The diseases causing insufficiency fractures of the spine in young and middle-aged patients

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1 The diseases causing insufficiency fractures of the spine in young and middle-aged patients Poster No.: C-2404 Congress: ECR 2010 Type: Educational Exhibit Topic: Musculoskeletal Authors: S. Y. Park, W. Jin, J. S. Park, K. N. Ryu; Seoul/KR Keywords: vertebrae, insufficiency fracture, osteoporosis DOI: /ecr2010/C-2404 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 16

2 Learning objectives To illustrate a variety of diseases related to insufficiency fractures of the spine in young and middle-aged patients Background Insufficiency fractures develop from the effects of normal or physiologic stress on abnormally weakened bone, in which the elastic resistance is reduced. There are various diseases that cause insufficiency fractures of the spine. Senile and postmenopausal states, use of steroids, endocrine disorders such as hyperparathyroidism or Cushing's disease, pregnancy, alcoholism, and malnutrition are the major causes of generalized osteoporosis and may result in insufficiency fractures in the vertebral bodies. Also, insufficiency fractures of the spine may be seen in osteomalacia or renal osteodystrophy. In young and middle-aged patients, insufficiency fracture of the spine is rarely seen. We describe various conditions causing multiple insufficiency fractures of the spine, especially in yound and middle-aged patients. Ref (1-3) Imaging findings OR Procedure details CASE 1: 31-year-old woman Chief complaint and present illness - back pain - postpartum period (delivery 2 months ago) Page 2 of 16

3 T-spine radiograph (Fig 1) - height loss with concave or wedge deformities in multiple thoracic vertebral bodies, concave deformities in upper lumbar vertebral bodies, and diffuse osteoporosis T-spine MRI (Fig 1) - T-spine MRI demonstrates multiple fractures at T5-T12 vertebral bodies, with or without surrounding bone marrow edema. Bone scan (Fig 1) - increased uptakes at T6-L3 vertebral bodies along superior endplates Bone mineral density (BMD) - osteoporosis with a lumbar spine (L1-L4) T score of -4.0 and a femur (neck) T score of -2.0 Laboratory results - alkaline phosphatase (ALP) 484 IU/L (#); total serum calcium (Ca) 7.4mg/dl (#); serum phosphorus (P) 1.9mg/dl (#); urinary Ca 0.143mg/24h; urinary creatinine (Cr) 0.7g/24h (#);C-terminal peptide ng/ml (#); parathyroid hormone (PTH) 85.0 pg/ml (#); serum osteocalcin 15 ng/ml; serum T3 47 ng/dl (#); serum free T ng/dl (#); and serum TSH 2.95 miu/l Diagnosis - Postpartum osteoporosis associated with multiple vertebral fractures Discussion Pregnancy and lactation are associated with considerable changes in calcium metabolism because of the increased necessities for fetal skeleton formation and breast milk production. In the last trimester of pregnancy, there is a need for calcium to allow mineralization of the fetal skeleton. During lactation, 250 to 350 mg of calcium is transferred daily from the mother to the neonate through the milk. Estradiol, prolactin and parathyroid hormone-related protein (PTHrP) play complex and variable roles in bone metabolism during pregnancy and lactation. Risk factors of postpartum fracture are thought to be rapid and excessive weight gain during pregnancy, transient osteoporosis during pregnancy, decrease in physical activity and endocrine and hormonal influences. Ref (4) Page 3 of 16

4 CASE 2: 35-year-old man Chief complaint - intermittent low back pain, right buttock and thigh pain for 4-5 years Past medical history - none L-spine radiograph (Fig 2) - concave deformities at bodies of L-spine with diffuse osteoporosis L-spine sagittal reformatted CT image (Fig 2) - biconcave whole lumbar vertebrae with subchondral transverse lines along endplates and diffuse osteoporosis L-spine MRI (Fig 2) - multiple subchondral low signal intensity lines along endplates at bodies of whole Lspine L-spine sagittal reformatted CT image at the level of right neural foramen of L-spine - spondylolysis: defect at pars interarticularis (defect at left pars interarticularis was not shown.) BMD - The BMD is below the expected range for age with a lumbar spine (L1-L4) T score of -2.7 Laboratory results - total serum Ca 8.7mg/dl; serum P 4.3mg/dl; urinary Ca 0.299mg/24h; urinary Cr 1.65g/24h (#); serum testosterone 5.59 ng/ml; serum sex hormone-binding globulin (SHBG) 51.7 nmol/l; serum 25-OH Vitamin D 25.7 pg/ml (R 11-70); serum C-terminal peptide ng/ml (#); serum PTH (intact) 30.0 pg/ml; serum osteocalcin 31.0 ng/ml Diagnosis -idiopathic osteoporosis Page 4 of 16

