Download PDF
CC BY-NC-ND 4.0 · World J Nucl Med 2022; 21(04): 302-313
DOI: 10.1055/s-0042-1750400
Original Article

18F-NaF PET/CT in Presumed Aseptic Pseudarthrosis after Spinal Fusion: Correlation with Findings at Revision Surgery and Intraoperative Cultures

Yacine El Yaagoubi
1   Department of Nuclear Medicine, Vinci Clinic, Alexandre Minkowski, Chambray-lès-Tours, France
,
Jean-Edouard Loret
2   Department of Neurosurgery, NCT+ Clinic, Saint-Cyr-sur-Loire, France
,
Eric Lioret
3   Department of Neurosurgery, Vinci Clinic, Alexandre Minkowski, Chambray-lès-Tours, France
,
Clément Thomas
3   Department of Neurosurgery, Vinci Clinic, Alexandre Minkowski, Chambray-lès-Tours, France
,
Adrien Simonneau
2   Department of Neurosurgery, NCT+ Clinic, Saint-Cyr-sur-Loire, France
,
Laurent Vinikoff
2   Department of Neurosurgery, NCT+ Clinic, Saint-Cyr-sur-Loire, France
,
Caroline Prunier-Aesch
1   Department of Nuclear Medicine, Vinci Clinic, Alexandre Minkowski, Chambray-lès-Tours, France
,
Alain Chetanneau
1   Department of Nuclear Medicine, Vinci Clinic, Alexandre Minkowski, Chambray-lès-Tours, France
,
Laurent Philippe
1   Department of Nuclear Medicine, Vinci Clinic, Alexandre Minkowski, Chambray-lès-Tours, France
,
Maja Ogielska
4   Department of Infectious Diseases, Vinci Clinic, Alexandre Minkowski, Chambray-lès-Tours, France
,
Louis Bernard
5   Department of Infectious Diseases, Bretonneau University Hospital, Tonnellé, Tours, France
› Author Affiliations
› Further Information
Also available at
   Permissions and Reprints

Abstract

Background Conventional imaging is useful to assess interbody fusion by showing complete trabecular bony bridging, but has a low positive predictive value for pseudarthrosis. Because alterations of bone metabolism may precede structural anatomical changes on computed tomography (CT), we aimed to investigate the ability of fluorine 18 sodium fluoride positron emission tomography/computed tomography (18F-NaF PET/CT) to identify pseudarthrosis after spinal fusion using surgical revision as the reference standard.

Methods We retrospectively reviewed 18F-NaF PET/CT scans performed between February 2019 and September 2020 in patients experiencing pain after spinal fusion. We included the 18 patients who underwent revision surgery for suspicion of pseudarthrosis. Five consecutive patients who were clearly fused on CT served as the control group.

Results In the revision surgery group (n=18), visual assessment by 18F-NaF PET/CT revealed that all 22 cages with an increased 18F-NaF uptake around intercorporal fusion material had mobility at revision surgery, whereas none of the fused patients (n=5) showed uptake around cage/intervertebral disk space. Among the 18 patients with presumed aseptic pseudarthrosis, intraoperative cultures revealed surgical site infection (SSI) caused by Cutibacterium acnes (C. acnes) in seven patients (38.9%). There was a statistically significant difference in standardized uptake values and uptake ratios between the revision surgery and control groups (p=5.3× 10−6 and p=0.0002, respectively).

Conclusions 18F-NaF PET/CT imaging appeared as a useful tool to identify pseudarthrosis following spinal fusion. The unexpectedly high prevalence (38.9%) of SSI caused by C. acnes found in presumed aseptic patients supports the utility of intraoperative cultures in revision cases for pseudarthrosis, even without preoperative clinical suspicion of SSI.

