Transcription
Revised May 30 2017Musculoskeletal MR ProtocolsJoint-based protocolsMSK 1: Shoulder MRIMSK 1A: Shoulder MR arthrogramMSK 1AB: Shoulder MR arthrogram (instability protocol)MSK 2: Elbow MRIMSK 2A: Elbow MR arthrogramMSK 3: Wrist MRIMSK 3A: Wrist MR arthrogramMSK 4: Hand/finger MRIMSK 4G: Finger MRI without contrast (thumb injury protocol)MSK 5: Pelvis and hip MRIMSK 5A: Hip MR arthrogramMSK 5SI: Sacro-iliac MRIMSK 5T: Pelvis MRI without contrast (trauma protocol)MSK 6: Knee MRIMSK 6A: Knee MR arthrogramMSK 6C: Conformis knee MRI (arthroplasty planning)MSK 6Z: Zimmer knee MRI (arthroplasty planning)MSK 7: Ankle MRIMSK 7A: Ankle MR arthrogramMSK 8: Forefoot MRIMSK 8M: Pre- and post-contrast foot MRI (Morton’s neuroma protocol)Non-joint-based protocolsMSK 9: Pre- and post-contrast upper extremity, lower extremity, or pelvisMRI (tumor/mass, infection protocol)MSK10: MR neurographyMSK11: Upper extremity or lower extremity MRI without contrast (longbone evaluation)MSK12: Thoracic spine, lumbar spine, and pelvis MRI without contrast(bone marrow survey)MSK13: Pre- and post-contrast hand MRI (arthritis protocol)MSK14: Chest MRI without contrast (pectoralis protocol)MSK15: Pelvic MRI without contrast (athletic pubalgia/sports herniaprotocol)
Revised May 30 2017Technical note: minimum matrix numbers for any sequences should ingeneral be around 256 (avoid matrices of 192 or less in square FOV’s).
Revised May 30 2017MSK 1: Shoulder MRIIndications: shoulder pain, internal derangement, rotator cuff tears.Sequences: shoulder in external rotation. Oblique coronal T2 FSE with fat saturation [3.0 mm thick, 0.6 mmgap] Oblique sagittal T1 SE Oblique sagittal T2 FSE with fat saturation Axial T1 SE Axial T2 FSE with fat saturationFor pre- and post-contrast exams, add the following: Non-contrast oblique coronal T1 SE with fat saturation. Post-contrast: oblique coronal, oblique sagittal, axial T1 SE with fatsaturation.Comments: Good for diagnosing rotator cuff tears; less effective for labralpathology. T2 FSE with fat saturation: adjust TE to 40 msec ( /-5 msec).
Revised May 30 2017MSK 1A: Shoulder MR arthrogramIndications: postoperative patients, rotator cuff tears, labral pathology.Sequences: shoulder in external rotation Axial T1 SE with fat saturation Oblique coronal T1 SE with fat saturation Oblique coronal T2 FSE with fat saturation [3.0 mm thick, 0.6 mmgap] Oblique sagittal T1 SE with fat saturation Oblique sagittal T1 SE Oblique sagittal T2 FSE with fat saturationComments: Good for both rotator cuff and labral pathology. T2 FSE with fat saturation: adjust TE to 40 msec ( /-5 msec).
Revised May 30 2017MSK 1AB: Shoulder MR arthrogram (instability protocol)Indications: antero-inferior labral pathology, shoulder dislocation/instability.Sequences: shoulder in external rotation Axial T1 SE with fat saturation Oblique coronal T1 SE with fat saturation Oblique coronal T2 FSE with fat saturation [3.0 mm thick, 0.6 mmgap] Oblique sagittal T1 SE with fat saturation Oblique sagittal T1 SE Oblique sagittal T2 FSE with fat saturation ABER T1 SE with fat saturationComments: Added sequence with shoulder in Abduction External Rotation putstraction on the anteroinferior labrum and inferior glenohumeralligament, diagnosing pathology resulting from anterior shoulderdislocations. Added benefit of assessing articular-surface rotator cuff tendon tears. T2 FSE with fat saturation: adjust TE to 40 msec ( /-5 msec).
