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Table of Contents
Hull University Teaching Hospitals NHS Trust - Nuclear Medicine
Uncontrolled if printed
| SOP Code | Title | Review Date |
|---|---|---|
| REF011 | Bone Scans Referral Criteria | 2027-06-10 |
| Authorised By | Authorising Role | Authorisation Signature (only on master paper copy) | Date Authorised |
|---|---|---|---|
| Dr N Ahmed | ARSAC Licence Holder | 2024-06-10 |
REF011 Bone Scan Referral Criteria
See REF000 - Referring to Nuclear Medicine (HUTH) for details of how to refer.
Description
Bone scans are a sensitive method for demonstrating disease in bone, often providing earlier diagnosis or demonstrating more lesions than are found on X-ray. It can be used to investigate a wide variety of conditions, both benign and malignant, in adults and children. It is a non-specific investigation and any lesion in bone such as fracture, infection, tumour or healing bone will show as an area of increased radiopharmaceutical accumulation. In many clinical situations, however, the anatomical distribution of the radiopharmaceutical combined with the clinical history or radiographs will suggest a specific diagnosis.
Imaging of the whole skeleton or specific areas can be performed. When infection of a bone or joint is suspected, or when an assessment of blood flow is required, a three phase investigation can be performed. This includes imaging of the blood flow and perfusion stages in addition to the standard imaging of bone uptake.
Two dimensional (planar) or three dimensional (SPECT) images can be acquired. SPECT images may be combined with a CT acquisition (on the same scanner) with the images fused to provide better localisation and characterisation of abnormal uptake.
| ARSAC Licence Holders | Indication |
|---|---|
| Prof Stephen Richard Underwood | bone imaging |
| Prof Ged Avery | bone imaging |
| Dr Najeeb Ahmed | bone imaging |
| Radiopharmaceutical | CT | |
|---|---|---|
| Typical Radiation Dose (mSv) | 2.9-3.9 | 3.2 |
Staff Entitled to Refer
- All UK registered medical practitioners
- Approved non-medical referrers as listed in departmental SOP E029
Supplementary Drugs
Sodium chloride for parenteral use (0.9% w/v)
Contraindications
| Medications | Some drugs may interfere with the quality of scintigraphic images: * Aluminium: reduced skeletal tracer uptake, diffuse hepatic tracer uptake, increased renal tracer uptake * Androgen deprivation therapy for prostate cancer (bicalutamide, oestrogens): increased mammary tracer uptake in case of gynecomastia * Bone-modifying agents including bisphosphonates (such as Zolendric Acid) and Denosumab or agents interfering with osteoblast function (e.g. cabozantinib): reduced skeletal tracer uptake * Corticosteroids: reduced skeletal tracer uptake, reduced tracer uptake at fracture sites * Haematopoietic growth factors: increased spinal tracer uptake, possible increased tracer uptake in the appendicular skeleton * Iron: increased renal tracer uptake, increased tracer uptake at site of intramuscular injection, diffuse hepatic tracer uptake * Methotrexate: diffuse hepatic tracer uptake * Nephrotoxic chemotherapy: increased renal tracer uptake and reduced skeletal tracer uptake * Nifedipine: reduced skeletal tracer uptake Please include details on the request of any such medications that the patient is taking. The investigation is best undertaken at a time as long as possible from the last dose i.e. just prior to the next dose to attain the best quality scan. Further information can be found in the The EANM practice guidelines for bone scintigraphy [1]. |
|---|---|
| Surgery | Bone uptake in prostheses can persist for months, even years, as a result of the surgery itself. Bone scans for investigation of the general causes for painful prosthesis should not be performed until at least 12 months post-surgery. If there is a high suspicion of infection, a White Cell Scan should be considered. |
| Ra223 Treatment | Bone scans should not be performed until at least 8 weeks after the last administration of Ra223 therapy |
| Medical Conditions | Axial Spondyloarthritis: Bone scintigraphy is not indicated for axial spondyloarthritis [2] Discitis: Bone scans have a sensitivity of 81.4% and specificity of 40.7%. The advantages of this radiopharmaceutical include low cost, low radiation burden, and single-day imaging procedure. It is limited, however, by low specificity. [3] If it is thought that it could be useful for a particular patient, please discuss with the ARSAC licence holder. Myeloma: Do not use isotope bone scans to identify myeloma related bone disease. [4] |
Clinical Indications
| Oncology |
|---|
| Solid tumours with high affinity for bone, including prostate, breast, lung, neuroblastoma, and renal cancer[1] [5] |
