Asian Spine J Search

CLOSE


Asian Spine J > Volume 13(6); 2019 > Article
Ariyawatkul, Pichaisak, Chavasiri, Vamvanij, Wilartratsami, and Luksanapruksa: The Role of Calcium Pyrophosphate Dihydrate Deposition in the Postoperative Outcome of Lumbar Spinal Stenosis Patients

Abstract

Study Design

Retrospective study.

Purpose

This study aimed to investigate the association of surgical intervention with clinical and quality of life (QoL) outcomes in patients who underwent posterior spinal surgery for lumbar spinal stenosis (LSS) with spinal calcium pyrophosphate dihydrate deposition (SCPPD) versus that in those who underwent the surgery for LSS without SCPPD.

Overview of Literature

Calcium pyrophosphate (CPP)-associated arthritis is one of the most common types of arthritis. The clinical outcomes are well studied in CPP-associated arthritis of the appendicular joints. However, few studies have investigated SCPPD.

Methods

A single-institution database was reviewed. LSS patients were categorized as those who did and did not have SCPPD, based on histologic identification. Clinical presentations and postoperative results were analyzed. Disability and QoL were assessed using the Oswestry Disability Index (ODI) and the 36-item Short-Form Health Survey.

Results

Thirty-four patients were enrolled, with 18 patients being allocated to the SCPPD group and 16 being allocated to the non- SCPPD group. Preoperative and postoperative pain scores were not significantly different between the groups (p=0.33 and p=0.48, respectively). The average preoperative ODI score in the SCPPD group was slightly higher than that in the non-SCPPD group (57 vs. 51, p=0.33); however, the postoperative ODI score was significantly lower (15 vs. 43, p=0.01). The postoperative physical function, vitality, and mental health of the SCPPD patients were also significantly improved (p=0.03, p=0.022, and p=0.022, respectively).

Conclusions

Surgical intervention resulted in good clinical outcomes in SCPPD patients. As per our findings, total removal of CPPinvolved tissue is unnecessary. As such, surgery should be performed as indicated according to clinical presentation without considering the presence of CPPD.

Introduction

Calcium pyrophosphate dihydrate crystal deposition (CPPD) or pseudogout is the third most common type of inflammatory arthritis. As compared to osteoarthritis, CPPD is associated with higher levels of inflammation, pain, stiffness, and functional limitation [1]. Induced inflammation is associated with pain, stiffness, and functional limitation in the affected joints. CPPD of the spine is a rare disease. CPPD in the lumbar area of the spinal structure (SCPPD) can be found in the intervertebral disc (Fig. 1) [2], disk fibrocartilage [3], ligamentum flavum [4,5], and facet joint [6-8]. The prevalence varies as per the spinal structure that is affected. Berlemann et al. [2] reported incidental CPPD in 12.6% of lumbar intervertebral discs. Yayama et al. [4] identified CPPD in 36.66% of ligamentum flavum samples, and Markiewitz et al. [5] reported CPPD in the ligamentum flavum in 24.5% of surgically treated patients. Inflammation in these structures may cause pain in the affected area as well as neuropathic pain that may be attributable to inflamed neural structures or compressive effect of the inflamed tissues. Common clinical presentations include back pain and/or radiating leg pain [6,8] that may mimic infection, cauda equina syndrome [9], spinal epidural hematoma [10], and spinal stenosis [11-14]. However, the clinical significance of SCPPD in patients who present with lumbar spinal stenosis (LSS) remains unclear. We hypothesized that posterior spinal surgery to correct LSS should increase inflammation in SCPPD patients as compared to that in non-SCPPD patients and that total removal of these structures may be necessary. We further hypothesized that different levels of inflammation and pathology in the two conditions would result in dissimilar pain levels and clinical outcomes. However, as per our literature review, no studies have validated these hypotheses. Thus, we aimed to study the effects of SCPPD in LSS patients.
This study aimed to investigate the association of surgical intervention with the clinical and quality of life (QoL) outcomes in patients who underwent posterior spinal surgery for LSS with SCPPD versus that in those who underwent the surgery for LSS without SCPPD.

