Shoulder MRI for Surgeons

AMSTERDAM / THE NETHERLANDS
www.esska-congress.org
Lennard Funk
1
lenfunk@shoulderdoc.co.uk

• Prof. Waqar Bhatti
2
• Dr. Jonathan Harris
• Dr. Sarah Jackson

QUIZ
3

4
QUESTION A
My IDEAL investigation for cuff pathology
is:
a. Ultrasound
b. MRI
c. MR Arthrogram
d. CT Arthrogram

5
QUESTION B
My IDEAL investigation for Instability is:
a. Ultrasound
b. MRI
c. MR Arthrogram
d. CT Arthrogram

QUESTION 1
Radiologists are better at interpreting MRI
scans than surgeons:
a. True
!
b. False
6

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
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
MRI

AMBIGUOUS REPORTS
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“Full width tear”
“Advanced muscle atrophy 
along with Infraspinatus”
“mild atrophy
supraspinatus”

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CONFUSING REPORTS
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There is a partial full tear of the
supraspinatus tendon.
There is a complete partial tear of the
supraspinatus tendon.

INADEQUATE SCANS
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Grainy Shadows
Movement

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

MR ARTHROGRAM V. SCOPE
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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

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

DO NOT RELY ON THE SCAN REPORT
An experienced Shoulder Surgeon better
Can correlate with clinical context
Experience of reviewing Scopes & Scans
19

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

MRI BASICS
• PD = Long TR & Short TE
• T1 = Short TR & Short TE
• T2 = Long TR & Long TE
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• 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

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MRI BASICS
• Fat Suppression
• PDFS
• T2 Gradient Echo
• STIR
• SPIR
• SPAIR
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• Labral Tears
• Bankart
• Perthes
• ALPSA
• SLAP
• GLAD
• GLOM

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T1 WI T2 FS
INFLAMMATION

MUSCLE OEDEMA
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T1 FS T2 FS

LABRAL TEARS
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T1 WI T1 FS

PLAIN MRI SEQUENCES
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• Hospital 1:
• Hospital 2:

MRI SEQUENCES
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• No universal standards
• Each Hospital has different MRI Protocols
• Each Radiologist has different experience
• Each clinical question demands different approach

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PLAIN MRI - PREFERENCES
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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

T1 WITH FS
SAGITTAL IN GLENOID PLANE
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SCAPULA ‘Y’ ON T1WI
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ARTEFACT
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ARTEFACT
• Rotator cuff repair
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ARTEFACT
• ACJ Metalwork
• Deodorant spray in axilla
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MR ARTHROGRAM
• Direct / Indirect
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INDIRECT ARTHROGRAM
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INDIRECT ARTHROGRAM

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ABER
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ABER

MR ARTHROGRAM
• Direct / Indirect
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SUMMARY
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• 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)

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
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I can see it now !

QUIZ
49

QUESTION 1
Radiologists are better at interpreting MRI
scans than surgeons:
a. True
!
b. False
50

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
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

WWW.SHOULDERDOC.CO.UK
53
Full Time / Part Time

54

Shoulder MRI for Surgeons

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