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Summary of imaging modalities for diagnosis of osteomyelitis in adults

Summary of imaging modalities for diagnosis of osteomyelitis in adults
Type of imaging test Sensitivity
(95% confidence interval)		 Specificity
(95% confidence interval)		 Ability to delineate extent of soft tissue infection Other characteristics
Conventional radiography (ie, plain x-ray) 0.70 (0.62 to 0.78) 0.82 (0.70 to 0.89) Poor
  • Lacks sensitivity during first 2 weeks of symptoms
  • Can detect fracture, metallic foreign body, and gas in soft tissue
  • Serial imaging may be useful in subacute to chronic infections
MRI 0.96 (0.92 to 0.97) 0.81 (0.71 to 0.88) Excellent
  • Excellent for ruling out osteomyelitis
  • Specificity is lower if bone marrow edema is the only finding
  • IV contrast (eg, gadolinium) is not necessary to diagnose osteomyelitis but is helpful for detecting soft tissue infection
  • Metallic foreign material may be a contraindication and may degrade image quality
CT 0.70 (0.41 to 0.89) 0.90 (0.58 to 0.98) Moderate
  • IV contrast optimizes detection of soft tissue infection
  • Metallic foreign material may degrade image quality
  • Serial imaging may be useful in subacute to chronic infections
PET 0.85 (0.72 to 0.93) 0.93 (0.83 to 0.97) Poor
  • Can distinguish soft tissue infection and Charcot arthropathy from osteomyelitis
  • Minimally affected by metallic foreign material
Scintigraphy* 0.84 (0.72 to 0.91) 0.71 (0.57 to 0.81) Poor
  • Results are delayed because tests take longer to complete
  • Helpful in patients with metal hardware that precludes use of MRI or CT
SPECT or SPECT-CT 0.95 (0.88 to 0.98) 0.82 (0.62 to 0.93) Poor
  • Can be used as stand-alone study or to augment scintigraphic studies

CT: computed tomography; IV: intravenous; MRI: magnetic resonance imaging; PET: positron emission tomography; SPECT: single photon emission CT.

* Scintigraphy refers to two-dimensional nuclear imaging studies, such as three-phase bone scan, tagged white blood cell scan, and gallium scan. Each of these is discussed in further detail in UpToDate's topic on imaging studies for osteomyelitis.
Data from: Llewellyn A, Jones-Diette J, Kraft J, et al. Imaging tests for the detection of osteomyelitis: A systematic review. Health Technol Assess 2019; 23:1.
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