Evaluation of lower back pain with bone scintigraphy and SPECT

Incidentally Found Soft Tissue 99mTc-DPD Uptake on Bone Scintigraphy Was Useful in an Early Diagnosis of Peripheral Arterial Disease

Peripheral arterial disease (PAD) is a critical disease which is presented by occlusion of peripheral arteries, while it could result in amputation of the involved limbs if it remained untreated before it would progress into tissue necrosis. It is usually diagnosed by CT angiography or conventional angiography, but its early diagnosis is challenging because its symptoms may be absent or like those of other diseases. In this case report, the authors showed that an atypical soft tissue uptake of lower limb incidentally found on a bone scintigraphy resulted in early diagnosis and successful treatment outcome of PAD.

Detecting lumbar lesions in 99m Tc-MDP SPECT by deep learning: Comparison with physicians

PURPOSE

^99m Tc-MDP single-photon emission computed tomography (SPECT) is an established tool for diagnosing lumbar stress, a common cause of low back pain (LBP) in pediatric patients. However, detection of small stress lesions is complicated by the low quality of SPECT, leading to significant interreader variability. The study objectives were to develop an approach based on a deep convolutional neural network (CNN) for detecting lumbar lesions in ^99m Tc-MDP scans and to compare its performance to that of physicians in a localization receiver operating characteristic (LROC) study.

METHODS

Sixty-five lesion-absent (LA) ^99m Tc-MDP studies performed in pediatric patients for evaluating LBP were retrospectively identified. Projections for an artificial focal lesion were acquired separately by imaging a ^99m Tc capillary tube at multiple distances from the collimator. An approach was developed to automatically insert lesions into LA scans to obtain realistic lesion-present (LP) ^99m Tc-MDP images while ensuring knowledge of the ground truth. A deep CNN was trained using 2.5D views extracted in LP and LA ^99m Tc-MDP image sets. During testing, the CNN was applied in a sliding-window fashion to compute a 3D "heatmap" reporting the probability of a lesion being present at each lumbar location. The algorithm was evaluated using cross-validation on a ^99m Tc-MDP test dataset which was also studied by five physicians in a LROC study. LP images in the test set were obtained by incorporating lesions at sites selected by a physician based on clinical likelihood of injury in this population.

RESULTS

The deep learning (DL) system slightly outperformed human observers, achieving an area under the LROC curve (AUC_LROC ) of 0.830 (95% confidence interval [CI]: [0.758, 0.924]) compared with 0.785 (95% CI: [0.738, 0.830]) for physicians. The AUC_LROC for the DL system was higher than that of two readers (difference in AUC_LROC [ΔAUC_LROC ] = 0.049 and 0.053) who participated to the study and slightly lower than that of two other readers (ΔAUC_LROC  = -0.006 and -0.012). Another reader outperformed DL by a more substantial margin (ΔAUC_LROC  = -0.053).

CONCLUSION

The DL system provides comparable or superior performance than physicians in localizing small ^99m Tc-MDP positive lumbar lesions.

Osteoartrose costovertebral: Diagnóstico diferencial raro de dorsalgia no paciente jovem. Relato de caso

The differential diagnosis of dorsal thoracic pain can be a challange due to the proximity of the dorsal column to vital organs as well as to its unique anatomy, innervation, and rib joint. The patterns of referred visceral pain require, in most cases, extensive complementary diagnostic tests in order to exclude severe conditions. Referred pain patterns often result in numerous and expensive visceral workups in order to exclude serious conditions, and costovertebral joint osteoarthritis is usually only considered when the origin of the pain remains unexplained. The authors present the case of a 40-year-old man with disabling dorsal pain due to isolated costovertebral osteoarthrosis. The symptomatology was controlled after injection of methylprednisolone guided by computed tomography. This clinical case aims to describe the clinical presentation of a rare entity that should be considered in the differential diagnosis of back pain.

