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CME QUIZ
Year : 2019  |  Volume : 17  |  Issue : 4  |  Page : 157-158

Anterior scalloping of lumbar vertebrae


1 Department of Orthopaedics, Government Medical College, Haldwani, Uttarakhand, India
2 Department of Pathology, Government Medical College, Haldwani, Uttarakhand, India

Date of Submission30-Sep-2018
Date of Decision13-Aug-2019
Date of Acceptance14-Aug-2019
Date of Web Publication12-Dec-2019

Correspondence Address:
Dr. Ganesh Singh Dharmshaktu
Department of Orthopaedics, Government Medical College, Haldwani, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cmi.cmi_38_18

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How to cite this article:
Dharmshaktu GS, Pangtey T. Anterior scalloping of lumbar vertebrae. Curr Med Issues 2019;17:157-8

How to cite this URL:
Dharmshaktu GS, Pangtey T. Anterior scalloping of lumbar vertebrae. Curr Med Issues [serial online] 2019 [cited 2020 Jan 19];17:157-8. Available from: http://www.cmijournal.org/text.asp?2019/17/4/157/272800

A 25-year-old immunocompetent female presented with a history of low back pain for the last 6 months, insidious in onset but progressing for the last 1 month in severity and duration with no diurnal variation. Pain increased on prolonged ambulation and forward bending and relieved transiently on taking pain medication with overall effect on activities of daily living. There was no history of any other comorbidity, past treatment, chronic disease, and other “red flags.” She was well immunized and had no history of evening rise of temperature or significant loss of weight and appetite. A radiograph of the lumbar spine, on careful observation, revealed that the fourth lumbar vertebral body had abnormal anterior concavity and the fifth one with similar milder features [Figure 1]. Radiographs at 2 weeks later showed more severe concavity of the vertebral body of last three lumbar vertebrae along with decreased disc spaces between them [Figure 2]a and [Figure 2]b.
Figure 1: The radiograph of the lumbar spine orthogonal views showing anterior concavity of third lumbar vertebra (arrow)

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Figure 2: Lateral radiographs at 2 (a) and 3 weeks (b) showing increased scalloping of lower lumbar vertebrae (arrows)

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  Questions Top


  1. What does the arrow in the radiograph indicate?
  2. What is clinical significance of this finding?
  3. What should be the line of management?
  4. What is the most common location of this disease?



  Answers Top


  1. Abnormal concavity of the vertebral body or scalloping, also termed “aneurysmal phenomenon,” is a rare sign of long-standing cold abscess and may be found in areas other than more common thoracic region
  2. This feature calls for advance imaging like magnetic resonance imaging (MRI) to confirm assist in diagnosis. This is more important in cases with no constitutional features. MRI here showed bone marrow edema in L2–L5 and S1 and 2 vertebrae with destruction of L3–4, L4–5, and L5–S1 disc with pre- and para-vertebral collections [Figure 3]. The huge presacral collection of cold abscess seemed to be contributing to the abnormal anterior scalloping of lower lumbar vertebrae by pressure effect
  3. The final diagnosis requires identification of the causative organism. Computerized tomography-guided aspiration and sampling were done and the diagnosis of tuberculosis (TB) confirmed on culture identification of Mycobacteriumtuberculosis.
  4. Spine is the most common site of skeletal TB that presents itself in myriad forms, most commonly with reduction of intervertebral disc space in paradiscal type of lesion.[1] Apart from this common presentation, vertebral body and posterior neural arch are the less common sites of involvements.


Osteoarticular TB constitutes a sizeable number of cases, but robust studies are still required for accurate methods of diagnosis, while imaging like MRI has added immense advantage to capture various stages and features of disease.[2],[3] While the lower thoracic and lumbar vertebrae are common sites of spinal TB, prelumbar and sacral abscess are rare features.[4] Long-standing abscess can indent anterior vertebral borders to give rise to scalloping of one or many adjacent sites, and delay in identification can also be catastrophic. The knowledge of “aneurysmal phenomenon” is thus beneficial for suspecting the pathology in endemic regions for early diagnosis and initiation of treatment.
Figure 3: Magnetic resonance images (a and b) depicting anterior lumbar scalloping (asterisk)

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Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Arathi N, Ahmad F, Huda N. Osteoarticular tuberculosis-a three years' retrospective study. J Clin Diagn Res 2013;7:2189-92.  Back to cited text no. 1
    
2.
Ansari S, Amanullah MF, Ahmad K, Rauniyar RK. Pott's spine: Diagnostic imaging modalities and technology advancements. N Am J Med Sci 2013;5:404-11.  Back to cited text no. 2
    
3.
Alvi AA, Raees A, Rehmani MA, Aslam HM, Saleem S, Ashraf J, et al. Magnetic resonance image findings of spinal tuberculosis at first presentation. Int Arch Med 2014;7:12.  Back to cited text no. 3
    
4.
Dharmshaktu GS, Singhal A, Singh P. Isolated sacrum tuberculosis with presacral and paraspinal abscess: Case report of a common disease at uncommon site. Int J Res Orthop 2015;1:28-30.  Back to cited text no. 4
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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