Imaging tests for the detection of osteomyelitis: a systematic review

Abstract

Background Osteomyelitis is an infection of the bone. Medical imaging tests, such as radiography, ultrasound, magnetic resonance imaging (MRI), single-photon emission computed tomography (SPECT) and positron emission tomography (PET), are often used to diagnose osteomyelitis. Objectives To systematically review the evidence on the diagnostic accuracy, inter-rater reliability and implementation of imaging tests to diagnose osteomyelitis. Data sources We conducted a systematic review of imaging tests to diagnose osteomyelitis. We searched MEDLINE and other databases from inception to July 2018. Review methods Risk of bias was assessed with QUADAS-2 [quality assessment of diagnostic accuracy studies (version 2)]. Diagnostic accuracy was assessed using bivariate regression models. Imaging tests were compared. Subgroup analyses were performed based on the location and nature of the suspected osteomyelitis. Studies of children, inter-rater reliability and implementation outcomes were synthesised narratively. Results Eighty-one studies were included (diagnostic accuracy: 77 studies; inter-rater reliability: 11 studies; implementation: one study; some studies were included in two reviews). One-quarter of diagnostic accuracy studies were rated as being at a high risk of bias. In adults, MRI had high diagnostic accuracy [95.6% sensitivity, 95% confidence interval (CI) 92.4% to 97.5%; 80.7% specificity, 95% CI 70.8% to 87.8%]. PET also had high accuracy (85.1% sensitivity, 95% CI 71.5% to 92.9%; 92.8% specificity, 95% CI 83.0% to 97.1%), as did SPECT (95.1% sensitivity, 95% CI 87.8% to 98.1%; 82.0% specificity, 95% CI 61.5% to 92.8%). There was similar diagnostic performance with MRI, PET and SPECT. Scintigraphy (83.6% sensitivity, 95% CI 71.8% to 91.1%; 70.6% specificity, 57.7% to 80.8%), computed tomography (69.7% sensitivity, 95% CI 40.1% to 88.7%; 90.2% specificity, 95% CI 57.6% to 98.4%) and radiography (70.4% sensitivity, 95% CI 61.6% to 77.8%; 81.5% specificity, 95% CI 69.6% to 89.5%) all had generally inferior diagnostic accuracy. Technetium-99m hexamethylpropyleneamine oxime white blood cell scintigraphy (87.3% sensitivity, 95% CI 75.1% to 94.0%; 94.7% specificity, 95% CI 84.9% to 98.3%) had higher diagnostic accuracy, similar to that of PET or MRI. There was no evidence that diagnostic accuracy varied by scan location or cause of osteomyelitis, although data on many scan locations were limited. Diagnostic accuracy in diabetic foot patients was similar to the overall results. Only three studies in children were identified; results were too limited to draw any conclusions. Eleven studies evaluated inter-rater reliability. MRI had acceptable inter-rater reliability. We found only one study on test implementation and no evidence on patient preferences or cost-effectiveness of imaging tests for osteomyelitis. Limitations Most studies included < 50 participants and were poorly reported. There was limited evidence for children, ultrasonography and on clinical factors other than diagnostic accuracy. Conclusions Osteomyelitis is reliably diagnosed by MRI, PET and SPECT. No clear reason to prefer one test over the other in terms of diagnostic accuracy was identified. The wider availability of MRI machines, and the fact that MRI does not expose patients to harmful ionising radiation, may mean that MRI is preferable in most cases. Diagnostic accuracy does not appear to vary with the potential cause of osteomyelitis or with the body part scanned. Considerable uncertainty remains over the diagnostic accuracy of imaging tests in children. Studies of diagnostic accuracy in children, particularly using MRI and ultrasound, are needed. Study registration This study is registered as PROSPERO CRD42017068511. Funding This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 61. See the NIHR Journals Library website for further project information.

Role of ultrasound and CT in the early diagnosis and surgical treatment of primary sternal osteomyelitis caused by Salmonella: Case reports

“…Its presentation may be nonspecific and the diagnostic value of plain radiography is not reliable ( 4 ). MRI, positron emission tomography and single-photon emission CT are reliable modalities for establishing the diagnosis of osteomyelitis, but further research on their diagnostic accuracy in children is required ( 9 , 10 ). In the present cases, these imaging methods were not used due to the disadvantages of harmful ionizing radiation, lack of cooperation by infants, long nursing time and other considerable uncertainties in infants (age, ≤1 year).…”

A Comparison of the Epidemiology, Clinical Features, and Treatment of Acute Osteomyelitis in Hospitalized Children in Latvia and Norway

“…Though they are only used in 20% of cases, X-ray images are useful for ruling out differential diagnoses such as trauma or malignancy [41]. Although it is known that no changes in conventional radiographs are expected at less than 7 to 10 days of the disease, and the sensitivity and specificity of early radiographs are low for diagnosis of osteomyelitis when compared to MRI [16,42,43], follow-up X-ray imaging can be useful in monitoring the response to antibacterial treatment, and an inexpensive way to rule out the chronicity of osteomyelitis [39,44]. MRI has been considered as the most informative diagnostic method for acute osteomyelitis, showing changes starting from day 3 of illness [3,41,45,46] and providing information on soft tissue involvement, including abscess formation, and the identification of a co-existing joint pathology [39].…”

“…However, the bone marrow cannot be viewed via a US scan, and the latter may therefore fail to identify acute osteomyelitis at early stages [39]. Ultrasound imaging has a lower sensitivity and specificity than MRI or bone scintigraphy [42], though it is invaluable in cases with metallic foreign bodies or other cases where MRI is contraindicated [42,43]. In addition, a US scan can be used for guidance when performing deep tissue cultures, pus drainage, or biopsies [47].…”

Analysis of synovial biopsies in osteomyelitis in a tertiary care center

“…Due to its wider availability and zero exposure to ionising radiation, MRI is supposed to be the most preferred imaging modality. 20 Multifocal osseous involvement can specifically be detected with the help of nuclear medicine. 19 Laboratory tests can indicate infection but are usually nonspecific for osteomyelitis.…”