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Original Research

The purpose of this study was to compare the diagnos- CONVENTIONAL. SPIN-ECHO (CSE) imaging has been ac-
tic performance of fat-saturation fast-spin-echo [FSE) cepted widely as a n accurate method of evaluating rotator
TO-weighted (T2W) sequences with conventional cuff pathology (1-7). Fast spin echo (FSE)is a n attractive
spin-echo (CSE)T2W sequences in the detection of ro-
tator cuff pathology using surgery as the reference alternative to CSE because the images produced provide
standard. Oblique coronal dual-echo CSE and FSE T2W similar contrast to the familiar CSE technique in a frac-
images with fat saturation from 50 surgically con- tion of the time (8-1 1). A drawback or FSE shoulder im-
firmed MR shoulder examinations were acquired on a aging is that fat remains bright on T2-weighted (T2W)
1.5-T M R scanner. Blinded MR readers retrospectively FSE images, complicating identification of more subtle
analyzed each imaging sequence separately and ulti- rotator cuff defects and making it difficult to identify
mately correlated both sequences together with 6nd- small amounts of bursal fluid. The application of fat sup-
ings at surgery. FSE was 100% sensitive and 94% pression has been shown to enhance the conspicuity of
specific in detection of full-thickness tears (n = 19) rotator cuff defects, subtle bursal inflammation, and
and 73% sensitive and 97% specific in the detection
of partial-thickness rotator cuff tears [n = 13).There
bone marrow edema while reducing chemical shift and
was no statistically significant difference in the per- respiratory motion artifacts (4-6,12).
formance of FSE with fat saturation compared with This study was performed to evaluate the diagnostic
CSE. The two discrepancies between imaging se- performance of fat-saturation FSE T2W imaging in the
quences related to the extent of partial-thickness detection of surgically confirmed rotator cuff pathology
tears. Our findings suggest that fat-saturation FSE im- and to compare its efficacy with that of CSE.
aging can effectively replace CSE imaging in the eval-
uation of rotator cuff pathology.
Our institution has supplemented fat-saturation FSE
Index terms: Fast spin-echo * MRI * Shoulder
images in the oblique coronal plane since the technique
became available at the end of 1992. We solicited clinical
JMRl 1997: 7:674-677 records from 531 consecutive MR shoulder examinations
performed during this period and we were able to obtain
Abbreviations: CSE = conventional spin echo, FSE = fast spin echo, PDW operative reports of 7 1 patients. Not all patients who were
= pmton density weighted. STIR = short tau inversion recovery. TlW = T1 imaged had symptoms that were referable to the cuff. Our
weighted, T2W = T 2 weighted. study group also contained patients with other shoulder
complaints, including instability. This potentially in-
creased the number of intact tendons in the study group
and also helped limit observer bias Tor tendon pathology.
Only patients who had surgical (open surgery or arthro-
scopic) confirmation of the status of the rotator cuff were
included in the study. In addition, patients with a history
of shoulder surgery (postoperative shoulders) were ex-
cluded. Fifty surgically confirmed shoulder MRIs made
up the final study population, which consisted of 18
women and 32 men, 28 to 84 years of age (mean, 51
years). The time between MRI and date of surgery ranged
from 1 to 198 days, with a mean of 55 days.
From the Deparlmrnr of radio lo^, Memorial Kcgional Hospital, 3501 Johm Oblique coronal images were acquired at 1.5-Tfield
son Street, Hollywood. FL 33332. E-mail: ReceivedJanuary strength (Signa, GE Medical Systems, Milwaukee, WI) with
8. 1997: accepted March 10. Address correspondence to M.B.Z. a dedicated phased-may surface coil (MRI Devices, Wau-
a ISMRM, 1997 kesha, WI]. Dual-echo spin-echo images were obtained
a. a.

