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Z Orthop Unfall 2023; 161(05): 544-551
DOI: 10.1055/a-2075-8873
Original Article

Value of [18F]FDG PET/CT in Diagnosis and Management of Spondylodiscitis

Stellenwert der [18F]FDG-PET/CT bei der Diagnose und dem Management der Spondylodiszitis
Constantin Lapa
1   Nuclear Medicine, Faculty of Medicine, University of Augsburg, Augsburg, Germany
2   Deutsche Gesellschaft für Nuklearmedizin (DGN), Berlin, Germany
,
Christoph Rischpler
3   Department of Nuclear Medicine, University Hospital Essen, Essen, Germany (Ringgold ID: RIN39081)
4   Department of Nuclear Medicine, Klinikum Stuttgart, Stuttgart, Germany
,
Ralph Alexander Bundschuh
5   Nuclear Medicine, Faculty of Medicine, University of Augsburg, Augsburg, Germany
,
Alexander Dierks
6   Nuclear Medicine, Faculty of Medicine, University of Augsburg, Augsburg, Germany
,
Sigmund Lang
7   Department of Trauma Surgery, University Medical Centre Regensburg, Regensburg, Germany
,
Georgi Wassilew
8   Clinic for Orthopedics and Orthopedic Surgery, University Medicine Greifswald, Greifswald, Germany (Ringgold ID: RIN60634)
,
Volker Alt
9   Department of Trauma Surgery, University Medical Centre Regensburg, Regensburg, Germany
10   Sektion Muskuloskelettale Infektionen der Deutschen Gesellschaft für Orthopädie und Unfallchirurgie (DGOU), Berlin, Germany
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Abstract

Vertebral osteomyelitis is the third most common form of osteomyelitis in patients over 50 years of age.

Whereas prompt (pathogen-directed) therapy is crucially associated with better outcomes, the heterogeneous clinical presentation of disease with unspecific symptoms often delays adequate treatment initiation. Diagnosis requires a careful investigation of medical history, clinical findings and diagnostic imaging, including magnetic resonance imaging and nuclear medicine techniques.

Due to its high sensitivity, [18F]FDG PET/CT is becoming increasingly important in diagnosis and management of spondylodiscitis, especially in the postoperative setting with presence of spinal hardware or other implantable devices in which MRI is limited.

Zusammenfassung

Die vertebrale Osteomyelitis ist die dritthäufigste Form der Osteomyelitis bei Patienten über 50 Jahren. Obwohl eine rasche (auf den Erreger ausgerichtete) Therapie mit besseren Ergebnissen verbunden ist, verzögert das heterogene klinische Erscheinungsbild der Erkrankung mit unspezifischen Symptomen oft die Einleitung der Behandlung. Die Diagnose erfordert eine sorgfältige Untersuchung der Krankengeschichte, der klinischen Befunde und Bildgebung einschließlich Magnetresonanztomografie und nuklearmedizinischer Verfahren.

Aufgrund der hohen Empfindlichkeit gewinnt das [18F]FDG PET/CT zunehmend an Bedeutung für die Diagnose und Behandlung der Spondylodiszitis, insbesondere im postoperativen Setting, wenn spinales Fremdmaterial oder andere Implantate vorhanden sind und folglich die Aussagekraft der MRT begrenzt ist.

Schlüsselwörter

Spondylodiszitis - FDG-PET/CT - molekulare Bildgebung - Osteomyelitis - Wirbelsäule

