The role of bone SPECT/CT in patients with persistent or recurrent lumbar pain following lumbar spine stabilization surgery
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.
KeywordsLumbar 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
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.
All patients gave written informed consent to the procedures performed and the fact that all data may be used for retrospective scientific analyses.
- 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
- 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
- 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
- 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.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
- 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
- 36.Collier BD Jr, Fogelman I, Brown ML. Bone scintigraphy: part 2. Orthopedic bone scanning. J Nucl Med. 1993;34:2241–6.Google Scholar
- 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