Low-back Pain Vexed by Avascular Necrosis of the Femoral Head
Link http://www.orthosupersite.com/view.asp?rID=23117ORTHOPEDICS 2007; 30:600 August 2007 A 44-year-old man reported mild low-back pain and right-sided leg pain for the past two months. He also had weakness in his right leg. He reported no concomitant numbness or tingling. Previous magnetic resonance imaging (MRI) was consistent with T12-L1 central disk protrusion with thecal compression. After physical therapy, the patient’s symptoms progressively worsened and he could not walk. Medical history was unremarkable for trauma, drug use, or hereditary illnesses. Physical examination revealed no tenderness, trigger points, or paravertebral muscle spasm in the the lumbosacral region. Straight-leg-raise tests were negative bilaterally. However, external and internal rotations of the right hip joint were painful and accompanied by minimal loss of hip muscle strength (4/5). Left hip joint examination was normal. A right hip pathology rather than a low-back problem was suspected, and MRI revealed avascular necrosis of the right femoral head. Interestingly, before the patient presented to the orthopedics department, he started to have concomitant left hip pain and another MRI showed early avascular necrosis on the left side. Any type of pain during physical examination may not always herald a pathology pertaining to that exact region. Other likely causes should be suspected; and the rest of the examination should be tailored accordingly.1 Likewise, in our patient, although the initial problem was back pain and the MRI had been somewhat consistent, prompt physical and radiological assessment showed that the hip pathology was causing the symptoms. Treatment also might vary according to the diagnoses. Moreover, one treatment method may be contraindicated in the other. In our case, physical therapy that would otherwise help a patient with low-back pathology was noncontributory, even unfavorable. Therefore, noteworthy in the management of relevant patients would definitely be to reconsider the diagnosis in case the initial treatment proved to be inconclusive. This is especially true in idiopathic cases of avascular necrosis of the femoral head; the chance of bilateral involvement during the disease course should be kept in mind. Reference Özçakar L, Korkmaz N. When you hear hooves, don’t forget zebras along with the horses. Rheumatol Int. 2003; 23:326.