Shoulder MRI for Surgeons

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It is not uncommon to receive ambiguous and incorrect imaging reports from radiologists. There are numerous reasons for this, such as poor clinical information, differential experience, imaging protocols, etc. As there is no unified protocol for MRI sequencing reports are limited by these factors. Studies have also shown that there is poor agreement on scan interpretation, with experienced surgeons being more accurate than radiologists, as they can better correlate the imaging with the clinical information. There is a lot of mystique and misunderstanding around MRI imaging and many surgeons find it confusing. In this lecture I will provide some of my tips and experience in understanding MRI scanning for the surgeon and clinician.

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Shoulder MRI for Surgeons

  1. 1. AMSTERDAM / THE NETHERLANDS www.esska-congress.org Lennard Funk 1 lenfunk@shoulderdoc.co.uk
  2. 2. AMSTERDAM / THE NETHERLANDS www.esska-congress.org • Prof. Waqar Bhatti 2 • Dr. Jonathan Harris • Dr. Sarah Jackson
  3. 3. AMSTERDAM / THE NETHERLANDS www.esska-congress.org QUIZ 3
  4. 4. AMSTERDAM / THE NETHERLANDS www.esska-congress.org 4 QUESTION A My IDEAL investigation for cuff pathology is: a. Ultrasound b. MRI c. MR Arthrogram d. CT Arthrogram
  5. 5. AMSTERDAM / THE NETHERLANDS www.esska-congress.org 5 QUESTION B My IDEAL investigation for Instability is: a. Ultrasound b. MRI c. MR Arthrogram d. CT Arthrogram
  6. 6. AMSTERDAM / THE NETHERLANDS www.esska-congress.org QUESTION 1 Radiologists are better at interpreting MRI scans than surgeons: a. True ! b. False 6
  7. 7. AMSTERDAM / THE NETHERLANDS www.esska-congress.org 7 QUESTION 2 MRI Sequences: a. T1 is best for pathology b. In T2 fat tissue is bright c. A long TR is shows inflammation b. STIR is a Fat Suppression sequence
  8. 8. AMSTERDAM / THE NETHERLANDS www.esska-congress.org 8 QUESTION 3 MR Arthrogram: a. ABER improves accuracy b. Cannot show Bony lesions c. Is not ideal for fatty infiltration d. Is 100% accurate for labral tears
  9. 9. AMSTERDAM / THE NETHERLANDS www.esska-congress.org 9 MRI
  10. 10. AMSTERDAM / THE NETHERLANDS www.esska-congress.org AMBIGUOUS REPORTS 10 “Full width tear” “Advanced muscle atrophy
 along with Infraspinatus” “mild atrophy supraspinatus”
  11. 11. AMSTERDAM / THE NETHERLANDS www.esska-congress.org 11
  12. 12. AMSTERDAM / THE NETHERLANDS www.esska-congress.org 12
  13. 13. AMSTERDAM / THE NETHERLANDS www.esska-congress.org 13
  14. 14. AMSTERDAM / THE NETHERLANDS www.esska-congress.org CONFUSING REPORTS 14 There is a partial full tear of the supraspinatus tendon. There is a complete partial tear of the supraspinatus tendon.
  15. 15. AMSTERDAM / THE NETHERLANDS www.esska-congress.org INADEQUATE SCANS 15 Grainy Shadows Movement
  16. 16. AMSTERDAM / THE NETHERLANDS www.esska-congress.org CUFF PATHOLOGY IN ASYMPTOMATIC • 96 MRI’s viewed by 2 radiologists • 20% PTT; 15% FTT – Increased with age: • >60yrs = 55% PTT; 30% FTT 16 Sher et al. JBJS. 1995
  17. 17. AMSTERDAM / THE NETHERLANDS www.esska-congress.org MR ARTHROGRAM V. SCOPE 17 Sensitivity Specificity Accuracy SLAP 0.42 0.92 77% Rotator Cuff Tear 0.50 0.86 83% Hill Sachs 0.91 0.78 90% Bankart 0.85 0.83 86% N Karlson, J Geoghan, L Funk; 2008
  18. 18. AMSTERDAM / THE NETHERLANDS www.esska-congress.org RADIOLOGIST LOCALITY • Nine radiologists - regional & secondary care • MR diagnostic accuracy is better when surgeon and radiologist work in the same institution. • Differences between local- and non-local MRA data suggest that diagnostic accuracy is better in the local secondary referral centre. 18 N Karlson, J Geoghan, L Funk; SECEC 2011
  19. 19. AMSTERDAM / THE NETHERLANDS www.esska-congress.org DO NOT RELY ON THE SCAN REPORT An experienced Shoulder Surgeon better Can correlate with clinical context Experience of reviewing Scopes & Scans 19
  20. 20. AMSTERDAM / THE NETHERLANDS www.esska-congress.org MRI BASICS • T1 - Fat Bright - Anatomy • T2 - Water Bright - Pathology • Standard 3mm thick slices • Thick slices = more signal & less grainy, but lower spatial resolution (due to volume averaging) 20
