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Shpigelman A, Shouval A, Koder I, Keret S, Slobodin G. Facet joint involvement in the inflammatory rheumatic disease. Joint Bone Spine 2024; 91:105674. [PMID: 38101697 DOI: 10.1016/j.jbspin.2023.105674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 11/12/2023] [Accepted: 11/21/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND The involvement of facet joints (FJ) in patients with inflammatory rheumatic disorders remains underexplored. This review aims to look at FJ disease from a rheumatologist's perspective, with the emphasis given to the clinical presentations and patterns of FJ engagement in axial spondyloarthritis (axSpA), psoriatic arthritis (PsA), rheumatoid arthritis (RA), and crystal-related arthropathies, and discussion of challenges in studying FJ in rheumatic disease. METHODS A systematic PubMed search using the pertinent keywords was performed, relevant articles extracted, and the acquired data critically assessed, interpreted, and organized according to the authors' experience and judgment. RESULTS FJ involvement is common in patients with radiographic axSpA, occurs throughout the spine, but is more frequently seen in the thoracic segment. The existing data suggests that the FJ are primarily affected by the disease process, while altered spine biomechanics due to the presence of syndesmophytes at the same vertebral level contributes to the FJ fusion. Predominant involvement of FJ of the cervical spinal segment has been suggested in PsA; however, prevalence and clinical significance of FJ involvement in PsA is still markedly underexplored. RA-related FJ disease of the cervical spine in patients with poorly controlled RA is not uncommon and can be related to significant morbidity, while the burden of FJ involvement in the thoracic and lumbar spinal segments in RA is also underexplored. FJ disease is possible in the course of crystal-related arthropathies, but the high level of suspicion is a prerequisite for the timely diagnosis. CONCLUSIONS The involvement of FJ in the course of inflammatory rheumatic disease is not uncommon. Prospective studies are needed to understand the epidemiology and significance of FJ disease in inflammatory rheumatic conditions.
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Affiliation(s)
- Arsen Shpigelman
- Spine Unit, Department of Orthopedic Surgery, Lady Davis Carmel Medical Center, Haifa, Israel; Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Aniela Shouval
- Rheumatology Unit, Bnai Zion Medical Center, Haifa, Israel
| | - Ilai Koder
- Spine Unit, Department of Orthopedic Surgery, Lady Davis Carmel Medical Center, Haifa, Israel
| | - Shiri Keret
- Rheumatology Unit, Bnai Zion Medical Center, Haifa, Israel
| | - Gleb Slobodin
- Rheumatology Unit, Bnai Zion Medical Center, Haifa, Israel.
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2
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Kunow A, Freyer Martins Pereira J, Chenot JF. Extravertebral low back pain: a scoping review. BMC Musculoskelet Disord 2024; 25:363. [PMID: 38714994 PMCID: PMC11075250 DOI: 10.1186/s12891-024-07435-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Accepted: 04/11/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Low back pain (LBP) is one of the most common reasons for consultation in general practice. Currently, LBP is categorised into specific and non-specific causes. However, extravertebral causes, such as abdominal aortic aneurysm or pancreatitis, are not being considered. METHODS A systematic literature search was performed across MEDLINE, Embase, and the Cochrane library, complemented by a handsearch. Studies conducted between 1 January 2001 and 31 December 2020, where LBP was the main symptom, were included. RESULTS The literature search identified 6040 studies, from which duplicates were removed, leaving 4105 studies for title and abstract screening. Subsequently, 265 publications were selected for inclusion, with an additional 197 publications identified through the handsearch. The majority of the studies were case reports and case series, predominantly originating from specialised care settings. A clear distinction between vertebral or rare causes of LBP was not always possible. A range of diseases were identified as potential extravertebral causes of LBP, encompassing gynaecological, urological, vascular, systemic, and gastrointestinal diseases. Notably, guidelines exhibited inconsistencies in addressing extravertebral causes. DISCUSSION Prior to this review, there has been no systematic investigation into extravertebral causes of LBP. Although these causes are rare, the absence of robust and reliable epidemiological data hinders a comprehensive understanding, as well as the lack of standardised protocols, which contributes to a lack of accurate description of indicative symptoms. While there are certain disease-specific characteristics, such as non-mechanical or cyclical LBP, and atypical accompanying symptoms like fever, abdominal pain, or leg swelling, that may suggest extravertebral causes, it is important to recognise that these features are not universally present in every patient. CONCLUSION The differential diagnosis of extravertebral LBP is extensive with relatively low prevalence rates dependent on the clinical setting. Clinicians should maintain a high index of suspicion for extravertebral aetiologies, especially in patients presenting with atypical accompanying symptoms.
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Affiliation(s)
- Anna Kunow
- Department of General Practice, University Medicine Greifswald, 17475, Fleischmannstraße, Greifswald, Germany.
| | | | - Jean-François Chenot
- Department of General Practice, University Medicine Greifswald, 17475, Fleischmannstraße, Greifswald, Germany
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3
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Ben Tekaya A, Nacef L, Bellil M, Saidane O, Rouached L, Bouden S, Tekaya R, Mahmoud I, Abdelmoula L. Lumbar Spinal Involvement in Calcium Pyrophosphate Dihydrate Disease: A Systematic Literature Review. Int J Gen Med 2022; 15:7639-7656. [PMID: 36226310 PMCID: PMC9550172 DOI: 10.2147/ijgm.s360714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 04/27/2022] [Indexed: 11/06/2022] Open
Abstract
Background Calcium-pyrophosphate-dihydrate-disease (CPPD) is a crystal-induced arthropathy. The lumbar-spinal involvement is rare and often under-diagnosed. This study aimed to report the case of a lumbar spine CPPD involvement and to perform a systematic review of clinical, imaging features of lumbar involvement in CPPD patients, and treatments that have been implemented. Methods This systematic review was conducted in accordance with the Preferred-Reporting-Items-for-Systematic-Reviews and Meta-Analyses (PRISMA) guidelines. Results One hundred and sixty-seven articles met the search criteria using electronic databases searches. We retained 28 articles (20 case reports, 2 case series, 1 family survey, 4 retrospective studies, and 1 prospective study) involving a total of 62 patients. The age ranged between 39 and 89 years old. Among patients with lumbar spine CPPD, 32 were women. The duration of symptoms varied between one day and 8 years. The affection has been discovered during back pain in most cases. In 5 studies, the diagnosis was made on histological specimens of patients operated on for another pathology. X-ray showed calcifications in 2 cases. CT-scan detected calcium deposit in 7 cases. MRI showed lesions going from the increased signal of the disk, to calcified or not-cystic lesion of the facet joints, an intramedullary mass mimicking a schwannoma. Histological examination established the diagnosis of CPPD in 21 patients in all studies. Medical treatment included NSAIDs, Colchicine, Interleukin-1-receptor-antagonist, and antibiotics. Surgery was performed on 13 patients and allowed to establish the histological diagnosis. Conclusion In the case of inflammatory back pain in elderly subjects, without an infectious gateway, diagnosis of CPPD should be considered, especially for patients with a history of spinal surgery or degenerative radiography changes. CT scan is more sensitive than conventional radiographs. The discovertebral biopsy is the Gold-Standard and should be performed whenever the diagnosis was uncertain. Treatment includes the medical and surgical components.
