Musculoskeletal imaging is gaining prominence in diagnostic radiology and has seen several momentous advancements in the recent years, abetted by growing research By Lakshmipriya Nair
Medical imaging has transformed the way healthcare is delivered in modern times. It has also seen rapid progress in the past few decades, spurred by the growing emphasis on evidence-based medicine.
One of its branches which has seen increased implementation in the recent years is musculoskeletal imaging. Defined as the imaging of the bones, joints, and connected soft tissues using an extensive array of modalities such as conventional radiography, computed tomography (CT), ultrasonography and magnetic resonance imaging (MRI), it is a field which is constantly evolving to offer timely and useful information about musculoskeletal anomalies to experts for enhanced continuum of patient care, from detection and diagnosis to post-treatment supervision.
As Dr Swapnil Zambre, Consultant Arthoscopy and Joint Replacement Surgeon, Fortis Hospital Kalyan, ascertains, “Musculoskeletal imaging, which essentially means getting various kinds of images or pictures of bones, muscles and nerve tissues that are facing disorders, has seen rapid but cumulative advances in terms of quality of information one can gather from these images.”
Adding to this, Dr Rajesh Lavakumar, Senior Consultant and MSK Lead, Columbia Asia Radiology Group, informs, “The speciality is vast and it encompasses diagnosis and image-guided therapy for all kinds of ailments affecting the musculoskeletal system ranging from congenital deformities, infections – bone/ soft tissue, cancers, rheumatological diseases and trauma – both accidental/ sport related. The speciality includes interventional/ therapeutic radiology pertaining to the musculoskeletal system in the form of ultrasound, fluoroscopy and CT-guided procedures which range from biopsies to injecting therapeutic drugs at specific targeted locations.”
An evolving sphere
The first X-ray, taken by Wilhelm Conrad Roentgen, of his wife’s hand, set the foundation for diagnostic radiology and marked the beginning of musculoskeletal imaging as well. Yet, recognition and progress as a sub-speciality, especially in India, came to the sphere only around two decades ago.
Dr Bhavin Jhankaria, Radiologist and Partner, Picture This by Jankharia, enlightens, “From being a non-speciality up to 10 years ago, now it is being accepted as a separate sub-speciality. Many radiologists spend more than 50 per cent of their time doing only musculoskeletal imaging.”
Reiterating this point, Dr Lavakumar says, “The importance of musculoskeletal radiology as a standalone speciality in India has begun to gain prominence only recently. The Musculoskeletal Society of India, dedicated to imaging, was formed just two years back albeit we’re making rapid progress in this speciality.”
However, since then, musculoskeletal radiology has witnessed significant advancements which have been instrumental in enhancing diagnostic sensitivity and specificity and enhanced the scope of image-guided treatment options. Research and growth of cross-sectional imaging like CT and MR imaging have also played pivotal roles in furthering the evolution of musculoskeletal radiology as a separate sub-speciality.
Revolutionising healthcare delivery
So, how has the sphere affected healthcare delivery over the years? What have been the major benefits?
Dr Zambre informs, “Musculoskeletal imaging has also allowed the clinicians to use the plain old X-rays to the maximum effect. When coupled with the size standardisation, it now allows the doctors to accurately get bone measurements, facilitating surgical planning for placing various metal implants in patient by accurately predicting the required size and shape even before the surgery. This has resulted in faster, minimally invasive surgery and rapid patient recovery.”
As Dr Lavakumar highlights, musculoskeletal imaging has aided early and accurate diagnosis, which in turn has been instrumental in:
- Avoiding unnecessary diagnostic/ exploratory procedures
- Less extensive and more appropriate surgery
- Use of interventional radiologic techniques have led to focused delivery of medication which improves outcome
- Prevention of late disabilities
- Eventual cost saving for patient — less days in hospital, treatment at early stage of disease, more productive years in career etc.
