Interventional Spine

Stuart R Pomerantz, M.D.
Bradley Buchbinder , M.D., Non ASSR Member
Joshua A. Hirsch , M.D>, ASSR Member

Excerpta

A 46 year old male presented with 10 days of progressively severe four-extremity weakness. He was found on MRI to have diffuse non-enhancing T2-hyperintense expansion of the cervical spinal cord. The differential diagnosis included infiltrative neoplasm as well as inflammatory etiologies such as transverse myelitis, infection and demyelinating disease. The neuroradiology service was asked to perform cerebrospinal fluid (CSF) sampling at a level cephalad to the lesion as the expansion had resulted in complete spinal block placing the patient at risk of herniation with lumbar puncture. Unfortunately, the typically safe location for high CSF sampling in the posterior C1-2 subarachnoid space was also too narrowed by cord expansion to attempt needle entry.

Collection of CSF by suboccipital puncture of the Cisterna Magna is only rarely performed currently. Though the size of the cistern is typically larger than the posterior subarachnoid space at the C1-2 level, it is a less favored site due to the relatively higher risk of encountering anomalous vessels and risking hemorrhagic or ischemic complications. When the procedure is necessary, as in this case, it is typically performed under fluoroscopic guidance using standard osseous landmarks. However, close examination of the vascular flow-void pattern in this patient’s sagittal T2-weighted MRI images revealed an extradural origin of the PICA from the right vertebral artery. As is typical for this uncommon variant, the right PICA coursed postero-medially and would be along the expcted midline needle trajectory utilized in the fluoroscopic approach to cisternal puncture.

Utilizing CT-guidance with concurrent intravenous contrast administration, the course of the anomalous PICA as well as the posterior aspect of the medulla were adequately visualized. A safe approach tailored to this patient’s particular anatomy was planned and the procedure successfully performed without complication. Final diagnsis is still pending at this time.

As cisternal puncture under CT guidance has, to our knowledge, not been described previously, several interesting technical issues arose in procedure planning and merit further discussion. Anatomic features such as the known propensity in this region for marked tenting of the dura and the requirement for a large CSF sample weighed heavily on the optimal choice of spinal needle. There are opposing risks and benefits with employing a large or small gauge needle or one with an atraumatic "pencil-point" tip versus a cutting bevel. The vascular variants encountered in this region will be disccused as well as additional planning issues such as ideal rate of IV contrast injection, patient positioning, and trajectory planning.

References

1. Ward E, et al. "Anatomic Evaluation of Cisternal Puncture" NEUROSURGERY 1989; 25(3): 412-415.
2. Portela LAP, et al. "Laceration of the Posterior Inferior Cerebellar Artery by Suboccipital Puncture of the Cisterna Magna" ARQ NEUROPSIQUIATR 2004; 62(3-B): 882-884.
3. Fine AD, et al. "Microsurgical Anatomy of the Extracranial-Extradural Origin of the Posterior Inferior Cerebellar Artery" J NEUROSURG 1999; 91: 645-652.
4. Macchi V, et al. "The Course of the Posterior Inferior Cerebellar Artery May be Related to its Level of Origin" SURG RADIOL ANAT 2004; 26: 60-65.
5. Heavner JE, et al. "Sharp Versus Blunt Needle: A Comparative Study of Penetration of Internal Structures and Bleeding in Dogs" PAIN PRACTICE 2003; 3(3): 226-231.
6. Fettes PDW, Wildsmith JAW. "Somebody Else’s Nervous System" BR J ANAESTH 2002; 88(6): 760-763.