Revised May 30 2017MSK 2: Elbow MRIIndications: pain, internal derangement.Sequences: elbow supinated at side (preferred) or overhead while prone. Coronal PD FSE Coronal T2 FSE with fat saturation [384 x 269 matrix, 3.0 mmthickness, 0.6 mm gap] Axial T1 SE Axial T2 FSE with fat saturation Sagittal T1 SE Sagittal T2 FSE with fat saturationFor pre- and post-contrast exams, add the following: Non-contrast coronal T1 SE with fat saturation. Post-contrast: coronal, sagittal, axial T1 SE with fat saturation.Comments: Make sure that axial sequences go distally enough to encompass thebiceps tendon insertion onto the radius. To evaluate for intra-articular bodies, recommend CT air arthrograminstead of MR arthrogram. T2 FSE with fat saturation: adjust TE to 40 msec ( /-5 msec).
Revised May 30 2017MSK 2A: Elbow MR arthrogramIndications: pain, internal derangement.Sequences: elbow supinated at side (preferred) or overhead while prone. Coronal T1 SE with fat saturation Coronal T2 FSE with fat saturation [384 x 269 matrix, 3.0 mmthickness, 0.6 mm gap] Axial T1 SE Axial T2 FSE with fat saturation Sagittal T1 SE with fat saturation Sagittal T2 FSE with fat saturationComments: Make sure that axial sequences go distally enough to encompass thebiceps tendon insertion onto the radius. To evaluate for intra-articular bodies, recommend CT air arthrograminstead of MR arthrogram. T2 FSE with fat saturation: adjust TE to 40 msec ( /-5 msec).
Revised May 30 2017MSK 3: Wrist MRIIndications: pain, occult scaphoid fractures.Sequences: wrist neutral at side or overhead while prone. Coronal PD FSE Coronal T2 FSE with fat saturation [384 x 210 matrix, 3.0 mmthickness, 0.3 mm gap] Axial T1 SE Axial T2 FSE with fat saturation Coronal 3-D GRE Sagittal T1 SEFor pre- and post-contrast exams, add the following: Non-contrast coronal T1 SE with fat saturation. Post-contrast: coronal, sagittal, axial T1 SE with fat saturation.Comments: Reduced sensitivity for triangular fibrocartilage tears and ligamentousinjury. T2 FSE with fat saturation: adjust TE to 40 msec ( /-5 msec).
Revised May 30 2017MSK 3A: Wrist MR arthrogramIndications: pain, internal derangement.Sequences: wrist neutral at side or overhead while prone. Coronal T1 SE with fat saturation Coronal T2 FSE with fat saturation [384 x 210 matrix, 3.0 mmthickness, 0.3 mm gap] Axial T1 SE with fat saturation Axial T2 FSE with fat saturation Sagittal T1 SE with fat saturation Sagittal T1 SEComments: More effective for evaluating the triangular fibrocartilage, as well asextrinsic and intrinsic carpal ligaments. T2 FSE with fat saturation: adjust TE to 40 msec ( /-5 msec).
Revised May 30 2017MSK 4: Hand/finger MRIIndications: pain, internal derangement.Sequences: hand prone at side or overhead. Coronal T1 SE Coronal T2 FSE with fat saturation Axial PD FSE Axial T2 FSE with fat saturation [384 x 250 matrix, 3.0 mm thickness,0.3 mm gap] Sagittal T1 SE Sagittal ‘gray’ STIRFor pre- and post-contrast exams, add the following: Non-contrast axial T1 SE with fat saturation. Post-contrast: coronal, sagittal, axial T1 SE with fat saturation.Comments: Coronal and axial sequences should encompass adjacent digits forcomparison Sagittal images can be done through the symptomatic finger(s) only. Slice thickness: 2-2.5 mm with minimal interslice gap. Axial T2 FSE with fat saturation: adjust TE to 40 msec ( /-5 msec).
