The value of SPECT/CT in localizing pain site and prediction of treatment response in patients with chronic low back pain

Prevalence of Degenerative Spinal Hot Spots on Bone Scintigraphy Among Orthopedic Patients

PURPOSE

Emerging nuclear imaging technologies are advancing the field of spinal diagnostics for degenerative changes. This study aimed to describe the prevalence of spinal hot spots in an orthopedic population undergoing bone scintigraphy (BS) for reasons unrelated to the spine and to assess the correlation of these hot spots with the presence of corresponding spinal complaints.

METHODS

A retrospective analysis of patients from the Department of Orthopedic Surgery and Traumatology who provided general consent for the use of their medical data. Adult patients who underwent single photon emission computed tomography (SPECT) over a two-year period for non-spinal complaints, along with a corresponding whole-body BS, were included. The primary endpoint was the prevalence of degenerative spinal hot spots detectable on BS. The secondary endpoint evaluated clinical complaints recorded in medical records for each spinal region.

RESULTS

Among 30 patients (mean age: 66.1 years; 30% male, 70% female), the prevalence of spinal hot spots on BS was 23.3% (n=7) in the cervical spine, 10% (n=3) in the thoracic spine, 33.3% (n=10) in the lumbar spine, and 6.7% (n=2) in the sacroiliac joint (SIJ). Most patients with cervical and lumbar hot spots had corresponding spinal symptoms, such as pain, tenderness, or stiffness, documented in their medical records, whereas thoracic complaints were less commonly noted.

CONCLUSION

The study outlines the prevalence of spinal hot spots in various spinal regions among a general orthopedic population undergoing bone scans for non-spinal complaints. A strong correlation was found between spinal complaints and high uptake in the cervical spine and lower back. These findings highlight the added value of comprehensive bone scan evaluations in clinical practice.

Spino-pelvic parameters and back pain in patients without coronal deformity or history of spinal surgery: A cross-sectional analysis

BACKGROUND

During the last two decades, there has been a growing interest in spinal sagittal alignment. Most published studies have focused on the role of spinopelvic parameters in patients with adult spinal deformity or in those with previous spinal fusion.

OBJECTIVE

The aim of this study was to explore possible association between disability related to back pain and spinopelvic parameters in the absence of coronal deformity or previous spinal surgery.

METHODS

In the setting of a larger study involving patients with low back pain (LBP), those without previous surgery or spinal deformity in the coronal plane were selected. A total of 52 patients (mean age 59 years, range 21-86, 23 men and 29 women) were found. The visual analogic scale (VAS) and Oswestry Disability Index questionnaire (ODI) were recorded. Surgimap software was used to measure the sagittal vertical axis (SVA), pelvic tilt (PT), pelvic incidence (PI), sacral slope (SS), and lumbar lordosis (LL). Statistical analysis was performed with SPSS Statistics software. Pearson or Spearman correlation were the test of choice depending on the specific variables.

RESULTS

A statistically significant association was found between SVA and ODI (r 0.59, p< 0.03). Increased pelvic tilt was also associated with more severe disability related to back pain (r 0.48, p< 0.03). PI-LL mismatch showed moderate association with disability and severity of back pain, although this association did not reach statistical significance (r 0.52, p< 0.08).

CONCLUSION

Our findings suggest that sagittal misalignment may be related with more severe disability and back pain in patients with minor or null deformity in the coronal plane.

SPECT/CT Scan: A New Diagnostic Tool in Pain Medicine

PURPOSE OF REVIEW

The purpose of this review is to evaluate the role of SPECT/CT in identifying facet joint arthropathy and the outcomes of interventions with SPECT/CT as an adjunct.

RECENT FINDINGS

A positive finding of facet arthropathy on SPECT/CT is associated with a higher likelihood of a unilateral procedure and a significantly more effective intervention compared with those performed on patients with facet arthropathy diagnosed only by clinical and/or radiologic examination. Surgical treatment of SPECT/CT-positive findings appears to have a good effect; however, due to limitations in the available studies, no strong conclusion can be drawn. SPECT/CT has a good correlation identifying pain generators in chronic neck and back pain. SPECT/CT-targeted facet interventions demonstrate a higher success rate, but SPECT/CT is not recommended as a first-line diagnostic tool prior to diagnostic facet interventions. More robust studies are needed to confirm the higher success of surgical treatment for SPECT/CT-positive facet arthropathy.