Keywords

spondylodiscitis - FDG-PET/CT - molecular imaging - osteomyelitis - spine


Publication History

Received: 20 December 2022

Accepted after revision: 23 February 2023

Article published online:
28 September 2023

© 2023. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Kehrer M, Pedersen C, Jensen TG. et al. Increasing incidence of pyogenic spondylodiscitis: a 14-year population-based study. J Infect 2014; 68: 313-320
    CrossrefPubMedSearch in Google Scholar
  • 2 Conan Y, Laurent E, Belin Y. et al. Large increase of vertebral osteomyelitis in France: a 2010–2019 cross-sectional study. Epidemiol Infect 2021; 149: e227
    CrossrefPubMedSearch in Google Scholar
  • 3 Issa K, Diebo BG, Faloon M. et al. The Epidemiology of Vertebral Osteomyelitis in the United States From 1998 to 2013. Clin Spine Surg 2018; 31: E102-E108
    CrossrefPubMedSearch in Google Scholar
  • 4 Lang S, Fromming A, Walter N. et al. Is There a Difference in Clinical Features, Microbiological Epidemiology and Effective Empiric Antimicrobial Therapy Comparing Healthcare-Associated and Community-Acquired Vertebral Osteomyelitis?. Antibiotics (Basel) 2021; 10: 1410
    CrossrefPubMedSearch in Google Scholar
  • 5 Renz N, Haupenthal J, Schuetz MA. et al. Hematogenous vertebral osteomyelitis associated with intravascular device-associated infections – A retrospective cohort study. Diagn Microbiol Infect Dis 2017; 88: 75-81
    CrossrefPubMedSearch in Google Scholar
  • 6 Kremers HM, Nwojo ME, Ransom JE. et al. Trends in the epidemiology of osteomyelitis: a population-based study, 1969 to 2009. J Bone Joint Surg Am 2015; 97: 837-845
    CrossrefPubMedSearch in Google Scholar
  • 7 Rupp M, Walter N, Baertl S. et al. Terminology of bone and joint infection. Bone Joint Res 2021; 10: 742-743
    CrossrefPubMedSearch in Google Scholar
  • 8 Akbar M, Sobottke R, Lehner B. et al. Pyogenic spondylodiscitis: therapy algorithm and a new classification for therapeutic decision-making. Orthopade 2012; 41: 749-758
    CrossrefPubMedSearch in Google Scholar
  • 9 Akbar M, Lehner B, Doustdar S. et al. Pyogenic spondylodiscitis of the thoracic and lumbar spine : a new classification and guide for surgical decision-making. Orthopade 2011; 40: 614-623
    CrossrefPubMedSearch in Google Scholar
  • 10 Berbari EF, Kanj SS, Kowalski TJ. et al. 2015 Infectious Diseases Society of America (IDSA) Clinical Practice Guidelines for the Diagnosis and Treatment of Native Vertebral Osteomyelitis in Adults. Clin Infect Dis 2015; 61: e26-46
    CrossrefPubMedSearch in Google Scholar
  • 11 Krogsgaard MR, Wagn P, Bengtsson J. Epidemiology of acute vertebral osteomyelitis in Denmark: 137 cases in Denmark 1978–1982, compared to cases reported to the National Patient Register 1991–1993. Acta Orthop Scand 1998; 69: 513-517
    CrossrefPubMedSearch in Google Scholar
  • 12 Kumar K. Spinal tuberculosis, natural history of disease, classifications and principles of management with historical perspective. Eur J Orthop Surg Traumatol 2016; 26: 551-558
    CrossrefPubMedSearch in Google Scholar
  • 13 Aagaard T, Roed C, Dahl B. et al. Long-term prognosis and causes of death after spondylodiscitis: A Danish nationwide cohort study. Infect Dis (Lond) 2016; 48: 201-208
    CrossrefPubMedSearch in Google Scholar
  • 14 Cheung WY, Luk KD. Pyogenic spondylitis. Int Orthop 2012; 36: 397-404
