Computed
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JOHN
Tomography
S. WILSON,1
MELVYN
of Musculoskeletal
KOROBKIN,’
HARRY
The utility of computed tomography (CT) in evaluation of musculoskeletal disorders was assessed In 55 selected patients. CT provided unique information leading to a correct diagnosis in 45% of cases. In 78% the extent of a lesion was more clearly defined than on conventional imaging procedures, and in the same percentage the CT findings were used to plan optimal therapy. CT was most useful in demonstrating absence of a suspected mass lesion and in defining the full extent of a lesion involving the soft tissues.
K. GENANT,’
to:
From
July
1976 through
June
1977,
approximately
and cysts. of bone
from
or sufficient
surgery
clinical
follow-up
data
with
which
and
Availability to select
Most obtaining
in hopes of or extent of a
lesion few
patients more than
were
was
provided
undoubtedly
new imaging from
were referred for CT scanning information about the diagnosis
method.
8 to 75 years
by
conventional
referred
because
imaging
The 32 men and 23 women
and
included
A
about
the
a complete
ranged
Metastatic
radiography
and often
ton.
Soft
tissue
tumors
were
examined
radionuclide
tumors
and
imaging
suspected
were
5005,
or the
GE CT/I
body
scanner.
Slices
field
for comparison.
and after urographic Received
A few patients
skele-
10 or 13 mm
evaluated
14,
1978;
accepted
after
revision
(2)
with
composed
normal
included
fibrous
of patients
lesions
with
(bone island
CT findings
who
sarcomas
histiocytomas.
had
,
The
infectious
Baker’s
clinical
cyst)
follow-up
with
the information
obtained
by the conven-
gained
by the
other
imaging
modalities.
CT was considered lished the presence
useful for diagnosis if it correctly or absence of a suspected lesion,
correctly
the
suggested
specific
histologic
nature
of
estabor if it a lesion.
of CT to offer additional
and useful
information
of disease, and treatment with the referring din-
Results
Tables for
thick
both
April
each
regarding
2 and 3 detail of the
the utility,
55 patients.
correct
or lack
of utility,
of CT
CT added
unique
information
in
patients
(45%).
diagnosis
25
Al-
though CT was usually unable to suggest a specific histologic diagnosis, lesions containing predominantly fatty or cystic components were correctly identified by their characteristic attenuation values. In addition, the
before
the intravenous injection of 300 ml of 25%-30% contrast material; most received no contrast agent. February
accord-
examined
from just above to just When an extremity was was included in the scan
were
was
evaluated
several
in the categories of diagnosis, extent planning was assessed in consultation cian.
with routine and xeroradiographic filming. Some patients had only standard radiographic projections prior to CT. CT scanning was performed using the EMI 5000, the EMI were obtained at 1 or 2 cm intervals below a known or suspected lesion. examined, the contralateral extremity
and
and miscellaneous
cases, the ability
by conventional
masses
grouped
or nonneoplastic:
CT was judged useful for treatment planning not only when it helped determine the mode of therapy (surgery, radiation, chemotherapy, or no therapy), but also when information about the extent of disease and its relation to specific bones, muscle bundles, or large nerves and blood vessels affected the size of incision and the degree of dissection, thus reducing the duration of surgery and the amount of tissue destruction. In most
of body
of the entire
tumors
tissue
group
patients
mation
size and habitus. The pre-CT workup was not prospectively planned but rather was that usually used in this hospital. Primary bone tumors were examined by conventional radiography and usually linear tomography.
soft
and compared
in age
spectrum
were
studied
tional procedures. Finally, after a critical review of each patient’s medical records and personal interviews with referring physicians, an estimate of the clinical utility of each CT examination was made. The CT examination was judged useful if it contributed uniquely to (1) establishing a correct diagnosis; (2) demonstrating the extent of a disease process; or (3) affecting the treatment plan. CT was not considered useful if it only confirmed infor-
of the
studies.
of curiosity
JR.2
examinations estalishing that no lesion had been present. Three of us (J.S. Wilson, M. Korobkin, and H.K. Genant) each evaluated the 55 cases in the following way. First, the results of conventional imaging procedures were reviewed and validated, including standard radiography, tomography, and xerography. Second , the results of each CT scan were reviewed
to
assess the accuracy and value of the CT findings. such information was the only criterion used patients evaluated in this report.
BOVILL,
process-neoplastic
The malignant
and
nonneoplastic
70 patients
to our radiology department for CT evaluation of disorders. Of these patients, 55 had records
G.
skeletal location-extremity, spine, or limb-girdle (shoulder, pelvis, or ribs); and (3) type of involvement-bone, soft tissue, or both (table 1). The 20 benign neoplasms studied included desmoid tumors, hemangiomas, osteoid osteomas, lipomas,
Methods
were referred musculoskeletal
EDWIN
disorders
disease
(1)
processes
and
AND
The musculoskeletal ing
Considerable controversy exists regarding the role of computed tomography (CT) in the diagnosis and management of disease, especially in the extracranial portions of the body. The value of CT in the assessment of space-occupying lesions of the musculoskeletal system has been reported only in a preliminary fashion [1-6]. We describe our early experience with CT in evaluating orthopedic disorders.
