Tophaceous pseudogout of the cervical spine: MR imaging and bone scintigraphy findings

Acute cervical epidural abscess with concurrent calcium pyrophosphate deposition after cervical spinal surgery: A case report

Background

Spinal epidural abscess (SEA) is a rare condition that may result in catastrophic outcomes. On the other hand, calcium pyrophosphate (CPP) deposition disease (CPPD) causes inflammatory arthritis. Spinal involvement of a crystal-induced inflammation caused by CPPD is also common. Surgery is a common risk factor for both SEA and CPPD; however, the postoperative acute onset of SEA complicated with CPPD is extremely rare.

Case Description

A man in his 70s presented to our hospital, complaining of right upper limb weakness, loss of dexterity, and gait disturbance. The diagnosis of cervical spondylotic myelopathy was made, and he performed laminectomy at C3, C4, and C5 levels. Four days after the laminectomy, he suffered from acute neck pain, weakness, and hypoesthesia in his arms and legs. Magnetic resonance imaging revealed a mass occupying the dorsal epidural space of C6 and C7, compressing the cervical spinal cord. Considering the acute symptomatology, an acute spinal epidural hematoma after surgery was suspected; therefore, emergency C6 and C7 laminectomy was performed. Surgical findings indicated that the pressure inside the spinal canal was elevated, and the mass was purulent exudate. Pathological examination showed suppurative inflammation with concomitant deposition of CPP. SEA complicated with CPPD was considered; therefore, antibiotics and non-steroidal anti-inflammatory drugs were administered. The motor weakness and hypoesthesia were improved despite a slight residual deficit in his dexterity.

Conclusion

An acute onset of SEA complicated with CPPD after cervical surgery has rarely been reported. The suppurative inflammation fostered by the crystal-induced inflammation may account for the acute symptomatology.

Calcium pyrophosphate deposition disease of the cervical and thoracolumbar spine: A report of two cases

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.

Tumoral pseudogout of the proximal interphalangeal joint of a finger: a case report and literature review

Tumoral pseudogout is a rare clinical form of calcium pyrophosphate dihydrate crystal deposition disease. Tumoral pseudogout can mimic other diseases such as chondroid tumor, tophaceous gout, or tumoral calcinosis. Its radiological features have been presented in some case reports, but no specific radiographic features have been identified. Here, we report an unusual case of recurrent tumoral pseudogout involving the proximal interphalangeal joint of the right long finger. This case presents with progressive radiological findings of the disease with an enlarging and recurrent calcified mass and secondary bony erosion and remodeling, along with a radiological-pathological correlation. We also review previously reported imaging findings of this disease entity, differential points in comparison to other diseases, and some key points for making the correct diagnosis.

Mimicry in older patients: tophaceous pseudogout as a tumorlike lesion: a case report

Pseudogout is frequently seen in painful arthritis of larger joints, especially the knees and shoulders. This case report describes a rare clinical entity of soft-tissue calcium pyrophosphate dihydrate crystal deposition disease surrounding the second metatarsal bone of an 81-year-old man with moderate painful swelling of the right forefoot for 2 years. Diagnostic imaging demonstrated a calcified soft-tissue tumor adjacent to the second metatarsal bone by considering a neoplastic process in the differential diagnosis. Excisional biopsy revealed a chalklike material on the calcified soft tissue that was pathognomonic for chondrocalcinosis or pseudogout. The excisional biopsy findings led to stagnation of the clinical symptoms, and no recurrence of the initial tumor was seen during 12-month follow-up. In the literature, only 28 cases of tophaceous pseudogout tumors in the extremities have been described. In these cases, the lesions were suspected of being chondrosarcomas. For this reason, a correct diagnosis has to be pursued by performing a biopsy to treat the disease correctly.

