(Radiographics. 1999;19:901-912.)
© RSNA, 1999
Evaluation of Lower Back Pain with Bone Scintigraphy and SPECT1
Michel De Maeseneer, MD,
Leon Lenchik, MD,
Hendrik Everaert, MD,
Stefaan Marcelis, MD,
Axel Bossuyt, MD,
Michel Osteaux, MD and
Paul Beeckman, MD
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.
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Abstract
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Bone scintigraphy and single photon emission computed tomography (SPECT) may be performed for evaluation of lower back pain, especially when a bone abnormality is suspected. Various patterns of tracer activity based on precise identification of the anatomic location of increased uptake may be observed and used to evaluate bones and joints. Lesions centered about the disk space and vertebral body include spondylodiskitis, metastatic disease, vertebral body fracture, and degenerative disease (disk disease, spondylosis deformans). In diskitis, tracer uptake has a vertical orientation. Metastatic involvement should be suspected in solitary lesions evaluated with SPECT when the area of increased uptake extends from the vertebral body into the pedicle. Fractures are seen on planar and SPECT images as a linear, horizontally oriented area of increased uptake centered in the vertebral body. In degenerative disease, increased uptake is centered about the disk space and may be seen in and project beyond the surface of the vertebral body. Lesions of the posterior arch (comprising the pedicle, lamina, and facet joints) include spondylolysis, pedicle lesions, osteoarthritis of the facet joints, and fracture of the transverse process. Scintigraphy may help differentiate long-standing asymptomatic spondylolysis from ongoing disease. In osteoarthritis of the facet joints, SPECT may be used to select patients to be treated with therapeutic injections. Increased uptake in the transverse process most often indicates a fracture, although tumors may also occur in this location. These findings at planar bone scintigraphy and SPECT allow differentiation of common pathologic conditions and can lead to a specific diagnosis.
Index Terms: Spine, arthritis, 33.70 • Spine, diseases, 33.25, 33.423 • Spine, emission CT (ECT), 33.12162 • Spine, fractures, 33.41 • Spine, radionuclide studies, 33.12162, 33.12172 • Spine, secondary neoplasms, 33.33
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INTRODUCTION
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Pain in the lower back can be caused by a variety of conditions including musculoligamentous, osteoarticular, and neurologic disorders. Many different imaging studies are commonly performed in patients with lower back pain. Despite the use of multiple imaging studies, however, the precise cause of back pain may remain obscure in some patients (1). The choice among various imaging methods in the evaluation of lower back pain usually depends on the suspected abnormality. When a neurologic condition such as disk herniation is suspected, computed tomography (CT) and magnetic resonance (MR) imaging are the preferred imaging modalities. Most musculoligamentous conditions are diagnosed clinically, have a self-limited course, and do not require diagnostic imaging. Several disorders of bone and joints may also be associated with lower back pain. In patients with a suspected bone abnormality, scintigraphy (including single photon emission computed tomography [SPECT]) may be considered as a first-line imaging test. However, the precise role of bone scintigraphy and SPECT in the evaluation of lower back pain is still controversial (2-4). In clinical practice, other procedures such as CT and MR imaging are often performed first, even if a bone abnormality is suspected.
Radiography, CT, and MR imaging in patients with lower back pain may reveal osteophytes, narrowing of the disk space, spondylolysis, Schmorl nodules, or osteoporotic fractures. However, the same imaging findings may be observed in asymptomatic persons, which brings into question the relationship between imaging findings and clinical symptoms (5-7). A potential advantage of bone scintigraphy is that it can show the physiologic activity of an osseous lesion, whereas radiography and CT show only morphologic changes (8-10). Thus, the patient's symptoms may be assumed to arise from an area that shows increased tracer uptake on a bone scintigram.
The use of SPECT has resulted in increased sensitivity and specificity compared with planar bone scintigraphy (11,12). The improved sensitivity of SPECT over planar imaging has been shown in several studies. In a prospective study of 100 patients evaluated for lower back pain, Gates (8) found 23 patients with an abnormality that was seen only with SPECT. Compared with planar bone scintigraphy, SPECT allows more accurate anatomic localization of increased uptake. Tomographic reconstructions provide a more precise display of tracer accumulation, which helps differentiate structures that would otherwise overlap on planar images. Because the anatomic location of tracer uptake is an important clue to the precise diagnosis, the specificity of SPECT is better than that of planar imaging. In addition, data on SPECT, CT, and MR images are presented in a similar way, and anatomic correlation between these various imaging methods becomes possible.
