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Evaluation of Lower Back Pain with Bone Scintigraphy and SPECT¹

¹ From the Department of Radiology and Nuclear Medicine, Sint Andriesziekenhuis, Tielt, Belgium (M.D.M., S.M., P.B.); the Departments of Radiology (M.D.M., M.O.) and Nuclear Medicine (H.E., A.B.), Vrije Universiteit Brussel, Laerbeeklaan 101, 1090 Brussels, Belgium; and the Department of Radiology, Bowman Gray School of Medicine, Winston-Salem, NC (L.L.). Presented as a scientific exhibit at the 1997 RSNA scientific assembly. Received July 6, 1998; revision requested August 18 and received November 12; accepted November 12. Supported by an RSNA Research and Education Fund Grant. Address reprint requests to M.D.M.

View larger version (92K): [in a new window]   Figure 1a.  (a) Photograph demonstrates the normal anatomy of the vertebral body and disk space (1); the posterior arch, including the pedicle (2), lamina (3), and facet joints (4); and the transverse process (5). (b) Differential diagnosis of lesions centered in the vertebral body, intervertebral disk space, and transverse process. Schematics represent views seen at planar anteroposterior scintigraphy or coronal tomographic reconstruction through the vertebral body (v). o = osteophytes, t = transverse process. A illustrates fracture of the vertebral body with secondary increased uptake (shaded area). B illustrates spondylodiskitis with increased uptake in two adjacent vertebral bodies (shaded areas) and at the level of the intervertebral disk space (black area). C depicts fracture of the transverse process with increased uptake at the corresponding level (shaded area). D illustrates degenerative disk disease or spondylosis deformans with increased tracer uptake at the level of the vertebral end plates and paravertebral osteophytes (black areas). (c) Differential diagnosis of lesions centered in the posterior arch. f = facet joint, l = lamina, p = pedicle, s = spinous process, v = vertebral body. A represents a planar anteroposterior scintigram, on which disorders involving the facet joints, pedicle, and lamina have a similar appearance. Tomographic reconstructions (SPECT) are necessary to differentiate between various conditions. Shaded areas indicate bilateral involvement of the posterior arch. B-E represent sagittal tomographic reconstructions. Precise anatomic location of increased tracer uptake on sagittal images may allow differentiation of various conditions that involve the posterior arch. B illustrates facet joint osteoarthritis with increased tracer uptake at the level of the superior facet joint (black area). C demonstrates a pedicle lesion with increased uptake at the corresponding level (black area). D illustrates metastatic disease, which is suggested by the increased uptake in both the posterior aspect of the vertebral body and an adjacent pedicle (black area). E depicts spondylolysis with increased uptake at the corresponding level (black area).

View larger version (36K): [in a new window]   Figure 1b.  (a) Photograph demonstrates the normal anatomy of the vertebral body and disk space (1); the posterior arch, including the pedicle (2), lamina (3), and facet joints (4); and the transverse process (5). (b) Differential diagnosis of lesions centered in the vertebral body, intervertebral disk space, and transverse process. Schematics represent views seen at planar anteroposterior scintigraphy or coronal tomographic reconstruction through the vertebral body (v). o = osteophytes, t = transverse process. A illustrates fracture of the vertebral body with secondary increased uptake (shaded area). B illustrates spondylodiskitis with increased uptake in two adjacent vertebral bodies (shaded areas) and at the level of the intervertebral disk space (black area). C depicts fracture of the transverse process with increased uptake at the corresponding level (shaded area). D illustrates degenerative disk disease or spondylosis deformans with increased tracer uptake at the level of the vertebral end plates and paravertebral osteophytes (black areas). (c) Differential diagnosis of lesions centered in the posterior arch. f = facet joint, l = lamina, p = pedicle, s = spinous process, v = vertebral body. A represents a planar anteroposterior scintigram, on which disorders involving the facet joints, pedicle, and lamina have a similar appearance. Tomographic reconstructions (SPECT) are necessary to differentiate between various conditions. Shaded areas indicate bilateral involvement of the posterior arch. B-E represent sagittal tomographic reconstructions. Precise anatomic location of increased tracer uptake on sagittal images may allow differentiation of various conditions that involve the posterior arch. B illustrates facet joint osteoarthritis with increased tracer uptake at the level of the superior facet joint (black area). C demonstrates a pedicle lesion with increased uptake at the corresponding level (black area). D illustrates metastatic disease, which is suggested by the increased uptake in both the posterior aspect of the vertebral body and an adjacent pedicle (black area). E depicts spondylolysis with increased uptake at the corresponding level (black area).