Revised May 30 2017MSK 4G: Finger MRI without contrast (thumb injuryprotocol)Indications: assess for ulnar collateral ligament injury/Stener lesion.Sequences: Oblique coronal T1 SE Oblique coronal T2 FSE with fat saturation [384 x 250 matrix, 2.0mm thickness] Axial T2 FSE with fat saturation Sagittal T2 FSE with fat saturationComments: Limited study geared towards assessing the ulnar collateral ligament. Slice thickness: 2-2.5 mm with minimal interslice gap. T2 FSE with fat saturation: adjust 40 msec ( /-5 msec).
Revised May 30 2017MSK 5: Pelvis and hip MRIIndications: pain, internal derangement, avascular necrosis.Sequences: Coronal T1 spin echo of bony pelvis Coronal STIR of bony pelvis Coronal T2 FSE with fat saturation of affected hip [3.5 mm thick,0.35 mm gap] Axial T2 FSE with fat saturation of affected hip Sagittal T1 SE of affected hip Oblique axial T2 FSE with fat saturation of affected hipFor pre- and post-contrast exams, add the following: Non-contrast axial T1 SE with fat saturation. Post-contrast: coronal, sagittal, axial T1 SE with fat saturation.Comments: Oblique axial sequence is done parallel to the femoral neck, and isuseful for diagnosing cam-type femoroacetabular impingement (FAI). Alpha angles are measured from the oblique axial images. Values are74 /- 5 degrees in patients with FAI, and 42 /- 2 degrees in controls.Notzli et al. J Bone Joint Surg Br 2002; 84: 556-560. T2 FSE with fat saturation: adjust TE to 40 msec ( /-5 msec).
Revised May 30 2017MSK 5A: Hip MR arthrogramIndications: pain, labral pathology.Sequences: Coronal STIR of bony pelvis Coronal T1 SE with fat saturation of hip [3.5 mm thick, 0.35 mm gap] Sagittal T1 SE with fat saturation of hip Sagittal T1 SE of hip Axial T2 FSE of hip with fat saturation of hip Oblique axial T1 SE with fat saturation of hipComments: Oblique axial sequence is done parallel to the femoral neck, and isuseful for diagnosing cam-type femoroacetabular impingement (FAI). Alpha angles are measured from the oblique axial images. Values are74 /- 5 degrees in patients with FAI, and 42 /- 2 degrees in controls.Notzli et al. J Bone Joint Surg Br 2002; 84: 556-560. T2 FSE with fat saturation: adjust TE to 40 msec ( /-5 msec).
Revised May 30 2017MSK 5SI: Sacro-iliac joint MRIIndications: sacroiliitis, joint infection.Sequences: Oblique coronal T1 SE through SI joints Oblique coronal STIR through SI joints Axial T1 SE Axial STIR Oblique coronal 3D FLASH through SI joints Opt: post-Gd oblique coronal T1 SE with fat saturation Opt: post-Gd axial T1 SE with fat saturationComments:
Revised May 30 2017MSK 5T: Pelvis MRI without contrast (trauma protocol)Indications: assess for pelvic ring, sacral, or hip fractures.Sequences: include entire bony pelvis Coronal T1 SE Coronal STIR Axial T1 SE Axial STIRComments: Limited survey to assess for occult fractures; best reserved for ERadd-ons during the day.
Revised May 30 2017MSK 6: Knee MRIIndications: pain, internal derangement.Sequences: Oblique sagittal PD FSE Oblique sagittal T2 FSE with fat saturation Oblique sagittal 3-D FLASH with fat saturation Axial PD FSE with fat saturation Coronal T1 SE Coronal PD FSE with fat saturationFor pre- and post-contrast exams, add the following: Non-contrast axial T1 SE with fat saturation. Post-contrast: coronal, sagittal, axial T1 SE with fat saturation.Comments: 3-D FLASH with fat saturation is dedicated to cartilage evaluation. T2 FSE with fat saturation: adjust TE to 40 msec ( /-5 msec). Optional for Smith-Nephew hardware scans only: substitute 1stsequence for sagittal T2 FSE (no fat saturation) with 2 mm slicethickness, 0mm interslice gap, 512 x 256 matrix, 22 cm FOV, ETL 7,Bw 200, 1 NEX.
