Bone scintigraphy in nonsurgically treated Ewing's sarcoma at diagnosis and follow-up: prognostic information of the primary tumor site

In order to detect skeletal metastases in patients with Ewing's sarcoma, bone scanning is commonly used. However, little information is available about the scintigraphic aspects of the primary Ewing's sarcoma during non-surgical treatment and follow-up. We studied retrospectively the significance of bone scintigraphic findings at the primary tumor site of 58 patients with a Ewing's sarcoma. These patients had chemotherapy and radiotherapy. At presentation 53/58 patients showed an increased tracer uptake at the primary tumor site while 5 patients with a pelvic or sacral bone localization had a normal scan. Bone scans made during treatment and more than 2 years thereafter in the 32 eligible patients demonstrated three patterns. In 16 patients the hot spot disappeared and no local tumor recurrence was encountered. In the other 16 patients the high uptake at the primary tumor site either persisted or diminished first to a normal uptake after a median period of 18 months (range 12-36 months) and returned again to a high uptake within 6-12 months. In these patients local Ewing's sarcoma was still present in 13, while in the other 3 cases a benign disorder (fracture, ectopic bone formation) was the underlying cause. These findings suggest that in non-surgically treated Ewing's sarcoma persisting increased tracer uptake or its recurrence is highly suspicious for the presence of Ewing's sarcoma, while bone scans becoming negative and remaining so for more than 12 months suggest the absence of local tumor.     

Insufficiency fractures of the sacrum: a cause of low back pain after lung transplantation

Insufficiency fractures of the sacrum were diagnosed during the first year after successful transplantation in four (5.6%) of 71 lung and heart-lung transplant recipients. Each patient had development of low back pain after minor or no trauma; all had osteoporosis. In each instance, plain radiographs failed to demonstrate the fracture, and the diagnosis was established by radionuclide bone scanning that demonstrated the characteristic "butterfly" (bilateral sacral fracture) or "half-butterfly" appearance (unilateral sacral fracture). Sacral insufficiency fractures, a significant cause of low back pain in lung transplant recipients, may be underdiagnosed in this population because routine radiographs do not usually reveal the fracture; bone scanning is the preferred diagnostic modality.     

99MTc-diphosphonate bone imaging and uptake in healing rat extraction sockets

Clinically positive bone scans of the jaws may result from a variety of benign dental conditions. An experimental system for studying radionuclide imaging and uptake in the jaws of rats was developed. Sequential 99mTc-diphosphonate bone scans and radionuclide uptake determinations were performed on rats after standardized extractions of their mandibular left first molars. Positive bone scans were seen 4-16 days after molar extraction, and increased radionuclide uptake was found in the healing extraction wounds 4-42 days after the extraction. Conventional radiography and histology fail to show unusual bony architecture in extraction sockets at such times. These results correlate with clinical findings in patients and suggest that human beings may have positive bone scans for several months after dental extraction.     

The reduction of chronic nonspecific low back pain through the control of early morning lumbar flexion. A randomized controlled trial

STUDY DESIGN: Eighteen-month, randomized controlled trial with partial crossover. OBJECTIVES: To test the hypothesis that the control of lumbar flexion in the early morning will significantly reduce chronic, nonspecific low back pain. SUMMARY OF BACKGROUND DATA: Previous studies have indicated an increased risk of low back pain with bending forward in the early morning, primarily because of increased fluid content in the intervertebral discs at that time. METHODS: After 6 months of recording baseline data, 85 subjects with persistent or recurring low back pain were randomly assigned to treatment and control groups. The treatment group received instruction in the control of early morning lumbar flexion. The control group received a sham treatment of six exercises shown to be ineffective in reducing low back pain. Six months later, the control group received the experimental treatment, Diaries were used to record daily levels of pain intensity, disability, impairment, and medication usage. RESULTS: Significant reductions in pain intensity (P < 0.01) were recorded for the treatment group, but not for the control group (point estimate, 33%; 95% confidence interval, 11-55%). After receiving the experimental treatment, the control group responded with similar reductions (P < 0.05). Significant reductions also were observed in total days in pain, disability, impairment, and medication usage. CONCLUSIONS: Controlling lumbar flexion in the early morning is a form of self-care with potential for reducing pain and costs associated with chronic, nonspecific low back pain.     

