Kümmell's disease — uncommon or underreported disease: A clinicopathological account of a case and review of literature
A 60-year-old gentleman, a laborer by profession, presented with the complaints of severe low back ache of 3 days duration and low grade fever for the past 2 weeks. There was no history suggestive of tuberculosis in the past. One year back, he had low backache of moderate intensity, precipitated by lifting and carrying heavy loads on his back, which resolved spontaneously. On clinical examination, there was focal tenderness over L4-5 vertebral levels with gross restriction of spinal movements and marked paraspinal spasm. No focal neurological deficits were detected. Routine hematological and biochemical parameters were normal except for high ESR of 94 mm/1 h (Westergren). Chest X-ray did not reveal any radiological abnormality. Magnetic resonance imaging (MRI) of lumbosacral spine [] revealed collapse of L4 body with relatively preserved disc spaces. The collapsed L4 vertebral body was hypointense on T1W image and hyperintense on T2W image []. There was no area of abnormal enhancement or any prevertebral or para spinal collection. Computed tomography (CT) of spine [Figures and ] revealed L4 vertebral body collapse. He underwent L4 laminectomy, L3-5 transpedicular fixation, and the biopsy of the L4 body. Histopathology revealed thin irregular osteoporotic bony lamellae and fragments of pale ischemic bony bits []. The enclosed marrow spaces revealed fresh hemorrhage bordered by clusters of foamy histiocytes as response to fresh hemorrhage reflecting trauma []. There was abundant fibrin and early necrosis of the marrow without any osteoblastic or osteoclastic activity. There was no evidence of tuberculosis (absence of granulomatous pathology or acid fast bacilli). The possibility of post-traumatic avascular necrosis (KD) was suggested. As tuberculosis could not be conclusively excluded, he received antitubercular therapy (ATT).\nOn subsequent reviewing of MRI, radiological features were not favoring tuberculosis, as the disc space was well preserved. There was no pre or paravertebral collection of inflammatory granulation tissue and the collapsed vertebral body did not have abnormal enhancement or signal changes. Review of the CT scan revealed L4 vertebral body collapse with cortical breach, linear fracture of lamina on the left side, and presence of intravertebral “vacuum cleft” on radiograph [Kümmell's sign – a retrospective observation ()]. Clinical history was suggestive of mild trauma and delayed acute presentation, and hence, diagnosis of KD was made and ATT was stopped. Postoperatively, his pain improved significantly. At discharge, he was ambulatory without any neurological deficits. Serum ADA performed at 3 months of follow up, which was normal. At 12 months follow up, he was ambulatory and was doing well. There were no clinical signs or symptoms attributable to tuberculosis.