Calcium pyrophosphate arthropathy of the spine: case report and review of the literature

Orthostatic hypotension as an unusual presentation of spinal calcium pyrophosphate deposition disease: case report and review of literature

Calcium pyrophosphate crystal deposition disease (CPPD), also known as pseudogout, with spinal involvement, is associated with clinical manifestations of acute nerve compression or chronic spinal stenosis. Precipitation of crystals of calcium pyrophosphate dihydrate in connective tissues can lead to acute inflammatory arthritis, degenerative chronic arthropathies, and radiographic evidence of cartilage calcification. We present a case of an 87-year-old woman, with unstudied chronic polyarthralgia and symptomatic orthostatic hypotension. It were documented acute calcium pyrophosphate deposition wrist arthritis, and cervical CT and MRI was suggestive of spinal involvement of CPPD. Workup excluded other causes of OH. Surgical approach could be indicated to minimize the symptoms, but it was contra-indicated due to the patient's performance status, so histological diagnosis was not possible. Muscle atrophy played an important part in the rapid progression of this insidious chronic disease. Conservative and symptomatic treatment achieve scarce short-term clinical improvement. Spinal involvement of CPPD was thought to be rare but recent studies show a higher prevalence than expected. We call for attention to the extent of structural changes that may occur when not early diagnosed nor treated. High clinical suspicion is required and this is, to our knowledge, the first report of orthostatic hypotension as a presentation of CPPD.

The use of Anakinra in treatment of calcium pyrophosphate crystal deposition disease: Analysis of own experience and a literature review

Calcium pyrophosphate crystal deposition disease (CPPD) is a disease caused by the deposition of calcium pyrophosphate crystals, mainly in the articular cartilage, and often manifests as severe acute or chronic arthritis. Therapy given in such cases with non-steroidal anti-inflammatory drugs, colchicine, methotrexate and glucocorticoids is often effective. In these cases, the possibility of prescribing biological drugs, primarily interleukin 1 (IL-1) inhibitors, is being considered. The article analyzes the experience of using Anakinra, an IL-1 receptor antagonist, registered in the Russian Federation in 2021, in 5 patients with persistent arthritis in CPPD. The article also presents an analysis of data from key studies on the use of the drug in patients with CPPD.

Spinal disorders mimicking infection

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.

Lumbar Extradural Pseudogout Mass Manifesting as Radiculopathy: A Case Report

BACKGROUND

Calcium pyrophosphate dihydrate (CPPD) disease, also known as pyrophosphate arthropathy or pseudogout, is defined as CPPD deposition within the articular cartilage. It was first described in 1962. The representative locations where CPPD disease occurs include the most common knee joint, followed by the wrist joint. Joint swelling and pain are the most common clinical presentations, and the typical differential diagnosis is degenerative arthritis. Microscopically, the specimen demonstrates numerous positively birefringent rhomboid shaped crystals when examined under polarized light.

CASE REPORT

We present a 70-year-old female with right painful sciatica accompanied by coexisting affected limb soreness and clumsiness. Her final diagnosis was unusual lumbar extradural tumoral pseudogout that was worth noticing. Tumoral CPPD deposition was excised after laminectomy. Subsequently, her symptoms were abated postoperatively without a need for more analgesics. Her neurological function was properly recovered.

CONCLUSION

This is a rare report to proffer pseudogout in an unfamiliar lumbar extradural location, which is an unexpected diagnosis. Making a precise tentative diagnosis for the ongoing disease entity might be difficult for the clinicians because the clinical manifestations of this pathology are similar to those of other common degenerative lumbar spinal diseases.

Trauma Induced Calcium Pyrophosphate Deposition Disease of the Lumbar Spine

Inflammatory arthritis, such as pseudogout or otherwise referred to as calcium pyrophosphate (CPP) crystal arthritis or calcium pyrophosphate deposition (CPPD) disease, is characterized by the deposition of crystal formation and deposition in large joints. CPPD is known to affect the elderly population and commonly manifests as inflammation of knees, hips, and shoulders. CPPD disease involving the spine has been infrequently encountered in practice and rarely described in the literature. Here, we describe a case of an 80-year-old female with no known history of inflammatory arthritis who presented with left lower extremity weakness and fall, initially thought to have discitis, later confirming CPPD of the spine through biopsy and ultimately resolution of symptoms with anti-inflammatory agents. Although consisting of different clinical presentations, two other case reports have described CPPD of the spine with similar radiographic findings, to this author's knowledge. With the radiologic similarities, this unique case serves to raise awareness in the medical community and possibly place pseudogout of the spine on the differential list when such cases are encountered. As a result, patients can be initiated on benign anti-inflammatory agents, avoiding invasive testing and unnecessary antibiotic exposure.

