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Kanjanakeereewong I, Tirawanish P, Suvithayasiri S, Ruangchainikom M. Differential diagnosis of pseudogout of the lumbar spine. BMJ Case Rep 2024; 17:e259628. [PMID: 39277195 DOI: 10.1136/bcr-2024-259628] [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] [Indexed: 09/17/2024] Open
Abstract
This case report details a rare instance of calcium pyrophosphate dihydrate crystal deposition disease (CPPD), commonly known as pseudogout, affecting the lumbar spine. A man in his mid-50s of age presented with severe low-back pain and fever, initially suspected as a spinal infection. Elevated erythrocyte sedimentation rate and leucocytosis were observed, while the initial imaging showed only lumbar spondylosis with arthritic changes in the right L4-L5 facet joint. However, an MRI revealed a cystic lesion at the right L5-S1 facet joint without signs of spondylodiscitis. Ultrasound-guided needle aspiration and synovial fluid analysis, including polarised light microscopy, identified calcium pyrophosphate crystals. Treatment with intravenous pain management was initially ineffective. Confirmation of CPPD led to successful treatment with oral colchicine, resulting in rapid pain alleviation and fever reduction. The patient reported significant improvement at a 2-week follow-up. This case emphasises the importance of thorough investigation in differentiating common symptoms and avoiding unnecessary treatments, highlighting the role of histological examination in diagnosing rare conditions like spinal CPPD.
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Affiliation(s)
| | - Panlop Tirawanish
- Division of Orthopedic, Golden Jubilee Medical Center,Faculty of Medicine Siriraj hospital, Nakorn Pathom, Thailand
| | - Siravich Suvithayasiri
- Department of Orthopedics, Chulabhorn Hospital, Bangkok, Thailand
- Bone and Joint Excellence Center, Thonburi Hospital, Bangkok, Thailand
| | - Monchai Ruangchainikom
- Orthopaedic Surgery, Mahidol University Faculty of Medicine Siriraj Hospital, Bangkok, Thailand
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De Azevedo SM, Pichel RC, Freitas E, Campar A, Marinho A, Mendonça T. Orthostatic hypotension as an unusual presentation of spinal calcium pyrophosphate deposition disease: case report and review of literature. ROMANIAN JOURNAL OF INTERNAL MEDICINE = REVUE ROUMAINE DE MEDECINE INTERNE 2023; 61:212-215. [PMID: 37671719 DOI: 10.2478/rjim-2023-0021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Indexed: 09/07/2023]
Abstract
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.
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Affiliation(s)
- Sofia Moura De Azevedo
- Internal Medicine Service, Centro Hospitalar Universitário de Santo António. Largo do Prof. Abel Salazar, 4099-001 Porto, Portugal
| | - Rita Carrilho Pichel
- Medical Oncology Service, Centro Hospitalar Universitário de Santo António. Largo do Prof. Abel Salazar, 4099-001 Porto, Portugal
| | - Egídio Freitas
- Dermatology Service, Centro Hospitalar Universitário de Santo António. Largo do Prof. Abel Salazar, 4099-001 Porto, Portugal
| | - Ana Campar
- Clinical Immunology Unit, Centro Hospitalar Universitário de Santo António. Largo do Prof. Abel Salazar, 4099-001 Porto, Portugal
| | - António Marinho
- Clinical Immunology Unit, Centro Hospitalar Universitário de Santo António. Largo do Prof. Abel Salazar, 4099-001 Porto, Portugal
| | - Teresa Mendonça
- Internal Medicine Service, Centro Hospitalar Universitário de Santo António. Largo do Prof. Abel Salazar, 4099-001 Porto, Portugal
- Clinical Immunology Unit, Centro Hospitalar Universitário de Santo António. Largo do Prof. Abel Salazar, 4099-001 Porto, Portugal
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Eliseev MS, Cheremushkina EV, Nasonov EL. The use of Anakinra in treatment of calcium pyrophosphate crystal deposition disease: Analysis of own experience and a literature review. RHEUMATOLOGY SCIENCE AND PRACTICE 2022. [DOI: 10.47360/1995-4484-2022-570-577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
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.
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Affiliation(s)
| | | | - E. L. Nasonov
- V.A. Nasonova Research Institute of Rheumatology; I.M. Sechenov First Moscow State Medical University of the Ministry of Health Care of Russian Federation (Sechenov University)
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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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Lo PC, Yue CT, Kung WM. Lumbar Extradural Pseudogout Mass Manifesting as Radiculopathy: A Case Report. J Multidiscip Healthc 2021; 14:1593-1598. [PMID: 34234447 PMCID: PMC8253935 DOI: 10.2147/jmdh.s316738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 06/17/2021] [Indexed: 02/05/2023] Open
Abstract
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.
