3268
Osteochondral Lesions
3269
 Avascular Necrosis
3270
Quadrilateral Space Syndrome
3270
Parsonage-Turner Syndrome
3271
3204
 
they remain electrically isolated from each other. Although MRI scanners can handle as many as 8 or 16multicoil array channels,currently most shoulder array coils are four-channel arrays (Fig.99-1).Shoulder multicoil arrays will permit imaging with high resolution,small fields of view,and thin sections.
Pulse Sequences and Parameters
Conventional spin-echo sequences have for the mostpart been replaced in MRI by fast spin-echo imagingsequences.Short repetition time (TR)/time to echo (TE)images are still,however,helpful to demonstrateanatomic details and are most often used in MR arthrography.The tissue contrast is similar in fast spin-echo imagingsequences to that seen with conventional spin echo;however,fat is more intense on T2-weighted fast spin-echo images,and therefore differentiating fat from fluidsignal can sometimes be difficult.Blurring of anatomicstructures is another problem,especially on short TEsequences.Comparative studies have established theefficacy of fast spin-echo techniques.
2-6
Since marrow fatis brighter,marrow edema can be obscured and fluid intears or in effusions may be more difficult to identify.Thus most commonly,fat-suppression techniques areadded.Gradient-echo sequences
2,5,7-9
may be applied inimaging the shoulder.These techniques can be used for kinematic imaging
10-15
and are also used to evaluate theglenoid labrum.Problems with the gradient-echotechnique include the vacuum phenomenon,
16
 which may simulate loose bodies or calcification,and increasedmagnetic-susceptibility artifact.Fat suppression is useful in shoulder MRI as it canincrease the conspicuity of an abnormality.This effectismost prominent on T2-weighted sequences.Detec-tionof abnormal enhancement after contrast injectionisimproved on T1-weighted images by using fat sup-pression.TR and TE can also be reduced on T2-weightedfast spin-echo sequences without loss of tissue contrast,and imaging sequences with TEs in the 35 to 45 ms rangeare often used with fat saturation in place of imag-ingsequences with longer TEs and poorer SNR.Fatsuppression also reduces phase-encoding and chemicalshift artifacts.The two most common types of fat sup-pression are short tau inversion recovery (STIR) imagingand fat saturation.STIR images exhibit combined T1 andT2 contrast,which enhance sensitivity but diminisspecificity.Fat saturation uses a radiofrequency pre-saturation pulse applied at the resonant frequency of lipid protons,followed by a gradient pulse designed tospoil any residual signal intensity of fat.This technique isbetter with high field-strength systems and a highly uniform magnetic field.
6,17
Methods such as STIR and fat-saturation T2 can improve visualization of rotator cuff tendon injuries (Fig.99-2) and hyaline cartilage lesions,and are also used to evaluate marrow abnormalities,andinflammatory and post-traumatic processes.They maalso be useful to evaluate labral tears.Performance of high-resolution imaging using largematrices has recently become available,with systemscapable of performing 512
×
512 matrices,or usingparallel imaging,3-T magnets,and appropriate coils evenhigher matrices may be employed (Fig.99-3).Thesetechniques may improve visualization of subtle abnor-malities involving the labrum and rotator cuff.Smaller fields of view 
18
are also helpful in the evaluation of theshoulder.Large matrix and/or small field of view imagingis made possible by higher field strength,improvementsin scanner hardware,better local coils,or such standardfactors as increased excitations and longer repetitiontime.A narrow receiver bandwidth also improves SNR.The slice thickness is also an important determinantof spatial resolution.Slice thicknesses of 2 mm on two-dimensional (2D) spin- and gradient-echo sequencesandthicknesses of 1mm or less on 3D Fourier transform(FT) images are available on most scanners for routineusage.These are also very useful for evaluating such 
C H A P T E R 
99
S
HOULDER
3205
AB
F I G U R E 99-1
Technique.
 A,
Four-channel array coil consisting of four linear coils arranged in a strip. The arrows represent theB1 field of each coil in the array.
B,
Four-channel array shoulder coil positioned on a normal volunteer. Patients areimaged in a supine position, with their arm by the side in the neutral rotation.
(Courtesy of Tom Schubert, MRIDevices Corporation, Waukesha, WI
.
 )
 
structures as the glenoid labrum and subtle injuries of articular cartilage.Contiguous thin slices ensure that therelevant anatomy is adequately covered and also reducepartial volume averaging.
MRI Arthrography
In the absence of a native effusion MRI can beperformed after the injection of saline or a gadopentatedimeglumine/saline mixture for MR arthrography.
19-35
 A saline/gadopentate dimeglumine mixture (1.0mL of gadopentate dimeglumine/200 mL of saline) is injected.This can be achieved by diluting 0.1 mL of gadolinium in20mL of saline.The amount depends on the capacity of the joint,but is typically 12 to 15 mL,which is somewhatgreater than for conventional arthrography.The patientis then taken to the MRI scanner and the appropriateimage sequences are obtained.As mentioned earlier,fat-saturation techniques are often utilized in conjunction toincrease the conspicuity of the contrast.
32,34,36
Intra-articular gadolinium distends the joint and potentially can more directly identify abnormalities (Fig.99-4).Inthe shoulder,it is utilized to assess the rotator cuff undersurface and to improve assessment of torn tendonedges in complete cuff tears.It is very helpful in eval-uating the postoperative shoulder and in assessingpatients with glenohumeral instability and SLAP tears, when findings are uncertain,or when there is no nativeeffusion.
1
Positioning patients in abduction and externalrotation (ABER)
37-39
may help visualize posterior under-surface lesions in posterosuperior subglenoid impinge-ment and help to visualize labroligamentous abnor-malities in complex instability cases,including Bankartlesion variants.MR arthrography may help locate loosebodies but may not be as effective as CT air arthrography for this application.Disadvantages of gadolinium injection are that itrequires an injection into the joint,making the study semi-invasive.Fluoroscopy is required for injection andtherefore the total examination time is increased.Our patients are injected under C arm fluoroscopic guidance.In addition,imaging may be logistically difficult toperform if the scanner is remote from the fluoroscopicunit.Although no toxic effects are known,the intra-articular use of gadolinium
21
has not yet been approvedby the Food and Drug Administration (FDA).Indirect MR arthrography is achieved by injectionofparamagnetic MR contrast media intravenouslinsteadof as an intra-articular injection as in direct MR arthrography.
40-43
In some cases,exercising the jointresults in considerable signal intensity increase within
3206
S E C T I O N
VII
M
USCULOSKELETAL
S
 YSTEM
A B
F I G U R E 99-2
Fat suppression.
 A,
Conventional spin-echo T2-weighted image.
B,
T2-weighted fast spin-echo (FSE) image with fatsaturation. Fat saturation increases the conspicuity of the tendon disruption (
arrows
in
 A 
and
B
).
F I G U R E 99-3
Image of the shoulder obtained with a four-channel phased-array coil at3T. Note the severe tendinosis and small undersurface anterodistal partial tear (
arrow 
).
(Courtesy of Larry Tannenbaum MD, Edison, NJ.)

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