Sybermedica

ESSR Sports Sub-Committe MRI Imaging Protocols

The publication of these MRI protocols is supported by the Football Association

 

With acknowledgement to the Department of Musculoskeletal Radiology, Chapel Allerton Hospital, Leeds, UK. for their origination of the protocols presented here.

 

List of Available Protocols (click on link)

Back Protocols

Routine Lumbar Spine for low back pain and sciatica

Chapel Allerton Side-Strain Protocol

Upper Limb

Shoulder

Elbow

Wrist

Lower Limb

Knee

Ankle/Hindfoot

Forefoot

Hamstring - Acute

Hamstring - Non-acute

Thigh (Quadriceps)

Calf

Muscle Tear

Muscle tear

Other Spine and Body

Sacro-ileac

Cervical spine

Thoracic spine

Whole spine

Pelvis and groin

Hip pain

 

Back Protocols

Routine Lumbar Spine Protocol for low back pain and sciatica

Coverage should be from T11 down to S2, with sufficient slices to include left and right nerve roots (see Fig. 1/2)

Protocols

  • Sag T2 (FS) to include tips of transverse processes
  • Sag T1 to include tips of transverse processes
  • Axial T2 lower 3 disc levels (plus any other stenosed level) – L3/4 to L5/S1 parallel to each disc. (As in Fig.3)
  • Axial T1 lower 3 disc levels (plus any other stenosed level) – L3/4 to L5/S1 parallel to each disc. As above.
  • Coronal oblique T2FS and T1– centred on L5/S1 parallel to sacrum/SIJ (As in Fig.4)

Note: If coccygeal pain mentioned on request (coccydinia), do STIR sag coccyx.

 

Chapel Allerton Side-Strain Protocol

This technique is entirely dependent upon the availability of a small Field of View surface coil (see below). If your unit does not possess one, complete the recommended sequences, using either the spine coil or a larger surface coil – if possible, the patient should be positioned to lie on the affected side (this minimizes motion artefact from breathing).

Patient Positioning (Critically Important)

Ascertain the exact position of the suspected tear and mark this with an oil capsule. Position the coil over the capsule and secure in place with tape and/or bandages. Position the patient supine and plug the coil in. Check that the capsule/coil haven‟t moved from original position.

Protocols

  • Large Field of View localiser
  • Large Field of View FISP‟s (oil capsule finder) in all 3 planes
  • Large Field of View STIR Coronal of whole abdo (include oil capsule) – provides the Radiologist with an accurate (Rib) level of where the tear is.
  • Small FoV (80x80mm) T2FS Axial centred on oil capsule (in Fig.5a & 5b)
  • Small FoV T1 Axial (as above)
  • Small FoV (80x80mm) T2FS Coronal Oblique (as in Fig.6)
  • Small FoV T1 Coronal Oblique (as above)
  • Check with Radiologist/Clinician


If using a larger surface coil, use high res (3mm’s, 160x160mm FoV) STIR sequences in place of the small FoV T2 Fat Sat’s and T1’s.

 

Upper Limb Protocols

Shoulder Protocol

Positions:

1)  Standard

Supine, hand by side, palm up. If palm up not possible, then thumb up. Must not be internally rotated.

2) ABER

Hand palm up behind head, or at least above head

Scan Planes:

1) Axial

  • Do first, needed for setting up coronal oblique
  • Aligned perpendicular to the plane of the glenoid
  • Must include acromion on most superior slice
  • Must cover whole of glenoid (see green Field of View on fig.7 below)

 2) Coronal Oblique

  • Set up from high axial slice that shows supraspinatus tendon (SST – red arrow on fig.8 below)
  • Align along SST (green line on Fig.8 below)
  • Slices must cover from coracoid process anteriorly and include entire humeral head

3) Sagittal Oblique

  • Perpendicular to coronal oblique plane
  • Must extend laterally to include whole humeral head and extend medially to include whole of coracoid process

ABER Protocol

  • Align from coronal scout perpendicular to glenohumeral joint line (perpendicular to glenoid)
  • Ideally this will be along the humeral shaft but if arm is very abducted the angle of section will be less than this (see Fig.9)  

Shoulder Coil Protocols

1) Routine Protocol

  • Axial PD TSE (fat sat)
  • Coronal Obl PD TSE (fat sat)
  • Coronal Obl T2 TSE (fat sat)
  • Sagittal Obl T1 SE
  • Sagittal Obl T2 TSE (fat sat)

2) MR Arthrogram Protocol

  • Axial T1 SE
  • Axial T1 SE (fat sat)
  • Sagittal Obl T1 SE (fat sat)
  • Coronal Obl T1 SE (fat sat)
  • Coronal Obl T2 TSE (fat sat)

3) Body Matrix Coil (Reposition patient)

  • ABER Position T1 SE Axial Oblique (fat sat)

 

Elbow Protocol

Position

  • “Super-man” position with elbow placed inside knee coil (or Flex Coil if elbow locked in flexed position)
  • If above not achievable – supine with arm by side (using flex or body matrix coil). Watch out for phase-wrap, and ONLY select Flex coil when scanning.

