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Society of Nuclear Medicine

Procedure Guideline for Bone Scintigraphy


version 3.0, approved June 20, 2003

Authors: Kevin J. Donohoe, MD (Beth Israel Deaconess Medical Center, Boston, MA); Manuel L. Brown, MD (Henry Ford
Hospital, Detroit, MI); B. David Collier, MD (Faculty of Medicine, Kuwait University, Kuwait); Robert F. Carretta, MD
(Amersham Health, Princeton, NJ); Robert E. Henkin, MD (Loyola University Medical Center, Maywood, IL); Robert E.
O’Mara (University of Rochester School of Medicine and Dentistry, Rochester, NY); and Henry D. Royal, MD (Mallinck-
rodt Institute of Radiology, St. Louis, MO).

I. Purpose III. Common Indications


The purpose of this guideline is to assist nuclear A. Neoplastic disease
medicine practitioners in recommending, perform- B. Occult fracture
ing, interpreting, and reporting the results of bone C. Osteomyelitis
scintigraphy. D. Stress reaction/stress fracture
E. Avascular necrosis
F. Arthritides
II. Background Information and Definitions
G. Reflex sympathetic dystrophy
A. Bone scintigraphy is a diagnostic study used to H. Bone infarcts
evaluate the distribution of active bone forma- I. Bone graft viability
tion in the body. J. Otherwise unexplained bone pain
B. Whole-body bone scintigraphy produces planar K. Distribution of osteoblastic activity before ra-
images of the skeleton, including anterior and dionuclide therapy for bone pain
posterior views of the axial skeleton. Anterior
and/or posterior views of the appendicular
IV. Procedure
skeleton also are obtained. Additional views are
obtained as needed. A. Patient Preparation
C. Limited bone scintigraphy records images of 1. The rationale for performing the procedure
only a portion of the skeleton. and the details of the procedure itself should
D. Bone single-photon emission computed tomog- be explained to the patient in advance. Unless
raphy (SPECT) produces a tomographic image of contraindicated, patients should be well hy-
a portion of the skeleton. drated and instructed to drink 2 or more 8-oz
E. Multiphase bone scintigraphy usually includes glasses of water between the time of injection
blood flow images, immediate images, and de- and the time of delayed imaging. The patient
layed images. The blood flow images are a dy- should be asked to urinate immediately be-
namic sequence of planar images of the area of fore delayed imaging and to drink plenty of
greatest interest obtained as the tracer is injected. fluids for at least 24 h after radiopharmaceuti-
The immediate (blood pool or soft tissue phase) cal administration.
images include 1 or more static planar images of B. Information Pertinent to Performing the Proce-
the areas of interest, obtained immediately after dure
the flow portion of the study and completed 1. Question(s) to be answered by bone scintig-
within 10 min after injection of the tracer. De- raphy
layed images may be limited to the areas of in- 2. History of fractures, trauma, osteomyelitis, cel-
terest or may include the whole body, may be lulitis, edema, arthritis, neoplasms, metabolic
planar or tomographic, and are usually acquired bone disease, or limitation of function
2–5 h after injection. If necessary, additional de- 3. Current symptoms, physical findings
layed images may be obtained up to 24 h after 4. History of recent scintigraphy, especially with
131 67
tracer injection. I, Ga, or 111In
206 • BONE SCINTIGRAPHY

