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Preoperative SPECT Imaging As a Tool for Surgical Planning in Patients with Axial Neck and Back Pain

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Preoperative SPECT Imaging As a Tool for Surgical Planning in Patients with Axial Neck and Back Pain NEUROSURGICAL FOCUS Neurosurg Focus 47 (6):E19, 2019 Preoperative SPECT imaging as a tool for surgical planning in patients with axial neck and back pain G. Damian Brusko, BS,1 Roberto J. Perez-Roman, MD,1 Harold Tapamo, BS,1 S. Shelby Burks, MD,1 Aldo N. Serafini, MD,2 and Michael Y. Wang, MD1 1Department of Neurological Surgery and 2Division of Nuclear Medicine, Department of Radiology, University of Miami Miller School of Medicine, Miami, Florida OBJECTIVE Hybrid SPECT with CT imaging has been used to help elucidate pain generators in patients with axial neck and back pain, identifying potential sites for treatment. Few studies have examined its role in spine surgery and most literature focuses on its use postoperatively. The authors describe the largest series to date of patients with symp- tomatic spondylosis who underwent preoperative SPECT imaging for surgical planning. METHODS A retrospective medical and imaging record review was conducted to identify patients who underwent SPECT or SPECT/CT studies between January 2014 and May 2018. Patients who underwent spine surgical intervention for spondylosis with primary symptoms of axial neck or back pain and who had evidence of hypermetabolic foci on spinal SPECT imaging were included. Only those patients who subsequently underwent surgery on a spinal level associated with increased radiotracer uptake were included in the analysis. Patient baseline and demographic information, and data pertaining to SPECT imaging, surgical planning, and postoperative care were collected and analyzed. RESULTS A total of 23 patients with an average age at surgery of 60.0 ± 11.0 years were included. Fifteen patients (65.2%) were male. A total of 53 spinal levels were treated, with an average of 2.30 levels treated per patient. All patients underwent fusion surgery, either lumbar (n = 14), with interbody fusion most commonly used (64.2%); or cervical (n = 9), with anterior cervical discectomy and fusion (66.6%) being the most common. The average length of hospital stay was 3.45 ± 2.32 days. One patient developed a wound infection postoperatively, requiring readmission. At the 3-month follow-up, 18 patients (78.3%) reported clinical improvement in pain. Eleven patients (47.8%) reported complete symp- tom resolution at the 6-month follow-up. At 1 year postoperatively, 19 patients (82.6%) reported significant relief of their symptoms following surgery. CONCLUSIONS This is the largest series to date describing patients with axial neck and back pain who underwent pre- operative SPECT imaging and subsequent surgical intervention on the affected spinal levels. The results demonstrate that SPECT imaging may be a useful adjunct to guide surgical planning, resulting in substantial clinical improvement following surgery. https://thejns.org/doi/abs/10.3171/2019.9.FOCUS19648 KEYWORDS axial pain; imaging; preoperative planning; single-photon emission computed tomography; SPECT; spine surgery IGH-RESOLUTION SPECT or hybrid SPECT/CT im- lowing spine surgery when conventional imaging modali- aging has been increasingly used as a spinal im- ties such as CT or MRI were inconclusive.2,3 However, the aging modality. When other imaging studies ap- utility of postoperative SPECT imaging, particularly in the Hpear inconclusive, SPECT can be used to highlight sites early postoperative period, is limited because increased of mechanical stress and degeneration, especially when osteoblastic activity related to bony fusion results in a high combined with CT.9 However, use of SPECT imaging in degree of radiotracer uptake on SPECT imaging. the perioperative period has not been well described in the Thus, a more clinically impactful use for SPECT imag- existing literature. ing may be during the preoperative period. SPECT and Few studies have examined SPECT or hybrid SPECT/ hybrid SPECT/CT imaging have recently aided identifi- CT imaging to evaluate persistent or recurrent pain fol- cation of pain generators in patients with axial neck and SUBMITTED August 1, 2019. ACCEPTED September 5, 2019. INCLUDE WHEN CITING DOI: 10.3171/2019.9.FOCUS19648. ©AANS 2019, except where prohibited by US copyright law Neurosurg Focus Volume 47 • December 2019 1 Unauthenticated | Downloaded 10/09/21 09:11 PM UTC Brusko et al. back pain, indicating potential sites of degeneration.13,14 and lumbar spine were recorded for each patient based on Primarily occurring in the facet joints, the incidence of a review of the imaging report. arthropathy identified on SPECT imaging ranges between 42% and 48%.8 Despite the common occurrence of facet Surgical Interventions hypermetabolism, there is a paucity of literature