Technetium-99m methylene diphosphonate bone scan in the evaluation of bonyache after performing Hajj and/or Umra

Saleh A Othman

doi:10.4103/1319-6308.156365

ORIGINAL ARTICLE

Year : 2015 | Volume : 15 | Issue : 2 | Page : 176-180

Technetium-99m methylene diphosphonate bone scan in the evaluation of bonyache after performing Hajj and/or Umra

Saleh A Othman
Department of Radiology and Medical Imaging, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia

Date of Web Publication

6-May-2015

Correspondence Address:
Saleh A Othman
Department of Radiology and Medical Imaging, King Khalid University Hospital, King Saud University, P.O. Box: 7805(46), Riyadh 11472
Saudi Arabia

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/1319-6308.156365

Abstract

Background: During Hajj and Umra the pilgrim will be exposed to tense exercise he/she may not be used to in daily life. This may lead to several musculoskeletal injuries often revealed by clinical and radiological examination however, in some patients further investigations such as bone scan may be required. Aims: The aim of this report is to highlight the potential value of bone scan in the work up of pilgrims with bony ache developed after performing Hajj and/or Umra and in whom routine clinical and radiological examination failed to reveal the cause of their symptoms. Materials and Methods: Twenty three Saudi patients, 18 females with age range 28-70 years (mean = 58 years) and 5 male patients with age range 36-75 years (mean = 49 years) were included in the study. All patients were referred for bone scan within 1-month after performing Hajj and/or Umra. Three phase bone scan is the standard procedure to be performed. The procedure is performed using 700 MBq (20 mCi) technetium-99m methylene diphosphonate and a dual head gamma camera (Bright view from Phillips) equipped with low energy general purpose collimator. Results: Different patterns of bone scan were identified for each type of injury. Seventeen patients (14 females and 3 males) had positive bone scan (74%) and bone scan was negative in 4 female and 2 male patients (26%). Conclusion: The percentage yield of bone scan in evaluating the Muslim pilgrim with bony ache after performing Hajj and/or Umra is quiet high and thus bone scan can be recommended in the work up of those patients in whom clinical and radiologic examination failed to reveal the cause of their symptoms. Dual energy X-ray absorptiometry scan is also advised in patients with suspected insufficiency and stress fractures.

Abstract in Arabic

.ةرمعلا و جحلا كسانم ءادأ دعب ماظعلا ملاآ مييقت يف نيليثملا و 99 مويستنكتلا مادختساب يعطقملا ريوصتلا
ةدعل كلذ يدؤي دقو ةيداعلا ةيمويلا هتايح يف درفلا هيدؤي لا دق ادوهجم لذبي ةرمعلا وأ جحلا ةيدأت ءانثأ :ةساردلا ةيفلخ نوجاتحي دق ىضرملا ضعبو يعاعشلإاو يريرسلا صحفلا اهنع فشكي ام ابلاع ماظعلاو تلاضعلا يف تاباصإ.ماظعلل يعطقملا ريوصتلا ىلإ
نورعشي نيذلا جاجحلا ماظع صحفل ةلمتحملا ةدئافلا ىلع ءوضلا طيلست وه ريرقتلا اذه نم فدهلا : ةساردلا فادهأ فشكلل ينيتورلا يعاعشلأاو يريرسلا صحفلا ديفي لا نيذلا كئلوأو ؛ ةرمعلا وأ جحلا كسانم ءادأ دعب ماظعلا يف ملأب.ضارعلأا بابسأ نع
مهرامعأ تحوارت ثانلإا نم 18 ( نييدوعسلا ىضرملا نم نيرشعو ةثلاث رايتخا مت :اهجهنم و ةساردلا تانيع صحفلل ىضرملا عيمج ةلاحإ تمت .اماع 75 36 نيب مهرامعأ تحوارت روكذلا نم سمخو اماع 70 -28 نيب لحارم ثلاث ىلع صحفلا ىرجأ دقو .ةرمعلا وأ جحلا كسانم ءادأ دعب دحاو رهش دودح يف يعطقملا يعاعشلإا ةضفخنملا ةقاطلاب ةزهجم ةجودزم اريماكو نيليثملاو 99 مويسنكتلا تياب اقيم 700 مادختساب ءارجلإا ذيفنت مت. ةماعلا ضارغلأل
رشع ةعبسل ةيباجيإ جئاتن صحفلا رهظأ دقو تاباصلإا عاونأ نم عون لكل ماظعلا صحفلا طامنأ ديدحت مت :جئاتنلا )ثانلإا نم 4 و روكذلا نم 2( ةيبلس جئاتن ىضرم تس رهظأو %74 )روكذلا نم 3و ثانلإا نم 14 ( اضيرم
ةساردلا يصوت اذل .ماظعلا ملاآ ضارعأ مييقت يف ةيلاع نيرمتعملاو جاجحلل ماظعلا صحف جئاتن تناك :جاتنتسلاا ةقاطلاب ةينيسلا ةعشلأا مادختساي اضيا ةساردلا حصنتو .ماظعلا ملاآ ضارعأ ةفرعمل ةيعطقملا هعشلأا مادختساب .ةيداهجلأا روسكلا وأ روصقلا مهيف هبتشي نيذلا نيباصملل ةجودزملا

