DIAGNOSTIC RADIOLOGY Musculoskeletal and Breast Imaging PIONEERS OF AIIMS–MAMC–PGI IMAGING COURSE SERIES Manorama Berry Sudha Suri Veena Chowdhury PAST EDITORS Sima Mukhopadhyay Sushma Vashisht DIAGNOSTIC RADIOLOGY Musculoskeletal and Breast Imaging Third Edition Editors Veena Chowdhury MD Arun Kumar Gupta MD MNAMS FAMS Director-Professor and Head Professor and Head Department of Radiodiagnosis Department of Radiodiagnosis Maulana Azad Medical College All India Institute of Medical Sciences New Delhi, India New Delhi, India Niranjan Khandelwal MD DNB FICR Professor and Head Department of Radiodiagnosis Postgraduate Institute of Medical Education and Research Chandigarh, India Associate Editors Anju Garg MD Anjali Prakash DMRD DNB MNAMS Director-Professor Professor Department of Radiodiagnosis Department of Radiodiagnosis Maulana Azad Medical College Maulana Azad Medical College New Delhi, India New Delhi, India ® JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD New Delhi • Panama City • London ® Jaypee Brothers Medical Publishers (P) Ltd. 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Diagnostic Radiology: Musculoskeletal and Breast Imaging First Edition : 1998 Second Edition : 2005 Reprint : 2011 Third Edition : 2012 ISBN 978-93-5025-883-5 Printed at Contributors Alpana Manchanda MD Deep Narayan Srivastava MD MBA FICR Professor Professor Department of Radiodiagnosis Department of Radiodiagnosis Maulana Azad Medical College All India Institute of Medical Sciences New Delhi, India New Delhi, India Anjali Prakash DMRD DNB MNAMS Gaurav Shanker Pradhan DMRD DNB Professor Professor Department of Radiodiagnosis Department of Radiodiagnosis Maulana Azad Medical College Maulana Azad Medical College New Delhi, India New Delhi, India Anju Garg MD Jyoti Kumar MD Director-Professor Associate Professor Department of Radiodiagnosis Department of Radiodiagnosis Maulana Azad Medical College Maulana Azad Medical College New Delhi, India New Delhi, India Arun Kumar Gupta MD MNAMS FAMS Mahesh Prakash MD Professor and Head Associate Professor Department of Radiodiagnosis Department of Radiodiagnosis All India Institute of Medical Sciences Postgraduate Institute of Medical Education New Delhi, India and Research, Chandigarh, India Arun Malhotra DRM PhD Manavjit Singh Sandhu MD Professor and Head Professor Department of Nuclear Medicine Department of Radiodiagnosis All India Institute of Medical Sciences Postgraduate Institute of Medical Education New Delhi, India and Research, Chandigarh, India Ashu Seith Bhalla MD Mandeep Kang MD DNB Additional Professor Additional Professor Department of Radiodiagnosis Department of Radiodiagnosis All India Institute of Medical Sciences Postgraduate Institute of Medical Education New Delhi, India and Research, Chandigarh, India Atin Kumar MD DNB MNAMS Manphool Singhal MD DNB Associate Professor Assistant Professor Department of Radiodiagnosis Department of Radiodiagnosis All India Institute of Medical Sciences Postgraduate Institute of Medical Education New Delhi, India and Research, Chandigarh, India vi Diagnostic Radiology: Musculoskeletal and Breast Imaging Mukesh Kumar Yadav MD Sanjay Thulkar MD Assistant Professor Additional Professor Department of Radiodiagnosis Department of Radiodiagnosis Postgraduate Institute of Medical Education All India Institute of Medical Sciences and Research, Chandigarh, India New Delhi, India Niranjan Khandelwal MD DNB FICR Sapna Singh MD DNB MNAS Professor and Head Associate Professor Department of Radiodiagnosis Department of Radiodiagnosis Postgraduate Institute of Medical Education Maulana Azad Medical College and Research, Chandigarh, India New Delhi, India Paramjeet Singh MD Shivanand Gamanagatti MD MNAMS Professor Associate Professor Department of Radiodiagnosis Department of Radiodiagnosis Postgraduate Institute of Medical Education All India Institute of Medical Sciences and Research, Chandigarh, India New Delhi, India Punit Sharma MD Smriti Hari MD Senior Resident Associate Professor Department of Nuclear Medicine Department of Radiodiagnosis All India Institute of Medical Sciences All India Institute of Medical Sciences New Delhi, India New Delhi, India Raju Sharma MD MNAMS Sumedha Pawa MD Professor Director-Professor Department of Radiodiagnosis Department of Radiodiagnosis All India Institute of Medical Sciences Maulana Azad Medical College New Delhi, India New Delhi, India Rakesh Kumar MD PhD Veena Chowdhury MD Additional Professor Director-Professor and Head Department of Nuclear Medicine Department of Radiodiagnosis All