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Affiliation(s)
- Aicha Ben Tekaya
- Rheumatology Department, Charles Nicolle Hospital, Tunis, Tunisia,Faculty of Medicine of Tunis, University Tunis El Manar, Tunis, Tunisia,Correspondence: Aicha Ben Tekaya, Rheumatology Department, Charles Nicolle Hospital, Tunis, Tunisia, Tel +216 97850485, Email
| | - Lilia Nacef
- Rheumatology Department, Charles Nicolle Hospital, Tunis, Tunisia,Faculty of Medicine of Tunis, University Tunis El Manar, Tunis, Tunisia
| | - Mehdi Bellil
- Faculty of Medicine of Tunis, University Tunis El Manar, Tunis, Tunisia,Orthopedic Department, Charles Nicolle Hospital, Tunis, Tunisia
| | - Olfa Saidane
- Rheumatology Department, Charles Nicolle Hospital, Tunis, Tunisia,Faculty of Medicine of Tunis, University Tunis El Manar, Tunis, Tunisia
| | - Leila Rouached
- Rheumatology Department, Charles Nicolle Hospital, Tunis, Tunisia,Faculty of Medicine of Tunis, University Tunis El Manar, Tunis, Tunisia
| | - Selma Bouden
- Rheumatology Department, Charles Nicolle Hospital, Tunis, Tunisia,Faculty of Medicine of Tunis, University Tunis El Manar, Tunis, Tunisia
| | - Rawdha Tekaya
- Rheumatology Department, Charles Nicolle Hospital, Tunis, Tunisia,Faculty of Medicine of Tunis, University Tunis El Manar, Tunis, Tunisia
| | - Ines Mahmoud
- Rheumatology Department, Charles Nicolle Hospital, Tunis, Tunisia,Faculty of Medicine of Tunis, University Tunis El Manar, Tunis, Tunisia
| | - Leila Abdelmoula
- Rheumatology Department, Charles Nicolle Hospital, Tunis, Tunisia,Faculty of Medicine of Tunis, University Tunis El Manar, Tunis, Tunisia
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4
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Jaffee S, Jeong SW, Dabecco R, Elhamdani S, Yu A. Pseudogout, an unconventional imitator of the lumbosacral spine with associated chronic epidural hematoma: illustrative cases. JOURNAL OF NEUROSURGERY: CASE LESSONS 2022; 3:CASE21571. [PMID: 36130549 PMCID: PMC9379621 DOI: 10.3171/case21571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 10/20/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND Pseudogout, or calcium pyrophosphate dihydrate (CPPD) disease, is an inflammatory joint disease that most commonly involves the joints of the knees, ankles, and wrists. Pseudogout has also been known to involve the spine, especially the atlanto-occipital joint of the cervical spine, but there is limited documentation of its involvement in the lumbar spine. Though the atypical presentation of spinal pseudogout with findings consistent with discitis and epidural abscess has been documented, its presentation with associated chronic spinal epidural hematoma is a rare entity. OBSERVATIONS The authors present two separate cases of pseudogout involvement of the lumbar spine, one case presenting with a clinical and radiographic picture consistent with discitis and epidural abscess and the other with radiographic and operative findings consistent with a chronic epidural hematoma. LESSONS This case series demonstrates rare and atypical presentations of pseudogout within the lumbosacral spine.
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Affiliation(s)
- Stephen Jaffee
- Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Seung Won Jeong
- Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Rocco Dabecco
- Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Shahed Elhamdani
- Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Alexander Yu
- Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, Pennsylvania
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5
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Boudabbous S, Paulin EN, Delattre BMA, Hamard M, Vargas MI. Spinal disorders mimicking infection. Insights Imaging 2021; 12:176. [PMID: 34862958 PMCID: PMC8643376 DOI: 10.1186/s13244-021-01103-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 10/03/2021] [Indexed: 12/23/2022] Open
Abstract
Spinal infections are very commonly encountered by radiologists in their routine clinical practice. In case of typical MRI features, the diagnosis is relatively easy to interpret, all the more so if the clinical and laboratory findings are in agreement with the radiological findings. In many cases, the radiologist is able to make the right diagnosis, thereby avoiding a disco-vertebral biopsy, which is technically challenging and associated with a risk of negative results. However, several diseases mimic similar patterns, such as degenerative changes (Modic) and crystal-induced discopathy. Differentiation between these diagnoses relies on imaging changes in endplate contours as well as in disc signal. This review sought to illustrate the imaging pattern of spinal diseases mimicking an infection and to define characteristic MRI and CT patterns allowing to distinguish between these different disco-vertebral disorders. The contribution of advanced techniques, such as DWI and dual-energy CT (DECT) is also discussed.
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Affiliation(s)
- Sana Boudabbous
- Division of Radiology, Department of Diagnosis, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland. .,Faculty of Medicine of the Geneva University, Geneva, Switzerland.
| | - Emilie Nicodème Paulin
- Division of Radiology, Medical Imaging Department, Hospital of Neuchatel, Neuchâtel, Switzerland
| | - Bénédicte Marie Anne Delattre
- Division of Radiology, Department of Diagnosis, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland.,Faculty of Medicine of the Geneva University, Geneva, Switzerland
| | - Marion Hamard
- Division of Radiology, Department of Diagnosis, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland
| | - Maria Isabel Vargas
- Faculty of Medicine of the Geneva University, Geneva, Switzerland.,Division of Neuroradiology, Diagnostic Department, University Hospitals of Geneva, Geneva, Switzerland
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6
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Imaging of facet joint diseases. Clin Imaging 2021; 80:167-179. [PMID: 34333352 DOI: 10.1016/j.clinimag.2021.07.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 06/26/2021] [Accepted: 07/03/2021] [Indexed: 02/01/2023]
Abstract
Facet joints are the important articular pillars of the spine. Several pathologies can occur in and around the facet joint, including extra ossicles, traumatic dislocation, osteoarthritis, synovial cyst, axial spondyloarthritis, rheumatoid arthritis, calcium pyrophosphate deposition disease, septic arthritis, and malignant and benign neoplasms. Imaging is the mainstay to detect and characterize these diseases. In this review, we discuss the anatomy and function of facet joints, imaging techniques, and the imaging findings of several facet joint diseases. This information may be helpful to radiologists to make the correct diagnosis and optimize the management of patients with facet joint diseases.
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Anaya JEC, Coelho SRN, Taneja AK, Cardoso FN, Skaf AY, Aihara AY. Differential Diagnosis of Facet Joint Disorders. Radiographics 2021; 41:543-558. [PMID: 33481690 DOI: 10.1148/rg.2021200079] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Spinal pain due to facet joint disease is difficult to diagnose since the clinical history and physical examination findings are usually nonspecific. Facet joint disorders have a wide range of causes and, because of the potential for chronic back pain and disability, an accurate diagnosis is essential. The most frequent cause of pain in facet joints is osteoarthritis, which can be assessed at radiography, CT, or MRI. Ganglion and synovial cysts of the facet joints can cause compressive symptoms of adjacent structures, especially radiculopathy, lower back pain, and sensory or motor deficits. In ankylosing spondylitis, imaging findings of the facet joints are useful not only for diagnosis but also for monitoring structural changes. In septic arthritis of the facet joints, an early diagnosis at MRI is essential. Gout and metabolic diseases are best evaluated at dual-energy CT, which allows the depiction of crystals. Traumatic dislocations of facet joints are usually unstable injuries that require internal reduction, fixation, and fusion and can be well assessed at CT with three-dimensional reconstructions. Facet joint neoplasms like osteoid osteoma, plasmacytoma, tenosynovial giant cell tumor, and osteochondroma are best evaluated at CT or MRI. The authors provide an overview of key imaging features of the most common facet joint disorders along with anatomic tips and illustrative cases. Acknowledging key imaging findings for the differential diagnosis of facet joint disorders plays a crucial role in the diagnostic accuracy and proper treatment approach for such entities. Online supplemental material is available for this article. ©RSNA, 2021.
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Affiliation(s)
- Julia E C Anaya
- From the Division of Musculoskeletal Radiology, Laboratório Delboni Auriemo, Diagnósticos da América SA (DASA), R. Dr. Diogo de Faria 1379, Vila Clementino, São Paulo, SP 04037-005, Brazil (J.E.C.A., S.R.N.C., A.K.T., F.N.C., A.Y.S., A.Y.A.); Division of Musculoskeletal Radiology, Alta Diagnósticos, São Paulo, Brazil (J.E.C.A., S.R.N.C., A.K.T., A.Y.S.); Musculoskeletal Imaging Division, Hospital Israelita Albert Einstein, São Paulo, Brazil (A.K.T.); Department of Diagnostic Imaging, Federal University of São Paulo, São Paulo, Brazil (F.N.C., A.Y.A.); Division of Musculoskeletal Radiology, Hospital do Coração (HCor), São Paulo, Brazil (A.K.T., A.Y.S.); and Teleimagem, São Paulo, Brazil (A.K.T., A.Y.S.)
