General Spine

Jeremy B McCue, MD, Non ASSR Member
Patrick Turski, MD, Non ASSR Member
Garth Warren, BS, Non ASSR Member
Lindell R Gentry, MD, Non ASSR Member
Victor Haughton, MD, ASSR Member

Excerpta Extraordinaire

Excerpta

This case illustrates the utility of MR imaging in assessing ligamentous and neurologic injury in craniocervical trauma in a patient who developed isolated bilateral hypoglossal palsy after a farming accident.

Case:
10 Year old male presented with no gross neurological deficit after being crushed under a 700 pound hay bale. Patient complained of thoracic pain and was found to have mild compression fractures at T11-L1. Patient did not complain of neck pain. Routine imaging revealed severe cervical prevertebral soft tissue swelling with no fractures. CT cervical spine showed borderline widening of the basion-dens interspace with normal pre-dental space.

Several hours after admission the patient developed dysphonia and swallowing difficulty and was diagnosed clinically with bilateral hypoglossal nerve palsy. MRI of the cervico-occipital junction revealed severe ligamentous injury with complete disruption the apical ligament(Image 1), left alar ligament, and partial disruption of the right alar ligament and left tectorial membrane(Image 2/3). Additionally there was development of a large retroclival epidural hematoma extending to the hypoglossal canals bilaterally compressing the hypoglossal nerves (Image 4).

This case is an unusual presentation of a typically devastating injury. The patient presented neurologically intact, subsequently progressing to develop isolated hypoglossal palsy. Cranial nerve palsy been described as a rare complication in atlanto-occipital injury although typically associated with occipital condylar fractures.

Images

General Spine

Jocelyn H Medina, M.D., Non ASSR Member
Stephen Falcone, M.D., ASSR Member
Kevin Abrams, M.D., ASSR Member

Excerpta Extraordinaire

Excerpta

Spontaneous intracranial hypotension (SIH) is a syndrome of postural headaches arising spontaneously, without prior lumbar puncture. It is a benign condition that is difficult to diagnose because of its highly variable and often nonspecific clinical and imaging presentation (1, 2, 3). It is thought to be caused by development of cerebrospinal fluid (CSF) leaks usually in the spine (4). Spinal imaging may be necessary in order to identify the site of the CSF leakage, particularly in refractory or diagnostically difficult cases or when a surgical or invasive approach is planned(5). This study retrospectively reviews the spinal findings of eleven patients with SIH in order to further characterize the spinal findings in the disease.

Purpose

The role of spinal imaging in diagnosis and management of SIH has not been well established. Multiple spinal findings have been reported in SIH, but the sensitivity and specificity of these findings has not been well characterized in the current literature (6,7). The first major goal of our study is to better characterize spinal findings and determine which findings are clinically useful. A second goal of our research is to define when spinal imaging is necessary in SIH and demonstrate that in the appropriate clinical setting, spinal imaging is a useful and beneficial tool in the diagnosis and management of the disease.

Methods & Materials

Eleven (4 male, and 7 female) patients ages 25-56years old with the clinical diagnosis of Spontaneous Intracranial Hypotension were identified at University of Miami/Jackson Memorial Hospital, and Baptist Memorial Hospital. Clinical records and operative reports were reviewed where applicable. All cranial MRI, spinal MRI, and CT myelograms were collected for each patient and retrospectively reviewed by 2 attending neuroradiologists. Four of the patients had complete imaging workup to include cranial and spinal MRI, and CT myelography of the entire spine. Three patients had MRI imaging of the brain and spine, but no myelogram. Three patients had spinal MRI imaging only and one patient had a CT myelogram of the entire spine and MRI of the brain and upper cervical spine.

Results

Fluid collections were the most common imaging finding and were seen in 10 of 11 patients (91%). A thickened epidural venous plexus was another common imaging finding seen in 9 patients (82%). Dural enhancement was seen in 64%. Four patients (36%) had evidence of a high signal between the spinous processes of C1 and C2, or the false c1/2 localizing sign describe previously by Shievink (8). 27% (3 patients) had nerve root cysts, and 3 (27%) patients had dilated epidural veins. In the 5 patients who underwent CT myelography, 4 patients (36%) had active extravasation of contrast.

