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

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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.
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ORIGINAL ARTICLE
The role of bone SPECT/CT in patients with persistent or recurrent
lumbar pain following lumbar spine stabilization surgery
Khulood Al-Riyami
1
&Stefan Vöö
1
&Gopinath Gnanasegaran
2
&Ian Pressney
3
&Adam Meir
4
&Adrian Casey
4
&
Sean Molloy
5
&James Allibone
4
&Jamshed Bomanji
1
Received: 8 June 2018 /Accepted: 19 August 2018 /Published online: 6 September 2018
#Springer-Verlag GmbH Germany, part of Springer Nature 2018
Abstract
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, CTand 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
99m
Tc-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
99m
Tc-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).PositiveSPECT/CTfindingsin
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.
Keywords Lumbar spine stabilization surgery .SPECT .SPECT/CT
Introduction
Low back pain is a common disorder, with international studies
having found prevalence rates between 12% and 35% and life-
time prevalence rates ranging from 49% to 80% [1,2]. It is
caused mainly by degenerative spinal disorders, such as
spondylolisthesis, degenerative scoliosis, degenerative disc dis-
ease and recurrent disc herniations [3,4]. The management of
low back pain varies from conservative to more invasive
methods, such as spinal stabilization surgery that involves the
placement of metallic screws, rods, plates or cages. Such surgery
*Jamshed Bomanji
jamshed.bomanji@nhs.net
1
Institute of Nuclear Medicine, University College London Hospital,
235 Euston Road, London NW1 2BU, UK
2
Department of Nuclear Medicine, Royal Free Hospital, London, UK
3
Imaging Unit, Royal National Orthopaedics Hospital, London, UK
4
Department of Neurosurgery, National Hospital for Neurology and
Neurosurgery, Queens Square, London, UK
5
Spinal Surgical Unit, Royal National Orthopaedics Hospital,
London, UK
European Journal of Nuclear Medicine and Molecular Imaging (2019) 46:989998
https://doi.org/10.1007/s00259-018-4141-x
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
... Various metrics have already been explored for other applications and could be implemented for bone SPECT. Visual grading to assign discrete numbers to uptake patterns is a semi-quantitative approach which can supplement clinical reports with numerical data (Fig. 2) (Al-Riyami et al. 2018;Kim et al. 2017). However, this is a subjective and crude method which does Fig. 1 a-f According to one study, no statistically significant systematic differences were observed between results produced using planar whole-body bone scans, SPECT-CT, and PET-CT on newly diagnosed, high-risk prostate cancer (Fonager et al. 2017). ...
... A significant amount of work is required by the scientific community to generate evidence for the former. Unlike the case for PET, demonstrable clinical benefit has not been observed in longitudinal or cross-sectional form for quantitative SPECT yet (Al-Riyami et al. 2018;De Laroche et al. 2018). Assessments of correlations between quantitative results and certain clinical outcomes would provide results that throw the most weight behind quantitative SPECT's cause (e.g. ...
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... Цифрові параметри повинні бути точними, мати клінічне значення і бути специфічними для конкретних діагностичних умов. Візуальне сортування для визначення дискретних чисел для моделей поглинання є напівкількісним підходом, що може доповнювати клінічні звіти з числовими даними [1,22]. Однак це суб'єктивний метод, що не завжди відображає клінічну картину. ...
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... We reviewed 13 original articles that focused on SPECT/CT for spinal imaging [7][8][9][10][11][12][13][14][15][16][17][18][19], eight that focused on SPECT/CT of the foot and/or ankle imaging [19][20][21][22][23][24][25][26], ten that focused on SPECT/CT at the knee imaging [19][20][21][27][28][29][30][31][32][33][34], six that focused on SPECT/CT for hip imaging [19,[35][36][37][38][39], and four that focused on SPECT/CT for wrist imaging [19,[40][41][42]. Two of the publications on spinal imaging included no information on device settings or on slice thickness, and one publication each pertaining to foot/ankle and knee imaging harbored no information on optimizing slice thickness. ...
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Most patients presenting with uncomplicated acute low back pain (LBP) and/or radiculopathy do not require imaging. Imaging is considered in those patients who have had up to 6 weeks of medical management and physical therapy that resulted in little or no improvement in their back pain. It is also considered for those patients presenting with red flags raising suspicion for serious underlying conditions, such as cauda equina syndrome, malignancy, fracture, and infection. Many imaging modalities are available to clinicians and radiologists for evaluating LBP. Application of these modalities depends largely on the working diagnosis, the urgency of the clinical problem, and comorbidities of the patient. When there is concern for fracture of the lumbar spine, multidetector CT is recommended. Those deemed to be interventional candidates, with LBP lasting for > 6 weeks having completed conservative management with persistent radiculopathic symptoms, may seek MRI. Patients with severe or progressive neurologic deficit on presentation and red flags should be evaluated with MRI. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (the RAND/UCLA Appropriateness Method and the Grading of Recommendations Assessment, Development, and Evaluation) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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The effects of spinal fusion on fused segment and the adjacent, unfused segments play a significant role in the clinical effectiveness of spinal fusion for low-back pain with or without sciatica. Much of the information on this important subject is derived from clinical impressions. The purpose of this biomechanical study is to investigate the altered kinematics and biomechanics of the three different types of spinal fusion (posterior, bilateral-lateral, and anterior) on the adjacent, unfused segment as well as within the fused segment and to investigate their clinical implications. Sixteen fresh human cadaver lumbosacral spines were tested under a simulated physiologic loading condition. The test specimens included three motion segments, L3-4, L4-5, and L5-S1. To study the mechanics of the lumbar spine under combined compression and bending loads, a special apparatus was designed. These loads were applied by an MTS machine through two sets of pulley systems. The loads, as well as dispiacement data from both actuators, were recorded. A video camera system was utilized to record the kinematics of the spinal motion segment. The unfused specimen was tested first, and the fused specimen then was retested under the identical loading conditions. A total of 16 spine specimens were tested and evaluated-five posterior, four bilateral-lateral, and seven anterior fusions. All types of fusion resulted in increased bending and axial stiffnesses. Overall, anterior fusion provided the largest increase in stiffness, followed by bilateral-lateral fusion and posterior fusion. The kinematic data obtained from the video system shows cephalad shift of the center of rotation by fusion of L5-S1. This shift was largest in the bilateral-lateral fusion and in the posterior fusion. The posterior fusion produced posterior shift in addition to the cephalad shift. In anterior fusion and bilateral-lateral fusion, there was no detectable motion within the fused segment. But in the case of posterior fusion, a small amount was detected in the anterior markers (or anterior portion of the disc). All types of fusion demonstrated stabilizing effects on the fusion and produced increased stress on the adjacent, unfused segments, especially the facet joints. The bilateral-lateral fusion is the best method providing good stabilization to the fused segment and having the least effect on the adjacent unfused segments. Posterior fusion is the worst type of fusion producing the highest amount of stress in the adjacent segments and allowing a small but significant amount of motion across the retained disc.
Article
Late complications after spinal fusion are usually evaluated using conventional radiographs, CT or MRI. Unfortunately, these postoperative imaging are sometimes inconclusive mainly due to artifacts formation.