Images

General Spine

Carmen L. Anderson, MD
Gregg H Zoarski , MD, ASSR Member

Excerpta

Coccidioidomycosis is a fungal infection with has regional predilection, affecting those in the southwestern United States, Central America, and South America. In all cases of coccidioidomycosis, dissemination occurs in 0.5%. Disseminated coccidioidomycosis with central nervous system manifestations is even more uncommon. Involvement of the spine is exceedingly rare, occurring in only 25% of those with disseminated disease. "Typical" radiological findings of coccidioidal spondylitis have been reported to include preservation of the intervertebral disk spaces, involvement of the vertebral bodies, and paraspinal soft tissue masses without gibbous deformity of the spine. We report a case of coccidioidal spondylitis with emphasis on its unusual imaging presentation in the spine. Plain radiographs and MR imaging in this patient demonstrated an unusual radiographic presentation of vertebral osteomyelitis with loss of the intervertebral disk spaces, prevertebral and paravertebral abscesses with epidural extension, and seeding of the spinal cord is illustrated.

General Spine

Christopher K Moses, MD
Jayne Seekins , DO, Non ASSR Member
Abbie Cluver , MD, Non ASSR Member
Zoran Rumboldt , MD, Non ASSR Member
Nada Besenski , MD, Non ASSR Member

Excerpta

A 19-year-old white male presented in the summer of 2003 with episodic, debilitating headaches starting after severe dehydration requiring IV rehydration. The headaches were worse in the morning and with sneezing or coughing. MR imaging showed small caliber transverse venous sinus thrombosis left worse than right and lumbar puncture demonstrated an increased opening pressure of 50 cm water. He was started on anticoagulation and was discharged. He then returned soon after for worsening headaches and was found to have papilledema bilaterally. Cranial nerves were intact. On catheter venogram no clot or stenosis was found; therefore, anticoagulation was stopped. All of the patient�s serum and CSF blood work was negative except for hypercellular, predominantly monocytic cells, with no malignant cells, suggesting aseptic meningitis. The patient had intermittent lumbar punctures for symptom relief. Repeat MRI demonstrated increased T1 signal intensity and diffuse thickening and contrast enhancement of the leptomeninges. The patient presented to a different institution for a second opinion and developed a third nerve palsy for which a VP shunt was placed.

After discharge he developed bilateral, left worse than right lower extremity paresis. The patient then went to another institution for a third opinion. Neuroaxis imaging was repeated and demonstrated abnormal leptomeningeal thickening and contrast enhancement within majority of the spinal cord (Images 1 and 2). The patient underwent a laminectomy from T12-L1 and biopsy was negative for all fungal, bacterial, viral and acid fast tests. Pathology showed pleomorphic cells with large hyperchromatic irregular nuclei that were GFAP immunostain positive, and the patient was diagnosed with a malignant neoplasm with glial differentiation consistent with leptomeningeal gliomatosis (Images 3 and 4). The patient was started on Temozolomide and radiation therapy for a total of 37.5 GyTD/15fx. The patient then developed near total bilateral lower extremity plegia. He had urinary retention, but no bowel dysfunction. He reported pain in the lower back and legs. Upper extremity function was normal. There was sensory level at T12. Two weeks later the patient presented with new onset tonic-clonic seizures. Brain MR imaging was consistent with posterior reversible encephalopathy and no change in the meningeal gliomatosis. The patient was placed on Dilantin, and there have been no further seizures. The clinical condition has progressed to decreased perianal sensation but maintains the urge to defecate. He no longer has headaches but at times has diplopia. Interval repeat MRI of the neuroaxis demonstrates decrease in overall leptomeningeal nodularity. The patient has been placed on a decadron and Temozolomide taper.

Primary diffuse leptomeningeal gliomatosis (PDLG) is a rare fatal neoplastic syndrome characterized by widespread infiltration of the meninges by tumor apparently arising from heterotopic glial nests, but without evidence of tumor within the brain or spinal cord. Heterotopic glial nests occur in the subarachnoidal space in about 1% of unselected necropsies, most often affecting medulla (57%), and with a higher incidence (25%) in patients with congenital malformation of the nervous system (1,2,3).

