Pseudogout of Lumbar Spine
A 74-year Caucasian female presented with severe worsening low back pain, right radicular pain, and difficulty walking for 3 days. She did not have fever or Leukocytosis. ESR and CRP were elevated at 60 mm/hr and 94.8 mg/L. Images showed marked signal enhancement at L5-S1, concerning for discitis versus osteomyelitis as well as epidural phlegmon formation and extension of inflammation into paraspinal musculature. IV antibiotics started. IR guided L5-S1 disc biopsy was non-diagnostic for discitis or osteomyelitis. After a discussion of the management options, the patient underwent posterior debridement, discectomy, right-sided L5-S1 laminectomy, facetectomy, and L5-S1 fusion in a 2 stages surgery. Surgical cultures and the universal PCR specimen range were negative. Pathology of the epidural tissue showed pseudogout in the spinal bone and cartilage. The patient received anti-inflammatory agents, pain management, 2 weeks inpatient-rehabilitation, and was discharged back home with significant improvement in the patient’s strength, pain, and gait.
Although pseudogout is a common disease affecting the peripheral joints, the involvement of the spine is uncommon. To our knowledge, there are few cases that were reported for pseudogout that affects axial spine mainly the facet joints. This case is interesting because it is the third reported case of pseudogout that mimics osteomyelitis of spine, indicating a paucity of information regarding pseudogout in the axial spine of a patient with no past medical history of pseudogout. The case also showed a significant improvement in strength and gait during inpatient rehabilitation.
This case highlights the need to consider pseudogout in the differential diagnosis of acute back pain. There have only been a few cases reported in the literature up to date, so this case will provide further insight into diagnosis and clinical management of spinal pseudogout.
Amanda Reyes– Volunteer Research Fellow, Beaumont Hospital- Taylor
Hashem Zokary– PMR resident, Beaumont Hospital Taylor
Joe Mendez– Faculty and Chairman-- Rehabilitation Department, Beaumont Hospital-Taylor
P. Tyler Roskos– Clinical Neuropsychologist, Beaumont-Hospital Taylor Physical Medicine and Rehabilitation