b. Figure 2. Example of imaging concordance. Partial-thickness
tear. (a) CSE in a patient with a confirmed deep partial-thickness
p’igure 1. Example of imaging concordance. Full-thickness ro- tear of the undersurface of the supraspinatus tendon (arrow).@)
tator cuff tear. (a] Oblique coronal CSE demonstrates a full- Note how conspicuous fluid in the tendon defect appears on this
thickness rotator ruff tear with tendon retraction (arrows]. Ib) FSE image with fat saturation (arrow).
FSE with fat saturation depicts the same tear (arrows) with de-
creased scan time. Dual-echo CSE and single-echo T2W fat-saturation FSE
oblique coronal sequences were reviewed jointly by two ra-
with TR/TE = 2300-2500/13-18,70 msec, 14-cm field of diologists (S.D.N., M.B.Z.) who were experienced in mus-
view, 4-mm thickness with a 0.5-1.0-mm gap, two signal culoskeletal imagmg and blinded to patient informationand
averages, and a 256 X 128 matrix. The average imaging operative findings. Surgical reports were not reviewed until
time for the CSE series was 11 minutes and 15 seconds. after all of the MR images had been evaluated. Any discrep-
FSE images (effective TR/TE = 2500-3650/63-68 msec) ant cases were re-reviewed in an attempt to idenbfy the
were obtained with €at saturation (Chem Sat, GE Medical source of discordant findings. Results were subjected to
Systems), an echo train length of 8, 14-cm field of view, 4- statistical analysis using x2 test.
mm thickness with a 0.5-1.0-mm gap, two signal averages, For statistical purposes, the shoulders were subdivided
and a 256 X 192 matrix. The average imaging time for the into three groups: no tear, partial tear, and complete tear.
FSE sequence was 3 minutes. A higher matrix size was cho- Tendinosis and tendon surface fraying were placed into
sen for the FSE sequence because greater resolution was the “no tear” category for statistical analysis. Partial tears
possible without a sigmficant increase in scan time. were diagnosed on MR when there was a defect in the

Volume 7 Number 4 JMRl 675

Table 1
M R Diagnosis of Rotator Cuff Tears Versus Surgical
Sensitivitv Specificitv PPV N W
Complete tears at FSE 100% 94% 90% 100%
surgery(n= 19) CSE 100% 90% 86% 100%
Partial tears at. FSE 73% 97% 89% 93%
surgery In = 13) CSE 80% 97% 89% 95%
Note.-FSE, fast spin echo: CSE, conventional spin echo; PPV,
positive predictive value: NPV, negative predictive value.

tendon with focal fluid signal on T2W that extended to no

more than one tendon surface. Complete tears were di-
agnosed on MR when there was a defect in the tendon
that extended to both tendon surfaces and had fluid in-
tensity signal on T2W images.
lmages were obtained at the same section locations and
windowed in a similar fashion to allow valid comparison
of the two sequences. Image quality was subjectively as-
sessed as good, fair, or nondiagnostic.

