THIS 16 YEAR OLD PRESENTS WITH BILATERAL SACROILIAC PAIN – WHAT’S THE DIAGNOSIS?

Case History

This 16 year old male patient presents with left and right-sided buttock and lumbosacral pain. No history of any surgical intervention. Morning stiffness is noted clinically.

Discussion

Note the significant sclerosis of the mid and lower portion of the sacroiliac joints bilaterally. The articular margins are somewhat instinct characteristic of the appearance of early sacroiliitis which may explain the patient’s presenting signs and symptoms.

The lumbar spine did not show any evidence of ankylosing spondylitis or enteropathic spondylitis. Patients with a history of chronic Crohn’s disease or ulcerative colitis may develop an ankylosing spondylitis radiographic presentation and is usually limited to the sacroiliac joints and lumbar spine seldom progressing above the thoracolumbar junction.

An important radiographic peril is that if the sacroiliac joints appear to be indistinct suggesting sacroiliitis the second most common location for early ankylosing spondylitis is a marginal syndesmophyte at the T12/L1 junction. This was not present in this case.

This patient should be referred to a rheumatologist for complete blood work to include HLAB-27 antigen, ESR, CRP, and a CBC.

Patients can be comanaged with ankylosing spondylitis but there are certain drugs now that can limit the progression of ankylosing spondylitis if found early and managed appropriately. This case came through our chiropractic radiology practice from one of our referring doctors from Alabama. This is a current case at this time. I believe the blood tests will help confirm the diagnosis of ankylosing spondylitis.

An Old Football Injury Creates A Bazaar Radiological Appearance

Case History

This 60 year old male patient presents with low back pain and sciatica. He relates a history of playing high school football where he went to punt the ball and missed the ball with a defensive player running under his leg causing him to further extend his leg. He developed immediate pain in his buttocks.

Diagnosis – Rider’s Bone (Ischial Tuberosity Avulsion)

Note the extensive bone production seen inferior to the lateral aspect of the left ischial tuberosity. This represents an avulsion of the secondary growth center (apophysis) for the ischial tuberosity as a result of the forceful contraction of the hamstring while trying to kick the football.

These can be acute or chronic injuries or frequently bilateral. With healing, overgrowth of the avulsed apophysis occurs, often leaving a wide radiolucent gap between the avulsed fragment and the parent ischium. This overgrowth may be the effect of increased blood flow to the ischial apophysis.

Occasionally the involved ischial apophysis may assume a size larger than the parent ischium. This large overgrowth could be confused with an osteochondroma if attached to the bone. The patient’s history of a previous severe hamstring injury and the fact that the lesion is asymptomatic secures the proper diagnosis. Reduction in hip mobility is common and surgical intervention has not been encouraged. These fractures are seen most commonly in cheerleaders and hurdlers. Since chronic stress often produces this lesion in horseback riders the residual bony fragment has been called “Rider’s Bone”.

SPINAL FUSION – WHAT’S THE REAL CAUSE?

History: 52-year-old male patient with deep seated neck pain and reduced range of motion.

There is an extensive amount of spinal hyperostosis noted from C2 through C6 on the anterior aspect of the vertebral bodies. This spinal hyperostosis is very characteristic of diffuse idiopathic skeletal hyperostosis (DISH). These patients have a reduced range of motion and can experience dysphagia. An additional finding in this patient is degenerative disc space narrowing at the C2/3 level. All the remainder of the cervical discs and the facets are reasonably well preserved. That is often a characteristic finding of patient’s with DISH.

This patient additionally has congenital agenesis of the posterior arch of the atlas with a posterior arch and tubercle of the atlas fusing to the spinous process of C2 creating a characteristic “mega spinous process sign”. Note the anterior tubercle of the atlas is enlarged by means of hypertrophy. This occurs as a result of altered upper cervical biomechanical movement.

An additional finding associated in some patients with DISH is ossification of the stylohyoid ligament which is noted here. This is seen just above the hyoid bone and extending to the styloid as a very large ossific bar. Patients with DISH on occasion may fuse the posterior longitudinal ligament (OPLL). Ossification of the posterior longitudinal ligament may produce spinal stenosis and symptoms in the upper and lower extremity. These findings should be looked for very closely clinically. This appearance of spinal fusion is quite different than the finer and delicate areas of bone spurring and fusion associated with ankylosing spondylitis.