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Severe Back Pain in a Patient Undergoing Long-Term Hemodialysis

Tsao, Yu-Tzu MD; Tsai, Wei-Chi MD; Lin, Shih-Hua MD

American Journal of Physical Medicine & Rehabilitation: July 2009 - Volume 88 - Issue 7 - p 595
doi: 10.1097/PHM.0b013e3181a0d960
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From the Division of Nephrology (Y-TT, S-HL), Department of Medicine; and Department of Physical Medicine and Rehabilitation (W-CT), Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.

All correspondence and requests for reprints should be addressed to Shih-Hua Lin, MD, Division of Nephrology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Number 325, Section 2, Cheng-Kung Road, Neihu 114, Taipei, Taiwan.

A 46-yr-old uremic woman on regular hemodialysis for 12 yrs presented with a 6-mo history of intractable back pain. She had been treated with analgesics and antidepressants integrated with acupuncture, chiropractic manipulation, and even epidural steroid injections. Muscle power was grade 4 over the bilateral lower limbs with mildly diminished pain and touch sensations from the sacrum downward. The remaining physical findings were unremarkable. Her serum alkaline phosphatase and intact parathyroid hormone were gradually elevated despite adequate dialysis, phosphate binders, and calcitriol to control hyperphosphatemia. A lateral radiograph of the thoracolumbar spine was characteristic of “rugger jersey spine” (Fig. 1), necessitating a comprehensive survey for renal osteodystrophy. Technetium-99m sestamibi scintigraphy showed a cervical parathyroid adenoma, which was responsible for the tertiary hyperparathyroidism. Parathyroidectomy was indicated, but she declined.



Osteosclerosis is one of the major radiographic findings of renal osteodystrophy.1 It may affect different bony elements but mainly predominates in the axial skeleton. The pathophysiology of osteosclerosis from advanced renal failure is complex. Augmented osteoclastic activity secondary to elevated parathyroid hormone causes bone resorption, visualized as central radiolucency. Subchondrol osseous resorption may lead to collapse of the weakened bone with widening of the intervertebral space and indistinctness of articular surfaces. In response, osteoblasts form an increased amount of unmineralized osteoid, most notably at the endplates of vertebral bodies, creating the band-like radiopaque zones resembling the horizontal stripes on the jerseys worn by rugby players.2

Some disease processes may mimic the rugger jersey spine sign. Paget disease, metastatic lesions, osteoporosis, or osteomalacia is commonly confused with the rugger jersey spine. The most important factor to keep in mind when differentiating spinal dystrophic findings is that the rugger jersey spine sign is multisegmental because it involves multiple vertebral bodies.3 The bands of increased opacity along the superior and inferior aspect of the vertebral bodies differ from the uniformly increased opacity seen in Paget disease, skeletal metastasis, or lymphoma.

Parathyroidectomy remains the mainstay of treatment usually with rapid and effective relief of clinical symptoms; however, radiographic resolution is only seen in about one third of patients.4 In conclusion, rugger jersey spine sign is a diagnostic radiographic feature of osteosclerosis associated with high-turnover renal osteodystrophy. It should be addressed that, because back pain may come from a plethora of causes, only identifying the nature of culprit lesions early on can avoid unnecessary intervention and achieve better outcomes. Clinicians must maintain a heightened awareness of this distinct manifestation.

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1.Alvarez-Ude F, Feest TG, Ward MK, et al: Hemodialysis bone disease: Correlation between clinical, histologic, and other findings. Kidney Int 1978;14:68–73
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4.Kim HC, Cheigh JS, David DS, et al: Long term results of subtotal parathyroidectomy in patients with end-stage renal disease. Am Surg 1994;60:641–9
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