Trauma Induced Calcium Pyrophosphate Deposition Disease of the Lumbar Spine

Abstract

Inflammatory arthritis, such as pseudogout or otherwise referred to as calcium pyrophosphate (CPP) crystal arthritis or calcium pyrophosphate deposition (CPPD) disease, is characterized by the deposition of crystal formation and deposition in large joints. CPPD is known to affect the elderly population and commonly manifests as inflammation of knees, hips, and shoulders. CPPD disease involving the spine has been infrequently encountered in practice and rarely described in the literature. Here, we describe a case of an 80-year-old female with no known history of inflammatory arthritis who presented with left lower extremity weakness and fall, initially thought to have discitis, later confirming CPPD of the spine through biopsy and ultimately resolution of symptoms with anti-inflammatory agents. Although consisting of different clinical presentations, two other case reports have described CPPD of the spine with similar radiographic findings, to this author's knowledge. With the radiologic similarities, this unique case serves to raise awareness in the medical community and possibly place pseudogout of the spine on the differential list when such cases are encountered. As a result, patients can be initiated on benign anti-inflammatory agents, avoiding invasive testing and unnecessary antibiotic exposure.

Figure 1

Axial and sagittal T1 and T2-weighted and coronal and sagittal short-TI inversion recovery (STIR) images of the lumbar spine without intravenous contrast administration. Axial and sagittal T1-weighted images were then acquired following intravenous administration of 80 mL of Gadavist. The image shows vertebral body edema and enhancement most evident at the L4L5 level. Paravertebral soft tissue thickening is seen at the L5-S1 level, with extension into the left neural foramina. Findings are suggestive of osteomyelitis/discitis.

Figure 2

Figure 3

Thoracic (a) and lumbar (b) spine MR images demonstrate some enhancement within the C7–T1 acet joints as well as the T1–2 and T9–12 intervertebral discs. There is also ventral epidural enhancement from T9 to T12 and some enhancement within the lumbar surgical site.

Figure 4

MRI of the lumbar spine (T1 fat sat + gadolinium): the gadolinium-enhanced sagittal T1-weighed MR image shows peripheral enhancement of L4-L5 disc and marrow edema extending from the L4 and L5 vertebrae with anterior epidural abscess-like spondylodiscitits (arrow). The MR image shows inflammation with enhancement of L1-L2 and L4-L5 zygapophysial joints (stars).