Assessment of metabolic bone disease: review of new nuclear medicine procedures

Chronic low back pain

Most episodes of low back pain are mechanical in origin and resolve within a 12-week period. These acute episodes of back pain are associated with muscle strain and intervertebral disc herniation with radiculopathy. A smaller proportion of individuals have back pain with a duration greater than 12 weeks. These patients have back pain secondary to a wide variety of mechanical and nonmechanical disorders. The mechanical disorders associated with chronic low back pain include osteoarthritis and lumbar spinal stenosis; the nonmechanical disorders include infectious, neoplastic, rheumatologic, endocrinologic, vascular, and gynecologic. The clinical symptoms associated with each variety of disorder helps guide the appropriate diagnostic evaluation. Plain roentgenograms are useful in documenting the presence of spinal stenosis, benign or malignant tumors, osteoporosis, sacroiliitis, and spondylitis. CT scan is helpful in defining the bony alterations associated with malignant tumors and the vascular abnormalities associated with aneurysms. MR imaging is the technique of choice to document the extent of malignant processes and the presence of endometriosis in the pelvis. The therapy of these entities are specific for the disease entity causing the chronic low back pain. Although most of the disorders that cause chronic low back pain cannot be cured, therapy can decrease pain and improve function of the symptomatic patient.

The influence of aortic calcification on spinal bone mineral density in vitro

We examined the influence of aortic calcification on the spine phantom bone mineral density (BMD). Soft X-ray photographs of human aortae were taken to calculate the percent calcification of aortic tissues. Human aorta laid on lumber spine phantom was placed in the bottom of 15 cm of water and BMD and bone mineral content (BMC) were measured in the anteroposterior view. Samples with severe aortic calcification (over 30%) caused a 2.5% increase of BMD. There might be a relatively small influence of aortic calcification on the value of L2-L4 BMD, but changes over time in a patient could falsely elevate values.

The value of bone scintigraphy in the follow-up of vertebral osteoporosis

In an open study, we have assessed the bone/soft tissue uptake index in recent osteoporotic vertebral collapse using scintigraphy. The evolution of these cases was followed-up at 6 months in 22 patients treated with 100 IU of salmon calcitonin plus 500 mg of elemental calcium/10 days per month and in 18 patients treated with 500 mg of elemental calcium only on a daily basis. There were no index differences between groups prior to treatment. At six months, the group treated with calcitonin plus calcium showed a significant decrease from 10.2 +/- 6.4 to 3.2 +/- 1.1 (p less than 0.001), while the calcium only group did not show any significant changes (12.1 +/- 6.6 vs 9.2 +/- 4.6), considering that there were significant differences between groups (p less than 0.001). On a mid-term basis, these results have shown the values of the bone/soft tissue index in the follow-up of osteoporotic vertebral collapse.

High bone turnover in fibromyalgia

This paper seeks to determine if patients with a fibromyalgic syndrome have specific abnormalities of skeletal homeostasis. Radioisotopic evaluation of skeletal remodeling showed higher Fogelman index and increased 24-hour pyrophosphate retention in the group of fibromyalgics (n = 28) when compared to the control group (n = 16). Bone density (lumbar vertebrae and femoral neck) was not significantly different from control subjects. These data might suggest an accelerated bone metabolism in these patients.

Quantification of bone mineral content using dual-photon absorptiometry in a normal Japanese population

The bone mineral content of lumbar spine and/or total body were quantified in 217 healthy Japanese (86 males and 131 females) using a Dichromatic Bone Densitometer (Norland Corp., Model 2600). The bone mineral density of the third lumbar vertebra (L3 BMD) decreased significantly after age 20 in males (r = -0.417, p less than 0.0002), with acceleration of the decrease after age 50 (r = -0.621, p less than 0.00002). A significant correlation was found between L3 BMD and age after age 40 (r = -0.747, p less than 0.0001) in females. L3 BMD correlated with both the body height (r = 0.335, p less than 0.0001) and the body weight (r = 0.340, p less than 0.0001). Total bone mineral content from the second to fourth lumbar vertebrae correlated significantly with total body bone mineral (r = 0.880, p less than 0.00001) in these normal subjects. Lumbar spine bone mineral as measured by dual-photon absorptiometry is lower in Japan than the bone mass in the United States, although not lower than in other parts of the world.

Non-invasive measurement of bone: a review of clinical and research applications in the horse

The current methods for non-invasive measurement of bone quality are reviewed. In the horse this has traditionally involved the use of radiography, but there are now two other modalities available for the critical evaluation of cortical bone quality and strength. These utilise single photon absorptiometry and ultrasound velocity. Photon absorptiometry gives a direct measurement of bone mineral content, by using a monoenergetic radionuclide source, and transverse ultrasound velocity in bone gives a measure of bone stiffness or elasticity. They can both be used conveniently on the metacarpus of the conscious horse. Both ultrasound velocity and bone mineral content can be used as accurate indicators of skeletal maturity. In addition, the effects of disuse on bone and certain types of lameness can be monitored accurately. Preliminary data show an association with exercise in young and mature horses. There also appears to be considerable scope for in vivo research of bone changes in horses produced by immobilisation, weightlessness, exercise and nutrition.