| | - Silmara R N Coelho
- From the Division of Musculoskeletal Radiology, Laboratório Delboni Auriemo, Diagnósticos da América SA (DASA), R. Dr. Diogo de Faria 1379, Vila Clementino, São Paulo, SP 04037-005, Brazil (J.E.C.A., S.R.N.C., A.K.T., F.N.C., A.Y.S., A.Y.A.); Division of Musculoskeletal Radiology, Alta Diagnósticos, São Paulo, Brazil (J.E.C.A., S.R.N.C., A.K.T., A.Y.S.); Musculoskeletal Imaging Division, Hospital Israelita Albert Einstein, São Paulo, Brazil (A.K.T.); Department of Diagnostic Imaging, Federal University of São Paulo, São Paulo, Brazil (F.N.C., A.Y.A.); Division of Musculoskeletal Radiology, Hospital do Coração (HCor), São Paulo, Brazil (A.K.T., A.Y.S.); and Teleimagem, São Paulo, Brazil (A.K.T., A.Y.S.)
| | - Atul K Taneja
- From the Division of Musculoskeletal Radiology, Laboratório Delboni Auriemo, Diagnósticos da América SA (DASA), R. Dr. Diogo de Faria 1379, Vila Clementino, São Paulo, SP 04037-005, Brazil (J.E.C.A., S.R.N.C., A.K.T., F.N.C., A.Y.S., A.Y.A.); Division of Musculoskeletal Radiology, Alta Diagnósticos, São Paulo, Brazil (J.E.C.A., S.R.N.C., A.K.T., A.Y.S.); Musculoskeletal Imaging Division, Hospital Israelita Albert Einstein, São Paulo, Brazil (A.K.T.); Department of Diagnostic Imaging, Federal University of São Paulo, São Paulo, Brazil (F.N.C., A.Y.A.); Division of Musculoskeletal Radiology, Hospital do Coração (HCor), São Paulo, Brazil (A.K.T., A.Y.S.); and Teleimagem, São Paulo, Brazil (A.K.T., A.Y.S.)
| | - Fabiano N Cardoso
- From the Division of Musculoskeletal Radiology, Laboratório Delboni Auriemo, Diagnósticos da América SA (DASA), R. Dr. Diogo de Faria 1379, Vila Clementino, São Paulo, SP 04037-005, Brazil (J.E.C.A., S.R.N.C., A.K.T., F.N.C., A.Y.S., A.Y.A.); Division of Musculoskeletal Radiology, Alta Diagnósticos, São Paulo, Brazil (J.E.C.A., S.R.N.C., A.K.T., A.Y.S.); Musculoskeletal Imaging Division, Hospital Israelita Albert Einstein, São Paulo, Brazil (A.K.T.); Department of Diagnostic Imaging, Federal University of São Paulo, São Paulo, Brazil (F.N.C., A.Y.A.); Division of Musculoskeletal Radiology, Hospital do Coração (HCor), São Paulo, Brazil (A.K.T., A.Y.S.); and Teleimagem, São Paulo, Brazil (A.K.T., A.Y.S.)
| | - Abdalla Y Skaf
- From the Division of Musculoskeletal Radiology, Laboratório Delboni Auriemo, Diagnósticos da América SA (DASA), R. Dr. Diogo de Faria 1379, Vila Clementino, São Paulo, SP 04037-005, Brazil (J.E.C.A., S.R.N.C., A.K.T., F.N.C., A.Y.S., A.Y.A.); Division of Musculoskeletal Radiology, Alta Diagnósticos, São Paulo, Brazil (J.E.C.A., S.R.N.C., A.K.T., A.Y.S.); Musculoskeletal Imaging Division, Hospital Israelita Albert Einstein, São Paulo, Brazil (A.K.T.); Department of Diagnostic Imaging, Federal University of São Paulo, São Paulo, Brazil (F.N.C., A.Y.A.); Division of Musculoskeletal Radiology, Hospital do Coração (HCor), São Paulo, Brazil (A.K.T., A.Y.S.); and Teleimagem, São Paulo, Brazil (A.K.T., A.Y.S.)
| | - André Y Aihara
- From the Division of Musculoskeletal Radiology, Laboratório Delboni Auriemo, Diagnósticos da América SA (DASA), R. Dr. Diogo de Faria 1379, Vila Clementino, São Paulo, SP 04037-005, Brazil (J.E.C.A., S.R.N.C., A.K.T., F.N.C., A.Y.S., A.Y.A.); Division of Musculoskeletal Radiology, Alta Diagnósticos, São Paulo, Brazil (J.E.C.A., S.R.N.C., A.K.T., A.Y.S.); Musculoskeletal Imaging Division, Hospital Israelita Albert Einstein, São Paulo, Brazil (A.K.T.); Department of Diagnostic Imaging, Federal University of São Paulo, São Paulo, Brazil (F.N.C., A.Y.A.); Division of Musculoskeletal Radiology, Hospital do Coração (HCor), São Paulo, Brazil (A.K.T., A.Y.S.); and Teleimagem, São Paulo, Brazil (A.K.T., A.Y.S.)
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8
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Moon AS, Mabry S, Pittman JL. Calcium pyrophosphate deposition disease of the cervical and thoracolumbar spine: A report of two cases. NORTH AMERICAN SPINE SOCIETY JOURNAL (NASSJ) 2020; 3:100026. [PMID: 35141594 PMCID: PMC8819963 DOI: 10.1016/j.xnsj.2020.100026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 08/09/2020] [Accepted: 08/17/2020] [Indexed: 11/30/2022]
Abstract
Background Spinal calcium pyrophosphate deposition disease (CPPD) is uncommon, and often resembles more common spine pathologies causing pain and neural compression. Here, we present two unusual cases of CPPD of the cervical and thoracolumbar spines. Case description Case 1: A 71-year old female smoker presented with a large epidural mass causing rapidly progressive cervical myelopathy with weakness in the upper and lower extremities. Case 2: A 66-year-old morbidly obese male presented with chronic back pain for several years associated with progressively worsening radicular pain in his left lower extremity. Outcome The first case is an example of tumoral CPPD involving the facet joint and expanding into the epidural space. The second case was an example of CPPD involving a thoracolumbar facet cyst, resulting in unilateral radiculopathy. Both patients were treated surgically and had significant improvement in symptoms post-operatively. Conclusions CPPD in the spine is an uncommon diagnosis but should be considered in the differential diagnosis of patients presenting with back pain and associated neurological symptoms. Accurate diagnosis of spinal CPPD is important in that it will guide postoperative management with anti-inflammatory medications and reduce risk of recurrence.
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9
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Isolated septic facet joints: an underdiagnosed distinct clinical entity. Skeletal Radiol 2020; 49:1295-1303. [PMID: 32248446 DOI: 10.1007/s00256-020-03434-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 03/21/2020] [Accepted: 03/24/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES We review a series of isolated septic facet joints (ISFJ) that present as a distinct clinical entity compared with spondylodiscitis. We aim to raise awareness that septic facet joints are not a rare entity in the era of modern imaging. METHODS We reviewed 353 patients with confirmed spine infections from 2008 to 2017. Of the 353 cases, there were 152 septic facet joints based on MR imaging. Sixty-two presented as ISFJ without evidence of spondylodiscitis and were reviewed. RESULTS Patients were predominantly male 38/62 (61%). The mean age was 56.7 years. Onset of back pain was more acute compared with spondylodiscitis and usually unilateral. The distribution was as follows: 6 cervical, 12 thoracic, and 44 lumbar facets. The majority of ISFJ, 53/62 (85%), were associated with an epidural abscess (EDA) 53/62. The cervical and thoracic EDA required surgical decompression more frequently than lumbar; 100%, 75%, and 53% respectively. Pathogen was identified in 59/62 (95%) cases. Most cases were associated with bacteremia 50/62 (81%). Seven ISFJ were introduced iatrogenically. All iatrogenic ISFJ required surgical decompression. CONCLUSION Septic facet joints are not rare, but frequently overlooked as the origin of an epidural abscess. The majority of cases are hematogenously seeded and associated with bacteremia. Surgical decompression is frequently required secondary to the high incidence of associated epidural abscess. Iatrogenic septic facet joints are rare but associated with significant morbidity. From a clinical standpoint, it is helpful to delineate the origin of EDA as either secondary to spondylodiscitis or SFJ.