FSE images revealed 21 complete tears, 10 partial a.
tears, and 19 intact tendons. CSE images revealed 22
complete tears, 10 partial tears, and 18 intact tendons.
At surgery, 19 patients had a complete tear, 13 patients
had a partial tear, and 18 patients had intact tendons.
There was no statistically significant difference (P> .8)
in the diagnostic performance between the FSE and CSE
sequences. With regard to surgically proven complete
tears [Fig. l),FSE was 100% sensitive and 94% specific,
compared with CSE which was 100% sensitive and 90%
specific. With regard to partial tears (Fig. 2), FSE was
73% sensitive and 97% specific, compared with CSE,
which was 80% sensitive and 97% specific. When com-
plete and partial tears were grouped together, FSE im-
aging had an overall sensitivity of 90% and a specificity
of 96Yo compared with surgical findings. CSE had a sen-
sitivity of 93% and a specificity of 94%. Table 1 summa-
rizes our statistical findings.
Two discrepancies between imaging sequences were
identified. One discrepancy occurred in a tendon with
significant morphologic alterations that, in addition, had
a subtle articular-sided partial-thickness tear diagnosed
on CSE and confirmed at surgery. This partial tear was
not identified on FSE images. The FSE images in this
case were judged to be only fair in technical quality, re- b.
lated to inhomogenous fat saturation and patient motion,
which may have contributed to the discordant finding. Figure 3. False-positive complete tear by CSE. (a) CSE sug-
The other imaging discrepancy also occurred in a tendon gested subtle areas of full-Chickness extension of a deep par-
with diffuse morphologic alteration. The CSE sequence tial-thickness tendon defect (arrows)within a diffusely abnormal
was interpreted as showing a subtle focus of full-thick- rotator cuff. Surgical exploration did not confirm the complete
tear. (a) The corresponding FSE sequence reveals the partial-
ness tearing that was seen neither on the FSE images nor thickness defects [arrows) and the diffusely abnormal cuff, but
at surgery (Fig. 3). Note also was made of two cases in the bursal surface appears intact, similar to what was found at
which tendon surface fraying described at surgery was surgery. Also note the marrow edema in the humeral head,
better appreciated on the dual-echo CSE than on the which is more prominent on this FSE imag?.
T2W FSE sequence.
With respect to the overall correlation with surgical volved the description of the depth of partial-thickness
findings, there was one case that was false-positive on tears. In two cases, intrasubstance partial-thickness
both CSE and FSE. This was diagnosed as a partial- tears were described on MRI but were not found at sur-
thickness tear at the articular surface, but the tendon gery. Because this is recognized to be a blind area for the
was considered normal at surgery. When this case was surgeon. these two latter cases were not labeled false-
reviewed, the MR images still were believed to reflect a positives.
partial tear. Other discrepancies with surgical findings Of the FSE images, 30 were judged to be of good quality
included two cases in which superficial partial-thickness and 20 were fair. Of the CSE images, 29 were judged to
tears were described as tendon surface fraying/ be of good quality and 2 1 were fair. No cases were deemed
irregularity at imaging. Two other discordant cases in- to be nondiagnostic in quality.