Four patients had surgical correlation. Three of these had complete concordance with imaging and surgical findings. The patient with discordant surgical and imaging findings was felt to have a leak by CT myelography extending into the region of the brachial plexus. At surgery, no active extravasation of CSF was seen at the site. However, the site was surgically packed and the patients clinical symptoms subsequently resolved.

Conclusion

An array of imaging findings were identified in this series of patients with SIH. All the patients in the series had at least two of findings in the spine defined by this study even in the absence of classic intracranial imaging findings. Notably, most of the patients in this series demonstrated spinal fluid collections, dural enhancement and a thickened epidural venous plexus, suggesting that these may represent sensitive findings for the disease. The use of contrast was also noted to be extremely helpful in distinguishing thickened venous plexus from fluid collections.

References

1. Schaltenbrand G (1938). Neuere Anschauungen zur Pathophysiologie der Liquorzirkulation. Zeentralbl Neurochir 3: 290-300.
2. Jacobs MB, Wasserstein PH (1991) Spontaneous intracreanial hypotension: An uncommon and underrecognized cause of headache. West J Med 155: 178-180
3. Messori A, Salvolini U (2002). Comment on Chiappariniet al.: spinal radiological findings in nine patients with spontaneous intracranial hypotension. Neuroradiology 44: 151-152.
4. Schievink WI, Meyer FB, Atkinson JLD, Mokri B (1996) Spontaneious spinal cerebrospinal fluid leaks and intracranial hypotension. J Neurosurg 84: 598-605.
5. Spelle, L, Boulin A, Tainturier C, Visot A, Graveleau P, Pierot L (2001) Neuroimaging features of spontaneous intracranial hypotension. Neuroradiology 43: 622-627.
6. Messori A, Polonara G, Salvolini U (2001) Dilation of Cervical Epidural veins in intracranial hypotension. AJNR 22: 224-225.
7. Chiaparini L, Farina L, D’Incerti, Erbetta A, Pareyson, Carriero R, Savoiardo M (2002). Spinal radiological findings in nine patients with spontaneous intracreanial hypotension. Neuroradiology 44: 143-150.
8. Schievink WI, Maya MM, Tourje J (2004). False localizing sign of C1/2 cerebrospinal fluid leak in spontaneous intracranial hypotension. J Neurosurg 100:639-644.

General Spine

Michal M Mendiratta-Lala, M.D., Non ASSR Member
Horia Marin, M.D., Non ASSR Member
Suresh C Patel, M.D., Non ASSR Member
Rajan Jain, M.D., Non ASSR Member

Excerpta Extraordinaire

Excerpta

Pilomyxiod astrocytoma(PMA) is a rare sub-type of pilocytic astrocytoma, commonly originates in the hypothalamus or optic chiasm and presents in infants with only three cases of PMA of the spinal cord reported in children less than eight years of age. This is a rare case report of PMA presented as an intradural not an intramedullary mass involving the entire spinal canal, in a 34 year old female. The intradural tumor was located dorsal to the entire spinal cord was hypointense on T1 weighted images and extremely bright on T2 weighted images. The intradural PMA avidly enhanced with contrast material and filled the entire thecal sac of the spinal canal including the lumbar-sacral spinal canal distal to the conus medullaris. PMA is composed of glial cells within a monophasic pattern in an extensive myxoid/mucinous background. The myxoid/mucinous background is probably the reason for extreme brightness on T2Weighted images. PMA lacks Rosenthal fibers and rarely have eosingophillic granular bodies with neoplastic cells radiating from vessels producing an angiocentric pattern. The histologic features differentiates it from the pilocytic astrocytoma. Due to aggressive characteristics, PMA is associated with shorter progression free survival rates.

Purpose

Spinal intradural extramedullary tumors account for two-thirds of all intraspinal tumors, and the most common are nerve sheath tumors. Spinal cord astrocytomas are an infrequent lesion, which rarely occur after 60 years of age, and are the most frequent histologic type of spinal cord tumor in the pediatric population. (1) Spinal cord astrocytomas are most commonly intradural intramedullary lesions. Unlike astrocytomas in the brain, spinal cord astrocytomas are usually low grade lesions. (1) There are subtypes of astrocytomas, the most common are pilocytic, fibrillary, and anaplastic. Recently, a rare pilomyxoid variant has been described, known as pilomyxoid astrocytoma (PMA). (in contrast to the biphasic pattern of pilocytic astrocytoma (PA), appears as monomorphous piloid cells in a loose fibrillary and myxoid background, without Rosenthal fibers.(2)) While the most common origin is in the hypothalamus or optic chiasm, and the most frequent age group is in infants, PMA in the spinal cord has been rarely described, and only in children (3.4). In this report, we describe an unusual case of PMA located extensively within the spinal canal as an intradural extramedullary lesion in a young adult.

