Bone scintigraphy in patients with pain

Abstract

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.

Keywords: Complex regional pain syndrome; Diagnostic imaging; Extremity pain; Low back pain; Nuclear medicine; Radionuclide imaging; SPECT CT.

Fig. 1. Multiple bone metastases of lung cancer patient: (A) Bone scintigraphy shows increased uptake at L2, L4, L5, sacrum, both pelvic bones, and left proximal femur. (B) Computed tomography shows sclerotic bone lesions at L2, L4, and L5, corresponding with bone scintigraphy.

Fig. 2. Multiple bone metastases of renal cell carcinoma patient: (A) Bone sincintigraphy show ‘cold lesion’; at L2 and L5. (B) Computed tomography shows osteolytic bone lesions at L2, L3, and L5.

Fig. 3. Hemangioma at T11: (A) Bone scintiraphy shows mildly increased uptake at T11. (B) Computed tomography shows osteolytic bone lesion with sclerotic margin.

Fig. 4. Patient with compression fracture: (A) Bone scintigraphy showed horizontal uptake of L1 which means recent compression fracture. (B) Computed tomography showed compression fracture of L1 and L3. Consequently, compression fracture of L3 was thought to old fracture.

Fig. 5. Patient with vertebral osteomyelitis: (A) Flow, (B) blood pool, and (C) delayed phases showed increased uptake.

Fig. 6. Patient with facet joint arthritis: (A) Planar image showed focal uptake at L5 (B) Single photon emission computed tomography, and (C) Single photon emission computed tomography/Computed tomography showed focal uptake at facet joints.

Fig. 7. Patient with spondylolysis: (A) Single photon emission computed tomography showed increased uptake at pars interarticularis of L5 and (B) Computed tomography showed a bony defect in the pars interarticularis.

Fig. 8. Sixty-three years old female patient with CRPS of left wrist and hand. TPBS showed increased uptake at left hand and wrist in all three phase: (A) a wrist X-ray, (B) flow, (C) blood pool, and (D) delayed phases.

Fig. 9. Forty-six years old female patient with CRPS of right wrist and hand. Increased uptake is shown only on delayed image at right wrist and hand without abnormalities on flow and blood pool phases: (A) flow, (B) blood pool, and (C) delayed phases.

Fig. 10. Forty-four years old male patient with CRPS of left wrist and hand. Decreased uptake on flow and blood pool phase, while increased uptake on delayed phase at left wrist and hand: (A) flow, (B) blood pool, and (C) delayed phases.

Fig. 11. Fifty-four years old male patient with CRPS of left wrist and hand. All three phases showed decreased uptake at left wrist and hand: (A) flow, (B) blood pool, and (C) delayed phases.