Subjects
Disorders
correct
diagnosis
of
no
pathology
was
made
in
eight
18, 1978.
Presented atthe annual meeting of the American
Roentgen Ray Society, Boston, September 1977. Scholar in Radiological Research, and recipient of National
M. Korobkin is a James Picker Foundation ment Award GM 00055 from the National Institute of General ‘Department of Radiology, University of California School 2Department of Orthopedic Surgery, University of California
Am J Roentgenol © 1978 American
July 1978
131 :55-61
,
Roentgen
Ray Society
Medical
Institutes
of Health Research
Career Develop-
Sciences.
of Medicine,
San
School
of Medicine, 55
Francisco,
California
San Francisco,
94143.
California
Address
reprint
requests
to M. Korobkin.
94143.
0361 -803X/78/0700
-
0055
$00.00
WILSON
56 TABLE Distribution
of Patients
ET AL.
1
According
to Lesion
patients whose physical examination suggested the presence of a soft tissue mass. In 43 patients (78%), the precise location or extent of a lesion was better defined by CT than the conventional imaging procedures (figs. 1-5). CT was also considered useful in planning optimal treatment in 43 patients (78%). Utility in treatment planning was more often related to demonstration of extent of disease than to establishment
Categories
Patients
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Category
Disease Process: Neoplastic: Benign Primary
malignant
Metastatic Subtotal Nonneoplastic: Infectious Negative study
Miscellaneous
No.
%
20
36
7
13
11
20
38
69
5 8
9 14
of a correct
4
8
17
31
Location: Extremity
25
46
Limbgirdle
21
38
9
16
Subtotal
Spine Type: Bone Soft tissue
Both
13
24
22 20
40 36
TABLE Contribution
of CT in Evaluation
2
of Nonneoplastic
Disorders unique
Final
Diagnosis
diagnosis.
In one patient (fig. 2), the CT demonstration of extension of a recurrent hemangioma of the chest wall into the abdominal cavity was clinically unsuspected, dictating conservative rather than surgical therapy. In another patient, demonstration of a pedicle attachment of a desmoid tumor (fig. 3) demonstrated the necessity for a wide resection of the underlying gluteus muscle. In a patient with an osteoid osteoma of the femur (fig. 5), the transaxial display of the precise location of the nidus along the circumference of the bone resulted in a more limited surgical resection of the involved cortical region than would have otherwise been performed. When irradiation was the mode of treatment, CT usually provided
.
Diagnosis
of Musculoskeletal Information
Provided
System by CT
Extent of Lesion
.
Treatment
Planning
Confirmed: Discitis
L4-L5
Discitis
and
prevertebral
abscess
T10-T11
Identified abscess
large
prevertebral
-
+
Diagnosis
+
need for surgical debridement Extent of lesion indicated need
and extent
of lesion
indicated for sur-
gical debridement Discitis
L4-L5
Sterile
abscess
Osteophyte
-
of flank
Identified mass
of sacroiliac
joint
Poorly
low density defined
flank
sclerotic
-
-
+
Extent
+
agement Diagnosis permitted apy
conservative
ther-
+
Diagnosis
conservative
ther-
Ic-
sion by tomography, clearly identified as OsBone
islands,
iliac
teophyte Identified
wings
pected
by CT multiple
lesions
to original
Brody’s
abscess
proximal
femur
unsus-
in addition
of lesion
permitted
lesion,
Bullet fragment
tibia
+
Excluded cation
man-
lesion
-
Precise
anatomic
intraarticular
lo-
depiction
of lesion fa-
biopsy
+
-
+
-
-
Diagnosis
permitted
conservative
ther-
apy Diagnosis apy
permitted
conservative
ther-
Diagnosis apy
permitted
conservative
ther-
Diagnosis
permitted
conservative
ther-
permitted
conservative
ther-
permitted
conservative
ther-
-
in acetabulum
surgical
apy
cilitated Inflammatory
facilitated
of bullet
Suspected: Recurrent
liposarcoma
of thigh
Recurrent tumor of thigh Recurrent desmoid tumor maximus
of gluteus
Established
mass Established mass Established
absence
of
absence
of
-
absence
of soft
-
absence
of
-
tissue
Calf mass
Established mass
Calf mass
Established
absence
of
-
Calf
mass Established mass
absence
of
-
absence
of
-
mass
Scapular
mass
Chest wall mass
Established mass Established mass
apy Diagnosis apy Diagnosis apy Establishing
diagnosis
led to conserva-
tive therapy absence
of
-
Diagnosis
apy
permitted
conservative
ther-
CT
OF
MUSCULOSKELETAL
DISORDERS
TABLE Contribution
of CT in Evaluation
3
of Neoplastic
Disorders Unique
Final
Diagnosis
of Musculoskeletal Information
Provided
System by cT
E t nt
Diagnosis
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57
eio:
Primary bone tumor: Osteosarcoma of rib
+
Treatment
Definition
of soft tissue extent
