Black bone magnetic resonance imaging in clinical practice: Systematic review of current perspectives and insights

Article selection

The abstracts were considered and examined based on the following criteria: The papers were written in English; studies that included black bone MRI imaging findings and performances; clinical assessments; studies that compared black bone MRI with conventional imaging; clinical applications; image quality; and surgical factors were included in the evaluation and assessment framework. There was consideration given to every sort of study, including case investigations and case retrieval. To determine whether or not the black bone MRI parameters were confirmed, the contents of the publications were analyzed. Studies and case collections that contained insufficient data and results that were both inconclusive were not taken into consideration. Based on the initial evaluation regarding titles and abstracts, complete publications were gathered. After the results of the database search were used to exclude duplicate research, assessments were conducted between the selection requirements and the titles, abstracts, and overall findings of the articles. The reviews of the reference collections of studies that were determined through the search process that was described previously were carried out, and further publications were found. A representation of the article preference approach is shown in Figure 1.

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Figure 1:

Flow diagram of article selection.

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Electronic search

Searches were undertaken on the online literature databases of Science Direct, Springer, PubMed/Medline, and Wiley Online Library to discover papers relevant to all of the available dates. An initial search method was developed for use in PubMed and then updated for use in other electronic databases. The primary search combined essential black bone MRI imaging words, such as craniofacial imaging, with the following terms: Black bone, gradient echo, and orthopedic imaging.

Data extraction

From 2012 until 2023, electronic searches were conducted using Medline (PubMed) and embedded with other databases. Mendeley was used for referencing. The whole papers were examined to determine whether it matched the requirements and whether the data retrieval was adequate. For each study, the following details were collected: surgical parameters, imaging features, distinction, investigation, tissues and bone evaluation, and any other pertinent references to the review process. The most notable findings, operative accuracy, sample size and features, year of publication, author name, country, and other relevant information were extracted from the included articles.

Data synthesis

The main emphasis was research on black bone MRI’s imaging characteristics and surgical accuracy in tissue and bone structural analysis, and ascertained its capacity in enhanced imaging. Imaging results were assessed and matched with conventional imaging methods as part of the process of assessing diagnosis performance and accuracy. Furthermore, variations in imaging techniques and processing approaches were considered.

CT imaging

CT has shown its immense role in medical imaging with its ability to create detailed cross-sectional images of the body. It allows precise visualization and detection of bony structures with high-resolution images, with improved differentiation of the pathologies associated with it.^[16] CT offers an optimal modality for accurately assessing the displacement of bone fragments and the associated injury to the spinal cord and nerve branches. It has shown its usefulness in identifying a wide range of medical illnesses, including infections, tumors, fractures, and cardiovascular diseases. Its high-resolution images make it possible to precisely see bones, blood arteries, and soft tissues.^[17,18] Rapid detection and treatment of bone fractures and disorders are made possible by CT scans’ noninvasiveness and speed, which makes them perfect for use in emergency scenarios. Surgical planning and evaluation are facilitated by the capacity to rebuild complex bone architecture in three dimensions using 3D technology.^[19,20] A major factor in CT’s accuracy as a diagnostic tool is its capacity to provide fine-grained images of soft-tissue and bone structures. This makes it the treatment of choice for many different ailments, such as bone tumors, degenerative disorders, and trauma.^[21] Precise surgical planning and postoperative evaluation are made easier by the clarity and detail of CT images. A CT scan is highly effective in differentiating between tissues with comparable densities, enabling the diagnosis of subtle abnormalities.^[22]

When it comes to the fetal skeletal and cranial morphological examination, CT is an indispensable technique. This allows for a precise evaluation of bone structure, growth rates, and abnormalities, as it provides images that are both detailed and high-resolution. Congenital anomalies, skeletal dysplasia, and cranial irregularities are all characteristics that can be identified with the help of CT scans. By allowing for a more comprehensive study and measurement of fetal bones, the three-dimensional reconstructions that CT provides are of great assistance in the process of early detection and treatment planning.^[23,24] It is extremely important in the diagnosis and treatment of conditions affecting the base of the skull. This imaging technique offers comprehensive visualization of the bone structures, enabling precise detection of irregularities such as neoplasms, fractures, and innate malformations.^[25] The detailed images obtained through CT scans are instrumental in determining the scope of the disease, evaluating the impact on essential anatomical components, and facilitating the development of surgical strategies.^[26] It has shown its indispensable impact in spine and joint imaging due to its unparalleled capacity to generate high-resolution, intricate images of both bone and soft-tissue structures. In the realm of spine imaging, CT plays a crucial role in assessing a wide array of conditions such as fractures, spinal stenosis, disc herniation, and degenerative diseases. Its capability to offer meticulous visualization of vertebrae, intervertebral discs, and adjacent tissues is invaluable in facilitating accurate diagnosis.^[27,28]

