ORIGINAL ARTICLE Sensitivity and Specificity of 3-phase Bone Scintigraphy in the Diagnosis of Complex Regional Pain Syndrome of the Upper Extremity Nicole Wu¨ppenhorst, MD,* Christoph Maier, PhD,* Jule Frettlo¨h, PhD,* Werner Pennekamp, MD,w and Volkmar Nicolas, PhDw motion are seldom or not mentioned at all in these criteria.3–7 Objectives: Joint and bone alterations are seldom mentioned in the Furthermore, the increased bone metabolism as shown by diagnostic criteria for complex regional pain syndrome (CRPS) increased periarticular tracer uptake using 3-phase bone even though they are important for long-term outcome. Altered scintigraphy (TPBS)8 is not included in the diagnostic periarticular bone metabolism can be detected by 3-phase bone criteria. The diagnostic efficacy of TPBS, although frequen- scintigraphy (TPBS). Although frequently examining the diagnos- 9–12 tic efficacy of TPBS is debatable. tly examined has been widely debated. One reason is the methodologic differences between studies reporting diag- Methods: In all, 78 TPBS (45 CRPS/33 control group) were evalua- nostic sensitivity ranging between 19% and 97% and ted qualitatively and quantitatively. Sensitivity and specificity of the specificity ranging between 56% and 97% for phase 3 of qualitative blinded reviewer analysis (n = 57) compared with quan- TPBS.9,12–17 Moreover, there exists no consensus concern- titative region of interest (ROI)-based analysis over the metacarpo- ing the usefulness of phases 1 and 2. TPBS shows tracer phalangeal, proximal, and distal interphalangeal joints (n = 74) were evaluated. Patients’ sex, age, duration of CRPS, inciting event, extent uptake at 3 different time points after tracer injection. of joint alteration, and handedness were included as covariables. Phases 1 and 2 are obtained directly after tracer injection and represent the perfusion and blood pooling in the limb, Results: Qualitative blinded reviewer TPBS analysis had a high whereas phase 3 (obtained 2 to 3 hours after injection) specificity (83%-100%). However, sensitivity was 31% to 50%. Inter- represents the tracer uptake in the bone. rater reliability was moderate (k score 0.56). Using the ROI-based TPBS can be evaluated qualitatively, using descrip- evaluation, the highest sensitivity (69%) and specificity (75%) (ROI score Z1.32) was shown for phase 3, whereas sensitivity of phases 1 tion of asymmetry in tracer uptake, or quantitatively, using and 2 rapidly declined to 50%. Duration of CRPS until TPBS was the region of interest (ROI) technique to quantify tracer the only variable with significant impact on ROI scores of phase 3 uptake in specific limb regions. In general, qualitative (F = 23.7; P = 0.000; R2 = 0.42). ROI scores declined with increas- evaluation has been performed to date.8,9,12–22 Some studies ing duration of CRPS. used additional or sole ROI evaluation.16,20,21,23–26 ROIs were usually localized over the entire hand, but not over Discussion: In conclusion, TPBS is a highly specific tool for diagnos- 16,20,21,23,26 ing CRPS of the upper limb. ROI evaluation of phase 3 within the single joints. Proximal interphalangeal (PIP) and first 5 months after onset of CRPS is an appropriate additional distal interphalangeal (DIP) joints have not been examined diagnostic tool to confirm or exclude CRPS of the upper extremity. to date, although clinical signs and symptoms often include these joints.5 Furthermore, the influence of CRPS duration Key Words: complex regional pain syndrome, 3-phase bone scinti- at the time of assessment on the diagnostic value of TPBS graphy, sensitivity, specificity, ROI, duration of CRPS has not previously been evaluated.9,10,23–25,27 (Clin J Pain 2010;26:182–189) The aim of the present study was to determine the sensitivity and specificity of TBPS in the diagnosis of CRPS of the upper extremity. Emphasis was placed on examina- tion of interrater reliability and standardization of the ROI urrent established diagnostic criteria for complex regional analysis in CRPS patients and a control group (CG). Age, Cpain syndrome (CRPS) comprise continuing pain, sex, duration of CRPS, inciting event, extent of joint 1,2 sensory, autonomic, and motor changes. Although im- alteration, and handedness were included as covariables. portant for long-term outcome, the alterations of joints, To assess differences between qualitative and quantitative periarticular bone, and deep somatic tissues, which are evaluation, we compared additionally blinded reviewer and clinically detectable as joint pain and decreased range of ROI-based analysis of TPBS. Received for publication February 11, 2009; revised September 13, PATIENTS AND METHODS 2009; accepted September 19, 2009. From the Departments of *Pain Management; and wDiagnostic Radiol- Patients ogy, Interventional Radiology and Nuclear Medicine, BG-Kliniken Bergmannsheil Bochum, Ruhr-University Bochum, Germany. The Ethics Committee of the Ruhr-University of Supported by BMBF grants (German Research Network on Neuro- Bochum (registry number 2173) approved this study. In pathic Pain, DFNS). all, 78 patients attending the pain clinic with pain in the Reprints: Christoph Maier, PhD, Abteilung fu¨ r Schmerztherapie, upper limb were enrolled (Fig. 1). These patients underwent Berufsgenossenschaftliche Kliniken Bergmannsheil-Universita¨ tsklinik, TPBS in the department of nuclear medicine as a diagnostic Bu¨ rkle-de-la-Camp-Platz 1, D-44789 Bochum, Germany (e-mail: [email protected]). procedure. At the same time, the patients were clinically Copyright r 2010 by Lippincott Williams & Wilkins examined in the department of pain management. 