Pediatric Bone Scintigraphy Update

Helen R. Nadel, MD, FRCPC (Diag Rad) (Nuc Med), ABR (Diag Rad) (Ped Rad), ABNM

Bone scintigraphy is a sensitive tool to evaluate the musculoskeletal system in children.

Hybrid imaging using computed tomography (CT) in combination with conventional bone
scan and single photon emission computed tomography improves specificity and diagnos-
tic accuracy. It also improves laboratory efficiency and may save the patient an additional
visit to the hospital for a separate cross-sectional imaging study. We have found this
technique to be particularly helpful in localizing a cause for pain in children who are
nonverbal and to better delineate small bone and soft-tissue lesions that can occur with
diagnoses of trauma, infection, and tumor. Special attention to technique of positioning the
patient for potential CT examination is an adaptation that must be made by the technologist.
Because of radiation concerns of the additional CT, obviously these examinations should
be tailored to the individual child and be performed for limited sites directed to the
abnormality observed on the associated single photon emission computed tomography
examination or directed by the appropriate history.
Semin Nucl Med 40:31-40 © 2010 Elsevier Inc. All rights reserved.

B one scintigraphy still remains one of the most common

indications for radionuclide examination in children. It is
a sensitive examination to identify alterations in bone metab-
children who are neurodevelopmentally delayed may require
sedation for the procedure to be performed. In those instances,
a pediatric anesthesiologist and their team handle all sedation,
olism for any cause, but because of this nonspecificity the and it is their decision as to whether conscious sedation or gen-
findings obtained from the scintigraphic examination must eral anesthesia is performed. The sedation process is usually
be correlated with the patient’s clinical history and appro- only applied to the delayed imaging phase. In all instances, the
priate conventional and cross-sectional imaging. With the child is fully monitored during the procedure and is recovered
development of hybrid imaging in nuclear medicine, par- by nursing staff before being discharged home.
ticularly single-photon emission computed tomography Administered radiopharmaceutical dose is usually
(SPECT/CT), this is now a reality for obtaining the perti- weight-based. There has been some attempt to standardize
nent correlative imaging in a single study in the nuclear the administered dose of radiopharmaceutical. The Euro-
medicine department. pean Association of Nuclear Medicine has published their
There have been several excellent reviews of bone scintigra- pediatric dose card on the basis of a multiple of baseline
phy since pediatric bone update was reported in this journal in activity depending on the weight of the child to obtain
2007.1-4 This current update is to identify some of the differ- weight-independent effective dose measurements for ad-
ences in evaluating the skeletal system in children and to high- ministered activity. The calculation for administered ac-
light how hybrid imaging has been incorporated into the evalu- tivity in MBq is baseline activity ⫻ multiple depending on
ation to diagnose musculoskeletal disorders in children. weight with minimum of 40 MBq administered activity.5
The European Association of Nuclear Medicine website
Technical has the dosage card for all common radiopharmaceuticals
and recommended administered radiopharmaceutical
In our department sedation is not routinely employed when doses in children.6 North American pediatric centers have
performing bone scintigraphy. However, in certain instances recently been surveyed on their administered doses and
have shown variability in the administered dose of radio-
pharmaceutical.7 Our current recommendation for admin-
Division of Nuclear Medicine, Department of Radiology, British Columbia istered dose of 99mTc-methylene diphosphonate (99mTc-
Children’s Hospital, University of British Columbia, Vancouver, Canada. MDP) for bone scintigraphy is 0.2-0.3 mCi/kg with a
Address reprint requests to Helen R. Nadel, MD, FRCPC (Diag Rad) (Nuc
Med), ABR (Diag Rad) (Ped Med), ABNM, Department of Nuclear Med-
minimum dose of 3 mCi and maximum dose of 15 mCi.
icine, British Columbia Children’s Hospital, 4480 Oak St, Vancouver, A physician screens all requests for scintigraphic exam-
BC V6H 3V4, Canada. E-mail: [email protected] ination before an examination booking is made. At that

