In this lecture, we examine a postoperative cervical spine case in a 39-year-old female who continued to experience severe neck pain following anterior cervical discectomy and fusion (ACDF). Despite MRI evaluation, the etiology of her worsening symptoms remained unclear, prompting referral for SPECT/CT.
The discussion walks through the delayed-phase SPECT/CT findings, highlighting focal intense uptake at the superior endplate of C6, accompanied by cortical osteolysis, cystic change, subtle lucency at the bone–prosthesis interface, and sclerosis; features characteristic of inflammatory (pathologic) osteolysis, rather than expected postoperative remodeling or stress shielding.
The lecture emphasizes how SPECT/CT can identify hardware-related complications not always apparent on MRI, the imaging distinctions between inflammatory versus non-inflammatory osteolysis, and the critical role of CT slice thickness and acquisition quality in evaluating prosthetic interfaces.

Learning objectives

By the end of this lecture, participants will be able to:

• Differentiate inflammatory from non-inflammatory osteolysis on SPECT/CT based on uptake patterns and characteristic CT morphology.
• Recognize key imaging markers of pathological hardware-related complications after ACDF, including endplate osteolysis, lucency at the bone–implant interface, and associated sclerosis or cystic change.
• Understand the added value of delayed-phase SPECT/CT when postoperative MRI is inconclusive or limited by metal artifact.
• Identify when focal, intense uptake adjacent to cervical implants is concerning and should prompt surgical reassessment.
• Appreciate the importance of optimized CT acquisition parameters, particularly thin slices, when evaluating prostheses for subtle lucencies or early loosening.