The value of SPECT scans in identifying back pain likely to benefit from facet joint injection

Clinical Rheumatology Unit, Guy's Hospital, London.
British journal of rheumatology 12/1996; 35(12):1269-73. DOI: 10.1093/rheumatology/35.12.1269
Source: PubMed


Lumbar facet disease is sometimes implicated in low back pain. Identification is difficult and this may account for a variable response. Single photon emission computerized tomography (SPECT) is a scanning technique which enables localization of facet joint pathology. We determined whether recognition of facet disease by this method improved the response to corticosteroid injection treatment. Fifty-eight patients with low back pain and displaying accepted clinical criteria for facet joint disease were evaluated by SPECT. Twenty-two had facetal uptake of isotope. These and the tender facet joints of 36 scan-negative patients were injected with 40 mg methylprednisolone and 1 ml 1% lignocaine under X-ray control. Pain was assessed by a blind observer using the McGill questionnaire (MGQ), Present Pain Intensity score (PPI) and a Visual Analogue Scale (VAS). VAS, PPI and MGQ were reduced in the scan-positive patients at 1 month (P = 0.05, P = 0.0005, P = 0.005) and MGQ at 3 months (P = 0.01), whilst scan-negative patients were unchanged. The percentage of scan-positive patients who reported improvement was 95% at 1 month and 79% at 3 months, significantly greater than the control group (P = 0.0005, P = 0.01). Within 6 months, pain improvement in the SPECT-positive group was no longer statistically significant. Tenderness did not correlate with increased uptake on SPECT scan. Osteoarthritis of the facets was more common in the SPECT-positive patients (P < 0.001), but did not correspond with sites of increased uptake on SPECT scan. These results suggest that SPECT can enhance the identification of back pain sufferers likely to obtain short-term benefit from facet joint injection.

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Available from: Richard J Stratton, Jul 07, 2014
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    • "Imaging exams have been considered to be poor tools to identify chronic lumbar pain originating from the facet joints (30-33), as are a patient's clinical features and history (25,26). To the best of our knowledge, no controlled study has investigated the diagnosis of facet joint chronic lumbar pain using controlled medial branch anesthetic block (CMB) in an attempt to identify the prevalence of false positives in a three-month follow-up. "
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    ABSTRACT: OBJECTIVES: To verify the incidence of facetary and low back pain after a controlled medial branch anesthetic block in a three-month follow-up and to verify the correlation between the positive results and the demographic variables. METHODS: Patients with chronic lumbar pain underwent a sham blockade (with a saline injection) and then a controlled medial branch block. Their symptoms were evaluated before and after the sham injection and after the real controlled medial branch block; the symptoms were reevaluated after one day and one week, as well as after one, two and three months using the visual analog scale. We searched for an association between the positive results and the demographic characteristics of the patients. RESULTS: A total of 104 controlled medial branch blocks were performed and 54 patients (52%) demonstrated >50% improvements in pain after the blockade. After three months, lumbar pain returned in only 18 individuals, with visual analogue scale scores >4. Therefore, these patients were diagnosed with chronic facet low back pain. The three-months of follow-up after the controlled medial branch block excluded 36 patients (67%) with false positive results. The results of the controlled medial branch block were not correlated to sex, age, pain duration or work disability but were correlated with patient age (p<0.05). CONCLUSION: Patient diagnosis with a controlled medial branch block proved to be effective but was not associated with any demographic variables. A three-month follow-up is required to avoid a high number of false positives.
    Full-text · Article · Aug 2014 · Clinics (São Paulo, Brazil)
    • "The difference in incidence of neurologic symptoms and reduction in functional capacity between SPECT positive and negative patients was statistically significant (P = 0.002). Specificity of SPECT findings to identify active disease was further confirmed by Dolan[23] who noted that there is 95% response rate after injection therapy of SPECT positive facets. Pneumaticos in a recent study,[24] proved that significant improvement in back pain is noted only when SPECT positive facet joints are subjected to injection therapy. "
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    ABSTRACT: Abnormal morphologic findings in imaging were thought to explain the etiology of low back pain (LBP). However, it is now known that variety of morphologic abnormalities is noted even in asymptomatic individuals. Single photon emission computed tomography/computed tomography (SPECT/CT) could be used to differentiate incidental findings from clinically significant findings. This study was performed to define the SPECT/CT patterns in patients with LBP and to correlate these with clinical and magnetic resonance imaging (MRI) findings. Thirty adult patients with LBP of duration 3 months or more were prospectively evaluated in this study. Patients with known or suspected malignancy, trauma or infectious processes were excluded. A detailed history of sensory and motor symptoms and neurologic examination was performed. All the patients were subjected to MRI and bone scintigraphy with hybrid SPECT/CT of the lumbo-sacral spine within 1 month of each other. The patients were classified into those with and without neurologic symptoms, activity limitation. The findings of clinical examination and imaging were compared. MRI and SPECT/CT findings were also compared. Thirty patients (18 men and 12 women; mean age 38 years; range 17-64 years) were eligible for the study. Clinically, 14 of 30 (46%) had neurologic signs and or symptoms. Six of the 30 patients (20%) had positive straight leg raising test (SLRT). Twenty-two of the 30 patients (73%) had SPECT abnormality. Most frequent SPECT/CT abnormality was tracer uptake in the anterior part of vertebral body with osteophytes/sclerotic changes. Significant positive agreement was noted between this finding and MRI evidence of degenerative disc disease. Only 13% of patients had more than one abnormality in SPECT. All 30 patients had MRI abnormalities. The most frequent abnormality was degenerative disc disease and facet joint arthropathy. MRI showed single intervertebral disc abnormality in 36% of the patients and more than one intervertebral disc abnormality in remaining 64% patients. Fifteen of the 30 patients had facet joint arthropathy. 60% of these patients had involvement of more than one level facet joints while 38% had associated inter vertebral disc disease. 83% of the patients with positive SLRT had SPECT and MRI abnormalities. 100% of patients with neurologic symptoms had SPECT and MRI abnormalities. Addition of hybrid SPECT/CT data will help differentiate incidental from significant MRI abnormalities as all patients with LBP have MRI abnormalities and most have MRI abnormalities at multiple sites. Tracer uptake in the anterior part of the vertebral body represents degenerative disc disease. MRI is sensitive and SPECT/CT is specific for facet joint arthropathy. Both investigations are best used complementary to each other.
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    • "Current clinical applications for SPECT in OA are limited due to the practicalities of low count rates and inefficient use of the camera field-of-view (Collier, Johnson et al. 1985). Bone SPECT has been used in the diagnosis of facet joint OA in the spine with studies showing that it may improve patient selection for therapeutic facet blocks (Holder, Machin et al. 1995; Dolan, Ryan et al. 1996). Conventional radiography and MRI are still the main modes of investigating the painful knee, SPECT has also been used to investigate chronic knee pain. "

    Full-text · Chapter · Feb 2012
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