    CrossrefPubMedSearch in Google Scholar
  • 15 Yagdiran A, Otto-Lambertz C, Lingscheid KM. et al. Quality of life and mortality after surgical treatment for vertebral osteomyelitis (VO): a prospective study. Eur Spine J 2021; 30: 1721-1731
    CrossrefPubMedSearch in Google Scholar
  • 16 Vettivel J, Bortz C, Passias PG. et al. Pyogenic Vertebral Column Osteomyelitis in Adults: Analysis of Risk Factors for 30-Day and 1-Year Mortality in a Single Center Cohort Study. Asian Spine J 2019; 13: 608-614
    CrossrefPubMedSearch in Google Scholar
  • 17 Hofmann W. Chameleon spondylodiscitis : Challenge for geriatricians. Z Gerontol Geriatr 2017; 50: 623-636
    CrossrefPubMedSearch in Google Scholar
  • 18 Herren C, von der Höh N, Dreimann M. Diagnostik und Therapie der Spondylodiszitis – S2k-Leitlinie. 2020
    Search in Google Scholar
  • 19 Lang S, Rupp M, Hanses F. et al. Infections of the spine : Pyogenic spondylodiscitis and implant-associated vertebral osteomyelitis. Unfallchirurg 2021; 124: 489-504
    CrossrefPubMedSearch in Google Scholar
  • 20 Gupta A, Kowalski TJ, Osmon DR. et al. Long-term outcome of pyogenic vertebral osteomyelitis: a cohort study of 260 patients. Open Forum Infect Dis 2014; 1: ofu107
    CrossrefPubMedSearch in Google Scholar
  • 21 Maus U, Andereya S, Gravius S. et al. Procalcitonin (PCT) as diagnostic tool for the monitoring of spondylodiscitis. Z Orthop Unfall 2009; 147: 59-64
    Thieme ConnectPubMedSearch in Google Scholar
  • 22 McHenry MC, Easley KA, Locker GA. Vertebral osteomyelitis: long-term outcome for 253 patients from 7 Cleveland-area hospitals. Clin Infect Dis 2002; 34: 1342-1350
    CrossrefPubMedSearch in Google Scholar
  • 23 Kowalski TJ, Layton KF, Berbari EF. et al. Follow-up MR imaging in patients with pyogenic spine infections: lack of correlation with clinical features. AJNR Am J Neuroradiol 2007; 28: 693-699
    PubMedSearch in Google Scholar
  • 24 Mazzie JP, Brooks MK, Gnerre J. Imaging and management of postoperative spine infection. Neuroimaging Clin N Am 2014; 24: 365-374
    CrossrefPubMedSearch in Google Scholar
  • 25 Radcliff K, Morrison WB, Kepler C. et al. Distinguishing Pseudomeningocele, Epidural Hematoma, and Postoperative Infection on Postoperative MRI. Clin Spine Surg 2016; 29: E471-E474
    CrossrefPubMedSearch in Google Scholar
  • 26 Rayes M, Colen CB, Bahgat DA. et al. Safety of instrumentation in patients with spinal infection. J Neurosurg Spine 2010; 12: 647-659
    CrossrefPubMedSearch in Google Scholar
  • 27 Prandini N, Lazzeri E, Rossi B. et al. Nuclear medicine imaging of bone infections. Nucl Med Commun 2006; 27: 633-644
    CrossrefPubMedSearch in Google Scholar
  • 28 Love C, Palestro CJ. Nuclear medicine imaging of bone infections. Clin Radiol 2016; 71: 632-646
    CrossrefPubMedSearch in Google Scholar
  • 29 Ozmen D, Ozkan N, Guberina N. et al. Computed-tomography-guided biopsy in suspected spondylodiscitis: Single-center experience including 201 biopsy procedures. Orthop Rev (Pavia) 2019; 11: 7793
    CrossrefPubMedSearch in Google Scholar
  • 30 Raghavan M, Lazzeri E, Palestro CJ. Imaging of Spondylodiscitis. Semin Nucl Med 2018; 48: 131-147
    CrossrefPubMedSearch in Google Scholar
  • 31 Gemmel F, Rijk PC, Collins JM. et al. Expanding role of 18F-fluoro-D-deoxyglucose PET and PET/CT in spinal infections. Eur Spine J 2010; 19: 540-551
