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

  • Khulood Al-Riyami
  • Stefan Vöö
  • Gopinath Gnanasegaran
  • Ian Pressney
  • Adam Meir
  • Adrian Casey
  • Sean Molloy
  • James Allibone
  • Jamshed BomanjiEmail author
Original Article



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.


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.


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.


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.


Lumbar spine stabilization surgery SPECT SPECT/CT 



We acknowledge the support of the NIHR Biomedical Research Centre, University College London Hospital.

Compliance with ethical standards



Conflicts of interest


Ethical approval

Due to the retrospective character of the study, ethical approval was waived by the institutional ethics committee. The study conforms with the principles outlined in the Declaration of Helsinki second revision.

Informed consent

All patients gave written informed consent to the procedures performed and the fact that all data may be used for retrospective scientific analyses.


  1. 1.
    Hoy D, March L, Brooks P, Blyth F, Woolf A, Bain C, et al. The global burden of low back pain: estimates from the Global Burden of Disease 2010 study. Ann Rheum Dis. 2014;73:968–74.CrossRefGoogle Scholar
  2. 2.
    Maniadakis N, Gray A. The economic burden of back pain in the UK. Pain. 2000;84:95–103.CrossRefGoogle Scholar
  3. 3.
    Deyo RA, Bass JE, Walsh NE, Schoenfeld LS, Ramamurthy S. Prognostic variability among chronic pain patients: implications for study design, interpretation, and reporting. Arch Phys Med Rehabil. 1988;69:174–8.Google Scholar
  4. 4.
    Willems PC, Staal JB, Walenkamp GH, de Bie RA. Spinal fusion for chronic low back pain: systematic review on the accuracy of tests for patient selection. Spine J. 2013;13:99–109.CrossRefGoogle Scholar
  5. 5.
    Martin BI, Mirza SK, Comstock BA, Gray DT, Kreuter W, Deyo RA. Reoperation rates following lumbar spine surgery and the influence of spinal fusion procedures. Spine (Phila Pa 1976). 2007;32:382–7.CrossRefGoogle Scholar
  6. 6.
    Williams AL, Gornet MF, Burkus JK. CT evaluation of lumbar interbody fusion: current concepts. AJNR Am J Neuroradiol. 2005;26:2057–66.Google Scholar
  7. 7.
    Nizard RS, Wybier M, Laredo JD. Radiologic assessment of lumbar intervertebral instability and degenerative spondylolisthesis. Radiol Clin North Am. 2001;39:55–71, v–viCrossRefGoogle Scholar
  8. 8.
    Malhotra A, Kalra VB, Wu X, Grant R, Bronen RA, Abbed KM. Imaging of lumbar spinal surgery complications. Insights Imaging. 2015;6:579–90.CrossRefGoogle Scholar
  9. 9.
    Sumer J, Schmidt D, Ritt P, Lell M, Forst R, Kuwert T, et al. SPECT/CT in patients with lower back pain after lumbar fusion surgery. Nucl Med Commun. 2013;34:964–70.CrossRefGoogle Scholar
  10. 10.
    Damgaard M, Nimb L, Madsen JL. The role of bone SPECT/CT in the evaluation of lumbar spinal fusion with metallic fixation devices. Clin Nucl Med. 2010;35:234–6.CrossRefGoogle Scholar
  11. 11.
    Berquist TH. Imaging of the postoperative spine. Radiol Clin North Am. 2006;44:407–18.CrossRefGoogle Scholar
  12. 12.
    Young PM, Berquist TH, Bancroft LW, Peterson JJ. Complications of spinal instrumentation. Radiographics. 2007;27:775–89.CrossRefGoogle Scholar
