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P-065 - Avascular Necrosis of Hip confounding the clinical picture and treatment response of Lumbar Radiculopathy

POSTER ABSTRACT
Location:  Exhibit Hall

    Author/Presenter(s)

  • KA

    Kavya Arvind, BBA, MHA

    Kavya Arvind
    Touro University College of Osteopathic Medicine
    Dallas, Texas

  • JZ

    Jeff Zhao, DO

    Physician Mentor
    Dallas Orthopedic & Shoulder Institute
    Dallas, Texas

  • LP

    Lisa Patino, LVN

    Research Coordinator and Office Manager
    Cardinal Pain Center
    Dallas, Texas

Abstract Title: Avascular Necrosis of Hip confounding the clinical picture and treatment response of Lumbar Radiculopathy

Background:

67 yo Caucasian Male presented to primary care physician and interventional pain physician with complaints of severe left -sided hip, bilateral leg and back pain for the past 2 years. Pain progressed despite usage of NSAIDs and acetaminophen. Patient denied chronic tobacco, alcohol use. He does have a history of one time use of medrol dose pack for 5 days during the year that he was suffering from back pain and hip pain. He does have a history of Rheumatoid and Psoriatic arthritis but has not had long term use of steroids. In addition his history was notable for 5 different episodes of repeated COVID-19 infections since 2020.



He has received 2 initial and booster dose of COVID-19 vaccine in 2021.



MRI of Lumbar spine revealed severe Facet arthritis, Spinal stenosis at multiple levels including l45 and l5s1 where the central stenosis at 6mm and severe stenosis at bilateral l5 nerve root.



He underwent Epidural steroid injections and physical therapy with limited relief; A repeat MRI of the Lumbar spine and pelvis revealed severe Avascular necrosis of the hips. The left hip avascular necrosis worse than the right side. The patient was referred to an orthopedic surgeon for hip replacement.

Purpose/Objectives: Avascular necrosis (AVN) is a joint disease caused by inadequate subchondral blood circulation in the bone leading to degeneration and collapse of the joint. AVN can be caused by traumatic or non-traumatic causes including autoimmune diseases, corticosteroid use, alcohol or tobacco use disorder, sickle cell disease, or other myeloproliferative disorders to name a few (1,2). In addition, the hypercoagulable state induced by COVID-19 infection can lead to thrombosis and ischemia of the bone (3). While concomitant steroid use can increase the risk of avascular necrosis, severe COVID-19 infections can predispose patients to a hypercoagulable state which could serve as an impetus for the compromised vascular supply to the joint (1,2,4,5).

The endothelial cell inflammation and injury result in widespread vasculitis, tissue hypoperfusion, thrombosis of the blood vessels which manifests in the long term sequelae of the COVID-19 disease (7). Avascular necrosis of joints, if misdiagnosed, could lead to severe complications.




Methods: The endothelial cell inflammation and injury result in widespread vasculitis, tissue hypoperfusion, thrombosis of the blood vessels which manifests in the long term sequelae of the COVID-19 disease (7). Avascular necrosis of joints, if misdiagnosed, could lead to severe complications and joint collapse.


Results: Avascular necrosis (AVN), also known as osteonecrosis, is a joint disease caused by inadequate subchondral blood circulation in the bone leading to degeneration and collapse of the joint. AVN can be caused by traumatic or non-traumatic causes including autoimmune diseases, corticosteroid use, alcohol or tobacco use disorder, sickle cell disease, or other myeloproliferative disorders to name a few (1,2). In addition, the hypercoagulable state induced by COVID-19 infection can lead to thrombosis and ischemia of the bone (3). While concomitant steroid use can further increase the risk of avascular necrosis, severe COVID-19 infections can predispose patients to a hypercoagulable, vasculitic state which could serve as an impetus for the compromised vascular supply to the bony joint (1,2,4,5).

Conclusions/Implications for future research and/or clinical care: While all physicians need to be aware of potential post-COVID-19 compilations, orthopedic surgeons and pain management physicians play a unique role in early diagnosis and treatment of avascular necrosis of different joints. MRI of the affected joints remains the gold standard for diagnosis of avascular necrosis of bone (8,9). Early diagnosis and treatment of these complications will help to reduce morbidity and mortality in patients.

References: 1.Lafforgue P. Pathophysiology and natural history of avascular necrosis of bone. Joint Bone Spine. 2006 Oct 1;73(5):500–7.

2. Shah KN, Racine J, Jones LC, Aaron RK. Pathophysiology and risk factors for osteonecrosis. Curr Rev Musculoskelet Med. 2015 Jul 5;8(3):201–9.

3. Greistorfer T, Jud P. Clinical characteristics of COVID-19 associated vasculopathic diseases. Thromb J. 2023 May 25;21(1):61.

4. Maronese CA, Zelin E, Avallone G, Moltrasio C, Romagnuolo M, Ribero S, et al. Cutaneous vasculitis and vasculopathy in the era of COVID-19 pandemic. Front Med. 2022 Aug 23;9:996288.

5. Becker RC. COVID-19-associated vasculitis and vasculopathy. J Thromb Thrombolysis. 2020 Oct;50(3):499-511.

6. Agarwala SR, Vijayvargiya M, Pandey P. Avascular necrosis as a part of “long COVID-19.” BMJ Case Rep. 2021 Jul 2;14(7):e242101.

7. Parikh S, Gomez O, Davis T, Lyon Z, Corces A, Parikh S, et al. Avascular Necrosis as a Sequela of COVID-19: A Case Series. Cureus [Internet]. 2023 Feb 23 [cited 2024 Jan 21];15(2).

8. Imhof H, Breitenseher M, Trattnig S, Kramer J, Hofmann S, Plenk H, et al. Imaging of avascular necrosis of bone. Eur Radiol. 1997 Mar 1;7(2):180–6.

9. Manenti G, Altobelli S, Pugliese L, Tarantino U. The role of imaging in diagnosis and management of femoral head avascular necrosis. Clin Cases Miner Bone Metab. 2015;12(Suppl 1):31–8.