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A Case of Osseous Sarcoidosis of the Lumbar Spine 2008

General Spine

Christopher P Petrie, DC,
Jean-Nicolas Poirier, DC, DACBR, Non ASSR Member

Excerpta Extraordinaire

Excerpta

We present an educational retrospective case study of a patient suffering from chronic low back pain and lumbar spine vertebral sarcoidosis.

A 64 year-old male presented with chronic low back pain with radiation down the left leg to the calf. He rated his pain level at 10/10. He had severe ambulatory limitations and complained that he could not sit. A plain film radiographic examination demonstrated extensive degenerative changes at the vertebral endplates, discs and facet joints predominantly in the lower lumbar spine. No destructive osseous lesions were seen involving the lumbar vertebrae. A disc herniation was clinically suspected at L5-S1. A period of conservative treatment failed to resolve the patient's symptoms, and a magnetic resonance imaging (MRI) evaluation of the lumbar spine was recommended to evaluate the lumbosacral disc changes. Multiple lesions ranging from 4mm to 2cm in largest diameter were seen scattered throughout the vertebral bodies from L1-S2. The lesions appeared sharply delineated and demonstrated homogeneous low signal intensity on T1 and T2- weighted sequences. Conversely, two small lesions involving L4 and L5 demonstrated high signal intensity on fluid-sensitive sequences. A small rim of high signal intensity was also seen on T2-weighted sequences incompletely surrounding the largest lesions at L3 and L4. There was no evidence of pathological fracture or soft tissue or epidural extension of the disease. A large disc bulge was seen at L5-S1, accompanied by advanced facet arthrosis and ligamentum flavum hypertrophy, leading to spinal canal stenosis and bilateral neural foraminal encroachment. Fat suppression and contrast-enhanced sequences were not performed.

A biopsy sample of the lesions revealed the presence of a noncaseating granulomatous disease. The patient was diagnosed with vertebral sarcoidosis. A chest radiographic examination failed to demonstrate any mediastinal or pulmonary involvement of the disease. The patient denied treatment for sarcoidosis and no follow-up MRI examination was performed. He continued a period of conservative care that eventually improved his low back pain. The true etiology of the pain (mechanical low back vs. osseous sarcoidosis) was never established.

This unusual case of provided an opportunity to learn more about the clinical and imaging presentation of vertebral sarcoidosis, a rare and usually painful condition. The imaging findings are variable and nonspecific and may simulate metastatic disease. Biopsy is required for accurate diagnosis.

References

Fisher AJ, Gilula LA, Kyriakos M, Holzaepfel CD. MR imaging changes of lumbar vertebral sarcoidosis. AJR Am J Roentgenol. 1999;173:354-6.

Rua-Figueroa I, Gantes MA, Erausquin C, Mhaidli H, Montesdeoca A. Vertebral sarcoidosis: clinical and imaging findings. Semin.Arthritis Rheum. 2002;31:346-52.

Waanders F, van HP, Krikke A, Wesseling J, Nieboer P. Sarcoidosis mimicking metastatic disease: a case report and review of the literature. Neth.J Med 2006;64:342-5.

Lisle D, Mitchell K, Crouch M, Windsor M. Sarcoidosis of the thoracic and lumbar spine: imaging findings with an emphasis on magnetic resonance imaging. Australas.Radiol 2004;48:404-7.

This case was previously presented at the American College of Chiropractic Radiology (ACCR) 2007 Annual Workshop, October 17-20 in Denver, CO.

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