Indian Journal of Nuclear Medicine

INTERESTING IMAGES
Year
: 2015  |  Volume : 30  |  Issue : 2  |  Page : 183--184

Bone single-photon emission computed tomography and three-dimensional computed tomography in the diagnosis of low costal variation and pathologies


Güler Silov1, Zeynep Erdoğan1, Ayşegül Özdal1, Aysel Özaşlamacı2,  
1 Department of Nuclear Medicine, Kayseri Training and Research Hospital, Kayseri, Turkey
2 Department of Radiology, Kayseri Training and Research Hospital, Kayseri, Turkey

Correspondence Address:
Dr. Güler Silov
Department of Nuclear Medicine, Kayseri Training and Research Hospital, Kayseri 38010
Turkey

Abstract

In general, there are five lumbar vertebras in normal human subjects. But occasionally there are six. In such a situation, a radiologist need to discern between lumbarization of S1 (S1 vertebra becomes segmented and mimics L5) or due to hypoplastic 12 th ribs, hence the T12 vertebra is wrongly assumed to be L1. These interesting images serve a multimodality approach to right aplasia/left hypoplasia of 12 th rib, injury of left 11 th rib and subluxation of left 11 th Costovertebral joint in a patient with lumbar back pain.



How to cite this article:
Silov G, Erdoğan Z, Özdal A, Özaşlamacı A. Bone single-photon emission computed tomography and three-dimensional computed tomography in the diagnosis of low costal variation and pathologies.Indian J Nucl Med 2015;30:183-184


How to cite this URL:
Silov G, Erdoğan Z, Özdal A, Özaşlamacı A. Bone single-photon emission computed tomography and three-dimensional computed tomography in the diagnosis of low costal variation and pathologies. Indian J Nucl Med [serial online] 2015 [cited 2022 Sep 30 ];30:183-184
Available from: https://www.ijnm.in/text.asp?2015/30/2/183/152990


Full Text

A 37-year-old woman with left low back pain for 3 mount durations was admitted to the department of orthopedic surgery and traumatology. Patient was not described any major trauma. Her laboratory finding was compatible with iron deficiency anemia. Other serologic and hematologic results are within normal limits. On anteroposterior and lateral radiography at first glance, there was six lumbar vertebra [Figure 1]a. This distinction matters little to the health of the patient him/herself but can have a terrible effect if the surgeon decides to operate on him/her and there is a misconception of the level. [1],[2],[3] There are typically no anatomic complications using the anterior approach from beneath the costal margin. The posterior approach requires an incision at the level of the spinous process of the first lumbar vertebra to avoid entering the pleura. [4],[5],[6] On the thoracolumbar computed tomography (CT), there was only five lumbar vertebra and right 12 th rib aplasia and left 12 th rib hypoplasia [Figure 1]b. But there was no pathological finding to explain the pain.{Figure 1}

The patient with intense low back pain was also further investigated with three phase bone scintigraphy (TPBS), whole body bone scintigraphy (WBBS) and thoracolumbar bone single-photon emission computed tomography (SPECT). There were no abnormal findings on the first two phase of TPBS. On the WBBS, there were not seen the ribs of 12 th and moderate diffuse activity involvement was observed on the left 11 th rib [Figure 2]a. In the coronal SPECT images, there was diffuse increased uptake in the left 11 th rib [Figure 2]b. On the three-dimensional-CT imaging, left 12 th hypoplastic rib was observed while right one was not. Also left 11 th Costovertebral joint was subluxated [Figure 3]. Ribs 11 and 12 do not attach to an anterior costal cartilage or transverse process, but rather invest into the fascia and musculature of the lateral and posterior abdominal wall. Ribs 11 and 12 are described as having caliper motion, primarily influenced by their relationship to their muscular attachments. The caliper motion of ribs eleven and twelve can be seen to be related to the near-vertical orientation of the small transverse processes of T11 and T12 as well as the way the ribs invest into the abdominal musculature, thoracolumbar fascia, and diaphragm. Another important lower extremity muscle affecting rib cage motion is the quadrates lumborum, which originates from the iliolumbar ligament and the posterior part of the iliac crest, runs along the posterior lateral aspect of the vertebral column, and inserts on the transverse processes of the upper four lumbar vertebra and the inferior aspect of the 12 th rib on each side. [7] According to all of these findings, repetitive daily minor posttraumatic subluxation of the left 11 th rib and injury was diagnosed in this patient.{Figure 2}{Figure 3}

References

1Merks JH, Smets AM, Van Rijn RR, Kobes J, Caron HN, Maas M, et al. Prevalence of rib anomalies in normal Caucasian children and childhood cancer patients. Eur J Med Genet 2005;48:113-29.
2Edwards DK 3 rd , Berry CC, Hilton SW. Trisomy 21 in newborn infants: Chest radiographic diagnosis. Radiology 1988;167:317-8.
3Grangé G, Tantau J, Acuna N, Viot G, Narcy F, Cabrol D. Autopsy findings related to Down's syndrome: 101 cases. J Gynecol Obstet Biol Reprod (Paris) 2006;35:477-82.
4Spain DA, Martin RC, Carrillo EH, Polk HC Jr. Twelfth rib resection. Preferred therapy for subphrenic abscess in selected surgical patients. Arch Surg 1997;132:1203-6.
5Kato H, Kiyokawa H, Inoue H, Kobayashi S, Nishizawa O. Anatomical reconsideration to renal area: Lessons learned from radical nephrectomy or adrenalectomy through a minimal incision over the 12 th rib. Int J Urol 2004;11:709-13.
6Kato H, Nishizawa O. Supracostal approach - An excellent exposure for renal and adrenal surgery. Hinyokika Kiyo 2001;47:449-52.
7De Stefano LA. Greenman's Principles of Manual Medicine. Philadelphia: Lippincott; 2011. p. 265-6.