Artifacts Mimicking Hardware Loosening After Iterative Metal Artifact Reduction (iMAR) Processing in Spinal Surgery

Metallic implants often produce artifacts in computed tomography (CT) imaging, complicating the interpretation of postoperative findings. This case report describes a 63-year-old male with a history of cervical and lumbar spine surgeries who presented with worsening radicular pain. The patient underwent cervical decompression laminectomy and posterior instrumented fusion. Postoperative CT, processed with an iterative metal artifact reduction (iMAR) algorithm, revealed unexpected hypodense lucencies surrounding pedicle screws and fixation hardware, initially suggestive of hardware loosening or infection. However, these lucencies were not seen in non-processed images, indicating their artifactual nature. This case highlights the potential for iMAR to generate misleading findings that may mimic clinical conditions, emphasizing the need for a careful approach when interpreting iMAR-processed images in conjunction with clinical context and pre-processed datasets to prevent unnecessary interventions.