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(Radiographics. 1999;19:912-914.)
© RSNA, 1999

Invited Commentary

Invited Commentary and Author's Response

Donald S. Schauwecker, PhD, MD

Department of Radiology, Indiana University School of Medicine, Indianapolis, Indiana

In the past, it may have been acceptable to report that "there are several areas of focal increased uptake, which may represent degenerative changes, metastases, and so on." However, clinicians are no longer satisfied with such a loose interpretation. It is fortunate that De Maeseneer et al (1) and Gates (2,3) have shown how to increase the specificity of bone scintigraphy with the use of SPECT.

In their article, De Maeseneer et al chose many good examples to demonstrate that the location of the abnormality often helps identify the underlying pathologic condition. The referring clinician is much happier with a report such as, "At SPECT, the increased uptake extends from the body into the right pedicle of L-3 and therefore is most likely a metastasis." We have used a pattern approach similar to that outlined by Gates for more than 2 years, and its use has definitely improved our interpretations.

The use of SPECT and a pattern approach can increase the specificity of bone scintigraphy. Equally important, several authors have shown that SPECT increases the sensitivity of bone scintigraphy (4–6) (Figure). Therefore, SPECT appears to increase both the sensitivity and specificity of bone scintigraphy in the evaluation of the lower back. Yet, contrary to the experience of many clinicians, a large metanalysis could find only weak evidence to support the use of SPECT in the evaluation of lower back pain (7).



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  		Figure 1a. Lower back pain in a 61-year-old man. (a) Anteroposterior radiograph of the lumbar sacral spine is suspicious for bone loss in the right half of the L-3 vertebral body (arrow). (b) Posterior planar bone scintigram of the lumbar spine obtained 1 day later appears normal. (c, d) Coronal (c) and transverse (d) SPECT scintigrams show a photopenic defect in the right half of the L-3 body and the right pedicle. (e) Transverse CT scan obtained through L-3 4 days after b shows metastatic lung cancer in the spine.

 


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  		Figure 1b. Lower back pain in a 61-year-old man. (a) Anteroposterior radiograph of the lumbar sacral spine is suspicious for bone loss in the right half of the L-3 vertebral body (arrow). (b) Posterior planar bone scintigram of the lumbar spine obtained 1 day later appears normal. (c, d) Coronal (c) and transverse (d) SPECT scintigrams show a photopenic defect in the right half of the L-3 body and the right pedicle. (e) Transverse CT scan obtained through L-3 4 days after b shows metastatic lung cancer in the spine.

 


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  		Figure 1c. Lower back pain in a 61-year-old man. (a) Anteroposterior radiograph of the lumbar sacral spine is suspicious for bone loss in the right half of the L-3 vertebral body (arrow). (b) Posterior planar bone scintigram of the lumbar spine obtained 1 day later appears normal. (c, d) Coronal (c) and transverse (d) SPECT scintigrams show a photopenic defect in the right half of the L-3 body and the right pedicle. (e) Transverse CT scan obtained through L-3 4 days after b shows metastatic lung cancer in the spine.

 


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  		Figure 1d. Lower back pain in a 61-year-old man. (a) Anteroposterior radiograph of the lumbar sacral spine is suspicious for bone loss in the right half of the L-3 vertebral body (arrow). (b) Posterior planar bone scintigram of the lumbar spine obtained 1 day later appears normal. (c, d) Coronal (c) and transverse (d) SPECT scintigrams show a photopenic defect in the right half of the L-3 body and the right pedicle. (e) Transverse CT scan obtained through L-3 4 days after b shows metastatic lung cancer in the spine.

 


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  		Figure 1e. Lower back pain in a 61-year-old man. (a) Anteroposterior radiograph of the lumbar sacral spine is suspicious for bone loss in the right half of the L-3 vertebral body (arrow). (b) Posterior planar bone scintigram of the lumbar spine obtained 1 day later appears normal. (c, d) Coronal (c) and transverse (d) SPECT scintigrams show a photopenic defect in the right half of the L-3 body and the right pedicle. (e) Transverse CT scan obtained through L-3 4 days after b shows metastatic lung cancer in the spine.

 
When should SPECT be used for the evaluation of the symptomatic lower back? Obviously, it is desirable to perform SPECT in all cases, but this may not be possible because SPECT is time consuming and requires specialized equipment. Each institution will need to make an informed decision on the basis of their equipment, patient population, patient mix, and so on. For us, the first priority is the symptomatic patient with normal findings at planar scintigraphy of the lower back. The second priority is the patient with a single lesion of uncertain cause. Rarely do we perform SPECT in patients in whom planar bone scintigraphy shows a clear pathogenesis such as multiple metastases or obvious degenerative disease.

In conclusion, multiple authors have shown that SPECT increases sensitivity by showing lesions that would otherwise be missed (4-6). De Maeseneer et al (1) and Gates (2,3) have produced atlases that demonstrate that lesion location is strongly correlated with pathogenesis, thereby increasing specificity. Taken together, these studies indicate that SPECT increases the accuracy of bone scintigraphy in the lower back. It is unfortunate that, at present, rigorous scientific proof for these conclusions seems to be lacking (7).