Keywords: Bone scan, bonyache, Hajj, Umra

How to cite this article:
Othman SA. Technetium-99m methylene diphosphonate bone scan in the evaluation of bonyache after performing Hajj and/or Umra. Saudi J Sports Med 2015;15:176-80

How to cite this URL:
Othman SA. Technetium-99m methylene diphosphonate bone scan in the evaluation of bonyache after performing Hajj and/or Umra. Saudi J Sports Med [serial online] 2015 [cited 2023 Jun 10];15:176-80. Available from: https://www.sjosm.org/text.asp?2015/15/2/176/156365

Introduction

Hajj and Umra are essential rituals for each Muslim and require a visit to Makah in Saudi Arabia. It is obvious that when these ceremonials are practiced; the pilgrim will be exposed to intense physical exercise not used to in daily life. ^[1] This may lead to several types of musculoskeletal injuries; the severity of which will depend on the age of the pilgrim, and other predisposing factors. The consequence of these injuries will be expressed in different degrees of complains ranging from vague nonlimiting symptoms to a more serious ones.

Clinical evaluation often reveals the cause of the pilgrim complaints, however, in some of them further investigation including conventional radiograph, computed tomography (CT) scan, magnetic resonance imaging (MRI) or a bone scan may be required. The latter has been reported to be more sensitive than plain radiograph in early detection of musculoskeletal injuries. ^[2],[3]

The aim of this report is to determine the value of bone scan in the work up of pilgrims with bonyache developed after performing Hajj and/or Umra and in whom routine clinical and radiological examination failed to reveal the cause of their symptoms.

Materials and methods

Twenty three Saudi patients, 18 females with age range 28-70 years (mean = 58 years) and 5 males with age range 36-75 years (mean = 49 years) were included in the study. All patients were referred for bone scan within 1-month after performing Hajj and/or Umra. Clinical presentation was reported by the pilgrims as one of the following complains: Back pain, hip pain, mid foot pain and plantar pain.

A three phase bone scan of the suspected area was performed followed by whole body scan in all patients after injection of 740 MBq (20 mCi) of technetium-99m methylene diphosphonate and a dual head gamma camera (Bright view from Phillips) equipped with low energy general purpose collimator.

The four pain categories led to four bone scan patterns: First pattern: Increased uptake in pars inter articularis of a lumbar vertebra in patients with low back pain (LBP) diagnostic of spondylolysis. Second pattern: Increased uptake in the superficial aspect of greater trochanter diagnostic of trochanteric bursitis. Third pattern: Focal increased blood flow, blood pool and tracer uptake in mid foot diagnostic of stress fracture. Fourth pattern: Diffuse or focal increased uptake in the plantar aspect of the foot diagnostic of plantar fasciitis.