Novel Musculoskeletal and Orthopedic Applications of 18F-Sodium Fluoride PET

PET imaging with ¹⁸F-sodium fluoride (NaF), combined with computed tomography or magnetic resonance, is a sensitive method of assessing bone turnover. Although NaF-PET is gaining popularity in detecting prostate cancer metastases to bone marrow, osseous changes represent secondary effects of cancer cell growth. PET tracers more appropriate for assessing prostate cancer metastases directly portray malignant activity and include ¹⁸F-fluciclovine and prostatic specific membrane antigen ligands. Recent studies investigating NaF-PET suggest utility in the assessment of benign musculoskeletal disorders. Emerging applications in assessing traumatic injuries, joint disease, back pain, orthopedic complications, and metabolic bone disease are discussed.

Does bone scintigraphy show Modic changes associated with increased bone turnover?

Purpose

Our purpose was to evaluate whether Modic changes (MC) revealed in lumbar MRI are associated with increased tracer uptake shown in bone scintigraphy. To our knowledge, this has not previously been studied.

Methods

We included patients with MC shown in lumbar MRI and bone scintigraphy performed within six months before or after MRI. Exclusion criteria included metastasis and other specific lesions in the area of interest such as discitis, tumors or fractures. We compared the level and type of MC to the degree of tracer uptake shown in bone scintigraphy. Tracer uptake was assessed both visually and quantitatively. We calculated the lesion-to-normal-bone ratios between the MC area with increased tracer uptake and the vertebra with normal tracer uptake. We used linear mixed models in statistical analyses.

Results

Our study sample consisted of 93 patients (aged 37-86) with 299 MC (28 Type 1 (M1), 50 mixed Type 1/2 (M1/2), 3 mixed Type 1/3 (M1/3), 211 Type 2 (M2), 6 mixed Type 2/3 (M2/3), and 1 Type 3 (M3)). Of all the MC, 26 (93 %) M1, 34 (64 %) in the combined M1/2 and M1/3 group, and 11 (5 %) in the combined M2, M2/3 and M3 group showed increased tracer uptake. The mean lesion-to-normal-bone ratio was higher for lesions with a Type 1 component (M1, M1/2 and M1/3) than for other types, at 1.55 (SD 0.16) for M1; 1.44 (SD 0.21) for combined M1/2 and M1/3; and 1.28 (SD 0.11) for combined M2, M2/3 and M3; p = 0.001).

Conclusion

In most cases, MC with a Type 1 component showed increased tracer uptake in bone scintigraphy. This indicates that bone turnover is accelerated in the M1 area.

Bone scintigraphy in patients with pain

Nuclear medicine imaging is widely used in pain medicine. Low back pain is commonly encountered by physicians, with its prevalence from 49% to 70%. Computed tomography (CT) or magnetic resonance imaging (MRI) are usually used to evaluate the cause of low back pain, however, these findings from these scans could also be observed in asymptomatic patients. Bone scintigraphy has an additional value in patients with low back pain. Complex regional pain syndrome (CRPS) is defined as a painful disorder of the extremities, which is characterized by sensory, autonomic, vasomotor, and trophic disturbances. To assist the diagnosis of CRPS, three-phase bone scintigraphy is thought to be superior compared to other modalities, and could be used to rule out CRPS due to its high specificity. Studies regarding the effect of bone scintigraphy in patients with extremity pain have not been widely conducted. Ultrasound, CT and MRI are widely used imaging modalities for evaluating extremity pain. However, SPECT/CT has an additional role in assessing pain in the extremities.

Increased 99mTc MDP activity in the costovertebral and costotransverse joints on SPECT-CT: is it predictive of associated back pain or response to percutaneous treatment?

PURPOSE

Pain related to costovertebral and costotransverse joints is likely an underrecognized and potentially important cause of thoracic back pain. On combined single-photon emission computed tomography and computed tomography (SPECT-CT), increased technetium-99m methylene diphosphonate (99mTc MDP) activity at these articulations is not uncommon. We evaluated whether this activity corresponds with thoracic back pain and whether it predicts response to percutaneous injection.

