Images in Clinical Rheumatology
Mechanical Low Back Pain as a Presentation of Anterior Limbus Vertebra
Lumbalgia mecánica como forma de presentación de vértebra limbus anterior
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Se aprecia irregularidad de la esquina superior y anterior del cuerpo vertebral L3. El espacio intervertebral L2-L3 se encuentra estrechado. Se observan pequeñas formaciones osteofitarias anteriores en L2 y L4. La densidad de los cuerpos vertebrales se conserva; b) TC con reconstrucción MPR sagital, donde se observan con mayor detalle la irregularidad del borde súpero-anterior del cuerpo L3, apreciándose esclerosis tanto en el platillo vertebral hundido como en los contornos del fragmento óseo separado del resto del hueso. También se observa una listesis L5-S1 y una hernia de Schmorl en el platillo superior de L1; c) RM secuencia SET1 en el plano sagital. La intensidad de los cuerpos vertebrales está conservada y el fragmento óseo separado del cuerpo L3 presenta la misma intensidad de señal que el resto del hueso; d) RM secuencia SET2 en el plano sagital. Los hallazgos complementan lo observado en la secuencia SET1. Se observa disminución de altura y señal de los discos intervertebrales L2-L3, L3-L4 y L5-S1 en relación con deshidratación en el contexto de una discopatía degenerativa. En L5-S1 se observa, también, una hernia discal posterocentral migrada cranealmente, acompañando a la listesis; e) Secuencias de RM en el plano sagital SET1 en fase y fase opuesta. En estas secuencias la señal del cartílago discal es alta y brillante. Se puede apreciar cómo se introduce entre el fragmento óseo y la región más anterior del platillo superior de L3, y f) Esquema que representa los cambios observados en las imágenes de la izquierda. Nótese como el disco intervertebral L2-L3 se introduce a través de la superficie anterior del cuerpo vertebral L3. También se puede ver una herniación de Schmorl en el platillo superior de L1 y una protrusión global del disco L5-S1 con hernia discal posterocentral acompañando a la listesis L5-S1.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Carmen Carrasco Cubero, Duarte Gibellino Coelho Achega, M. Ángeles Férnández Gil, Jose Luis Álvarez Vega" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Carmen" "apellidos" => "Carrasco Cubero" ] 1 => array:2 [ "nombre" => "Duarte Gibellino" "apellidos" => "Coelho Achega" ] 2 => array:2 [ "nombre" => "M. 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Ángeles Férnández Gil, Jose Luis Álvarez Vega" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Carmen" "apellidos" => "Carrasco Cubero" "email" => array:1 [ 0 => "mcarrascocubero@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Duarte Gibellino" "apellidos" => "Coelho Achega" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "M. Ángeles" "apellidos" => "Férnández Gil" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "Jose Luis" "apellidos" => "Álvarez Vega" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Reumatología, Hospital Perpetuo Socorro, Complejo Hospitalario Universitario de Badajoz, Badajoz, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Centro de Salud Valdepasillas, Badajoz, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Radiodiagnóstico, Hospital Perpetuo Socorro, Complejo Hospitalario Universitario de Badajoz, Badajoz, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Lumbalgia mecánica como forma de presentación de vértebra limbus anterior" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1428 "Ancho" => 995 "Tamanyo" => 264184 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Limbus vertebra: (A) lateral radiograph of lumbar spine. The image shows the irregularity of the superior and anterior corners of the vertebral body at lumbar 3 (L3). The L2–L3 intervertebral space is narrowed. There are small anterior osteophytic formations at L2 and L4. The density of the vertebral bodies is conserved; (B) computed tomography with sagittal multiplanar reconstruction, in which the irregularity of the anterosuperior margin of L3 vertebral body can be seen in greater detail. Sclerosis can be observed both in the recessed vertebral endplates and around the osseous fragments separated from the rest of the bone. Listhesis can also be detected at L3–sacral 1 (S1) and Schmorl's node in the superior endplate at L1; (C) magnetic resonance imaging (MRI) of sagittal spin-echo T1-weighted (SET1) sequences. The intensity of the vertebral bodies is conserved and the osseous fragment separated from the L3 body has the same signal intensity has the rest of the bone; (D) MRI of sagittal spin-echo T2-weighted sequences. The findings complement what can be observed in the SET1 sequence. There is a decrease in height and signal of intervertebral discs at L2–L3, L3–L4 and L5–S1 in relation to dehydration in the setting of a degenerative disc disease. There is also a posterior central disc herniation at L5–S1, that migrated cranially, accompanied by listhesis; (E) MRI sagittal SET1 sequences in-phase and out-of-phase. In these sequences, the signal of the disc cartilage is high and bright. It can be seen how it is introduced between the osseous fragment and the foremost region of the superior L3 endplate; (F) drawing representing the changes observed in the images to the left. It can be seen that the L2–L3 intervertebral disc is introduced through the anterior surface of the L3 vertebral body. A Schmorl node can also be seen in the superior endplate of L1 and a protrusion of the L5–S1 disc, with a posterior central disc herniation, accompanied by listhesis at L5–S1.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The patient was a 39-year-old farmer who had nothing remarkable in his clinical history. He presented with self-limiting, chronic, mechanical low back pain, without radiation, fever or systemic symptoms. Physical examination revealed only pain on palpation of the lumbar spinous processes and limited anterior dorsiflexion. Laboratory values, including serological findings and protein profile, were normal. A radiograph of the lumbar spine (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A) showed an irregular sclerotic lesion in the epiphysis of lumbar 3 (L3). Lumbar computed tomography (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B) showed irregularity, crush fracture and fragmentation preceding L3. Magnetic resonance imaging of the lumbar spine (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C–E) revealed a limbus vertebra (LV) at L3, degenerative disc disease at L2–L4 and L5–sacral 1 (S1) and disc herniation at L3–L4 and L5–S1.