Dr Jhankaria opines, “Sub-specialists provide better quality of reads of MRIs and X-rays and this improves healthcare delivery overall.”
Thus, the experts unanimously agree that musculoskeletal imaging has brought significant advantages to healthcare delivery. So what are reigning trends is this area? Dr Lavakumar answers, “The current trends in MSK imaging are cartilage imaging, PET CT, diffusion weighted sequences on MRI, MR arthrography, 3 Tesla MRI for small parts and high resolution ultrasound. These have greatly improved diagnostic capabilities and accuracy when compared with traditional MR sequences and ultrasound that we limited ourselves to – till fairly recent times. If studies like MR arthrography becomes integral and common practices, it will add immense value to patient care.”
On the other hand, Dr Zambre says, “The single biggest advancement in the field of musculoskeletal imaging, which has not only bought down costs, but is also environment-friendly, has been the advent of digital X-rays. If properly implemented, one no longer requires the X-ray plates, which can fade and get spoilt with time. With digital X-rays, all information can be stored on a USB drive. However, the biggest advantage is, perhaps, the ability to play around with the digital X-ray images by way of ability to zoom-in and zoom-out various areas of the image, and the ability to change contrasts, which has allowed the clinicians to get better insights into picking up diagnosis for problems such as hairline fractures, which they would have missed before due to small image size and poor quality.
He further opines, “Another trend in musculoskeletal imaging that is emerging is that of portable ultrasound. Advances in the field of electronics and constant cost cuts have put more sensitive and advanced, and laptop-sized ultrasound machines in the hands of surgeons. These are now being used in one-stop sports medicine clinics where surgeon can – immediately after a patient exam – perform an ultrasound to confirm a diagnosis, thus preventing delay in the treatment. Since it is performed by the same surgeon who has been intimately aware of the anatomy of the body part being examined, the accuracy of ultrasound diagnosis gets magnified, overcoming the operator dependency in this modality to a large extent.”
Dr Zambre also highlights, “Advances continue in the field of musculoskeletal imaging. One such development is the 3D MRIs, which will allow us to assess in detail in three dimensions the nature of injuries, especially in the soft tissues where the CT scans fall woefully short. When coupled with 3D printers, musculoskeletal imaging could allow us to print patient specific implants and synthetic tissues in near future. Another trend is the even more detailed 9 to 21 Tesla MRIs, which may not necessarily have direct clinical use as of now, are currently allowing us to study cellular metabolism better and to look at effects of newer drugs on cells, speeding up the launch of newer drugs. However the most exciting anticipation about the future is that of the Dynamic CT.”
He further enlightens, “In orthopaedics, quite a few problems manifest themselves only when the patients move and work. Until recently, the doctors had been hemmed in by static imaging, where the patient lays still either in X-ray or MRI or CT, and one is not able to appreciate pathology due its dynamic nature. Dynamic Fast CT machines which are already a niche reality, will change that and allow doctors do not only carry out the better diagnosis, but will also enable them to tailor surgeries more precisely.”
Dr Jhankaria feels that the modality’s rise as a major sub-speciality itself is a significant trend. He opines, “The main trend is the fact that young radiologists are taking this up as a sub-speciality. It is a multi-modality and musculoskeletal radiologists often read X-rays and MRIs as well as perform ultrasounds and USG-guided procedures.”
Challenges to conquer
Thus, the modality has seen significant progress in recent times. It is undeniable that it’s making an indelible mark in the advances made by medical imaging. Yet, it has not yet achieved its true potential. Challenges continue to dog its growth trajectory. As Dr Lavakumar says, “The fact that high quality musculoskeletal radiology is not widely available in India is a reflection of the country’s priorities. We’ve been a developing country for long and have been focusing on life and death issues so far. Only recently we’ve begun to look at quality of life as well. India has only in the recent years been seeing a steady rise in sports and fitness interests. Whilst it improves the general health of our nation, today’s radiologists are also challenged to help solve complex injuries.” He further informs, “There continues to be a lacuna in formal teaching of ultrasound and MRI skills pertaining to diagnosis of musculoskeletal pathology.”