Heterotopic cell nests in the leptomeninges can cause a clinical picture similar to chronic infectious meningitis (4,5). Headache, papilledema, neck stiffness, back pain, paresthesia, lower extremity paresis and incontinence are common symptoms. Negative cytology is a common finding in PDLG, while in secondary gliomatosis cytology is often an aid in diagnosing the etiology.

On imaging, diffuse, or less commonly, nodular meningeal enhancement involving brain, spinal cord and cauda equina with clumped nerve roots is common (3,4,6). Differential diagnosis of clumped nerve roots includes primary brain tumor (ependymoma, medulloblastoma), arachnoiditis, infection (TB, CMV, HIV, Brucellosis, and Rocky Mountain spotted fever), lymphoma, sarcoid and Dejerine-Sottas disease. Leptomeningeal gliomatosis may also simulate occlusive vasculopathy such as multifocal infarcts and cerebral vasculitis

This case serves as a reminder that diffuse leptomeningeal thickening of a glial nature can occur in the absence of a primary intra-axial tumor. The diagnosis of PDLG should be applied only when no other primary tumor is found. PDLG should not be confused with much more often occurring secondary meningeal gliomatosis due to primary CNS tumors, primary CNS lymphoma, or any other disease which may present with clumped nerve roots on imaging.

References

1. Cooper IS, Kernohan JW. Heterotopic nests in the subarachnoid space: histologic characteristics, mode of origin and relation to meningeal gliomas. J Neuropathol Exp Neurol 1951;10:16-21
2. Barborie A, Dunn EM, and Bridges LR, et al. Primary Diffuse leptomeningeal gliomatosis predominantly affecting the spinal cord: case report and review of the literature. J Neurol Neurosurg Psychiatry 2001;70:256-258
3. Kastenbauer S, Danek A, Klein W, et al. Primary diffuse leptomeningeal gliomatosis: unusual MRI with non-enhancing nodular lesions on the cerebellar surface and spinal leptomeningeal enhancement. J Neurol Neurosurg Psychiatry 2000;69:385-388
4. Ho KL, Hoshner SA, Wolfe DE. Primary leptomeningeal gliomatosis symptoms suggestive of meningitis. Arch Neurol 1981;38:662-666
5. Rees JH, Balakas N, Agathonikou A, et al. Primary diffuse leptomeningeal gliomatosis simulating tuberculous meningitis. J Neurol Neurosurg Psychiatry 2001;70:120-122
6. Pingi A, Trasimeni G, Di Biasi C, et al. Diffuse leptomeningeal gliomatosis with osteoblastic metastases and no evidence of intraaxial lesions. AJNR 1995;16:1018-1020

Images

General Spine

Abbie J Cluver, M.D.
Timothy Smith , M.D., Non ASSR Member
Jayne Seekins , M.D., Non ASSR Member
Christopher Moses , M.D., Non ASSR Member
Nada Besenski , M.D. Ph.D., Non ASSR Member
Zoran Rumboldt , M.D., ASSR Member

Excerpta

A 66-year-old man with history of hyperuricemia and multiple gout flare-ups in both feet presented with complaints of back pain radiating to the right chest, unsteady gait, and intermittent burning sensation in both feet, worse on the right. There were no bowel or bladder symptoms. The physical examination revealed mild ataxia and posterior column deficits with normal strength in the upper and lower extremities and normal deep tendon reflexes. There was a sensory level deficit consistent with a mid-thoracic lesion.
Radiographs of the thoracic spine demonstrated effacement of the T6 pedicle on the right (Image 1). MR imaging showed a mass of low T1 and T2 signal (Images 2 and 3) with homogenous contrast enhancement that involved the right side of T6 vertebral body with extension into enlarged right pedicle and transverse process and facet joint. An extradural intracanalicular portion of the mass that was compressing the spinal cord at T5-6 level (Images 2 and 3). There was also involvement of the paraspinal muscles and of the right sixth rib. The findings were thought to be consistent with an invasive lesion, likely a metastatic tumor.
T5 and T6 laminectomies were performed followed by excision of the right-sided intracanalicular extradural portion of the lesion at T6 that measured 4.3×3.5×1.0 cm. Intraoperative frozen specimens confirmed that the lesion was caused by calcium pyrophosphate dihydrate (CPPD) deposition disease with involvement of the ligamentum flavum, which is better seen on permanent slides (Image 4). The excised specimen also revealed characteristic birefringent crystals on polarized-light microscopy. The diagnosis of pseudogout was made and further dissection of the soft tissue mass from the facet joint was discontinued. The patient did well post-operatively and was discharged two days following surgery.

