Background <p>Chronic low-back pain (LBP) is an extremely common symptom, especially in the older population. It is difficult to diagnose using conventional imaging because the underlying mechanisms of chronic LBP are complex and often multifactorial. With the development of single-photon emission computed tomography/computed tomography (SPECT/CT), a more precise method has become available for identifying the source of chronic LBP by localizing radiotracer uptake and detecting subtle anatomical and physiological signs of instability or inflammation. Its ability to highlight pain-generating structures has substantially improved diagnostic confidence in degenerative spine disease, contributing to its widespread clinical adoption.</p> Objective <p>This review evaluates the diagnostic performance, clinical utility, and technical considerations of SPECT/CT in degenerative spine diseases, with particular emphasis on its contribution to clinical decision-making. We provide an overview of its use in patients with persistent chronic low back pain, discuss how precise localization of pain-generating structures may inform both invasive and non-invasive management strategies, and examine its value in preoperative planning. In addition, the advantages and limitations of SPECT/CT relative to conventional imaging modalities are summarized.</p> Methods <p>A narrative review was performed using focused searches of major medical databases. Studies were included according to their relevance to clinical use, interpretation, and management implications of SPECT/CT.</p> Results <p>Across the literature, SPECT/CT demonstrated high diagnostic performance in detecting clinically significant pain generators, particularly facet joint arthropathy, active pars lesions, adjacent segment disease, pseudarthrosis, and symptomatic vertebral compression fractures. Multiple studies report that SPECT/CT frequently influences management decisions, enhances preoperative planning, guides targeted spinal injections or ablations, and distinguishes between symptomatic and incidental degenerative changes. Furthermore, SPECT/CT has demonstrated value in postoperative patients where other modalities are limited by the presence of metallic implants, and in confirming metabolically active lesions that require intervention.</p> Conclusions <p>SPECT/CT has demonstrated itself to be an effective imaging modality for localizing pain generators and facilitating spine surgeons in formulating appropriate treatment strategies for degenerative spine diseases and failed fusion. When conventional imaging is inconclusive, SPECT/CT serves as an additional imaging modality with high sensitivity to detect subtle lesions along the spinal axis. Overall, current evidence highlights the growing role of SPECT/CT in targeted diagnosis and individualized treatment planning.</p>