METHODS

All 99mTc MDP SPECT-CT spine examinations completed at our institution from March 2008 to March 2014 were retrospectively reviewed to identify those with increased 99mTc MDP activity in the costovertebral or costotransverse joints. The presence of corresponding thoracic back pain, percutaneous injection performed at the relevant joint(s), and response to injection were recorded.

RESULTS

A total of 724 99mTc MDP SPECT-CT examinations were identified. Increased 99mTc MDP activity at costovertebral or costotransverse joints was reported in the examinations of 55 patients (8%). Of these, 25 (45%) had corresponding thoracic back pain, and nine of 25 patients (36%) underwent percutaneous injection of the joint(s) with increased activity. At clinical follow-up two days to 12 weeks after injection, one patient (11%) had complete pain relief, two (22%) had partial pain relief, and six (67%) had no pain relief.

CONCLUSION

The findings suggest that increased activity in costovertebral and costotransverse joints on 99mTc MDP SPECT-CT is only variably associated with the presence and location of thoracic back pain; it does not predict pain response to percutaneous injection.

Utility of single photon emission computed tomography/computed tomography imaging in evaluation of chronic low back pain

Introduction:

Abnormal morphologic findings in imaging were thought to explain the etiology of low back pain (LBP). However, it is now known that variety of morphologic abnormalities is noted even in asymptomatic individuals. Single photon emission computed tomography/computed tomography (SPECT/CT) could be used to differentiate incidental findings from clinically significant findings.

Objective:

This study was performed to define the SPECT/CT patterns in patients with LBP and to correlate these with clinical and magnetic resonance imaging (MRI) findings.

Materials and Methods:

Thirty adult patients with LBP of duration 3 months or more were prospectively evaluated in this study. Patients with known or suspected malignancy, trauma or infectious processes were excluded. A detailed history of sensory and motor symptoms and neurologic examination was performed. All the patients were subjected to MRI and bone scintigraphy with hybrid SPECT/CT of the lumbo-sacral spine within 1 month of each other. The patients were classified into those with and without neurologic symptoms, activity limitation. The findings of clinical examination and imaging were compared. MRI and SPECT/CT findings were also compared.

Results:

Thirty patients (18 men and 12 women; mean age 38 years; range 17-64 years) were eligible for the study. Clinically, 14 of 30 (46%) had neurologic signs and or symptoms. Six of the 30 patients (20%) had positive straight leg raising test (SLRT). Twenty-two of the 30 patients (73%) had SPECT abnormality. Most frequent SPECT/CT abnormality was tracer uptake in the anterior part of vertebral body with osteophytes/sclerotic changes. Significant positive agreement was noted between this finding and MRI evidence of degenerative disc disease. Only 13% of patients had more than one abnormality in SPECT. All 30 patients had MRI abnormalities. The most frequent abnormality was degenerative disc disease and facet joint arthropathy. MRI showed single intervertebral disc abnormality in 36% of the patients and more than one intervertebral disc abnormality in remaining 64% patients. Fifteen of the 30 patients had facet joint arthropathy. 60% of these patients had involvement of more than one level facet joints while 38% had associated inter vertebral disc disease. 83% of the patients with positive SLRT had SPECT and MRI abnormalities. 100% of patients with neurologic symptoms had SPECT and MRI abnormalities.

Conclusion:

Addition of hybrid SPECT/CT data will help differentiate incidental from significant MRI abnormalities as all patients with LBP have MRI abnormalities and most have MRI abnormalities at multiple sites. Tracer uptake in the anterior part of the vertebral body represents degenerative disc disease. MRI is sensitive and SPECT/CT is specific for facet joint arthropathy. Both investigations are best used complementary to each other.