5. Results of prior bone scintigraphy of Radiopharmaceuticals).


6. Results of prior imaging studies, such as con- E. Image Acquisition
ventional radiographs, computed tomogra- 1. Flow images
phy, and magnetic resonance imaging If flow images are acquired, the camera
7. History of therapy that might affect the re- should be positioned over the region of inter-
sults of bone scintigraphy (e.g., antibiotics, est before tracer injection. The acquisition
steroids, chemotherapy, radiation therapy, computer should be programmed to acquire
diphosphonates, or iron therapy) approximately 30 frames. When digital im-
8. History of orthopedic (e.g., presence and loca- ages are acquired, blood flow images may be
tion of prosthetic implants) and nonorthope- obtained in a 64 × 64 × 16 or greater matrix at
dic (e.g., ileal conduit) surgery that might af- 1–3 s/frame. If film is used, 3–5 s/frame may
fect the results of bone scintigraphy be used.
9. Relevant laboratory results (e.g., prostate-spe- 2. Blood pool (tissue phase) images
cific antigen in patients with prostate cancer) Blood pool images should be acquired imme-
10. History of anatomic or functional renal abnor- diately after the flow portion of the study and
malities completed within 10 min of tracer injection,
C. Precautions for approximately 3–5 min/image. After 10
None min, some activity may be apparent in the
D. Radiopharmaceutical skeleton. Blood pool images are usually ob-
Several 99mTc-labeled radiopharmaceuticals (e.g. tained in a 128 × 128 × 16 or greater matrix,
diphosphonates) are available for bone scintigra- with count density of approximately 300,000
phy. The usual administered activity for adult counts/image (150,000–200,000 counts/im-
patients is 740–1,110 MBq (20–30 mCi) injected age may be adequate for extremities).
intravenously. For markedly obese adult pa- 3. Delayed (skeletal phase) images
tients, the administered activity may be in- Routine delayed images are usually obtained
creased to 11–13 MBq/kg (300–350 µCi/kg). For from 2–5 h after injection.
pediatric patients, the administered activity is Whole-body bone scintigraphy can be ac-
9–11 MBq/kg (250–300 µCi/kg), with a mini- complished with multiple overlapping im-
mum of 20–40 MBq (.05–1.0 mCi). The maximum ages (i.e., spot imaging) or with continuous
administered activity for pediatric patients images (i.e., whole-body scan) obtained in an-
should not exceed the administered activity for terior and posterior views with a high-resolu-
an adult. tion or ultrahigh-resolution collimator. When
Bone radiopharmaceuticals are subject to oxi- spot views are used as the primary method of
dation. Care should be taken to avoid introduc- acquiring bone images, the areas of bony
ing air into the multidose vial. Quality control skeleton covered by the spot views must over-
should be performed before administration of lap to avoid missing regions of the skeleton.
the radiopharmaceutical (see the Society of Nu- The first spot view of the axial skeleton,
clear Medicine [SNM] Procedure Guideline for Use usually the chest, is acquired for approxi-

Radiation Dosimetry in Adults

Radiopharmaceuticals Administered Organ Receiving the Effective


Activity Largest Radiation Dose* Dose
MBq mGy/MBq mSv/MBq
(mCi) (rad/mCi) (rem/mCi)

99m
Tc-phosphates 740–1110 Bone 0.0080
and phosphonates (20–30) 0.063 (0.030)
Intravenously (0.23)

*
International Commission on Radiological Protection. Radiation Dose to Patients from Radiopharmaceuticals. ICRP re-
port 53. London, UK: ICRP; 1988:215. Values for normal bone uptake and normal renal function. See also Medical
Internal Radiation Dose Committee dose estimate report No. 13: radiation absorbed dose for 99mTc-labeled bone
imaging agents. J Nucl Med. 1989;30:1117–1122.
SOCIETY OF NUCLEAR MEDICINE PROCEDURE GUIDELINES MANUAL AUGUST 2003 • 207

Radiation Dosimetry in Children


(5 Years Old)

Radiopharmaceuticals Administered Organ Receiving the Effective


Activity Largest Radiation Dose* Dose
MBq/kg mGy/MBq mSv/MBq
(mCi/kg) (rad/mCi) (rem/mCi)
99m
Tc-phosphates 9–11 Bone 0.025
and phosphonates (0.20–0.30) 0.22 (0.093)
Intravenously (0.81)
Min: 0.50 mCi
Max: 30 mCi

*International Commission on Radiological Protection. Radiation Dose to Patients from Radiopharmaceuticals.


ICRP report 53. London, UK: ICRP; 1988:215. Values for normal bone uptake and normal renal function. See
also Medical Internal Radiation Dose Committee dose estimate report No. 13: radiation absorbed dose for
99m
Tc-labeled bone imaging agents. J Nucl Med. 1989;30:1117–1122.