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10
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Acute Attack of Pseudogout with the Wide Lesion in Lumbar Spondylolytic Spondylolisthesis. Case Rep Orthop 2020; 2020:4512695. [PMID: 32802536 PMCID: PMC7411475 DOI: 10.1155/2020/4512695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 07/02/2020] [Accepted: 07/18/2020] [Indexed: 12/04/2022] Open
Abstract
Objective To report a rare case of an acute attack of calcium pyrophosphate dihydrate (CPPD) deposition disease in a patient with lumbar spondylolytic spondylolisthesis, which demonstrated widespread lesion with neurological deficit. Methods An 86-year-old woman presented with high fever and bilateral neurological deficit of the lower extremities. Results CRP was elevated (20.9 mg/dl). Plain radiographs and computed tomography images showed bilateral L4 spondylolytic spondylolisthesis. Sagittal magnetic resonance (MR) images revealed effusion at the L3-4 interspinous space, and a gadolinium- (GD-) enhanced epidural mass was observed at the level of L4 vertebral body. Axial MR images showed an intra- or epidural lesion at L2-3. Moreover, epidural GD-enhanced masses compressed the dural sac in the shape of a cross at the L3-4 and L4-5 segments. The patient was suspected of having pyogenic arthritis of the lumbar spine in initial diagnosis. A total of 1.2 ml of fluid with a murky, pus-like synovial effusion was aspirated from the L3-4 interspinous space under the fluoroscopic image. Smear speculum of synovial fluid tested negative for bacteria and fungi; however, a number of crystals were seen. Based on the result of smear speculum, we suspected the pathology as crystal deposition disease. Based on polarized light microscopy, which revealed monocle or triclinic intracellular crystals with a positive birefringence, the patient was diagnosed with pseudogout of the lumbar spine. Nonsteroidal anti-inflammatory drugs (NSAIDs) were administered by intravenous drip injection for 3 days, and local and systemic inflammatory signs, as well as neurological deficits, dramatically improved. Conclusions We encountered the rare case of an acute attack of pseudogout with the wide lesion in the lumbar spondylolytic spondylolisthesis. Multiple culture of the effusion provided a definitive diagnosis, which allowed for appropriate, minimally invasive treatment for 8 weeks of NSAID administration that provided the satisfactory recovery from the symptoms.
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11
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A case of acute calcium pyrophosphate arthritis in two rare sites of involvement: The cervical facet and atlantoaxial joint. Jt Dis Relat Surg 2020; 31:395-398. [PMID: 32584744 PMCID: PMC7489169 DOI: 10.5606/ehc.2020.74329] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 04/06/2020] [Indexed: 11/24/2022] Open
Abstract
Calcium pyrophosphate dihydrate deposition (CPPD) disease, also known as pseudogout, in which crystals are deposited in the joints and/or soft tissues, leads to a variety of articular and periarticular disorders. Herein we report a 67-year-old female patient with neck pain who was diagnosed as CPPD disease of both the atlantoaxial joint and right C4-C5 facet joint with radiological findings. The combined use of computed tomography and magnetic resonance imaging can be helpful in establishing a diagnosis and providing the correct treatment.
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New classification of facet joint synovial cysts. Acta Neurochir (Wien) 2020; 162:929-936. [PMID: 32086604 DOI: 10.1007/s00701-020-04264-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Accepted: 02/10/2020] [Indexed: 01/26/2023]
Abstract
PURPOSE Facet cysts develop due to degeneration of the zygapophyseal joints and can lead to radiculopathy and neurogenic claudication. Various surgical options are available for facet cyst excision. The aim was to facilitate surgical treatment of lumbar facet cysts based on a new classification. METHODS We retrospectively analyzed all patients of the last 10 years in whom a facet cyst was surgically removed (ipsilateral laminotomy, contralateral laminotomy, and segmental fusion). Several radiological parameters were analyzed and correlated with the patients' outcome (residual symptoms, perioperative complications, need for re-operation, need for secondary fusion, facet cyst recurrence). RESULTS One hundred eleven patients (55 women; median age 64 years) could be identified. Thirty-three (48%) of 69 cases, for which MRI data were available, were classified as medial facet cyst (compressing the spinal canal), 6 facet cysts were localized intraforaminal (9%) and 30 cases (43%) mediolateral (combination of both). The contralateral approach had the lowest rate for revision surgery (7.5%, p = .038) and the lowest prevalence of residual complaints (7.5%, p = .109). A spondylolisthesis and a higher/steeper angle of the facet joints were associated with poorer patient outcome. CONCLUSIONS Lateral facet joint cysts are best resected by a contralateral approach offering the best outcome while medial cysts are suitable for removal by an ipsilateral laminotomy. The approach of mediolateral cysts can be determined by the width of the lamina and the angle of the joint. Segmental fusion should be considered in cases with detected spondylolisthesis and/or steep facet joints.
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Ko S, Chae S, Choi W, Kwon J, Choi JY. The effectiveness of vitamin D supplementation in functional outcome and quality of life (QoL) of lumbar spinal stenosis (LSS) requiring surgery. J Orthop Surg Res 2020; 15:117. [PMID: 32209124 PMCID: PMC7092593 DOI: 10.1186/s13018-020-01629-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 03/10/2020] [Indexed: 01/24/2023] Open
Abstract
Study design This is a retrospective cohort comparative study. Background Vitamin D supplementation is considered to be associated with good functional outcome. Thus, a few studies have proposed vitamin D supplementation is benefit to the functional outcome in LSS requiring surgery. The purpose of this study is to identify the prevalence of vitamin D deficiency in patients with LSS requiring surgery, and to compare the differences between the cases whether vitamin D is supplemented and vitamin D is not supplemented in terms of a QoL during postoperative 2 year. Methods All patients with LSS who underwent surgery from March 1, 2015 to August 31, 2016 were enrolled. Among them, 61 patients with vitamin D deficiency were divided into two groups (supplemented group (A) and non-supplemented group (B)). Functional outcomes using Oswestry Disability Index (ODI) and Rolland Morris Disability Index (RMDQ) and QoL using SF-36 were evaluated at 12-month and 24-month follow-up periods. Differences in functional score and SF-36 between the vitamin D supplemented and non-supplemented group were compared. Results Among the total 102 patients, 78 patients (76.5%) had vitamin D deficiency. Of the 78 patients, 61 patients were included, 27 patients were group A and 27 patients were group B. There was no difference in age and 25-OHD level between the two groups (all 0 > 0.05). Group A were better functional outcomes at 2 years after surgery (p < 0.05). On the QoL, group A were higher score than group B from 12 month later after surgery (p < 0.05). Conclusions Vitamin D deficiency was highly prevalent in LSS patients (76.5%). Assessment of serum 25-hydroxyvitamin D (25(OH)D) is recommended in LSS needing surgical intervention and active treatment vitamin D supplementation and maintenance of normal range should be considered for better postoperative functional outcome and QoL.
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Affiliation(s)
- Sangbong Ko
- Department of Orthopaedic Surgery, College of Medicine, Daegu Catholic University, Duryugongwon-ro 17-gil, Nam-gu, Daegu city, Korea.