0001-2998/10/$-see front matter © 2010 Elsevier Inc. All rights reserved. 31

doi:10.1053/j.semnuclmed.2009.10.001
32 H.R. Nadel

Figure 1 (A) A 12-year-old male with swelling noted in right supraclavicular area. Whole-body bone scintigraphy
showed an area of mild delayed increased activity in the right supraclavicular area lateral to the sternoclavicular
junction (arrow). (B) Maximum intensity projection (MIP) image of bone SPECT in axial plane better defines the focal
abnormality (arrow). (C) Fused coronal SPECT/CT identifies that the increased activity is due to developmental variant
of congenitally fused first and second rib. (D) CT performed for the SPECT/CT study is processed as a 3D volume
rendered reconstruction, and clearly identifies the congenital rib fusion abnormality that appears as an area of increased
activity on the bone scan (arrow).

time, the examination technique is tailored by notation on reconstruction is performed on the SPECT study, and res-
the requisition, to answer the diagnostic question and to olution recovery software is employed when the study is
instruct the technologist as to whether the study has im- reconstructed. The addition of CT to the study is usually
mediate and delayed imaging, where SPECT might be per- suggested when the examination request is triaged by the
formed, and if there is a likelihood of additional coregis- nuclear medicine physician, but the actual decision to
tered CT and if that CT study is likely to require an perform additional CT is not made until the planar and
intravenous contrast administration. After the administer- SPECT imaging is reviewed with the patient still on the
ing of the radiopharmaceutical to the patient, whole-body table during the time of the examination. For bone scin-
imaging is always performed. We do not perform limited tigraphy usually noncontrast, nonattenuation correction
regional bone scan examinations in children. In most bone CT scan is performed of the area of interest using limited
scan examinations the study is performed with immediate CT acquisition to the area of abnormality on the bone scan
blood pool imaging often of the whole-body as an anterior/ to minimize exposure to the patient. The parameters for
posterior whole-body pass and then subsequent delayed acquisition of the CT study would be similar to those used
whole-body imaging after a delay of 2-3 hours post injec- for conventional stand-alone CT study. Dose modulation
tion of 99mTc-MDP. SPECT is routinely used to further is applied to all CT acquisitions. Images are reconstructed
evaluate the area of suspected abnormality as directed by and displayed in multiple formats for both fused and un-
history or to define an abnormality observed on planar fused images. All advanced processing that can be per-
imaging in any part of the body including hands and feet. formed for conventional CT can be applied to CT images
The acquisition is performed with a high-resolution colli- acquired on a multislice SPECT/CT hybrid device. The
mator and using a 128 ⫻ 128 matrix, SPECT is acquired quality of the images will depend on the slice thickness of
with a noncircular orbit with 30 seconds per stop, iterative the acquisition and the resolution parameters that the CT
Pediatric bone scintigraphy update 33

Figure 2 (A) Whole-body bone scan performed in a teenager with foot pain shows focal increased activity in the right
foot second metatarsal. Positioning for the whole-body bone image has the feet internally rotated. (B) Coronal MIP
SPECT and (C) sagittal MIP SPECT. In these images the feet are positioned without internal rotation for SPECT so that
they will be correctly oriented for CT imaging. (D) Sagittal fused SPECT/CT multiplanar reformations. The SPECT/CT
confirms the presence of healing stress fracture in the left second metatarsal bone. (E) 3D CT reconstructed from the
SPECT/CT acquisition shows the cortical thickening at the site of the healing fracture in the second metatarsal.

scanner device can provide (Figs. 1 and 2). A single com- field of view at the start of the SPECT acquisition as the patient
prehensive report is provided for both the bone scan ex- cannot be moved between the SPECT and CT acquisition to
amination and the CT scan study. ensure the best possible fusion is obtained of the 2 studies.
If it is anticipated that CT might be added to the examination Positioning of feet for SPECT in particular needs to be in the
then careful attention must be made by the technologist to en- same position as would be used for routine CT evaluation of the
sure that there are no artifacts such as metal in the anticipated feet (Figs. 1 and 2).
34 H.R. Nadel

Figure 4 Multiplanar 18F-sodium fluoride bone scan images in child

with back pain showing increased activity in bilateral L3 pars inter-
articularis. (Images courtesy of Dr Ted Treves, Boston Children’s
Hospital.)