optimized
Parosteal
osteosarcoma
of tibia
Established
parosteal
than medullary of tumor
rather
radiation
of tumor
therapy
plan
-
location
Chondrosarcoma of scapula Chordoma of sacrum Enchondroma
+
Planning
-
Extent of lesion apy plan
+
optimized
radiation
ther-
of femur
Enchondroma of femur Osteochondroma of rib Osteochondroma
-
of femur
+
Demonstration
+
sion altered surgical management Extent of lesion facilitated surgical
of intrathoracic
exten-
re-
moval
Giant cell tumor
Desmoplastic
of humerus
fibroma
+
of ilium
+
Demonstration of lack of soft tissue involvement dictated curettage rather than biopsy and extensive resection Extent of lesion optimized radiation therapy plan
Aneurysmal
bone
cyst of pelvis
+
Bone cyst of iliac wing
CT number
established
di-
+
Localization of lesion rather than anterior
+
Precise
+
facilitated removal Precise anatomic localization facilitated removal
+
Definition
+
tated needle biopsy and radiation apy Diagnosis indicated need for biopsy
+
Precise
agnosis Osteoid
Osteoid
osteoma
osteoma
Metastatic 112
of tibia
of femur
neoplasm
anatomic
posterior approach
localization
of nidus of nidus
to bone:
L5
Lytic lesion
of L5 estab-
lished by CT: not seen plain films
of soft
tissue
localization
tent facilitated wing
+
facili-
ther-
Precise
and definition
Plain films suggested aneurysm: CT showed soft tissue mass invading iliac wing
of ex-
biopsy
definition
of soft tissue
nent optimized Iliac wing
extension
on
Iliac wing Iliac
indicated surgical
radiation
compo-
therapy
+
Diagnosis and extent optimized radiation
of lesion therapy
Both iliac wings
+
Definition mized
Acetabulum Sacrum
+
Extent
+
apy plan Extent of soft tissue involvement ral foramina precluded surgery
+
-
+
Demonstration
plan
led to and plan
of soft tissue masses radiation therapy plan
opti-
+
Sacrum Sacrum
CT excluded suspected soft tissue mass but showed
of lesion
optimized
radiation
therof sac-
sacral lesion Soft tissue tumor: Soft tissue sarcoma
of calf
of encapsulation
correctly suggested bloc resection
Liposarcoma
of paraspinous
Paraspinous
metastatic
muscles
carcinoma
.
.
by fat
feasibility
+
Extent of lesion facilitated procedure and radiation
+
Precise localization of soft tissue guided needle biopsy
Hemangioma
of leg
+
Hemangioma
of thigh
+
Extent
of lesion
facilitated
of en
debulking therapy mass
surgical
moval
Hemangioma
of chest wall
+
Definition
of intraabdominal
led to conservative
therapy
extension
re-
58
WILSON TABLE
ET
AL.
3, continued Unique
Final
Information
Diagnosis
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Diagnosis
Lipomaofthigh Lipoma
CT number agnosis CT number
of thigh
Provided
Treatment
Fibrous
Fibrous
CT number agnosis
histiocytoma
histiocytoma
Arteriovenous
di-
+
Extent of lesion moval
facilitated
surgical
re-
established
di-
+
Extent
facilitated
surgical
re-
facilitated
surgical
re-
facilitated
surgical
re-
facilitated
surgical
re-
Desmoid
tumor
presence
of le-
of calf
+
Pooling
+
gluteus
of contrast
of gluteus
correct
.
moval
region.
Established current
presence
Extent
of lesion
moval
agent
diag-
maximus
of suprascapular
of lesion
moval Extent of lesion moval Extent of lesion
+
sion not seen on plain films Established presence of lesion not seen on plain films
malformation
tumor
di-
Established
suggested nosis Desmoid
established
of calf
maximus
Planning
established
agnosis
Lipomaofthigh
by CT
Extent of Lesion
of re-
+
Identification
+
cilitated surgical Small size of tumor tive therapy
tumor
the
most
tion
accurate
method
of pedicle
of defining
fa-
attachment
removal dictated
conserva-
the optimal
radia-
portals.
Table
4 shows
more
specifically
the contribution
of CT treatment
in establishing diagnosis, extent of lesion, and planning, tabulated according to the category
Diagnostically, often in patients
CT provided unique with nonneoplastic
with
purely
tissue
ders
of the
defining
soft
and
the extent
in all
categories,
those
involving
tissue.
lesions,
extremities
and
especially of
the
in those
or both 55
with
disor-
useful
in planning and
CT
in
treatment
lesions
bone
patients
(fig. 6). The effect of intravenous scans of the musculoskeletal
more in those
CT was
in neoplastic
the spine
In three
and
limb-girdle.
of disease
of lesion.
information diseases,
and
adjacent
made
in
soft
no
useful
contribution
few patients in attenuation was
for whom value
produced
tients
[7],
showed
no
contrast material system was variable
it was used. Marked of an arteriovenous but
large
focal increase malformation
hemangiomas
recognizable
on CT in the
in
two
pa-
change.