View larger version (13K): [in a new window]   Figure 1c.  (a) Photograph demonstrates the normal anatomy of the vertebral body and disk space (1); the posterior arch, including the pedicle (2), lamina (3), and facet joints (4); and the transverse process (5). (b) Differential diagnosis of lesions centered in the vertebral body, intervertebral disk space, and transverse process. Schematics represent views seen at planar anteroposterior scintigraphy or coronal tomographic reconstruction through the vertebral body (v). o = osteophytes, t = transverse process. A illustrates fracture of the vertebral body with secondary increased uptake (shaded area). B illustrates spondylodiskitis with increased uptake in two adjacent vertebral bodies (shaded areas) and at the level of the intervertebral disk space (black area). C depicts fracture of the transverse process with increased uptake at the corresponding level (shaded area). D illustrates degenerative disk disease or spondylosis deformans with increased tracer uptake at the level of the vertebral end plates and paravertebral osteophytes (black areas). (c) Differential diagnosis of lesions centered in the posterior arch. f = facet joint, l = lamina, p = pedicle, s = spinous process, v = vertebral body. A represents a planar anteroposterior scintigram, on which disorders involving the facet joints, pedicle, and lamina have a similar appearance. Tomographic reconstructions (SPECT) are necessary to differentiate between various conditions. Shaded areas indicate bilateral involvement of the posterior arch. B-E represent sagittal tomographic reconstructions. Precise anatomic location of increased tracer uptake on sagittal images may allow differentiation of various conditions that involve the posterior arch. B illustrates facet joint osteoarthritis with increased tracer uptake at the level of the superior facet joint (black area). C demonstrates a pedicle lesion with increased uptake at the corresponding level (black area). D illustrates metastatic disease, which is suggested by the increased uptake in both the posterior aspect of the vertebral body and an adjacent pedicle (black area). E depicts spondylolysis with increased uptake at the corresponding level (black area).

View larger version (137K): [in a new window]   Figure 2a.  Spondylodiskitis in a 60-year-old man with a 6-month history of lower back pain. (a) Planar scintigram shows involvement centered about the disk space and adjacent L-2 and L-3 vertebral bodies (arrows). The pattern was readily identified, and SPECT added little information in this case. (b) Corresponding radiograph shows disk space narrowing and destruction of vertebral end plates (arrows). (c) Transverse CT scan shows several paravertebral abscesses (arrows).

View larger version (142K): [in a new window]   Figure 2b.  Spondylodiskitis in a 60-year-old man with a 6-month history of lower back pain. (a) Planar scintigram shows involvement centered about the disk space and adjacent L-2 and L-3 vertebral bodies (arrows). The pattern was readily identified, and SPECT added little information in this case. (b) Corresponding radiograph shows disk space narrowing and destruction of vertebral end plates (arrows). (c) Transverse CT scan shows several paravertebral abscesses (arrows).

View larger version (164K): [in a new window]   Figure 2c.  Spondylodiskitis in a 60-year-old man with a 6-month history of lower back pain. (a) Planar scintigram shows involvement centered about the disk space and adjacent L-2 and L-3 vertebral bodies (arrows). The pattern was readily identified, and SPECT added little information in this case. (b) Corresponding radiograph shows disk space narrowing and destruction of vertebral end plates (arrows). (c) Transverse CT scan shows several paravertebral abscesses (arrows).

