Bone Scan Whole Body with SPECT or SPECT/CT Area of Interest The bone scan was regarded for many years as the reference standard for detecting stress-induced injuries and was valued for its sensitivity. Dobrindt et al [17] reported the sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of bone scintigraphy for detection of stress injuries as 92.9%, 73.8%, 83.3%, 78.0%, and 91.2%, respectively. Planar scintigraphy combined with single-photon emission CT (SPECT) is more accurate in diagnosing stress injuries than planar scintigraphy alone [18]. The objection to the studies quoting high accuracy for bone scintigraphy is that, in all of them, positive bone scintigraphy is taken as the reference standard for detecting stress fractures and therefore sensitivity is 100%. However, depending on the staging criteria for bone scintigraphy pattern, the abnormalities may in fact be stress reactions rather than actual stress fractures [19-21]. Nonetheless, bone scintigraphy shows stress fractures days to weeks earlier than radiographs in many instances and differentiates between osseous and soft tissue injury as well. CT Area of Interest With IV Contrast There is no relevant literature to support the use of CT area of interest with intravenous (IV) contrast because it does not provide added information over noncontrast imaging with regard to stress injury. CT Area of Interest Without and With IV Contrast There is no relevant literature to support the use of CT area of interest without and with IV contrast because it does not provide added information over noncontrast imaging with regard to stress injury. CT Area of Interest Without IV Contrast CT is not supported for the initial imaging of suspected stress fractures but may offer an adjunct role when other imaging modalities are equivocal [22], particularly in the pelvis or sacrum.
Stress Fatigue Insufficiency Fracture Including Sacrum Excluding Other Vertebrae PCAs. Bone Scan Whole Body with SPECT or SPECT/CT Area of Interest The bone scan was regarded for many years as the reference standard for detecting stress-induced injuries and was valued for its sensitivity. Dobrindt et al [17] reported the sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of bone scintigraphy for detection of stress injuries as 92.9%, 73.8%, 83.3%, 78.0%, and 91.2%, respectively. Planar scintigraphy combined with single-photon emission CT (SPECT) is more accurate in diagnosing stress injuries than planar scintigraphy alone [18]. The objection to the studies quoting high accuracy for bone scintigraphy is that, in all of them, positive bone scintigraphy is taken as the reference standard for detecting stress fractures and therefore sensitivity is 100%. However, depending on the staging criteria for bone scintigraphy pattern, the abnormalities may in fact be stress reactions rather than actual stress fractures [19-21]. Nonetheless, bone scintigraphy shows stress fractures days to weeks earlier than radiographs in many instances and differentiates between osseous and soft tissue injury as well. CT Area of Interest With IV Contrast There is no relevant literature to support the use of CT area of interest with intravenous (IV) contrast because it does not provide added information over noncontrast imaging with regard to stress injury. CT Area of Interest Without and With IV Contrast There is no relevant literature to support the use of CT area of interest without and with IV contrast because it does not provide added information over noncontrast imaging with regard to stress injury. CT Area of Interest Without IV Contrast CT is not supported for the initial imaging of suspected stress fractures but may offer an adjunct role when other imaging modalities are equivocal [22], particularly in the pelvis or sacrum.