References

  1. De Maeseneer M, Lenchik L, Everaert H, et al. Evaluation of lower back pain with bone scintigraphy and SPECT. RadioGraphics 1999; 19:901-912.[Abstract/Free Full Text]
  2. Gates GF. Bone SPECT imaging of the painful back. Clin Nucl Med 1996; 21:560-571.[Medline]
  3. Gates GF. SPECT bone scanning of the spine. Semin Nucl Med 1998; 28:78-94.[Medline]
  4. Gates GF. SPECT imaging of the lumbosacral spine and pelvis. Clin Nucl Med 1988; 13:907-914.[Medline]
  5. Ryan PJ, Evans PA, Gibson T, Fogelman I. Chronic low back pain: comparison of bone SPECT with radiography and CT. Radiology 1992; 182:849-854.[Abstract/Free Full Text]
  6. Han LJ, Au-Yong TK, Tong WC, Chu KS, Szeto LT, Wong CP. Comparison of bone single-photon emission tomography and planar imaging in the detection of vertebral metastases in patients with back pain. Eur J Nucl Med 1998; 25:635-638.[Medline]
  7. Littenberg B, Siegel A, Tosteson AN, Mead T. Clinical efficacy of SPECT bone imaging for low back pain. J Nucl Med 1995; 36:1707-1713.[Abstract/Free Full Text]

Author's Response

Michel De Maeseneer, MD

Department of Radiology, Vrije Universiteit Brussel, Brussels, Belgium

We have read with interest the comments of Dr Schauwecker with regard to our article (1). The use of SPECT allows for more accurate anatomic localization of the area of increased uptake compared with planar imaging. As Dr Schauwecker points out, the location of the abnormality often helps identify the pathologic condition; consequently, the specificity of SPECT is increased in comparison with planar imaging. Even if a specific diagnosis cannot be suggested in all patients, the precise location of tracer uptake may be determined on SPECT images and the involved region studied with other imaging methods such as CT. In addition, several authors have shown that SPECT improves the sensitivity of an examination compared with planar imaging (2–4).

We have used a pattern approach for several years and have found it to be extremely helpful in our clinical work. However, we thank Dr Schauwecker for indicating that, contrary to the experience of many clinicians, no large studies in the literature support the use of SPECT in the evaluation of lower back pain (5).

We do not entirely agree with Dr Schauwecker as to the precise indications for SPECT, although we acknowledge that this is an area of controversy. We rarely perform bone scintigraphy and SPECT in patients with neurologic symptoms, for whom we believe MR imaging is the preferred examination. In patients with a suspected osseous lesion, bone scintigraphy (including SPECT) may be considered. Because SPECT is time consuming, it may indeed be difficult to perform this study in all patients referred for bone scintigraphy. Even so, SPECT has been shown to be more sensitive than planar imaging, so that normal findings at planar bone scintigraphy do not exclude the possibility of an osseous lesion. We agree with Dr Schauwecker that the use of SPECT should be considered when a solitary lesion is seen on planar images, although in some conditions such as vertebral body fracture or spondylodiskitis the pattern of tracer uptake may be evident on planar bone scintigrams.

We also thank Dr Schauwecker for pointing out that the value of SPECT in the evaluation of lower back pain remains to be scientifically assessed (5). In the meantime, we have provided a guide to the interpretation of SPECT studies of the lower back based on our experience and the experience of other authors (1,6,7).

References

  1. De Maeseneer M, Lenchik L, Everaert H, et al. Evaluation of lower back pain with bone scintigraphy and SPECT. RadioGraphics 1999; 19:901-912.
  2. Gates GF. SPECT imaging of the lumbosacral spine and pelvis. Clin Nucl Med 1988; 13:907-914.
  3. Ryan PJ, Evans PA, Gibson T, Fogelman I. Chronic low back pain: comparison of bone SPECT with radiography and CT. Radiology 1992; 182:849-854.
  4. Han LJ, Au-Yong TK, Tong WC, Chu KS, Szeto LT, Wong CP. Comparison of bone single-photon emission tomography and planar imaging in the detection of vertebral metastases in patients with low back pain. Eur J Nucl Med 1998; 25:635-638.
  5. Littenberg B, Siegel A, Tosteson AN, Mead T. Clinical efficacy of SPECT bone imaging for low back pain. J Nucl Med 1995; 36:1707-1713.
  6. Gates GF. Bone SPECT imaging of the painful back. Clin Nucl Med 1998; 21:560-571.
  7. Gates GF. SPECT bone scanning of the spine. Semin Nucl Med 1998; 28:78-94.

Related Article

Evaluation of Lower Back Pain with Bone Scintigraphy and SPECT
Michel De Maeseneer, Leon Lenchik, Hendrik Everaert, Stefaan Marcelis, Axel Bossuyt, Michel Osteaux, and Paul Beeckman
RadioGraphics 1999 19: 901-912. [Abstract] [Full Text] [PDF]




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