WHAT DOES TERRI'S BONE SCAN MEAN?
It is my opinion that the most likely reason for these bone scan findings in March of 1991 is that someone either was physically abusing Terri or they dropped/mishandled her severely.
A reader asked me to comment on Terri Schiavo's bone scan report.
Here are my initial thoughts:
It is perilous to try and interpret just the bone scan REPORT. I need to see the scan itself and the correlative X-rays.
However, that being said, several things are unusual.
First, the DATE on this bone scan is March 1991. Terri's cardiopulmonary arrest -- as far as I can tell -- was in February 1990; therefore, the abnormalities that are described occured AFTER Terri's February 1990 arrest, probably in the weeks or month(s) just prior to the bone scan, unless she had a second arrest at some point -- and I do not have that history. Certainly there was trauma. As I understand it, the issue is how the trauma occurred.
Trauma from CPR generally involves the anterior aspects of the ribs where they join the sternum. This is usually due to vigorous compression during CPR. Any other proposed trauma during CPR would need to be documented by the notes or by eye witnesses as to the mechanism (e.g.: did she fall off the stretcher?).
The bone scan report of TS describes an injury NOT to the anterior ribs, but, to a different part of the ribs-- posteriorly -- namely at the juncture of the ribs and vertebrae (the costovertebral juncture, or CVJ). In addition, although the report mentions several rib fractures, it does not specify if they were all CVJ located or in different/various locations. This is important. Finally, I do not see a report of correlative x-rays for the ribs, which would be helpful to determine the TIMING of the injury (fractures look very different depending on WHEN they occurred).
The compression fracture of L-1 is interesting. This is certainly NOT a typical injury that occurs during CPR as it generally involves an AXIAL load (i.e. on the top of the head; or from the top DOWN); a caveat here: if TS was anorectic for a prolonged period or on certain medications she could have been osteoporotic, in which case some might claim that a mild compression fracture of L-1 would not be so unusual-- however this is only true in ambulatory people, which Terri was not.
The uptake over Terri's distal right femur is the most peculiar element in this report. This is an unusual finding in ANY situation and I would have to see the scan and films to be sure of what it means; however, if there is PERIOSTEAL ELEVATION then one would have to posit (as did the person who interpreted Terri's bone scan) the possibility of bleeding underneath the thin covering of the bone (the periosteum) which is a finding that correlates highly with trauma, specifically, abuse.
It would be difficult to propose a mechanism that caused this type of problem unless a specific witness arises to declare he or she remembers a specific event that would have caused this UNUSUAL finding.
I would want to know if Terri had a BLEEDING problem at any time, because that might explain this finding.
Certainly IN A CHILD (which Schiavo, obviously was not), the combination of posterior rib fractures, vertebral compression fractures, and distal femoral periosteal elevation is ABSOLUTELY POSITIVELY DIAGNOSTIC for child abuse and any radiologist who missed this diagnosis would be subject to disciplinary action from his peers and state licensing board. SEE: http://radiographics.rsnajnls.org/cgi/content/full/23/4/811
It is my opinion that the most likely reason for these bone scan findings in March of 1991 is that someone either was physically abusing Terri or they dropped/mishandled her severely.
The x-rays might make all of this clearer if we can obtain them.
n.b.
Teri's fractures could be of the "insufficiency" type (caused by prolonged immobilization/dietary irregularities) and some might posit this explanation; however, in a nonambulatory bedridden patient under careful supervision, I find this untenable, especially given their distribution which are so typical for ABUSE.
Here's the link to the bone scan report: http://www.terrisfight.org/images/bonescan.jpg
yay, the ruling came down. now you guys can find another ambulance to chase. :)
Posted by: Texas Cowboy | March 23, 2005 at 02:43 AM
TC, nice to see you have such a cheerful attitude about a human being slowing dehydrating and starving to death. That's the spirit! No wonder you defended Hitler, you two have much in common.
Posted by: | March 23, 2005 at 02:55 AM
Previous poster, I think you meant "slowly dehydrated and starved to death".