Materials and Methods

This study was conducted at a university-based tertiary referral center. The protocol for this study was approved by the Siriraj Institutional Review Board, Faculty of Medicine Siriraj Hospital, Mahidol University (IRB approval no., Si233/2014).
A single-institution database was reviewed, identifying LSS patients who were surgically treated with posterior spinal surgery during the 2003–2011 study period. All the LSS patients were categorized as those with and without SCPPD. Definite diagnosis of SCPPD was confirmed using histologic identification of calcium pyrophosphate (CPP). Clinical presentations, complications, and postoperative results of both the groups were analyzed.
SCPPD patients who underwent decompressive laminectomy and/or fusion were included after histopathologic diagnosis. Non-SCPPD patients were then matched using demographic data. Patients were excluded if their medical chart contained incomplete data and/or the follow-up period was <2 years.
All the patients underwent decompressive laminectomy with or without discectomy as per the clinical and magnetic resonance imaging findings (Fig. 2). No patient underwent total removal of CPP-involved tissues or steroid injection (adequate decompression was confirmed in all cases without total facetectomy or total discectomy). Spinal fusion with or without instrumentation was performed if the patient had significant back pain or instability. Ligamentum flavum, facet capsule, and disc specimens were sent for histopathologic examination for all patients. The enrolled patients were divided into the following two groups: SCPPD group (18/34) and non-SCPPD group (16/34) as per the histopathologic report. Patients in the SCPPD group did not receive colchicine postoperatively.
Data were collected via chart abstraction; demographic data, clinical presentations, operative data, radiographic findings, and postoperative data were recorded. Pain was evaluated using the Verbal Rating Scale (VRS) (range, 0–10). All the patients completed the 36-item Short-Form Health Survey (SF-36) version 2.0 questionnaire (Thai version) [15] and the Oswestry Disability Index (ODI) low back pain version 1.0 questionnaire (Thai version) [16] before the surgery and at the last follow-up. Informed consent was obtained from all patients at the last followup. Fusion was evaluated using plain radiographs.
Descriptive statistics, including mean, standard deviation, median, minimum, maximum, and range values, were calculated for quantitative data, while frequencies were calculated for categorical and ordinal variables. Mann-Whitney U-test and chi-square test were used to compare continuous variables and categorical variables, respectively. A p-value <0.05 was considered statistically significant. Data were analyzed using the SPSS statistics ver. 13.0 (SPSS Inc., Chicago, IL, USA).

Results

Thirty-four patients (15 men and 19 women) were enrolled, with 18 patients allocated to the SCPPD group and 16 to the non-SCPPD group. Demographic, clinical, and operative data are shown in Table 1. The mean operative time and mean intraoperative blood loss were not significantly different between the groups. The mean follow-up duration was 61.9 months (range, 41–92 months).
The demographic data of the groups were comparable; however, the mean body mass index (BMI) of the SCPPD group was significantly lower than that of the non-SCPPD group (23.56 kg/m2 versus 26.47 kg/m2, p=0.015). The commonly affected levels in both the groups were L4–5, L3–4, and L5–S1. No patient had a history of CPPD in other joints. Fourteen of the 18 SCPPD patients and 11 of the 16 non-SCPPD patients underwent spinal fusion. None of these patients required additional surgery because of nonunion or surgical complications.
Preoperative and postoperative pain scores were not significantly different between the groups (p=0.33 and p=0.48, respectively). The average preoperative ODI score in the SCPPD group was slightly higher than that in the non-SCPPD group (57 versus 51, p=0.33); however, the postoperative score was significantly lower (15 versus 43, p=0.01). Physical function, vitality, and mental health were also significantly improved in the SCPPD group at the last follow-up (p=0.03, p=0.022, and p=0.022, respectively). Regarding other items and summary scores, no statistically significant differences were observed between the groups. Preoperative and postoperative VRS, ODI, and SF-36 data are shown in Table 2. There were no statistically significant differences in the postoperative scores among the three operative procedures. Subgroup analysis of the SCPPD group for each operative procedure is presented in Table 3; no significant differences were detected among the three surgical procedures.