Cross-Sectional Imaging for Inflammatory Arthropathy of the Pelvis

Inflammatory arthropathy predominantly affecting the axial skeleton can cause pain, stiffness, disability, and ankylosis. This article discusses the use of cross-sectional imaging in the domain of inflammatory pelvic and axial arthropathy highlighting the key distinguishing features of common known diseases and their differential diagnoses.

Calcium pyrophosphate deposition disease of the temporomandibular joint

Calcium pyrophosphate dihydrate deposition disease (CPDD, tophaceous pseudogout) is a rare crystal arthropathy characterized by calcium pyrophosphate crystal deposition in joint spaces, episodes of synovitis, and radiological features of chondrocalcinosis. We present a case of 61-year-old woman who presented with left temporomandibular joint (TMJ) pain, difficulty chewing, left facial numbness, left-sided hearing loss, and left TMJ swelling. Imaging of the temporal fossa revealed a large mass emanating from the temporal bone at the TMJ, extending into the greater wing of the sphenoid and involving the mastoid bone and air cells posteriorly. Fine needle aspiration demonstrated polarizable crystals with giant cells. Intraoperatively, the TMJ was completely eroded by the mass. Final pathology was consistent with tophaceous pseudogout. CPDD has rarely been reported involving the skull base. None of the cases originally described by McCarty had TMJ pseudogout. Symptoms are generally pain, swelling, and hearing loss. Management is nearly always surgical with many patients achieving symptomatic relief with resection. CPDD is associated with many medical problems (including renal failure, gout, and hyperparathyroidism), but our patient had none of these risk factors. This case demonstrates that CPDD can involve the skull base and is best treated with skull base surgical techniques.

Cauda equina syndrome caused by pseudogout involving the lumbar intervertebral disc

Calcium pyrophosphate dihydrate (CPPD) deposition disease, also known as pseudogout, is a disease that causes inflammatory arthropathy in peripheral joints, however, symptomatic involvement of the intervertebral disc is uncommon. Herein, we describe a 59-yr-old patient who presented with cauda equina syndrome. Magnetic resonance imaging of the patient showed an epidural mass-like lesion at the disc space of L4-L5, which was compressing the thecal sac. Biopsy of the intervertebral disc and epidural mass-like lesion was determined to be CPPD deposits. We reviewed previously reported cases of pseudogout involving the lumbar intervertebral disc and discuss the pathogenesis and treatment of the disease.

Acute lumbar spinal pseudogout attack after instrumented surgery

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.

Tophaceous pseudogout of the thoracic spine

Calcium pyrophosphate dihydrate deposition disease (CPDD, tophaceous pseudogout) is a rare crystal arthropathy characterized by pyrophosphate crystal deposition in joints, synovitis and chondrocalcinosis on imaging. We present the case of a 72-year-old man with 6 months of left chest pain; magnetic resonance imaging revealed a T9/T10 herniated disc. Intraoperatively, the material was sent for pathological analysis revealing pseudogout. Axial calcium pyrophosphate crystal deposition is rare but reported in the literature and found at the craniocervical junction and skull. Spinal calcium pyrophosphate crystal deposition is rare in the thoracic spine. It is often asymptompatic and can involve the disc or ligaments. This case demonstrates a unique presentation of CPDD.

Thoracic myelopathy caused by calcified ligamentum flavum

Calcification of the ligamentum flavum is a rare manifestation of the calcium pyrophosphate dihydrate deposition disease (CPPD). In CPPD deposition disease, spinal involvement is rare. Until now, thoracic spine CPPD causing thoracic cord compression has been reported in only sporadic cases. We report a new case of thoracic calcification of the ligamentum flavum. In our case, similar to the other reported cases, an affected middle-aged woman despite the clinical and MRI signs of myelopathy had an unexpected important and rapid improvement of the neurological picture. This condition should be considered in differential diagnosis of thoracic cord compression to offer the patient an early and useful surgical treatment.

