Assessment of bone graft incorporation by 18 F-fluoride positron-emission tomography/computed tomography in patients with persisting symptoms after posterior lumbar interbody fusion

Background: Posterior lumbar interbody fusion (PLIF) is a method that allows decompression of the spinal canal and nerve roots by laminectomy combined with fusion by means of intervertebral cages filled with bone graft and pedicle screw fixation. Conventional imaging techniques, such as plain radiography and computed tomography (CT), have limitations to assess bony fusion dynamics. Methods: In 16 PLIFs of 15 patients with persisting symptoms, positron-emission tomography (PET)/CT scans were made 60 min after intravenous administration of 156 to 263 MBq of (18) F-fluoride, including 1-mm sliced, high-dose, non-contrast-enhanced CT scanning. Maximal standard uptake values (SUVmax) of various regions were calculated and correlated with abnormalities on CT. Results: Subsidence of the cages into the vertebral endplates was the most frequently observed abnormality on CT (in 16 of 27 or 59% of evaluable endplates). Endplate SUVmax values were significantly higher for those patients with pronounced (p < 0.0001) or moderate (p < 0.013) subsidence as compared to those with no subsidence. Additionally, a significant correlation between vertebral and ipsilateral pedicle screw entrance SUVmax values (p < 0.009) was found, possibly indicating posterior transmission of increased bone stress. In our patient group, intercorporal fusion was seen on CT in 63% but showed no correlation to intercorporal SUVmax values. Conclusions: With the use of (18) F-fluoride PET/CT, intervertebral cage subsidence appeared to be a prominent finding in this patient group with persisting symptoms, and highly correlating with the degree of PET hyperactivity at the vertebral endplates and pedicle screw entry points. Further study using (18) F-fluoride PET/CT should specifically assess the role of metabolically active subsidence in a prospective patient group, to address its role in nonunion and as a cause of persisting pain.