When to use bone scintigraphy. It can reveal things other studies cannot

Despite advances in nuclear medicine, bone scintigraphy remains an important imaging technique. It is sensitive in detecting stress fractures and bone metastases and can assess suspected injury that is difficult to see on plain films (e.g., rib fracture). Scintigraphy is useful in evaluating new symptoms, response to therapy, and prognosis in patients with known malignant tumor. In patients with low back pain, the technique can determine the age of fractures to help identify osteoporosis and can uncover other causes of the pain (e.g., spondylolysis, arthritis). When Paget's disease is suggested by unexplained bone pain or an elevated serum alkaline phosphatase level, bone scintigraphy is a useful screening test. Combined with other appropriate nuclear medicine studies, it helps in early identification and localization of osteomyelitis. Scintigraphic scans can provide a general indicator of malignant versus benign disease (according to the amount of lesion activity seen) and may produce characteristic findings in certain primary tumors (e.g., osteoid osteoma) that are difficult to evaluate with other methods.     

Bone metastasis with superimposed osteomyelitis in prostate cancer

The following case of a male patient with a history of prostate cancer suffering from pain and swelling in the right mandibular area illustrates the well-known diagnostic problem of a superinfected tumor. Orthopan tomography and CT showed no defects in bone structure or smooth tissue. Whole-body bone scanning showed increased tracer uptake in the mandibular bone and in several other locations in the skeletal system. Antigranulocyte immunoscintigraphy showed increased uptake over the right mandible, whereas the other metastatic sites were visualized as cold spots. A second CT scan depicted a sclerotic lesion with surrounding periostal reaction and soft-tissue swelling and was interpreted as osteomyelitis. Therefore, clinical symptoms, bone scanning, antigranulocyte immunoscintigraphy and follow-up CT resulted in a diagnosis of osteomyelitis, although open needle biopsy revealed the lesion to be prostate cancer metastasis with massive leukocytic invasion.     

Focal areas of increased renal tracer uptake on bone scans can mimic metastases in the lower ribs

Focal renal concentration of radioactivity can simulate metastatic deposits in the lower ribs on bone scintigrams. 400 consecutive bone scintigrams were reviewed for focal areas of increased tracer activity in the kidneys. 62 patients (15.5%) had at least one renal hot spot. In 42 of these 62 patients (67.7%) there was an increased focal uptake in the left kidney (18 upper pole, 18 middle pole and six lower pole). 50 out of 62 bone scans (80.7%) showed increased activity in the right kidney (14 upper pole, 32 middle pole and four lower pole). With the incidence of focal areas of activity in the upper poles of the kidneys being 8%, the interpretation of a single focal abnormality projected over the lower ribs should be made with particular care, especially in cancer patients.     

The Bagby and Kuslich method of lumbar interbody fusion. History, techniques, and 2-year follow-up results of a United States prospective, multicenter trial

STUDY DESIGN: A prospective, multicenter trial of the Bagby and Kuslich method of lumbar interbody stabilization for chronic discogenic low back pain, with follow-up evaluation at 3 months, 6 months, and yearly thereafter, with independent radiographic analysis. OBJECTIVES: To report the history of development, the surgical techniques, and results of the Bagby and Kuslich method when used to manage discogenic pain of the lumbar spine in humans. SUMMARY OF BACKGROUND DATA: Disabling chronic low back pain frequently is resistant to conservative management. The "Bagby Basket" effectively has fused the equine and baboon spine. The results of biomechanical and animal studies performed over the last 20 years have suggested that a similar but improved design--the Bagby and Kuslich device--would be useful in stabilizing the human spine. METHODS: From 1992 to 1995, 947 patients with chronic discogenic low back pain were treated by Bagby and Kuslich interbody fusion in a strict, multicenter, prospective clinical trial by using either the open anterior or open posterior approach. The study involved 42 surgeons at 19 medical centers. The authors of the current report analyzed the fusion rates, pain relief, functional status, and complications occurring in patients who underwent long-term follow-up observation. RESULTS: The Bagby and Kuslich method is safe and effective when compared with methods described in previous reports of posterior and anterior lumbar interbody arthrodesis performed by using bone graft alone. Fusion occurred in 91% of patients at 24 months after surgery, and pain was eliminated or reduced in 84%. Function was improved in 91%. There were no device-related deaths, cases of major paralyses, device failures, or deep infections. CONCLUSIONS: Carefully selected middle-aged patients with chronic low back pain secondary to degenerative disc disease can be treated effectively and safely by skilled surgeons using the Bagby and Kuslich device for one- and two-level interbody fusion.     