Discussion

The present study revealed that SCPPD group patients had a significantly higher average age than the non-SCPPD group patients. SCPPD group patients also had higher levels of back pain than the non-SCPPD group patients; however, the difference in the pain levels of the groups was not statistically significant. Preoperative pain score, percentage of back pain, ODI, and SF-36 score were not significantly different between the groups, although the SCPPD group patients had a significantly lower BMI. This finding may indicate that inflammation in CPP-involved tissue plays the role. The most common affected levels were L4–5 and L3–4 in both the groups. Markiewitz et al. [5] reported that SCPPD patients had more acute symptoms with similar clinical presentation. No pathognomonic sign of SCPPD has been reported in the literature. Although facet cyst is reportedly associated with SCPPD, we found that the incidence of facet cyst was comparable in the two groups.
Very few studies have described the surgical treatment in SCPPD patients. Mahmud et al. [17] reported successful relief of symptoms in SCPPD patients after surgical decompression and/or fusion. However, to our knowledge, no study has reported any comparison between SCPPD and non-SCPPD in LSS. The authors hypothesized that surgical intervention would result in more inflammation in patients with LSS and SCPPD who already had more inflammatory features than LSS patients without SCPPD. The present study revealed comparable pain and overall QoL in the groups after the surgical treatment, although total removal of CPP-involved tissues was not performed for any patient. There was no statistically significant difference between the groups in terms of preoperative disability, pain, and QoL. Although the SCPPD group patients showed significantly better postoperative clinical results for disability, physical function, vitality, and mental health, there was no significant difference between the groups for overall physical and mental health at the last follow-up. Operative procedures (i.e., fusion and instrumentation) may not correlate with postoperative function because the subgroup analysis did not detect any significant differences among the three surgical procedures. This may be attributable to selection bias. The authors conclude that total removal of CPP-involved tissues is not mandatory, given that all SCPPD group patients demonstrated significant improvement in pain, ODI, and SF-36 QoL scores. Limitations of this study included the fact that it was a single-center retrospective study and involved a relatively small number of participants. In this study, we determined fusion using plain radiographs. Computed tomography scan would have been more accurate for evaluating fusion. A large, prospective multi-center study may be able to obtain additional information on the clinical impact of SCPPD in degenerative spine disease.

Conclusions

To our knowledge, this is the first study to investigate the effect of CPPD on clinical and QoL outcomes in surgically treated LSS patients. Surgical intervention resulted in good clinical outcomes in SCPPD patients. As per our findings, total removal of CPP-involved tissue is not necessary for outcome improvement. Thus, surgery should be performed as indicated based on the clinical presentation without considering the presence of CPPD.

Conflicts of interest

No potential conflict of interest relevant to this article was reported.

Acknowledgments

The authors gratefully acknowledge professor Thossart Harnroongroj for assistance with manuscript development, Miss Natnicha Sriburiruk, Miss Siranart Kumpravat, and Miss Julaporn Pooliam for assistance with statistical analysis.

Fig. 1.
(A) Intervertebral disc (H&E staining, ×400) shows minimal calcium pyrophosphate dihydrate deposition (purple staining material in the center). (B) The purple staining material shows rhomboid-shaped crystals on polarized light.
asj-2018-0280f1.jpg
Fig. 2.
(A–D) demonstrated preoperative plain radiograph and T2-weighted MRI of 67-year-old woman who had severe back pain with bilateral radicular pain, underwent laminectomy and uninstrumented posterolateral fusion. (D) Axial T2-weighted magnetic resonance image showed cystic mass originated from ligamentum flavum without calcification at L3–4 level. (E–H) Postoperative plain radiographs and MRI of the same patient. MRI, magnetic resonance imaging.
asj-2018-0280f2.jpg
Table 1.
Demographic, clinical, and operative data
Characteristic SCPPD group (N=18) Non-SCPPD group (N=16) p-value
Gender (female) 12 (66.7) 7 (43.8) 0.179
Age (yr) 71±5.6 65.9±9.7 0.064
Body mass index (kg/m2) 23.6±3.4 26.5±3.0 0.015
ASA class 1/2/3 2/14/2 3/12/1 0.751
Underlying disease 0.457
 Hypertension 14 (77.8) 12 (75.0)
 Diabetes mellitus 4 (22.2) 6 (37.5)
 Dyslipidemia 10 (55.6) 7 (43.8)
 Gout 1 (5.6) 1 (6.3)
Smoker 0 0 NS
Chief complaint 0.011
 Back pain 8 (44.4) 1 (6.3)
 Radicular pain 3 (16.7) 2 (12.5)
 Neurodeficit 2 (11.1) 0
 Claudication 5 (27.8) 13 (81.3)
Radiographic finding 0.642
 Spondylolisthesis 11 (61.1) 11 (68.8)
 Magnetic resonance imaging: facet cyst 2 (11.1) 2 (12.5)
Affected level 0.236
 L1–2 0 1
 L2–3 2 0
 L3–4 10 7
 L4–5 15 12
 L5–S1 8 4
No. of involved spine 0.63
 1 11 11
 2 14 15
 3 8 5
 4 0 1
Cases presented with revision surgery 2 (11.1) 0 0.487
Types of surgery 0.593
 DCL 4 5
 DCL+PLF 11 10
 DCL+instrumented PLF 3 1
Operative time (min) 151.7±28.9 143.1±25.2 0.367
Intraoperative blood loss (mL) 553±426 519±276 0.798
Complications 0.487
 Nerve injury 0 0
 Dural tear 2 0

Values are presented as number (%), mean±standard deviation, or number. p-value <0.05 indicates statistical significance.