Keywords

fluorine-18 sodium fluoride - positron emission tomography/computed tomography - spinal fusion - pseudarthrosis - Cutibacterium acnes


Publication History

Article published online:
09 September 2022

© 2022. World Association of Radiopharmaceutical and Molecular Therapy (WARMTH). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

Thieme Medical and Scientific Publishers Pvt. Ltd.
A-12, 2nd Floor, Sector 2, Noida-201301 UP, India

 

  • References

  • 1 Martin BI, Mirza SK, Comstock BA, Gray DT, Kreuter W, Deyo RA. Reoperation rates following lumbar spine surgery and the influence of spinal fusion procedures. Spine 2007; 32 (03) 382-387
    CrossrefPubMedSearch in Google Scholar
  • 2 Larsen JM, Capen DA. Pseudarthrosis of the lumbar spine. J Am Acad Orthop Surg 1997; 5 (03) 153-162
    CrossrefPubMedSearch in Google Scholar
  • 3 Rager O, Schaller K, Payer M, Tchernin D, Ratib O, Tessitore E. SPECT/CT in differentiation of pseudarthrosis from other causes of back pain in lumbar spinal fusion: report on 10 consecutive cases. Clin Nucl Med 2012; 37 (04) 339-343
    CrossrefPubMedSearch in Google Scholar
  • 4 Grubb SA, Lipscomb HJ. Results of lumbosacral fusion for degenerative disc disease with and without instrumentation. Two- to five-year follow-up. Spine 1992; 17 (03) 349-355
    CrossrefPubMedSearch in Google Scholar
  • 5 O'Beirne J, O'Neill D, Gallagher J, Williams DH. Spinal fusion for back pain: a clinical and radiological review. J Spinal Disord 1992; 5 (01) 32-38
    PubMedSearch in Google Scholar
  • 6 Williams AL, Gornet MF, Burkus JK. CT evaluation of lumbar interbody fusion: current concepts. AJNR Am J Neuroradiol 2005; 26 (08) 2057-2066
    PubMedSearch in Google Scholar
  • 7 Young PM, Berquist TH, Bancroft LW, Peterson JJ. Complications of spinal instrumentation. Radiographics 2007; 27 (03) 775-789
    CrossrefPubMedSearch in Google Scholar
  • 8 Ryan PJ, Evans PA, Gibson T, Fogelman I. Chronic low back pain: comparison of bone SPECT with radiography and CT. Radiology 1992; 182 (03) 849-854
    CrossrefPubMedSearch in Google Scholar
  • 9 Even-Sapir E, Mishani E, Flusser G, Metser U. 18F-Fluoride positron emission tomography and positron emission tomography/computed tomography. Semin Nucl Med 2007; 37 (06) 462-469
    CrossrefPubMedSearch in Google Scholar
  • 10 Al-Zaghal A, Ayubcha C, Kothekar E, Alavi A. Clinical applications of positron emission tomography in the evaluation of spine and joint disorders. PET Clin 2019; 14 (01) 61-69
    CrossrefPubMedSearch in Google Scholar
  • 11 Fischer DR, Zweifel K, Treyer V. et al. Assessment of successful incorporation of cages after cervical or lumbar intercorporal fusion with [(18)F]fluoride positron-emission tomography/computed tomography. Eur Spine J 2011; 20 (04) 640-648
    CrossrefPubMedSearch in Google Scholar
  • 12 Brans B, Weijers R, Halders S. et al. Assessment of bone graft incorporation by 18F-fluoride positron-emission tomography/computed tomography in patients with persisting symptoms after posterior lumbar interbody fusion. EJNMMI Res 2012; 2 (01) 42
    CrossrefPubMedSearch in Google Scholar
  • 13 Quon A, Dodd R, Iagaru A. et al. Initial investigation of 18F-NaF PET/CT for identification of vertebral sites amenable to surgical revision after spinal fusion surgery. Eur J Nucl Med Mol Imaging 2012; 39 (11) 1737-1744
    CrossrefPubMedSearch in Google Scholar
  • 14 Peters M, Willems P, Weijers R. et al. Pseudarthrosis after lumbar spinal fusion: the role of 18F-fluoride PET/CT. Eur J Nucl Med Mol Imaging 2015; 42 (12) 1891-1898
    CrossrefPubMedSearch in Google Scholar