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Affiliation(s)
- Po-Cheng Lo
- Department of Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, 23142, Taiwan
| | - Chung-Tai Yue
- Department of Anatomic Pathology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, 23142, Taiwan
| | - Woon-Man Kung
- Division of Neurosurgery, Department of Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, 23142, Taiwan
- Correspondence: Woon-Man Kung Division of Neurosurgery, Department of Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No 289, Jianguo Road, Xindian District, New Taipei City, 23142, Taiwan Email
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Trauma Induced Calcium Pyrophosphate Deposition Disease of the Lumbar Spine. Case Rep Rheumatol 2020; 2020:3218350. [PMID: 32095306 PMCID: PMC7035534 DOI: 10.1155/2020/3218350] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 12/20/2019] [Indexed: 02/07/2023] Open
Abstract
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.
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Alian A, Omar H, Chhabra A. Cross-Sectional Imaging for Inflammatory Arthropathy of the Pelvis. Semin Ultrasound CT MR 2017; 38:279-290. [PMID: 28705372 DOI: 10.1053/j.sult.2016.11.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
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.
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Affiliation(s)
- Ali Alian
- Musculoskeletal Radiology, University of Texas Southwestern Medical Center, Dallas, TX; Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Hythem Omar
- Musculoskeletal Radiology, University of Texas Southwestern Medical Center, Dallas, TX; Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Avneesh Chhabra
- Musculoskeletal Radiology, University of Texas Southwestern Medical Center, Dallas, TX; Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX; Musculoskeletal Radiology, Russell H. Morgan Department of Radiology & Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, MD.
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Srinivasan V, Wensel A, Dutcher P, Newlands S, Johnson M, Vates GE. Calcium pyrophosphate deposition disease of the temporomandibular joint. J Neurol Surg Rep 2013; 73:6-8. [PMID: 23946918 PMCID: PMC3658656 DOI: 10.1055/s-0032-1329190] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
- Vasisht Srinivasan
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York
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10
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Lee J, Cho KT, Kim EJ. Cauda equina syndrome caused by pseudogout involving the lumbar intervertebral disc. J Korean Med Sci 2012; 27:1591-4. [PMID: 23255864 PMCID: PMC3524444 DOI: 10.3346/jkms.2012.27.12.1591] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2012] [Accepted: 08/27/2012] [Indexed: 12/20/2022] Open
Abstract
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.
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Affiliation(s)
- Jungjun Lee
- Department of Neurosurgery Dongguk University Ilsan Hospital, Goyang, Korea
| | - Keun-Tae Cho
- Department of Neurosurgery Dongguk University Ilsan Hospital, Goyang, Korea
| | - Eo-Jin Kim
- Department of Pathology, Dongguk University Ilsan Hospital, Goyang, Korea
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11
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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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12
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Srinivasan V, Kesler H, Johnson M, Dorfman H, Walter K. Tophaceous pseudogout of the thoracic spine. Acta Neurochir (Wien) 2012; 154:747-50; discussion 750. [PMID: 22367409 DOI: 10.1007/s00701-012-1308-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2011] [Accepted: 02/09/2012] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Vasisht Srinivasan
- Department of Neurosurgery, University of Rochester Medical Center, NY 14623, USA.
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13
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Giulioni M, Zucchelli M, Damiani S. Thoracic myelopathy caused by calcified ligamentum flavum. Joint Bone Spine 2007; 74:504-5. [PMID: 17709270 DOI: 10.1016/j.jbspin.2007.01.029] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2006] [Accepted: 01/31/2007] [Indexed: 10/23/2022]
Abstract
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.
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Affiliation(s)
- Marco Giulioni
- Department of Neurosurgery, Bellaria Hospital, Via Altura, 3, 40100 Bologna, Italy.
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Doita M, Shimomura T, Maeno K, Nishida K, Fujioka H, Kurosaka M. Calcium pyrophosphate dihydrate deposition in the transverse ligament of the atlas: an unusual cause of cervical myelopathy. Skeletal Radiol 2007; 36:699-702. [PMID: 17265158 DOI: 10.1007/s00256-006-0273-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2006] [Revised: 11/21/2006] [Accepted: 12/28/2006] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- M Doita
- Department of Orthopedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan.
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15
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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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16
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Abstract
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.
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Lecoules S, Blade JS, Bordier L, Desramé J, Coutant G, Bechade D, Algayres JP. [A spinal disease which causes toothache...]. Rev Med Interne 2005; 26 Suppl 2:S307-9. [PMID: 16129185 DOI: 10.1016/s0248-8663(05)81295-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- S Lecoules
- Clinique médicale, hôpital d'Instruction de Armées du Val-de-Grâce, Paris, France
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Mahmud T, Basu D, Dyson PHP. Crystal arthropathy of the lumbar spine: a series of six cases and a review of the literature. ACTA ACUST UNITED AC 2005; 87:513-7. [PMID: 15795202 DOI: 10.1302/0301-620x.87b4.15555] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
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.