Have to agree with you. TC seems to have some special mandate in regards to "useless eaters", much like Hitler.
His atttitude doesn't concur with any Texan that I ever knew. Must be one of those "carpetbaggers".
Posted by: NotADoctor | March 23, 2005 at 03:10 AM
Any reasonable person who compares the sources I referenced can see that there is no hyperbole whatsoever in making the comparison. The T-4 program is rhetorically and historically the direct predecessor to the travesty we are witnessing in the Terri Schiavo case.
Posted by: thoughtomator | March 23, 2005 at 04:16 AM
Hitler and Bush, one and the same. Well okay, Bush only killed 100,000 civilians. So much for the culture of life! :)
Posted by: Texas Cowboy | March 23, 2005 at 05:02 AM
Texas are you sayin you support Bush AND Hitler? Are you one of dem dere skinheads I herd tell of?
Posted by: realtexan | March 23, 2005 at 05:11 AM
Let's all remember Godwin's law and drop the Nazi comparison.
Thanks.
Posted by: Jeremy | March 23, 2005 at 12:38 PM
CodeBlueBlogger,
The law firm representing Terri's parents (the Gibbs law firm) emailed me by mistake because I had posted on my blog what you have been writing about Terri's scans and reports.
They want your help.
I have forwarded to you the email they sent me by mistake. Please check your email to get their phone number, etc.
If you can't find it, email me.
Posted by: Ed Jordan | March 23, 2005 at 03:40 PM
Michael Shiavo's lawyer said Friday Terri took Communion. If she can't swallow how did she take Communion? There are so many questions concerning her. She doesn't derserve to lose her life in this cruel way. I do not know anyone her age especially in 1990 who would say no to a feeding tube. Tragic.
Posted by: Rob | March 23, 2005 at 06:32 PM
Rob, the poor girl never said that she wouldn't want to live via feeding tube, she made a casual remark that she "wouldn't want to live like that" in regards to a ventilator when they were discussing Michael Schiavo's grandmother. Judge Greer blocked testimony from acquaintances of Terri's that stated otherwise. Greer and Felos are bent on killing her now because they have extracted all the money they can from her guardianship account.
Posted by: | March 23, 2005 at 07:07 PM
How is it you can publish medical records without that person't permission?
Posted by: | March 25, 2005 at 10:39 PM
Physicians and Hospitals can't release records without the permission of the patient or guardian or a court order.
Once they are in the public domain, they are fair game, however they happened to get there.
Posted by: | March 25, 2005 at 11:15 PM
November 21, 2003, deposition
(excerpts) taken from Dr. Walker, a board-certified radiologist at Manatee Memorial Hospital. Dr. Walker is the doctor that prepared the bone-scan report from the image of Terri Schiavo taken on March 5, 1991.
15 Q What is a total-body bone scan used for
16 typically?
17 A It's to look for abnormalities of the
18 bone, whether they -- if they would be recent
19 abnormalities.
20 Q Recent --
21 A Recent.
22 Q -- abnormalities?
23 A Correct.
24 Q Is it also a technique to diagnose
25 osteoporosis?
1 A No.
3 Q And the next sentence, "There are an
4 extensive number of focal abnormal areas of nuclide
5 accumulation of intense type." What does that mean?
6 A Well, that means that there are a lot of
7 areas that look black on the images because lots of
8 that radioactive decaying material was happening at
9 those points and was being recorded by the imaging
10 system.
11 Q Okay. "These include multiple bilateral
12 ribs." What would that mean to you?
13 A Well, you know, there's left ribs and
14 right ribs. And that would mean that more than two
15 ribs on each side were involved.
13 Q "Several of the thoracic vertebral
14 bodies, the L1 vertebral body, both sacroiliac
15 joints." These are all areas that were abnormal on
16 the scan?
17 A That's what this indicates, yes.
18 Q "The distal right femoral diaphysis,"
19 what area of the body is that?
20 A That would be the right leg, the upper
21 part of the right leg.
22 Q Distal?
23 A Above the knee.
5 Q So on the thigh bone above the kneecap
6 but not involving the joint?