| Bone tumours and bone dysplasia, including osteosarcoma, osteoid osteoma, osteoblastoma, fibrous dysplasia, giant cell tumour and osteopoikilosis[1][5] |
| Soft tissue sarcomas, including rhabdomyosarcoma[1] |
| Paraneoplastic syndromes, including hypertrophic pulmonary osteoarthropathy, algodystrophy, polymyalgia rheumatica, poly(dermato)myositis and osteomalacia[1] |
| Assessment of bone remodelling prior to radionuclide therapy[1][5] |
| Rheumatology |
| Chronic inflammatory arthritis, including rheumatoid arthritis, spondyloarthropathies and related disorders (ankylosing spondylitis, psoriatic arthritis, Reiter’s arthritis, SAPHO syndrome [synovitis, acne, pustulosis, hyperostosis, osteitis], chronic recurrent multifocal osteomyelitis) and sacroiliitis[1] |
| Osteoarthritis of the lumbar facet joints, hip, femorotibial and femoropatellar osteoarthritis, rhizarthrosis and tarsal osteoarthritis[1] |
| Enthesopathies, including plantar fasciitis, Achilles tendinitis and bursitis[1] |
| (Avascular) osteonecrosis, which is most frequently located at the femoral head, femoral condyle and tibial plateau[1] |
| Osteonecrosis of the jaw (ONJ)[1] |
| Complex regional pain syndrome type I of the hand, hip, knee and foot[1] |
| Tietze’s syndrome (costochondritis) [1] |
| Polymyositis[1] |
| Paget’s disease[1] |
| Langerhans cell histiocytosis (LCH): single system LCH and multisystem LCH with bone involvement[1] |
| Non-Langerhans cell diseases, such as Erdheim–Chester disease, Schnitzler syndrome, and Rosaï Dorfman disease[1] |
| Other rare osteoarticular diseases, such as sarcoidosis with bone involvement, mastocytosis, Behçet’s disease, and familial Mediterranean fever[1] |
| Bone and joint infections |
| Osteomyelitis (acute, subacute or chronic, of bacterial, mycobacterial or fungal origin) [1] |
| Septic arthritis [1] |
| Spondylodiscitis or spondylitis [1] |
| Septic loosening or mechanical complication of internal fixation (long bones or spine) or arthroplasty (hip, knee, ankle or shoulder)[1] |
| Malignant (necrotising) external otitis[1] |
| Orthopaedics, sports and traumatology |
| Periostitis, including shin splints and thigh splints[1] |
| Enthesopathies, including plantar fasciitis, Achilles tendinitis and bursitis[1] |
| Spondylolisthesis (acute or subacute)[1] |
| Radiological occult stress-related fractures (e.g. scaphoid, tarsals) or nonspecific symptoms[1] |
| Insufficiency fractures, including osteoporotic vertebral or occult fractures, sacral fractures, femoral head or neck fractures, tibial plateau fractures, tarsal and metatarsal fractures[1] |
| Septic loosening, mechanical complication, and synovitis of internal fixation (long bones or spine) or prosthesis (hip, knee, ankle, or shoulder)[1] |
| Pseudoarthrosis (delayed union, non-union)[1] |
| Periarticular heterotopic ossification[1] |
| Viability of bone graft[1] |
| Metabolic bone disease |
| Hyperparathyroidism (primary and secondary)[1] |
| Osteomalacia[1] |
| Renal osteodystrophy[1] |
| Rare skeletal manifestations of endocrine disorders, including hyperthyroidism and acromegaly[1] |
| Vitamin D deficiency[1] |
| Paediatrics |
| Osteochondritis of the hip (Legg-Calvé-Perthes disease)[1] |
| Transient synovitis of the hip[1] |
| Osteoid osteoma[1] |
| Battered child syndrome[1] |
| Mandibular condylar hyperplasia[1] |
| Bone infarction (sickle cell disease, thalassaemia)[1] |
| Exploration of unexplained symptoms |
| Subacute or chronic musculoskeletal or bone pain with normal clinical examination and radiographs • Arthralgia, monoarthritis, oligoarthritis, polyarthritis, localised or multifocal bone pain and backache[1] |
| Further exploration of abnormal biochemical (e.g. phosphate or calcium metabolism) or radiological findings[1] |
| Fever of unknown origin: exclusion of osteomyelitis[1] |
| Metabolic assessment prior to initiation of therapy |
| Evaluation of the activity of arthropathies and to confirm active synovitis prior to radiation synovectomy or before infiltration of facet joints with corticosteroids[1] |
| Evaluation of osteoblast activity in case of Paget’s disease before initiating treatment with bisphosphonates[1] |
| Assessment of benign or malignant vertebral compression fracture prior to vertebroplasty or kyphoplasty[1] |
[1]
The EANM practice guidelines for bone scintigraphy. Eur J Nucl Med Mol Imaging (2016) 43:1723–1738
[2]
Spondyloarthritis in over 16s: diagnosis and management. NICE guideline [NG65] Published date: 28 February 2017 Last updated: 02 June 2017
[3]
Joint EANM/ESNR and ESCMID-endorsed consensus document for the diagnosis of spine infection (spondylodiscitis) in adults. Eur J NuclMed Mol Imaging (2019) 46:2464–2487
[4]
Myeloma: diagnosis and management NICE guideline [NG35] Last updated: 25 October 2018