676 JMRl July/August 1997

Subjectively, we felt that the improved spatial and con- cuff would certainly be of value, especially for low and
trast resolution of the FSE images with fat saturation of- midfield strength MR scanners.
ten facilitated the recognition of tendon defects. The In conclusion, the FSE T2W fat-saturation sequence
higher resolution of the FSE images offered improved de- seems to perform well in the detection of rotator cuff de-
piction of tendon defects, but the lower resolution CSE fects. Compared with CSE, FSE allows the use of larger
images were equally capable of detecting tendon pathol- matrices and may decrease patient motion and respira-
ogy. The addition of fat saturation to the FSE images tory artifacts. The use of Faster imaging sequences has
made fluid appear more conspicuous, which assisted in the additional benefit of potentially increasing patient
differentiating tears from tendinosis. Inhomogeneity of fat throughput. In conjunction with fat saturation, our find-
suppression was apparent on many of the FSE images, ings suggest that T2W FSE imaging may be able to re-
but there were no cases in which we believed that diag- place CSE imaging in the evaluation of rotator cuff tearsl.
nostic quality was sacrificed.
1. Farley TE, Neumann CH, Steinbach LS,Jahnke AJ, Petersen
DISCUSSION SS. Full-thickness tears of the shoulder: diagnosis with MR
FSE provides similar tissue contrast to CSE with imaging. h l R Am J Roentgenol 1992: 158:347-351.
shorter imaging times. Recently published investigations 2. Iannotti JP, Zlatkin MB, Esterhai J L , et al. Magneticresonance
imaging ofthe shoulder. J Bone Joint Surg Am 1991; 73: 17-29.
(13,14)have helped confirm the accuracy of FSE shoul- 3. Kjellin J , Ho CP, Cenfla, et al. Alteration of the supraspinatus
der imaging compared with CSE. We found that the ad- t.endon a t MR imaging: correlation with histopathologic findings
dition of fat saturation increases the conspicuity of fluid in cadavers. Radiology 1991; 181:837-841.
within tendon defects and reduces chemical shift and 4. Mirowitz SA. Normal rotator cuff: MR imaging with conven-
tional and fat-suppression techniques. Radiology 1991: 180:
respiratory motion artifact. Our data show no statistically 735-740.
significant difference in detection and characterization of 5. Quinn SF, Sheley RC, Demlow TA, Szumowski J . Rotator cuff
rotator cuff defects between T2W FSE images with fat sat- tendon tears: evaluation with fat-suppressed MR imaging with
uration and T2W CSE imaging. Diagnostic performance arthroscopic correlation in 100 patients. Radiology 1995; 195:
497-50 1.
of both sequences was consistent with data presented 6. Traughber PD, Goodwin TE. Shoulder MRI: arthroscopic cor-
previously in the literature [l-7). Both sequences per- relation with emphasis on partial tears. J Comput Assist Tomogr
formed better in the diagnosis of complete tears than par- 1992; 16:129-133.
tial tears. Subjectively, the improved image resolution 7. Zlatkin MB, Iannotti JP, Roberts MC, et a]. Rotator cuff tears
diagnostic performance of MR imaging. Radiology 1989: 172.
and increased contrast of the FSE sequence facilitated 223-229.
the recognition of tears. 8. Constable RT, Anderson AW, Zliong J, Gore JC. Factors influ-
T2W sequences are the most commonly used sequence encing contrast in fast spin-echo MR imaging. Magn Reson Im-
in the detection of rotator cuff tears. Proton-densitj- aging 1992; 10:497-511.
9. Rubin DA, Kneeland JB, Listerud J, UnderbergDavis ST.
weighted (PDW) and T1-weighted (TlWJ sequences also Dalinka MK. MR diagnosis of meniscal tears of the knee: value
are useful because they allow better visualization often- of iast spin-echo vs. conventional spin-echo pulse sequences,.
dinosis and subtle morphologic alterations of the tendon AJRAm J Roentgenol 1994; 1621131-1135.
surface, although the clinical implications of these find- 10. Jones KM, Mulkern RV, Schwartz RB, Oshio K, Barnes PD,
Joelsz FA. Fast spin-echo MK imaging of the brain and spine:
ings are still in debate. Because we used only a single current concepts. AJRAm J Roentgenol 1992; 158:131%1320.
late-echo FSE sequence, we were less able to detect these 11. Smith RC, Rcinhold C, Lange RC, McCauley TR. Kier R, McCarthy
latter changes and thus did not include them in our sta- S. Fast spin-echo MR imaging of the female pelvis: Part I. Use
of a whole-volume coil. Radiology 1992: 184:665-669.
tistical analysis. If the CSE T2W sequence is abandoned, 12. Reinus WR, Shady KL, Mirowitz SA, Totty WG. MR diagnosis
we suggest the use of a short TE sequence (either CSE of rotator cuff tears of the shoulder: value of usingT2-weighted
T l W or FSE PDW to continue detecting these tendon fat-saturated images. AJR Am J Roentgenol 1995: 164:1451-
changes. 1455.
13. Singson Ru, Hoang T, Dan S, Friedman M. MR evaluation of
Implementation of this FSE pulse sequence is easiest rotator cuff pathology using T2-weighted fast spin-echo tech-
with MRI scanners that can reliably generate fat satura- nique with and without fat suppression. AJR Am J Roentgenol
tion. Inhomogeneous fat saturation or inadvertent satu- 1996: 166:1061-1065.
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ME. MR imaging of the rotator cuff mechanism: comparison of
agnostic images. A similar investigation employing FSE spin-echo and turbo spin-echo sequences. AJR Am J Roent-
short tau inversion recovery (STIR)to evaluate the rotator genol 1996; 167:333-338.

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