Management of metastatic sacral tumours

PURPOSE

Metastatic involvement of the sacrum is rare and there is a paucity of studies which deal with the management of these tumours since most papers refer to primary sacral tumours. This study aims to review the available literature in the management of sacral metastatic tumours as reflected in the current literature.

METHODS

A systematic review of the English language literature was undertaken for relevant articles published over the last 11 years (1999-2010). The PubMed electronic database and reference lists of key articles were searched to identify relevant studies using the terms "sacral metastases" and "metastatic sacral tumours". Studies involving primary sacral tumours only were excluded. For the assessment of the level of evidence quality, the CEBM (Oxford Centre of Evidence Based Medicine) grading system was utilised.

RESULTS

The initial search revealed 479 articles. After screening, 16 articles identified meeting our inclusion criteria [1 prospective cohort study on radiosurgery (level II); 2 case series (level III); 4 retrospective case series (level IV) and 9 case reports (level IV)].

CONCLUSION

The mainstay of management for sacral metastatic tumours is palliation. Preoperative angioembolisation is shown to be of value in cases of highly vascularised tumours. Radiotherapy is used as the primary treatment in cases of inoperable tumours without spinal instability where pain relief and neurological improvement are attainable. Minimal invasive procedures such as sacroplasties were shown to offer immediate pain relief and improvement with ambulation, whereas more aggressive surgery, involving decompression and sacral reconstruction, is utilised mainly for the treatment of local advanced tumours which compromise the stability of the spine or threaten neurological status. Adjuvant cryosurgery and radiosurgery have demonstrated promising results (if no neurological compromise or instability) with local disease control.

The assessment of bee venom responses in an experimental model of mono-arthritis using Tc-99m DPD bone scintigraphy

OBJECTIVES

Several recent studies have shown that bee venom (BV) has an anti-nociceptive and anti-inflammatory effect on arthritis. However, objective methods for evaluation of the therapeutic effect of BV is insufficient in animal studies and clinical trials. Our purpose was to determine the usefulness of bone scintigraphy using Tc-99m DPD (3,3-diphosphono-1,2-propan-dicarbonacid) about effects of BV applied to carrageenan-induced mono-arthritis (CIA) model.

METHODS

Mono-arthritis was induced by an intra-articular injection of carrageenan in Sprague-Dawley rats. Administration of BV (0.8 mg/kg) was performed at 30 min before and at 4 h after the induction of mono-arthritis. We assigned rats to BV-before, BV-after, control-before and control-after groups and compared the results of each group by the weight-loading test and bone scintigraphy. The rats received an intravenous injection of 37 MBq of Tc-99m DPD by the tail vein and then scanning was performed at 4 and 24 h after the injection. Visual assessment and quantitative analysis were performed for both knees.

RESULTS

The BV-before and BV-after groups were more improved than the control groups on the weight load test (p < 0.05). Bone scintigraphy showed lower activity in the BV-before group than in the control-before group (p < 0.05) on the 4 h imaging. However, a significant difference in the BV-before and BV-after groups was not observed on the 24 h imaging.

CONCLUSIONS

BV had therapeutic effects by anti-nociceptive and anti-inflammatory activity in the CIA and bone scintigraphy performed on 4 h imaging provided visual and quantitative information for the assessment of the therapeutic response to BV as an objective method in mono-arthritis model.

Transitional lumbosacral vertebrae and low back pain: diagnostic pitfalls and management of Bertolotti's syndrome

OBJECTIVE

Bertolotti's syndrome is a spine disorder characterized by the occurrence of a congenital lumbar transverse mega-apophysis in a transitional vertebral body that usually articulates with the sacrum or the iliac bone. It has been considered a possible cause of low back pain.

METHOD

We analyzed the cases of Bertolotti's syndrome that failed clinical treatment and reviewed the literature concerning this subject.