View larger version (114K): [in a new window]   Figure 3a.  Spondylodiskitis in a 44-year-old woman. Coronal (a) and sagittal (b) volume-rendered SPECT images show increased uptake centered about the disk space and adjacent vertebral bodies (arrows). The pattern could also be identified on planar images (not shown).

View larger version (81K): [in a new window]   Figure 3b.  Spondylodiskitis in a 44-year-old woman. Coronal (a) and sagittal (b) volume-rendered SPECT images show increased uptake centered about the disk space and adjacent vertebral bodies (arrows). The pattern could also be identified on planar images (not shown).

View larger version (104K): [in a new window]   Figure 4a.  Metastatic disease in a 64-year-old man. (a, b) Coronal (a) and sagittal (b) volume-rendered SPECT images show multiple areas of increased tracer uptake (arrows). Although more lesions were seen on SPECT images, planar images (not shown) that demonstrated multiple regions of increased uptake also suggested the presence of metastatic disease. (c) Corresponding sagittal T1-weighted MR image (repetition time msec/echo time msec = 580/15) shows widespread areas of low signal intensity.

View larger version (103K): [in a new window]   Figure 4b.  Metastatic disease in a 64-year-old man. (a, b) Coronal (a) and sagittal (b) volume-rendered SPECT images show multiple areas of increased tracer uptake (arrows). Although more lesions were seen on SPECT images, planar images (not shown) that demonstrated multiple regions of increased uptake also suggested the presence of metastatic disease. (c) Corresponding sagittal T1-weighted MR image (repetition time msec/echo time msec = 580/15) shows widespread areas of low signal intensity.

View larger version (116K): [in a new window]   Figure 4c.  Metastatic disease in a 64-year-old man. (a, b) Coronal (a) and sagittal (b) volume-rendered SPECT images show multiple areas of increased tracer uptake (arrows). Although more lesions were seen on SPECT images, planar images (not shown) that demonstrated multiple regions of increased uptake also suggested the presence of metastatic disease. (c) Corresponding sagittal T1-weighted MR image (repetition time msec/echo time msec = 580/15) shows widespread areas of low signal intensity.

View larger version (136K): [in a new window]   Figure 5a.  Solitary metastatic lesion in a 52-year-old woman with lower back pain. (a, b) Sagittal (a) and transverse (b) SPECT images show involvement of the vertebral body (v) with extension into the pedicle (p). (c, d) Transverse CT scan (c) and sagittal reconstructed image (d) show a mixed lytic and sclerotic lesion extending from the vertebral body (top two arrows in c, arrowheads in d) into the pedicle (lowest arrow in c, arrows in d).

View larger version (92K): [in a new window]   Figure 5b.  Solitary metastatic lesion in a 52-year-old woman with lower back pain. (a, b) Sagittal (a) and transverse (b) SPECT images show involvement of the vertebral body (v) with extension into the pedicle (p). (c, d) Transverse CT scan (c) and sagittal reconstructed image (d) show a mixed lytic and sclerotic lesion extending from the vertebral body (top two arrows in c, arrowheads in d) into the pedicle (lowest arrow in c, arrows in d).

View larger version (154K): [in a new window]   Figure 5c.  Solitary metastatic lesion in a 52-year-old woman with lower back pain. (a, b) Sagittal (a) and transverse (b) SPECT images show involvement of the vertebral body (v) with extension into the pedicle (p). (c, d) Transverse CT scan (c) and sagittal reconstructed image (d) show a mixed lytic and sclerotic lesion extending from the vertebral body (top two arrows in c, arrowheads in d) into the pedicle (lowest arrow in c, arrows in d).

View larger version (162K): [in a new window]   Figure 5d.  Solitary metastatic lesion in a 52-year-old woman with lower back pain. (a, b) Sagittal (a) and transverse (b) SPECT images show involvement of the vertebral body (v) with extension into the pedicle (p). (c, d) Transverse CT scan (c) and sagittal reconstructed image (d) show a mixed lytic and sclerotic lesion extending from the vertebral body (top two arrows in c, arrowheads in d) into the pedicle (lowest arrow in c, arrows in d).

