Andersson lesions (AL) are rare destructive discovertebral lesions found in patients with
ankylosing spondylitis (AS), characterized by areas of bone destruction and sclerosis at the
vertebral endplates and intervertebral discs. ALs can be found in 85.5% of AS patients via
whole-spine MRI, but only identified at 37.5% with plain radiographs, suggesting an
underestimated true prevalence of these lesions [1]. ALs cause chronic pain, resulting in
significant reductions in quality of life. Management for ALs ranges from conservative
measures, including physiotherapy and pharmacological interventions, to surgical solutions
such as spinal instrumentation and fusion [2]. There is a notable gap in the literature
addressing alternative therapeutic options for patients with symptomatic ALs who fail
conservative treatment but are not candidates for surgery.

Our patient is a 59 year-old male with longstanding AS and worsening ten-year history of mid-
thoracic, lumbar, and sacral pain. Prior medical treatments included physiotherapy and opioids
with minimal relief. Sacral pain improved with sacroiliac joint injections and medial branch blocks.
AS was managed w/ methotrexate, etanercept, and leflunomide. Initial bone scan showed
increased signaling at antero-superior corner of T8 body, with repeat scans showing T8-9 edema,
possibly a spinal hemangioma. Due to complicated atypical tuberculosis cellulitis, biologics were
discontinued, resulting in thoracic pain refractory to strong opioid use. Repeat CT showed
luceny/erosion at inferior endplate of T7. US Guided T7-T8 erector spinae block provided
moderate relief while biologics were held during antibiotic therapy. After adalimumab was
resumed, left paramedial T6-T7 epidural steroid injection provided 90% relief. In follow up MRI,
resolution of T7 edema was noted with chronic Schmorl’s node formation, indicating lesion was
likely an undiagnosed AL.

A systematic literature search was conducted across four databases (PubMed, Scopus, Embase, CENTRAL) and supplemented by manual citation review, in accordance with the Arksey-O’Malley scoping review framework.[4] A Boolean search strategy was used, incorporating a variety of keywords and subject headings relating to pain/VR/gaming. Eligible studies featured (1) primary peer-reviewed research (conference papers included), (2) adult or pediatric patients undergoing medical procedures or diagnosed with acute pain conditions based on ICD-10 criteria, (3) pain-related primary outcomes, (4) use of an HMD to deliver immersive VR, and (5) gamified VR interventions (defined as having in-game objectives along with interactivity beyond passive 360° viewing). Given that VR gaming for pain management is an emerging topic, both experimental and observational studies were considered. Screening was performed on Rayyan, eligible articles exported to Zotero, and extracted data synthesized in tabular form.

AS complicated by ALs is an under-diagnosed condition that can significantly impact patients’
quality of life. Currently researched treatment options overlook other interventions for pain
relief beyond pharmacotherapy, conservative treatment, and surgical intervention. We
present a case where ESP and ESI provided greater than 1 year of 60-90% relief for a patient
with a history of ineffective conservative and pharmacologic treatment that was not an
appropriate surgical candidate. This successful intervention offers a potential treatment
options for clinicians managing thoracic pain caused by AS complicated by ALs, underscores
the need for further awareness and research of AL management.

In patients with AS complicated by ALs, timely diagnosis and appropriate management are
crucial to improving outcomes and quality of life. This case highlights the potential role of
epidural steroid injections as a bridge for acute pain relief when conservative measures fail,
and surgical interventions are not feasible. Further research is needed to validate the efficacy
of ESIs and refine pain management guidelines for this challenging condition.