SCPPD, spinal calcium pyrophosphate dihydrate deposition; ASA, American Society of Anesthesiologists; NS, not significant; DCL, decompressive laminectomy; PLF, posterolateral fusion.

Table 2.
Preoperative and postoperative VRS, ODI, and SF-36 data
Variable SCPPD group (N=18) Non-SCPPD group (N=16) p-value
VRS
 Preoperative score 8.0 7.0 0.330
 Postoperative score 3.0 3.0 0.480
 Improvement 6.5 4.0 0.130
ODI
 Preoperative score 57.0 51.0 0.330
 Postoperative score 15.0 43.0 0.010
 Improvement 34.0 15.0 0.010
Physical functioning
 Preoperative score 25.0 22.5 0.443
 Postoperative score 50.0 25.0 0.003
 Improvement -12.5 -5.0 0.237
Role-physical
 Preoperative score 0 0 0.510
 Postoperative score 12.5 0 0.551
 Improvement 0 0 0.986
Bodily pain
 Preoperative score 41.0 41.0 0.959
 Postoperative score 72.0 53.0 0.551
 Improvement -15.5 -11.5 0.798
General health
 Preoperative score 45.0 41.0 0.670
 Postoperative score 61.0 52.0 0.095
 Improvement -16.0 -8.5 0.330
Vitality
 Preoperative score 52.5 40.0 0.075
 Postoperative score 62.5 50.0 0.022
 Improvement -2.5 -2.5 0.646
Social functioning
 Preoperative score 75.0 62.5 0.224
 Postoperative score 75.0 62.5 0.198
 Improvement -6.25 0 0.878
Role-elemental
 Preoperative score 0 0 0.551
 Postoperative score 66.7 0 0.154
 Improvement 0 0 0.506
Mental health
 Preoperative score 66.0 52.0 0.313
 Postoperative score 78.0 62.0 0.022
 Improvement -10.0 0 0.443
Physical health summary scale
 Preoperative score 25.9 28.8 0.746
 Postoperative score 36.4 35.3 0.251
 Improvement -7.3 -3.6 0.463
Mental health summary scale
 Preoperative score 45.0 39.7 0.175
 Postoperative score 51.2 43.7 0.081
 Improvement -6.0 0.5 0.313

Values are presented as median. p-value <0.05 indicates statistical significance.

VRS, Verbal Rating Scale; ODI, Oswestry Disability Index; SF-36, 36-item Short-Form Health Survey; SCPPD, spinal calcium pyrophosphate dihydrate deposition.

Table 3.
Subgroup analysis for each operative procedure in spinal calcium pyrophosphate dihydrate deposition group patients
Variable DCL (n=4) DCL+PLF (n=11) DCL+instrumented PLF (n=3) p-value
VRS
 Preoperative score 9 8 5 0.054
 Postoperative score 1 3 1 0.348
 Improvement 7 6 4
ODI
 Preoperative score 74 56 22 0.181
 Postoperative score 5 16 8 0.147
 Improvement 57 32 14
Physical functioning
 Preoperative score 35 20 45 0.185
 Postoperative score 45 50 45 0.950
 Improvement -10 -30 0
Role-physical
 Preoperative score 37.5 0 50 0.030
 Postoperative score 37.5 0 75 0.086
 Improvement -12.5 0 -25
Bodily pain
 Preoperative score 62 22 74 0.014
 Postoperative score 74 62 74 0.175
 Improvement -21.5 -29 0
General health
 Preoperative score 45 45 75 0.074
 Postoperative score 57 57 77 0.244
 Improvement -24.5 -15 -2
Vitality
 Preoperative score 60 50 60 0.322
 Postoperative score 70 55 70 0.058
 Improvement -7.5 5 10
Social functioning
 Preoperative score 87.5 62.5 75 0.032
 Postoperative score 87.5 62.5 75 0.136
 Improvement 6.25 -12.5 12.5
Role-elemental
 Preoperative score 33.4 0 33.3 0.349
 Postoperative score 66.7 66.7 33.3 0.960
 Improvement -33.4 0 0
Mental health
 Preoperative score 82 52 76 0.171
 Postoperative score 78 80 76 0.877
 Improvement -2 -24 0
Physical health summary scale
 Preoperative score 35.6 23.6 48 0.039
 Postoperative score 36.8 34.2 45.3 0.096
 Improvement -6.2 -11.6 0.7
Mental health summary scale
 Preoperative score 49.8 44.7 51.1 0.319
 Postoperative score 53 50.2 42.8 0.632
 Improvement -7 -5.5 -2

Values are presented as median. p-value<0.05 indicates statistical significance.