7 A That's what that particular thing says,
8 but I think somewhere in there also, it mentioned
9 that both knees --
10 Q Right. Right after that.
11 A Right after that. So that's different
12 from the knee activity.
13 Q And, "Both ankles, right greater than
14 left." Those are two additional areas that showed
15 up as abnormalities on the scan?
16 A That's correct. Correct.
13 Q Would you draw any conclusions from that
14 how old the ossification was?
15 A You could say that it wasn't real old,
16 because typically, as we mentioned, the bone is a
17 dynamic structure, and it's constantly being
18 remodeled normally. So the body tends to take away
19 extra bone eventually to remodel it to look like
20 normal bone. So typically old bone injuries are
21 remodeled so that eventually they may almost
22 disappear, particularly in young people. In the
23 very young, a fracture you won't even see in three
24 or four years, it will be totally erased.
8 Q Then you go on to say, "Most likely the
9 femoral periosteal reaction reflects a response to a
10 subperiosteal hemorrhage." Would that be a bone
11 bruise?
12 A Correct.
16 Q Then you go on to say, "And the activity
17 in L1 correlates perfectly with the compression
18 fracture which is presumably traumatic."
19 A That's what it says.
20 Q In other words, the x-ray confirmed the
21 L1 fracture?
22 A The x-ray shows an abnormality at L1
23 which happens to correspond with the abnormal bone
24 turnover on the bone scan at that point.
7 Q Is this compression fracture, then, in
8 common parlance, a broken back?
9 A Yes.
10 Q Is there any way to tell how old that
11 fracture would be?
12 A Well, as I've alluded to, the bone scan
13 gives some suggestion of that.
14 Q More recent rather than less recent?
15 A Correct. Typically in trauma the rule of
16 thumb is that a traumatic fracture is not active on
17 the bone scan after 12 to 18 months.
9 Q The report goes on to say, "The
10 presumption is that the other multiple areas of
11 abnormal activity also relate to previous trauma."
12 A That's what it says.
13 Q And, again, that's based on the fact that
14 Dr. Carnahan is a rehab physician, that you were
15 asked to evaluate for trauma?
16 A And the pattern of activity is fairly
17 typical of multiple traumatic injuries of relatively
18 recent origin.
19 Q I realize you can't assign a cause to
20 these injuries that you picked up in this report.
21 But typically in your experience, what would be the
22 causes of this pattern of abnormality?
23 A In somebody her age, an auto accident is
24 by far the most typical cause.
25 Q Assume that she was not in an auto
1 accident but that she had suffered an anoxic or
2 hypoxic encephalopathy type of injury from a cardiac
3 arrest and had been bedridden for a year at this
4 point. What might account for these abnormalities?
5 A In my knowledge, that type of injury
6 would not account for this pattern of abnormalities.
5 Q Okay. Is this a pattern of heterotrophic
6 ossification as reported in the literature that you
7 looked at?
8 A Not typically.
9 Q What makes it atypical?
10 A Well, if I were to pick one thing, I
11 would say the activity in the ribs is not typical.
12 And typically heterotrophic ossification occurs
13 around the joints because they're not being moved.
14 And typically you will see on the radiographs
15 calcium deposits actually sitting there. And they
16 don't look like periosteal reaction typically
17 either; they have a different appearance.
4 Q Can you say, then, within a reasonable
5 degree of medical certainty whether this bone scan
6 is consistent with heterotrophic ossification?
7 A In my knowledge, it's not consistent with
8 heterotrophic ossification as I typically see it.
21 Q Okay. And later on in your direct
22 examination you were saying that traumatic fractures
23 typically are not active on a bone scan after 12 to
24 18 months. Is that correct?
25 A That's correct.
19 Q Okay. Is there any way for you to say
20 from looking at this report when any of these
21 occurrences took place that caused the abnormality
22 to appear on the bone scan?
23 A I can only say that if they were
24 traumatic that they probably occurred within 18
25 months.
1 Q Is it possible that the abnormalities
2 that you noted on the right femoral diaphysis and
3 metaphysis could have occurred if the patient was
4 standing and suffered a cardiac arrest and fell to
5 the floor?