View larger version (82K): [in a new window]   Figure 6a.  Fracture of the vertebral body in an 82-year-old woman. (a) Planar scintigram shows a linear, horizontally oriented area of increased tracer uptake in the L-2 vertebral body (arrow). (b) SPECT images also demonstrate tracer uptake (arrows) but add little information.

View larger version (50K): [in a new window]   Figure 6b.  Fracture of the vertebral body in an 82-year-old woman. (a) Planar scintigram shows a linear, horizontally oriented area of increased tracer uptake in the L-2 vertebral body (arrow). (b) SPECT images also demonstrate tracer uptake (arrows) but add little information.

View larger version (80K): [in a new window]   Figure 7a.  Degenerative disease in a 45-year-old woman. (a, b) Coronal (a) and transverse (b) SPECT images show increased uptake centered in the vertebral body (v) and about the disk space (arrows). s = spinous process. (c) Corresponding anteroposterior radiograph shows small traction osteophytes at the L4-5 level (arrows), a finding indicative of active degenerative disease. Because the osteophytes were small in this case, extension beyond the vertebral body was not seen on the SPECT images.

View larger version (67K): [in a new window]   Figure 7b.  Degenerative disease in a 45-year-old woman. (a, b) Coronal (a) and transverse (b) SPECT images show increased uptake centered in the vertebral body (v) and about the disk space (arrows). s = spinous process. (c) Corresponding anteroposterior radiograph shows small traction osteophytes at the L4-5 level (arrows), a finding indicative of active degenerative disease. Because the osteophytes were small in this case, extension beyond the vertebral body was not seen on the SPECT images.

View larger version (122K): [in a new window]   Figure 7c.  Degenerative disease in a 45-year-old woman. (a, b) Coronal (a) and transverse (b) SPECT images show increased uptake centered in the vertebral body (v) and about the disk space (arrows). s = spinous process. (c) Corresponding anteroposterior radiograph shows small traction osteophytes at the L4-5 level (arrows), a finding indicative of active degenerative disease. Because the osteophytes were small in this case, extension beyond the vertebral body was not seen on the SPECT images.

View larger version (39K): [in a new window]   Figure 8a.  Spondylolysis in a male patient. (a, b) Coronal (a) and transverse (b) SPECT images show bilateral increased uptake in the posterior arch (arrows in a, arrowheads in b). On sagittal images, increased uptake due to spondylolysis is seen in the same horizontal plane as the vertebral body. (c) Oblique radiograph of the lumbar spine shows a defect at the L5-S1 level (arrows).

View larger version (32K): [in a new window]   Figure 8b.  Spondylolysis in a male patient. (a, b) Coronal (a) and transverse (b) SPECT images show bilateral increased uptake in the posterior arch (arrows in a, arrowheads in b). On sagittal images, increased uptake due to spondylolysis is seen in the same horizontal plane as the vertebral body. (c) Oblique radiograph of the lumbar spine shows a defect at the L5-S1 level (arrows).

View larger version (118K): [in a new window]   Figure 8c.  Spondylolysis in a male patient. (a, b) Coronal (a) and transverse (b) SPECT images show bilateral increased uptake in the posterior arch (arrows in a, arrowheads in b). On sagittal images, increased uptake due to spondylolysis is seen in the same horizontal plane as the vertebral body. (c) Oblique radiograph of the lumbar spine shows a defect at the L5-S1 level (arrows).

View larger version (136K): [in a new window]   Figure 9a.  Pedicle lesion in a 22-year-old woman. (a-c) Coronal (a), sagittal (b), and transverse (c) SPECT images show increased uptake posterior to the vertebral body (arrow in a and b, b in c). p = pedicle. (d) Corresponding oblique radiograph shows sclerosis of the L-3 pedicle corresponding to an osteoid osteoma (arrows).