CPPD deposition disease or pseudogout is the most common crystalline arthropathy and can manifest in many clinical forms. The presentations can range from asymptomatic to severe pain with marked joint and bone destruction. CPPD crystals can deposit in fibrocartilage, hyaline cartilage and within other soft tissues, mimicking gout, septic joints, and other arthropathies. Pseudogout of the spine is often asymptomatic, but it may cause vertebral body destruction, severe sclerosis of the bone and disc space narrowing. Deposition of CPPD crystals into the ligamentum flavum and posterior longitudinal ligament is a rare but known cause of spinal cord compression and myelopathy of insidiouds onset. The involved ligament is characteristically thickened, of low to intermediate signal on both T1 and T2-weighted MR images, characteristically calcified on CT, due to massive focal deposition of CPPD crystals. We are, however, not aware of any described cases where CPPD crystal deposits in the ligamentum flavum caused frank lytic lesions of the adjacent bone with extension into the soft tissues, simulating an aggressive neoplasm.

References

1. Steinbach L. Calcium pyrophosphate dihydrate and calcium hydroxyapatite crystal deposition diseases: imaging perspectives. Radiol Clin N Am 2004;42:185-205

2. Muthukumar N, Karuppaswamy U. Tumoral calcium pyrophosphate dihydrate deposition disease of the ligamentum flavum. Neurosurgery 2003;53:103-8

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General Spine

Zoran J Rumboldt, M.D.
Cynthia A Welsh , M.D., Non ASSR Member
Suhas Pai , M.D., Non ASSR Member

Excerpta

A 47-year-old female presented with a 2-year history of truncal and lower extremity weakness and paresthesias, bowel and bladder incontinence and increased reflexes in her lower extremities. The symptoms almost completely resolved after a year, but then started progressing during the past month. MR imaging demonstrated an anterior extramedullary mass of low T1 and T2 signal extending from T1 to T6 (Image 1 and 2). The lesion compressed the spinal cord and showed strong predominantly peripheral contrast enhancement (Image 3). Following T1 to T6 laminectomy, an induration of the dura was found intraoperatively. Multiple biopsy specimens were taken and demonstrated chronic dural inflammation with dense collagen fibers and lymphoplasmacytic infiltrate on histology.
A 68-year-old female presented with a 2-month history of progressive lower extremity weakness and urinary retention, decreased sensation in lower extremities bilaterally and a poor rectal tone. MR imaging showed an enhancing mass compressing the spinal cord, hypointense on T2 and isointense on T1-weighted images. The lesion was anteriorly located at C3 and C4, and encompassing the cord from C5 to T2 levels. After C6-C7 laminectomy, a large amount of thickened ligament, dura, and granular epidural tissue were evacuated from the epidural space. Histology demonstrated chronic inflammatory reaction with xanthomatous inflammation.

Idiopathic hypertrophic pachymeningitis (IHP) is an uncommon entity, which usually affects cranial meninges. It is a fibrosing inflammatory process that thickens the dura mater that is considered when no identifiable cause is found and exact etiopathogenesis is still unknown.

The spinal form is extremely rare with only a handful of cases described, none in radiological literature. It presents as a chronic progressive disease with manifestations of radiculopathy, myelopathy or a combination of the two. It either occurs alone or as a craniospinal form, usually involving the cervical and thoracic dura.