Calcium pyrophosphate dihydrate deposition in the transverse ligament of the atlas: an unusual cause of cervical myelopathy

A 75-year-old male presented with progressive myelopathy due to massive retro-odontoid deposits of calcium pyrophosphate dehydrate (CPPD) crystals. Magnetic resonance imaging revealed a non-enhanced isointense extradural mass on a T1-weighted image and a heterogeneous intense mass on a T2-weighted image. Computed tomography (CT) showed linear calcification within the mass. The mass was resected via a posterolateral approach resulting in marked improvement of the symptoms. Histological examination revealed birefringent rhomboid crystals consistent with CPPD. The preoperative differential diagnosis of periodontoid CPPD deposition disease in the elderly population should be considered, particularly if CT studies demonstrate small areas of calcification within the retro-odontoid mass.

Crystal arthropathy of the lumbar spine: a report of 4 cases

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.

Recurrent back pain and fevers

An elderly woman presented with her third episode of back pain, fever and neurological deficits. She subsequently developed pseudogout of the knee, and a diagnosis was made of systemic calcium pyrophosphate deposition disease (CPPD) involving the spine and causing intermittent cauda equina syndrome. This case illustrates the difficulty of differentiating infection from CPPD.

Crystal arthropathy of the lumbar spine: a series of six cases and a review of the literature

There have been very few reports in the literature of gout and pseudogout of the spine. We describe six patients who presented with acute sciatica attributable to spinal stenosis with cyst formation in the facet joints. Cytopathological studies confirmed the diagnosis of crystal arthropathy in each case. Specific formation of a synovial cyst was identified pre-operatively by MRI in five patients. In the sixth, the diagnosis was made incidentally during decompressive surgery. Surgical decompression alone was undertaken in four patients. In one with an associated degenerative spondylolisthesis, an additional intertransverse fusion was performed. Another patient had previously undergone a spinal fusion adjacent to the involved spinal segment, and spinal stabilisation was undertaken as well as a decompression. In addition to standard histological examination material was sent for examination under polarised light which revealed deposition of urate or calcium pyrophosphate dihydrate crystals in all cases. It is not possible to diagnose gout and pseudogout of the spine by standard examination of a fixed specimen. However, examining dry specimens under polarised light suggests that crystal arthropathy is a significant aetiological factor in the development of symptomatic spinal stenosis associated with cyst formation in a facet joint.

Foraminal deposition of calcium pyrophosphate dihydrate crystals in the thoracic spine: possible relationship with disc herniation and implications for surgical planning

✓ The authors report two cases of nodular calcium pyrophosphate dihydrate (CPPD) crystal deposition close to the thoracic neural foramen, which caused chronic radiculopathy. Preoperatively, the lesions were interpreted as calcified disc herniations. Both patients underwent surgery in which an extended transfacet pedicle-sparing approach was used. Incision of the posterior longitudinal ligament released soft degenerated material. In both cases, histological examination showed abundant degenerative debris along with CPPD crystals.

Spinal CPPD deposition is a comparatively rare disease that almost invariably involves the posterior aspect of the spinal canal, typically the ligamentum flavum. The exceptional foraminal location of the lesions reported here, combined with the surgical findings, indicated that the CPPD crystals were deposited on a laterally herniated disc fragment. A distinctive feature in both cases was the soft consistency of the resected tissue. The consistency of the disc material and the location of the lesion in the axial plane (that is, median compared with lateral) are key factors in determining the optimal surgical approach to thoracic disc herniations. In describing consistency, terms such as “calcified” and “hard” have been used interchangeably in the literature. In the cases reported here, what appeared on computerized tomography and magnetic resonance imaging studies to be densely calcified lesions were shown intraoperatively to be soft herniations.

The authors' experience underscores that not all densely calcified herniated discs are hard. Although detection of this discrepancy would have left surgical planning for the lateral disc herniations unchanged, it could have altered planning for centrally or centrolaterally located disc herniations.

