Pain
Samantha P. Kultgen, MD
Resident Physician
University of Wisconsin
Middleton, Wisconsin, United States
Sandip Biswal, MD
Professor of Radiology
University of Wisconsin
Madison, Wisconsin, United States
Michael Suer, MD
Vice Chair of PM&R
University of Wisconsin
Madison, Wisconsin, United States
Samantha Kultgen, MD
University of Wisconsin
Middleton, Wisconsin, United States
A 15-year-old girl with no significant past medical history presented to her pediatrician’s office with a nine-month history of low back pain that radiated up to her mid to upper back that began upon returning to sports after a period of time off due to the COVID pandemic. She had minimal relief with conservative management, including ibuprofen, acetaminophen, physical therapy, osteopathic manipulative therapy, and massage therapy, and initial x-rays and MRI were unrevealing. Fluorine-18 fluorodeoxyglucose (18F-FDG) PET/MRI identified multiple potential pain generators, including the lumbar interspinous ligament and the left T12 costovertebral joint. She underwent corticosteroid injections in the L1-2, L3-4, and L4-5 interspinous ligaments and later in the left T12 costovertebral joint with significant pain relief.
It has historically been very difficult to accurately and confidently identify causes of chronic neuropathic pain. In this case, we presented a 15-year-old girl with chronic mid and low back neuropathic pain. While there were known regions of pain on physical exam, MRI alone was unable to identify any structural abnormalities that could be contributing to pain. With the addition of PET to the MRI, areas of possible inflammation could be more closely analyzed on MRI. This, combined with a thorough pain history and physical exam, allowed for a determination of most likely pain contributors, including the lumbar interspinous ligaments and the left T12 costovertebral joint. This led to effective interventions in the form of steroid injections that provided substantial pain relief.
This case highlights that PET/MRI may be a helpful modality for identifying pain generators otherwise unidentified on traditional musculoskeletal imaging. Further research into the role of PET/MRI on chronic musculoskeletal pain is warranted to better define appropriate patient selection and interventions.