The lesions on MR images are typically hypointense on both T1 and T2-weighted images and show uniform dense enhancement of the thickened meninges. Two patterns of enhancement have been described, with linear form showing better therapeutic response compared to nodular form, possibly related to less fibrosis and more vascularity.

These findings may simulate menigioma, lymphoma, tuberculosis, and sarcoidosis, while an association with Wegener’s granulomatosis has been found in some cases. It has been also proposed that Tolosa-Hunt syndrome and IHP may represent the same entity.

Surgical decompression provides relief, while steroid therapy has been considered the mainstay of therapy in this disease, and azathioprine and cyclophosphamide have been tried.

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General Spine

Jamie L Baisden, MD
Guillermo Carrera , MD, ASSR Member
Brain Bunch , MD, Non ASSR Member
Kim Rickert , MD, Non ASSR Member
Vladimir Osipov , MD, Non ASSR Member

Excerpta

Aseptic vertebral body osteonecrosis or Kummell-Verneuli’s disease is an uncommon entity. Spinal cord injury attributed to Kummell’s disease is even more rare. Kummel’s disease is more commonly a radiographic diagnosis based on collapse or flattening of one or more vertebrae with associated intravertebral vacuum cleft. It is often associated with severe osteoporosis, chronic long-term corticosteroid therapy, and a history of trauma. Nontraumatic vertebral collapse is often more commonly associated with malignancy or osteomyelitis.

We present a case of a 77 yo afroamerican female who presented with pectoral and epigastric chest pain neurologically intact. A helical CT demonstrated an acute pulmonary embolosm and a destructive lesion of the T6 vertebrae. The patient developed a rapidly progressive paraparesis resulting in complete T6 pareplegia within 3 days of the initial CT. Metastatic workup included spinal MRI, CT, plain films, bone scan, CXR,laboratory studies, and a CT of the chest abdomen and pelvis. Only the T6 osteolytic lesion with adjacent pre- and paravertebral reactive tissue was identified. CT-directed needle biopsy was nondiagnostic. Cultures revealed no growth. Thoracic laminectomy and open biopsy provided pathologic conformation of vertebral osteonecrosis with no evidence of malignancy.

We present this case to review the radiologic and pathologic findings of vertebral osteonecrosis resulting in spinal cord injury.

Images

General Spine

Peter x Kalina, MD

Excerpta

A 59-year-old female presented with a long history of progressing low back pain. It was made worse with prolonged standing and walking. The pain initially involved the back with radiation to the right groin. Lately, it was worse on the left with involvement of the posterior thigh and calf, greater on the left. It was worse with extension. Facet and sacroiliac injections had provided only short lasting relief.

MRI revealed large bilateral L4-5 synovial cysts resulting in significant central spinal canal stenosis.
The cysts were surgically excised and the patient’s symptoms significantly improved.

Synovial cysts of the spine are typically unilateral in the lower lumbar region (especially L4-5). They develop as a result of facet degenerative disease and excessive joint motion. The clinical differential diagnosis includes other etiologies producing symptoms and signs of nerve root/thecal sac compression, especially disk herniation. Surgical cyst resection is usually limited to patients who fail conservative measures including rest and intra-articular injections.

Bilateral lumbar synovial cysts are extremely rare with only a few reported cases in the literature.

General Spine

Peter x Kalina, MD
Norbert G Campeau , MD, Non ASSR Member

Excerpta

A 68-year-old man presented with progressive numbness and tingling in both legs, slowly progressing upward to lower abdomen. He had episodes of coldness or burning of his feet. His gait became increasing unsteady with occasional falls. Five years earlier he had a radical prostatectomy for prostate carcinoma. Physical exam revealed a sensory level just above the umbilicus level. There was marked loss of vibratory sensation in the lower limbs. MRI demonstrated an osseous lesion at T6 to T9 with associated epidural soft tissue mass and resultant cord compression. This was interpreted as metastatic diseases. Decompressive laminectomy with partial tumor resection was performed. Pathology revealed a benign hemangioma. Post-operative radiation was initiated. The patient made a significant neurologic recovery.