Calcium pyrophosphate dihydrate and calcium hydroxyapatite crystal deposition diseases: imaging perspectives

Calcium pyrophosphate dihydrate crystal deposition disease and calcium hydroxyapatite deposition disease are common crystal diseases that have characteristic imaging appearances. This article gives a background on each disorder and discusses the qualities that distinguish them from each other and from other arthropathies.

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.

Ganglion cyst in the ligamentum flavum of the cervical spine causing myelopathy: report of two cases

BACKGROUND

Ganglion cyst in the ligamentum flavum is commonly found in the lower lumbar region; occurrence in the cervical region is extremely rare. We report two cases of ganglion cyst in the cervical region and the clinical, pathological, and radiological findings.

METHODS

The first patient was an 81-year-old man who was admitted to our hospital with gradually progressive gait disturbance and radiating pain in both arms and legs, which was dominant on the left side. The second patient was a 65-year-old man with progressive muscle weakness of the extremities who was admitted with radiating pain in the right arm. In both cases, the cervical spinal cord had been compressed by the cystic mass with degeneration of the ligamentum flavum (the former left, the latter right) at the level of C3-4.

RESULTS

The extradural-intraspinal cystic masses, which were revealed by computed tomography (CT) and magnetic resonance imaging (MRI) to be situated antero-laterally to the cervical laminae, were removed surgically without difficulty. After surgery, the symptoms and neurologic signs improved in both cases.

CONCLUSIONS

Ganglion cyst in the ligamentum flavum of the cervical spine is a very rare lesion causing radiculo-myelopathy. In both our cases, a correct diagnosis could be established preoperatively based on CT myelogram and MRI findings, and the results of surgery were excellent.

Foramen magnum syndrome secondary to calcium pyrophosphate crystal deposition in the transverse ligament of the atlas

STUDY DESIGN

This report illustrates two rare cases of foramen magnum syndrome caused by a retro-odontoid mass in which calcium pyrophosphate dihydrate crystals were found.

OBJECTIVES

To analyze the preoperative studies and the diagnostic criteria and to discuss the surgical treatment. The present cases will be compared with previous ones described in the literature.

SUMMARY OF BACKGROUND DATA

Deposition of calcium pyrophosphate dihydrate crystals occurs into the fibrous and hyaline cartilage of the joints and intervertebral discs of the spine. Half of the patients known to have a chondrocalcinosis had asymptomatic calcification in the odontoid region. Ten patients were published in the literature as having a spinal cord syndrome secondary to calcium pyrophosphate dihydrate deposition in the odontoid region.

METHODS

In both cases the preoperative studies were analyzed, and the retro-odontoid mass was resected and histologically examined. Both had an anterior transoral approach and have been followed for 1 year.

RESULTS

According to the preoperative radiographs the diagnosis was suspected and confirmed histologically. Transoral approach was done with no need in either case for a posterior stabilization.

CONCLUSIONS

Compression of the spinal cord by calcium pyrophosphate dihydrate deposition may occur. The preoperative diagnosis may be highly suspected after radiographic study and histologically confirmed. Transoral resection is the treatment of choice. Posterior stabilization should be considered only in cases of craniovertebral instability.

Calcium pyrophosphate dihydrate crystal deposition disease: imaging perspectives

Calcium pyrophosphate dihydrate (CPPD) crystal deposition disease is widespread in elderly persons and has various clinical presentations that can be confounding to clinicians. It is characterized by acute, subacute, or chronic joint inflammation and deposition of CPPD crystals in hyaline cartilage, fibrocartilage, and other soft tissue structures. We have learned a great deal about imaging findings of CPPD crystal deposition disease. New facts about the disorder and clues to radiologic diagnosis continue to be revealed. This article will provide a review of imaging characteristics of this disease with emphasis on some recent findings. The nomenclature, epidemiology, classification, and pathophysiology will be explained. A discussion of the clinical manifestations and treatment will be followed by a review of the characteristic imaging features.

Calcium pyrophosphate dihydrate crystal deposition in and around the atlantoaxial joint: association with type 2 odontoid fractures in nine patients

PURPOSE

To investigate the histopathologic anatomy of calcium pyrophosphate dihydrate (CPPD) crystal deposition in and around the atlantoaxial joint and the association between CPPD crystal deposition and subchondral cysts, erosions, and fracture involving the odontoid process of the axis.