  13. 13.
    Abul-Kasim K, Ohlin A. Evaluation of implant loosening following segmental pedicle screw fixation in adolescent idiopathic scoliosis: a 2 year follow-up with low-dose CT. Scoliosis. 2014;9:13.CrossRefGoogle Scholar
  14. 14.
    Lusins JO, Danielski EF, Goldsmith SJ. Bone SPECT in patients with persistent back pain after lumbar spine surgery. J Nucl Med. 1989;30:490–6.Google Scholar
  15. 15.
    Gates GF, McDonald RJ. Bone SPECT of the back after lumbar surgery. Clin Nucl Med. 1999;24:395–403.CrossRefGoogle Scholar
  16. 16.
    Hudyana H, Maes A, Vandenberghe T, Fidlers L, Sathekge M, Nicolai D, et al. Accuracy of bone SPECT/CT for identifying hardware loosening in patients who underwent lumbar fusion with pedicle screws. Eur J Nucl Med Mol Imaging. 2016;43:349–54.CrossRefGoogle Scholar
  17. 17.
    Heimburger C, Hubele F, Charles YP, Steib J-P, Namer I-J, Rust E. Bone scan SPECT/CT for the diagnosis of late complications after spinal fusion: definition and evaluation of interpretation criteria. Médecine Nucléaire. 2015;39:105–21.CrossRefGoogle Scholar
  18. 18.
    Rager O, Schaller K, Payer M, Tchernin D, Ratib O, Tessitore E. SPECT/CT in differentiation of pseudarthrosis from other causes of back pain in lumbar spinal fusion: report on 10 consecutive cases. Clin Nucl Med. 2012;37:339–43.CrossRefGoogle Scholar
  19. 19.
    Cetinkal A, Kaya S, Kutlay M, Velioglu M, Urhan M, Colak A, et al. Can scintigraphy explain prolonged postoperative neck pain? Turk Neurosurg. 2011;21:539–44.Google Scholar
  20. 20.
    Even-Sapir E, Martin RH, Mitchell MJ, Iles SE, Barnes DC, Clark AJ. Assessment of painful late effects of lumbar spinal fusion with SPECT. J Nucl Med. 1994;35:416–22.Google Scholar
  21. 21.
    Slizofski WJ, Collier BD, Flatley TJ, Carrera GF, Hellman RS, Isitman AT. Painful pseudarthrosis following lumbar spinal fusion: detection by combined SPECT and planar bone scintigraphy. Skelet Radiol. 1987;16:136–41.CrossRefGoogle Scholar
  22. 22.
    Al-Riyami K, Gnanasegaran G, Van den Wyngaert T, Bomanji J. Bone SPECT/CT in the postoperative spine: a focus on spinal fusion. Eur J Nucl Med Mol Imaging. 2017;44:2094–104.CrossRefGoogle Scholar
  23. 23.
    Patel ND, Broderick DF, Burns J, Deshmukh TK, Fries IB, Harvey HB, et al. ACR appropriateness criteria low back pain. J Am Coll Radiol. 2016;13:1069–78.CrossRefGoogle Scholar
  24. 24.
    Van den Wyngaert T, Strobel K, Kampen WU, Kuwert T, van der Bruggen W, Mohan HK, et al. The EANM practice guidelines for bone scintigraphy. Eur J Nucl Med Mol Imaging. 2016;43:1723–38.CrossRefGoogle Scholar
  25. 25.
    Carreon LY, Djurasovic M, Glassman SD, Sailer P. Diagnostic accuracy and reliability of fine-cut CT scans with reconstructions to determine the status of an instrumented posterolateral fusion with surgical exploration as reference standard. Spine (Phila Pa 1976). 2007;32:892–5.CrossRefGoogle Scholar
  26. 26.
    Larsen JM, Capen DA. Pseudarthrosis of the lumbar spine. J Am Acad Orthop Surg. 1997;5:153–62.CrossRefGoogle Scholar
  27. 27.
    van Tulder MW, Koes BW, Bouter LM, Metsemakers JF. Management of chronic nonspecific low back pain in primary care: a descriptive study. Spine (Phila Pa 1976). 1997;22:76–82.CrossRefGoogle Scholar