Even though CT scans have significant diagnostic capabilities, they also involve exposure to ionizing radiation, which carries potential health risks. One of the primary concerns is the increased risk of developing cancer, as ionizing radiation can cause DNA damage and potentially lead to the formation of mutations. The level of risk associated with radiation exposure depends on various factors, including the patient’s age, the specific body part undergoing scanning, and the radiation dose received from multiple scans.^[29,30] It is important to note that children and young adults are particularly vulnerable to the effects of radiation due to their rapidly dividing cells and longer life expectancies. It has also been depicted as a potential risk associated with fetal scans and cranial imaging.^[31] Black bone MRI in the field of MRI, the black bone MRI is a specialized technique that was developed to visualize bone structures with a high level of contrast and resolution. This technique makes bones appear black on a bright background of soft tissues, in contrast to the conventional MRI technique, which uses dark bones.^[5] Surgical planning and patient education are two areas that can benefit greatly from the utilization of black bone MRI due to its excellent spatial resolution, which enables precise three-dimensional reconstructions.^[14,15]

Wolharn et al.,^[6] demonstrated in a comparative study for bone analysis of sacroiliac joints in 79 patients. In contrast with CT imaging, it demonstrated excellent image quality and comprehensive bone characteristics. In addition, it was noted that black bone MRI can be utilized as an alternative to standard CT methods for the detection of cortical and trabecular bone changes. Black bone MRI showed improved intraoperative safety in craniosynostosis surgery with computer-assisted design. It also showed enhanced image quality and features of the intracranial structures.^[8] Robinson et al.^[7] highlighted the use of black bone MRI in fetal assessment, notably in the screening for abnormalities and anomalies of the spinal column. In addition, it detailed the evaluation of craniofacial disorders that are connected with fetal syndromes, both to diagnose and demonstrate skeletal dysplasias, as well as the processes involved in fetal necropsy. In contrast to the conventional imaging techniques of radiography and CT, it is possible to utilize it to evaluate the measurement of the fetal skull without creating the potential risk of exposure to ionizing radiation. By serving as an alternative method to CT, the incorporation of black bone MRI into the MR necropsy protocol has the potential to bring about a substantial improvement in both the picture quality and the surgical accuracy. Black bone MRI was initially developed to analyze and diagnose craniofacial disorders. To achieve better delineation of facial structural anomalies and increased contrast between soft-tissue and bone, the application of a low flip angle was found to be effective. It is also able to assist in the process of 3D virtual mapping for oral cancer therapy. The novel approach of MRI can be used as a substitute for significant dose reduction in younger patients who have higher imaging.^[5]

In the process of evaluating lower jaw tumors, the black bone MRI is an effective instrument that provides several distinct advantages, including the ability to visualize both bone and soft-tissue involvement. Due to the good contrast that this method gives between the tumor and the bone, it is possible to make an accurate assessment of bone infiltration, which is essential for the staging of the tumor and the planning of surgical procedures. Through its ability to detect early marrow involvement and evaluate the extent of soft tissue distribution, it offers a comprehensive assessment of the extent to which the tumor has spread.^[14] Dremmen et al.^[10] demonstrated in a study conducted on 28 children and stated exceptional performance in detecting skull fractures, especially those that are more subtle or non-displaced, which are more likely to be missed by traditional CT scans. When it comes to traumatic brain injury evaluation, one of the most important advantages of black bone MRI is that it is optimized for bone visualization. In addition, it offers acceptable imaging of intracranial soft tissues, which enables a thorough evaluation of both bony and soft-tissue lesions in a single examination.