Dr Zambre also explains, “In India, in major metropolitan and town areas, newer X-ray and MRI modalities have made an amazing penetration across the board, and are now at par with most of the developed nations. However, the necessary expertise that is required in radiology, to interpret these more detailed images, has been somewhat patchy and varies from excellent to adequate.”
Dr Lavakumar also states the steps being taken by his hospital to mitigate these issues. He says, “To address this, we at Columbia Asia Radiology Group have been attempting to create awareness about current trends in musculoskeletal imaging by organising workshops in collaboration with musculoskeletal specialists from Leeds University, UK and also ‘Radiology Contact Programs’ for global and Indian radiologists to hone their skills while rising to the upcoming healthcare demands. The most recent batch came all the way from Indonesia.”
Events like MUSoc 2015, an event which promotes musculoskeletal ultrasound, also seek to meliorate the domain. Dr Nidhi Bhatnagar, MS-USG Consultant, Max Panchsheel, Sanjeevan Hospital and General Secretary, Muskuloskeletal Ultrasound Society says, “At MUSoc 2015, we will be teaching all seven major joints e.g. shoulder, elbow, wrist hand, hip, knee, ankle and foot. It has topics of interest for not only the radiologists but also for rheumatologists, orthopaedicians, sports medicine consultants and pain management physicians. There will be hands-on, teaching workshops to impart focused training. We will be emphasising each aspect of musculoskeletal ultrasound .”
The way forward
So, what does the future hold for this sub-speciality? Answering this query, Dr Lavakumar says, “Injuries in contact sports like football, hockey, kabbadi, wrestling, boxing or even non-contact sports like golf, cricket, tennis, cycling, badminton, track and field professionals need high quality specialist care, be it orthopaedic surgery, sports medicine or physiotherapy. Correct diagnosis is crucial for good quality care – that is where musculoskeletal radiology as a speciality plays a pivotal role. Suboptimal care has drastic implications on one’s career which impacts quality of life both physically and financially. In today’s technology driven world, easy and quick access to musculoskeletal sub-speciality radiologist should be possible.” He adds, “Hence, educating radiologists and clinicians alike would play a key role. I see a dramatic increase in musculoskeletal radiology educational programmes throughout India and internationally. A short stint internationally will certainly add perspective and value to one’s practice.”
Dr Zambre states, “The diagnostic accuracy will continue to improve in surgeons with time, as they continue to get direct feedback of their diagnostic accuracy when operating on the patient subsequently, thus correlating the findings. Ultrasounds in clinics are not only proving a useful diagnostic assistance, but are also allowing doctors to deliver ultrasound-guided injections into the body areas safely and accurately, thus greatly increasing their efficacy. Patients, who previously had either blind injections or needed to wait for the availability of a radiologist, can have it done straightaway, thus decreasing the cost with faster treatments. Improvements in images obtained by the newer 3 Tesla MRI machines have also had a significant impact not only on the diagnosis (pretty much invalidating diagnostic arthroscopy), but also on the patient’s treatments. Newer machines have been able to show cartilage and ligament injuries in far greater detail, allowing tailor-made treatment for injuries which might previously have been missed. On the whole, the above advances, coupled with better surgical training and newer treatment modalities, have allowed us to treat and restore functions in pathologies, previously simply left untreated.”
Thus, it is evident that musculoskeletal imaging is finding accelerating usage in varied areas including imaging of tumours and tumour-like lesions, cases of trauma, vertebroplasty and other spinal interventions etc. Moreover, as a constantly budding speciality, it has undergone several transformations, aided by increasing research on new imaging techniques and application of the proven techniques in novel fields.
So, as Dr Jhankaria concludes, “It is here to stay and as time passes, the depth of knowledge will increase and help patients and doctors understand and treat disease better.
* Pics used for representational purposes