India Institute of Medical Sciences Maulana Azad Medical College New Delhi, India New Delhi, India Rashmi Dixit MD Vivek Gupta MD Professor Associate Professor Department of Radiodiagnosis Department of Radiodiagnosis Maulana Azad Medical College Postgraduate Institute of Medical Education New Delhi, India and Research, Chandigarh, India Sameer Vyas MD Assistant Professor Department of Radiodiagnosis Postgraduate Institute of Medical Education and Research, Chandigarh, India Preface to the Third Edition Musculoskeletal radiology has witnessed tremendous strides since Roentgen took the first X-ray of the hand in 1895. Conventional radiology remains the mainstay in the initial evaluation of trauma and bone tumors. The limited resolution of X-ray to delineate various components of the musculoskeletal system has now been overcome by advances in cross- sectional imaging. Magnetic resonance imaging (MRI) and dual energy computed tomography (CT) demonstrate each detail of ligament, tendon, muscle and bone. The first edition of Musculoskeletal and Breast Radiology was published in 1998 followed by the second edition in 2005. The present edition has been designed to provide an integrated approach to musculoskeletal disorders. The first section deals with all imaging modalities in detail. There is also an updated section on MR imaging. All chapters have been thoroughly revised. Being a developing nation, infections continue to be a health problem and an entire section is devoted to it. The importance of conventional radiography has been emphasized because all radiology services have an X-ray unit and further the differential diagnosis of various bone lesions should not be made on CT and MRI alone without referring to recent plain radiographs. The text is intended to assist in the interpretation of imaging studies and in suggesting the appropriate imaging technique to clinicians involved in patient care. The second part of the book contains updated chapters on Breast imaging, including a new one titled A Systematic Approach to Imaging of Breast Lesions. Breast interventions are being increasingly performed, and a new chapter on the same has been added. The role of PET-CT in breast cancer is also included as a new chapter. Dr Sumedha Pawa, the associate editor of the previous edition passed away in October 2011, just as preparations for this edition were underway. We acknowledge her contribution and wish to place on record our heartfelt thanks to her. We dedicate this edition to her. The editors take this opportunity to thank the faculty of the three organizing institutions who have put their collective experience in this book. We would also like to express our appreciation to Shri Jitendar P Vij (Chairman and Managing Director), Mr Tarun Duneja (Director-Publishing), Ms Samina Khan and other staff of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, for their professionalism and dedication towards publication of this book. Veena Chowdhury Arun Kumar Gupta Niranjan Khandelwal Anju Garg Anjali Prakash Preface to the First Edition There has been a significant increase in the awareness as well as in the actual incidence of detection of disorders related to the musculoskeletal system and the breast over the years. At the same time, a continuous revolution, occurring in the field of imaging over these years, has given a new insight in the proper diagnosis, management and follow-up of these disorders. With the availability of a large number of imaging techniques today, including conventional radiology, computed tomography (CT), magnetic resonance imaging (MRI), ultrasonography (USG), interventional procedures and radioisotope studies, each having its own merits and limitations, it has become essential on the part of the present day radiologist to be able to advise and use the most cost-effective methodology in a given clinical situation. Such a need assumes even a greater importance in the limited resources situation of a developing country. It is necessary for a radiologist of today to learn the basic aspects and role of various imaging modalities in a given clinical situation for taking the fullest advantage of these modalities. The need for a closer cooperation and understanding of each other’s role between the radiologist and a clinician had never been felt greater before. The present book on Musculoskeletal and Breast Imaging, the fifth in the series of AIIMS-MAMC-PGI imaging courses, is a further attempt in this direction. The book has been broadly divided into two sections, i.e. the musculoskeletal disorders