Scan Planes

1) Axial

  • Must do first as needed to set up coronal and sagittal plane
  • Position from superiorly, 1cm above humeral epicondyles; and inferiorly, 2cm below the radial head.

2) Coronal

  • Plane here is critical. Set up along anterior aspect of distal humerus (see Fig. 10 below). This gives a plane of section through the two epicondyles.

3) Sagittal Oblique

  • Perpendicular to coronal oblique plane (see Fig.10 below)

Protocols

1) Routine Protocol

  • Axial PD TSE
  • Axial T2 TSE (fat sat)
  • Coronal PD TSE
  • Coronal Obl T2 TSE (fat sat)
  • Sagittal Obl PD TSE (fat sat)

2) MR Arthrogram Protocol

  • Axial T1 SE
  • Sagittal T1 SE (fat sat)
  • Coronal T1 SE (fat sat)
  • Coronal T2 TSE (fat sat)

 

Wrist Protocol

Position

  • Arm must be supinated. This can be achieved using dedicated quadrature or surface coil either in horizontal position with palm up, or in vertical position with thumb up.
  • Wrist in neutral position, no radial or ulnar deviation and no flexion or extension.

Scan Planes

1) Axial

  • Must do first as needed to set up coronal and sagittal plane – to include from radial/ulnar styloid processes to above carpo-metacarpal joints.

2) Coronal

  • Plane here is critical. Line coronal plane up along anterior (volar) aspect of distal radius (Fig.11). It is essential to use an axial slice from a level 2cm below the distal radio-ulnar joint.

3) Sagittal

  • Perpendicular to coronal plane – to include all soft-tissues either side of radius/ulna.

Protocols

1) Routine Protocol

  • Axial PD FSE
  • Coronal T1 TSE
  • Coronal T2 TSE (fat sat)
  • Sagittal T2 TSE (fat sat)
  • + 3D acquired in Coronal Plane - VIBE

2) MR Arthrogram Protocol

  • Axial T1 SE
  • Sagittal T1 SE (fat sat)
  • Coronal T1 SE (fat sat)
  • Coronal T2 TSE (fat sat)
  • Coronal 3D VIBE

3) Suspected Scaphoid Fracture

  • Sagittal T2 TSE (fat sat)
  • Coronal T1 SE
  • Coronal T2 TSE (fat sat)

4) Scaphoid Non-Union

  • Axial PD TSE
  • Coronal T1 TSE
  • Coronal Obl T2 TSE (fat sat) angled through scaphoid – see Fig.12
  • Sagittal Obl T2 TSE (fat sat) – see fig.13
  • Coronal post Gadolinium T1 TSE (fat sat)

 
 

 

Lower Limb Protocols

Knee Protocol (without knee coil)

Scan Planes

1) Axial

  • Established parallel to the knee joint line. Include whole patella, down to fibula head (see fig.14 below)

2) Coronal

  • Set up (on axial slice) along posterior aspects of the femoral condyles on the axial plane (see green line on diagram below).
  • Coverage to include posterior aspect of patella to 2cm behind femoral condyles.

3) Sagittal Oblique

  • Set up on an axial slice - along medial aspect of lateral condyle. This is approximately along the line of the ACL (see Fig.15).
  • Coverage must include both colateral ligaments.

Knee Protocol with Knee Coil/Foot Coil/Body Matrix (Size dependent)

1) Routine Protocol

  • Axial PD FSE (fat sat)
  • Coronal PD FSE (fat sat)
  • Sagittal Obl PD FSE (fat sat)
  • Coronal T1 SE
  • Sagittal Obl T2 FSE (fat sat)

2) Patellar tracking (beach ball)

For Patellar tracking studies (beach ball test) the patient is positioned prone with their ankles over the inflated beach ball. An oil capsule is placed on the back of the affected knee. When ready the stopper is removed from the beach ball and the patient asked to deflate it by pressing down onto the table. Ensure the patient does not lift their knees off the table during the deflation and that they use a constant pressure.