Discussion Assessment clinical the
of the
medicine
high
cost
considerable
disagreement
(A) and tomogram
(B) showing
large ossified mass surrounding tibia and fibula; origin of lesion is not clearly demarcated. C. CT scan demonstrating mass arising from tibial cortex. This and absence of frank medullary invasion correctly suggested diagnosis of parosteal osteosarcoma.
of diagnostic initial
study
ability correct
affecting
to
imaging
provide the
the
defined
information
useful the
of
efficacy there
definition
in the
determining
course
to contrib-
of
of
is effi-
For purposes
of CT we
as
CT is currently
surrounding Unfortunately,
procedures.
utility
disorders,
diagnosis,
care.
about
of the
musculoskeletal
9].
in
importance is seen
of medical
of the controversy techniques [8.
cacy radiograph
advances
cost
procedures
increasing
at the center new imaging
this 1.-Conventional
of diagnostic
of technologic
ute to the spiraling
Fig.
efficacy
is assuming
of
evaluation efficacy
of as
the
in establishing
extent
treatment-information
a
of disease,
or
which
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CT
OF
MUSCULOSKELETAL
DISORDERS
59
Fig.
2.-A,
Chest
radiograph
showing soft tissue mass along (ateral chest wall 2 years after resection of hemangioma in this area. B. CT scan clearly demonstrating large soft tissue mass invading chest wall and extending intraabdominally and adjacent to spleen (arrows). Treatment by surgical resection was cxcluded.
TABLE
Utility
4
of CT in 55 Patients % Patients
Lesion
Fig.
3.-CT
attachment underlying
scan
ofdesmoid
(arrow), dictating gluteal muscle.
was not demonstrated
tumor
of buttock
necessity
region
showing
of wide surgical
Disease process: Neoplastic Nonneoplastic Location: Extremity Limb girdle Spine Type of involvement Bone Softtissue Both
pedicle
resection
of -.
on the more
conventional
This study is not a definitive statement on the precise value of CT in the evaluation of the musculoskeletal system. Such a statement would require a prospective study of a large number of unselected patients, all of whom would undergo CT as well as all the conventional radiologic examinations. Instead it is an examination of the addition of CT to conventional practice for a group of patients selected by their physicians on the basis of advantages
of CT.
The
high
rate
of
utility
of
CT in our retrospective study probably reflects, at least in part, the selected nature of our patient population. Many patients whose conventional imaging procedures provided the necessary information were probably not referred for CT evaluation, automatically increasing the potential overall utility in the group that was referred. Despite the limitations discussed above, it does seem that CT can frequently offer unique information regarding the diagnosis and extent of disease in a wide variety
of the
patient.
useful
for
extent
of a lesion,
either
alone
the Our
study
or adjacent
Treat ment
92 47
76 82
25 21 9
52 43 33
68 86 89
76 76 89
13 22 20
38 68 25
85 68 85
54 91 80
d negative
CT findings.
and that such information or nonsurgical management suggests
disorders
especially
Extent
32 76
disorders, surgical
orthopedic
Diagnosis
.
38 17*
de monstrate
Eight of these patients
of musculoskeletal can often affect
imaging
procedures.
presumed
Total Pa’ tients
Category
that
CT
will
by demonstrating
if it involves
be the
the soft
most full
tissues,
to bone.
REFERENCES 1 . Alfidi AJ, Haaga J, Meaney TF, Maclntyre WJ, Gonzalez L, Tarar R, Zelch MG, BoIler M, Cook SA, Jelden G: Computed tomography of the thorax and abdomen; a preliminary report. Radiology 1 1 7 : 257-264, 1975
2. Sheedy
II PF, Stephens
DH, Hattery
AR, Muhm
JR, Hartman
GW: Computed tomography of the body: initial clinical trial with the EMI prototype. Am J Roentgeno! 127:23-51 , 1976 3. Stanley RJ, Sagel SS, Levitt AG: Computed tomography of the body: early trends in application and accuracy of the method . Am J Roentgeno! 127 : 53-67 , 1976 4. Weinberger G, Levinsohn EM: Computed tomography in the evaluation of sarcomatous tumors of the thigh. Am J Roentgeno! 130:115-118, 1978
WILSON
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60
ET AL.
Fig. 4.-A, Radiograph after left hemipelvectamy quite assess
graphically response
showing large destructive lesion metastatic from renal cell tumor in left iliac wing. B, Film 2 years showing erosion of lumbosacral region and poorly defined soft tissue mass in this area. C, CT scan delineating the size and extent of soft tissue component of recurrent tumor. Serial CT scans were used to
to subsequent
chemotherapy.
5. Berger PE, Kuhn JP: Computed tomography of tumors of the musculoskeletal system in children. Radiology 127 : 171175, 1978
6. Schumacher
TM, Genant
HK, Korobkin
MI,
Bovill
Jr EG:
Computed tomography: its use in space-occupying lesions of the musculoskeletal system. J Bone Joint Surg. In press, 1978 7, Korobkin M, Kressel HY, Moss AA, Koehler RE: Computed
tomographic 811, 1978
8. Abrams
angiography
HL, McNeil
tomography
of the body.
BJ: Medical
Radiology
implications
126:807-
of computed 298 : 255-
(“CAT
scanning”).
I . N Eng!