Community survey of factors associated with consultation for low back pain

OBJECTIVE: To investigate the psychosocial factors associated with consultation for low back pain. DESIGN: Two phase cross sectional postal survey. SETTING: Bradford Metropolitan Health District. SUBJECTS: 1813 adults responding to the phase 1 questionnaire. 540 of the 782 with an episode of low back pain in the past 12 months completed the second questionnaire. MAIN OUTCOME MEASURES: Six psychosocial constructs. RESULTS: 406 (52%) of the respondents reporting back pain in the past 12 months had not consulted a health professional. Logistic regression showed that consultation was associated with externalised beliefs regarding pain management (odds ratio 3.6; 95% confidence interval 2.1 to 6.0). Duration of pain affected the factors associated with consultation. Consultation for episodes lasting less than two weeks (n=290) was associated with greater than median pain (3.0; 1.7 to 5.5), consultation for episodes over two weeks (n=243) was associated with increased disability (3.7; 1.5 to 9.0), and consultation for episodes over three months (n=143) with increased depression (3.9; 1.3 to 11.8). CONCLUSIONS: The results support a role for psychosocial factors in consultation for low back pain and suggest that the reasons for consultation vary with duration of pain. Duration of the episode may be a useful guide to management of non-specific low back pain.     

Use of ultrasonography methods in the diagnosis of neurogenic paraosteoarthropathy in spinal cord injury

To assess the role of the ultrasonic imaging evaluation of articular lesions suspected to be the initial presentation of heterotopic ossifications (HO), 59 consecutive injured patients were studied. 32 out of 59 patients showed clinical signs of local inflammation in one of the articular sites of the upper or lower limbs, sonographic scans proved to be diagnostic of HO in 7 out of those 32 patients before their radiographic findings. Serial sonographic examinations were performed utilizing a 7.5 MegaHertz transducer probe for 2 months. The imaging abnormalities were correlated with biochemical levels of serum alkaline phosphatase, modifications of radiographic features and bone 99nTC scintigraphy. Scintigraphy revealed to have a high sensitivity but a low specificity for the diagnosis of HO. Also the serum levels of alkaline phosphatase were not a sensitive indicator of early HO in our group of patients. Moreover serial sonographic scans confidently excluded the HO in the 25 patients with no initial signs of the disease without any false negative results. Thus, early sonographic assessment of patients, with spinal cord injury in which local signs of inflammation suggest initial HO formation, revealed to be superior to the other utilized technique for the diagnosis of HO and may be considered a valuable alternative in particular to evaluate the evolutive pattern of this disease.     

Socioeconomic incidences and prognostic factors of low back pain caused by occupational injuries among the hospital personnel of Grenoble University Hospital Center

Low back pain is generally believed to be common among hospital employees. This cross-sectional, retrospective study was carried out to determine the annual incidence of low back pain ascribable to occupational injuries in hospital employees and to evaluate factors influencing the prognosis of these injuries. In 1989, 70 employees working at the Grenoble Teaching Hospital (GTH) reported an occupational injury responsible for low back pain. Each of these employees filled out an epidemiological questionnaire during a routine evaluation by a rheumatologist. Overall annual incidence of occupational injuries with subsequent low back pain was 1.9% among GTH employees. Higher incidences were seen among employees whose occupations involved patient transfer, as well as among nursing assistants. Activities associated with an increased risk of low back pain included handling of patients or objects and work requiring prolonged periods in uncomfortable positions or in the standing position. A previous history of low back disease and a longer period of time in the current work were also associated with an increased risk of low back pain. Characteristic clinical profiles of patients with low back pain subsequent to occupational injury were determined by occupation and type of hospital department. The analysis of long-duration absence from work and long-term consequences on career confirmed the significant adverse socioeconomic impact of these injuries.     