5 Discussion Idiopathic osteoporosis can be defined as osteoporosis that occurs in men without any known cause and represents approximately 40-50% of all osteoporosis in men. There is an age limit associated with this definition. The three major cuases of osteoporosis in men are alcohol abuse, glucocorticoid excess and hypogonadism. Im many series, these etiologic account for 40-50% of all men with osteoporosis. Ref (5) CASE 3: 37-year-old man Chief complaint - both hip pain (severer at right hip) 6 months ago and low back pain 3 years ago Past medical history - heart surgery for atrial septal defect 23 years ago - hypertension L-spine radiograph (Fig 3) - height loss with concave or wedge deformities in bodies of T11-L5 and diffuse osteoporosis L-spine MRI (Fig 3) - multiple insufficiency fractures at T11-L5 vertebral bodies, which are located close to endplates Hip AP radiograph (Fig 4) - Looser's zone at medial cortex of left proximal femoral shaft, diffuse osteoporosis Bone scan (Fig 3) - increased uptakes at left scapula, right acromioclavicular joint and shoulder, ribs, spines, symphysis pubis, both femoral heads, and right foot Chest CT (not shown) - rib fractures Page 5 of 16

6 Abdomen CT (not shown) - no abnormality in abdomen Hip MR (Fig 5) after 3 months - insufficiency fractures are seen at both femoral heads, ilii, and symphysis pubis. Looser's zone is noted at medial cortex of left femoral shaft. Bone mineral density (BMD) after 3 months - osteoporosis with a lumbar spine (L1-L4) T score of -4.2 and a femur (neck) T score of -3.2 Chest PA after 3 months (Fig 4) - Looser's zone is newly visible at lateral border of left scapula. PET CT after 4 months (not shown) - no visible abnormal hypermetabolic lesion In-111 Octreotide scan after 6 months (not shown) - no abnormal increased uptake Laboratory results - serum ALP 932 IU/L (#); total serum Ca 8.6mg/dl; serum P 2.1mg/dl (#); urinary Ca 0.044mg/24h (#); urinary P 530.2mg/24h; urinary Cr 0.78g/24h (#); serum 1,25-(OH)2 Vitamin D pg/ml (#); serum C-terminal peptide ng/ml (#); serum PTH 35.0 pg/ml; serum osteocalcin 18.2 ng/ml Diagnosis - osteomalacia possibly due to vitamine D deficiency (the patient didn't undergo bone biopsy. This diagnosis was made by laboratory results and imaging findings.) CASE 4: 62-year-old woman Chief complaint - dry mouth, anorexia, weight loss (7kg during last 1 year) Page 6 of 16

7 Past medical history - hypothyroidism with medication, hypertension L-spine radiograph (Fig 6) - osteosclerosis along endplates and bone resorption with osteoporosis at spine L-spine MRI (Fig 6) - multiple insufficiency fractures along endplates at T10-L5 vertebral bodies Thyroid US (Fig 6) - mixed (solid and cystic) tumor in inferior pole of left thyroid was suggested and the differential diagnosis was parathyroid tumor Bone scan (Fig 9) There was diffusely increased uptake in whole body bones, especially calvarium (suggestive of superscan pattern). Mildly increased uptakes were noted along endplates at L-spine and lower T-spine. Focally increased uptakes were noted at distal portion of th left clavicle and left 9 rib posterior arc. Liver activity was visualized. Parathyroid MIBI scan (Fig 6) 10-minute pinhole image shows focal increased uptake at region just inferior to left thyroid, which persisted on 2-hour delayed image. BMD - osteoporosis with a lumbar spine (L1-L4) T score of -3.3 and a femur (neck) T score of -2.4 Laboratory results - serum ALP 2317 IU/L (#); total serum Ca 13.5mg/dl (#); serum P 2.0mg/dl (#); ionized calcium 1.94mmol/L (#);T3 105ng/dl; Free T4 1.67ng/dl; TSH 0.09mIU/L (#) Diagnosis - Parathyroid, left lower, excision: Primary hyperparathyroidism due to parathyroid carcinoma Page 7 of 16