    CrossrefPubMedSearch in Google Scholar
  • 32 Diehn FE. Imaging of spine infection. Radiol Clin North Am 2012; 50: 777-798
    CrossrefPubMedSearch in Google Scholar
  • 33 Zhang N, Zeng X, He L. et al. The Value of MR Imaging in Comparative Analysis of Spinal Infection in Adults: Pyogenic Versus Tuberculous. World Neurosurg 2019; 128: e806-e813
    CrossrefPubMedSearch in Google Scholar
  • 34 Arbelaez A, Restrepo F, Castillo M. Spinal infections: clinical and imaging features. Top Magn Reson Imaging 2014; 23: 303-314
    CrossrefPubMedSearch in Google Scholar
  • 35 Ledbetter LN, Salzman KL, Shah LM. Imaging Psoas Sign in Lumbar Spinal Infections: Evaluation of Diagnostic Accuracy and Comparison with Established Imaging Characteristics. AJNR Am J Neuroradiol 2016; 37: 736-741
    CrossrefPubMedSearch in Google Scholar
  • 36 Khalid M, Siddiqui MA, Qaseem SM. et al. Role of magnetic resonance imaging in evaluation of tubercular spondylitis: pattern of disease in 100 patients with review of literature. JNMA J Nepal Med Assoc 2011; 51: 116-121
    PubMedSearch in Google Scholar
  • 37 Homagk L, Marmelstein D, Homagk N. et al. SponDT (Spondylodiscitis Diagnosis and Treatment): spondylodiscitis scoring system. J Orthop Surg Res 2019; 14: 100
    CrossrefPubMedSearch in Google Scholar
  • 38 Gasbarrini A, Boriani L, Nanni C. et al. Spinal infection multidisciplinary management project (SIMP): from diagnosis to treatment guideline. Int J Immunopathol Pharmacol 2011; 24: 95-100
    CrossrefPubMedSearch in Google Scholar
  • 39 Talbott JF, Narvid J, Chazen JL. et al. An Imaging-Based Approach to Spinal Cord Infection. Semin Ultrasound CT MR 2016; 37: 411-430
    CrossrefPubMedSearch in Google Scholar
  • 40 Shifrin A, Lu Q, Lev MH. et al. Paraspinal Edema Is the Most Sensitive Feature of Lumbar Spinal Epidural Abscess on Unenhanced MRI. AJR Am J Roentgenol 2017; 209: 176-181
    CrossrefPubMedSearch in Google Scholar
  • 41 Davis DP, Salazar A, Chan TC. et al. Prospective evaluation of a clinical decision guideline to diagnose spinal epidural abscess in patients who present to the emergency department with spine pain. J Neurosurg Spine 2011; 14: 765-770
    CrossrefPubMedSearch in Google Scholar
  • 42 Lazzeri E, Bozzao A, Cataldo MA. et al. Joint EANM/ESNR and ESCMID-endorsed consensus document for the diagnosis of spine infection (spondylodiscitis) in adults. Eur J Nucl Med Mol Imaging 2019; 46: 2464-2487
    CrossrefPubMedSearch in Google Scholar
  • 43 Kihira S, Koo C, Mahmoudi K. et al. Combination of Imaging Features and Clinical Biomarkers Predicts Positive Pathology and Microbiology Findings Suggestive of Spondylodiscitis in Patients Undergoing Image-Guided Percutaneous Biopsy. AJNR Am J Neuroradiol 2020; 41: 1316-1322
    CrossrefPubMedSearch in Google Scholar
  • 44 Daghighi MH, Poureisa M, Safarpour M. et al. Diffusion-weighted magnetic resonance imaging in differentiating acute infectious spondylitis from degenerative Modic type 1 change; the role of b-value, apparent diffusion coefficient, claw sign and amorphous increased signal. Br J Radiol 2016; 89: 20150152
    CrossrefPubMedSearch in Google Scholar
  • 45 Dumont RA, Keen NN, Bloomer CW. et al. Clinical Utility of Diffusion-Weighted Imaging in Spinal Infections. Clin Neuroradiol 2019; 29: 515-522
