Lumbosacral transitional vertebral with intertrochanteric fibrous dysplasia
Presentation
Right-sided anterior hip and thigh pain.
Patient Data
The frontal projection revealed a mild right-sided lumbar scoliosis secondary to an L5 lumbosacral transitional vertebra with enlargement of the right transverse process. The enlargement of the right L5 transverse process appears to be fused to the sacrum, leading to a suspected type 3b Castellvi classification lumbosacral transitional vertebra, which prompted a Ferguson projection of the pelvis to be obtained. Large osteophyte proliferation was noted from the right inferior corner of L4 vertebral body. There is an intertrochanteric lucency with a thick rim of sclerosis seen in the right proximal femur, which would be better visualized using a pelvic or Ferguson projection.
The Ferguson projection confirmed the presence of complete fusion of the enlarged L5 transverse process. A normal transverse process is seen on the left of L5. This projection also allows for appreciation of the L4 osteophyte formation on the right and the significant loss of disc height. There is a large intertrochanteric lucent lesion with a thick rim of sclerosis seen in the proximal aspect of the right femur.
The lateral projection revealed reduced lumbar lordosis consistent with chronic low back pain. Reduced height of the L4-5 intervertebral disc space. Osteophyte proliferation from the anterosuperior corner of L5 vertebral body without fusion.
Case Discussion
These findings led to the diagnosis of fibrous dysplasia of the right proximal femur. Due to the expansile nature of these lesions, the patient was referred for additional investigations and pain management options. The decision was made by the patient and the medical team that surgical and pharmaceutical management was the most appropriate management strategy rather than chiropractic/manual therapies.
The patient presented with a history of chronic episodic low back pain and right-sided radiculopathy for which she has undergone microdiscectomy of L4-5 intervertebral disc six years before her presentation.
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