Computerized techniques used to study hyper metabolism in patient with adult spinal deformity: A case report

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Computerized techniques used to study hyper metabolism in patient with adult spinal deformity: A case report

A 60-year-old female patient complained of severe low back pain. She was examined using radio-graphic techniques. After radio-graphic examination of her spine, it was observed that her spine showed degenerative kyphoscoliosis with rotation of the lumbar vertebrae, for which she received treatment of rheumatoid arthritis (RA). Her rheumatoid arthritis was controlled but, she still complained about pain. It was also observed that she had no diabetes mellitus.

The most likely diagnosis of this presentation is:

  • Rheumatoid Arthritis

  • Low Back Pain

  • Spinal Deformity

Introduction:

Adult spinal deformity (ASD) often affects a large number of the elders and its prevalence is increasing day by day. ASD patients experience greater functional limitations and worse quality of life than the normal population. Sagittal imbalance is generally correlated with pain. Some authors also provided the evidence that paravertebral muscles in patients with lumbar degenerative kyphosis are weak and atrophic with fatty infiltration and speculated LBP in patients is probably due to fatigue in weak extensor muscles. Some studies have reported the increased activity in paravertebral muscles in kyphotic position. In this study, we report the first case of a patient who presented with painful degenerative kyphoscoliosis and was evaluated with flourine-18-fluoro-2-deoxy-D-glucose positron-emission tomography/computed tomography (18F-FDG-PET/CT) preoperatively.

Treatment:

Followed by detailed diagnosis, 8F-FDG-PET/CT was performed immediately prior to the operation at the Department of Endocrine Surgery of our hospital for the follow-up of thyroid carcinoma. In this, patient fasted for at least 5h and then FDG was injected in supine position. Her plasma glucose level was 93 mg/dl. PET scan was done 50 min after the injection. The maximum standardized uptake value (SUV-max) was 9.7 on the right side and 4.9 on the left side.

As the LBP was not improved by conservative treatment, surgery was done. Treatment with posterior spinal fusion from Th10 to the ilium with inter-body fusion and decompression at the level of L3/4, L4/5, and L5/S was done. Although a spinal orthosis was applied post operatively, proximal junctional failure with compression fracture of Th11, which caused severe paraplegia, occurred at 2 months after the primary operation. Therefore, we performed revision surgery, extending the fusion level to Th2.

Discussion:

This study showed that with the development of surgical techniques and the improvement in implants, many ASD patients were treated. It has been reported that vigorous muscle exercise, stress-induced muscle tension, and activities such as talking or chewing can cause a physiological increase in the uptake of 18F-FDG in the muscles involved. In this case, the chronically stretched extensor muscles due to the kyphoscoliotic posture showed a pathological uptake of 18F-FDG due to the increased muscle activity and that increased uptake completely disappeared after the appropriate posture was acquired. Some of the well-known factors causing LBP include intervertebral disc degeneration, facet joint arthritis, sacro-iliac joint dysfunction, and paravertebral muscle disorder. In this case, although the patient was receiving treatment for RA, arthritis of the facet joint or sacro-iliac joint was not detected on 18F-FDG-PET/CT. On the basis of these findings, LBP in this case was considered to be caused by chronic fatigue in the paravertebral muscles, which was visualized with 18F-FDG-PET/CT.

Learning:

18F-FDG-PET/CT has proven to be an effective treatment in low back pain which revealed that in the para vertebral muscles was caused by chronic fatigue. Rheumatoid arthritis was also treated before the surgery. MRI was also performed which showed the complete disappearance of the increased uptake in the para vertebral muscles.

References:

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