Asymptomatic intraosseous vertebral hemangiomas are common benign neoplasms. However, extraosseous extension of an aggressive vertebral hemangioma is a rare cause of thoracic spinal cord compression. In addition to CT and MRI, work-up may include angiography. Treatment options include surgery, radiation, embolization, vertebroplasty and sclerosis.

Interventional Spine

Suresh C Patel, M.D.
Horia Marin , M.D., Non ASSR Member
Todd Aho , M.D., Non ASSR Member
Sanders William , M.D., Non ASSR Member

Excerpta

Lumbar Arterial Venous Fistula and Pseudo Aneurysm
With Retroperitoneal Hematoma-A Complication of L3-L4 Disk Space Biopsy Procedure

1. Purpose:

Vascular injury is a rare adverse event for common spinal interventional procedures. This case reports a possible mechanism of rare complication of development of an arterial aneurysm and A-V fistula following disc space aspiration and biopsy.

2. Materials and Methods:

A 56 year old male with a history of aortic valve endocarditis and aortic valve replacement had a magnetic resonance imaging finding of diskitis/osteomyelitis L3-L4 which progressed despite anti bacterial therapy with a larger phlegmon and abscess formation. Patient underwent a disk space aspiration and bone biopsy at L3-L4 with a coaxial system using an 18 gauge needle, which was non-diagnostic. Repeat bone biopsy was attempted using a 14 gauge coaxial system. After the introduction of the trocar, a "brisk pulsatile" arterial blood flow was encountered. Procedure was terminated. Patient was observed for the next five days which showed a gradual drop of hemoglobin from 10 to 6 grams. The CT scan of abdomen showed a large left sided retroperitoneal hematoma. Selective angiography identified a pseudo aneurysm of the left third lumbar vertebral artery and the arterial venous fistula. Both the pseudo aneurysm and arterial venous fistula were successfully treated with combination of coiling and glue. Patient hemoglobin subsequently stabilized at 9.4 grams.

3. Discussion:

Traumatic arterial venous fistula and pseudo aneurysm of the spinal vertebral arteries are rare and infrequent complication for diagnostic and therapeutic spinal procedures with incidence of 1-5% reported for lumbar disc surgery. Exact incidence of vascular injury from percutaneous lumbar spinal procedures is not known. We believe that this complication occurred from an anatomic variant of the left third lumbar artery being a common large trunk for the 3rd, 4th and 5th lumbar arteries and larger cutting end of the trocar introducer. The large caliber of the main trunk of the left third lumbar artery was susceptible to this vascular injury and complication. It is advisable to closely monitor patients with serial hemoglobin measurements, possible CT scan of abdomen and diagnostic angiogram if arterial blood is encountered during spinal interventional procedures.

General Spine

Michael D Nelson, MD
Norbert Campeau , MD, Non ASSR Member

Excerpta

A nineteen year old female with a five-year history of back pain had undergone multiple MRI examinations of the cervical spine, which were interpreted as showing a mass expanding right C6-C7 neural foramen, presumed to represent a Neurofibroma. The patient was referred to our institution for a Neurofibromatosis workup. Repeat MRI of the cervical spine again demonstrated an abnormality involving the right C6-C7 neural foramen, however additional osseous abnormalities were noted involving the right C6-C7 facet joint. Follow up CT imaging of cervical spine was recommended, and this clearly demonstrated that all of the abnormalities were related to a chronic unilateral locked facet joint. Specifically, there was no evidence for a Neurofibroma. Our case illustrates that the diagnosis of unilateral locked facet may be difficult to establish on the basis of MRI imaging alone.

References

None