18F-Sodium Fluoride
Bone Scintigraphy in Children
With the increased availability of positron emission to-
mography (PET) imaging in children and the current
shortage of 99mTc-based radiopharmaceuticals, there may
be more potential for using 18F-PET/CT bone scans in
Figure 3 18F-sodium fluoride whole-body bone scan images of children. No specific preparation is required. The scan is
8 months old infant showing multiple abnormal areas of increased usually performed 60 minutes post injection of the radio-
activity involving upper and lower extremities, and left scapular pharmaceutical but the window available for scanning is
spine representing multiple fractures, in keeping with the diagnosis from 30 minutes to 4 hours to obtain high quality imag-
of nonaccidental injury. (Images courtesy of Dr Ted Treves, Boston es.8,9 Lim et al10 performed 94 18F-sodium fluoride PET
Children’s Hospital.)
bone scans in teenagers and young adults and was able to
discern causes for the back pain in 55% using this tech-
nique. Scan was performed 30 minutes after injection of
the radiotracer, hence shortening the time of the study

Figure 5 (A) Child presenting with multiple fractures. A whole-body bone scan shows abnormal activity diffusely in the
skull, right humerus, around pelvis and proximal femora, and spine. Findings are suspicious for systemic disease, such
as neoplasm. Neck mass confirmed on ultrasound and found at biopsy to represent neuroblastoma. (B) Staging 123I
meta-iodobenzylguanidine scan confirms the multiple bony areas of involvement and shows abnormal activity in left
neck and in abdomen compatible with the diagnosis of stage 4 neuroblastoma. (C) Coronal CT scan reconstructed
image shows left neck soft tissue mass displacing vascular structures. There is a midline abdominal mass arising from
the right suprarenal area and nodal disease in the mid abdomen. Bone windows (not shown) confirmed bony lesions
observed on bone scan.
Pediatric bone scintigraphy update 35

Figure 6 Child with cerebral palsy who has pain in back but is not able to verbally communicate site of pain.
(A) Whole-body imaging shows scoliosis and a focal lesion at the right side of mid lumbar spine. SPECT/CT confirmed
bilateral spondylolysis with increased activity. (B) Fused SPECT/CT shows a spondylolysis with focal increased activity
in the right L3 pars. (C) Fused SPECT/CT shows a spondylolysis with focal increased activity in the left L4 pars.
(D) 3D-CT image shows deficiency of posterior spinous processes in the lumbar spine from previous laminectomy that
may have produced the altered stress that led to development of the bilateral spondylolysis.

compared with conventional MDP bone scan. They found Trauma

the images to be of higher resolution than MDP bone scan
with similar radiation dosimetry. The cost was higher for Even though it is rare for the bone scan to be the first study in
the PET study but this may be offset by increased through- a child with trauma, there are some instances where bone
put and current increased cost of 99mTc-based radiophar- scintigraphy may be helpful in revealing injury that is not
maceuticals (Figs. 3 and 4). defined by conventional radiographs.3 This is particularly
helpful in non-verbal neurodevelopmentally delayed chil-
dren who are not able to verbalize and localize the site of
Indications pain. The bone scan provides a total body screen that is
sensitive to detect the site of bone or soft tissue abnormality
A limp, painful limb or back, suspected occult trauma, and and then often the addition of SPECT/CT can provide accu-
suspected infection or inflammation for benign indications rate diagnosis (Figs. 6 and 7). Toddler’s fractures can occur
and staging or metastatic workup in a child with known from pelvis to feet and can be difficult to diagnose with con-
malignancy are the common indications for bone scintigra- ventional radiographs. The bone scan will identify the site of
phy in children. The bone scan examination is very sensitive injury (Fig. 8).
but has low specificity and must be correlated with patient
history and physical findings and then further diagnostic or
pathologic investigation may be needed in any individual
child.4 Findings on bone scintigraphy performed for unex-
Nonaccidental Injury
plained pain may be the first indication of a systemic illness The bone scan plays a complementary role to the radio-
or neoplasm (Fig. 5). For primary bone tumors bone scintig- graphic skeletal survey that is mandatory in all children sus-
raphy is 100% sensitive but now may be replaced by PET/CT pected of nonaccidental injury particularly under 2 years of
for staging evaluation. age.11 All areas of abnormality identified on bone scintigra-
36 H.R. Nadel