RESULTS

Five patients in our series had severe low back pain due to the neo-articulation and two of them were successfully submitted to surgical resection of the transverse mega-apophysis. Taking into account the clinical and surgical experience acquired with these cases, we propose a diagnostic-therapeutic algorithm.

CONCLUSION

There is still no consensus about the most appropriate therapy for Bertolotti's syndrome. In patients in whom the mega-apophysis itself may be the source of back pain, surgical resection may be a safe and effective procedure.

The value of SPECT in the detection of stress injury to the pars interarticularis in patients with low back pain

The medical cost associated with back pain in the United States is considerable and growing. Although the differential diagnosis of back pain is broad, epidemiological studies suggest a correlation between adult and adolescent complaints. Injury of the pars interarticularis is one of the most common identifiable causes of ongoing low back pain in adolescent athletes. It constitutes a spectrum of disease ranging from bone stress to spondylolysis and spondylolisthesis. Bone stress may be the earliest sign of disease. Repetitive bone stress causes bone remodeling and may result in spondylolysis, a non-displaced fracture of the pars interarticularis. A fracture of the pars interarticularis may ultimately become unstable leading to spondylolisthesis. Results in the literature support the use of bone scintigraphy to diagnose bone stress in patients with suspected spondylolysis. Single photon emission computed tomography (SPECT) provides more contrast than planar bone scintigraphy, increases the sensitivity and improves anatomic localization of skeletal lesions without exposing the patient to additional radiation. It also provides an opportunity for better correlation with other imaging modalities, when necessary. As such, the addition of SPECT to standard planar bone scintigraphy can result in a more accurate diagnosis and a better chance for efficient patient care. It is our expectation that by improving our ability to correctly diagnose bone stress in patients with suspected injury of the posterior elements, the long-term cost of managing this condition will be lowered.

CT arthrography, MR arthrography, PET, and scintigraphy in osteoarthritis

CT arthrography and MR arthrography are accurate methods for the study of surface cartilage lesions and cartilage loss. They also provide information on subchondral bone and marrow changes, and ligaments and meniscal lesions that can be associated with osteoarthritis. Nuclear medicine also offers new insights in the assessment of the disease. This article discusses the strengths and limitations of CT arthrography and MR arthrography. It also highlights nuclear medicine methods that may be relevant to the study of osteoarthritis in research and clinical practice.

Diagnosis and management of sacral tumors

Sacral tumors pose significant challenges to the managing physician from diagnostic and therapeutic perspectives. Although these tumors are often diagnosed at an advanced stage, patients may benefit from good clinical outcomes if an aggressive multidisciplinary approach is used. In this review, the epidemiology, clinical presentation, imaging characteristics, treatment options, and published outcomes are discussed. Special attention is given to the specific anatomical constraints that make tumors in this region of the spine more difficult to effectively manage than those in the mobile portions of the spine.

Added Value of SPECT/CT Fusion in Assessing Suspected Bone Metastasis: Comparison with Scintigraphy Alone and Nonfused Scintigraphy and CT

PURPOSE

To evaluate retrospectively if there is additional diagnostic value of fused single photon emission computed tomographic (SPECT) and computed tomographic (CT) images in assessing possible bone metastases.

MATERIALS AND METHODS

Institutional review board approval was obtained, and each patient provided written informed consent. Bone scintigraphy--including planar and SPECT imaging-and CT were performed with a combined SPECT/CT system in 45 oncologic patients (24 men, 21 women; mean age, 64.7 years +/- 8.7), with a total of 42 metastatic bone foci and 40 benign foci. The reference standard was follow-up radiologic imaging. Two independent readers first analyzed only bone scintigraphic images and next analyzed two separate sets of bone scintigraphic and CT images. They then analyzed bone scintigraphic, CT, and fused images and focused on the additional value of fused images. Diagnostic confidence for each lesion was scored. The three analyses were performed 7 days apart, and the images were presented in random order at each session. The value of additional fused images was assessed by using receiver operating characteristic analysis.