Imaging findings in a rare case of extra-articular chondrocalcinosis

We report the imaging findings in extra-articular chondrocalcinosis in a 53-year-old man with swelling and pain in right scapular area for 1 year. Plain radiography showed a right scapular area calcific mass. The clinical suspicion was of a soft tissue sarcoma. As a part of diagnostic workup, a bone scan and a PET/CT scan were done. Bone scan revealed intense MDP uptake in the right scapular area. FDG PET/CT revealed intense FDG uptake in the mass. The biopsy revealed chondrocalcinosis. This is an addition to our long list of causes of extraosseous uptake of MDP.

Villonodular synovitis (PVNS) of the spine

OBJECTIVE

To describe the imaging features of spinal pigmented villonodular synovitis (PVNS).

DESIGN AND PATIENTS

We retrospectively reviewed 15 cases of pathologically proven spinal PVNS. Patient demographics and clinical presentation were reviewed. Radiologic studies were evaluated by consensus of two musculoskeletal radiologists for spinal location, spinal segments affected, lesion center, detection of facet origin and intrinsic characteristics on radiography (n=11), myelography (n=7), CT (n=6) and MR imaging (n=6).

RESULTS

Women (64%) were more commonly affected than men (36%) with an average age of 28 years. Clinical symptoms were pain (45%), neurologic (9%) or both (36%). Lesions most frequently affected the cervical spine (53%) followed by the thoracic (27%) and lumbar regions (20%). The majority of lesions (93%) were centered in the posterior elements with frequent involvement of the pedicle (67%), neural foramina (73%), lamina (67%) and facets (93%). No lesions showed calcification. Determination of a facet origin by imaging was dependent on imaging modality and lesion size. A facet origin could be determined in 45% of cases by radiography vs 67% of patients by CT (n=6) and MR (n=6). Large lesions (greater than 3 cm in at least one dimension) obscured the facet origin in all cases with CT and/or MR imaging (44%,n=4). Small lesions (less than 3 cm in any dimension) demonstrated an obvious facet origin in all cases by CT and/or MR imaging (56%,n=5). Low-to-intermediate signal intensity was seen in all cases on T2-weighted MR images resulting from hemosiderin deposition with "blooming effect" in one case with gradient echo MR images.

CONCLUSIONS

PVNS of the spine is rare. Large lesions obscure the facet origin and simulate an aggressive intraosseous neoplasm. Patient age, a solitary noncystic lesion centered in the posterior elements, lack of mineralization and low-to-intermediate signal intensity on all MR pulse sequences may suggest the diagnosis in these cases. Small lesions demonstrate a facet origin on CT or MR imaging. This limits differential considerations to synovial-based lesions and additional features of a solitary focus, lack of underlying disease or systemic arthropathy, no calcification as well as low-to-intermediate signal intensity on all MR images should allow spinal PVNS to be suggested as the likely diagnosis.

Pseudogout attack of the lumbar facet joint: a case report

STUDY DESIGN

A case of acute low back pain caused by pseudogout attack of the lumbar facet joint is reported.

OBJECTIVE

To report a new cause of acute low back pain previously unreported in the literature.

SUMMARY OF BACKGROUND DATA

There have been some reports of lumbar spinal stenosis caused by calcium pyrophosphate dihydrate crystal deposition. However, there are no known reports of pseudogout attack of the lumbar facet joint.

METHODS

An axial magnetic resonance imaging scan demonstrated joint effusion at the level of the bilateral L4-L5 facet joint. Aspiration of the left L4-L5 facet joint yielded 1.5 mL of pus-like synovial effusion. Multiple cultures of synovial fluid tested negative for bacteria and fungi, whereas compensated polarized light microscopy revealed monoclinic or triclinic crystals with a positive birefringence.

RESULTS

The symptoms of acute low back pain lasted for 3 days. Local and systemic inflammatory signs, as well as symptoms, gradually improved after joint aspiration. A follow-up evaluation 8 months after lumbar facet joint aspiration showed complete resolution of pain and no neurologic deficit.

CONCLUSIONS

Pseudogout attack of the lumbar facet joint is rare, but this clinical entity should be added to the differential diagnosis of acute low back pain.