and the breast disorders, each section dealing at length with the relevant imaging techniques and their interpretations in various disease processes. There are 19 chapters, dealing with all important aspects of these systems. The multimodality imaging approach to bone, soft tissue and joint diseases is presented while retaining the major emphasis on conventional radiological findings. There are separate sections devoted to imaging modalities for infections and inflammations, metabolic bone disorders and tumors. The text is intended to assist in the interpretation of imaging studies of patients with these disorders and in suggesting the appropriate imaging technique to the clinicians involved in their care. The role of mammography in early diagnosis of breast cancer and in helping in breast conservation need not be overemphasized. The section on breast imaging deals in detail with the role of screening mammography, its relevance as it pertains to our country, the current status of various other imaging modalities and future directions in the imaging of breast. The purpose of this book is to provide the reader with essential information in all important aspects of the subspecialty of musculoskeletal and breast imaging, and we hope that it serves as a compliment to the AIIMS-MAMC-PGI course, through its concise, comprehensive and current survey on the subject. We are grateful to all our faculty staff and other eminent teachers for contributing their experiences through their excellent write-ups in all these volumes providing a balanced view on the modern day practice of Radiology in various clinical situations. We also thank the series publishers M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, Shri Jitendar P Vij (Chairman and Managing Director) and other staff, for timely publication of all these volumes in an excellent form. But for their active and persistent involvement, such a gigantic task would not have been a reality. We do sincerely hope that all these volumes, including the present one published under the AIIMS-MAMC-PGI imaging course series, shall be able to fulfill the desired aims and shall continue to guide the readers in their daily office practice of radiology. Readers response shall always remain the ultimate guiding spirit in this direction. Manorama Berry Veena Chowdhury Sudha Suri Sima Mukhopadhyay Contents Part One: MUSCULOSKELETAL IMAGING IMAGING MODALITIES 1. Diagnostic Approach to Focal Bone Lesions: Conventional Radiography, Computed Tomography and Magnetic Resonance Imaging .................................................................... 3 Shivanand Gamanagatti, Raju Sharma 2. Basic Principles and Current Concepts of Musculoskeletal Magnetic Resonance Imaging.................... 20 Raju Sharma, Shivanand Gamanagatti 3. Nuclear Medicine Imaging for Musculoskeletal Disorders................................................................... 35 Rakesh Kumar, Punit Sharma, Arun Malhotra 4. Angiography and Interventions in Musculoskeletal Lesions ................................................................ 49 Deep Narayan Srivastava INFECTIONS/INFLAMMATIONS 5. Tuberculosis of Bones and Joints ......................................................................................................... 64 Gaurav Shanker Pradhan, Veena Chowdhury 6. Nontubercular Bone and Joint Infections............................................................................................. 80 Manphool Singhal, Niranjan Khandelwal 7. Tuberculosis of the Spine..................................................................................................................... 94 Rashmi Dixit 8. Noninfective Inflammatory Arthritis...................................................................................................113 Mandeep Kang, Mahesh Prakash 9. Nontubercular Infections of the Spine................................................................................................133 Sameer Vyas, Manavjit Singh Sandhu 10. Degenerative Disease of the Spine and Joints ....................................................................................149 Jyoti Kumar, Sumedha Pawa METABOLIC BONE DISEASES 11. Skeletal Disorders of Metabolic and Endocrine Origin........................................................................177 Alpana Manchanda, Arun Kumar Gupta 12. Osteoporosis ......................................................................................................................................212 Mukesh Kumar Yadav, Vivek Gupta, Niranjan Khandelwal