DISCUSSION:
This patient's symptoms are most likely the results of vascular claudication.
Vascular claudication needs to be differentiated from neurogenic claudication in patients presenting with symptoms of leg pain that is worse with prolonged walking. Variables that support a diagnosis of vascular claudication include: 1) symptoms resolve when the patient ceases walking but remains standing upright (neurogenic symptoms improve only if the patient sits), risk factors including smoking, diabetes mellitus, hypertension, and hyperlipidemia, and 3) a history of peripheral vascular disease as evidenced by prior cardiac stenting, an ABI of < 0.9, and radiographs showing arterial calcification.
The “SLICE” study found low reliability for the grading of cartilaginous lesions in long bones and differentiating benign from malignant lesions and high from low grade malignant lesions.
Ryzewicz et al. discussed the difficulty in clinically and radiographically differentiating enchondromas from low-grade chondrosarcomas. They found on review of the literature that chondrosarcomas more likely had night pain and had more aggressive appearing imaging characteristics. Differentiating low grade chondrosarcomas from enchondromas is challenging.
Sontheimer et al provide an evidenced-based review of the diagnosis and treatment of vascular claudication. They emphasize that once PVD is suspected, physicians can screen patients using ABI testing on one or both extremities. The presence of an ABI less than 0.9 is consistent with PVD.
Figure A shows a lateral lumbar radiograph with no evidence on spondylolithesis. It is notable of aortic calcification, supporting the diagnosis of PVD. Figure B and C are T2 weighted MRI of the lumbar spine. They show disc bulgining with an annular tear, but no evidence of frank disc herniation or spinal stenosis. Figure D show an enchondroma of the distal femur. There is no radiographic evidence of malignant transformation.
Incorrect Answers:
Answer 1: The MRI is consistent for minor disc bulging and an annular tear, but shows no frank disc herniation.
Answer 2: The radiographs reveals a benign appearing enchondroma of the distal femur. These lesions usually are asymptomatic and found incidentally and should be observed.
Answer 3: The MRI shows facet arthrosis on the left, with no significant central or lateral recess stenosis. These findings, in addition to the symptoms that are not typical of spinal stenosis (his symptoms resolves when he ceases walking but remains standing upright), make the diagnosis of vascular claudication more likely.
Answer 5: Rarely enchondromas may transform into chondrosarcomas and become symptomatic. In this situation radiological characteristics become more aggressive with cortical scalloping, periosteal reaction on MRI, and/or increased size with transformation. These findings are not present in this patient.
REFERENCES:
1.
Skeletal Lesions Interobserver Correlation Among Expert Diagnosticians (SLICED) Study group: Reliability of histopathologic and radiologic grading of cartilaginous neoplasms in long bones. J Bone Joint Surg Am 2007;89:2113-2123
PMID:17908885 (Link to Abstract)
2.
Ryzewicz M, Manaster BJ, Naar E, Lindeque B. Low-grade cartilage tumors: Diagnosis and treatment. Orthopaedics 2007;30:35-46
PMID:17260660 (Link to Abstract)
3.
Sontheimer DL. Peripheral vascular disease: diagnosis and treatment. Am Fam Physician. 2006 Jun 1;73(11):1971-6. Review.
PMID:16770929 (Link to Abstract)
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