View larger version (126K): [in a new window]   Figure 9b.  Pedicle lesion in a 22-year-old woman. (a-c) Coronal (a), sagittal (b), and transverse (c) SPECT images show increased uptake posterior to the vertebral body (arrow in a and b, b in c). p = pedicle. (d) Corresponding oblique radiograph shows sclerosis of the L-3 pedicle corresponding to an osteoid osteoma (arrows).

View larger version (115K): [in a new window]   Figure 9c.  Pedicle lesion in a 22-year-old woman. (a-c) Coronal (a), sagittal (b), and transverse (c) SPECT images show increased uptake posterior to the vertebral body (arrow in a and b, b in c). p = pedicle. (d) Corresponding oblique radiograph shows sclerosis of the L-3 pedicle corresponding to an osteoid osteoma (arrows).

View larger version (141K): [in a new window]   Figure 9d.  Pedicle lesion in a 22-year-old woman. (a-c) Coronal (a), sagittal (b), and transverse (c) SPECT images show increased uptake posterior to the vertebral body (arrow in a and b, b in c). p = pedicle. (d) Corresponding oblique radiograph shows sclerosis of the L-3 pedicle corresponding to an osteoid osteoma (arrows).

View larger version (99K): [in a new window]   Figure 10a.  Facet joint osteoarthritis in a 64-year-old woman. (a, b) Sagittal (a) and transverse (b) SPECT images show unilateral increased uptake in the posterior arch and in the same horizontal plane as the disk space (arrows; d in a). sp = spinous process, v = vertebral body. (c) Corresponding oblique radiograph shows facet joint osteoarthritis at the L4-5 level (arrows).

View larger version (90K): [in a new window]   Figure 10b.  Facet joint osteoarthritis in a 64-year-old woman. (a, b) Sagittal (a) and transverse (b) SPECT images show unilateral increased uptake in the posterior arch and in the same horizontal plane as the disk space (arrows; d in a). sp = spinous process, v = vertebral body. (c) Corresponding oblique radiograph shows facet joint osteoarthritis at the L4-5 level (arrows).

View larger version (148K): [in a new window]   Figure 10c.  Facet joint osteoarthritis in a 64-year-old woman. (a, b) Sagittal (a) and transverse (b) SPECT images show unilateral increased uptake in the posterior arch and in the same horizontal plane as the disk space (arrows; d in a). sp = spinous process, v = vertebral body. (c) Corresponding oblique radiograph shows facet joint osteoarthritis at the L4-5 level (arrows).

View larger version (117K): [in a new window]   Figure 11a.  Fracture of the transverse process in a 30-year-old man. (a) Planar scintigram shows increased uptake lateral to L3 (arrows). (b) Corresponding spot radiograph shows fracture of the transverse process (arrows).

View larger version (99K): [in a new window]   Figure 11b.  Fracture of the transverse process in a 30-year-old man. (a) Planar scintigram shows increased uptake lateral to L3 (arrows). (b) Corresponding spot radiograph shows fracture of the transverse process (arrows).

View larger version (112K): [in a new window]   Figure 12a.  Fracture of the apophyseal process in a male patient. (a, b) Coronal (a) and transverse (b) SPECT images show increased uptake lateral to the vertebral body and centered about the costovertebral junction (arrows). (c) Corresponding transverse CT scan shows a fracture of the apophyseal process (arrows).

View larger version (84K): [in a new window]   Figure 12b.  Fracture of the apophyseal process in a male patient. (a, b) Coronal (a) and transverse (b) SPECT images show increased uptake lateral to the vertebral body and centered about the costovertebral junction (arrows). (c) Corresponding transverse CT scan shows a fracture of the apophyseal process (arrows).

View larger version (123K): [in a new window]   Figure 12c.  Fracture of the apophyseal process in a male patient. (a, b) Coronal (a) and transverse (b) SPECT images show increased uptake lateral to the vertebral body and centered about the costovertebral junction (arrows). (c) Corresponding transverse CT scan shows a fracture of the apophyseal process (arrows).