Value of [¹⁸F]FDG PET/CT in diagnosis and management of spondylodiscitis

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.

Keywords

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

Publication History

Received: 20 December 2022

Accepted after revision: 23 February 2023

Article published online:
24 May 2023

• 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 DOI: 10.1016/j.jinf.2013.11.011. (PMID: 24296494)
• 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 DOI: 10.1017/S0950268821002181. (PMID: 34612186)
• 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
• 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 DOI: 10.3390/antibiotics10111410.
• 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
• 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 DOI: 10.2106/JBJS.N.01350. (PMID: 25995495)
• 7 Rupp M, Walter N, Baertl S. et al. Terminology of bone and joint infection. Bone Joint Res 2021; 10: 742-743 DOI: 10.1302/2046-3758.1011.BJR-2021-0371. (PMID: 34786949)
• 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 DOI: 10.1007/s00132-012-1998-4. (PMID: 22926539)
• 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 DOI: 10.1007/s00132-011-1742-5. (PMID: 21451996)
• 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 DOI: 10.1093/cid/civ482. (PMID: 26229122)
• 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 DOI: 10.3109/17453679808997789. (PMID: 9855235)
• 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 DOI: 10.1007/s00590-016-1811-x. (PMID: 27435619)
• 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 DOI: 10.3109/23744235.2015.1103897. (PMID: 26484577)
• 14 Cheung WY, Luk KD. Pyogenic spondylitis. Int Orthop 2012; 36: 397-404 DOI: 10.1007/s00264-011-1384-6. (PMID: 22033610)
• 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 DOI: 10.1007/s00586-020-06519-z. (PMID: 32613398)
• 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 DOI: 10.31616/asj.2018.0295. (PMID: 30866620)
• 17 Hofmann W. Chameleon spondylodiscitis : Challenge for geriatricians. Z Gerontol Geriatr 2017; 50: 623-636 DOI: 10.1007/s00115-018-0546-9. (PMID: 29808417)
• 18 Herren C, von der Höh N, Dreimann M. Diagnostik und Therapie der Spondylodiszitis – S2k-Leitlinie. 2020
• 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 DOI: 10.1007/s00113-021-01002-w. (PMID: 33970304)
• 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 DOI: 10.1093/ofid/ofu107. (PMID: 25734175)
• 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 DOI: 10.1055/s-2008-1038974. (PMID: 19263315)
• 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 DOI: 10.1086/340102. (PMID: 11981730)
• 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
• 24 Mazzie JP, Brooks MK, Gnerre J. Imaging and management of postoperative spine infection. Neuroimaging Clin N Am 2014; 24: 365-374 DOI: 10.1016/j.nic.2014.01.003. (PMID: 24792614)
• 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 DOI: 10.1097/BSD.0b013e31828f9203. (PMID: 27755204)
• 26 Rayes M, Colen CB, Bahgat DA. et al. Safety of instrumentation in patients with spinal infection. J Neurosurg Spine 2010; 12: 647-659
• 27 Prandini N, Lazzeri E, Rossi B. et al. Nuclear medicine imaging of bone infections. Nucl Med Commun 2006; 27: 633-644 DOI: 10.1097/00006231-200608000-00006. (PMID: 16829764)
• 28 Love C, Palestro CJ. Nuclear medicine imaging of bone infections. Clin Radiol 2016; 71: 632-646 DOI: 10.1016/j.crad.2016.01.003. (PMID: 26897336)
• 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 DOI: 10.4081/or.2019.7793. (PMID: 30996840)
• 30 Raghavan M, Lazzeri E, Palestro CJ. Imaging of Spondylodiscitis. Semin Nucl Med 2018; 48: 131-147 DOI: 10.1053/j.semnuclmed.2017.11.001. (PMID: 29452617)
• 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 DOI: 10.1007/s00586-009-1251-y. (PMID: 20052505)
• 32 Diehn FE. Imaging of spine infection. Radiol Clin North Am 2012; 50: 777-798 DOI: 10.1016/j.rcl.2012.04.001. (PMID: 22643395)
• 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 DOI: 10.1016/j.wneu.2019.04.260. (PMID: 31103765)
• 34 Arbelaez A, Restrepo F, Castillo M. Spinal infections: clinical and imaging features. Top Magn Reson Imaging 2014; 23: 303-314 DOI: 10.1097/RMR.0000000000000032. (PMID: 25296275)
• 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 DOI: 10.3174/ajnr.A4571. (PMID: 26585257)
• 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
• 37 Homagk L, Marmelstein D, Homagk N. et al. SponDT (Spondylodiscitis Diagnosis and Treatment): spondylodiscitis scoring system. J Orthop Surg Res 2019; 14: 100 DOI: 10.1186/s13018-019-1134-9. (PMID: 30971277)
• 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
• 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 DOI: 10.1053/j.sult.2016.05.006. (PMID: 27616314)
• 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
• 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
• 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 DOI: 10.1007/s00259-019-04393-6. (PMID: 31399800)
• 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 DOI: 10.3174/ajnr.A6623. (PMID: 32554421)
• 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
• 45 Dumont RA, Keen NN, Bloomer CW. et al. Clinical Utility of Diffusion-Weighted Imaging in Spinal Infections. Clin Neuroradiol 2019; 29: 515-522 DOI: 10.1007/s00062-018-0681-5. (PMID: 29582111)
• 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 DOI: 10.1259/bjr.20140011. (PMID: 24999081)
• 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
• 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 DOI: 10.1016/j.ejrad.2015.03.027. (PMID: 25899662)
• 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
• 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 DOI: 10.1097/RLU.0000000000000336. (PMID: 24445277)
• 51 Herren C, Jung N, Pishnamaz M. et al. Spondylodiscitis: Diagnosis and Treatment Options. Dtsch Arztebl Int 2017; 114: 875-882 DOI: 10.3238/arztebl.2017.0875. (PMID: 29321098)
• 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 DOI: 10.1007/s15010-016-0914-y. (PMID: 27317050)
• 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
• 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 DOI: 10.1007/s00259-017-3912-0. (PMID: 29256136)
• 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 DOI: 10.1007/s005860100339. (PMID: 11806396)
• 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
• 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 DOI: 10.1186/1471-2334-13-73. (PMID: 23388066)
• 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
• 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
• 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 DOI: 10.1007/s00259-014-2898-0. (PMID: 25186431)
• 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
• 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 DOI: 10.2967/jnumed.115.171561. (PMID: 27199353)
• 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 DOI: 10.1097/01.BRS.0000065483.07790.34. (PMID: 12811277)
• 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 DOI: 10.1016/j.jbspin.2019.01.009. (PMID: 30711697)
• 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 DOI: 10.1007/s00259-020-05109-x. (PMID: 33210240)
• 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 DOI: 10.1097/BRS.0b013e3181b1fd33. (PMID: 19829257)
• 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 DOI: 10.1007/s00259-012-2179-8. (PMID: 22820649)
• 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
• 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
• 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
• 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 DOI: 10.2967/jnumed.117.193854. (PMID: 28729430)
• 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 DOI: 10.3413/Nukmed-0971-18-04. (PMID: 30267402)
• 73 Wang Y, Li Y, Han L. et al. 18)F-FDG and (68. BMC Musculoskelet Disord 2022; 23: 592 DOI: 10.1148/radiol.211424. (PMID: 34981976)