    CrossrefPubMedSearch in Google Scholar
  • 46 Moritani T, Kim J, Capizzano AA. et al. Pyogenic and non-pyogenic spinal infections: emphasis on diffusion-weighted imaging for the detection of abscesses and pus collections. Br J Radiol 2014; 87: 20140011
    CrossrefPubMedSearch in Google Scholar
  • 47 Patel KB, Poplawski MM, Pawha PS. et al. Diffusion-weighted MRI “claw sign” improves differentiation of infectious from degenerative modic type 1 signal changes of the spine. AJNR Am J Neuroradiol 2014; 35: 1647-1652
    CrossrefPubMedSearch in Google Scholar
  • 48 Kakigi T, Okada T, Sakai O. et al. Subcutaneous fluid collection: An imaging marker for treatment response of infectious thoracolumbar spondylodiscitis. Eur J Radiol 2015; 84: 1306-1312
    CrossrefPubMedSearch in Google Scholar
  • 49 Boden SD, Davis DO, Dina TS. et al. Postoperative diskitis: distinguishing early MR imaging findings from normal postoperative disk space changes. Radiology 1992; 184: 765-771
    CrossrefPubMedSearch in Google Scholar
  • 50 Prodromou ML, Ziakas PD, Poulou LS. et al. FDG PET is a robust tool for the diagnosis of spondylodiscitis: a meta-analysis of diagnostic data. Clin Nucl Med 2014; 39: 330-335
    CrossrefPubMedSearch in Google Scholar
  • 51 Herren C, Jung N, Pishnamaz M. et al. Spondylodiscitis: Diagnosis and Treatment Options. Dtsch Arztebl Int 2017; 114: 875-882
    CrossrefPubMedSearch in Google Scholar
  • 52 Smids C, Kouijzer IJ, Vos FJ. et al. A comparison of the diagnostic value of MRI and (18)F-FDG-PET/CT in suspected spondylodiscitis. Infection 2017; 45: 41-49
    CrossrefPubMedSearch in Google Scholar
  • 53 Meller J, Koster G, Liersch T. et al. Chronic bacterial osteomyelitis: prospective comparison of (18)F-FDG imaging with a dual-head coincidence camera and (111)In-labelled autologous leucocyte scintigraphy. Eur J Nucl Med Mol Imaging 2002; 29: 53-60
    CrossrefPubMedSearch in Google Scholar
  • 54 Kouijzer IJE, Scheper H, de Rooy JWJ. et al. The diagnostic value of (18)F-FDG-PET/CT and MRI in suspected vertebral osteomyelitis – a prospective study. Eur J Nucl Med Mol Imaging 2018; 45: 798-805
    CrossrefPubMedSearch in Google Scholar
  • 55 Schmitz A, Risse JH, Grunwald F. et al. Fluorine-18 fluorodeoxyglucose positron emission tomography findings in spondylodiscitis: preliminary results. Eur Spine J 2001; 10: 534-539
    CrossrefPubMedSearch in Google Scholar
  • 56 Hungenbach S, Delank KS, Dietlein M. et al. 18F-fluorodeoxyglucose uptake pattern in patients with suspected spondylodiscitis. Nucl Med Commun 2013; 34: 1068-1074
    CrossrefPubMedSearch in Google Scholar
  • 57 Ioannou S, Chatziioannou S, Pneumaticos SG. et al. Fluorine-18 fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography scan contributes to the diagnosis and management of brucellar spondylodiskitis. BMC Infect Dis 2013; 13: 73
    CrossrefPubMedSearch in Google Scholar
  • 58 Skanjeti A, Penna D, Douroukas A. et al. PET in the clinical work-up of patients with spondylodiscitis: a new tool for the clinician?. Q J Nucl Med Mol Imaging 2012; 56: 569-576
    PubMedSearch in Google Scholar
  • 59 Gratz S, Dorner J, Fischer U. et al. 18F-FDG hybrid PET in patients with suspected spondylitis. Eur J Nucl Med Mol Imaging 2002; 29: 516-524