An investigation was done by Connor et al.^[12] to assess the role of Black bone MRI in cochlear implantation. In addition, it provided a more detailed illustration of the diseases and anatomy of the cortical bones. The images that it generates are of high resolution, and they may be used to make precise reconstructions of multiple aspects of the patient’s anatomy. This can be helpful in both the planning of surgical procedures and the awareness of the patient. Black bone MRI can also be helpful in accurately distinguishing between normal sutures and those that have fused early. It has demonstrated a remarkable ability for the identification and diagnosis of craniosynostosis, with a strong emphasis on accurate diagnosis.^[13] A study was done on 34 children by Kralik et al.^[15] investigated the utility of black bone MRI in the identification and diagnosis of skull fractures with presumed head trauma. During the process of assessment, it demonstrated a greater level of accuracy as well as sensitivity. Through the use of enhanced imaging characteristics, it enables thorough distinction and analysis of fractures. When it comes to pre-operative assessment, black bone MRI could serve as a complement to three-dimensional CT. Details on sutures in the skull and intracranial perceptions, as well as information on brain structures, can be obtained from one imaging session due to this approach. When it comes to the identification and evaluation of skull malformations, as well as planning, it is an effective surgical tool.^[9]

Black bone MRI represents a highly promising advancement in medical imaging technology, especially for the evaluation of bony structures without the necessity of ionizing radiation. This innovative technique provides exceptional resolution for visualizing cortical bone and offers significant advantages in pediatric and young adult populations, where the potential risks associated with radiation exposure are paramount.^[13,15] Despite the considerable potential of black bone MRI, further comprehensive studies are imperative to enhance its utilization, optimize imaging protocols, and ascertain its diagnostic precision in comparison to conventional imaging modalities. Black bone MRI has shown a significantly lower gas detection rate when compared to CT, which can impact overall analysis.^[6] Another significant problem it faces is bone-air interactions, specifically in the paranasal sinuses, mastoid air cells, and nasal cavities. Air has a very low proton density, which causes a considerable loss of MRI signal in certain locations. This reduces the contrast between bone and surrounding air, making poor identification of tiny bone structures. In the sinuses, where bone meets air-filled cavities directly, this can lead to poor visibility of bony features, reducing diagnostic precision.^[10,12-14] Furthermore, susceptibility artifacts are widespread in these areas due to magnetic field inhomogeneities generated by sudden changes in tissue composition. These artifacts alter the look of bone near air spaces, resulting in signal holes and image blurring.^[6,9,15,32] Black bone MRI cannot reliably detect bony abnormalities in diseases such as spina bifida aperta and small linear skull fractures due to spatial distortions at the bone-air interface. Delicate features may be obscured by signal loss and susceptibility artifacts, resulting in poor visualization of minor fractures or small bone defects.^[7,10,12] It was also observed that the assessment of skull fractures can only be obtained at certain locations, which cannot be generalized for all areas.^[8] Despite these limitations, black bone MRI can transform bone imaging, especially in pediatric and trauma situations where radiation exposure is a concern, by offering a safer alternative to CT scans.

The included studies demonstrated significant methodological heterogeneity, with variations in research design, imaging procedures, and clinical objectives. While some research was prospective,^{[5,6,9,12,13]} others used retrospective data,^{[7,8,10,14,15]} which inevitably limits control over confounding factors. The MRI field strength employed varied from 1.5T^{[5,10,12,13,15]} to 3T^[6,7,9] scanners, with different implications for image resolution, artifact susceptibility, and signal-to-noise ratios. The imaging sequences were also not the norm; whereas all investigations employed gradient echo-based protocols for black bone MRI, some used point wise encoding time reduction with radial acquisition, while others used modified Dixon sequences. These inconsistencies affect diagnostic consistency and repeatability. Furthermore, there was significant clinical variation, with target populations ranging from fetuses^[7] and pediatrics^{[5,8-10,13,15]} to individuals with oncologic or rheumatologic conditions.^[5,6,12,14]

Limitations

Few limitations were encountered during the review process. The scope of available data was initially restricted by the relatively small number of publications specifically addressing Black bone MRI. This scarcity posed challenges in identifying consistent patterns or drawing comprehensive conclusions, emphasizing the need for more focused research and standardized approaches in the future. Despite these limitations, Black bone MRI shows significant promise as a non-ionizing alternative to CT, particularly in pediatric and craniofacial imaging. Its adoption by radiologists could enhance diagnostic safety while maintaining detailed anatomical visualization. However, integrating this technique into routine clinical practice requires more than encouraging preliminary findings. Large-scale, multicentre studies are essential to assess its diagnostic accuracy across diverse patient populations and clinical scenarios. Additionally, the current variability in imaging characteristics underlines the urgent need for standardized acquisition protocols and postprocessing techniques. Establishing these standards will ensure consistency, facilitate cross-institutional comparisons, and accelerate clinical integration. Continued research and well-structured trials will be vital in determining the true clinical utility of Black bone MRI and refining its role in bone imaging.