In this article, we discuss and illustrate the use of bone scintigraphy and SPECT in the evaluation of lower back pain. In addition, we examine an interpretative approach based on patterns of tracer activity that can help differentiate various pathologic conditions and lead to a specific diagnosis.
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TECHNIQUE
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We routinely obtained planar and SPECT images with a standard gamma camera 3 hours after the administration of 740 MBq of technetium-99m methylene diphosphonate. Images were obtained with either a three-head Multispect-3 (Siemens Bodyscan, Hoffman Estates, Ill) or a one-head Sophy DSX (Sopha, Buc, France) camera. Both systems were equipped with low-energy collimators. Total body scanning was performed with the Siemens camera; the scanning speed for planar images was set at 15 cm/sec. For tomographic images, each detector was rotated through 360° according to a body-contoured orbit, and 96 20-second projections were acquired. Reconstructions were performed by means of filtered back projection with use of a Butterworth filter with a cutoff frequency adapted to the count density. Reconstructed and displayed pixel thickness was 3.56 mm. For the one-head camera, targeted planar images with a 40-cm field of view were obtained. Tomographic imaging was performed through 360° according to a body-contoured orbit, and 64 20-second projections were obtained. Reconstructions were performed by means of filtered back projection with use of a Hamming-Hann filter.
SPECT images were displayed with a linear gray scale as transverse, sagittal, and coronal sections. Transverse sections were utilized to obtain volume-rendered images. SPECT images such as those depicted in this article typically required 20–25 minutes to obtain.
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ANATOMIC CONSIDERATIONS
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Lesions centered in the vertebral body include metastatic disease, fracture of the vertebral body, infection, and degenerative disease. Lesions centered about the disk space are often related to spondylodiskitis or disk degeneration (Fig 1b).
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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).
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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).
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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).
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Lesions of the posterior arch (consisting of the pedicle, lamina, and facet joints) can usually be differentiated with use of sagittal reconstructions (Fig 1c). Lesions in the lamina are often caused by spondylolysis. Lesions that involve the facet joints are often due to osteoarthritis. On sagittal SPECT images, lesions that involve the lamina can be differentiated from those that involve the facet joints by noting that the lamina are located in the same horizontal plane as the vertebral body, whereas the facet joints are located in the same horizontal plane as the disk space. Lesions that involve the pedicles can be differentiated from lesions of both the lamina and the facet joints by noting that, on either sagittal or transverse SPECT images, pedicle lesions are adjacent to the vertebral body, whereas the other lesions are more posterior. Lesions that involve the transverse process often represent fractures.
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PATHOLOGIC CONDITIONS
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Vertebral Body and Disk Space
Spondylodiskitis.—In diskitis, tracer uptake is centered about the disk space and adjacent vertebral bodies and has a vertical orientation. Early diskitis typically shows increased tracer uptake on bone scintigrams despite normal findings on radiographs. The specificity for infection can be improved with use of three-phase bone scanning, Ga-67 scanning, Tc-99m–labeled leukocyte scanning, Tc-99m antigranulocyte antibodies scanning, or MR imaging. CT and MR imaging may be necessary to demonstrate paravertebral abscesses commonly associated with diskitis (13,14) (Figs 2, 3).
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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).
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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).
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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).
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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).
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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).
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Metastatic Disease.—Metastatic involvement of the vertebra may become apparent radiographically only with advanced disease. Involvement of the vertebral body becomes evident only after the lesion extends into the pedicle. Thus, destruction of the pedicle is often the first radiographic clue to metastatic involvement of the vertebra, even though it actually occurs late in the metastatic process (15). At present, the search for metastatic disease is one of the most common indications for bone scintigraphy. Bone scintigraphy is considered more sensitive than radiography in the detection of metastatic lesions, although it occasionally produces false-negative results. When multiple areas of increased tracer uptake are seen at planar imaging, SPECT usually adds little to the diagnostic value of bone scintigraphy. However, SPECT has potential value in the differential diagnosis of a solitary lesion. Even-Sapir et al (16) showed that, with solitary lesions, metastatic involvement should be suspected when the area of increased uptake extends from the vertebral body into the pedicle. Simultaneous involvement of the vertebral body and a portion of the posterior arch (but not of the pedicle) is most often caused by benign conditions. Delpassand et al (17) found that only 26% of lesions with involvement limited to the vertebral body were malignant (Figs 4, 5).
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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.
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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.
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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.
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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).
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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).
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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).
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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).