Radiopharmacological profiles of tracers under pathophysiological conditions. 99mTc-methylene diphosphonate uptake by bone in altered thyroid status

The uptake of 99mTc-MDP, a skeletal radiotracer, was studied at early and late (3 h) time intervals in rats induced with altered thyroid status. Thyroid dysfunction resulted in disturbances in bone mineral metabolism. Rats rendered hypothyroid showed an overall retardation in growth and also considerably reduced skeletal uptake, especially at early time periods. On the other hand, rats rendered hyperthyroid did not show any significant alteration of the skeletal uptake as compared with controls despite enhanced bone turnover normally observed in hyperthyroidism.

Radionuclide imaging in metabolic and systemic skeletal diseases

Radionuclide imaging with Tc-99m diphosphonates is not an effective method for detecting or ruling out most osteoporotic diseases including senile osteoporosis or accelerated postmenopausal osteoporosis, and the slow loss of bone tissue generally remains undetected by this modality. Nonetheless, it frequently surpasses or supplements radiographic findings in evaluating the focal complications of metabolic bone disease, including fractures, microfractures, stress fractures, vertebral compressions, Milkman-Looser zones, aseptic necrosis, and acute infarction. In contrast to its secondary role in osteoporosis, bone imaging is of prime importance in investigating hypercalcemia, because the major cause of this abnormality is skeletal metastatic malignancy. In defective bone mineralization due to hyperparathyroidism or osteomalacia, a general increase in diphosphonate skeletal uptake is detected more frequently than radiographic abnormalities. However, normal skeletal images do not rule out metabolic bone disease. Biochemical testing is more reliable in detecting primary hyperparathyroidism. On the other hand, in renal osteodystrophy, biochemical abnormalities are variable and bone imaging is helpful in assessing the severity of skeletal involvement, but not its etiology. Many methods of quantitating the kinetics of Tc-99m diphosphonates have been explored, such as plasma clearance, bone-to-soft-tissue ratios, 24-hour total body retention and 24-hour urinary excretion. None of these have been widely accepted. The value of bone imaging is established in other systemic diseases, most notably in Paget's disease, hypertrophic pulmonary osteoarthropathy, sickle cell disease, fibrous dysplasia, and sympathetic dystrophy.

Single- and dual-photon absorptiometry in osteoporosis and osteomalacia

Single- and dual-photon absorptiometric methods have been used in the past to identify populations at risk for bone loss, to define the osteoporotic syndrome in terms of bone mass, and to evaluate treatment regimens to prevent bone loss. Technical improvements have made these procedures available for the nontraumatic measurement of bone mineral in the management of the individual patient suspected of having osteoporosis or other bone loss. This requires a different approach to data interpretation because decisions have to be made on the basis of a single measurement. Osteoporosis and osteomalacia cannot be distinguished by bone mineral measurements because both are characterized by a decrease in content of bone mineral. Bone mineral measurements can be used to assess the risk of fracture and, with it, the severity of bone loss. This allows treatment decisions to be made. Repeated measurements made under well-defined conditions allow estimation of long-term rate of bone loss and monitoring of treatment effect.

Scintigraphic evaluation of reflex sympathetic dystrophy: comparative study of the course of the disease under two therapeutic regimens

A study was made of 26 patients diagnosed as phase I reflex sympathetic dystrophy. In all of them, a bone:soft tissue uptake index was quantified by scintigraphic scanning before treatment and 3 months later. Eighteen patients were treated with 100 MRC units salmon calcitonin, followed by 500 mg elemental calcium 4 hours after hormone administration. The treatment was administered 10 days a month separated by intervals free of therapy. The other 8 patients were treated without interruption with 500 mg naproxen every 12 hours. In the group treated with calcitonin and calcium, the uptake index declined from 13.3 +/- 8.2 to 4.1 +/- 1.8 (p less than 0.001). The uptake index rose from 2.1.3 +/- 17.7 to 31.1 +/- 23.0 (NS) in the naproxen group. Using the Student t-test for paired samples to evaluate individual changes, a highly significant difference was reached (p less than 0.005) in the calcitonin-calcium group. The difference was also significant (p less than 0.01) in the naproxen group, but it was negative (t = 3.620). These results confirm the efficacy of treating reflex sympathetic dystrophy with calcitonin and calcium and the superiority of this treatment as compared with nonsteroidal anti-inflammatory drugs.