Acute back pain with neurological symptoms is a medical emergency. Here we report a case of severe degenerative spine disease with raised inflammatory markers due to an atypical cause.
A 90-year-old male patient presented to our emergency department with acute sciatica-like back pain, urinary retention, constipation, and weakness in his lower limbs (manual muscle testing grade 4/5). His C-reactive protein was raised at 400 mg/L (normal < 7 mg/L) with neutrophil leukocytosis. His lumbar spine magnetic resonance imaging (MRI) confirmed severe multilevel degenerative disc and facet joint disease with ligamentum flavum hypertrophy, causing severe central and right foraminal stenosis without epidural collection, discitis, or visible calcifications. His abdominopelvic computed tomography (CT) showed no abscess or malignancy. He received a prolonged antimicrobial course for sepsis without clinical improvement. Four weeks later, he developed polyarthritis, and his knee aspiration confirmed rhomboid-shaped, positively birefringent crystals consistent with calcium pyrophosphate deposition (CPPD) disease.
When imaging was reevaluated, his spine CT exhibited mineralized deposits within the spinal canal and periarticular facet joints (Figure 1B) at the L4/5 level. The calcifications were also seen bilaterally within the sacroiliac joints (SIJs; Figure 2). His pain improved and he recovered within days following treatment with prednisolone and colchicine; he regained full mobility shortly.
(A) Sagittal CT view showing L4/5 spondylolisthesis and vacuum phenomenon (asterisk); and (B) axial view exhibiting calcifications within the spinal canal and facet joints at this level (arrows). CT: computed tomography.
Axial CT scan showing calcifications (arrows) within sacroiliac joints. CT: computed tomography.
The prevalence of CPPD increases with age. It is commonly superimposed on underlying degenerative joint disease and can involve all spinal structures and SIJs.1 Spinal presentations include cervical myelopathy, cauda equina, crowned dens, and radiculopathy, and can also mimic meningitis, pyogenic discitis, or malignancy.2,3 The diagnosis is typically established through guided biopsy/aspiration or histological examination following spinal surgery by applying polarizing microscopy. CT is the imaging modality of choice for detecting spinal CPPD disease as MRI is less sensitive for calcific deposits.4
Footnotes
The authors declare no conflicts of interest relevant to this article. No ethical approval is required for case reports according to the authors’ institutions and patient consent was obtained.
- Copyright © 2024 by the Journal of Rheumatology