| | - Seungbum Chae
- Department of Orthopaedic Surgery, College of Medicine, Daegu Catholic University, Duryugongwon-ro 17-gil, Nam-gu, Daegu city, Korea
| | - Wonkee Choi
- Department of Orthopaedic Surgery, College of Medicine, Daegu Catholic University, Duryugongwon-ro 17-gil, Nam-gu, Daegu city, Korea
| | - Jaibum Kwon
- Department of Orthopaedic Surgery, College of Medicine, Daegu Catholic University, Duryugongwon-ro 17-gil, Nam-gu, Daegu city, Korea
| | - Je-Yong Choi
- Department of Biochemistry and Cell Biology, Kyungpook National University, Daegu, Korea
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Patel DM, Weinberg BD, Hoch MJ. CT Myelography: Clinical Indications and Imaging Findings. Radiographics 2020; 40:470-484. [DOI: 10.1148/rg.2020190135] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Dhruv M. Patel
- From the Division of Neuroradiology, Department of Radiology and Imaging Sciences, Emory University, Atlanta, Ga
| | - Brent D. Weinberg
- From the Division of Neuroradiology, Department of Radiology and Imaging Sciences, Emory University, Atlanta, Ga
| | - Michael J. Hoch
- From the Division of Neuroradiology, Department of Radiology and Imaging Sciences, Emory University, Atlanta, Ga
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Ariyawatkul T, Pichaisak W, Chavasiri C, Vamvanij V, Wilartratsami S, Luksanapruksa P. The Role of Calcium Pyrophosphate Dihydrate Deposition in the Postoperative Outcome of Lumbar Spinal Stenosis Patients. Asian Spine J 2019; 13:1001-1009. [PMID: 31352727 PMCID: PMC6894964 DOI: 10.31616/asj.2018.0280] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Accepted: 04/08/2019] [Indexed: 11/23/2022] Open
Abstract
Study Design Retrospective study. Purpose This study aimed to investigate the association of surgical intervention with clinical and quality of life (QoL) outcomes in patients who underwent posterior spinal surgery for lumbar spinal stenosis (LSS) with spinal calcium pyrophosphate dihydrate deposition (SCPPD) versus that in those who underwent the surgery for LSS without SCPPD. Overview of Literature Calcium pyrophosphate (CPP)-associated arthritis is one of the most common types of arthritis. The clinical outcomes are well studied in CPP-associated arthritis of the appendicular joints. However, few studies have investigated SCPPD. Methods A single-institution database was reviewed. LSS patients were categorized as those who did and did not have SCPPD, based on histologic identification. Clinical presentations and postoperative results were analyzed. Disability and QoL were assessed using the Oswestry Disability Index (ODI) and the 36-item Short-Form Health Survey. Results Thirty-four patients were enrolled, with 18 patients being allocated to the SCPPD group and 16 being allocated to the non- SCPPD group. Preoperative and postoperative pain scores were not significantly different between the groups (p=0.33 and p=0.48, respectively). The average preoperative ODI score in the SCPPD group was slightly higher than that in the non-SCPPD group (57 vs. 51, p=0.33); however, the postoperative ODI score was significantly lower (15 vs. 43, p=0.01). The postoperative physical function, vitality, and mental health of the SCPPD patients were also significantly improved (p=0.03, p=0.022, and p=0.022, respectively). Conclusions Surgical intervention resulted in good clinical outcomes in SCPPD patients. As per our findings, total removal of CPPinvolved tissue is unnecessary. As such, surgery should be performed as indicated according to clinical presentation without considering the presence of CPPD.
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Affiliation(s)
- Thanase Ariyawatkul
- Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Witchate Pichaisak
- Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Cholavech Chavasiri
- Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Visit Vamvanij
- Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Sirichai Wilartratsami
- Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Panya Luksanapruksa
- Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Ujihara T, Yamamoto K, Kitaura T, Katanami Y, Kutsuna S, Takeshita N, Hayakawa K, Ohmagari N. Calcium Pyrophosphate Deposition Disease Involving a Lumbar Facet Joint Following Urinary Tract Infection. Intern Med 2019; 58:1787-1789. [PMID: 30799353 PMCID: PMC6630135 DOI: 10.2169/internalmedicine.2099-18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
A 75-year-old woman was admitted with urosepsis due to Escherichia coli infection. After improvement with a ureteral stent and antimicrobial agent, she complained of back pain and showed elevated inflammation marker levels. Arthralgia and arthritis of multiple peripheral joints were noted, and radiography indicated cartilage calcification. Magnetic resonance imaging revealed lumbar facet joint effusion. Her symptoms improved with nonsteroidal anti-inflammatory drug administration. Thus, she was diagnosed with calcium pyrophosphate deposition (CPPD)-related facet joint arthritis (FJA) rather than infectious FJA. CPPD-related FJA is an important differential diagnosis in elderly individuals with a risk of CPPD disease who complain of back pain.
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Affiliation(s)
- Tetsuro Ujihara
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Japan
- Department of Gastroenterology, New Tokyo Hospital, Japan
| | - Kei Yamamoto
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Japan
| | - Tsuyoshi Kitaura
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Japan
| | - Yuichi Katanami
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Japan
| | - Satoshi Kutsuna
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Japan
| | - Nozomi Takeshita
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Japan
| | - Kayoko Hayakawa
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Japan
| | - Norio Ohmagari
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Japan
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Affiliation(s)
- Hélène Petit
- Rheumatology Department, Strasbourg University Hospital, Hautepierre Hospital;
| | - Luc Marcellin
- Pathology Department, Strasbourg University Hospital, Hautepierre Hospital
| | - Emmanuel Chatelus
- Rheumatology Department, Strasbourg University Hospital, Hautepierre Hospital, Strasbourg, France
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Kim T, Kim BJ, Kim SH, Lee SH. Tophaceous Gout in the Lumbar Spinal Canal Mimicking Epidural Spinal Tumor. KOREAN JOURNAL OF SPINE 2017; 14:50-52. [PMID: 28704909 PMCID: PMC5518431 DOI: 10.14245/kjs.2017.14.2.50] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 05/29/2017] [Accepted: 06/05/2017] [Indexed: 12/28/2022]
Abstract
Gout is an inflammatory arthritis characterized by deposition of monosodium urate crystals in joints. Though gout frequently involves the big toe or other extremities, it rarely occurs in the spinal canal. A 35-year-old man presented with left L5 radiculopathy. He had leg pain for 8 months and received several epidural steroid injections. Magnetic resonance imaging revealed a 1.7×1.1-cm ovoid contrast-enhancing mass, causing pressure erosion of the left L5 pedicle. Microscopic laminotomy was performed at the left L5 lamina. White chalky materials, identified at the left lateral recess of the spinal canal, were removed in a piecemeal manner. The histopathologic diagnosis was tophaceous gout. Although the patient’s radiating pain did not resolve postoperatively, it was dramatically relieved with uric acid-lowering medications. If a mass effect is suspected, surgical removal of gouty tophi might aid in symptom release and definite diagnosis. Medical treatment after rheumatology consultation is crucial.
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Affiliation(s)
- Taeshin Kim
- Department of Neurosurgery, Korea University Ansan Hospital, Ansan, Korea
| | - Bum-Joon Kim
- Department of Neurosurgery, Korea University Ansan Hospital, Ansan, Korea
| | - Se-Hoon Kim
- Department of Neurosurgery, Korea University Ansan Hospital, Ansan, Korea
| | - Seung-Hwan Lee
- Department of Neurosurgery, Korea University Ansan Hospital, Ansan, Korea
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19
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Interventions for Lumbar Synovial Facet Joint Cysts: A Comparison of Percutaneous, Surgical Decompression and Fusion Approaches. World Neurosurg 2017; 98:492-502. [DOI: 10.1016/j.wneu.2016.11.044] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Revised: 11/05/2016] [Accepted: 11/07/2016] [Indexed: 02/06/2023]
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20
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Elgafy H, Liu X, Herron J. Spinal gout: A review with case illustration. World J Orthop 2016; 7:766-775. [PMID: 27900275 PMCID: PMC5112347 DOI: 10.5312/wjo.v7.i11.766] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Revised: 07/19/2016] [Accepted: 08/18/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To summarize clinical presentations and treatment options of spinal gout in the literature from 2000 to 2014, and present theories for possible mechanism of spinal gout formation.
METHODS The authors reviewed 68 published cases of spinal gout, which were collected by searching “spinal gout” on PubMed from 2000 to 2014. The data were analyzed for clinical features, anatomical location of spinal gout, laboratory studies, imaging studies, and treatment choices.
RESULTS Of the 68 patients reviewed, the most common clinical presentation was back or neck pain in 69.1% of patients. The most common laboratory study was elevated uric acid levels in 66.2% of patients. The most common diagnostic image finding was hypointense lesion of the gout tophi on the T1-weighted magnetic resonance imaging scan. The most common surgical treatment performed was a laminectomy in 51.5% and non-surgical treatment was performed in 29.4% of patients.
CONCLUSION Spinal gout most commonly present as back or neck pain with majority of reported patients with elevated uric acid. The diagnosis of spinal gout is confirmed with the presence of negatively birefringent monosodium urate crystals in tissue. Treatment for spinal gout involves medication for the reduction of uric acid level and surgery if patient symptoms failed to respond to medical treatment.
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21
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Abstract
Gout is characterized by the deposition of monosodium urate crystals and by acute and chronic inflammation in response to crystals so deposited. Multiple case reports and series describe the deposition of monosodium urate in the spine as a rare manifestation of gout, but the actual prevalence of spinal involvement is unknown and likely to be higher than generally anticipated. Here we review the characteristics of 131 previously reported cases of spinal involvement in gout. We focus in particular on the use of imaging modalities and the extent to which they correlate with presenting symptoms and tissue diagnoses. The recent innovation of using dual-energy computerized tomography to identify urate crystal deposition holds promise for reducing the need for surgical intervention and for establishing a true prevalence rate for spinal gout.