99Tcm-labelled chimeric human/mouse anti-granulocyte antibody bone marrow scintigraphy: a preliminary clinical study

Bone marrow scintigraphy using 99Tcm-labelled chimeric anti-granulocyte antibody (anti-NCA-95) was performed in 17 patients with haematological disorders and skeletal metastases. Chimeric anti-NCA-95 antibody (chNCA95 Ab, 0.2 mg) labelled with 444 MBq 99Tcm was administered to obtain bone marrow images 4 h post-injection. One week later, an 111In-chloride bone marrow scan was performed on nine patients with haematological disorders. Lumbar bone marrow-to-background (L/B) and ilium-to-background (I/B) uptake ratios were calculated for each scan. In six patients with suspected skeletal metastases, 99Tcm-HMDP bone scans were performed. No patient had any adverse reaction or any immune reaction over 20 weeks. In the patients with haematological disorders, the L/B and I/B ratios of the 99Tcm-chNCA95 Ab scan were 3.41 +/- 0.90 and 1.23 +/- 0.31, whereas those of the 111In-chloride scan were 1.58 +/- 0.32 and 1.00 +/- 0.32, respectively. In assessing findings of irregular central bone marrow uptake and peripheral expansion of the bone marrow, the 99Tcm-chNCA95 Ab scan was much better than the 111In-chloride scan. In the six patients with suspected skeletal bone metastases, three true-positive and two true-negative results were observed. This preliminary study has revealed that 99Tcm-chNCA95 Ab scanning is safe and useful in the diagnosis of haematological disorders and skeletal metastases.     

Recommendations of the Brain Tumor Subcommittee for the reporting of trials. SIOP Brain Tumor Subcommittee. International Society of Pediatric Oncology

Depression was examined in 45 patients evaluated within 2 months of diagnosis of MS. At the time of testing, 40% of the MS sample met the diagnostic criteria for major depression, 22% had adjustment disorder with depressed mood and 37% showed no evidence of mood disorder. Personal and family history of depression in patients with MS was also examined and compared with a sample of patients with chronic low back pain (CLBP) who were matched for age, gender, marital and employment status and current level of depression. Fifty-two per cent of patients with MS reported experiencing a depressive episode before the onset of MS compared with 17% of patients with CLBP (P < 0.001). Sixteen patients with MS (35%) reported family history (parent or sibling) of treatment for depression compared with seven (15%) of patients with CLBP (P < 0.05). MS patients with a history of depression reported more initial symptoms than MS patients without a history of depression. Clinical and theoretical implications of the findings are discussed.     

Evidence for selective use of bone scans in early stage breast cancer

To determine the usefulness of bone scans in detecting metastatic disease in women with early stage breast cancer, records of 193 patients who had bone scans preformed and underwent breast conservation therapy at a single institution were reviewed. Patients with invasive T1 or T2 breast carcinomas were eligible for this study; patients with a true positive bone scan were excluded from conservation therapy and, thus, were excluded from this study. The incidence of false positive bone scans in this study population was 32.6% (63/193 patients). Patients over 50 years of age had a significantly greater incidence of false positive bone scans (p<0. 05). In the 63 patients with false positive bone scans, 101 radiographs were performed to exclude metastatic disease in areas of increased uptake identified on bone scan. No significant difference in the rate of false positive bone scans was seen in relation to tumor size, pathologic or clinical nodal status or hormone receptor activity of the primary tumor. Thus, selective use of bone scans is advocated in patients with early stage (T1 or T2) breast cancer.     

Etiology, histopathology, and outcome of surgery in achillodynia

Fifty-eight patients suffering from achillodynia for a median of 12 months (range, 4-240 months) were analyzed using history, clinical findings, ultrasound findings, histopathology, and surgical outcome. Surgical criteria were daily pain or inability to perform sports activity and failure of nonoperative treatment. There were 34 men and 24 women, 31% (18 of 58 patients) of whom had no direct association with sports or vigorous physical activity. Ultrasonography was performed in all cases and showed low echogenous areas (N = 48), increased tendon diameter (N = 40), and/or peritendinous fluid (N = 11). Histopathological evaluation of tendon biopsies, obtained from regions showing pathology at surgery (N = 35), revealed altered fiber structure and arrangement, focal variations in cellularity, extracellular glycosaminoglycans, neovascularization, and/or hyalinization. In no case was inflammatory cell infiltration observed. At a median clinical follow-up of 25 months after surgery, symptoms were decreased in 86% of patients, and 76% had reached a higher activity level compared with the level before surgery. Complications occurred in 13% of operations. In conclusion, achillodynia is not always associated with excessive physical activity. Macroscopic pathologic tendons showed marked histopathologic changes, correlating well with ultrasound findings. Surgical treatment was beneficial in most cases, despite a relatively high complication rate. The etiology and reason for the lack of healing response to rest and nonoperative treatment are unclear.     