Figure 7 Nonverbal child with cerebral palsy who seems to be in pain clinically. Bone scan is performed in an attempt to
localize the pain. Due to severe scoliosis, the patient is difficult to position and the anatomy is distorted. SPECT of the pelvis
is performed as the patient seems to be clinically in pain when the pelvis is manipulated. A dynamic review of the SPECT MIP
images when the patient is still undergoing the study suggests that there is a focus of increased activity in the right femoral
neck area. Without repositioning the patient a noncontrast, nonattenuation CT scan of the right hip area is acquired. (A)
SPECT MIP image of the pelvis shows focal abnormality in the area of the right femoral neck suggesting a possible right
femoral neck fracture (arrowhead). (B) SPECT/CT images confirm the focal area of increased activity in the right upper thigh
is in the soft tissues anterior to the femoral neck in an area of myositis ossificans. (C) CT image showing the area of myositis
ossificans anterior to the femoral neck (arrow).

phy must be evaluated with radiographs. In addition, the

bone scan is insensitive in detecting skull abnormalities and
skull radiographs must always be obtained. The bone scan is
particularly sensitive to detecting injury in the small joints of
hands and feet. It may also detect injury that is difficult to
visualize in flat bones, such as scapula and pelvis. Careful
attention to technique is required. The images must be mag-
nified as appropriate and single bone or extremity imaging
should be obtained as coned spot views often in 2 projections
rather than whole-body single pass anterior and posterior
views in young infants. It is our routine to perform whole-
body blood pool and delayed imaging with SPECT of the
thorax. Posterior contiguous rib fractures that are often pa-
thognomonic of “shaken babies” are easily observed on
SPECT imaging. CT study combined with SPECT has proven
helpful to delineate small lesions in ribs or flat bones (Figs. 3
Figure 8 (A) Fourteen month old male brought to the emergency de- and 9).
partment by his father twice in a 48 hour period as he is refusing to put
weight on his left leg. Radiograph of the left tibia does not show obvious
fracture. (B) Anterior spot image of bone scan shows focal abnormality Back Pain in Children
of the mid left fibula (arrow) compatible with an occult toddler type
fracture. Toddler type fracture can occur from spine to small bones of
SPECT/CT has been particularly helpful in the investigation
feet and is considered a repetitive stress injury on normal bone. It of children with back pain. The differential diagnosis often
usually occurs just as young children are learning to weight-bear and includes spondylolysis as a cause of the pain (Fig. 6). With
exerting abnormal biomechanical stress on the bones of the lower ex- coregistered SPECT/CT a single study can be performed thus
tremities. (C) Follow-up radiograph shows periosteal reaction in the eliminating the need for an additional visit to the hospital for
mid left fibula (arrowhead) in keeping with healing fracture. CT scan at a separate time. Other conditions that are often
Pediatric bone scintigraphy update 37

can identify these variations of normal and can often show

increased activity on the bone scan if there is abnormal bio-
mechanical stress causing bone reaction at these areas.
SPECT/CT can also be helpful in the identification of other
developmental variants (Fig. 1).

Figure 9 SPECT MIP multiplanar images from bone scan in infant Chronic Regional Pain Syndrome
who presents with an abnormal head CT. Multiple contiguous left Chronic regional pain syndrome is characteristically diag-
anterior rib fractures compatible with nonaccidental injury. (Color
nosed on bone scintigraphy. In contrast to adult forms of this
version of figure is available online.)
diagnosis, children often have a “cold variant” of this entity in
diagnosed include enthesitis of ligaments attached to spinous which both the immediate and delayed phase of bone scin-
processes in athletic children; compression fractures and tigraphy show decreased activity in the affected limb. The
other ligamentous injuries associated with avulsion of iliac abnormality can be recognized in children who have open
spines either anterior superior iliac spine or anterior inferior epiphyses by the incongruence of the involved epiphyseal
iliac spine and transitional vertebrae that may be a source of plate activity compared with remote ipsilateral and contralat-
bone stress. Transitional vertebrae at the lumbosacral junc- eral epiphyseal plate activity to ensure the “correct” side of
tion can often be a cause of bone pain in children. SPECT/CT involvement is appreciated.12,13 (Fig. 10).