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Vertebral Body Fracture.—Compression fractures of the spine are the most common complication of osteoporosis in elderly people (18). In young people, fractures are more commonly related to acute trauma. On planar and SPECT images, fractures are seen as a linear, horizontally oriented area of increased uptake centered in the vertebral body (Fig 6). With healing, the increased uptake may gradually return to normal over a 6- to 9-month period (18). Vertebral fractures may also occur secondary to metastatic disease. Identification of pedicle involvement may be a clue to the correct diagnosis in such cases.
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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.
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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.
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Degenerative Disease.—In patients with degenerative disease of the spine (disk disease, spondylosis deformans), increased uptake may be seen in the vertebral body, is centered about the disk space, and may project beyond the surface of the vertebral body (9,10) (Fig 7).
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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.
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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.
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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.
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Posterior Arch
Spondylolysis.—In patients with spondylolysis, a defect occurs in the pars interarticularis. If the defect is bilateral, forward displacement of the vertebral body (spondylolisthesis) may occur. At radiography, spondylolysis may be demonstrated on oblique views, although CT is more sensitive for diagnosis. Conventional radiography and CT may also show osseous hypertrophy, which often accompanies these lesions. At scintigraphy, increased uptake is often present in the posterior arch (Fig 8). These lesions are some distance from the vertebral body and, on sagittal SPECT images, are in the same horizontal plane as the vertebral body. Scintigraphy may help differentiate long-standing asymptomatic spondylolysis from ongoing disease. Collier et al (19) concluded that if spondylolysis is the cause of lower back pain, defects are associated with increased tracer uptake, which is best appreciated on SPECT images. SPECT may also be used to identify abnormalities of the pars interarticularis in symptomatic persons with normal findings at radiography and CT. Such lesions may represent stress injuries that are detected with scintigraphy before they are seen at radiography (19–21).
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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).
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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).
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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).
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Pedicle Lesions.—Involvement of the pedicles is common in metastatic disease. However, lesions confined to the pedicle with no vertebral body involvement are seldom due to metastatic disease. Indeed, several studies have failed to demonstrate metastatic disease confined to the pedicle (16). In young adults, fractures or benign tumors (osteoid osteoma, osteoblastoma) may be encountered. About 10% of osteoid osteomas occur in the posterior elements of the spine. With osteoid osteomas, increased uptake may be evident on postinjection, blood-pool, and delayed images. CT imaging is the best method for confirming a diagnosis of osteoid osteoma by showing a nidus with reactive sclerosis (22,23) (Fig 9).
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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).
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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).
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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).
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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).
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Osteoarthritis of the Facet Joints.—Osteoarthritis of the facet joints is commonly seen on radiographs in both symptomatic and asymptomatic individuals. In some patients, lower back pain may be related to facet joint osteoarthritis. This syndrome is often referred to as painful facet syndrome. On SPECT images obtained in patients with chronic lower back pain, a considerable number of lesions are seen in the facet joints. Ryan et al (10) showed that these lesions corresponded to radiographically identifiable disease in only 4% of patients. Findings at SPECT may be used to select patients to be treated with local injections of corticosteroids and anesthetics. Using a positive response to such injections as an end point, Holder et al (24) showed that SPECT is useful in determining which patients are most likely to have a response to facet joint injections. On sagittal SPECT images, lesions that involve the facet joints are in the same horizontal plane as the disk space. In contrast, spondylolysis is seen in the same horizontal plane as the vertebral body (25) (Fig 10).
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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).
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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).
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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).
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Fracture of the Transverse Process.—Increased uptake in the transverse process is most often due to a fracture, although tumors may also occur in this location. Fractures of the transverse process may cause considerable pain and are occasionally missed on radiographs of the abdomen or lumbar spine unless spot radiographs are obtained (Figs 11, 12).
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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).
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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).
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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).
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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).
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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).
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CONCLUSIONS
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A variety of patterns of increased activity can be demonstrated on SPECT images obtained in patients with lower back pain. Areas of increased tracer uptake can be more accurately localized with SPECT than with planar imaging owing to increased spatial resolution. In addition, scintigraphy may be used to determine the precise cause of symptoms in patients with multiple abnormalities seen at other imaging studies. Lesions centered about the disk space and vertebral body include spondylodiskitis, metastatic disease, vertebral body fracture, and degenerative disease. Lesions of the posterior arch include spondylolysis, pedicle lesions, osteoarthritis of the facet joints, and fracture of the transverse process.
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Acknowledgments
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We thank Eddy Broodtaerts, RA, Camel Tebache, MD, and Freddy Machiels, MD.
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Footnotes
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See the commentary by Schauwecker
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Abbreviation: SPECT = single photon emission computed tomography
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Abstract
INTRODUCTION
