A 68-yr-old woman with a history of T1NOMO intraductal breast cancer and pulmonary sarcoidosis presented with a 2-mo history of worsening right buttock and lateral thigh pain. The pain was sharp, of variable severity, aggravated by standing and walking and lessened by sitting. Symptoms were worse at night. She denied constitutional symptoms and red flags. Her physical examination demonstrated no focal lower limb weakness; she had normal symmetric reflexes, intact light touch and pinprick sensation, and normal gait. There was no focal palpation tenderness over the spine or buttock.
Lumbar spine magnetic resonance imaging showed severe L3–4 spinal stenosis, with T1 and T2 magnetic resonance imaging (Fig. 1) revealing hypointense lesions in the lumbosacral spine, including the sacrum and iliac bones. These lesions were enhanced on postcontrast sequences, suggestive of metastatic disease. Whole-body bone scan showed increased uptake of the L1 and L3/L4 vertebral body levels, consistent with metastatic disease. Positron emission tomography scan results were normal, without any abnormal activity to indicate malignant disease. She eventually underwent bone marrow biopsies demonstrating noncaseating granulomatous inflammation, consistent with sarcoidosis. Clinically, her right buttock and leg pain was felt to be secondary to her severe lumbar spinal stenosis. Her pain symptoms responded to a flexion bias physical therapy exercise program and oral Gabapentin.
Sarcoidosis, also called Morbus Boeck disease, is an idiopathic, inflammatory granulomatous condition occurring more commonly in women and black individuals.1 Sarcoidosis has a variable presentation and prognosis. It can involve one or multiple organ systems and can be progressive or can resolve spontaneously. The lungs are involved in more than 90% of cases.2 Skeletal involvement is much less frequent; the prevalence has been reported to range from less than 1% to 13%.2,3 The small bones of the hands and feet are most often involved, whereas spinal disease is rare. 4 Spinal sarcoidosis usually involves the thoracolumbar region.4
The radiographic appearance of vertebral-based sarcoidosis has not been well defined. In one series, the lesions were generally lytic, with well-defined borders, but some of the lesions were mixed lytic and sclerotic. The posterior elements were usually spared, as were the intervertebral discs.1 Given that spine magnetic resonance imaging findings can be nonspecific, the differential diagnosis includes metastatic disease, myeloma, lymphoma, histoplasmosis, coccidioidomycosis, and tuberculosis.1 Biopsy is frequently required to confirm the diagnosis. The treatment of vertebral sarcoidosis depends on the clinical picture. In our patient, her vertebral lesions improved on subsequent lumbar magnetic resonance imaging, and no additional treatment was necessary.
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3. Watts M, Sundaram M: Diagnosis: Osseous sarcoidosis. Orthopedics
2009; 32: 779–80
4. Wendling D, Desmurs H, Royer F, et al.: Inaugural cervical vertebral sarcoidosis. J Rheumatol
2008; 35: 362–5