DOI:10.2214/AJR.06.5002
AJR 2006; 186:265-266
© American Roentgen Ray Society
MR Arthrography Is Not Proven to Be Preferred Baseline MRI Examination
Paul D. Traughber,
Steve Merandi and
Kathryn A. Traughber
McCall Memorial Hospital McCall, ID
McCall Memorial Hospital McCall, ID and MRI Center of Idaho, Boise,
ID
Albertson College of Idaho Caldwell, ID
We must take issue with some of the conclusions in the recent article by
Magee et al. [1] about shoulder
MR arthrography. We do so because to concur with their findings would be to
agree that MR arthrography was compared to state-of-the-art conventional MRI.
This does not appear to be the case.
The study by Magee et al.
[1] reportedly compared MR
arthrography with standard T1- and T2-weighted sequences. Our prior
experience, and that of others, has shown increased sensitivity of
fat-suppression MRI techniques compared with results from standard techniques
with surgical confirmation
[2-4].
Authors specifically comparing the two techniques report increased lesion
conspicuity with fat suppression
[5]. Indeed, we note that Magee
et al. appear to have used (but did not report) prearthrography proton
density- or T2-weighted fat-suppression sequences in at least some of their
patients. For example, referring to their Figure 3, the axial proton density
fast spin-echo sequence appears to use fat suppression, which results in good
visualization of the posterior labral tear
[1]. One notes that other
reported studies in which the use of fat suppression was inconsistent are less
conclusive [6].
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Fig. 1 —53-year-old man with right shoulder pain for several months.
Fat-suppression proton density-weighted image (TR/TE, 2,066/30) reveals
presence of both partial-thickness rotator cuff tear (short
arrowheads) and superior labral anteroposterior (SLAP) tear (long
arrowhead).
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We believe most musculoskeletal radiologists perform fat-suppression proton
density-weighted fast spin echo and T2-weighted fast spin echo as the
preferred methods of examining the cuff. Therefore, for the study by Magee et
al. to have the validity that they suggest, it would have needed to
consistently compare pre-arthrography fat-suppression proton density- and
T2-weighted sequences with MR arthrography. Those authors might argue that it
is unlikely that MR arthrography would miss partial-thickness tears, so
accuracy would not be an issue. However, the standard MR arthrographic
technique that they used closely examines only the joint side of the cuff.
Investigators have noted that a substantial percentage of partial-thickness
tears are found on the bursal side of the cuff, which would not be optimally
examined on MR arthrography alone
[2,
6].
We recommend on high-field-strength units that both fat-suppressed proton
density- and T2-weighted sequences be obtained in the coronal oblique plane,
paralleling the long axis of the supraspinatus tendon, and also in at least
one other plane. Anecdotally, this often allows us to simultaneously identify
both cuff and labral abnormalities (Fig.
1). We have not, however, specifically studied our accuracy in
detecting labral tears.
In summary, we think that in most patients baseline MR arthrography is
unnecessary, invasive, and expensive. We view with concern the practice of
some centers in the West that perform shoulder MR arthrography as the baseline
examination in many of their patients. We recommend that state-of-the-art
conventional MRI, including fat-suppression sequences, be performed as the
first MRI evaluation. One possible exception would be highlevel throwing
athletes, in whom a combined evaluation might be warranted as the baseline
study in certain clinical situations.
References
- Magee T, Williams D, Mani N. Shoulder MR arthrography: which
patient group benefits most? AJR 2004;183
: 969-974[Abstract/Free Full Text]
- Traughber PD, Goodwin TE. Shoulder MRI: arthroscopic correlation
with emphasis on partial tears. J Comput Assist Tomogr1992; 16:129
-133[Medline]
- Quinn SF, Sheley RC, Demlow TA, Szumowski J. Rotator cuff tendon
tears: evaluation with fat-suppressed MR imaging with arthroscopic correlation
in 100 patients. Radiology 1995;195
: 497-500[Abstract/Free Full Text]
- Traughber P, Czech M. Accuracy of fat-suppressed MR imaging of the
shoulder for detection of partial-thickness rotator cuff tears. (commentary)
Radiology 1996;198
: 293[Free Full Text]
- Singson RD, Hoang T, Dan S, Friedman M. MR evaluation of rotator
cuff pathology using T2-weighted fast spin-echo technique with and without fat
suppression. AJR 1996;166
: 1061-1065[Abstract/Free Full Text]
- Balich SM, Sheley RC, Brown TR, et al. MR imaging of the rotator
cuff tendon: interobserver agreement and analysis of interpretive errors.
Radiology 1997;204
: 191-194[Abstract/Free Full Text]
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