The role of bone SPECT/CT in patients with persistent or recurrent lumbar pain following lumbar spine stabilization surgery.

PURPOSE: Despite recent advances in lumbar spine stabilization surgery (LSSS), a high number of patients continue to complain of persistent/recurrent lumbar pain after LSSS. Conventional imaging (plain radiography, CT and MRI) is commonly performed to assess potential lumbar pain generators, but findings are equivocal in approximately 20% of patients. The purpose of this study was to assess the diagnostic performance of 99mTc-HDP bone SPECT/CT in identifying potential pain generators in patients with persistent/recurrent lumbar pain after LSSS but in whom conventional diagnostic imaging is inconclusive. METHODS: A total of 187 patients (median age 56 years, 70 men) with persistent/recurrent lumbar pain following LSSS with inconclusive conventional imaging (plain radiography, CT and/or MRI) underwent 99mTc-HDP bone SPECT/CT and were included in the study. Tracer uptake on SPECT/CT, as an indicator of ongoing or altered osteoblastic activity, was assessed in the lumbar spine stabilization segment(s) and in adjacent segments. Uptake intensity was graded as (1) high (the same as or more than iliac crest uptake), (2) mild (the same as or more than nondiseased vertebral uptake but less than iliac crest uptake), or (3) negative (normal scan). Mild and high uptake were regarded as positive. RESULTS: In 160 of the 187 patients (85.6%), SPECT/CT showed positive mild or high tracer uptake in the LSSS region. More than half of the patients had abnormal tracer uptake in the stabilized segments (56.7%) and/or in the adjacent segments (55.6%). Although positive stabilized segment findings were commonly seen at <2 years (70.3%) and the rate decreased with time after LSSS, they were seen at >6 years after surgery in 38.2% of patients. In 51.4% of patients, abnormal activity was seen in the adjacent segments <2 years after LSSS, suggesting early/accelerated degeneration after surgery. The proportion of patients with abnormal activity in the adjacent segments increased to 67.3% at >6 years after LSSS (p < 0.05). Positive SPECT/CT findings in the stabilized segments were more frequent in patients with three or more stabilized segments (p < 0.05), but were not more frequent in the adjacent segments. Overall, positive SPECT/CT guided therapy in 64% of patients, which included facet joint/nerve root injections or re-do surgery at active sites and/or adjacent sites. CONCLUSION: Bone SPECT/CT is a sensitive diagnostic tool for identifying altered osteoblastic activity, which might be a pain generator in patients with persistent/recurrent pain after lumbar surgery especially when conventional imaging is inconclusive.

Spinal Cervical Meningiomas: The Challenge Posed by Ventral Location.

OBJECTIVE: To evaluate the incidence, clinical presentation, operative techniques, and long-term outcome of spinal cervical meningiomas after surgery. METHODS: Twenty-two patients harboring spinal meningiomas on cervical region were treated between 2004 and 2014 in our department. Diagnosis was made via magnetic resonance imaging and confirmed histologically. Microsurgical resection was performed through different surgical approaches according to location of the tumor. To remove the tumor, the posterior, far-lateral, and combined approaches were used, respectively, in 13 patients (56%), 8 patients (35%), and 2 patients (9%). RESULTS: The mean follow-up was 40 ± 26.5 months. The most common site of dural attachment of meningioma was ventral or ventrolateral to the spinal cord. Macroscopic resection was considered complete in 55% of cases. Neurologic improvement was observed in 60% of cases. The rate of operative mortality and morbidity was high (26.5%). Five patients underwent postoperative radiotherapy according to the actual recommendation, and the overall recurrence rate was 9%. CONCLUSIONS: Spinal meningiomas are benign tumors for which advances in imaging tools and microsurgical techniques have yielded better results. The goal of surgery should be the total resection, which significantly decreases the risk of recurrence with an acceptable morbidity. Cervical locations represent a challenge particularly for ventro and ventrolaterally located tumors. Despite the difficulty of performing a complete resection, the results obtained in this work advocate for the use of the far-lateral approach to manage meningiomas locate anterior to the neural axis.

Trombone tongue: a new clinical sign for significant medullary compression at the craniovertebral junction. Case report.

The authors describe a previously unreported clinical sign that may indicate the onset of significant compression of the medulla oblongata in cases of craniovertebral junction abnormalities. This 17-year-old boy presented with mild bilateral leg weakness. Imaging studies revealed severe basilar invagination and a marked Chiari malformation. While awaiting surgery, his tongue developed an involuntary constant protrusion-intrusion repetitive motion. The onset of this so-named "trombone tongue" sign was followed shortly afterward by rapidly progressive spastic tetraparesis. After the authors performed a transmaxillary clivectomy, foramen magnum decompression, and occipitocervical fusion, they noted that the abnormal tongue motion promptly resolved and the tetraparesis gradually improved. The authors discuss their current understanding of the central control of tongue movements and present a hypothesis on the pathogenesis of trombone tongue based on the neuroanatomical basis of another abnormal tongue movement sign, lingual myoclonus.

Displaced fracture through the anterior atlantal synchondrosis.

In the acute setting, accurate radiological interpretation of paediatric cervical spine trauma can be difficult due to a combination of normal variants and presence of multiple synchondroses. We present a rare case of a fracture through the anterior atlantal synchondrosis in a paediatric spine. A five-year-old boy, who fell backwards onto the top of his head while swinging across on a monkey bar frame, presented with neck pain, cervical muscle spasm and decreased right lateral rotation and extension of his neck. Computed tomography showed a displaced diastatic fracture through right anterior atlantal synchondrosis. There are only 12 cases of paediatric C1 fractures reported in the world literature. The importance of considering this diagnosis in the appropriate clinical setting, and the normal variants in the paediatric atlas that can cause diagnostic dilemma to the interpreting radiologist, are discussed in this case report.

Excision of an osteoid osteoma from the body of the axis through an anterior approach.

Osteoid osteoma is seen less commonly in the vertebral body than in the posterior elements of the spine. To the authors' knowledge, this is only the second reported case of an osteoid osteoma affecting the body of the axis. The patient described in this report presented with the classic symptomatology of pain and torticollis. Radiological imaging confirmed the diagnosis. A superior extension of the anterior Smith-Robinson approach, through the "window of access" described by Fasel, was used to excise this lesion. Following surgical excision, there was complete resolution of the presenting symptomatology and functionally the range of motion of the cervical spine returned to normal. We avoided instrumentation and C1-C2 fusion so that rotation of the cervical spine could be maintained. There were no signs of recurrence of the tumour within the 4-year follow-up period. It presented in a classic way but, despite this, it took 2 years from the onset of these symptoms to reach a definitive diagnosis. This osteoid osteoma was successfully excised through a superior extension of the anterior Smith-Robinson approach.