Medical Imaging Analysis Report

I. Radiological Findings

Based on the provided lumbar spine and sacroiliac joint CT and MRI images, the following features are observed:

• On the lateral and axial CT images of the lumbar region, there is local bony destruction or erosion-like change in the sacroiliac joint, showing relatively clear but irregularly shaped bone defects.
• CT-guided puncture images indicate that the needle has entered the suspected lesion area, suggesting local sampling or biopsy was performed.
• MRI T1 and T2 sequences show a soft tissue mass signal around the sacroiliac joint with relatively clear margins, without obvious vertebral collapse or significant spinal canal stenosis.
• Pathological specimens (histological images) show a large amount of aggregated material and inflammatory cell infiltration, consistent with tophus structure (urate crystal deposits).

Overall, the lesions indicated by the imaging are mainly located at the sacroiliac joint, accompanied by local bony erosion, possible soft tissue mass, and pathologically confirmed urate crystal deposition.

II. Potential Diagnosis

Based on the imaging findings and the patient’s medical history, the following diagnoses are considered:

1. Sacroiliac gouty arthritis (axial gout)
   Reason: The patient has clear risk factors for gout, such as hyperuricemia, chronic kidney disease, and long-term corticosteroid use. Gout involving the sacroiliac joint can occur. The irregular bony erosions on imaging and the pathology results indicating urate crystals both support a diagnosis of gout.
2. Sacroiliac joint infection (e.g., septic arthritis or sacroiliac osteomyelitis)
   Reason: Infection can also cause sacroiliac joint lesions, characterized by bony destruction and abnormal surrounding soft tissue. However, this patient’s symptoms are not typical, and laboratory tests (e.g., white blood cell count, inflammatory markers such as CRP) are essentially normal, making infection less likely.
3. Other inflammatory diseases of the sacroiliac joint (e.g., ankylosing spondylitis)
   Reason: Ankylosing spondylitis can involve the sacroiliac joint, typically in a bilateral and symmetrical manner, often with clinical restriction of low back movement. This patient does not exhibit significant symptoms, and the imaging findings more likely suggest focal gouty tophi.

III. Final Diagnosis

Taking into account the patient’s past medical history (hyperuricemia, kidney disease, use of immunosuppressants), imaging findings (sacroiliac joint bony erosion and soft tissue lesion), and pathological results (urate crystal deposits in the tissue), the most likely diagnosis is:

Gouty arthritis of the sacroiliac joint (axial gout).

IV. Treatment Plan and Rehabilitation

Based on the patient’s diagnosis and current clinical status (no significant symptoms or functional impairment), the following treatment and rehabilitation measures are recommended:

1. Conservative Pharmacological Treatment
   • Uric acid control: Utilize allopurinol or febuxostat to lower serum uric acid levels and maintain them within a reasonable range.
   • Anti-inflammatory and analgesic therapy: For acute attacks or localized pain, short-term use of NSAIDs (if renal function permits) or low-dose glucocorticoids can be considered.
   • Adjustment of existing medications: Consider reducing medications that may elevate uric acid levels or collaborate with nephrology/endocrinology to optimize the therapeutic regimen.
2. Nutrition and Lifestyle Management
   • Diet modification: Reduce high-purine foods (e.g., organ meats, seafood), increase intake of fruits, vegetables, and low-fat dairy products.
   • Weight control: If body mass index is high, weight reduction under the guidance of nutrition and exercise rehabilitation specialists is advised.
   • Avoid or limit alcohol: To prevent further increases in uric acid levels.
3. Rehabilitation Training and Exercise Prescription
   • General Principle: A gradual, individualized approach following the FITT-VP principle (Frequency, Intensity, Time, Type, Progression, Volume, and Pattern).
   • Initial Phase (Low Intensity):
     • Frequency: 3 times per week, on alternate days.
     • Intensity: Low-intensity aerobic activities, such as walking on level ground or stationary cycling, 15–20 minutes each time, maintaining heart rate at 40%–50% of the maximum.
     • Time: No more than 30 minutes per session to avoid excessive load.
   • Intermediate Phase (Moderate Intensity):
     • As the body adapts, gradually increase walking duration to 30–40 minutes and slightly raise the intensity to 50%–60% of the maximum heart rate.
     • Light strength training can be introduced, such as basic equipment exercises targeting core and lower limb muscles.
   • Later Phase (Further Enhancement):
     • If well tolerated, gradually progress to moderate-to-high intensity exercise (heart rate up to 60%–70% of maximum), with exercise duration extended to 40–60 minutes, 3–5 times per week.
     • Emphasize joint protection to avoid excessive weight-bearing movements, such as deep squats or high-impact running and jumping.
   • Note:
     • Patients with renal or cardiopulmonary impairments should be closely monitored by professionals, and parameters such as heart rate, blood pressure, and respiratory rate may be evaluated as needed.
     • If joint pain worsens or an acute gout attack occurs, promptly suspend or adjust the exercise regimen and seek medical evaluation.
4. Surgical Indications

   If severe nerve compression or significant joint damage with intractable pain is present, surgical intervention may be considered. Since this patient does not currently exhibit severe pain or neurological symptoms, surgery is not recommended.

V. Disclaimer

This report is based solely on the provided medical history and imaging data and serves as a preliminary analysis. It does not replace an in-person clinical diagnosis or professional medical advice. Should any questions or changes in condition arise, please seek further evaluation at a licensed medical institution in a timely manner.