HISTORY: She has a history of neurosurgery 4 years ago (laminectomyL1 - body ablation D12-L1 - complex arthodesis D10-L2) for a rare paraganglioma tumor.

CLINICAL: Since 2 months she complaints about intense back pain at dorso-lumbar junction. She developped hyperthermia and a blood culture came out positive (gram- enterobacter aerogenes MR).

ICONOGRAPHY: 

  Figure 1. The plain X-rays of chest, abdomen and dorso-lumbar junction demonstrated no abnormality. The CT and NMR scan were non-diagnostic with suboptimal quality due to the arthodesis materials.

Figure 2. We did perform the GALLIUM SCAN following a SIMULTANEOUS DUAL ISOTOPE PROTOCOL GALLIUM-BONE SCAN (Gallium67-HDPTc99m) on 1-Day. The dual Ga-Tc planarWB scan demonstrated a focus of enhanced uptake of Gallium at the inferior dorsal segment and post-neurosurgery bone remodeling HDP-uptake at the dorso-lumbar junction.

Figure 3-4. The dual Ga-Tc SPECT confirmed and revealed a paravertebral focus of Gallium-uptake at D8-D11 level and another central spinal focus at D9-D10 (Fig 4) but no enhanced bone-uptake at these levels.

CONCLUSION: Paravertebral abcess at D8-D11 levels with spinal/discal extension. TAKE HOME MESSAGE: Gallium is preferred to radiolabelled leucocytes for spinal infectious pathology. In the era of SPECT-CT, alternative does exist when you don't have (yet) a CT or when CT would probably not help due to metallic artifacts. SIMULTANEOUS DUAL ISOTOPE SCAN is a smart, safe, and helpful technique and can done in 1-Day.

References:

• Steinling M, Coequyt S, Marchandise X, Beuscart R, Vergnes R. Simultaneous scintigraphy exploration using MDP - 99 Tc and 67GA in infectious steoarticular pathology. Initial result. Rev Rhum Mal Osteoartic. 1982 Jul-Sep;49(8-9):635-41.
• Steinling M, Coequyt S, Brion M, Beaucaire G, Marchandise X, Vergnes R, Fourrier A. Fast Diagnosis (6h) of clinically silent pyonephrosis by combined use of 99mTc-MDP and 67Ga citrate. Eur J Nucl Med. 1981;6(8):379-81.

Comment from the Editor (Prof. S. Goldman, ULB).

We would like to remind that it is unusual to image Gallium-67 as early as 6 hours after injection. Yet this approach is mentionned in the SNM guidelines.

"Scintigrams are generally obtained 24–72 h after injection of the radiopharmaceutical. Delayed scintigrams at 96 h or later may be necessary for accurate interpretation and are particularly helpful in the abdomen when normal colonic and renal activity can make scintigram interpretation difficult. Early 3–4-h scintigrams can be helpful in cases of acute inflammation to avoid extensive bowel activity." Here is the link to the SNM guidelines .