A bone densitometry using dual energy X-ray absorptiometry (DEXA) using (i-DXA from General Electric) of lumbar spine and both femoral neck was performed 2 days or more after the bone scan when considered of necessary.

Results

Different patterns of bone scan were identified for each type of injury. Seventeen patients (14 females and 3 males) had positive bone scan (74%) and bone scan was negative in 4 female and 2 male patients (26%). The different positive bone scan patterns were as follow: (Pattern 1): 7/9 females and 0/1 males [Figure 1]. (Pattern 2): 2/2 females and 0/1 males [Figure 2]. (Pattern 3): 2/4 females and 1/1 male [Figure 3]. And finally (Pattern 4): 3/3 females and 2/2 males [Figure 4].

Figure 1: Posterior view of a bone scan of lumbosacral area showing bilateral focal increased uptake in pars interarticularis of fifth lumbar vertebra (arrows)

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Figure 2: Posterior pelvic view of a bone scan showing focal increased uptake in left greater trochanteric region compatible with bursitis (arrow)

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Figure 3: Three phase bone scan – (a) Focal increased blood flow (arrow). (b) Focal increased blood pool (arrow). (c) Increased tracer uptake in mid right foot compatible with fracture(arrow). (d) Plain radiograph of right foot with no evidence of fracture

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Figure 4: Bone scan (delayed images) showing diffuse increased uptake in plantar aspect of both feet (arrows) consistent with plantar fasciitis

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Discussion

Millions of Muslims visit Mekkah Mukarmah in the Kingdome of Saudi Arabia each year with the purpose of performing Umra and/or Hajj. Many of the pilgrims usually have a sedentary life with limited physical activities. Others are elderly people with chronic underlying disease such as osteoporosis. Vague musculoskeletal symptoms are not uncommon in many pilgrims after concluding the rituals of Umra and/or Hajj. These symptoms can be transient and fade out after few days of rest. However, in some pilgrims the symptoms may persist for longer period of time and some can be related to musculoskeletal injuries of variable degrees. Clinical examination usually reveal the cause, however, some of the patients may require further investigations including plain radiograph, CT scan and bone scan. The bone scan has been reported to be very sensitive in detecting trauma and in general it will be positive within 1-2 days of a traumatic bone event. ^[4] In addition, bone scan is useful not only in acute trauma but also in subacute injury. ^[5] One of the potentials of bone scan is its higher sensitivity compared to plain radiograph in early detection of musculoskeletal trauma and in revealing associated unsuspected injuries or other pathology which may explain the patient's symptoms. ^[6]

Insufficiency fractures has been defined in 1964 by Pentecost et al. as fractures that result when minimal stress is applied to abnormal bone characterized by decreased elastic resistance. ^[7]

Spondylolysis represent a fatigue or insufficiency fractures of the par inter-articularis of the vertebra secondary to repeated minor trauma and in 95% of cases involves the fifth lumbar vertebra which can be unilateral or bilateral. ^[8],[9],[10] Spondylolysis is a common cause of LBP and bone scan has been reported to be more sensitive that plain radiograph in detecting the disease and revealing the cause of the LBP. ^[11] The cause of this type of fracture in elderly postmenopausal women usually is an underlying reduced bone density or osteoporosis which can be screened easily by bone densitometry DXA scan. ^[12] The bone scan was of great value in revealing the cause of LBP in a patient which presented with LBP after completing her pilgrimage. Plain radiograph failed to detect any obvious abnormality while the bone scan findings were typical of bilateral spondylolysis showing bilateral increased uptake in the pars inter-articularis of L5 vertebra [Figure 1]. The cause of this fracture was later confirmed by DEXA scan which showed osteoporotic value. And hence it was associated with fracture, the final diagnosis was severe osteoporosis as per WHO classification. ^[12] Bursitis is the inflammation of the bursae and commonly involved joints are knees, hips, elbows and shoulders. Bursitis can be caused by excessive pressure, repetitive movement or trauma. Trochanteric bursitis known also as greater trochanteric pain syndrome is inflammation of the trochanteric bursa. Most frequently occur in the elderly and obese patients and history of trauma can be elicited in 25% of cases. ^[13]