describ- Following the identification of hypermetabolism on ing SPECT imaging as a preoperative planning tool. In SPECT imaging, a subset of included patients underwent the present study, we describe the largest series to date of surgical intervention. Selection of patients for surgery was patients with axial neck or back pain who underwent pre- augmented by preoperative SPECT imaging when other operative SPECT imaging for surgical planning. We also conventional imaging modalities such as radiography, CT, examine the effectiveness of surgical intervention based and MRI failed to identify a clear pain generator or in pa- on patient-reported improvements during a 1-year follow- tients with multilevel spinal pathologies as potential cul- up period. prits for axial pain. All available imaging studies, clinical presentation, and physical examination findings as well Methods as surgeon and patient preferences were used in the sur- Patient Population gical decision-making process. Only those patients who subsequently underwent spine surgery with the senior au- A retrospective medical and imaging record review was thor (M.Y.W.) on a spinal level associated with increased conducted to identify all adult patients (age > 18 years) radiotracer uptake were included in the final analysis. All who underwent SPECT or SPECT/CT studies between patients underwent a spinal fusion procedure, with the January 2010 and April 2018. Patients who presented with specific technique determined by clinical indications and primary symptoms of axial neck or back pain and who surgeon preference. had evidence of hypermetabolic foci on spine SPECT im- aging were identified. In addition to a primary complaint Statistical Analysis of axial pain, the majority of patients had concomitant di- Categorical variables are reported with percentages agnoses of spinal stenosis, mild spondylolisthesis, spondy- and continuous variables are reported as means with stan- losis, or a spinal deformity such as scoliosis or kyphosis. dard deviation. Data analysis was conducted using Excel Two patients preoperatively reported symptoms of a ra- 2016 (Microsoft Corp.). diculopathy in addition to axial neck and back pain. All patients with a diagnosed neoplasm, infections, inflamma- tory spondyloarthropathy, history of trauma, or any patho- Results logical fracture were excluded. Demographic and baseline Baseline and Radiographic Characteristics characteristics were collected for each patient, and radio- A total of 23 patients underwent spine surgery on a hy- graphic reports and images for SPECT scans were also permetabolic level following identification on SPECT im- reviewed. Clinical information regarding surgical inter- aging. The average age at time of surgery was 60.0 ± 11.0 vention, in-hospital postoperative care, and clinic visits at years; 15 patients (65.2%) were male and 8 were female. 3, 6, and 12 months were collected as well. Provider clinic Twenty patients (86.9%) underwent hybrid SPECT/CT im- notes from follow-up visits were examined to determine aging. The primary indications for SPECT imaging were the extent of axial pain resolution during each visit based pseudarthrosis (37.5%), axial back pain (32.0%), and axial on the patient’s subjective reporting of their symptomatol- neck pain (28.1%). Fifteen patients (65.2%) demonstrated ogy. Patients were then grouped into one of 3 categories: evidence of degenerative pathology in the lumbar spine, 9 “no improvement or worsening,” “some improvement,” or patients (39.1%) in the cervical spine, and 5 patients (21.7%) “complete resolution.” in the thoracic spine. Five patients had involvement of more than one spinal region. The incidence of increased radionu- SPECT Imaging clide uptake per spinal level is shown in Table 1. High-resolution SPECT imaging was completed using a standardized spine-bone protocol. Following 24-mCi Surgical Intervention and Outcomes intravenous injections of 99Tc-methylene diphosphonate, a A total of 53 spinal levels were treated, with an aver- triple-phase planar bone scintigraphy with immediate and delayed images, whole-body bone scans, and tomograph- ic imaging using SPECT or SPECT/CT was performed (ADAC Vertex dual head scanner; Philips Medical Sys- TABLE 1. Number of patients with SPECT hypermetabolism per tems). Patients were identified based on the Current Pro- spinal level cedural Terminology (CPT) codes 78315, 78320, or 78306. Cervical Thoracic Lumbar Triple phase, tomographic SPECT, and whole-body bone Level No. Level No. Level No. and/or joint imaging procedures were included for review, and hybrid SPECT/CT or plain SPECT protocols were in- C2–3 2 T5–6 1 L1–2 1 cluded. A nuclear medicine radiologist evaluated all imag- C3–4 4 T10–11 1 L2–3 7 ing studies, characterizing increased radionuclide uptake C4–5 2 T12–L1 2 L3–4 7 as hypermetabolic foci secondary to active or increased C5–6 2 L4–5 5 osteoblastic activity.
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