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Case 214

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M.J.C., 71-year-old female, was diagnosed with cryptogenic cirrhosis 10 years ago, standard jaundice predominantly cholestatic, currently ranked B9 (Child-Pugh Score). Complains about moderate low back pain, predominantly mechanical, without radiation, which began a month ago, no history of previous trauma. In use of furosemide, spironolactone and lactulose. On examination: pallor +/4+, jaundiced 2+/4+, afebrile, lower limbs without edema. Painless abdomen without masses. Pain in the lumbar spine with worsening on palpation. It was requesteda computed tomography (CT) of the thoracolumbar spine.

Considering the image and the clinical data, which of the alternatives below explains best the low back pain of the patient?

a) Nerve root compression by disc herniation

25%

b) Ankylosing spondylitis

25%

c) Osteoporotic vertebral compression fracture

25%

d) Degenerative osteoarthritis

25%
   

Image analysis

Image 1: In the computed tomography (CT) of the patient, there is homogeneous and diffuse reduction of bone density of all vertebrae, whose contours are slightly irregular – these findings are consistent with osteoporosis. It can be observed a significant reduction in height of two non-contiguous thoracic vertebral bodies (red arrows), with preservation of the adjacent intervertebral discs. At the levels of flatness, there are slight protrusion of the vertebral body into the spinal canal (dotted green line).

Highlights

- Osteoporosis: reduction of mineralized bone mass, making it fragile and vulnerable to fractures, which are the major complication. Important risk factors: female gender, advanced age and menopause;
- The gold standard for diagnosis of osteoporosis is bone densitometry;
- The osteoporotic vertebral compression fracture by CT scan shows an important reduction in the height of the vertebral bodies and preservation of the adjacent intervertebral discs;
- Liver cirrhosis favors secondary osteoporosis because the functional liver loss, which occurs due to the subversion of its architecture, leads to increased osteoclastic activity and decreased osteoblastic;
- Osteoporotic vertebral compression fracture: fracture that leads to reduction of the height of the vertebra by decreased bone density, common in the lumbar due to sustained weight. Usually painless, with the loss of stature as the chief complaint.

References

Zhengyi Yang, PhD, James F. Griffith, MD, Ping Chung Leung, MD, and Raymond Lee, PhD. “Effect of Osteoporosis on Morphology and Mobility of the Lumbar Spine”. SPINE Volume 34, Number 3, pp E115–E121.

- Purohit,T., Cappell, M. “Primary biliary cirrhosis: Pathophysiology, clinical presentation and therapy”. World J Hepatol 2015 May 8; 7(7): 926-941. ISSN 1948-5182 (online).

- Hajiabbasi, A., Shafaghi, A., Fayazi, H.S.,  Shenavar, I., Emami,M.H.H., Parsa,G.P., Amir, A. “The Factors Affecting Bone Density in Cirrhosis”. Hepat Mon. 2015 April; 15(4): e26871.

- American Gastroenterological Association Clinical Practice Committee. “AGA Technical Review on Osteoporosis in Hepatic Disorders”. GASTROENTEROLOGY 2003;125:941–966.

- Bandeira,F., de Carvalho, E.F. “Prevalence of osteoporosis and vertebral fractures in postmenopausal women attending reference centers”. Rev Bras Epidemiol 2007; 10(1): 86-98.

Authors

Bárbara Queiroz, acadêmica de Medicina do 12º período da Faculdade Medicina da UFMG.

E-mail: barbara.bragaglia[arroba]gmail.com

 

Davi Teixeira Urzêdo Queiroz, acadêmico de Medicina do 6º período da Faculdade Medicina da UFMG.

E-mail: davituq[arroba]gmail.com

 

Luciana Jacintho Caleiro, acadêmica de Medicina do 6º período da Faculdade Medicina da UFMG.

E-mail: luciana_caleiro[arroba]hotmail.com

 

Luiza Soares Cirne de Toledo, acadêmica de Medicina do 6º período da Faculdade Medicina da UFMG.

E-mail: luizasctoledo[arroba]gmail.com

Supervisor

Alexandre Viarella Giannetti, Neurosurgeon at the Hospital das Clínicas da UFMG.

E-mail:agjg[arroba]terra.com.br

Reviewers

Daniela Braga, André Guimarães, Débora Faria, Luísa Bernardino and Professor Viviane Parisotto. 

Translated by

Luísa Bernardino Valério, 4th year medical student at UFMG.

E-mail: luisabernardino[at]gmail.com

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