mately 500,000–1 million counts. The remain- 60–120 stops, 64 × 64 × 16 or greater matrix,
ing spot views are then acquired for the same and 10–40 s/stop. An equivalent total number
time as the first view. Spot images may be ob- of counts should be acquired if continuous ac-
tained using a 128 × 128 × 16 or 256 × 256 × 16 quisition is used.
matrix. Whole-body views are usually ob- 5. Other imaging
tained in a 256 × 1024 × 16 or greater matrix. Additional delayed (6–24-h) images will re-
Computer acquisition, processing, and dis- sult in a higher target-to-background ratio
play of images are very helpful and particu- and may permit better evaluation of the pelvis
larly so in pediatric populations because of if it was obscured by bladder activity on the
extreme ranges of normal uptake. Films of routine delayed images. Six- to twenty-four-h
scintigrams photographed with different in- delayed imaging may be particularly helpful
tensities also may be helpful when digital pro- in patients with renal insufficiency or urinary
cessing and review are not available. retention.
When whole-body scanning is used, the A pinhole collimator may be used if very
count rate (usually of the anterior chest) high-resolution images of a specific area are
should be determined before image acquisi- necessary. Approximately 75,000–100,000
tion. The scanning speed should be adjusted counts should be obtained for pinhole colli-
so that routine delayed (obtained 2–5 h after mator views. Zoom magnification or a con-
injection) anterior or posterior whole-body verging collimator also may be used to im-
images contain >1.5 million counts. If the prove resolution, particularly when small
scanner electronically joins multiple passes, structures or pediatric patients are being im-
care must be taken to avoid having the “zip- aged. The physician interpreting the image
per” superimposed on the spine. should be notified when collimators that in-
When the probability of disseminated dis- troduce distortion (e.g., a pinhole collimator)
ease is small, a limited study is reasonable. are used.
When disseminated disease is more likely, Other views (e.g., lateral, oblique, or tan-
spot views limited to the area of interest may gential) and special views (e.g., frog-leg views
be a source of error if distant disease is pre- of the hips or sitting-on-detector [caudal]
sent. views of the pelvis) may be obtained when
4. SPECT imaging necessary.
In some patients, SPECT imaging is helpful to F. Interventions
better characterize the presence, location, and The pelvis can be difficult to evaluate when
extent of disease. SPECT imaging should be there is overlying bladder activity. In patients
performed as recommended by the camera with pelvic symptoms, 1 or more of the follow-
manufacturer. Typical acquisition and pro- ing additional views may better evaluate the
cessing parameters are 360° circular orbit, pelvis.
208 • BONE SCINTIGRAPHY

1.
Repeat images immediately after voiding 3. Soft tissues
2.
Sitting-on-detector (caudal) or oblique views a. Normal structures should be noted:
3.
Lateral views i. Kidneys
4.
24-hr–delayed images ii. Bladder
5.
SPECT acquisition. Single or multiple rapid iii. Generalized interstitial uptake com-
(5–10 min/acquisition) SPECT acquisition(s) pared with normal bone
are preferred to avoid artifacts caused by (a) Increased
changing activity in the bladder. Bladder arti- (1) Renal failure
facts are exaggerated in the plane in which the (2) Dehydration
SPECT acquisition begins and ends. Begin- (3) Shortened interval between in-
ning SPECT acquisition with the camera jection and imaging
heads in the left and right lateral positions (for (b) Decreased
dual-head camera) or posterior position (for (1) Superscan
single-head camera) will help reduce bladder- (2) Prolonged interval between in-
filling artifact. jection and imaging
6. Image immediately after catheterization of b. Focal tracer uptake
the bladder. (Note: Bladder catheterization c. Diffuse tracer uptake
should be reserved for patients in whom visu- 4. Bone scans are very sensitive for disease, but
alization of the pelvis is essential.) specificity of findings is low and must be in-
G. Processing terpreted in light of other information
Generally no special processing of planar imag- a. History
ing is required. For general SPECT image pro- b. Physical exam
cessing guidelines, refer to the SNM Procedure c. Other test results
Guideline for General Imaging. d. Comparison with previous studies
H. Interpretation Criteria I. Reporting
1. Increased (decreased) tracer activity in the 1. Description of technique
bone compared with normal bone. a. Flow images
a. Focal b. Blood pool images
b. Diffuse c. Delayed images
c. Indicates increased (decreased) osteoblas- d. Injection site
tic activity e. SPECT (if applicable)
d. Differential diagnosis is long, but can be 2. Description of abnormal tracer uptake
narrowed in light of: a. Increased
i. Configuration of the abnormality or ab- b. Decreased
normalities c. Pattern of abnormal uptake
ii. Location and number of abnormalities d. Bone findings
e. Focal decrease without adjacent increase in e. Soft tissue findings
tracer uptake is: 3. Correlation with other studies
i. Less common than focally increased ac- 4. Comparison with previous studies
tivity 5. Interpretation
ii. Often caused by benign conditions: a. Narrow differential as much as possible
(a)Attenuation b. Recommend further, more definitive
(b) Artifact study(ies), if differential diagnosis is broad
(c) Absence of bone (e.g., surgical resec- J. Quality Control
tion) See the SNM Procedure Guideline for General
2. Change in focal abnormalities compared with Imaging.
previous study K. Sources of Error
a. Decrease in intensity of tracer uptake and 1. Urine contamination or a urinary diversion
number of abnormalities: reservoir
i. Often indicates improvement 2. Injection artifacts
ii. May be secondary to focal therapy (e.g., 3. Prosthetic implants, radiographic contrast
radiation therapy) materials, or other attenuating artifacts that
b. Increase in intensity of tracer uptake and in might obscure normal structures
number of abnormalities may indicate: 4. Homogeneously increased bony activity (e.g.,
i. Progression of disease “superscan”)
ii. Flare response to therapy 5. Patient motion
SOCIETY OF NUCLEAR MEDICINE PROCEDURE GUIDELINES MANUAL AUGUST 2003 • 209