Unexpected Solitary Subcutaneous Metastasis From Esophageal Carcinoma Revealed by MDP Bone Scintigraphy

ABSTRACT

A 60-year-old man with back pain underwent 99mTc-MDP to evaluate bone metastases from newly esophageal carcinoma. No bone metastasis was found on the whole-body bone scan. Unexpectedly, subcutaneous metastasis revealed increased 99mTc-MDP activity.

Role of Single-Photon Emission Computed Tomography Imaging in the Diagnosis and Treatment of Chronic Neck or Back Pain Caused by Spinal Degeneration: A Systematic Review

BACKGROUND

Chronic neck or back pain is a common clinical problem. The most likely cause is degenerative change, whereas other causes are relatively rare. There is increasing evidence on using hybrid single-photon emission computed tomography (SPECT) to identify the pain generator in spine degeneration. This systematic review explores the diagnostic and therapeutic evidence on chronic neck or back pain examined by SPECT.

METHODS

This review is reported in accordance with the PRISMA guidelines. In October 2022, we searched the following sources: MEDLINE, Embase, CINAHL, SCOPUS, and 3 other sources. Titles and abstracts were screened and classified into diagnostic studies, facet block studies, and surgical studies. We synthesized the results narratively.

RESULTS

The search yielded 2347 records. We identified 10 diagnostic studies comparing SPECT or SPECT/computed tomography (CT) with magnetic resonance imaging, CT, scintigraphy, or clinical examination. Furthermore, we found 8 studies comparing the effect of facet block intervention in SPECT-positive and SPECT-negative patients with cervicogenic headache, neck pain, and lower back pain. Five surgical studies describing the effect of fusion for facet arthropathy in the craniocervical junction, subaxial cervical spine, or the lumbar spine were identified.

CONCLUSIONS

According to the available literature, a positive finding on SPECT in facet arthropathy is associated with a significantly higher facet blockade effect. Surgical treatment of positive findings has a good effect, but this has not been confirmed by controlled studies. SPECT/CT might therefore be a useful method in the evaluation of patients with neck or back pain, especially in cases of unclear findings or multiple degenerative changes.

The role of spinal surgery in the treatment of low back pain

Low back pain (LBP) is common and a leading cause of disability and lost productivity worldwide. Acute LBP is frequently self-resolving, but recurrence is common, and a significant proportion of patients will develop chronic pain. This transition is perpetuated by anatomical, biological, psychological and social factors. Chronic LBP should be managed with a holistic biopsychosocial approach of generally non-surgical measures. Spinal surgery has a role in alleviating radicular pain and disability resulting from neural compression, or where back pain relates to cancer, infection, or gross instability. Spinal surgery for all other forms of back pain is unsupported by clinical data, and the broader evidence base for spinal surgery in the management of LBP is poor and suggests it is ineffective. Emerging areas of interest include selection of a minority of patients who may benefit from surgery based on spinal sagittal alignment and/or nuclear medicine scans, but an evidence base is absent. Spinal surgery for back pain has increased substantially over recent decades, and disproportionately among privately insured patients, thus the contribution of industry and third-party payers to this increase, and their involvement in published research, requires careful consideration.

Diagnostic Value of Bone SPECT/CT Using 99mTc-Methylene Diphosphonate in Patients with Unspecified Chest Wall Pain

PURPOSE

We investigated the diagnostic performance of single photon emission computed tomography (SPECT)/computed tomography (CT) as a combination of functional and anatomic imaging, in patients with unspecified chest wall pain.

METHODS

Fifty-two patients with unspecified chest wall pain and no history of recent major traumatic events or cardiac disease were included. The number and location of radioactive chest wall lesions were evaluated on both planar images and SPECT/CT. The clinical diagnosis was made based on all of the clinical and imaging data and follow-up information.

RESULTS

Chest wall diseases were diagnosed in 42 patients (80.8 %). SPECT/CT showed abnormal findings in 35 (67.3 %) patients with positive predictive value (PPV) of 97.1 %. SPECT/CT revealed 56 % more lesions than planar bone scan (P = 0.002) and most of the abnormal radioactive lesions (94.6 %) showed combined morphological changes on the matched CT component. When comparing between age subgroups (< 60 y vs. ≥ 60 y), the prevalence of chest wall disease and diagnosis rate of fracture was significantly higher in the older age group. On SPECT/CT, the older age group showed higher frequency of having abnormal finding (95.8 % vs. 42.9 %, P < 0.001) and significantly more lesions were detected (a total of 189 vs. 32, P = 0.003).