  21. 21. AMSTERDAM / THE NETHERLANDS www.esska-congress.org MRI BASICS • PD = Long TR & Short TE • T1 = Short TR & Short TE • T2 = Long TR & Long TE 21 • TE is always < TR • Short TR < 500ms • Long TR > 1500ms • Short TE < 30ms • Long TE > 90ms http://www.imaios.com/en/e-Courses/e-MRI/MRI-signal-contrast/Signal-weighting
  22. 22. AMSTERDAM / THE NETHERLANDS www.esska-congress.org 22
  23. 23. AMSTERDAM / THE NETHERLANDS www.esska-congress.org 23
  24. 24. AMSTERDAM / THE NETHERLANDS www.esska-congress.org 24
  25. 25. AMSTERDAM / THE NETHERLANDS www.esska-congress.org MRI BASICS • Fat Suppression • PDFS • T2 Gradient Echo • STIR • SPIR • SPAIR 25 • Labral Tears • Bankart • Perthes • ALPSA • SLAP • GLAD • GLOM
  26. 26. AMSTERDAM / THE NETHERLANDS www.esska-congress.org 26 T1 WI T2 FS INFLAMMATION
  27. 27. AMSTERDAM / THE NETHERLANDS www.esska-congress.org MUSCLE OEDEMA 27 T1 FS T2 FS
  28. 28. AMSTERDAM / THE NETHERLANDS www.esska-congress.org LABRAL TEARS 28 T1 WI T1 FS
  29. 29. AMSTERDAM / THE NETHERLANDS www.esska-congress.org PLAIN MRI SEQUENCES 29 • Hospital 1: • Hospital 2:
  30. 30. AMSTERDAM / THE NETHERLANDS www.esska-congress.org MRI SEQUENCES 30 • No universal standards • Each Hospital has different MRI Protocols • Each Radiologist has different experience • Each clinical question demands different approach
  31. 31. AMSTERDAM / THE NETHERLANDS www.esska-congress.org 31
  32. 32. AMSTERDAM / THE NETHERLANDS www.esska-congress.org PLAIN MRI - PREFERENCES 32 1. Full Series ! ! 2. T1 Axial - Bony Bankarts 3. T1 Sag - Bony Bankarts 4. T1 Sag - extend medial to scapula ‘Y’ 5. T2 FS Cor - Cuff, ACJ, Bursa
  33. 33. AMSTERDAM / THE NETHERLANDS www.esska-congress.org T1 WITH FS SAGITTAL IN GLENOID PLANE 33
  34. 34. AMSTERDAM / THE NETHERLANDS www.esska-congress.org SCAPULA ‘Y’ ON T1WI 34
  35. 35. AMSTERDAM / THE NETHERLANDS www.esska-congress.org ARTEFACT 35
  36. 36. AMSTERDAM / THE NETHERLANDS www.esska-congress.org ARTEFACT • Rotator cuff repair 36
  37. 37. AMSTERDAM / THE NETHERLANDS www.esska-congress.org ARTEFACT • ACJ Metalwork • Deodorant spray in axilla 37
  38. 38. AMSTERDAM / THE NETHERLANDS www.esska-congress.org MR ARTHROGRAM • Direct / Indirect 38
  39. 39. AMSTERDAM / THE NETHERLANDS www.esska-congress.org INDIRECT ARTHROGRAM 39
  40. 40. AMSTERDAM / THE NETHERLANDS www.esska-congress.org 40 INDIRECT ARTHROGRAM
  41. 41. AMSTERDAM / THE NETHERLANDS www.esska-congress.org 41
  42. 42. AMSTERDAM / THE NETHERLANDS www.esska-congress.org 42
  43. 43. AMSTERDAM / THE NETHERLANDS www.esska-congress.org ABER 43
  44. 44. AMSTERDAM / THE NETHERLANDS www.esska-congress.org 44 ABER
  45. 45. AMSTERDAM / THE NETHERLANDS www.esska-congress.org MR ARTHROGRAM • Direct / Indirect 45
  46. 46. AMSTERDAM / THE NETHERLANDS www.esska-congress.org SUMMARY 46 • Beware / Be aware of Reports • Full 6 series • T1 FS Axial - Instability • T2 FS Cor - Rotator Cuff • T1 Sag to Scapula ‘Y’ • MRA: – Direct – T1 FS in 2 planes (axial; sagittal) – ABER (if able)
  47. 47. AMSTERDAM / THE NETHERLANDS www.esska-congress.org RELATIONSHIPS • Clinical Imaging is a ‘request for consultation to clarify a clinical query’ • NOT ‘ordering’ an investigation ! • Vetting of request should be an MSK Radiologist • Provide clear clinical info and query 47
  48. 48. AMSTERDAM / THE NETHERLANDS www.esska-congress.org 48 I can see it now !
  49. 49. AMSTERDAM / THE NETHERLANDS www.esska-congress.org QUIZ 49
  50. 50. AMSTERDAM / THE NETHERLANDS www.esska-congress.org QUESTION 1 Radiologists are better at interpreting MRI scans than surgeons: a. True ! b. False 50
  51. 51. AMSTERDAM / THE NETHERLANDS www.esska-congress.org 51 QUESTION 2 MRI Sequences: a. T1 is best for pathology b. In T2 fat tissue is bright c. A long TR is shows inflammation b. STIR is a Fat Suppression sequence
  52. 52. AMSTERDAM / THE NETHERLANDS www.esska-congress.org 52 QUESTION 3 MR Arthrogram: a. ABER improves accuracy b. Cannot show Bony lesions c. Is not ideal for fatty infiltration d. Is 100% accurate for labral tears
  53. 53. AMSTERDAM / THE NETHERLANDS www.esska-congress.org WWW.SHOULDERDOC.CO.UK 53 Full Time / Part Time
  54. 54. AMSTERDAM / THE NETHERLANDS www.esska-congress.org 54

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