Interferon-gamma and monoclonal antibody 131I-labeled CC49: outcomes in patients with androgen-independent prostate cancer

To assess the tumor targeting, safety, and efficacy of monoclonal antibody 131I-labeled CC49 in patients with androgen-independent prostate cancer, 16 patients received 75 mCi/m2 of the radiolabeled antibody after 7 days of IFN-gamma pretreatment. Sequential tumor biopsies in three patients showed a median 5-fold (range, 2-6-fold) increase in the proportion of cells staining positively for the TAG-72 antigen, whereas one showed a decrease in staining. Fourteen patients received 131I-labeled CC49, whereas 2 showed a disease-related decrease in performance status, precluding antibody treatment. The antibody localized to sites of metastatic androgen-independent prostate cancer in 86% (12 of 14; 95% confidence interval, 57-95%) of cases. Both osseous and extraosseous sites were visualized, and in six (42%) patients, more areas were visible when the radioimmunoconjugate was used than were apparent when conventional scanning techniques were used. The localization of the conjugate in the marrow cavity was usually a site not visualized by the radionuclide bone scan, in which the isotope localizes primarily to the tumor-bone interface. The dose-limiting toxicity was thrombocytopenia because five (36%) patients showed grade IV and seven (50%) showed grade III effects. In addition, six (42%) patients, four of whom were hospitalized, showed a flare in baseline pain, and four showed a decrease in pain. No patient showed a >50% decline in prostate-specific antigen, although radionuclide bone scans remained stable in four cases for a median of 4 months. The results are consistent with dosimetry estimates showing that the delivered dose to tumor was subtherapeutic and suggest that approaches that exclusively target the bone tumor interface or the marrow stroma may be unable to completely eradicate disease in the marrow cavity. For CC49, improving outcomes would require repetitive dosing, which was precluded by the rapid development of a human antimouse antibody response.     

Sacroiliac joint tuberculosis. Classification and treatment

The authors treated 16 patients with tuberculosis of the sacroiliac joint. Twelve were treated surgically and four were treated conservatively. The clinical symptoms were buttock and low back pain in all patients, and most had difficulty walking (68.6%) and had radicular pain in their lower limbs (50%). Of the 16 patients, four (15%) had associated tuberculous spondylitis, six (37.5%) had an abscess in the gluteal region, and two (12.5%) had an abscess in the inguinal region. The diagnosis was proven by pathologic specimen in 12 patients and by clinical symptoms, laboratory data, and radiologic findings in the remaining four patients. The authors classified tuberculous sacroiliitis into four types based on the clinical and radiologic findings. Types 1 and 2 were treated conservatively with chemotherapy alone, whereas Types 3 and 4 were treated with surgery and chemotherapy. Healing occurred and was evident in patients who had curettage and arthrodesis (Types 3 and 4) at a mean of 20.8 months, which was comparable with healing in the patients who had chemotherapy alone that occurred at a mean of 23.5 months (Types 1 and 2). The authors suggest that the new classification will be helpful in determining the therapeutic plan of tuberculous sacroiliitis.     

The relationship between the serum level of prostate specific antigen and bone and CT scans in the staging of the primary carcinoma of the prostate

OBJECTIVE: To determine the relationship between the serum level of prostate-specific antigen (PSA) and the presence of abnormalities in a skeletal or CT scan in patients with primary carcinoma of the prostate. DESIGN: Retrospective. SETTING: Academic Medical Centre, Amsterdam. PATIENTS AND METHODS: The serum PSA levels were compared with the findings in the skeletal and CT scans of 440 patients with carcinoma of the prostate without clinical signs of metastases, seen in the period from January 1990 to December 1994 in the outpatient clinics for Urology of the Academic Medical Centre (AMC) in Amsterdam, Hospital Gooi-Noord in Blaricum and Hospital De Heel in Zaandam. CT scan data were analysed only from the AMC and Hospital Gooi-Noord. RESULTS: There were 76 patients with a positive bone scan (17.3%) and 31 (out of 337; 9.2%) with a positive CT scan. Higher PSA serum levels went together with increasing risk of abnormalities in bone or CT scan. Of 85 patients with PSA values < 10 micrograms/l, none had a positive bone scan and one (out of 73; 1%) a positive CT scan; of the 180 patients with PSA levels < 20 micrograms/l, 4 (2.2%) had a positive bone scan and 2 (out of 154; 1.3%) a positive CT scan. The T stage, the histological grading and the serum alkaline phosphatase activity appeared not to have any supplementary value. CONCLUSION: In view of the low frequency of abnormalities in a bone or CT scan in patients with low PSA levels, it appears justified no longer to recommend bone or CT scanning for staging of patients for a clinically non-metastasized carcinoma of the prostate and serum PSA levels < 20 micrograms/l.     