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22
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Lee H, Kim HS, Jung UH, Kwon HH, Lee YH, Park SH. Acute Pseudogout of the Neck: "Crowned Dens" Revisited. JOURNAL OF RHEUMATIC DISEASES 2016. [DOI: 10.4078/jrd.2016.23.2.122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Hyesun Lee
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Hyeon Su Kim
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Ui Hong Jung
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Hyun-Hee Kwon
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Young-Hwan Lee
- Department of Diagnostic Radiology, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Sung-Hoon Park
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
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23
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Willner N, Monoranu CM, Stetter C, Ernestus RI, Westermaier T. Gout tophus on an intradural fascicle: a case description. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2015; 25 Suppl 1:162-6. [PMID: 26556437 DOI: 10.1007/s00586-015-4309-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Revised: 10/26/2015] [Accepted: 10/27/2015] [Indexed: 01/27/2023]
Abstract
STUDY DESIGN Case report and review of literature. OBJECTIVE Detailed description of case and review of literature to determine its uniqueness with special regard to intradural gout tophus formation without any boney attachment or underlying systemic gout. Gout tophi commonly involve the peripheral joints of the upper and lower extremities. Rarely, gout tophi are located within the spinal cord, especially without any underlying hyperuricemia. METHODS We report the case of a 64-year-old patient presenting with radiculopathy along the right L2-dermatome and bladder dysfunction and review literature for further discussion. RESULTS Imaging studies showed a partly calcified round intradural lesion at the level L2 without contrast enhancement. The lesion was removed via a hemilaminectomy L2. It was adherent to a dorsal sensory fascicle exiting with the L2 nerve root. The neuropathological examination showed a gout tophus. Serologic testing revealed no signs of hyperuricemia. CONCLUSION To the best of our knowledge, this is the first report of a gout tophus originating from an intradural fascicle and without any boney attachment or underlying systemic gout. The literature is reviewed and possible pathophysiological mechanisms are discussed.
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Affiliation(s)
- Nadine Willner
- Department of Neurosurgery, University Hospital Würzburg, Josef-Schneider-Str. 11, 97080, Würzburg, Germany.
| | - Camelia-Maria Monoranu
- Department of Neuropathology, Institute of Pathology, Julius-Maximilian-University of Würzburg, Josef-Schneider-Str. 2, 97080, Würzburg, Germany
| | - Christian Stetter
- Department of Neurosurgery, University Hospital Würzburg, Josef-Schneider-Str. 11, 97080, Würzburg, Germany
| | - Ralf-Ingo Ernestus
- Department of Neurosurgery, University Hospital Würzburg, Josef-Schneider-Str. 11, 97080, Würzburg, Germany
| | - Thomas Westermaier
- Department of Neurosurgery, University Hospital Würzburg, Josef-Schneider-Str. 11, 97080, Würzburg, Germany
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Zheng ZF, Shi HL, Xing Y, Li D, Jia JY, Lin S. Thoracic cord compression due to ligamentum flavum gouty tophus: a case report and literature review. Spinal Cord 2015; 53:881-6. [PMID: 26078231 PMCID: PMC5399141 DOI: 10.1038/sc.2015.93] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 04/07/2015] [Indexed: 12/13/2022]
Abstract
Study design: Here we describe a patient who developed myelopathy due to gouty tophi of the ligamentum flavum in the thoracic spine. We also review similar cases previously reported in the literature. Objective: Our aim was to present a case of myelopathy due to thoracic spinal gouty tophus. Methods: We report the case of a 56-year-old male with history of peripheral gout and renal insufficiency. The patient complained of back pain and paraparesis of the left lower limb. Multiple tophi were noted over several interphalangeal and metatarsophalangeal joints. Neurological examination showed decreased left lower limb strength and a positive Babinski sign. Magnetic resonance imaging of the thoracic spine revealed hypertrophy of the ligamentum flavum at the level of T3/T4, T5/T6, T9/T10, T10/T11 and T11/T12. Results: A thoracic laminectomy at T1-T5 was performed. Chalky white granular material was found in the ligamentum flavum during surgery. Histological analysis of the specimen demonstrated a gouty tophus. The patient's back pain and paraparesis of the lower left limb improved. Conclusion: The clinician should include spinal gout in the differential diagnosis when dealing with patients with gout and axial pain with or without neurologic deficits. If this diagnosis is seriously entertained, then a CT scan or magnetic resonance imaging as well as tissue biopsy may be needed to establish the diagnosis.
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Affiliation(s)
- Z-F Zheng
- Department of Nephrology, General Hospital of Tianjin Medical University, Tianjin, China
| | - H-L Shi
- Department of Radiology, General Hospital of Tianjin Medical University, Tianjin, China
| | - Y Xing
- Department of Nephrology, General Hospital of Tianjin Medical University, Tianjin, China
| | - D Li
- Department of Nephrology, General Hospital of Tianjin Medical University, Tianjin, China
| | - J-Y Jia
- Department of Nephrology, General Hospital of Tianjin Medical University, Tianjin, China
| | - S Lin
- Department of Nephrology, General Hospital of Tianjin Medical University, Tianjin, China
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Abstract
BACKGROUND Tophi develop in untreated or uncontrolled gout. Their presence can lead to severe and potentially fatal complications. To date there have been no systematic reviews focused on the management of tophi in gout. OBJECTIVES To assess the benefits and harms of non-surgical and surgical treatments for the management of tophi in gout. SEARCH METHODS We searched three databases: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE. We handsearched American College of Rheumatology (ACR) and European League against Rheumatism (EULAR) abstracts from 2010 to 2011, references from included studies and trial registries. We completed the most recent search on 20 May 2013. SELECTION CRITERIA All published randomised controlled trials (RCTs) or controlled clinical trials with quasi-randomised methods of allocating participants to treatment examining interventions for tophi in gout in adults. Possible interventions included urate-lowering pharmacological treatment (e.g. benzbromarone, probenecid, allopurinol, febuxostat, pegloticase), surgical removal or other interventions such as haemodialysis. DATA COLLECTION AND ANALYSIS Two review authors extracted data from titles, abstracts and selected studies for detailed review, and extracted data and risk of bias independently. Major outcomes were number of participants with complete resolution of tophi, number of study participant withdrawals due to adverse events, joint pain reduction, function, quality of life, serum urate normalisation and total adverse events. MAIN RESULTS Only one study, at low risk of all biases, met the inclusion criteria. This was the pooled results from two RCTs (225 participants, 145 with tophi at baseline) randomised to one of three arms; pegloticase infusion every two weeks (biweekly), monthly pegloticase infusion (pegloticase infusion alternating with placebo infusion every two weeks) and placebo. Moderate-quality evidence from one study indicated that biweekly pegloticase 8 mg infusion reduced tophi in the subset of participants with tophi, but increased withdrawals due to adverse events in all participants, and monthly infusion appeared to result in less benefit.Biweekly pegloticase treatment resulted in resolution of tophi in 21/52 participants compared with 2/27 who received placebo (risk ratio (RR) 5.45, 95% confidence intervals (CI) 1.38 to 21.54; number needed to treat for an additional beneficial outcome (NNTB) 3 (95% CI 2 to 6).Eleven of 52 participants with monthly pegloticase treatment had complete resolution of one or more tophi compared with 2/27 who received placebo (RR 2.86, 95% CI 0.68 to 11.97).Participant-reported pain relief of 30% or greater, function, quality of life, serum urate normalisation, were reported for all participants but not separately for those with tophi; therefore, we did not include the results.Pegloticase administered biweekly resulted in more withdrawals due to adverse events compared with placebo (15/85 participants with pegloticase versus 1/43 participants with placebo; RR 7.59, 95% CI 1.04 to 55.55; number needed to treat for an additional harmful outcome (NNTH) 7, 95% CI 4 to 17). Pegloticase administered monthly also resulted in more withdrawals due to adverse events than placebo (16/84 participants with pegloticase versus 1/43 participants with placebo; RR 8.19, 95% CI 1.12 to 59.71; NNTH 6, 95% CI 4 to 14). Most withdrawals were due to infusion reactions.Total adverse events were high in all treatment groups: 80/85 participants administered pegloticase biweekly reported an adverse event compared with 41/43 from the placebo group (RR 0.99, 95% CI 0.91 to 1.07); 84/84 participants administered pegloticase monthly reported an adverse event versus 41/43 in the placebo group (RR 1.05, 95% CI 0.98 to 1.14). As 80% of adverse events were due to flares of gout, probably unrelated to the drug treatment per se, this may explain the high rate of adverse events in the placebo group - who were essentially untreated. AUTHORS' CONCLUSIONS This study showed pegloticase is probably beneficial in the management of tophi in gout, in terms of resolution of tophi, but with a high risk of adverse infusion reactions. However, there is a need for more RCT data considering other interventions, including surgical removal of tophi.
