Diagnostic and therapeutic impact of SPECT/CT in patients with unspecific pain of the hand and wrist

Abstract

Background: Unspecific pain of the hand/wrist is a diagnostic challenge. Radiographs and planar bone scan are useful diagnostic tools in patients with unspecific wrist pain. Both modalities are deficient, either by not presenting metabolic disorders or due to inadequate anatomical resolution. Single photon emission computed tomography/computed tomography (SPECT/CT) claims to fuse both features.

Methods: Fifty-one patients with persisting wrist pain were referred for evaluation by SPECT/CT. All patients received X-ray and early-phase/late-phase SPECT/CT imaging. SPECT/CT results were compared with X-ray alone and X-ray combined with planar bone scan. The therapeutic impact was evaluated in consensus with the referring hand surgeon.

Results: A total of 48 lesions were detected on plain radiographs, 117 on planar bone scan, and 142 on SPECT/CT. SPECT/CT detected significantly more lesions than the other imaging modalities. In 30 out of 51 patients (61%), a positive concordance between the clinical diagnosis and SPECT/CT findings was found. In 19 out of 51 patients (37%), SPECT/CT findings had significant impact on consecutive therapy.

Conclusions: SPECT/CT showed higher lesion detection rates compared to standard X-rays and planar bone scan. Significant impact on patient management could be demonstrated. SPECT/CT might be added to the workup of such a specific patient population when standard imaging fails to detect the patient's main pathology.

Figure 1

A 25-year-old male with left-sided wrist pain when grabbing and lifting. Tendinitis was suspected. (A) Plain radiographs showed no bone lesion. (B) SPECT/CT revealed an intense radioisotope uptake in the lunate bone corresponding with osteomalacia of the lunate bone followed by surgery (top row: three-dimensional (3D)-SPECT and fusion SPECT/CT, bottom row: planar SPECT and CT-alone).

Figure 2

A 32-year-old female with persistent dorsoradial wrist pain after distortion. (A) No bone lesion was detected on plain radiographs. (B) High radioisotope uptake in the distal radial epiphysis with bumpy RC joint surface, representing persistent bone remodeling after consolidated distal radial fracture (left: 3D-SPECT, right: fusion SPECT/CT). Occupational therapy was initiated after SPECT/CT.

Figure 3

A 28-year-old male with suspected RC osteoarthritis after scaphoid fracture 6 years ago. The patient has a consolidated pseudoarthrosis of the scaphoid bone and persistent wrist pain. (A) Plain radiographs show focal sclerosis of the proximal pole of the scaphoid. (B) Planar bone scan revealed uptake in the scaphoid bone on late-phase images (left: early phase, right: late phase). (C) Coronal SPECT/CT images showed uptake in the proximal scaphoid (osseous remodeling) and a vital proximal scaphoid fragment. The patient received revisional osteosynthesis of the scaphoid.

Figure 4

A 48-year-old female with symptomatic bilateral CMC-1 osteoarthritis. The patient had a history of trapezectomy on the left hand 3 years ago. (A) Plain radiographs showed moderate CMC-1 osteoarthritis on the left side. (B) Intense uptake in the right CMC-1 joint and moderate uptake in the left CMC-1 joint on early-phase imaging (left), intense radioisotope uptake in both CMC-1 joints on late-phase imaging (right). (C) SPECT/CT confirmed activated bilateral rhizarthritis/osteoarthritis with neoarticulation of the MC-1 and trapezoid bone on the right side. Patient received re-arthroplasty (top row: 3D-SPECT and fusion SPECT/CT, bottom row: planar SPECT and CT-alone).