J Med
McNeil (“CAT
BJ: Medical scanning”).
implications of computed II. N EngI J Med 298:310-
261, 1978 9. Abrams HL, tomography
318, 1978
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CT OF MUSCULO5KELETAL DISORDERS 61
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JOHN
Tomography
S. WILSON,1
MELVYN
of Musculoskeletal
KOROBKIN,’
HARRY
The utility of computed tomography (CT) in evaluation of musculoskeletal disorders was assessed In 55 selected patients. CT provided unique information leading to a correct diagnosis in 45% of cases. In 78% the extent of a lesion was more clearly defined than on conventional imaging procedures, and in the same percentage the CT findings were used to plan optimal therapy. CT was most useful in demonstrating absence of a suspected mass lesion and in defining the full extent of a lesion involving the soft tissues.
K. GENANT,’
to:
From
July
1976 through
June
1977,
approximately
and cysts. of bone
from
or sufficient
surgery
clinical
follow-up
data
with
which
and
Availability to select
Most obtaining
in hopes of or extent of a
lesion few
patients more than
were
was
provided
undoubtedly
new imaging from
were referred for CT scanning information about the diagnosis
method.
8 to 75 years
by
conventional
referred
because
imaging
The 32 men and 23 women
and
included
A
about
the
a complete
ranged
Metastatic
radiography
and often
ton.
Soft
tissue
tumors
were
examined
radionuclide
tumors
and
imaging
suspected
were
5005,
or the
GE CT/I
body
scanner.
Slices
field
for comparison.
and after urographic Received
A few patients
skele-
10 or 13 mm
evaluated
14,
1978;
accepted
after
revision
(2)
with
composed
normal
included
fibrous
of patients
lesions
with
(bone island
CT findings
who
sarcomas
histiocytomas.
had
,
The
infectious
Baker’s
clinical
cyst)
follow-up
with
the information
obtained
by the conven-
gained
by the
other
imaging
modalities.
CT was considered lished the presence
useful for diagnosis if it correctly or absence of a suspected lesion,
correctly
the
suggested
specific
histologic
nature
of
estabor if it a lesion.
of CT to offer additional
and useful
information
of disease, and treatment with the referring din-
Results
Tables for
thick
both
April
each
regarding
2 and 3 detail of the
the utility,
55 patients.
correct
or lack
of utility,
of CT
CT added
unique
information
in
patients
(45%).
diagnosis
25
Al-
though CT was usually unable to suggest a specific histologic diagnosis, lesions containing predominantly fatty or cystic components were correctly identified by their characteristic attenuation values. In addition, the
before
the intravenous injection of 300 ml of 25%-30% contrast material; most received no contrast agent. February
accord-
examined
from just above to just When an extremity was was included in the scan
were
was
evaluated
several
in the categories of diagnosis, extent planning was assessed in consultation cian.
with routine and xeroradiographic filming. Some patients had only standard radiographic projections prior to CT. CT scanning was performed using the EMI 5000, the EMI were obtained at 1 or 2 cm intervals below a known or suspected lesion. examined, the contralateral extremity
and
and miscellaneous
cases, the ability
by conventional
masses
grouped
or nonneoplastic:
CT was judged useful for treatment planning not only when it helped determine the mode of therapy (surgery, radiation, chemotherapy, or no therapy), but also when information about the extent of disease and its relation to specific bones, muscle bundles, or large nerves and blood vessels affected the size of incision and the degree of dissection, thus reducing the duration of surgery and the amount of tissue destruction. In most
of body
of the entire
tumors
tissue
group
patients
mation
size and habitus. The pre-CT workup was not prospectively planned but rather was that usually used in this hospital. Primary bone tumors were examined by conventional radiography and usually linear tomography.
soft
and compared
in age
spectrum
were
studied
tional procedures. Finally, after a critical review of each patient’s medical records and personal interviews with referring physicians, an estimate of the clinical utility of each CT examination was made. The CT examination was judged useful if it contributed uniquely to (1) establishing a correct diagnosis; (2) demonstrating the extent of a disease process; or (3) affecting the treatment plan. CT was not considered useful if it only confirmed infor-
of the
studies.
of curiosity
JR.2
examinations estalishing that no lesion had been present. Three of us (J.S. Wilson, M. Korobkin, and H.K. Genant) each evaluated the 55 cases in the following way. First, the results of conventional imaging procedures were reviewed and validated, including standard radiography, tomography, and xerography. Second , the results of each CT scan were reviewed
to
assess the accuracy and value of the CT findings. such information was the only criterion used patients evaluated in this report.
BOVILL,
process-neoplastic
The malignant
and
nonneoplastic
70 patients
to our radiology department for CT evaluation of disorders. Of these patients, 55 had records
G.
skeletal location-extremity, spine, or limb-girdle (shoulder, pelvis, or ribs); and (3) type of involvement-bone, soft tissue, or both (table 1). The 20 benign neoplasms studied included desmoid tumors, hemangiomas, osteoid osteomas, lipomas,
Methods
were referred musculoskeletal
EDWIN
disorders
disease
(1)
processes
and
AND
The musculoskeletal ing
Considerable controversy exists regarding the role of computed tomography (CT) in the diagnosis and management of disease, especially in the extracranial portions of the body. The value of CT in the assessment of space-occupying lesions of the musculoskeletal system has been reported only in a preliminary fashion [1-6]. We describe our early experience with CT in evaluating orthopedic disorders.