Atraumatic osteolysis of the distal clavicle: MR findings

OBJECTIVE: The purpose of this study was to describe the MRI appearance in atraumatic osteolysis of the distal clavicle (AODC). MATERIALS AND METHODS: We retrospectively evaluated MRI, medical records, ancillary diagnostic imaging studies and clinical course in five men and two women (mean age, 39 years) in whom the final clinical diagnosis of AODC was established. None of the patients had significant shoulder injury, but all participated in activities involving repetitive strain of the acromioclavicular (AC) joint. In three of these patients, we performed follow-up MRI (ranging from 5 1/2 to 15 months after the initial MRI). RESULTS: In all seven patients, signal intensity changes within the intramedullary portion of the distal clavicle on MRI were consistent with diffuse bone marrow edema. Marrow edema was most conspicuous on STIR imaging and occasionally could be misinterpreted as normal marrow signal patterns on spin-echo imaging. Cortical thinning or irregularity of the distal clavicle was seen in six cases and tiny subchondral cysts were seen in three, corresponding to subtle cystic changes on shoulder radiography. Limited bone scans obtained in two patients showed markedly increased uptake of radiotracer at the distal clavicle and AC joint. Histologic examination in one case showed disruption of articular cartilage, subchondral cysts, and metaplastic bone formation with increased osteoclastic activity. Follow-up MRI in three patients who were asymptomatic following conservative therapy showed normalization of marrow signal intensity. CONCLUSION: Atraumatic osteolysis of the distal clavicle is a relatively uncommon but important cause of shoulder pain. Particularly when the clinical history is suggestive of repetitive AC joint stress, MRI of the distal clavicle should be examined closely for marrow edema, cortical irregularity, and cystic changes. Such abnormalities may be especially conspicuous when STIR imaging techniques are used.     

Diagnosis of osteomyelitis. Accuracy and limitations of antigranulocyte antibody imaging compared to three-phase bone scan

Thirty-seven patients with suspected osteomyelitis in conjunction with diabetic gangrene (N = 14, group 1), arthroplasty (N = 8, group 2), and various diseases (N = 15, group 3) were examined. Three-phase bone scans, followed by granulocyte imaging using I-123 labeled anti-NCA 95 monoclonal antibodies, were performed to evaluate and compare the diagnostic accuracy of both procedures. Final diagnosis was established histologically, bacteriologically, or by both methods either through the clinical course or by long-term follow-up in patients in group 1. Osteomyelitis was proven in 17 out of the 37 patients. Bone and antigranulocyte imaging demonstrated positive results in all patients with osteomyelitis (sensitivity 100% for each method). No signs of skeletal infection were found in 20 patients. Fifteen of these patients had no antigranulocyte antibody accumulation, resulting in 75% specificity. Ten patients without infection had normal three-phase bone imaging results (specificity 50%). Antigranulocyte imaging results were negative in 6 out of 10 patients without osteomyelitis in groups 2 and 3 whose bone imaging results were questionable. However, because of identical bone and granulocyte imaging results, no increase of diagnostic accuracy could be obtained by additional granulocyte imaging in patients with diabetic gangrene. Final diagnoses of false-positive antigranulocyte studies were aseptic osteonecrosis (N = 2), loosening of prostheses, gouty arthritis, and pain after arthrolysis. In summary, antigranulocyte antibody imaging offered high sensitivity and acceptable specificity for the diagnosis of osteomyelitis. Diagnostic accuracy can be improved through the adjuvant use of antigranulocyte imaging for patients with suspected osteomyelitis, especially when radiographic and scintigraphic results are questionable or unreliable.