Multilevel “fish-vertebra” sign in a patient with idiopathic
“Fish-vertebra” is an uncommon deformity of vertebral body shape, consisting of central depression of the superior and inferior surfaces of vertebral bodies. It is characteristic in idiopathic osteoporosis and can help in the differential diagnosis of other conditions, such as osteomalacia, hyperparathyroidism, sickle cell disease, Paget disease, and multiple myeloma.

A 46-year-old man with a low back pain for over a year who was initially treated with analgetics, modification on daily activities, and physical therapy protocols presented in our department. The patient was a manual worker, without prior traumatic medical experience and medication history. The pain had increased during the last 4 weeks without any remarkable improvement after a combination of analgetics and opioid drugs. His pain was more intense when bending forward and was relieved on recumbent position. Neurovascular examination was normal.

His blood test investigation at the admission site was normal. Thoracolumbar plain radiograph revealed a symmetrical biconcave deformity of the vertebral bodies from T12 to L5. Magnetic resonance imaging (MRI) of the thoracolumbosacral spine confirmed the “fish-vertebra” sign of the lumbar vertebral bodies. Dual-energy X-ray absorptiometry (DEXA) revealed a T-score of ?3.9 at the spine. The patient underwent kyphoplasty, and he went home the following day. Biopsies from vertebral bodies were negative for malignancy, and the diagnosis of idiopathic osteoporosis was made. The patient was treated with teriparatide. After 1-year follow-up, the patient was almost pain-free and had returned back to his work.

This case describes the “fish-vertebra” in a patient with idiopathic osteoporosis. Detailed history, clinical examination, and radiological imaging are mandatory to establish diagnosis and facilitate differential diagnosis with various conditions, such as osteoporosis, osteomalacia, hyperparathyroidism, Paget disease, sickle cell disease, multiple myeloma, and systemic lupus erythematosus.