Subjects
Disorders
correct
diagnosis
of
no
pathology
was
made
in
eight
18, 1978.
Presented atthe annual meeting of the American
Roentgen Ray Society, Boston, September 1977. Scholar in Radiological Research, and recipient of National
M. Korobkin is a James Picker Foundation ment Award GM 00055 from the National Institute of General ‘Department of Radiology, University of California School 2Department of Orthopedic Surgery, University of California
Am J Roentgenol © 1978 American
July 1978
131 :55-61
,
Roentgen
Ray Society
Medical
Institutes
of Health Research
Career Develop-
Sciences.
of Medicine,
San
School
of Medicine, 55
Francisco,
California
San Francisco,
94143.
California
Address
reprint
requests
to M. Korobkin.
94143.
0361 -803X/78/0700
-
0055
$00.00
WILSON
56 TABLE Distribution
of Patients
ET AL.
1
According
to Lesion
patients whose physical examination suggested the presence of a soft tissue mass. In 43 patients (78%), the precise location or extent of a lesion was better defined by CT than the conventional imaging procedures (figs. 1-5). CT was also considered useful in planning optimal treatment in 43 patients (78%). Utility in treatment planning was more often related to demonstration of extent of disease than to establishment
Categories
Patients
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Category
Disease Process: Neoplastic: Benign Primary
malignant
Metastatic Subtotal Nonneoplastic: Infectious Negative study
Miscellaneous
No.
%
20
36
7
13
11
20
38
69
5 8
9 14
of a correct
4
8
17
31
Location: Extremity
25
46
Limbgirdle
21
38
9
16
Subtotal
Spine Type: Bone Soft tissue
Both
13
24
22 20
40 36
TABLE Contribution
of CT in Evaluation
2
of Nonneoplastic
Disorders unique
Final
Diagnosis
diagnosis.
In one patient (fig. 2), the CT demonstration of extension of a recurrent hemangioma of the chest wall into the abdominal cavity was clinically unsuspected, dictating conservative rather than surgical therapy. In another patient, demonstration of a pedicle attachment of a desmoid tumor (fig. 3) demonstrated the necessity for a wide resection of the underlying gluteus muscle. In a patient with an osteoid osteoma of the femur (fig. 5), the transaxial display of the precise location of the nidus along the circumference of the bone resulted in a more limited surgical resection of the involved cortical region than would have otherwise been performed. When irradiation was the mode of treatment, CT usually provided
.
Diagnosis
of Musculoskeletal Information
Provided
System by CT
Extent of Lesion
.
Treatment
Planning
Confirmed: Discitis
L4-L5
Discitis
and
prevertebral
abscess
T10-T11
Identified abscess
large
prevertebral
-
+
Diagnosis
+
need for surgical debridement Extent of lesion indicated need
and extent
of lesion
indicated for sur-
gical debridement Discitis
L4-L5
Sterile
abscess
Osteophyte
-
of flank
Identified mass
of sacroiliac
joint
Poorly
low density defined
flank
sclerotic
-
-
+
Extent
+
agement Diagnosis permitted apy
conservative
ther-
+
Diagnosis
conservative
ther-
Ic-
sion by tomography, clearly identified as OsBone
islands,
iliac
teophyte Identified
wings
pected
by CT multiple
lesions
to original
Brody’s
abscess
proximal
femur
unsus-
in addition
of lesion
permitted
lesion,
Bullet fragment
tibia
+
Excluded cation
man-
lesion
-
Precise
anatomic
intraarticular
lo-
depiction
of lesion fa-
biopsy
+
-
+
-
-
Diagnosis
permitted
conservative
ther-
apy Diagnosis apy
permitted
conservative
ther-
Diagnosis apy
permitted
conservative
ther-
Diagnosis
permitted
conservative
ther-
permitted
conservative
ther-
permitted
conservative
ther-
-
in acetabulum
surgical
apy
cilitated Inflammatory
facilitated
of bullet
Suspected: Recurrent
liposarcoma
of thigh
Recurrent tumor of thigh Recurrent desmoid tumor maximus
of gluteus
Established
mass Established mass Established
absence
of
absence
of
-
absence
of soft
-
absence
of
-
tissue
Calf mass
Established mass
Calf mass
Established
absence
of
-
Calf
mass Established mass
absence
of
-
absence
of
-
mass
Scapular
mass
Chest wall mass
Established mass Established mass
apy Diagnosis apy Diagnosis apy Establishing
diagnosis
led to conserva-
tive therapy absence
of
-
Diagnosis
apy
permitted
conservative
ther-
CT
OF
MUSCULOSKELETAL
DISORDERS
TABLE Contribution
of CT in Evaluation
3
of Neoplastic
Disorders Unique
Final
Diagnosis
of Musculoskeletal Information
Provided
System by cT
E t nt
Diagnosis
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57
eio:
Primary bone tumor: Osteosarcoma of rib
+
Treatment
Definition
of soft tissue extent
