SPECT/CT Imaging of the Lumbar Spine
in Chronic Low Back Pain
SOURCE: Chiropractic & Manual Therapies 2011 (Jan 11) ~ FULL TEXT
Michael H. Carstensen, Mashael Al-Harbi,
Jean-Luc Urbain, Tarik-Zine Belhocine
Department of Medical Imaging, St Joseph´s Hospital,
268 Grosvenor Street, N6A 4V2, London, Ontario, Canada
Mechanical low back pain is a common indication for Nuclear Medicine imaging. Whole-body bone scan is a very sensitive but poorly specific study for the detection of metabolic bone abnormalities. The accurate localisation of metabolically active bone disease is often difficult in 2D imaging but single photon emission computed tomography/computed tomography (SPECT/CT) allows accurate diagnosis and anatomic localisation of osteoblastic and osteolytic lesions in 3D imaging. We present a clinical case of a patient referred for evaluation of chronic lower back pain with no history of trauma, spinal surgery, or cancer. Planar whole-body scan showed heterogeneous tracer uptake in the lumbar spine with intense localization to the right lateral aspect of L3. Integrated SPECT/CT of the lumbar spine detected active bone metabolism in the right L3/L4 facet joint in the presence of minimal signs of degenerative osteoarthrosis on CT images, while a segment demonstrating more gross degenerative changes was quiescent with only mild tracer uptake. The usefulness of integrated SPECT/CT for anatomical and functional assessment of back pain opens promising opportunities both for multi-disciplinary clinical assessment and treatment for manual therapists and for research into the effectiveness of manual therapies.
The concept of lumbar facet joints causing or contributing to mechanical low back pain syndromes has been debated in the health care literature for decades . Practitioners of the various manual therapies commonly treat patients presenting with low back pain but are faced with the diagnostic challenge of trying to identify a tissue source of low back pain. While this complaint may be the result of any of a number of pathologies, the vast majority of low back pain falls under the diagnostic umbrella of ‘‘ mechanical low back pain ’’ . We present here the case of a patient with radiological signs of marked lumbosacral junction facet joint osteoarthrosis and clinical symptoms supportive of pathology in this region but with SPECT/CT findings suggestive of an active bony lesion at a more remote spinal segment.
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The patient in question was a 45-year-old Hispanic female who had lived in Canada for the previous 11 years. She reported a long history of manual labour and subsisted on similar occupations since arriving in Canada. At the time of her presentation, her occupation required prolonged periods of standing. The patient’s chief complaint was chronic low back pain. There was no antecedent trauma, bone surgery, or history of cancer. The onset of low back pain was described as insidious, with constant achy pain of at least two years duration which was progressively worsening. The pain remained localised to the central lower back in the area of the lumbosacral junction. The pain was rated at 3/10 (verbal scoring) at its best and 8/10 (verbal scoring) at its worst. An increase in pain was associated with an increased level of physical activity during the day, with the pain typically worse in the evening. During periods of increased pain, there were intermittent incidences of pain radiating to the right-sided posterior thigh and leg with “pins and needles” in the lateral toes of the right foot. Treatment to date had consisted of non-steroidal anti-inflammatory medication, which she felt had been of limited benefit. There had been no use of acupuncture, massage therapy, therapeutic exercise, or any manual therapies for this condition. The patient was referred to the department of Medical Imaging for evaluation of chronic lower back pain. The patient reported that no spinal imaging had been performed in investigation of these complaints. This was confirmed by a review of the patient’s records.
Imaging specialists typically do not examine patients who are referred into an imaging department for investigation. As such, no physical examination was performed in this case. Permission was granted after the images were interpreted only to interview the patient for this case report.
A three-phase bone scan was performed with 99mTc(Technetium)-MDP (methylene diphosphonate) including blood flow and blood pool imaging followed by a delayed whole-body scan. SPECT/CT imaging centered over the lumbar spine was subsequently performed on a Symbia T6 (Siemens), a dual-head gamma-camera incorporating a low-dose 6-slice non-contrast enhanced CT (12 mAs, 130 kVp, Effective Dose < 4 mSv). The CT scan duration was less than 1 min. Overall, the SPECT/CT scan duration was about 20 min. The SPECT/CT fused images were displayed on the e-soft 2007 workstation (Siemens) in axial, sagittal, and coronal slices.