Figure 10 (A) Blood flow, (B) blood pool, (C) delayed bone scan, and (D) MIP coronal SPECT bone scan images showing
3 phase and SPECT diffuse decreased activity in the left foot and ankle. (E) The radiograph of her left foot shows
abnormality suggestive of osteochondritis dissecans of the dome of the talus with an area of sclerosis and lucency noted
(arrow) but no focal increased activity is observed in this area on the conventional bone scan or on the correlative
SPECT/CT. Her pain is likely due to chronic regional pain syndrome. (Color version of figure is available online.)
38 H.R. Nadel

Figure 11 Fifteen month old female who has just returned from a tropical vacation presents with fever and limp.
(A) Posterior planar blood pool images of the pelvis shows hyperemia in the right sacroiliac area. The hyperemia is more
prominent anteriorly than posteriorly. (B) Post-intravenous contrast enhanced CT scan of the pelvis coregistered to the
SPECT examination identifies increased activity in the right sacroiliac joint area. (C) Postcontrast CT scan shows a
ring-enhancing lesion in the right iliacus muscle area in keeping with soft tissue abscess (red arrowhead), and within
the SI joint itself (blue arrowhead) and lateral to the ilium with bone involvement (yellow arrowhead). The bone scan
examination performed with hybrid SPECT/CT technology with the CT performed as postcontrast diagnostic CT scan
helped to establish the diagnosis of osteomyelitis of bone, septic arthritis of the right sacroiliac joint and soft tissue
cellulitis, and focal abscess in muscle.

Infection Another form of multifocal involvement can be observed

in chronic nonbacterial osteomyelitis in which no pathogen
While many institutions employ magnetic resonance imaging is found when the involved areas undergo biopsy.14-17 This
for diagnosis of acute osteomyelitis, the bone scan is still an entity usually occurs in teenagers with a female preponder-
efficient study for evaluating for possible infection or inflam- ance. The scintigraphic findings are similar to that for con-
mation of bone in children. Magnetic resonance imaging, ventional osteomyelitis. Common sites of involvement are
while not using radiation, does often necessitate the use of the metaphyseal portions of the long bones, medial ends
sedation, which is not the routine for conventional bone scin- of the clavicles, face, spine pelvis, and upper extremities.
tigraphy, including SPECT, in our department. Evaluation When the disease is quiescent the bone scan of previously
for infection or inflammation includes a multiphase bone involved sites may be negative.
scan (either 3-phase study including flow, pools, and delayed
imaging, or 2-phase study eliminating the flow phase). The
diagnosis of osteomyelitis is made with abnormalities de- Neoplasm
tected on immediate and delayed imaging. The addition of 24
hour imaging of the site of possible involvement can often Bone scintigraphy with SPECT is still indicated for children
help to distinguish between osteomyelitis and cellulitis. Cel- with primary bone neoplasms to include osteosarcoma and
lulitis typically shows clearing of the soft tissue activity at 24 Ewing sarcoma for staging evaluation to assess for bone me-
hours. With current generation of gamma cameras, good tastasis and skip lesions at presentation as per Children’s
high-resolution images to detect bone infection can be ob- Oncology Group imaging guidelines for these tumors.18
tained in all age children including neonates provided there PET/CT may eventually replace bone scintigraphy for staging
is careful attention to technical detail. Bone scintigraphy in evaluation but as yet there is no consensus that PET/CT
suspected osteomyelitis should not be obtained with a less should be the only study performed in suspected primary
than 24-hour history of symptoms, as the scan may not be as bone tumors. MDP bone scan is also recommended for end of
sensitive to detect abnormality before this time frame. It is treatment evaluation for children with osteosarcoma and if
important to remember that in children under 2 years of age previously positive in children with Ewing sarcoma. For routine
osteomyelitis has a hematogenous dissemination and can surveillance in high risk patients who have completed treatment
present as multifocal disease (Fig. 11). bone scan should be performed when directed by new symp-
Pediatric bone scintigraphy update 39

Figure 12 CT, bone SPECT, and fused SPECT/CT images in transaxial, coronal, and sagittal planes of an osteoid osteoma
of the tibia in a boy presenting with night pain. The images show the central nidus as an area of increased density within
a lucent area in the focal cortical thickening on the CT images that corresponds with the hottest area of bone scan
activity producing a “double-density” sign in this patient with an osteoid osteoma.

toms or abnormal findings on other imaging studies unless oncologic patients referred for bone scintigraphy. J Nucl Med
PET/CT has already shown recurrent or metastatic disease. 48:319-324, 2007
2. Scharf S: SPECT/CT imaging in general orthopedic practice. Semin
Benign lesions such as fibrous dysplasia, osteoid os-
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from bone scintigraphic evaluation. Fibrous dysplasia le- Semin Musculoskelet Radiol 11:281-300, 2007
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