Unusual Case: Low Back Pain with L1-L3 Degeneration and L1-L2 Instability
The patient is a 30-year-old male, non-smoker, of average weight. He presented with a 4-year history of moderate to severe low back pain, worse with physical activity, and occasional low-grade fever. He has been treated with physical therapy and non-narcotic medications with limited benefit. During the past 6 months, the intensity of the patient's pain has increased significantly, requiring narcotic pain medications and a lumbar corset, again with minimal benefit.
Two months prior to presentation, the patient developed pain in the right sternoclavicular joint and the manubriosternal area. He developed a diffuse rash on his upper back, which was diagnosed as Acne Conglobata.
Examination revealed tenderness over the right sternoclavicular and lower paraspinal areas. The patient exhibited decreased range-of-motion in the lumbar spine. He is neurologically intact.
Figures 1 and 2 (below) reveal sacroiliitis, inflammatory enthesopathy, and bony erosion of the end plates and anterior cortices at L1-L3. The patient has hyperostosis and osteitis throughout the lumbar spine.
Figure 1: Sagittal MRIs
Figure 2: Axial CT scans
Bone scintigraphy (Figure 3) shows decreased uptake at L1, L2, L5, along with moderate uptake at the left upper tip of the scapula and sacroiliac joint. Increased uptake was evident at the sternoclavicular joint and sternum (typical buffalo sign).
Figure 3: Bone scintigraphy shows increased uptake
Extension and flexion radiographs demonstrated degenerative changes at L1-L2 and L2-L3 disc spaces and instability at the L1-L2 disc spaces. (Figures 4, 5)
Synovitis Acne Pustulosis Hyperostosis Osteomyelitis Syndrome (SAPHO).
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At this point, our spine team proposes posterior pedicle fixation at L1-L2 with a posterolateral fusion. However, we are concerned about the effect of this fixation upon adjacent segment stability.
The case described is consistent with a variant of SAPHO. SAPHO has several different names and is considered by some to be a seronegative spondyloarthropathy. In most cases, the symptoms are self-limiting but recurrent.
In this particular case, symptoms of mechanical back pain should initially be treated with physical therapy, activity alteration, and possible external immobilization. In addition, reports have suggested the benefit of NSAIDs as a treatment option.
Degenerative changes at L1-L2 and L2-L3 may not account for all of the patient's symptoms and surgical intervention should be suggested with reservations. Following failure of symptom improvement with exhaustive non-operative care, spinal stabilization may include fusion via posterior, anterior, or a combined approach.
Based on the studies presented, limiting the fusion to L1-L2 may not be the best option. Furthermore, stabilization of the anterior column may provide better relief of mechanical symptoms and could be accomplished through a direct lateral approach.
Chamot, AM, Benhamou, CL, Kahn, MF (1987). Le syndrome acne pustulose hyperostose ostite (SAPHO): resultants d'une enquate nationale. Rev Rheum Mal Osteoartic 54: 187-96.
Benhamou CL, Chamot AM, Kahn MF. Synovitis-acne-pustulosis hyperostosis-osteomyelitis syndrome (SAPHO). A new syndrome among the spondyloarthropathies? Clin Exp Rheumatol. 1988 6(2):109-112.Apr-Jun;6(2):109-12.
Tehlirain C. Round 7: Synovitis-Acne-Pustulosis-Hyperostosis osteomyelitis syndrome (SAPHO). July 13, 2006. http://www.hopkins-arthritis.org/physician-corner/cme/rheumatology-rounds/sapho_rheumrounds7.html