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Affiliation(s)
- Melonie K Sriranganathan
- Department of Rheumatology, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, Hampshire, UK, SO16 6YD
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deSouza RM, Uff C, Galloway M, Dorward NL. Spinal epidural hematoma caused by pseudogout: a case report and literature review. Global Spine J 2014; 4:105-8. [PMID: 25072005 PMCID: PMC4078174 DOI: 10.1055/s-0033-1360722] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2013] [Accepted: 09/20/2013] [Indexed: 12/28/2022] Open
Abstract
Study Design Case report. Objective We present the first reported case of spontaneous spinal epidural hematoma secondary to calcium pyrophosphate crystal deposition disease (pseudogout) in a 75-year-old woman. Methods A retrospective review of the patient's case notes was undertaken and the limited literature on this subject reviewed. Results This patient presented with sudden-onset lower limb paresis, sensory loss, urinary retention, and back pain. Magnetic resonance imaging showed an epidural hematoma, which was evacuated. Histologic specimens of the clot showed calcium pyrophosphate dihydrate crystal deposits (pseudogout). Conclusion The importance of histopathologic review of surgical specimens is highlighted when considering the differential diagnosis of apparently spontaneous spinal epidural hematoma.
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Affiliation(s)
- R. M. deSouza
- Department of Neurosurgery, Royal Free Hospital, London, United Kingdom,Address for correspondence Miss Ruth-Mary deSouza, MRCS Department of Neurosurgery, Royal Free HospitalPond Street, London NW3 2QGUnited Kingdom
| | - C. Uff
- Department of Neurosurgery, Royal Free Hospital, London, United Kingdom
| | - M. Galloway
- Department of Pathology, Royal Free Hospital, London, United Kingdom
| | - N. L. Dorward
- Department of Neurosurgery, Royal Free Hospital, London, United Kingdom
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Abstract
STUDY DESIGN A case report. OBJECTIVE An elderly patient presented with an acute lumbar spinal pseudogout attack after lumbar instrumented surgery. SUMMARY OF BACKGROUND DATA Although gout and pseudogout are common diseases causing inflammatory arthropathy in peripheral joints, involvement of the spine is uncommon. Here, we report a patient experiencing an acute lumbar spinal pseudogout attack after lumbar instrumented surgery. METHODS The patient was treated for lumbar spondylolisthesis at L4 and L5 level and afterward complained of lower back and bilateral leg pain. Conservative treatment was not effective for the patient; therefore, we preformed posterior transforaminal lumbar interbody fusion surgery. RESULTS The postoperative course was uneventful; however, he experienced lower back pain 4 weeks after surgery. Magnetic resonance image showed changes in signal intensities of vertebra and fluid accumulation in posterior back muscles. A biopsy was performed, but the culture was negative for infection. Calcium pyrophosphate dehydrate was detected in the fluid. Thus, conservative therapy without antibiotics was performed, and the patient's symptoms disappeared within 2 weeks. CONCLUSION Here, we reported the first case of acute lumbar spinal pseudogout attack after lumbar instrumented surgery. We recommend considering pseudogout before and after surgery.
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Ahmad I, Tejada JG. Spinal gout: a great mimicker. A case report and literature review. Neuroradiol J 2012; 25:621-5. [PMID: 24029100 DOI: 10.1177/197140091202500518] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2012] [Accepted: 10/14/2012] [Indexed: 01/05/2023] Open
Abstract
Spinal gout is not as rare as was previously thought and mimics heterogeneous spinal conditions such as rheumatoid, septic, seronegative arthropathies and primary or secondary neoplasms. Imaging findings are nonspecific and usually manifest late. In clinical settings, suspicious for spinal gout, needle biopsy may help for further characterization. A 57-year-old man with no significant past medical history presented in the emergency department with severe non radiating low back pain of one week duration. His laboratory tests were significant for uric acid of 642 μmol/L, erythrocyte sedimentation rate 93 mm/hour, and C-reactive protein 8.3 mg/dl. The lumbar spine MRI showed nonspecific acute inflammatory extensive lumbar facet arthropathy and soft tissue enhancement. The radiological and clinical information was insufficient to differentiate among septic arthritis, rheumatoid arthritis, seronegative arthropathy or gout. A lumbar facet fluoroscopy-fluoroscopic CT-guided needle biopsy was performed. The biopsy demonstrated negative birefringent crystals consistent with gout. Although the spinal gout is not rare, few case reports describe the role of needle biopsy and mimics. We present a comparative review of limited reports addressing the role of needle biopsy in mimics of spinal gout.
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Affiliation(s)
- I Ahmad
- Radiology Department, Indiana University School of Medicine; Indianapolis, Indiana, USA -
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Namazie MRBM, Fosbender MR. Calcium pyrophosphate dihydrate crystal deposition of multiple lumbar facet joints: a case report. J Orthop Surg (Hong Kong) 2012; 20:254-6. [PMID: 22933691 DOI: 10.1177/230949901202000225] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Pseudogout of the lumbar facet joints is rare. We report on a 69-year-old woman with 2-level symptomatic synovial cysts of the facet joints caused by calcium pyrophosphate dihydrate crystal deposition. She underwent surgical decompression for sciatica and low back pain. At one-year follow-up, she had recovered completely.
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MRI of spinal bone marrow: part 2, T1-weighted imaging-based differential diagnosis. AJR Am J Roentgenol 2012; 197:1309-21. [PMID: 22109284 DOI: 10.2214/ajr.11.7420] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The purpose of this article is to review the structure of bone marrow and the differential diagnosis of bone marrow pathology on the basis of T1-weighted MRI patterns. CONCLUSION Bone marrow is an organ that is evaluated routinely during MRI of the spine, particularly lumbar spine evaluation. Thus, it is one of the most commonly performed MRI examinations. T1-weighted MRI is a fundamental sequence in evaluating spinal marrow, and an understanding of T1-weighted MR signal abnormalities is important for the practicing radiologist.
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Spontaneous regression of a symptomatic atlanto-occipital joint cyst. Case report. Neurochirurgie 2011; 57:129-32. [DOI: 10.1016/j.neuchi.2011.07.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2010] [Accepted: 03/21/2011] [Indexed: 11/22/2022]
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Spinal gout tophus: a very rare cause of radiculopathy. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2011; 21 Suppl 4:S400-3. [PMID: 21594750 DOI: 10.1007/s00586-011-1847-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2011] [Revised: 05/03/2011] [Accepted: 05/09/2011] [Indexed: 10/18/2022]
Abstract
Gout is a common metabolic disease characterized by the development of arthritis and nephropathy related to the deposition of monosodium urate crystals within the joints, periarticular tissues, skin and kidneys. Tophus formation seen around the spinal column is very rare, while occurrences of spinal gout tophus without systemic gout disease are much more unique. In our study, we report a spinal gout case that presented with right sciatica without previous history of systemic gout disease.
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Hirose J. Clinical presentation and diagnosis of calcium deposition diseases. ACTA ACUST UNITED AC 2010. [DOI: 10.2217/ijr.09.61] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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KONATALAPALLI RUKMINIM, DEMARCO PAULJ, JELINEK JAMESS, MURPHEY MARK, GIBSON MICHAEL, JENNINGS BRYAN, WEINSTEIN ARTHUR. Gout in the Axial Skeleton. J Rheumatol 2009; 36:609-13. [DOI: 10.3899/jrheum.080374] [Citation(s) in RCA: 84] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Objective.Gout typically affects the peripheral joints of the appendicular skeleton and rarely involves the axial joints. The literature on axial gout is limited to case reports and case series. This preliminary study was conducted to identify the frequency and characteristics of axial gout.Methods.Six hundred thirty medical records with ICD codes 274.0, 274.82, and 274.9 for peripheral gout were reviewed. Ninety-two patients had clinical or crystal-proven gout, of which 64 had prior computed tomography (CT) images of the spine performed for various medical reasons. These CT images were reviewed for features of axial gout, which include vertebral erosions mainly at the discovertebral junction and the facet joints, deposits of tophi, and erosions in the vertebral body, epidural space, ligamentum flavum and pars interarticularis.Results.Nine of the 64 patients had radiographic changes suggestive of axial gout. Lumbar vertebrae were most commonly involved, with facet joint erosions being the most common finding. Isolated involvement of the sacroiliac joints was seen in 2 patients. Axial gout had been diagnosed clinically in only one patient.Conclusion.Radiologic changes of axial gout were more common than recognized clinically, with a frequency of 14%. Since not all patients had CT images, it is possible that the frequency of axial involvement was even greater. A prospective study is needed to further define this process.