6 A Probably not. That wouldn't be a typical
7 mechanism of injury that would cause a periosteal
8 bruise. Typically you need a direct blow of some
9 kind. I suppose one could speculate that she fell
10 on a piece of furniture, that that could produce
11 that injury. But just typically falling on the
12 floor would not do that.
9 Q Okay. The bone scan and radiographic
10 report shows only one fracture. And that is a
11 compression fracture to L1. Correct?
12 A Well, I should clarify that by stating
13 that not all of the areas of bone-scan abnormality
14 were imaged concurrently. Okay. And that's
15 important. In other words, we didn't x-ray every
16 area that was hot on there. A couple of typical
17 areas were imaged but not all. Of those areas that
18 were imaged, the only area that showed what was a
19 clear fracture was L1.
2 Q The radiographs did not show any
3 fractures of the right femur. Correct?
4 A They don't show a typical fracture. They
5 show periosteal reaction, which could be the result
6 of a bone bruise, which is a bone injury that's not
7 a loss of continuity of the structure of the bone.
8 So to the extent that you define fracture as a loss
9 of structural continuity, then, yes, that is an
10 actual fracture as is typically described.
10 Q Okay. If an immobile patient is going
11 through physical therapy and part of the physical
12 therapy is to have manual manipulation of the legs,
13 particularly flexing of the knees, is it possible
14 that that physical therapy would result in an
15 abnormal appearance on a bone scan?
16 MS. ANDERSON: Objection. That question,
17 I think, is virtually unanswerable because it
18 is so vague.
19 A I could only speculate.
20 Q Okay. In your opinion, is that something
21 that would show up on a bone scan?
22 A I would think only if the joint were
23 injured would it show up on a bone scan. Just
24 simple manipulation of an injured part should not
25 show up as an abnormality on a bone scan.
22 Q Would a kick be the kind of direct blow
23 that would produce that femoral abnormality?
24 A That would be a possibility, yes.
25 Q Would being thrown into a sharp furniture
1 corner?
2 A That would be a possibility.
3 Q Would being struck with some sort of
4 blunt object like a golf club or something do it?
5 A Yes.
22 Q You mentioned that you have seen
23 fractures in bedridden patients before?
24 A Yes.
25 Q How frequently have you seen that?
1 A Rare.
2 Q It's rare?
3 A Yes.
http://www.zimp.org/stuff/03%20-%20WalkerDepositionDepo.htm
Posted by: | March 27, 2005 at 11:49 PM
Dr. Baden was on Fox last week singing a whole different tune than the transcript cited from October 2003 you posted. He said, after reviewing all the available records, that everything was consistent with Bulimia.
Where did he get the idea back then that she had a head injury? All I see is consistent with osteopenia, a year in bed, PT, CPR, and a collapse.
Wouldn't the scan show calcium activity that had been delayed during the years she was so low in calcium? Her exit summary http://www.terrisfight.org/documents/Humana%20Discharge%20Summary%20050990.pdf says she was low in calcium on admittance, and generally malnourished.
Wouldn't there be obvious bruises? If so, why would they wait until a year later to take a scan?
He's been very cold-hearted toward her parents, in my opinion, but I don't buy the bone scan as evidence of abuse when the rest of the profile seems classic for an eating disorder.
Posted by: Dita | March 28, 2005 at 05:20 AM
Dita:
The constellation of bone scan findings (posterior ribs, periosteal changes of distal femur, and vertebral fractures) are assumed abuse UNTIL PROVEN OTHERWISE. This is a radiological maxim. Ask ANY radiologist. It's standard training.
It is NOT normal for PT to be breaking ribs.
A vertebral superior endplate fracture indicates an AXIAL LOAD (top to bottom) that is unusual in a bedridden patient.
The periosteal elevationm of the distal femur is a typical finding once encounters when a baby or an uncommunicative patient's leg is GRABBED AROUND THE ANKLE AND PULLED/TWISTED.
There typically are NOT bruises in abused patients. Rib fractures are notoriously occult and there is rarely associated bruising. Same with vertebral body fractures.