  • Routine knee sequences
  • Re-position patient prone (as described previously).
  • Axial localiser.
  • Sag Localiser over both knees.
  • GRE dynamic sequence over two minutes (Dynamic TFL)...temporal resolution of around 7 secs. Need at least 1 sagittal and 3 axial through the patella at each time point. As the leg is extended against the deflating beach ball the patella moves superiorly so on set up most distal slice should be at or around the mid patella. Include both knees with sagittal on symptomatic side. If both symptomatic please state which side the sagittal has been acquired from. Place oil capsule on symptomatic side.

Ankle and Foot Protocols

Scan Planes given relative to tibial shaft!

Figure shows expected coverage of sagittal FOV with the expected coverage of the coronal (Fig.16) and Axial (Fig.17) series superimposed.

Ankle and Hindfoot

1) Routine Protocol (In this order)

  • Axial PD FSE
  • Axial T2 FSE (fat sat)
  • Sagittal T2 FSE (fat sat)
  • Coronal PD FSE
  • Coronal T2 FSE (fat sat)

2) Impingement Protocol

  • Routine protocol as above
  • Axial and Sagittal T1 Post Gad (fat sat)

Forefoot

SCAN PLANES GIVEN AS SAGITTAL, LONG AXIS (GREEN LINE) AND SHORT AXIS (RED LINE) Fig.18


Routine Protocol

  • FISP‟s in all 3 planes
  • Long axis T2 TSE (fat sat) or STIR
  • Short axis PD TSE
  • Short axis T2 TSE (fat sat) or STIR
  • Sagittal T1 SE

 

Muscle Tear Protocols

Suspected Muscle Tear Protocol

1) Routine Protocol

Check with patient re: site of suspected tear and mark with oil capsule(s) if appropriate.

  • Axial and Long Axis FISP‟s (to localise)
  • STIR/T2FS Coronal/Ssgittal
  • STIR/T2FS Axial
  • T1 Coronal
  • T1 Axial
  • Gad may be prescribed in some cases (check with radiologist)

2) Post exercise protocol

  • Routine protocol as above
  • 10 – 15 minutes moderate exercise
  • T1/STIR Axial immediately after cessation of exercise.
  • Radiologist may advocate post exercise, post contrast imaging.

 

Other Spine and Body Protocols

Routine Sacro-Iliac Joints

  • Centre at lower costal margin (as per L-spine).
  • STIR thoraco-lumbar spine (S1/2 up to T8/9).
  • FISP axials through SI joints.
  • T1 coronal oblique through SI joints (angled to sacrum, as seen in Fig.19A/B)
  • T2 FS coronal oblique (as above).

 

Routine Cervical Spine

Coverage should be from (superiorly) pituitary gland, down to T3/4, with sufficient slices to include left and right nerve roots.

Protocol

  • Sag T2
  • Sag T1
  • Axial T2 “Medic” (T2* Gradient Echo) C3/4 to C7/T1
  •  Include sag STIR if any high signal in the cord.

 

Routine Thoracic Spine

Always place an oil capsule (red arrow) in the mid-line at T12/L1 prior to commencing the examination. Coverage should be from C7/T1 down, to include the entire conus medularis (as seen below in Fig.22/23)

Protocol
 

  • Large Field of View Sag FISP (oil-capsule finder)
  • Sag T2 (must include oil capsule at bottom of FoV)
  • Sag T1

IF ABNORMALITY (review)

  • Axial T1 of abnormal areas
  • Axial T2 of abnormal areas

Whole Spine

This examination is split into 2 separate fields – C/T-spine and L-spine. Begin at the section that is most relevant, and move to the next. Overlap of fields is essential.
 
Routine L spine

  • Sag T2 of C and T spine (from pituitary down to conus or overlap)
  • Sag T1 of C and T spine (from pituitary down to conus or overlap) IF ABNORMALITY (review)
  • Axial T1 and T2 of abnormality (may be “disc” axials or “blocks”)

 Post-Op Spine Routine protocol

  • Sagittal T1FS + Gad (if metal-work present, omit FS)
  • Axial T1FS + Gad (As above)

Brachial Plexus

  • Sag T1 from cervical spine to midpoint of arm
  • Sag T2FS from cervical spine to midpoint of arm
  • Cor T2FS - FOV to include both shoulders
  • Ax T2FS from level of C5 to inferior axilla
  • Coronal SPACE of exiting nerve roots
  • Gadolinium not routinely given – discuss with radiologist as appropriate

Pelvis and Groin

Oblique axial plane here is critical for the adductor muscle insertions – see Fig.25
 

 

  • Coronal STIR of pelvis (anterior abdominal wall, back to posterior sacrum)
  • Sag FISP, to include entire pubic ramii (for the sole purpose of planning the axial obliques).
  • Axial T2FS pelvis (L5/S1 to lesser trochanters)
  • Oblique axial reduced FOV (parallel to superior pubic ramus) T2FS (see diagram)
  • Oblique axial reduced FOV (parallel to superior pubic ramus) T1FS + Gadolinium

Hip Pain

  • Cor T1 both hips
  • Cor T2FS or STIR both hips

If normal perform:

  • Axial T2FS pelvis (L5/S1 to below lesser trochanters) and stop.