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">The diagnosis was LV at L3 and listhesis at L5 with spondylolysis. The patient improved with conservative treatment (anti-inflammatory agents and muscle relaxants). Surgery was ruled out.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Limbus vertebra is a radiological finding. Its prevalence is unknown and its significance is uncertain. It is a bone defect that affects the vertebral body margin, which is the origin of this a triangular fragment with sclerotic borders (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>F). It is produced in the form of an intraosseous herniation of the nucleus pulposus through the vertebral ring apophysis, prior to the complete fusion of the vertebral body. Its pathogenesis is related to that of Schmorl's nodes and Scheuermann disease. The most common localization is the lumbar spine and it involves the anterosuperior corner, followed by the anteroinferior region. Posterior LV is less frequent, but has a more marked clinical and functional impact because the osseous fragments can move, thus narrowing the spinal canal.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In our case, the radiographic image could lead to a diagnosis of fracture, inflammation, infection or tumor, making additional imaging studies necessary.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The question as to whether LV is a variant of normality is controversial. Although there is little available literature, the cases described refer to patients who complain of back pain, not healthy individuals. There appears to be a pathological significance associated with low back pain. Clinical and epidemiological research on this entity should be embarked on under a new approach.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Ethical Disclosures</span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Protection of human and animal subjects</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Confidentiality of data</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Right to privacy and informed consent</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflicts of Interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors declare they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:3 [ "identificador" => "sec0005" "titulo" => "Ethical Disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0010" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0015" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0020" "titulo" => "Right to privacy and informed consent" ] ] ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflicts of Interest" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-01-18" "fechaAceptado" => "2016-02-25" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Carrasco Cubero C, Coelho Achega DG, Férnández Gil MÁ, Álvarez Vega JL. Lumbalgia mecánica como forma de presentación de vértebra limbus anterior. 2017;13:176–177.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1428 "Ancho" => 995 "Tamanyo" => 264184 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Limbus vertebra: (A) lateral radiograph of lumbar spine. The image shows the irregularity of the superior and anterior corners of the vertebral body at lumbar 3 (L3). The L2–L3 intervertebral space is narrowed. There are small anterior osteophytic formations at L2 and L4. The density of the vertebral bodies is conserved; (B) computed tomography with sagittal multiplanar reconstruction, in which the irregularity of the anterosuperior margin of L3 vertebral body can be seen in greater detail. Sclerosis can be observed both in the recessed vertebral endplates and around the osseous fragments separated from the rest of the bone. Listhesis can also be detected at L3–sacral 1 (S1) and Schmorl's node in the superior endplate at L1; (C) magnetic resonance imaging (MRI) of sagittal spin-echo T1-weighted (SET1) sequences. The intensity of the vertebral bodies is conserved and the osseous fragment separated from the L3 body has the same signal intensity has the rest of the bone; (D) MRI of sagittal spin-echo T2-weighted sequences. The findings complement what can be observed in the SET1 sequence. There is a decrease in height and signal of intervertebral discs at L2–L3, L3–L4 and L5–S1 in relation to dehydration in the setting of a degenerative disc disease. There is also a posterior central disc herniation at L5–S1, that migrated cranially, accompanied by listhesis; (E) MRI sagittal SET1 sequences in-phase and out-of-phase. In these sequences, the signal of the disc cartilage is high and bright. It can be seen how it is introduced between the osseous fragment and the foremost region of the superior L3 endplate; (F) drawing representing the changes observed in the images to the left. It can be seen that the L2–L3 intervertebral disc is introduced through the anterior surface of the L3 vertebral body. A Schmorl node can also be seen in the superior endplate of L1 and a protrusion of the L5–S1 disc, with a posterior central disc herniation, accompanied by listhesis at L5–S1.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:2 [ 0 => array:3 [ "identificador" => "bib0015" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Lumbalgia mecánica crónica en pacientes con vértebra limbus anterior: revisión de la literatura y presentación de tres casos clínicos" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "P.A. Martínez-Carpio" 1 => "A. Bedoya del Campillo" 2 => "M.J. Leal" 3 => "N. Lleopart" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Rev Arg Reumatol" "fecha" => "2013" "volumen" => "24" "paginaInicial" => "36" "paginaFinal" => "42" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0020" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Limbus vertebra" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J. Horneros" 1 => "S. Rodríguez" 2 => "R. Pérez" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Sem Fund Esp Reumatol" "fecha" => "2012" "volumen" => "13" "paginaInicial" => "62" "paginaFinal" => "64" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21735743/0000001300000003/v1_201705040052/S2173574317300035/v1_201705040052/en/main.assets" "Apartado" => array:4 [ "identificador" => "5795" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Images in Clinical Rheumatology" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735743/0000001300000003/v1_201705040052/S2173574317300035/v1_201705040052/en/main.pdf?idApp=UINPBA00004M&text.app=https://reumatologiaclinica.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173574317300035?idApp=UINPBA00004M" ]
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