8 Discussion Primary hyperparathyroidism results from parathyroid adenoma (80%), parathyroid gland hyperplasia (15-20%), or parathyroid carcinoma (<0.5%). Generalized osteopenia is the most common finding in primary hyperparathyroidism. Osteosclerosis is rarely encountered in primary hyperparathyroidism, on the other hand, is common in secondary hyperparathyroidism. Bone resorption is seen at subperiosteal, subchondral, intracortical, endosteal, and trabecular locations. Chondrocalcinosis is more common in primary rather than secondary hyperparathyroidism. Brown tumor, soft tissue calcifications, and periostitis are more commonly encountered in secondary hyperparathyroidism. Ref (6) CASE 5: 50-year-old woman Chief complaint - Gait disturbance, low back pain, bilateral posterior leg pain and numbness Past medical history - hemodialysis for chronic renal failure L-spine radiograph (Fig 7) - wedged deformities were seen at bodies of L1-4 and osteosclerosis along endplates was noted at L-spine. L-spine MRI (Fig 7) - demonstrates multiple insufficiency fractures along endplates at T11-S1 vertebral bodies with band-like low signal intensities, thickening of the posterior longitudinal ligaments, and central spinal canal stenosis at the level of L4-5 disc. -whole spine sagittal T2-weighted image shows multiple insufficiency fractures at thoracolumbar spines, thickening of the posterior longitudinal ligament C-spine MRI and 3D CT (Fig 8) - show thickening of the posterior longitudinal ligaments at C-spine without ossification. Also there is thickening of lig flava. These causes central spinal canal stenosis. Erosions and cysts in C2 body and lateral masses of C1 and T2-low signal intensity synovial hypertrophy are noted. Dialysis-related amyloidosis was suggested. Page 8 of 16

9 Diagnosis - Renal osteodystrophy Images for this section: Fig. 1: CASE 1: 31-year-old woman Page 9 of 16

10 Fig. 2: CASE 2: 35-year-old man Fig. 3: CASE 3: 37-year-old man Page 10 of 16

11 Fig. 4: CASE 3: 37-year-old man Fig. 5: CASE 3: 37-year-old man Page 11 of 16

12 Fig. 6: CASE 4: 62-year-old woman Page 12 of 16

13 Fig. 7: CASE 5: 50-year-old woman Page 13 of 16

14 Fig. 8: CASE 5: 50-year-old woman Page 14 of 16

15 Conclusion We should have a knowledge of various conditions causing insufficiency fractures of the spine and recommend additional examinations to find out the causes, especially in yound and middle-aged patients. Personal Information So Young Park, Wook Jin, Ji Seon Park, Kyung Nam Ryu So Young Park : Department of Radiology, East-West Neo Medical Center, KyungHee University, 149 Sangil-dong, Gangdong-gu, Seoul, , Republic of Korea. balgundol@hanmail.net Tel: Fax: Wook Jin : Department of Radiology, East-West Neo Medical Center, Kyung-Hee University, 149 Sangil-dong, Gangdong-gu, Seoul, , Republic of Korea. Ji Seon Park : Department of Radiology, Kyung Hee University Medical Center, Hoegidong, Dondaemun-gu, Seoul , Korea. Kyung Nam Ryu : Department of Radiology, Kyung Hee University Medical Center, Hoegi-dong, Dondaemun-gu, Seoul , Korea. References 1. Peh WC, Khong PL, Yin Y, et al. Imaging of pelvic insufficiency fractures. Radiographics 1996;16: Daffner RH, Pavlov H. Stress fractures: current concepts. AJR Am J Roentgenol 1992;159: Kawaguchi S, Yamashita T, Koshio H, Kirita T, Minaki Y, Yokogushi K. Insufficiency fracture of the spine: a prospective analysis based on radiographic and scintigraphic diagnosis. J Bone Miner Metab 2001;19: Page 15 of 16

16 4. Serarslan Y. Kalaci A. Akdemir GH. Yanat AN. Postpartum osteoporosis associated with vertebral fractures: report of two cases. World Spine Journal 2007;2: Bilezikian JP. Osteoporosis in men. J Clin Endocrinol Metab 1999;84: McDonald DK, Parman L, Speights VO, Jr. Best cases from the AFIP: primary hyperparathyroidism due to parathyroid adenoma. Radiographics 2005;25: Murphey MD, Sartoris DJ, Quale JL, Pathria MN, Martin NL. Musculoskeletal manifestations of chronic renal insufficiency. Radiographics 1993;13: Page 16 of 16

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