Bone scans do not show "calcium activity." They show osteoclast (bone cell) activity indicative of excessive BONE TURNOVER. The scan WOULD NOT show activity due to any kind of rebound effect from calcium levels (up or down). Absolutely not.
With THAT bone scan it would be considered malpractice NOT to suggest that Terri Schiavo was abused (I'm not saying by whom or how)UNTIL PROVEN OTHERWISE.
These are facts. I am an expert in this subject. There is absolutely NO denying what I am saying and I will (and may) say it in sworn testimony in court. I also have the literature (check my link above) solidly in my corner on this.
Posted by: CodeBlueBlogMD | March 29, 2005 at 05:12 PM
Her attending physicians, including the doctor who ordered the bone scan, testified by affidavit that the assumptions of trauma by the radiologist were wrong.
As for axial load, of course, but she was ambulatory a year before the scan, and the radiologist himself said it could have happened when she collapsed.
He also said what he saw in her ribs could be attributable to CPR.
The femur is interesting, but she had a radiograph of that knee at the hospital a year before, and it showed no bony abnormalities at that time. There was discussion about possible causes, something about a restraint, if I recall.
Posted by: Dita | March 30, 2005 at 06:18 AM
I think it's better to go to the horse's mouth if possible. Here's what I got from reading radiologist Walker's deposition several days ago.
Radiologist did not see the patient.
Injuries were not considered life-threatening enough to notify the referring physician (Carnahan).
No evidence of blow to the head.
Use of words "trauma" and "traumatic" is based in part on the type of patient typically referred by Carnahan and on the instruction to "evaluate for trauma".
Right ventral femur injury is consistent with falling against a piece of furniture.(1)
Minor L1 fracture is possible from falling to the floor.
Drs. Alcazaren and Carnahan, both of whom had direct contact with the patient and the latter having ordered the bone scan, did not corroborate the view that the patient had a "history of trauma", specifically abuse. Certainly the defendants in the 1992 malpractice case would have liked to deflect the blame for Mrs. Schiavo's fate onto an abusive husband, but they were not able to do so.
I just don't see a case for abuse here.
(1) According to the police report, she was found with her feet in the bathroom. If she had just emptied her bowels or vomited, she could have done a Valsalva's maneuver which precipitated the cardiac arrest and subsequent collapse. The injury to the front of her thigh could have been from falling against the toilet or bathtub rim, for example, assuming it occured at time of cardiac arrest and not subsequently or previously.
Posted by: mod ervador | March 30, 2005 at 03:25 PM
Oh, I forgot to mention in my last post, also from Walker's deposition,
rib abnormalities are consistent with resusitation.
Posted by: mod ervador | March 30, 2005 at 03:30 PM
When you are CRUSHED.... you get.... COMPRESSION FRACTURES... which set off a Potassium Imbalance.....that can cause Life-threatening rapid, irregular heartbeat. This is more severe than with hyperkalemia..... and then you get....hydrocephalus caused by obstructed CSF flow in the ventricular system caused by ambulatory mishandling due to the unknown injuries to the spinal column........???
Ideas anyone... not a doctor... but being CRUSHED could lead to the potassium imbalance....
Posted by: Hamlet | April 01, 2005 at 03:02 AM
Just wanted to add to the above... if he was on top of her... his weight 250 lb? and used his weight to crush her there would be little to no outward signs...but deep brusing??? Could explain the broken ribs too??
Posted by: Hamlet | April 01, 2005 at 03:08 AM
More on bone disorders and eating disorders: I researched the radiologic literature from 1997-2004 on anorexia/bulemia/osteoporosis/fractures etc and came up with one article linking anorexia and osteoporosis, in addition to a body of literature I found on MedLink from the National Library of Medicine, which includes 10 million articles. There are a lot of reports on osteoporosis and anorexia, well-documented in female athletes, and are a number of articles on fractures and bulemia. There is a strong evidence that Mrs. Schiavo was bulemic, according to testimony from friends. Tho' she was not thin-thin, she was thinner at the time of her cardiac arrest than she had ever been. She weighed between 200-250 lbs apparently in high school, and was definitely obese on the school photo I saw. She was average on her wedding photos,becoming thinner later. She was seeing a GYN for irregular menses, which can also be a complication of anorexia. Regarding abuse, two of her brain CT's on admission were read as normal. NO blood, no fractures, not even a scalp hematoma from her fall. Normal.