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distance Cook, GJ, Fogelman I. Skeletal metastases from breast
7. Imaging too soon after injection, before the ra- cancer: imaging with nuclear medicine. Semin Nucl
diopharmaceutical has been optimally Med. 1999;29:69–79.
cleared from the soft tissues Fogelman I, Collier BD, Brown ML. Bone scintigraphy:
8. Restraint artifacts caused by soft-tissue com- part 3. Bone scanning in metabolic bone disease. J
pression Nucl Med. 1993;34:2247–2252.
9. Prior administration of a higher energy ra- Gates, GF. SPECT bone scanning of the spine. Semin
dionuclide ( 131I, 67Ga, 111In) or of a 99mTc ra- Nucl Med. 1998;27:291–305.
diopharmaceutical that accumulates in an or- Holder LE. Bone scintigraphy in skeletal trauma. Radiol
gan that could obscure or confound the Clin North Am. 1993;31:739–781.
skeletal activity Pomeranz SJ, Pretorius HT, Ramsingh PS. Bone scintig-
10. Radioactivity extraneous to the patient raphy and multimodality imaging in bone neopla-
11. Significant findings outside the area of inter- sia: strategies for imaging in the new health care cli-
est that may be missed if a limited study is mate. Semin Nucl Med. 1994;24:188–207.
performed Ryan, PJ, Fogelman I. Bone scintigraphy in metabolic
12. Radiopharmaceutical degradation bone disease. Semin Nucl Med. 1997;27:291–305.
13. Changing bladder activity during SPECT of
pelvic region
VII. Disclaimer
14. Purely lytic lesions
15. Pubic lesions obscured by underlying bladder The Society of Nuclear Medicine has written and ap-
activity proved guidelines to promote the cost-effective use of
16. Renal failure high-quality nuclear medicine procedures. These
generic recommendations cannot be applied to all pa-
tients in all practice settings. The guidelines should not
V. Issues Requiring Further Clarification
be deemed inclusive of all proper procedures or exclu-
None sive of other procedures reasonably directed to obtain-
ing the same results. The spectrum of patients seen in a
specialized practice setting may be quite different from
VI. Concise Bibliography
the spectrum of patients seen in a more general practice
Brown ML, Collier BD, Fogelman I. Bone scintigraphy: setting. The appropriateness of a procedure will de-
part 1. Oncology and infection. J Nucl Med. pend in part on the prevalence of disease in the patient
1993;34:2236–2240. population. In addition, the resources available to care
Brown ML, O’Connor MK, Hung JC, et al. Technical as- for patients may vary greatly from one medical facility
pects of bone scintigraphy. Radiol Clin North Am. to another. For these reasons, guidelines cannot be
1993;31:721–730. rigidly applied.
Collier BD, Fogelman I, Brown ML. Bone scintigraphy: Advances in medicine occur at a rapid rate. The date
part 2. Orthopedic bone scanning. J Nucl Med. of a guideline should always be considered in deter-
1993;34:2241–2246. mining its current applicability.
Collier BD, Fogelman I, Rosenthall L, eds. Skeletal Nu-