Faculty Bibliography

Case/Program Description: A 68-year-old woman with a past medical history of osteoporosis and bilateral knee replacements was referred due to clinical concern for lumbar radiculopathy. She suffered a fall 7 weeks prior to presentation however had no radicular symptoms at that time. She presented with 1 week of left-sided radiating groin pain and weaknessoftheleftleg. She wasunabletobear weight withoutpainand pain worsened with prolonged walking and improved with rest. She had previously been prescribed oxycodone and oral steroids. Her previous imaging included hip radiographs which revealed no evidence of frac-tureandMRIofthelumbarspinewhichrevealedmoderatecanalstenosis at L4-5 and multilevel neuroforaminal stenosis without compromise. Sacral insufficiency fractures were seen on the right greater than left, but incompletely evaluated. Her exam was notable for pain with hip flexion, internal and external rotation, Stinchfield test, log roll test, and Patrick's test. Occult hip fracture and lumbar radiculopathy were considered as possible explanations for her symptoms.A left hip MRI was ordered to better characterize her injury. Setting: Quaternary care hospital. Results: Left hip MRI revealed a left obturator externus avulsion as well as bilateral sacral alar fractures and left parasymphyseal fracture. She was given oxycodone for pain management, and a manual wheelchair until she was able to bear weight without pain. She began a physical therapy program and 9 weeks after her injury she was able to walk with a rollator. Her osteoporosis treatment was addressed. Further developments will be discussed. Discussion: Pelvic ring fractures involving the sacral ala and the parasymphyseal region can be managed nonoperatively, and may present similarly to radiculopathy. In addition, this is the first reported case, to our knowledge, of obturator externus avulsion. Conclusions: Obturator externus avulsions should be considered in the setting of presumed occult hip fracture

Case/Program Description: The patient is an 88-year-old woman with history of hysterectomy who was referred for evaluation of acute onset low back and buttock pain of 2 weeks duration without any reported provocation or injury. The pain was 4/10, intermittent, aching, exacerbated by walking, alleviated by resting, sitting, Tylenol and Advil. There were no associated fevers, chills, radicular symptoms, bowel or bladder dysfunction, reported changes in weight, prior or recent injections or instrumentation of the spine. Exam was notable for an antalgic gait, pain with end flexion and bilateral oblique extension, tenderness over paraspinal muscles and facet joints as well as the left sacroiliac joint and posterior superior iliac spine. Motor, sensory, and deep tendon reflexes were intact. Setting: Outpatient Spine Center. Results: Lumbar radiographs showed multilevel degenerative disc disease, spondylosis, and multilevel facet arthrosis. Patient was started on naproxen and referred to outpatient physical therapy. She presented for early follow up 11 days later, with increasing 7/10 pain radiating to left anterior thigh. Exam notable for new tenderness over anterior midthigh, positive left Ober test, reproduction of left anterior thigh pain with Ely test, mild weakness of left hip flexors and diminished left lower reflexes. Lumbar MRI showed left L3-4 facet joint abnormality, adjacent marrow edema, and soft tissue abscess of the multifidus and psoas muscles. She was emergently referred for inpatient admission, and required a prolonged hospitalization. Discussion: Psoas abscess is a rare infectious disease with nonspecific clinical presentation and often insidious onset that frequently results in diagnostic difficulty and delays. Delays are often associated with high morbidity and mortality in these patients. Conclusions: It is crucial to maintain a high index of suspicion for infectious etiologies and utilize a combination of laboratory and imaging studies when working up back pain