I am a neuroradiologist. I have seen two images from two different CT scans of hers, the latter in 2002. The grey and white matter damage was devastating. The flaccid dilatation of the ventricles is most compatible with ex vacuo hydrocephalus. The CT findings are compatible with severe diffuse infarction, NOT myocardial infarction, but that of brain tissue. You cannot diagnose PVS from a CT scan. PVS is a clinical diagnosis, not a radiologic diagnosis. But you could infer severe global neurologic damage from her scan. AN MRI could not be done bec. of her experimental indwelling electrodes inserted years ago. An MRI would add little additional useful information. In order to remove these electrodes, she would have had to undergo an operation with some sort of anesthesia, risky business in view of her neurological state and her atrophic brain, which raises the risk of subdural hematoma due to tearing of cortical veins. Then there's the problem of not resuscitating her if she arrested. She has had a number of EEG's read as flat, no activity, one compromised by motion artifact. More EEG's are not necessary unless there is a marked improvement in her condition, which there never was.
Posted by: Kate Killebrew, MD | April 01, 2005 at 10:10 PM
More on the Bone Scan: ( I am a board-cert. radiologist, and a neuroradiologist) I just read the deposition of the radiologist who interp. the scan. He mentions multiple bilat. ribs, L 1, which was xrayed, Bilat SIJ, knees(I think-unclear), ankles and periosteal reaction R femur.I mentioned previously the lit on eating disorders/osteoporosis and fractures. The ribs may be due to the resuscitation. The bilat joints--SIJ's, knees(?), ankles-unusual in abuse.Common in metabolic disorders. I can think of two: a formerly starving person who is now adequately nourished (feeding tube).Then there would be increased joint activity, bilateral and diffuse. Also now adequately nourished but with disuse osteoporosis due to immobility, making the (natural) joint activity stand out. Periosteal reaction could be trauma, also reflecting healing insufficiency fracture. Children get diffuse periosteal reaction when the grow fast. Re the K+ 'imbalance'--remember that Mrs. S had a very LOW K, not just an 'imbalance'. It is virtually impossible for a well young woman to have low K,unless she is vomiting and drinking quantities of water or-iced tea. Then it could happen.
Posted by: Kate Killebrew, MD | April 01, 2005 at 10:37 PM
Another question.
Did Michael Schiavo's "beating" that you accuse him of giving Terri cause her to miss her period for several months before she collapse?
Damn. That's what I call a beating!
Think.
Posted by: Larry McGuire | April 02, 2005 at 10:58 PM
One more question.
Does a beating really cause a Potassium imbalance capable of causing such a great brain damage?
Is it me, or is this a lie? Can you provide a link in which we can read the relationship and the extent of Potassium imbalance and bone fractures (minor fractures for what I heard)?
Posted by: Larry | April 02, 2005 at 11:14 PM
SECONDARY AMENORRHEA
Pregnancy
Anxiety over pregnancy may cause a missed period, thereby increasing the anxiety even further
Drastic weight reduction
Vigorous athletics
Obesity
Emotional distress
Menopause (normal for women over age 45)
Endocrine disorders such as thyroid disease or pituitary disease/tumor
They DO cite DRAMATIC weight loss... which was not the case here.... Terri had been maintaining her present weight.... she had SLIMMED down by all accounts...
Speaking from experience... anxiety CAN and WILL cause problems... thus the admonishment of most ob/gyns to RELAX and let nature take it's course... is the first treatment employed in cases where the patient claims a failure to get pregnant or delayed or missed periods.
Also Emotional Abuse I believe would be cause for extreme emotional duress...
Once again.... there is NO way to know for sure.
Posted by: Hamlet | April 03, 2005 at 04:25 PM