If abnormal perform:

  • Axial T1 abnormal side (if both do pelvis)
  • Axial T2FS abnormal side (if both do pelvis)
  • Sag PD symptomatic hip joint

MR Arthrogram Hip

  • Axial T1FS of injected hip (red lines on Fig.26)
  • Coronal T1FS of injected hip (blue lines on Fig.27)
  • Sagittal T1FS of injected hip (yellow lines on Fig.27)
  • Coronal T2FS of injected hip
  • Axial oblique T1 WITHOUT FS (parallel to femoral neck on coronal scans – green lines on Fig.26)

 

HAMSTRINGS - ACUTE INJURY

ROUTINE PROTOCOL

Check with patient re: site of suspected tear and mark with oil capsule(s) if appropriate.
Area of interest will be posterior, so spinal coil elements alone are satisfactory. If suspected site of tear is medial/lateral or unsure, add Body Matrix/Large surface coil anteriorly and wrap over ?site of tear for extra signal. Hamstrings insert proximally into the ischial tuberosity and distally into the proximal portions of the tibia/fibulaComplete the following sequences (in order):

  • Axial and Long Axis localisers (find oil capsule)
  • STIR/T2FS Coronal (Blue lines on Fig’s) - to include tear site + 1 muscle insertion (closest)
  • STIR/T2 FS Sagittal (Red lines on Fig’s) - to cover tear site + 1 muscle insertion (closest)
  • STIR/T2 FS Axial (Green lines on Fig’s) - cover just the tear (if appropriate) or oil capsule (if no tear seen)
  • T1 Sagittal (copied exactly to STIR/T2FS Sagittal)
  • T1 Axial (copied exactly to STIR/T2FS Axial)

It is important to note that the desired coverage is entirely user-dependent - ie gauge this from the size of the tear/oedema present or the area of pain reported by the player. If no tear is seen, double-check edge of field of view because tears DO occur some distance from where the player indicates (referred pain). If T2FS was chosen for long axis imaging, be careful because loss of fat suppression is common at the far reaches of the FoV. Repeat sagittals with STIR if in any doubt.

HAMSTRINGS - RECURRENT/TROUBLESOME/NON-ACUTE INJURY

ROUTINE PROTOCOL

For players complaining of a long history of pain or recurrent injuries, it is important to image the entire hamstrings (from top to bottom) of the affected side. This situation will most commonly arise with proximal insertion pain (ischial tuberosity) - on Coronals try to include both sides for comparison.

  • Follow “Acute Injury” protocol
  • Add a STIR/T2FS & T1 sagittal to cover rest of hamstrings, and review.
  • Add axials if pathology present.


THIGH (QUADRICEPS) - ACUTE INJURY

ROUTINE PROTOCOL

Check with patient re: site of tear and mark with oil capsule(s) if appropriate. Area of interest will be anterior, so always use a surface coil/body matrix coil over this area for extra signal.

  • Axial and Long Axis localisers (find oil capsule)
  • STIR/T2FS Coronal - to include tear site + 1 muscle insertion (closest)
  • STIR/T2 FS Sagittal - to cover tear site + 1 muscle insertion (closest)
  • STIR/T2 FS Axial - cover just tear (if appropriate) or oil capsule (if no tear seen)
  • T1 Sagittal (copied exactly to STIR/T2FS Sagittal)
  • T1 Axial (copied exactly to STIR/T2FS Axial)


CALF - ACUTE INJURY

ROUTINE PROTOCOL

Check with patient re: site of tear and mark with oil capsule(s) if appropriate. The area of interest here will be posterior, therefore use of a spine coil is essential. Combine this with a surface coil or, preferably a peripheral angio coil for optimal image quality.

  • Axial and Long Axis localisers (find oil capsule)
  • STIR/T2FS Coronal (Red Lines on images) - to include tear site + 1 muscle insertion (closest)
  • STIR/T2 FS Sagittal (Blue Lines on images) - to cover tear site + 1 muscle insertion (closest)
  • STIR/T2 FS Axial (Green Lines on images) - cover just tear (if appropriate) or oil capsule (if no tear seen)
  • T1 Sagittal (copied exactly to STIR/T2FS Sagittal)
  • T1 Axial (copied exactly to STIR/T2FS Axial)

Ends