Revised May 30 2017MSK 6A: Knee MR arthrogramIndications: evaluating for meniscal retears in a postoperative knee.Sequences: Oblique sagittal T1 SE with fat saturation Oblique sagittal PD FSE with fat saturation Coronal T1 SE Coronal T1 SE with fat saturation Coronal T2 FSE with fat saturation Axial PD FSE with fat saturationComments: Keep ACE wrap around knee during scan, to direct intra-articularcontrast into regions around the menisci. T2 FSE with fat saturation: adjust TE to 40 msec ( /-5 msec).
Revised May 30 2017MSK 6C: ConforMIS knee MRI (arthroplasty planning)Indications: evaluating for knee implant design by ConforMISSequences: Sagittal PD FSE with fat saturation Coronal PD FSE with fat saturation Sagittal 3D FLASH with fat saturation Coronal 3D FLASH with fat saturationComments: Per manufacturer’s guidelines, first 2 sequences are required, and thenext 2 sequences are recommended.
Revised May 30 2017MSK 6Z: Zimmer knee MRI (arthroplasty planning)Indications: evaluating for knee implant design by ZimmerSequences: Axial T1 SE of ankle without fat saturation (TR 400-5000 msec, TE2.0-100 msec) Sagittal 3D FLASH with fat saturation of knee Add: sagittal T2 FSE of knee (Smith-Nephew sequence, see notes). Coronal T1 SE of knee Axial T1 SE of hip (TR 20-5000 msec, TE 2.0-100 msec)Comments: See manufacturer’s publication for more sequence parameters. Smith-Nephew planning sequence: perform sagittal T2 FSE (no fatsaturation) with 2 mm slice thickness and 0mm interslice gap, 512 x256 matrix, 22 cm FOV, ETL 7, Bw 200, 1 NEX.
Revised May 30 2017MSK 7: Ankle MRIIndications: pain, internal derangement.Sequences: place fiducial over symptomatic site Sagittal T1 SE Sagittal T2 FSE with fat sat Axial PD FSE Axial T2 FSE with fat saturation [448 x 223 matrix, 3.0 mm thick, 0.3mm gap] Coronal T2 FSE with fat saturation Coronal T1 SEFor pre- and post-contrast exams, add the following: Non-contrast axial T1 SE with fat saturation. Post-contrast: coronal, sagittal, axial T1 SE with fat saturation.For plantar fascia evaluation (and whole foot imaging requested), add thefollowing: Sagittal T2 FSE with fat saturation of forefoot. Axial T2 FSE with fat saturation of forefoot.Comments: If region of interest is localized to the midfoot, extend field of viewmore anteriorly as needed. When whole foot imaging is requested (and region of clinical concerncannot be localized to either hindfoot or forefoot): perform MSK 7and 8 concurrently but with separate sequences. Do not use largerFOV to encompass whole foot and ankle. T2 FSE with fat saturation: adjust TE to 40 msec ( /-5 msec).
Revised May 30 2017MSK 7A: Ankle MR arthrogramIndications: assess for intra-articular bodies, ligamentous injuries.Sequences: place fiducial over symptomatic site Sagittal T1 SE Sagittal T1 SE with fat saturation Axial T1 FSE with fat saturation Axial T2 FSE with fat saturation [448 x 223 matrix, 3.0 mm thick, 0.3mm gap] Coronal T1 SE with fat saturation Coronal T2 FSE with fat saturationComments: Contrast injection into the tibiotalar joint capsule. T2 fast spin echo with fat saturation: adjust TE to 40 msec ( /-5msec).
Revised May 30 2017MSK 8: Forefoot MRIIndications: pain, internal derangement.Sequences: place fiducial over symptomatic site Sagittal T1 SE Sagittal T2 FSE with fat saturation [320 x 192 matrix, 2.5 mm thick,0.25 mm gap] Long-axis T1 SE Long-axis STIR Short-axis T1 SE Short-axis T2 FSE with fat saturationFor pre- and post-contrast exams, add the following: Non-contrast short-axis T1 SE with fat saturation. Post-contrast: short axis, long-axis, sagittal T1 SE with fat saturation.Comments: Long-axis sequences are performed parallel to the metatarsal shafts.Short-axis images are done perpendicular to the metatarsals. When whole foot imaging is requested (and region of clinical concerncannot be localized to either hindfoot or forefoot): perform MSK 7and 8 concurrently but with separate sequences. Do not use largerFOV to encompass whole foot and ankle. T2 FSE with fat saturation: adjust TE to 40 msec ( /-5 msec).