optimized
Parosteal
osteosarcoma
of tibia
Established
parosteal
than medullary of tumor
rather
radiation
of tumor
therapy
plan
-
location
Chondrosarcoma of scapula Chordoma of sacrum Enchondroma
+
Planning
-
Extent of lesion apy plan
+
optimized
radiation
ther-
of femur
Enchondroma of femur Osteochondroma of rib Osteochondroma
-
of femur
+
Demonstration
+
sion altered surgical management Extent of lesion facilitated surgical
of intrathoracic
exten-
re-
moval
Giant cell tumor
Desmoplastic
of humerus
fibroma
+
of ilium
+
Demonstration of lack of soft tissue involvement dictated curettage rather than biopsy and extensive resection Extent of lesion optimized radiation therapy plan
Aneurysmal
bone
cyst of pelvis
+
Bone cyst of iliac wing
CT number
established
di-
+
Localization of lesion rather than anterior
+
Precise
+
facilitated removal Precise anatomic localization facilitated removal
+
Definition
+
tated needle biopsy and radiation apy Diagnosis indicated need for biopsy
+
Precise
agnosis Osteoid
Osteoid
osteoma
osteoma
Metastatic 112
of tibia
of femur
neoplasm
anatomic
posterior approach
localization
of nidus of nidus
to bone:
L5
Lytic lesion
of L5 estab-
lished by CT: not seen plain films
of soft
tissue
localization
tent facilitated wing
+
facili-
ther-
Precise
and definition
Plain films suggested aneurysm: CT showed soft tissue mass invading iliac wing
of ex-
biopsy
definition
of soft tissue
nent optimized Iliac wing
extension
on
Iliac wing Iliac
indicated surgical
radiation
compo-
therapy
+
Diagnosis and extent optimized radiation
of lesion therapy
Both iliac wings
+
Definition mized
Acetabulum Sacrum
+
Extent
+
apy plan Extent of soft tissue involvement ral foramina precluded surgery
+
-
+
Demonstration
plan
led to and plan
of soft tissue masses radiation therapy plan
opti-
+
Sacrum Sacrum
CT excluded suspected soft tissue mass but showed
of lesion
optimized
radiation
therof sac-
sacral lesion Soft tissue tumor: Soft tissue sarcoma
of calf
of encapsulation
correctly suggested bloc resection
Liposarcoma
of paraspinous
Paraspinous
metastatic
muscles
carcinoma
.
.
by fat
feasibility
+
Extent of lesion facilitated procedure and radiation
+
Precise localization of soft tissue guided needle biopsy
Hemangioma
of leg
+
Hemangioma
of thigh
+
Extent
of lesion
facilitated
of en
debulking therapy mass
surgical
moval
Hemangioma
of chest wall
+
Definition
of intraabdominal
led to conservative
therapy
extension
re-
58
WILSON TABLE
ET
AL.
3, continued Unique
Final
Information
Diagnosis
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Diagnosis
Lipomaofthigh Lipoma
CT number agnosis CT number
of thigh
Provided
Treatment
Fibrous
Fibrous
CT number agnosis
histiocytoma
histiocytoma
Arteriovenous
di-
+
Extent of lesion moval
facilitated
surgical
re-
established
di-
+
Extent
facilitated
surgical
re-
facilitated
surgical
re-
facilitated
surgical
re-
facilitated
surgical
re-
Desmoid
tumor
presence
of le-
of calf
+
Pooling
+
gluteus
of contrast
of gluteus
correct
.
moval
region.
Established current
presence
Extent
of lesion
moval
agent
diag-
maximus
of suprascapular
of lesion
moval Extent of lesion moval Extent of lesion
+
sion not seen on plain films Established presence of lesion not seen on plain films
malformation
tumor
di-
Established
suggested nosis Desmoid
established
of calf
maximus
Planning
established
agnosis
Lipomaofthigh
by CT
Extent of Lesion
of re-
+
Identification
+
cilitated surgical Small size of tumor tive therapy
tumor
the
most
tion
accurate
method
of pedicle
of defining
fa-
attachment
removal dictated
conserva-
the optimal
radia-
portals.
Table
4 shows
more
specifically
the contribution
of CT treatment
in establishing diagnosis, extent of lesion, and planning, tabulated according to the category
Diagnostically, often in patients
CT provided unique with nonneoplastic
with
purely
tissue
ders
of the
defining
soft
and
the extent
in all
categories,
those
involving
tissue.
lesions,
extremities
and
especially of
the
in those
or both 55
with
disor-
useful
in planning and
CT
in
treatment
lesions
bone
patients
(fig. 6). The effect of intravenous scans of the musculoskeletal
more in those
CT was
in neoplastic
the spine
In three
and
limb-girdle.
of disease
of lesion.
information diseases,
and
adjacent
made
in
soft
no
useful
contribution
few patients in attenuation was
for whom value
produced
tients
[7],
showed
no
contrast material system was variable
it was used. Marked of an arteriovenous but
large
focal increase malformation
hemangiomas
recognizable
on CT in the
in
two
pa-
change.
