Endgames Picture Quiz

Chronic lower back pain in a 24 year old man

BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f2817 (Published 08 May 2013) Cite this as: BMJ 2013;346:f2817
  1. Ramin Mandegaran, academic foundation year 2 doctor1,
  2. Shouvik Saha, specialist registrar in clinical radiology2,
  3. Amidevi Desai, consultant musculoskeletal radiologist2
  1. 1Royal Free London NHS Foundation Trust, London NW3 2QG, UK
  2. 2Radiology Department, Guys and St Thomas’ NHS Trust, London, UK
  1. Correspondence to: R Mandegaran ramin1986{at}hotmail.com

A 24 year old man presented with a nine month history of lower back pain, which was worse at night and stopped him sleeping. The pain did not radiate, was not related to activity, and was mostly relieved with ibuprofen. Physical examination was unremarkable and he had no neurological signs. His erythrocyte sedimentation rate and C reactive protein value were within normal limits. Plain lumbar radiographs showed a sclerotic right L4 lamina. Computed tomography of the lumbar spine was performed (fig 1).

Fig 1 Axial computed tomogram of the L4 vertebra

Questions

  • 1 What does the computed tomogram of the L4 vertebra show?

  • 2 What is the most likely diagnosis?

  • 3 What are the most appropriate radiological investigations for this patient?

  • 4 What are the management options for this patient?

Answers

1 What does the computed tomogram of the L4 vertebra show?

Short answer

The right L4 lamina and pedicle are expanded and sclerotic. A radiolucent nidus is seen within the lesion, together with calcification at the centre of the nidus.

Long answer

The right L4 lamina and pedicle are expanded and sclerotic (fig 2). A radiolucent nidus is seen within the lesion, as well as calcification at the centre of the nidus. Together with the clinical picture, these radiological findings are suggestive of osteoid osteoma. The differential diagnosis for a dense lamina or pedicle on plain radiography includes osteoblastic metastases, bone island, osteoblastoma, atypical infection, and lymphoma. However, the patient’s age and lack of a history of cancer make an osteoblastic metastasis or lymphoma unlikely. A bone island would not be symptomatic. Infection is unlikely because of the lack of infective clinical features in the history. Osteoblastoma can have a similar clinical presentation to that of osteoid osteoma but the tumours tend to be larger.1

Fig 2 Axial computed tomogram of the L4 vertebra showing osteoid osteoma in the right lamina and …

View Full Text

Sign in

Log in through your institution

Free trial

Register for a free trial to thebmj.com to receive unlimited access to all content on thebmj.com for 14 days.
Sign up for a free trial

Subscribe