182 | www.clinicalpain.com Clin J Pain Volume 26, Number 3, March/April 2010 Clin J Pain Volume 26, Number 3, March/April 2010 3-phase Bone Scintigraphy and CRPS FIGURE 1. Flow chart illustrating the enrollment and investigation of patients. Forty-five patients (20 female/44%) fulfilled the Ten seconds after the injection of approximately research diagnostic criteria for CRPS proposed by Bruehl 10 MBq/kg bodyweight 99mTc-MDP (totally, 500-700 MBq) et al,28 which is used as the diagnostic gold standard. All into the cubital vein of the unaffected side 60 dynamic frames CRPS patients (100%) had persistent limb pain spreading were acquired with patient’s hands palm side down on the to the affected distal extremity. At the time of evaluation, g camera (phase 1: 1 s/frame, 64 Â 64 matrix). Phase 1 imme- 100% decreased range of motion, 76% temperature asym- diately faded to the blood pool phase. A dynamic sequence of metry, 70% hyperhidrosis, 70% tremor, 58% edema, 38% 18 frames was subsequently recorded (phase 2: 10 s/frame, of the patients showed dynamic mechanical allodynia, 29% 64 Â 64 matrix). The static picture of the mineralization phase skin color changes, 15% trophic changes and 4% dystonia. was taken 2 to 3 hours after injection (phase 3: 5 min, Six of 45 CRPS patients had a nerve injury (radial 128 Â 128 matrix). nerve = 1; median nerve = 4; ulnar nerve = 1) and there- Except for 4 of 78 TPBS, all TPBS were evaluated fore were classified as CRPS II. quantitatively (see Results). A subgroup of 57 TPBS (45 In all, 33 patients (18 females/55%), who underwent CRPS/12 CG) was evaluated qualitatively. Twenty-one TPBS for suspected CRPS in the surgical department TPBS of the CG were evaluated only quantitatively because served as CG. After the clinical, neurologic, and radiologic after the first quantitative and qualitative evaluation, evaluation, the following diagnoses were made: posttrau- authors decided to increase the small sample size of the matic nerve injury of the forearm (15/45%; injured nerves: CG from 12 to 33 TPBS to have comparable sample sizes in radial = 4, median = 1, ulnar = 5, combined injuries = 5), both groups (Fig. 1). posttraumatic wrist osteoarthrosis (10/30%), postoperative The qualitative evaluation was undertaken by 1 or posttraumatic pain due to long-term disuse of the experienced resident and 3 consultants for radiology, forearm or hand with rapid improvement after onset of adequate exercise program (5/16%), factitious disorders (2/6%, proved by psychologic exploration followed by patient report), and polyneuropathy (1/3%). All of these patients TABLE 1. Clinical Characteristics of CRPS Patients (n = 45) had ongoing pain and in addition 71% decreased range of Inciting event (%) motion, 19% localized edema, 19% demonstrated allo- Surgically treated fractures 19 (42.2) dynia, 14% temperature asymmetry, 14% skin color Conservatively treated fractures 10 (22.2) changes, 10% trophic changes and 5% hyperhidrosis. Soft tissue injuries 8 (17.8) Combined injuries 6 (13.3) The mean ages in the CRPS and CGs were 50.7 years No inciting event reported 2 (4.4) (SD ± 11.5, range 26-76) and 48.9 years (SD ± 15.8, range Joint alterations*(%) 16-81), respectively (F = 0.35; P = 0.558). The average time Slight 15 (33.3) from onset of symptoms to TPBS was 9.8 months for the Severe 27 (60.0) CRPS group (SD ± 21.5, range 0.8-146 mo) and 18.6 Missing data 3 (6.7) months for the CG (SD ± 41.8, range 1.1-233) (F = 1.38; Handedness (%) P = 0.244). Additional clinical data concerning covariables Dominant hand affected 22 (48.9) included in evaluation of CRPS patients are presented in Nondominant hand affected 12 (26.7) Table 1. Ambidexterity 5 (11.1) Missing data 6 (13.3) TPBS Protocol and Evaluation *Joint alterations: slight = finger tip-to-palm-distance <3 cm, no All TPBS were performed using 99mTechnetium- contractures, slightly decreased range of motion or reduced mobility <20 labeled methylene diphosphonate (99mTc-MDP) and a degrees of several joints. Siemens E.CAM 180 dual-head g camera equipped with a Severe = finger tip-to-palm-distance Z3 cm, decreased range of motion because of contractures in >3 joints. low-energy high resolution collimator. All bone scans CRPS indicates complex regional pain syndrome.