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Panagiotopoulos EC, Syggelos SA, Plotas A, Tsigkas G, Dimopoulos P. Sciatica due to extrapelvic heterotopic ossification: a case report. J Med Case Rep 2008; 2:298. [PMID: 18783597 PMCID: PMC2556682 DOI: 10.1186/1752-1947-2-298] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2007] [Accepted: 09/10/2008] [Indexed: 11/28/2022] Open
Abstract
Introduction Sciatica is a common problem, usually caused by disc herniation or spinal stenosis. Low back pain is also present in most cases. When sciatica is the unique clinical finding, especially in young patients, extraspinal pathology should be investigated. Case presentation We describe a rare case of sciatica in a 32-year-old man, which was developed as a complication of post-traumatic pelvic heterotopic ossification. During the operation, the sciatic nerve was found to be bluish, distorted and compressed in an hourglass fashion around a heterotopic bone mass. The heterotopic bone tissue, 4 cm in diameter, was removed and the patient had fully recovered 3 months after the operation. Conclusion In cases of sciatica without back pain, the possibility of direct pressure of the sciatic nerve from cysts, tumours or bone, as in the present case, should be considered.
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Abstract
STUDY DESIGN A retrospective study of spinal stenosis patients admitted to Assaf Harofeh Medical Center Orthopedic Departments. OBJECTIVE To assess any correlation between systemic disease and spinal stenosis. SUMMARY OF BACKGROUND DATA Lumbar stenosis is a common spinal disease with various etiologies. No findings have been reported correlating spinal stenosis incidence with background diseases, although diabetes mellitus (DM) has been found to play a role in intervertebral disc degeneration and spondylolisthesis. METHODS Hospitalization records of patients with spinal stenosis admitted to Assaf Harofeh Medical Center Orthopedic Departments between 1984 and 1993 were checked for background diseases, age, and sex. The data collected were statistically evaluated for any correlation between spinal stenosis and chronic diseases and compared with the data published by the "Israeli Bureau of Statistics" and Israel's largest Health Maintenance Organization's chronic disease survey. RESULTS Of 537 patients with spinal stenosis 57% (308) were males and (229) 43% females with an average age of 60+/-14 years. Diseases occurring with a high incidence were hypertension (HTN)-23.2% (compared with 7.8% in the general population), DM-13.6% (5.9%), ischemic heart disease (IHD)-11.9%, and hyperlipidemia-4.4%. Patients with spinal stenosis had no significant age and sex distribution difference compared with the general population and no such difference was found for patients suffering from HTN, IHD, or DM. Isolating the effect of DM on HTN and IHD revealed that HTN was a primary disease whereas IHD was secondary to DM with significant statistical validation (P=0.003). CONCLUSIONS To the best of our knowledge this is the first study linking spinal stenosis and DM or HTN. It was found that chronic diseases do not alter the natural age and sex distribution of spinal stenosis. The major question remaining concerns the biologic mechanism linking spinal stenosis and DM or HTN.
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Lam HY, Cheung KY, Law SW, Fung KY. Crystal arthropathy of the lumbar spine: a report of 4 cases. J Orthop Surg (Hong Kong) 2007; 15:94-101. [PMID: 17429128 DOI: 10.1177/230949900701500122] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Gout or pseudogout, caused by deposition of crystals, rarely affects the spine. We report 4 cases with gout or pseudogout in the lumbar spine. Two had cauda equina syndrome and another 2 had spinal stenosis. To avoid unnecessary surgery, this should be considered in the differential diagnosis when treating patients with histories of gout or pseudogout for spinal problems.
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Affiliation(s)
- H Y Lam
- Department of Orthopaedics and Traumatology, Alice Ho Miu Ling Nethersole Hospital, Hong Kong.
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Abstract
Gout is a disease of antiquity but is increasing once again in prevalence despite availability of reasonably effective treatments. This may be related to a combination of factors, including diet, obesity, and diuretic use. Allergic reactions, noncompliance, drug interactions, and sometimes inefficacy all limit the effective use of current hypouricemic agents. There are new treatments for gout on the horizon, including febuxostat, a nonpurine inhibitor of xanthine oxidase with a potentially better combination of efficacy and side effects than allopurinol. Diagnostic progress is being made in that ultrasound may offer a noninvasive means of diagnosing tophaceous deposits in and around joints. The increasing prevalence of gout means that dermatologists will see more cutaneous manifestations of gout, including tophi, draining sinus tracts, panniculitis, and dystrophic calcifications.
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Affiliation(s)
- Gerald F Falasca
- Division of Rheumatology, Cooper University Hospital, Robert Wood Johnson Medical School at Camden, University of Medicine and Dentistry of New Jersey, Camden, NJ 08103, USA.
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Hou LC, Hsu AR, Veeravagu A, Boakye M. Spinal gout in a renal transplant patient: a case report and literature review. ACTA ACUST UNITED AC 2006; 67:65-73; discussion 73. [PMID: 17210304 DOI: 10.1016/j.surneu.2006.03.038] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2006] [Accepted: 03/31/2006] [Indexed: 12/14/2022]
Abstract
BACKGROUND Gout in the axial spine is rare. We present a case report on a renal transplant patient who developed fever and acute back pain at the L5 through S1 level secondary to sodium urate deposits. We review the literature on this rare disease and propose a management algorithm based on a resulting analysis. CASE DESCRIPTION A 37-year-old man with a history of gout and a renal transplant for IgA nephropathy presented with acute back pain and fever without evidence of neurological deficits. Magnetic resonance imaging revealed a uniformly contrast-enhancing infiltrative process involving the right pedicle, lamina, and inferior facet of the L5 vertebra. Computed tomography-guided needle biopsy revealed a friable white tissue consistent with sodium urate crystals. Conservative treatment with steroids and narcotics was used with good symptomatic relief. CONCLUSION Although few cases of gout involving the spine have been reported, its prevalence is likely grossly underestimated. Most patients have a history of gout and have elevated levels of serum urate level on presentation. The disease most commonly involves the lumbar spine. Patients usually have neurological deficits on presentation, and surgical decompression produces favorable outcomes. However, conservative medical management is appropriate for those with back pain only. Aggressive control of hyperuricemia is essential regardless of the method of treatment.
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Affiliation(s)
- Lewis C Hou
- Department of Neurosurgery, Stanford University Medical Center, Stanford, CA 94305-5327, USA.
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Abstract
Pathogenesis of gout inflammation remains unknown, but recent advances have been made with respect to initiation, amplification, and self-limitation. Direct crystal-cell membrane contact leads to cell activation, involving membrane-associated molecules. Resolution of acute gout inflammation is a mechanism that is controlled by monocyte-macrophage switch, which results in the loss of cytokine production capability and, conversely, the ability to produce anti-inflammatory molecules. MRI and ultrasound findings provide preliminary data that are not yet used in clinical trials. Diagnosis and management recommendations are missing, but this gap will be filled soon with the upcoming European League Against Rheumatism Task Force's recommendations on gout.
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Affiliation(s)
- Frédéric Lioté
- Fédération de Rhumatologie, Pôle Appareil Locomoteur (Centre Viggo Petersen), Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.
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Abstract
PURPOSE OF REVIEW This review is an attempt to keep current in the sparse literature addressing the still underutilized area of crystal identification. RECENT FINDINGS The emphasis has been on the subtleties of the microscopic identification of common crystals and other less common potentially confusing crystals. Imaging is noted to provide increasing help, but microscopic crystal identification remains the gold standard. SUMMARY Quality control is still a concern as is the infrequency of attempted arthrocentesis for crystal identification.
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Affiliation(s)
- Lan X Chen
- VA Medical Center, Rheumatology Research 151K, Philadelphia, Pennsylvania 19104, USA
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