CONCLUSION

SPECT/CT showed good diagnostic performance and proved to have higher sensitivity, detecting 56 % more lesions than planar bone scan. A negative result could be helpful for excluding pathologic chest wall disease. SPECT/CT might be recommended for integration in to the diagnostic workup in patients with unspecified chest wall pain, especially in patients ≥ 60 y of age, considering the high disease prevalence and the high frequency of positive results.

Primary pain generator identification by CT-SPECT in patients with degenerative spinal disease

OBJECTIVE

Axial spinal pain generators are difficult to identify using current diagnostic modalities. Merging CT with SPECT (CT-SPECT) scans allows for accurate identification of areas with increased osteoblastic activity, which may reflect pain generators. In this study, the authors aimed to evaluate the degree of pain improvement in patients who underwent surgery, addressing primary pain generators identified by CT-SPECT.

METHODS

The authors retrospectively reviewed all patients with chronic axial spine pain who underwent diagnostic CT-SPECT at their institution and analyzed pain improvement in those who underwent surgical treatment in order to determine whether CT-SPECT correctly identified the primary pain generator.

RESULTS

A total of 315 patients underwent diagnostic CT-SPECT between January 2014 and August 2018. Forty-eight patients underwent either cervical or lumbar fusion; there were 26 women (16 cervical, 10 lumbar) and 22 men (9 cervical, 13 lumbar). The overall axial spinal pain, as assessed through self-reporting of visual analog scale scores at 6 months postoperatively, improved from 9.04 ± 1.4 to 4.34 ± 2.3 (p = 0.026), with cervical fusion patients improving from 8.8 ± 1.8 to 3.92 ± 2.2 (p = 0.019) and lumbar fusion patients improving from 9.35 ± 0.7 to 4.87 ± 2.3 (p = 0.008).

CONCLUSIONS

CT-SPECT may offer a diagnostic advantage over current imaging modalities in identifying the primary pain generator in patients with axial spinal pain.

Two decades of SPECT/CT - the coming of age of a technology: An updated review of literature evidence

PURPOSE

Single-photon emission computed tomography (SPECT) combined with computed tomography (CT) was introduced as a hybrid SPECT/CT imaging modality two decades ago. The main advantage of SPECT/CT is the increased specificity achieved through a more precise localization and characterization of functional findings. The improved diagnostic accuracy is also associated with greater diagnostic confidence and better inter-specialty communication.

METHODS

This review presents a critical assessment of the relevant literature published so far on the role of SPECT/CT in a variety of clinical conditions. It also includes an update on the established evidence demonstrating both the advantages and limitations of this modality.

CONCLUSIONS

For the majority of applications, SPECT/CT should be a routine imaging technique, fully integrated into the clinical decision-making process, including oncology, endocrinology, orthopaedics, paediatrics, and cardiology. Large-scale prospective studies are lacking, however, on the use of SPECT/CT in certain clinical domains such as neurology and lung disorders. The review also presents data on the complementary role of SPECT/CT with other imaging modalities and a comparative analysis, where available.

The role of bone SPECT/CT in patients with persistent or recurrent lumbar pain following lumbar spine stabilization surgery

PURPOSE

Despite recent advances in lumbar spine stabilization surgery (LSSS), a high number of patients continue to complain of persistent/recurrent lumbar pain after LSSS. Conventional imaging (plain radiography, CT and MRI) is commonly performed to assess potential lumbar pain generators, but findings are equivocal in approximately 20% of patients. The purpose of this study was to assess the diagnostic performance of ^99mTc-HDP bone SPECT/CT in identifying potential pain generators in patients with persistent/recurrent lumbar pain after LSSS but in whom conventional diagnostic imaging is inconclusive.

METHODS

A total of 187 patients (median age 56 years, 70 men) with persistent/recurrent lumbar pain following LSSS with inconclusive conventional imaging (plain radiography, CT and/or MRI) underwent ^99mTc-HDP bone SPECT/CT and were included in the study. Tracer uptake on SPECT/CT, as an indicator of ongoing or altered osteoblastic activity, was assessed in the lumbar spine stabilization segment(s) and in adjacent segments. Uptake intensity was graded as (1) high (the same as or more than iliac crest uptake), (2) mild (the same as or more than nondiseased vertebral uptake but less than iliac crest uptake), or (3) negative (normal scan). Mild and high uptake were regarded as positive.