Revised May 30 2017MSK 8M: Forefoot MRI pre- and post-contrast (Morton’sneuroma protocol)Indications: assess for Morton’s neuroma.Sequences: place fiducial over symptomatic site Long-axis T1 SE Long-axis T2 FSE with fat saturation Short-axis T1 SE Short-axis T2 FSE with fat saturation Short-axis T1 SE with fat saturation Post-Gd short-axis T1 SE with fat saturation [320 x 192 matrix, 2.5mm thick, 0.25 mm gap]Comments: Long-axis sequences are performed parallel to the metatarsal shafts.Short-axis images are done perpendicular to the metatarsals. Perform scan with patients prone; flip short-axis images when sendingto PACS.
Revised May 30 2017MSK 9: Pre- and post-contrast long bone MRI (tumor/mass, orinfection protocol)Indications: osseous or soft tissue lesion, palpable or seen on other studies.Sequences: place fiducial over mass if palpable Coronal T1 SE Coronal STIR Axial T1 SE Axial T2 FSE with fat saturation Sagittal T1 SE with fat saturation Sagittal STIR Axial 2D FLASH in- and out-of-phase Axial Diffusion and ADC (b 50, 400, 800) Coronal pre-Gd 3D VIBE with fat saturation. Coronal post-Gd 3D VIBE with fat saturation (axial, sag reformats)Comments: On coronal and sagittal images, include entire long bone of concern.May include contralateral leg/thigh on coronal for comparison. On axial images, restrict slices to the actual lesion or site of concern.For T2 FSE with fat saturation: adjust TE to 40-50 msec. In- and out-of-phase imaging, DWI/ADC: restrict usage toexaminations performed for characterization of intra-osseous lesion. For studies attempting to diagnose a bone lesion, check PACS to seeif there is a diagnostic quality plain film of the lesion in question. Ifnot, consult with interpreting radiologist about sending the patient toobtain plain films in department following MRI scan.
Revised May 30 2017MSK10: MR neurographyIndications: evaluation of peripheral nerve disease.Sequences: Axial T1 SE (4 mm thick) Axial T2 SPAIR (2 mm thick) Coronal T1 SE (4 mm thick) Coronal T2 or STIR 3D SPACE (1-2 mm thick) Coronal T2 fast spin echo with fat saturation (3 mm thick) Sagittal T2 fast spin echo with fat saturation (3 mm thick)Comments: Field of view: ranges from 10-12 cm (wrist) up to 14-16 cm for kneeor thigh). Matrix ranges from 256 x 256 for smaller FOV, up to 512 x 512 forlarger FOV. For small FOV, no interslice gap. For larger FOV such as sciaticnerves, can have interslice gap for improved coverage of axial scans.
Revised May 30 2017MSK11: Upper or lower extremity MRI without contrast (longbone evaluation)Indications: non-specific pain; tibial stress fractures.Sequences: place fiducial over site of concern Coronal T1 SE Coronal STIR Sagittal T1 SE Sagittal STIR Axial T1 SE Axial T2 FSE with fat saturationComments: On coronal and sagittal images, include entire long bone of concern.May include contralateral leg/thigh on coronal for comparison. On axial images, restrict the slices to the actual lesion or site ofconcern. May include contralateral leg/thigh at tech’s or rad’sdiscretion. Typically done for humerus, femur, leg, or forearm.
