A 53-year old female patient was admitted to the Department of Neurology on an emergency basis due to a very strong, right-sided low back pain. In anamnesis the patient reported chronic (lasting for several years) and slight low back pain with periodical exacerbations manifested as sciatica, partially resolving after pharmacotherapy and physiotherapy. Besides, no significant diseases were reported in the past medical history.
Physical examination revealed limitation of motion and increased tone of paraspinal muscles in the lumbosacral spine on the right side, positive Lasègue and Mackiewicz signs on the right side, weaker right-sided ankle jerk reflex and hypoesthesia of the right buttock. The patient reported difficulties in urination. The presumptive diagnosis was right-sided sciatica. MR imaging of the lumbosacral spine (low-field MR unit 0.23 T, standard T1- and T2-weighted images, without contrast administration) demonstrated the presence of a small, midline herniation of the intervertebral disc at L5/S1 level, multi-level bulging and vertebral degenerative-deforming changes in the L-S spine. Laboratory tests revealed increased ESR (58 mm/h) and elevated CRP protein levels (30.9 mg/l). In order to find inflammatory lesions, urine analysis, abdominal ultrasonography and chest x-ray were performed; results of these examinations were normal. After administration of analgesics, non-steroidal anti-inflammatory drugs, muscle relaxants and physiotherapy, considerable improvement and pain relief were achieved in the patient. Diagnosis of right-sided radicular pain syndrome due to intervertebral disc herniation at L5/S1 level was established. Further monitoring of laboratory inflammatory markers and well-balanced lifestyle were recommended.
One month later, after a transient improvement the patient was re-admitted to the Department of Neurology due to a very strong, acute pain in the right lumbar area, radiating to the right buttock. Physical examination revealed pain of the paraspinal soft tissues in the right L4-S2 area and along muscle attachments at the right wing of ilium during palpation, slightly positive right-sided Lasègue and Mackiewicz signs, impaired superficial sensibility within anterior surfaces of the proximal thighs, and weaker right-sided ankle jerk reflex. The patient complained of a severe pain during even the slightest attempt to change position that resolved only in a supine position and after intramuscular administration of narcotic analgesic drugs. Bone scintigraphy (Tc99m) revealed a single focus of increased bone metabolism at the level of L5/S1 vertebrae, to the right from the vertebral body. With regard to unclear etiology of this lesion, further diagnostics was recommended in order to exclude a possible neoplastic process or active inflammation. Next, CT imaging of L4-S2 spine was performed, which demonstrated increased degenerative-productive changes in both L5/S1 facet joins, vacuum phenomenon in the right facet joint at this level, without any features of osteolysis in the site of ther increased marker uptake in scintigraphy. Additionally, a blurred outline of the soft tissue around the right L5/S1 facet joint was observed ().
Figure 1. Computed tomography of the spine. (A) soft-tissue window, blurred outline and increased density of paraspinal soft tissues in the right L5/S1 facet joint area (arrows). (B) bone window, degenerative-productive changes of the both L5/S1 facet joints, more (more ...)
Then, high–field MR examination was performed using 1.5 T scanner. T1- and T2-weighted images, with and without fat saturation followed by intravenous contrast administration were obtained. The images revealed an area of heterogenous contrast enhancement in the site of the right L5/S1 facet joint, involving: the facet joint, pedicle of vertebral arch and right L5 transverse process. The area of enhancement spread into the paraspinal soft tissues from L4/L5 level to S1/S2 border level. The flaval ligaments at L5/S1 level were also enhanced (). Rheumatological consultation excluded lesions associated with a systemic connected tissue disease. Finally, inflammatory infiltration surrounding the right facet joint at L5/S1 level was diagnosed. Analgesics, intravenous and oral antibiotics, as well as orthopaedic corset were used, which resulted in pain relief, disappearance of the radicular symptoms and normalisation of inflammatory markers in laboratory tests. A follow-up MR examination imaging of the lumbosacral spine were recommended in six weeks.
Figure 2. Magnetic resonance imaging of the spine. T1-weighted images with fat saturation after intravenous contrast medium administration in: axial (A), coronal (B) and sagittal (C) planes. Inhomogeneous contrast enhancement of the right L5/S1 facet joint area, (more ...)
Two months later the patient was admitted to the Department of Neurology due to another pain exacerbation, without accompanying radicular pain or neurological deficits. A high field MR examination of the lumbosacral spine performed prior to the admission (1.5 T scanner; T1-and T2-weighted images, T2 fatsat and T1 fatsat after contrast administration) revealed, as previously, the presence of inflammatory infiltration within the right facet joint at L5/S1 level, with a possible evolution towards phlegmonous tissue lesions in the right sacral region. After consultation by a neurosurgeon the patient was decided to be operated on. Revision of the right facet joint at L5/S1 level was performed; articular capsule and articular surfaces destroyed by inflammatory process were removed. A garamycin sponge was used locally. In addition, material for microbiological and histopathological examination was obtained. Postoperative period was uncomplicated. Microbiological culture did not produce any microorganisms. Histopathological examination revealed features of chronic, unspecific inflammatory process.
After the surgery a relief of the pain was achieved. The patient was discharged from the hospital in a good general condition, without any neurological deficits.
According to the previous recommendations, a follow-up bone scan (Tc99) was performed after six months from the previous examination, which revealed a total regression of the previously described, pathological focus at the level of L5/S1 on the right side.
A follow-up MR examination of the lumbosacral spine, performed after a year from the operation, did not demonstrate any significant pathologies.
At present, after a few years of follow-up, the patient stay in a good condition and does not show any symptoms of a low back pain.