    CrossrefPubMedSearch in Google Scholar
  • 60 Fuster D, Tomas X, Mayoral M. et al. Prospective comparison of whole-body (18)F-FDG PET/CT and MRI of the spine in the diagnosis of haematogenous spondylodiscitis. Eur J Nucl Med Mol Imaging 2015; 42: 264-271
    CrossrefPubMedSearch in Google Scholar
  • 61 Ohtori S, Suzuki M, Koshi T. et al. 18F-fluorodeoxyglucose-PET for patients with suspected spondylitis showing Modic change. Spine (Phila Pa 1976) 2010; 35: E1599-1603
    CrossrefPubMedSearch in Google Scholar
  • 62 Fahnert J, Purz S, Jarvers JS. et al. Use of Simultaneous 18F-FDG PET/MRI for the Detection of Spondylodiskitis. J Nucl Med 2016; 57: 1396-1401
    CrossrefPubMedSearch in Google Scholar
  • 63 De Winter F, Gemmel F, Van De Wiele C. et al. 18-Fluorine fluorodeoxyglucose positron emission tomography for the diagnosis of infection in the postoperative spine. Spine (Phila Pa 1976) 2003; 28: 1314-1319
    CrossrefPubMedSearch in Google Scholar
  • 64 Follenfant E, Balamoutoff N, Lawson-Ayayi S. et al. Added value of [(18)F]fluorodeoxyglucose positron emission tomography/computed tomography for the diagnosis of post-operative instrumented spine infection. Joint Bone Spine 2019; 86: 503-508
    CrossrefPubMedSearch in Google Scholar
  • 65 Paez D, Sathekge MM, Douis H. et al. Comparison of MRI, [(18)F]FDG PET/CT, and (99m)Tc-UBI 29–41 scintigraphy for postoperative spondylodiscitis-a prospective multicenter study. Eur J Nucl Med Mol Imaging 2021; 48: 1864-1875
    CrossrefPubMedSearch in Google Scholar
  • 66 Kim SJ, Kim IJ, Suh KT. et al. Prediction of residual disease of spine infection using F-18 FDG PET/CT. Spine (Phila Pa 1976) 2009; 34: 2424-2430
    CrossrefPubMedSearch in Google Scholar
  • 67 Nanni C, Boriani L, Salvadori C. et al. FDG PET/CT is useful for the interim evaluation of response to therapy in patients affected by haematogenous spondylodiscitis. Eur J Nucl Med Mol Imaging 2012; 39: 1538-1544
    CrossrefPubMedSearch in Google Scholar
  • 68 Pijl JP, Glaudemans A, Slart R. et al. FDG-PET/CT for Detecting an Infection Focus in Patients With Bloodstream Infection: Factors Affecting Diagnostic Yield. Clin Nucl Med 2019; 44: 99-106
    CrossrefPubMedSearch in Google Scholar
  • 69 Dauchy FA, Dutertre A, Lawson-Ayayi S. et al. Interest of [(18)F]fluorodeoxyglucose positron emission tomography/computed tomography for the diagnosis of relapse in patients with spinal infection: a prospective study. Clin Microbiol Infect 2016; 22: 438-443
    CrossrefPubMedSearch in Google Scholar
  • 70 Fuchs S, Grössmann N, Eckhardt H. et al. PET/PET-CT Evidenz zum Bedarf und zur Planung in Deutschland und Österreich: Update 2018. 2019
    PubMedSearch in Google Scholar
  • 71 Bouter C, Meller B, Sahlmann CO. et al. (68)Ga-Pentixafor PET/CT Imaging of Chemokine Receptor CXCR4 in Chronic Infection of the Bone: First Insights. J Nucl Med 2018; 59: 320-326
    CrossrefPubMedSearch in Google Scholar
  • 72 Bouter Y, Meller B, Sahlmann CO. et al. Immunohistochemical detection of chemokine receptor 4 expression in chronic osteomyelitis confirms specific uptake in 68Ga-Pentixafor-PET/CT. Nuklearmedizin 2018; 57: 198-203
    Thieme ConnectPubMedSearch in Google Scholar
  • 73 Wang Y, Li Y, Han L. et al. 18)F-FDG and (68. BMC Musculoskelet Disord 2022; 23: 592
    CrossrefPubMedSearch in Google Scholar