  • 15 Uçkay I, Dinh A, Vauthey L. et al. Spondylodiscitis due to Propionibacterium acnes: report of twenty-nine cases and a review of the literature. Clin Microbiol Infect 2010; 16 (04) 353-358
    CrossrefPubMedSearch in Google Scholar
  • 16 Shifflett GD, Bjerke-Kroll BT, Nwachukwu BU. et al. Microbiologic profile of infections in presumed aseptic revision spine surgery. Eur Spine J 2016; 25 (12) 3902-3907
    CrossrefPubMedSearch in Google Scholar
  • 17 Carreon LY, Djurasovic M, Glassman SD, Sailer P. Diagnostic accuracy and reliability of fine-cut CT scans with reconstructions to determine the status of an instrumented posterolateral fusion with surgical exploration as reference standard. Spine 2007; 32 (08) 892-895
    CrossrefPubMedSearch in Google Scholar
  • 18 Rutherford EE, Tarplett LJ, Davies EM, Harley JM, King LJ. Lumbar spine fusion and stabilization: hardware, techniques, and imaging appearances. Radiographics 2007; 27 (06) 1737-1749
    CrossrefPubMedSearch in Google Scholar
  • 19 Gates GF. SPECT bone scanning of the spine. Semin Nucl Med 1998; 28 (01) 78-94
    CrossrefPubMedSearch in Google Scholar
  • 20 Slizofski WJ, Collier BD, Flatley TJ, Carrera GF, Hellman RS, Isitman AT. Painful pseudarthrosis following lumbar spinal fusion: detection by combined SPECT and planar bone scintigraphy. Skeletal Radiol 1987; 16 (02) 136-141
    CrossrefPubMedSearch in Google Scholar
  • 21 Gates GF, McDonald RJ. Bone SPECT of the back after lumbar surgery. Clin Nucl Med 1999; 24 (06) 395-403
    CrossrefPubMedSearch in Google Scholar
  • 22 Sumer J, Schmidt D, Ritt P. et al. SPECT/CT in patients with lower back pain after lumbar fusion surgery. Nucl Med Commun 2013; 34 (10) 964-970
    CrossrefPubMedSearch in Google Scholar
  • 23 Damgaard M, Nimb L, Madsen JL. The role of bone SPECT/CT in the evaluation of lumbar spinal fusion with metallic fixation devices. Clin Nucl Med 2010; 35 (04) 234-236
    CrossrefPubMedSearch in Google Scholar
  • 24 Patel ND, Broderick DF, Burns J. et al. ACR appropriateness criteria low back pain. J Am Coll Radiol 2016; 13 (09) 1069-1078
    CrossrefPubMedSearch in Google Scholar
  • 25 Smith JS, Shaffrey CI, Sansur CA. et al; Scoliosis Research Society Morbidity and Mortality Committee. Rates of infection after spine surgery based on 108,419 procedures: a report from the Scoliosis Research Society Morbidity and Mortality Committee. Spine 2011; 36 (07) 556-563
    CrossrefPubMedSearch in Google Scholar
  • 26 Gouliouris T, Aliyu SH, Brown NM. Spondylodiscitis: update on diagnosis and management. J Antimicrob Chemother 2010; 65 (Suppl. 03) iii11-iii24
    CrossrefPubMedSearch in Google Scholar
  • 27 Follenfant E, Balamoutoff N, Lawson-Ayayi S. et al. Added value of [18F]fluorodeoxyglucose positron emission tomography/computed tomography for the diagnosis of post-operative instrumented spine infection. Joint Bone Spine 2019; 86 (04) 503-508
    CrossrefPubMedSearch in Google Scholar
  • 28 Portillo ME, Corvec S, Borens O, Trampuz A. Propionibacterium acnes: an underestimated pathogen in implant-associated infections. BioMed Res Int 2013; 2013: 804391
    CrossrefPubMedSearch in Google Scholar
  • 29 Ledermann HP, Schweitzer ME, Morrison WB, Carrino JA. MR imaging findings in spinal infections: rules or myths?. Radiology 2003; 228 (02) 506-514
    CrossrefPubMedSearch in Google Scholar
  • 30 Hong SH, Choi JY, Lee JW, Kim NR, Choi JA, Kang HS. MR imaging assessment of the spine: infection or an imitation?. Radiographics 2009; 29 (02) 599-612
    CrossrefPubMedSearch in Google Scholar