Revised May 30 2017MSK12: Thoracic spine, lumbar spine, and pelvis MRI (bonemarrow survey)Indications: assess extent of bone marrow metastases, typically for multiplemyeloma.Sequences: place skin marker over upper T-spine for determining levels. Large FOV sagittal T1 SE through C-, T-, and L-spine Large FOV sagittal STIR through C-, T-, and L-spine Large FOV coronal T1 SE through entire thorax Large FOV coronal STIR through entire thorax Coronal T1 SE through bony pelvis and femurs Coronal STIR through bony pelvis and femursComments: On sagittal spine sequences, divide spine into 2 scans if needed. Can recommend whole body PET-CT as an alternative means ofassessing myelomatous involvement. Bredella et al. AJR 2005; 184:1199-1204.
Revised May 30 2017MSK13: Pre- and post-contrast hand MRI (arthritis protocol)Indications: characterize and follow-up inflammatory arthritides in the handsand wrists.Sequences: if doing both hands/wrists, position hands and wrists together inprayer position, with skin marker over the dorsum of the right hand asreference. Patient should be in lateral decubitus position. Use knee orextremity coil. Axial T1 spin echo Axial T2 FSE with fat sat (TE 40 msec /- 5 msec) Coronal T1 spin echo Coronal T2 FSE with fat sat (TE 40 msec /- 5 msec) Post-Gadolinium axial T1 spin echo with fat saturation Post-Gadolinium coronal T1 spin echo with fat saturationComments: Use 3 mm slice thickness for all sequences. Rectangular FOV of around 130-140 mm: adjust as necessary toinclude entire carpal region; fingertips can be excluded if necessary. Reference: Schoellnast et al. AJR 2006; 187: 351-357. David Rubin,personal communication.
Revised May 30 2017MSK14: Non-contrast chest MRI (pectoralis protocol)Indications: characterize pectoralis major muscle/tendon injuries.Sequences: use coronal localizer to set axial scan landmarks. Axial T1 spin echo Axial T2 FSE with fat sat (TE 40 msec /- 5 msec) Oblique coronal T1 spin echo Oblique coronal STIR Axial T2 FSE with fat sat (TE 40 msec /- 5 msec) Oblique coronal T2 FSE with fat sat (TE 40 msec /- 5 msec) Oblique sagittal T2 FSE with fat sat (TE 40 msec /- 5 msec)Comments: If possible, position patient supine to minimize respiratory motion. Axials: scan from lower edge of humeral head down to the deltoidtuberosity of the humeral shaft, using coronal localizers. Oblique coronal sequences: set parallel to course of pectoralis majortendon from axial images. Use 5-inch surface coil centered over the axilla. 32 x 42 cm FOV for initial 4 sequences, 5 mm slice thickness with 0.5mm gap for axials, 3 mm slice thickness with 0.3 mm gap for obliquecoronals. 18 x 21 cm FOV for last 3 sequences centered around pectoralis majortendon insertion on humeral shaft. Reference: Lee et al. AJR 2000; 174: 1371-1375. Lee et al.Radiographics 2017; 37: 176-189.
Revised May 30 2017MSK15: Non-contrast pelvic MRI (athletic pubalgia/sportshernia protocol)Indications: pubic symphysis region pain, osteitis pubis.Sequences: Coronal T1 spin echo through bony pelvis. Coronal STIR through bony pelvis. Axial T2 FSE with fat sat through pelvis (TE 40 msec /- 5 msec) Sagittal T2 FSE with fat sat (TE 40 msec /- 5 msec): small FOV. Oblique axial PD FSE: small FOV. Oblique axial T2 FSE with fat sat (TE 40 msec /- 5 msec): smallFOV.Comments: Patients should empty bladders immediately prior to scan.For last 3 sequences only: Use 5-inch surface coil centered over symphysis. Oblique axial plane: use sagittal image near hip joint to set planeparallel to arcuate line. 4 mm slice thickness with 0 skip. 20 x 20 cm FOV, with 256 x 256 matrix. Reference: Omar et al. Radiographics 2008; 28: 1415-1438.
Musculoskeletal MR Protocols Joint-based protocols MSK 1: Shoulder MRI MSK 1A: Shoulder MR arthrogram MSK 1AB: Shoulder MR arthrogram (instability protocol) MSK 2: Elbow MRI MSK 2A: Elbow MR arthrogram MSK 3: Wrist MRI MSK 3A: Wrist MR arthrogram MSK 4: Hand/finger MRI MSK 4G
