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Bone Case 7 Answers

1) Describe the appearances

There are irregular areas of markedly raised uptake in the region of the right hemipelvis and inguinal region, best seen on the anterior images. There is a thoracolumbar scoliosis with several areas of mildly raised activity at T12-L1. There is blurring of the skull and cervical spine. The left hip appears grossly normal but the soft tissues of the left thigh appear more prominent.

2) Can you explain the appearances?

The right pelvic appearances are due to urinary diversion with ileal conduit and urostomy formation. The patient moved during the imaging of the head and neck, probably due to their degenerative scoliosis. Their undoubtedly painful back probably explains why they are not lying totally flat, which explains the apparent soft tissue abnormality.

3) What other views may be of use in this scenario?

Urine containing high levels of activity can be problematic for several reasons. Firstly, iatrogenic urinary diversion can create diagnostic traps to the unwary. Secondly, bone lesions in the pelvis or sacrum can be masked by high activity in the bladder, particularly in those with poor bladder emptying. Thirdly, urinary contamination of clothes and skin can create often marked artefacts.

In this scenario, some would consider it routine practice to perform outlet / squat views of the pelvis. Obviously, ensuring the stoma bag is empty is sensible. Lateral or oblique views of the pelvis may be of use if clear views of the bony pelvis have still not been obtained.

Click here to see an example of a nephrostomy on bone scan

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The text is entirely the opinion of the author and does not necessarily reflect that of RUH NHS Trust or the Bristol Radiology Training Scheme. Website content devised by Paul McCoubrie.