PMC8769429_01
Hand X-ray (A) showing ossification and joint space narrowing of the joints of the right 4th finger (white arrow), and foot X-ray (B) showing osteolysis of the right 4th toe (white arrowhead).
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F1
The diagnosis was based on swelling of her right 4th finger and toe, asymmetric ossification and joint space narrowing of the PIP/DIP joints of the right 4th finger, osteolysis of the 4th toe on X-ray (Fig. 1A and 1B), and negative rheumatoid factor (RF).
Lumbar spine X-ray lateral view 2 years prior to surgery (A) demonstrating grade 1 spondylolisthesis at L5/6. Preoperative lumbar spine dynamic X-rays (B, C) showing calcification in the L4/5 intervertebral foramen (white arrow), grade 2 spondylolisthesis/angulation at L5/6, and mild translation of L5/6 in flexion. Preoperative lumbar CT showing sagittal views (D, E) and axial views (F-H) demonstrating intraspinal canal calcifications at the levels of L4/5 and L5/6 (white arrowheads). CT: computed tomography.
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F2
L4-S1 radiculopathy. Lumbar spine X-rays demonstrated de novo development of calcification in the L4/5 intervertebral foramen and worsened L5/6 spondylolisthesis compared to the X-ray images 2 years before (Fig. 2A-2C). The dynamic X-rays showed 2.1 mm translation of L5 over L6 in the flexed position (Fig. 2B and 2C). L4-6, and some calcified lesions extended into the intervertebral foramen or lateral recesses at the right L4/5 and left L5/6 levels (Fig. 2D-2H). Lumbar magnetic resonance imaging (MRI) demonstrated severe canal stenosis at the L4/5 and L5/6 levels caused by a combination of spondylolisthesis and multiple intraspinal canal calcifications (Fig. 3A-3D).
T2-weighted lumbar MRI sagittal views (A, B) and axial views (C, D) showing compression of the common dural sac by multiple intraspinal canal calcifications at the levels of L4/5 and L5/6 (white arrows). Axial T2-weighted MRI (D) demonstrating hyperintensity facet joint effusion at L5/6 (white arrowheads). MRI: magnetic resonance imaging.
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L4-6, and some calcified lesions extended into the intervertebral foramen or lateral recesses at the right L4/5 and left L5/6 levels (Fig. 2D-2H). Lumbar magnetic resonance imaging (MRI) demonstrated severe canal stenosis at the L4/5 and L5/6 levels caused by a combination of spondylolisthesis and multiple intraspinal canal calcifications (Fig. 3A-3D). Axial T2-weighted MRI revealed facet joint opening and high signal intensity within the bilateral facet joints at L5/6 (Fig. 3D).
(A, B) Histopathologic examination of an intraspinal canal lesion showing a degenerated ligament with focal calcification. Hematoxylin and eosin staining, original magnification: x40 (A), x100 (B), scale bar = 50 mum. Postoperative lumbar spine X-ray lateral view (C) and CT sagittal view (D) showing suitable positioning of the cages and pedicle screws. The alignment of the lumbar spine was corrected. Three-month postoperative lumbar MRI sagittal view (E) showing decompression of the dural sac. CT: computed tomography.
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F4
Histopathology of the specimens revealed highly degenerated ligamentous tissues with focal calcification, and no cystic lesions or neoplastic processes were observed (Fig. 4A and 4B). Postoperative radiographs showed appropriate positioning of the cages and no apparent loosening of the pedicle screws (Fig. 4C and 4D). Lumbar MRI performed 3 months after surgery showed preservation of the dural sac decompression (Fig. 4E).