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Affiliation(s)
- T Mahmud
- Departmernt of Orthopaedics, Hemel Hempstead Hospital, Hillfield Road, Hemel Hempstead HP2 4AD, UK
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19
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Paolini S, Ciappetta P, Guiducci A, Principi M, Missori P, Delfini R. Foraminal deposition of calcium pyrophosphate dihydrate crystals in the thoracic spine: possible relationship with disc herniation and implications for surgical planning. J Neurosurg Spine 2005; 2:75-8. [PMID: 15658131 DOI: 10.3171/spi.2005.2.1.0075] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
✓ 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.
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Affiliation(s)
- Sergio Paolini
- Cattedra di Neurochirurgia, Università di Perugia, Servizio di Anatomia Patologica, Ospedale S Maria, Terni, Italy.
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20
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Steinbach LS. Calcium pyrophosphate dihydrate and calcium hydroxyapatite crystal deposition diseases: imaging perspectives. Radiol Clin North Am 2004; 42:185-205, vii. [PMID: 15049531 DOI: 10.1016/s0033-8389(03)00160-x] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Lynne S Steinbach
- Department of Radiology, University of California at San Francisco, 505 Parnassus, Room M-392, San Francisco, CA 94143-0629, USA.
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Baty V, Prost B, Jouvet A, Laurent J, Vallée B. Acute spinal cord compression and calcium pyrophosphate deposition disease. Case illustration. J Neurosurg 2003; 99:240. [PMID: 12956470 DOI: 10.3171/spi.2003.99.2.0240] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Vincent Baty
- Département de Médecine, Clinique Mutualiste Eugène Andrè, Lyon, France.
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Fujishiro T, Nabeshima Y, Yasui S, Fujita I, Yoshiya S, Fujii H. Pseudogout attack of the lumbar facet joint: a case report. Spine (Phila Pa 1976) 2002; 27:E396-8. [PMID: 12221374 DOI: 10.1097/00007632-200209010-00028] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Takaaki Fujishiro
- Department of Orthopaedic Surgery, Himeji St. Mary's Hospital, Himeji, Japan
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Yamamoto A, Nishiura I, Handa H, Kondo A. Ganglion cyst in the ligamentum flavum of the cervical spine causing myelopathy: report of two cases. SURGICAL NEUROLOGY 2001; 56:390-5. [PMID: 11755976 DOI: 10.1016/s0090-3019(01)00639-5] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
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.
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Affiliation(s)
- A Yamamoto
- Takeda General Hospital, Department of Neurosurgery, Kyoto-city, Kyoto, Japan
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Assaker R, Louis E, Boutry N, Bera-Louville A, Paul Lejeune J. Foramen magnum syndrome secondary to calcium pyrophosphate crystal deposition in the transverse ligament of the atlas. Spine (Phila Pa 1976) 2001; 26:1396-400. [PMID: 11426159 DOI: 10.1097/00007632-200106150-00027] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- R Assaker
- Department of Neurosurgery, Lille University Hospital, Lille, France.
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Dudler J, Stucki RF, Gerster JC. Aseptic psoas pyomyositis and erosive discitis in a case of calcium pyrophosphate crystal deposition disease. Rheumatology (Oxford) 2000; 39:1290-2. [PMID: 11085815 DOI: 10.1093/rheumatology/39.11.1290] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Steinbach LS, Resnick D. Calcium pyrophosphate dihydrate crystal deposition disease: imaging perspectives. Curr Probl Diagn Radiol 2000; 29:209-29. [PMID: 11104172 DOI: 10.1016/s0363-0188(00)90014-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
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Kakitsubata Y, Boutin RD, Theodorou DJ, Kerr RM, Steinbach LS, Chan KK, Pathria MN, Haghighi P, Resnick D. Calcium pyrophosphate dihydrate crystal deposition in and around the atlantoaxial joint: association with type 2 odontoid fractures in nine patients. Radiology 2000; 216:213-9. [PMID: 10887250 DOI: 10.1148/radiology.216.1.r00jl36213] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
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.
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Affiliation(s)
- Y Kakitsubata
- Department of Radiology, University of California, San Diego, Veterans Affairs Medical Center, 3350 La Jolla Village Dr, San Diego, CA 92161, USA
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Zünkeler B, Schelper R, Menezes AH. Periodontoid calcium pyrophosphate dihydrate deposition disease: "pseudogout" mass lesions of the craniocervical junction. J Neurosurg 1996; 85:803-9. [PMID: 8893717 DOI: 10.3171/jns.1996.85.5.0803] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- B Zünkeler
- Division of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, USA
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Sabo RA, Tracy PT, Weinger JM. A series of 60 juxtafacet cysts: clinical presentation, the role of spinal instability, and treatment. J Neurosurg 1996; 85:560-5. [PMID: 8814156 DOI: 10.3171/jns.1996.85.4.0560] [Citation(s) in RCA: 126] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- R A Sabo
- Department of Neurological Surgery, University of Illinois College of Medicine at Peoria, USA
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