  • 31 De Winter F, Vogelaers D, Gemmel F, Dierckx RA. Promising role of 18-F-fluoro-D-deoxyglucose positron emission tomography in clinical infectious diseases. Eur J Clin Microbiol Infect Dis 2002; 21 (04) 247-257
    CrossrefPubMedSearch in Google Scholar
  • 32 Inanami H, Oshima Y, Iwahori T, Takano Y, Koga H, Iwai H. Role of 18F-fluoro-D-deoxyglucose PET/CT in diagnosing surgical site infection after spine surgery with instrumentation. Spine 2015; 40 (02) 109-113
    CrossrefPubMedSearch in Google Scholar
  • 33 Gemmel F, Rijk PC, Collins JM, Parlevliet T, Stumpe KD, Palestro CJ. Expanding role of 18F-fluoro-D-deoxyglucose PET and PET/CT in spinal infections. Eur Spine J 2010; 19 (04) 540-551
    CrossrefPubMedSearch in Google Scholar
  • 34 Georgakopoulos A, Pneumaticos SG, Sipsas NV, Chatziioannou S. Positron emission tomography in spinal infections. Clin Imaging 2015; 39 (04) 553-558
    CrossrefPubMedSearch in Google Scholar
  • 35 Bolander FC, Akerlund B, Axelsson R. FDG-PET/CT limitations in the diagnosis of spinal implant infection. J Med Imaging Case Rep. 2019; 3 (02) 27-29
    Search in Google Scholar
  • 36 Lankinen P, Lehtimäki K, Hakanen AJ, Roivainen A, Aro HT. A comparative 18F-FDG PET/CT imaging of experimental Staphylococcus aureus osteomyelitis and Staphylococcus epidermidis foreign-body-associated infection in the rabbit tibia. EJNMMI Res 2012; 2 (01) 41
    CrossrefPubMedSearch in Google Scholar
  • 37 Khalil JG, Gandhi SD, Park DK, Fischgrund JS. Cutibacterium acnes in spine pathology: pathophysiology, diagnosis, and management. J Am Acad Orthop Surg 2019; 27 (14) e633-e640
    CrossrefPubMedSearch in Google Scholar
  • 38 Steinhaus ME, Salzmann SN, Lovecchio F. et al. Risk factors for positive cultures in presumed aseptic revision spine surgery. Spine 2019; 44 (03) 177-184
    CrossrefPubMedSearch in Google Scholar
  • 39 Burkhard MD, Loretz R, Uçkay I, Bauer DE, Betz M, Farshad M. Occult infection in pseudarthrosis revision after spinal fusion. Spine J 2021; 21 (03) 370-376
    CrossrefPubMedSearch in Google Scholar
  • 40 Jakab E, Zbinden R, Gubler J, Ruef C, von Graevenitz A, Krause M. Severe infections caused by Propionibacterium acnes: an underestimated pathogen in late postoperative infections. Yale J Biol Med 1996; 69 (06) 477-482
    PubMedSearch in Google Scholar
  • 41 Hahn F, Zbinden R, Min K. Late implant infections caused by Propionibacterium acnes in scoliosis surgery. Eur Spine J 2005; 14 (08) 783-788
    CrossrefPubMedSearch in Google Scholar
  • 42 Updegrove GF, Armstrong AD, Kim HM. Preoperative and intraoperative infection workup in apparently aseptic revision shoulder arthroplasty. J Shoulder Elbow Surg 2015; 24 (03) 491-500
    CrossrefPubMedSearch in Google Scholar
  • 43 Grosso MJ, Frangiamore SJ, Ricchetti ET, Bauer TW, Iannotti JP. Sensitivity of frozen section histology for identifying Propionibacterium acnes infections in revision shoulder arthroplasty. J Bone Joint Surg Am 2014; 96 (06) 442-447
    CrossrefPubMedSearch in Google Scholar
  • 44 Kelly II JD, Hobgood ER. Positive culture rate in revision shoulder arthroplasty. Clin Orthop Relat Res 2009; 467 (09) 2343-2348
    CrossrefPubMedSearch in Google Scholar
  • 45 Heimburger C, Hubele F, Charles YP, Steib JP, Namer IJ, Rust E. Évaluation de critères d'interprétation de la tomoscintigraphie d'émission monophotonique au 99mTC-HMDP pour le diagnostic des complications tardives des arthrodèses rachidiennes. Med Nucl (Paris) 2015; 39: 105-121
    Search in Google Scholar
  • 46 Grant FD, Fahey FH, Packard AB, Davis RT, Alavi A, Treves ST. Skeletal PET with 18F-fluoride: applying new technology to an old tracer. J Nucl Med 2008; 49 (01) 68-78
    CrossrefPubMedSearch in Google Scholar