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      Multidisciplinary approach to L3/L4 lumbar disc prolapse masquerading as focal limb myositis-a radiological challenge

      case-report

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          Abstract

          Prolapsed intervertebral discs are commonly associated with back ache and sciatica. Management is often conservative with analgesia and physiotherapy. Nerve root injections and discectomy procedures are used where conservative measures fail. Majority of patients present with symptoms of pain and motor weakness; however, a few can present as focal myositis of lower limb muscles in the distribution of radiculopathy. MRI scans of limbs are rarely done in these cases but if done can confound the radiologist. Our case report emphasize the importance of multidisciplinary approach for a L3 nerve radiculopathy with confounding clinical presentation of focal lower limb myositis of unknown etiology.

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          Most cited references11

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          Lumbosacral radiculopathy.

          Gerard Tarulli, Jenny E Raynor (2007)
          Lumbosacral radiculopathy is one of the most common disorders evaluated by neurologists and is a leading referral diagnosis for the performance of electromyography. Although precise epidemiologic data are difficult to establish, the prevalence of lumbosacral radiculopathy is approximately 3% to 5%, distributed equally in men and women. Degenerative spondyloarthropathies are the principal underlying cause of these clinical syndromes and are increasingly commonplace with age. Men are most likely to develop symptoms in their 40s, whereas women are affected most commonly between ages 50 and 60. The clinical presentation and initial management of lumbosacral radiculopathies of various etiologies are discussed.
          Article 0 comments Cited 71 times – based on 0 reviews     Review now
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            MRI appearance of muscle denervation.

            E M Walsh, N Venkatanarasimha, Dennis P M Hughes … (2008)
            Muscle denervation results from a variety of causes including trauma, neoplasia, neuropathies, infections, autoimmune processes and vasculitis. Traditionally, the diagnosis of muscle denervation was based on clinical examination and electromyography. Magnetic resonance imaging (MRI) offers a distinct advantage over electromyography, not only in diagnosing muscle denervation, but also in determining its aetiology. MRI demonstrates characteristic signal intensity patterns depending on the stage of muscle denervation. The acute and subacutely denervated muscle shows a high signal intensity pattern on fluid sensitive sequences and normal signal intensity on T1-weighted MRI images. In chronic denervation, muscle atrophy and fatty infiltration demonstrate high signal changes on T1-weighted sequences in association with volume loss. The purpose of this review is to summarise the MRI appearance of denervated muscle, with special emphasis on the signal intensity patterns in acute and subacute muscle denervation.
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              MR Imaging of Atraumatic Muscle Disorders.

              Edward Smitaman, Dyan V. Flores, Catalina Mejía Gómez … (2018)
              Atraumatic disorders of skeletal muscles include congenital variants; inherited myopathies; acquired inflammatory, infectious, or ischemic disorders; neoplastic diseases; and conditions leading to muscle atrophy. These have overlapping appearances at magnetic resonance (MR) imaging and are challenging for the radiologist to differentiate. The authors organize muscle disorders into four MR imaging patterns: (a) abnormal anatomy with normal signal intensity, (b) edema/inflammation, (c) mass, and (d) atrophy, highlighting each of their key clinical and imaging findings. Anatomic muscle variants, while common, do not produce signal intensity alterations and therefore are easily overlooked. Muscle edema is the most common pattern but is nonspecific, with a broad differential diagnosis. Autoimmune, paraneoplastic, and drug-induced myositis tend to be symmetric, whereas infection, radiation-induced injury, and myonecrosis are focal asymmetric processes. Architectural distortion in the setting of muscle edema suggests one of these latter processes. Intramuscular masses include primary neoplasms, metastases, and several benign masslike lesions that simulate malignancy. Some lesions, such as lipomas, low-flow vascular malformations, fibromatoses, and subacute hematomas, are distinctive, but many intramuscular masses ultimately require a biopsy for definitive diagnosis. Atrophy is the irreversible end result of any muscle disease of sufficient severity and is the dominant finding in disorders such as the muscular dystrophies, denervation myopathy, and sarcopenia. This imaging-based classification, in correlation with clinical and laboratory data, will aid the radiologist in interpreting MR imaging findings in patients with atraumatic muscle disorders. ©RSNA, 2018.
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                Author and article information

                Contributors
                Ramandeep Singh Saini
                Daniel Hurry
                Rasvin Singh
                Andrew Dapaah
                Chetna Sharma
                Denis Calthorpe
                Virendra Jain
                Ravi Kothari
                Journal
                Journal ID (nlm-ta): BJR Case Rep
                Journal ID (iso-abbrev): British Institute of Radiology
                Journal ID (publisher-id): bjrcr
                Title: BJR | Case Reports
                Publisher: The British Institute of Radiology.
                ISSN (Electronic): 2055-7159
                Publication date Collection: 01 May 2021
                Publication date (Electronic): 24 February 2021
                Volume: 7
                Issue: 3
                Electronic Location Identifier: 20200126
                Affiliations
                [1 ]org-divisionRoyal Derby Hospital , Derby, UK
                Author notes
                Address correspondence to: Mr Ramandeep Singh Saini. E-mail: ramandeep.saini@ 123456nhs.net
                Article
                Publisher-manuscript ID: BJRCR-D-20-00126
                DOI: 10.1259/bjrcr.20200126
                PMC ID: 8171130
                SO-VID: 36ca0249-02bf-4e6e-b1ae-0a014739e850
                Copyright © © 2021 The Authors. Published by the British Institute of Radiology
                License:

                This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International License, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited.

                History
                Date received : 14 July 2020
                Date revision received : 26 January 2021
                Date accepted : 12 February 2021
                Page count
                Figures: 5, Tables: 0, Equations: 0, References: 11, Pages: 0, Words: 2949
                Categories
                Subject: Case Report
                Compound subject: bjrcr, BJRCR
                Compound subject: musc, Musculoskeletal

                Data availability:

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