Clinical examination may reveal local tenderness and limitation in range of motion. X-ray and MRI may reveal tears or swelling in the bursa but often they are normal. ^[14] Trochanteric bursitis gives characteristic pattern of uptake on bone scan as in [Figure 2] is of an obese female patient who concluded her Hajj and reported to her physician with left hip pain. She admitted that when she was in Mina camp she was sleeping on the ground and that was uncomfortable but according to her believes she thinks the greater she suffers the greater will be gods reward. That act led probably to pressure on the bursae of left greater trochanter and its inflammation which was reflected as increased uptake on bone scan while the plain X-ray on the same day was negative (not shown).

Stress fracture refers to fracture occurring in normal bone that has been subjected to repetitive stress produced by unaccustomed or over-strenuous activity. ^[15],[16] During Tawaf and Sai the pilgrim has to walk a considerable distance and tries to finish the rituals in a short time which implies overstress especially on bones of both feet and tibia which may lead to stress fracture in one or more of the bony structures in those regions. In addition, some pilgrims performs more than one Umra during his/her visit which adds further stress on the mentioned bones. In acute trauma the three phases of the bone scan are positive. [Figure 3] is of a male patient who came back from Mecca after performing two consecutive Umras on the same day and was complaining of foot pain. Three phase bone scan showed focal area of increased blood flow, blood pool and tracer uptake in mid-tarsal region of right foot which is typical for a fracture [Figure 3]a-c] while the radiograph of right foot on the same day was normal [Figure 3]d]. This confirms the known diagnostic power of bone scan in earlier detection of those lesions even 12 weeks before radiograph becomes positive. ^[4],[5] Plantar fasciitis is an inflammatory process of the plantar fascia. It is commonly associated with weight bearing, obesity and conditions which require walking long periods of time on hard surfaces. This is typically seen during Tawaf and Sai where the pilgrim has to walk on solid concrete without shoes or socks which leads to inflammation of the plantar fascia in one or both feet. Foot pain caused by plantar fasciitis may occur in several locations: Along the entire course of the entire plantar fascia due to microtears in the band, at the insertion point of the fascia in the calcaneus, along the medial edge of the arch or outer edge of the arch or in the middle of the arch.

The diagnosis of plantar fasciitis is empiric and based on history of pain in the heel or other locations in the foot that is worse in the morning. Bone scan has been useful in the identification and evaluation of plantar fasciitis with scan showing specific appearance of increased uptake at the calcaneal insertion or focal or diffuse uptake in other parts of the plantar fascia. ^{[17],[18],[19],[20]} [Figure 4], is a limited bone scan of an obese male patient with limited activity who after concluding the rituals of his Umra and returned home started to complain of bilateral plantar pain, burning sensation and hotness raising the probability of plantar fasciitis. The bone scan was obtained to confirm the diagnosis and guide the treatment. The bone scan gave a pattern of bilateral diffuse plantar uptake simulating plantar pads.

It is obvious that in patients with LBP and those with stress fracture the low bone density was low. Several studies have shown that adult Saudi population has low bone density compared to their counterpart of adult Americans. ^[21] In addition the incidence of low bone density (osteopenia and osteoporosis) was also high. ^{[22],[23],[24]} This fact justifies the order of bone density measurement (DEXA scan) on the same day of the bone scan in these two groups. In the other two groups, the bone scan showed the potential in revealing not only osseous abnormalities but also soft tissue ones as well.

Conclusion

The percentage yield of bone scan in evaluating the Muslim pilgrim with bony ache after performing Hajj and/or Umra is quiet high justifying the recommendation of bone scan in the work up of those patients in whom clinical and radiologic examination failed to reveal the cause of their symptoms. DEXA scan is also advised in patients with suspected insufficiency and stress fractures.

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