RESULTS

After review of fused images to classify indeterminate lesions, reviewer 1 became more confident in diagnosis of the 15 benign lesions and two metastases, and reviewer 2 became more confident in diagnosis of the seven benign lesions and one metastasis. The area under the receiver operating characteristic curve for reviewer 1 was 0.589 for scintigraphic images, 0.831 for separate data sets of scintigraphic and CT images, and 0.947 for fused images. The corresponding areas under the receiver operating characteristic curve for reviewer 2 were 0.771, 0.885, and 0.968, respectively.

CONCLUSION

Results demonstrate the increased diagnostic confidence obtained with fused SPECT/CT images compared with separate sets of scintigraphic and CT images in differentiating malignant from benign bone lesions.

Diffuse vertebral body edema due to calcified intraspongious disk herniation

We describe the case of a patient with a recent history of high back pain, with magnetic resonance imaging (MRI) of the thoracic spine showing intervertebral disk herniation into the spongious bone of the vertebral body of T9 that might have caused diffuse, low signal intensity on fluid-attenuated inversion recovery T1-weighted (FLAIR-T1W) images, high signal intensity magnetic resonance (MR) on T2-weighted (T2W) images and T2-weighted fat-suppressed images (T2W-FSIs) and marked enhancement on the vertebral body of T9 with gadolinium on T1-weighted fat-suppressed images (T1W-FSIs) images. Those findings suggested diffuse edema and might be indistinguishable from tumoral or inflammatory diseases, but the plain films and the reformatted sagittal computed tomography scans of the thoracic spine were helpful to show a calcified part of the intervertebral disk migrating into the vertebral body of T9. The patient made full recovery from the symptoms after conservative treatment and at the follow-up MRI showed normalization of the bone marrow signal intensity of the vertebral body of T9.

Fractured osteophyte demonstrated on SPECT and computed tomography

ABSTRACT We present an interesting case of a fractured osteophyte causing back pain that was demonstrated both on bone single photon emission computed tomography (SPECT) and computed tomography (CT). The magnetic resonance images, thoracic anterior spine plain radiograph, whole-body bone scan passes, and thoracic spot view were not impressive. Bone SPECT was the impetus for getting the CT scan. The CT scan not only demonstrated the osteophyte but a pseudarthrosis that was probably causing the pain. If it were not for the positive SPECT bone scan, the CT scan would not have been ordered after unimpressive magnetic resonance imaging.

Imaging modalities for identifying the origin of regional musculoskeletal pain

Regional musculoskeletal pain is one of the most common complaints in daily rheumatological practice. Conventional radiology remains the cornerstone of diagnostic imaging in these patients despite the advent of new, fascinating imaging techniques. Ultrasonography may have a relevant impact on final diagnosis or therapeutic choices. It is highly sensitive to the identification of fine, soft-tissue changes and it should be considered as an integral part of the clinical examination in most patients. Scintigraphy is indicated when multifocal processes have to be excluded and when high sensitivity is required. Computed tomography is an excellent tool for the assessment of osseous based abnormalities. Magnetic resonance has several characteristics of the ideal diagnostic tool. However, its appropriateness in the evaluation of many regional musculoskeletal conditions is a matter for discussion. An appropriate diagnostic programme for patients with regional musculoskeletal pain has to be focused on the strengths and weaknesses of various imaging techniques.

Management of common stress fractures. When to apply conservative therapy, when to take an aggressive approach

Stress fractures are an increasingly common injury in primary care patient populations. Early diagnosis and prompt conservative therapy are effective for most of these injuries. Special attention to clues from history taking and physical examination in an at-risk patient population can lead physicians to the correct diagnosis. Most stress fractures resolve with rest and progressive reintroduction of stressors, but certain injuries, such as stress fractures of the femoral neck and fifth metatarsal, have a high risk of complications and require aggressive therapy.