  28. 28.
    Rutherford EE, Tarplett LJ, Davies EM, Harley JM, King LJ. Lumbar spine fusion and stabilization: hardware, techniques, and imaging appearances. Radiographics. 2007;27:1737–49.CrossRefGoogle Scholar
  29. 29.
    Ryan PJ, Evans PA, Gibson T, Fogelman I. Chronic low back pain: comparison of bone SPECT with radiography and CT. Radiology. 1992;182:849–54.CrossRefGoogle Scholar
  30. 30.
    Quinnell RC, Stockdale HR. Some experimental observations of the influence of a single lumbar floating fusion on the remaining lumbar spine. Spine (Phila Pa 1976). 1981;6:263–7.CrossRefGoogle Scholar
  31. 31.
    Pneumaticos SG, Chatziioannou SN, Hipp JA, Moore WH, Esses SI. Low back pain: prediction of short-term outcome of facet joint injection with bone scintigraphy. Radiology. 2006;238:693–8.CrossRefGoogle Scholar
  32. 32.
    Lee I, Budiawan H, Moon JY, Cheon GJ, Kim YC, Paeng JC, et al. The value of SPECT/CT in localizing pain site and prediction of treatment response in patients with chronic low back pain. J Korean Med Sci. 2014;29:1711–6.CrossRefGoogle Scholar
  33. 33.
    Russo VM, Dhawan RT, Baudracco I, Dharmarajah N, Lazzarino AI, Casey AT. Hybrid bone SPECT/CT imaging in evaluation of chronic low back pain: correlation with facet joint arthropathy. World Neurosurg. 2017;107:732–8. Scholar
  34. 34.
    Gruskay JA, Webb ML, Grauer JN. Methods of evaluating lumbar and cervical fusion. Spine J. 2014;14:531–9.CrossRefGoogle Scholar
  35. 35.
    Lehmann TR, Spratt KF, Tozzi JE, Weinstein JN, Reinarz SJ, el-Khoury GY, et al. Long-term follow-up of lower lumbar fusion patients. Spine (Phila Pa 1976). 1987;12:97–104.CrossRefGoogle Scholar
  36. 36.
    Collier BD Jr, Fogelman I, Brown ML. Bone scintigraphy: part 2. Orthopedic bone scanning. J Nucl Med. 1993;34:2241–6.Google Scholar
  37. 37.
    Fischer DR, Zweifel K, Treyer V, Hesselmann R, Johayem A, Stumpe KD, et al. Assessment of successful incorporation of cages after cervical or lumbar intercorporal fusion with [(18)F]fluoride positron-emission tomography/computed tomography. Eur Spine J. 2011;20:640–8.CrossRefGoogle Scholar
  38. 38.
    Lee CK, Langrana NA. Lumbosacral spinal fusion. A biomechanical study. Spine (Phila Pa 1976). 1984;9:574–81.CrossRefGoogle Scholar
  39. 39.
    Levin DA, Hale JJ, Bendo JA. Adjacent segment degeneration following spinal fusion for degenerative disc disease. Bull NYU Hosp Jt Dis. 2007;65:29–36.Google Scholar
  40. 40.
    Lehman VT, Murphy RC, Maus TP. 99mTc-MDP SPECT/CT of the spine and sacrum at a multispecialty institution: clinical use, findings, and impact on patient management. Nucl Med Commun. 2013;34:1097–106.CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  • 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
    Email author
  1. 1.Institute of Nuclear MedicineUniversity College London HospitalLondonUK
  2. 2.Department of Nuclear MedicineRoyal Free HospitalLondonUK
  3. 3.Imaging UnitRoyal National Orthopaedics HospitalLondonUK
  4. 4.Department of NeurosurgeryNational Hospital for Neurology and NeurosurgeryLondonUK
  5. 5.Spinal Surgical UnitRoyal National Orthopaedics HospitalLondonUK

Personalised recommendations