RESULTS

In 160 of the 187 patients (85.6%), SPECT/CT showed positive mild or high tracer uptake in the LSSS region. More than half of the patients had abnormal tracer uptake in the stabilized segments (56.7%) and/or in the adjacent segments (55.6%). Although positive stabilized segment findings were commonly seen at <2 years (70.3%) and the rate decreased with time after LSSS, they were seen at >6 years after surgery in 38.2% of patients. In 51.4% of patients, abnormal activity was seen in the adjacent segments <2 years after LSSS, suggesting early/accelerated degeneration after surgery. The proportion of patients with abnormal activity in the adjacent segments increased to 67.3% at >6 years after LSSS (p < 0.05). Positive SPECT/CT findings in the stabilized segments were more frequent in patients with three or more stabilized segments (p < 0.05), but were not more frequent in the adjacent segments. Overall, positive SPECT/CT guided therapy in 64% of patients, which included facet joint/nerve root injections or re-do surgery at active sites and/or adjacent sites.

CONCLUSION

Bone SPECT/CT is a sensitive diagnostic tool for identifying altered osteoblastic activity, which might be a pain generator in patients with persistent/recurrent pain after lumbar surgery especially when conventional imaging is inconclusive.

Bone SPECT/CT in Postoperative Spine

Back pain is a common problem and the diagnosis and treatment depend on the clinical presentation, yet overlap between pain syndromes is common. Imaging of patients with chronic back pain in both pre- and postoperative scenarios include radiological, radionuclide, and hybrid techniques. In general, these techniques have their own advantages and limitations. The aim of surgery is to eliminate pathologic segmental motion and accompanying symptoms, especially pain. However, surgical procedures are not without complications and localizing the cause of the pain is often challenging. Radiobisphosphonate bone SPECT/CT is reported to be useful in evaluating benign orthopedic conditions and it often provides valuable information such as accurate localization and characterization of bone abnormalities. In this review, routinely used spinal surgical techniques and procedures are discussed, as well as the acute and delayed complications related to spinal surgery, the role of conventional imaging, and the potential uses of radionuclide bone SPECT/CT to diagnose pseudoarthrosis, cage subsidence, loosening and misalignment, hardware failure, and postoperative infection.

Bone SPECT/CT in the postoperative spine: a focus on spinal fusion

Low back pain is a global problem affecting one in 10 people. The management of low back pain varies from conservative to more invasive methods with a spectacular increase in the number of patients undergoing spinal fusion surgery during the last decade. Conventional radiological and radionuclide studies are often used in the assessment of persistent or recurring pain after spinal surgery with several advantages and limitations related to each technique. This article reviews the key contribution of integrated bone SPECT/CT in evaluating patients with persistent or recurring pain after spinal surgery, focusing on spinal fusion. Current literature supports the use of bone SPECT/CT as an adjunct imaging modality and problem-solving tool in evaluating patients with suspicion of pseudarthrosis, adjacent segment degeneration, and hardware failure. The role of bone SPECT/CT in post-operative orthopaedic scenarios is evolving, and this review highlights the need for further research on the role of bone SPECT/CT in these patients.

Primary pain generator identification by CT-SPECT in a patient with low back pain: a case report

Background

Chronic low back pain is one of the most common conditions encountered in the middle-age population. Identifying the primary pain generator is notoriously difficult. The computed tomography–single-photon emission computed tomography (CT–SPECT) is emerging as a new diagnostic modality for this purpose.

Case presentation

This 68-year-old Caucasian male presented with intractable low back pain refractory to maximal conservative treatment, including medication and extensive physical therapy. The lumbar computed tomography, magnetic resonance imaging, and flexion–extension X-rays showed advanced degenerative changes throughout the lumbar spine, but no single level significantly worse than the others. The CT–SPECT showed markedly increased uptake at the L1–2 disc level and only minimal uptake at the other levels. The patient underwent a minimally invasive lateral L1–2 fusion with near-complete resolution of his low back pain.

Conclusions

The CT–SPECT may provide a unique tool in establishing the primary pain generator in patients with degenerative spine disease.