MATERIALS AND METHODS

One adult cadaver demonstrating calcification in the retro-odontoid area at computed tomography (CT) was selected for further radiography, CT, and magnetic resonance (MR) imaging at the C1-2 level. Anatomic sectioning and histologic evaluations were performed in the specimen. For clinical study, radiographs (n = 5), CT scans (n = 8), and MR images (n = 6) in nine patients (mean age, 74.4 years) with odontoid process fractures and CPPD crystal deposits in and around the atlantoaxial joint were reviewed.

RESULTS

In the cadaveric specimen, radiography and CT demonstrated calcifications in the transverse ligament; histologic evaluation confirmed that these calcifications were CPPD crystal deposits. In all nine patients, radiography (n = 5) and CT (n = 8) also showed calcification in areas adjacent to the odontoid process, which included the transverse ligament. T1- and T2-weighted MR imaging showed a retro-odontoid mass of low signal intensity that compressed the cervical cord in six patients. CT, MR imaging, or both demonstrated subchondral cysts, osseous erosions, or a type 2 odontoid fracture in all patients.

CONCLUSION

CPPD crystal deposition disease involving the C1-C2 articulation can be a clinically important entity that may place affected patients at increased risk of pathologic fracture of the odontoid process.

Periodontoid calcium pyrophosphate dihydrate deposition disease: "pseudogout" mass lesions of the craniocervical junction

Between 1984 and 1996, seven patients with symptomatic masses located posterior to the odontoid process and containing calcium pyrophosphate dihydrate crystals were evaluated by the senior author (A.H.M). All patients presented with distal paresthesias and myelopathy and underwent transoral-transpharyngeal resection of the anterior arch of C-I, the odontoid process, and the compressing mass. Histological examination revealed the characteristic changes of calcium pyrophosphate dihydrate (CPPD) deposition disease, with nodular deposits of birefringent rhomboid crystals. On magnetic resonance imaging, the masses appeared predominantly isointense with neural tissue on T1-weighted images and iso-to hyperintense on T2-weighted images. On computerized tomography scans, small area of calcifications within the masses were apparent in all cases. All patients improved postoperatively, with six of seven patients requiring posterior fixation for instability as a second procedure. Calcium pyrophosphate dihydrate deposition causing periodontoid mass lesions is a distinct clinical disease entity that probably is underdiagnosed. In the authors' l opinion, the diagnosis can often be established preoperatively by the distinctive neuroradiological appearance of the masses. Therefore, CPPD deposition disease should be considered in the differential diagnosis of masses of the craniocervical junction, because it is amenable to early surgical intervention. The consulting neuropathologist should be made aware of this diagnostic possibility at the time of surgery.

A series of 60 juxtafacet cysts: clinical presentation, the role of spinal instability, and treatment

Spinal instability may be a cause of juxtafacet cyst formation and the pain and disability that occur after surgical excision of the cyst. To determine the role of instability, a retrospective review of charts identified 60 facet cysts in 56 patients treated over a 6-year period. Three patients developed an asynchronous cyst at the same level but on the opposite side of the previously resected cyst and one patient had a recurrent cyst in the same location. Forty-one cysts were present in patients with radiculopathy and 16 in patients with neurogenic claudication. Two patients presented with myelopathy and one had cauda equina syndrome. Thirty-six of the 60 cysts were located at L4-5, the most mobile segment. Fifteen patients had spondylolisthesis, of whom two experienced worsening spondylolisthesis postoperatively. Seven patients had scoliosis and 20 had systemic arthritis. Fifty-five cysts were resected via mesial facetectomy. Six of the patients undergoing this procedure had transverse process fusions at initial surgery for preoperative instability. Two others required fusion for post-operative instability and increased spondylolisthesis. Follow-up review was available in 95% of patients with an average duration of 12 months. Forty patients had excellent relief of symptoms, 12 had occasional back pain, and one patient did poorly. Flexion/extension views of the spine are recommended both pre- and postoperatively to identify the need for fusion in patients with juxtafacet cysts.