Pearls and Pitfalls of 18F Sodium Fluoride PET-CT Bone Imaging for Evaluation of Back Pain and Spine Pathology

Abstract

Study design: The following paper is a review article with case presentations showing how to order, perform and interpret 18F sodium fluoride PET/CT of the spine. It discusses its advantages and limitations in evaluating the orthopedic spine patient. Objective:The purpose of this article is to aid physicians and technologists in performing, analyzing, ordering, and preparing 18F sodium fluoride PET/CT in the spine surgery setting for patients suffering from back pain. Summary of background data:The evaluation of patients who have already undergone spine surgery who present with persistent pain has always been a diagnostic challenge in the orthopedic setting. While CT and MRI are conventionally used to aid diagnosis, 18F sodium fluoride PET/CT has been an undervalued tool in the setting of the complex diagnosis of back pain especially following surgical fusion. The aim of this paper is to educate radiologists, orthopedic surgeons and clinicians in use of PET/CT bone scan in the orthopedic setting. Methods:In our review article, we adopt the oncology protocol of 18F sodium fluoride PET/CT and modify it to fit the CT spine protocol. We determine which radiologic parameters are most effective in image acquisition and describe the steps involved in preparing the patient for imaging, imaging acquisition and interpretation. We illustrate this article with cases describing how 18F sodium fluoride PET/ CT can alter diagnosis and help manage difficult cases.Results: 18F sodium fluoride PET/CT is a valuable resource in the orthopedic surgeon's acumen to identify pain generators of the spine. Additionally, this article further describes the use of PET/CT in the imaging of the spine by discussing PET/CT's advantages and limitations compared to other imaging modalities, the clinical indications for when to use PET/CT, and the proper patient preparation, radiopharmaceutical preparation, imaging acquisition, data processing and physician analysis and reporting. In our experience PET/ CT bone imaging is often superior to CT alone in demonstrating potential post-surgical complications including loosening and healing changes. Conclusion: This article aids physicians and technologists in un-derstanding what is involved in performing PET/CT studies of the spine. In several cases, we described PET/CT's advantages in the orthopedic setting in identifying the pain generator of the spine. By using these guidelines, 18F sodium fluoride PET/CT and its potential benefits in the spine surgery setting can be further explored.