Thoracolumbar Junction Syndrome Causing Pain around Posterior Iliac Crest: A Case Report
A 42-year-old Korean woman with low back pain, general weakness, loss of appetite, and indigestion for 3 months presented to the Department of Family Medicine, Dongsan Medical Center, Daegu, Korea via the outpatient clinic for evaluation and conservative management. The patient has been followed up on for hypertension, dyslipidemia, and osteogenesis imperfecta for 8 years.\nThe patient had been treated with monthly intravenous administration of pamidronate 15 mg for osteoporosis since the dual-energy X-ray absorptiometry had demonstrated a T score of -2.93 8 years ago, but there was no improvement in bone mass density. The patient has had percutaneous vertebroplasty for a T11 compression fracture 6 years ago, but her low back pain has continued. The patient had presented to the orthopedic outpatient clinic with aggravation of low back pain 4 years ago, in which she was diagnosed with osteogenesis imperfecta and had an magnetic resonance imaging (MRI) demonstrating a T11 compression fracture with thoracolumbar kyphotic deformity. One year ago, the patient had kyphosis correction with autogenous bone grafting for continued low back pain and 30 degrees kyphosis. A relief in symptoms was reported for some time thereafter, but her symptoms worsened for the past 3 months, requiring conservative treatment including pain medication and physical therapy.\nThe patient has been taking angiotensin receptor blockers and statins daily for 4 years for hypertension and hyperlipidemia with intermittent use of zolpidem for insomnia. Her daughter and son were diagnosed with osteogenesis imperfecta as well and have been followed up at pediatrics. Her mother has a history of cerebrovascular disease.\nThe laboratory data upon admission were within normal limits. Plain radiograph of the pelvis showed no change from previous testing. Thoracic MRI demonstrated no significant changes other than improvement in kyphosis at the T10-11 level from the previous surgery.\nThe patient's general weakness, depressed mood, insomnia and decreased appetite have been improving with the management of major depressive disorder which includes emotional support and medical management using mirtazapine 15 mg daily. However, the patient was complaining of aggravated pain on the left posterior iliac crest area, rating it as an 8/10 on the visual analogue scale (VAS).\nOn physical examination, she exhibited local hyperesthesia and tenderness on the skin over the left posterior iliac crest compared to the right side when a fold of the skin and subcutaneous tissue was taken and rolled. Tenderness upon palpation of spinous processes and the facet joint of the thoracolumbar junction was also observed. Based on these typical findings of physical examination of the posterior iliac crest and nonspecific findings of imaging studies, the patient was diagnosed with thoracolumbar junction syndrome.\nThe patient could not benefit from facet joint injection which was tried in cooperation with the pain clinic at our facility on the 4th day of admission. The continuation and severity of the symptoms prompted the decision to proceed with epidural nerve block using triamcinolone and 0.5% mepivacaine. The patient reported an improvement in pain, reporting a 4.5/10 on the VAS. On the 8th day of admission, a lumbar sympathetic nerve block was performed with 0.5% mepivacaine upon patient's complaining of increased pain to 5.5/10 on the VAS. The patient reported a reduction in pain, reporting a 2/10 on VAS thereafter. The patient's gastrointestinal symptoms including bloating and lower abdominal pain, also improved after epidural block, suggesting that the symptoms were also functional disabilities accompanied by throcolumbar junction syndrome. The patient was discharged on the 11th day of admission with improved clinical symptoms and instructed to follow-up via the outpatient clinic.