Discussion Assessment clinical the
of the
medicine
high
cost
considerable
disagreement
(A) and tomogram
(B) showing
large ossified mass surrounding tibia and fibula; origin of lesion is not clearly demarcated. C. CT scan demonstrating mass arising from tibial cortex. This and absence of frank medullary invasion correctly suggested diagnosis of parosteal osteosarcoma.
of diagnostic initial
study
ability correct
affecting
to
imaging
provide the
the
defined
information
useful the
of
efficacy there
definition
in the
determining
course
to contrib-
of
of
is effi-
For purposes
of CT we
as
CT is currently
surrounding Unfortunately,
procedures.
utility
disorders,
diagnosis,
care.
about
of the
musculoskeletal
9].
in
importance is seen
of medical
of the controversy techniques [8.
cacy radiograph
advances
cost
procedures
increasing
at the center new imaging
this 1.-Conventional
of diagnostic
of technologic
ute to the spiraling
Fig.
efficacy
is assuming
of
evaluation efficacy
of as
the
in establishing
extent
treatment-information
a
of disease,
or
which
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CT
OF
MUSCULOSKELETAL
DISORDERS
59
Fig.
2.-A,
Chest
radiograph
showing soft tissue mass along (ateral chest wall 2 years after resection of hemangioma in this area. B. CT scan clearly demonstrating large soft tissue mass invading chest wall and extending intraabdominally and adjacent to spleen (arrows). Treatment by surgical resection was cxcluded.
TABLE
Utility
4
of CT in 55 Patients % Patients
Lesion
Fig.
3.-CT
attachment underlying
scan
ofdesmoid
(arrow), dictating gluteal muscle.
was not demonstrated
tumor
of buttock
necessity
region
showing
of wide surgical
Disease process: Neoplastic Nonneoplastic Location: Extremity Limb girdle Spine Type of involvement Bone Softtissue Both
pedicle
resection
of -.
on the more
conventional
This study is not a definitive statement on the precise value of CT in the evaluation of the musculoskeletal system. Such a statement would require a prospective study of a large number of unselected patients, all of whom would undergo CT as well as all the conventional radiologic examinations. Instead it is an examination of the addition of CT to conventional practice for a group of patients selected by their physicians on the basis of advantages
of CT.
The
high
rate
of
utility
of
CT in our retrospective study probably reflects, at least in part, the selected nature of our patient population. Many patients whose conventional imaging procedures provided the necessary information were probably not referred for CT evaluation, automatically increasing the potential overall utility in the group that was referred. Despite the limitations discussed above, it does seem that CT can frequently offer unique information regarding the diagnosis and extent of disease in a wide variety
of the
patient.
useful
for
extent
of a lesion,
either
alone
the Our
study
or adjacent
Treat ment
92 47
76 82
25 21 9
52 43 33
68 86 89
76 76 89
13 22 20
38 68 25
85 68 85
54 91 80
d negative
CT findings.
and that such information or nonsurgical management suggests
disorders
especially
Extent
32 76
disorders, surgical
orthopedic
Diagnosis
.
38 17*
de monstrate
Eight of these patients
of musculoskeletal can often affect
imaging
procedures.
presumed
Total Pa’ tients
Category
that
CT
will
by demonstrating
if it involves
be the
the soft
most full
tissues,
to bone.
REFERENCES 1 . Alfidi AJ, Haaga J, Meaney TF, Maclntyre WJ, Gonzalez L, Tarar R, Zelch MG, BoIler M, Cook SA, Jelden G: Computed tomography of the thorax and abdomen; a preliminary report. Radiology 1 1 7 : 257-264, 1975
2. Sheedy
II PF, Stephens
DH, Hattery
AR, Muhm
JR, Hartman
GW: Computed tomography of the body: initial clinical trial with the EMI prototype. Am J Roentgeno! 127:23-51 , 1976 3. Stanley RJ, Sagel SS, Levitt AG: Computed tomography of the body: early trends in application and accuracy of the method . Am J Roentgeno! 127 : 53-67 , 1976 4. Weinberger G, Levinsohn EM: Computed tomography in the evaluation of sarcomatous tumors of the thigh. Am J Roentgeno! 130:115-118, 1978
WILSON
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60
ET AL.
Fig. 4.-A, Radiograph after left hemipelvectamy quite assess
graphically response
showing large destructive lesion metastatic from renal cell tumor in left iliac wing. B, Film 2 years showing erosion of lumbosacral region and poorly defined soft tissue mass in this area. C, CT scan delineating the size and extent of soft tissue component of recurrent tumor. Serial CT scans were used to
to subsequent
chemotherapy.
5. Berger PE, Kuhn JP: Computed tomography of tumors of the musculoskeletal system in children. Radiology 127 : 171175, 1978
6. Schumacher
TM, Genant
HK, Korobkin
MI,
Bovill
Jr EG:
Computed tomography: its use in space-occupying lesions of the musculoskeletal system. J Bone Joint Surg. In press, 1978 7, Korobkin M, Kressel HY, Moss AA, Koehler RE: Computed
tomographic 811, 1978
8. Abrams
angiography
HL, McNeil
tomography
of the body.
BJ: Medical
Radiology
implications
126:807-
of computed 298 : 255-
(“CAT
scanning”).
I . N Eng!
J Med
McNeil (“CAT
BJ: Medical scanning”).
implications of computed II. N EngI J Med 298:310-
261, 1978 9. Abrams HL, tomography
318, 1978
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CT OF MUSCULO5KELETAL DISORDERS 61