DCL, decompressive laminectomy; PLF, posterolateral fusion; VRS, Verbal Rating Scale; ODI, Oswestry Disability Index.

References

1. Zhang W, Doherty M, Bardin T, et al. European League Against Rheumatism recommendations for calcium pyrophosphate deposition: part I: terminology and diagnosis. Ann Rheum Dis 2011 70:563–70.
crossref pmid
2. Berlemann U, Gries NC, Moore RJ, Fraser RD, Vernon-Roberts B. Calcium pyrophosphate dihydrate deposition in degenerate lumbar discs. Eur Spine J 1998 7:45–9.
crossref pmid pmc pdf
3. Ellman MH, Vazques LT, Brown NL, Mandel N. Calcium pyrophosphate dihydrate deposition in lumbar disc fibrocartilage. J Rheumatol 1981 8:955–8.
pmid
4. Yayama T, Kobayashi S, Sato R, et al. Calcium pyrophosphate crystal deposition in the ligamentum flavum of degenerated lumbar spine: histopathological and immunohistological findings. Clin Rheumatol 2008 27:597–604.
crossref pmid pdf
5. Markiewitz AD, Boumphrey FR, Bauer TW, Bell GR. Calcium pyrophosphate dihydrate crystal deposition disease as a cause of lumbar canal stenosis. Spine (Phila Pa 1976) 1996 21:506–11.
crossref pmid
6. Fujishiro T, Nabeshima Y, Yasui S, Fujita I, Yoshiya S, Fujii H. Pseudogout attack of the lumbar facet joint: a case report. Spine (Phila Pa 1976) 2002 27:E396–8.
crossref pmid
7. Namazie MR, Fosbender MR. Calcium pyrophosphate dihydrate crystal deposition of multiple lumbar facet joints: a case report. J Orthop Surg (Hong Kong) 2012 20:254–6.
crossref pmid
8. Gadgil AA, Eisenstein SM, Darby A, Cassar Pullicino V. Bilateral symptomatic synovial cysts of the lumbar spine caused by calcium pyrophosphate deposition disease: a case report. Spine (Phila Pa 1976) 2002 27:E428–31.
crossref pmid
9. Lee J, Cho KT, Kim EJ. Cauda equina syndrome caused by pseudogout involving the lumbar intervertebral disc. J Korean Med Sci 2012 27:1591–4.
crossref pmid pmc
10. DeSouza RM, Uff C, Galloway M, Dorward NL. Spinal epidural hematoma caused by pseudogout: a case report and literature review. Global Spine J 2014 4:105–8.
crossref pmid
11. Delamarter RB, Sherman JE, Carr J. Lumbar spinal stenosis secondary to calcium pyrophosphate crystal deposition (pseudogout). Clin Orthop Relat Res 1993 289:127–30.
crossref
12. Sadique T, Bradley JG, Jackson AM. Central spinal stenosis due to pseudogout: a case report. J Bone Joint Surg Br 1994 76:672–3.
crossref pmid
13. Dehais J. Central spinal stenosis due to pseudogout. J Bone Joint Surg Br 1995 77:335.
crossref
14. Drouillard PJ, Mrstik LL. Lumbar spinal stenosis associated with hypertrophied ligamentum flavum and calcium pyrophosphate crystal deposition. J Am Osteopath Assoc 1988 88:1019–21.
pmid
15. Jirarattanaphochai K, Jung S, Sumananont C, Saengnipanthkul S. Reliability of the medical outcomes study short-form survey version 2.0 (Thai version) for the evaluation of low back pain patients. J Med Assoc Thai 2005 88:1355–61.
pmid
16. Sanjaroensuttikul N. The Oswestry low back pain disability questionnaire (version 1.0) Thai version. J Med Assoc Thai 2007 90:1417–22.
pmid
17. Mahmud T, Basu D, Dyson PH. Crystal arthropathy of the lumbar spine: a series of six cases and a review of the literature. J Bone Joint Surg Br 2005 87:513–7.
crossref pmid


ABOUT
ARTICLE CATEGORY

Browse all articles >

BROWSE ARTICLES
EDITORIAL POLICY
FOR CONTRIBUTORS
Editorial Office
Department of Orthopedic Surgery, Uijeongbu St. Mary’s Hospital, College of Medicine, The Catholic University of Korea,
271 Cheonbo-ro, Uijeongbu 11765, Korea
Tel: +82-31-820-3578    Fax: +82-31-847-3671    E-mail: spinepjb@catholic.ac.kr                

Copyright © 2020 by Korean Society of Spine Surgery. All rights reserved.

Developed in M2community

Close layer
prev next