Methods & Materials

Case Report:

A 32 year old female presented with a three-week history of progressive neck and back pain associated with nausea and vomitting. She also had weakness in both upper and lower extremities with 4/5 motor strength. Her examination revealed hyperreflexia of the right knee, with downgoing plantar reflexes bilaterally. She had paresthesias in the C6-T1 dermatomes, with intact mental status and cranial nerves.

MRI of the entire spine confirmed an intradural extramedullary lesion, from the C5 level inferiorly into the thoracic region, causing anterior spinal cord compression, occupying most of the thecal sac, and with a small syrinx cavity at the C5 level. There was extensive post-contrast enhancement, with some central areas of non-enhancement. There was also scalloping of the posterior margin of the vertebral bodies.

Because of the associated cervical myelopathy, she underwent bilateral laminectomy at C5-T1, with durotomy and partial resection of the intradural extramedullary tumor, for cord decompression. The tumor appeared gelatinous and fibrous in nature, and aggressively herniated out upon opening of the dura mater. The tumor was extensively removed in the exposed region, with piecemeal removal of the tumor from the lateral gutters. Formalin fixed pathologic analysis described an astrocytic neoplasm, consistant with a pilocytic variant, with an MIB-1 index of 3%.

Post-surgically, the patient began to develop increasing lower extremity weakness, with muscle strength 4/5 pre-operatively to 0-1/5 post-operatively, as well as development of bladder dysfunction. Repeat MRI demonstrated the initial post surgical changes, with residual tumor visualized, and anterior compression of the spinal cord. The patient returned to the OR for decompression of the lower thoracic spine, with intradural debulking of the tumor and duroplasty. The entire tumor could not be excised because it was extremely adherent to the spinal cord and the nerve roots more distally.

Formalin fixed pathologic analysis was performed for a second time, and showed neoplastic proliferation of glial cells, with pleopmorphic nuclei and piloid fibrillary processes. There was hyalinized vessels throughout, with an abundance of myxoid/mucinous matrix, in a monophasic background, consistant with the pilomyxoid variant of pilocytic astrocytoma.

Radiation therapy from T1-L3 levels were initiated, and currently, patient is still undergoing XRT. Post-operatively, she continued to have plegia of her lower extremities, and spinal cord rehabilitation was intitiated.

Results

Discussion:

Spinal cord astrocytoma is an uncommon finding, and only represents 6-8% of spinal cord tumors (7), most of which are intradural intramedullary. Most are pilocytic astrocytomas (PA), as opposed to nonpilocytic (fibrillary, anaplastic) (7). Recently, a subgroup of pilocytic astocytoma with similar histologic features, but with other associated findings and outcomes, was identified, known as pilomyxoid astrocytoma (PMA). Most reported PMA’s occur in the hypothalamic/chiasmatic region, and occurs within the first four years of life. Komotar et al recently described 3 cases of PMA in the spinal cord, however, all in children less than 8 years of age (4). The mean age of diagnosis of PMA is 18 months, although it can present in early childhood (4, 5, 12).

The usual clinical presentation is variable, and can progress over a time span of months to years. Pain is the earliest and most frequent complaint (1). Sensory disturbances, such as dysthesias or loss of sensation are also common (1). Weakness, spastisity, and loss of bowel and bladder function occurs late (15).

PMA is usually well-circumscribed with solid or cystic components and rarely has calcifications (5). The lesions are isointense on T1 weighted MRI and hyperintense on T2 weighted MRI, with variable enhancement post-gadolinium. There may be associated peritumoral edema, mass effect, and necrosis (5). Radiographic findings of PMA are similar to that of PA (5).

Therefore, the diagnosis of PMA is usually made from the histological findings (5). PMA is composed of glial cells within a monophasic pattern in an extensive myxoid/mucinous background. This is in contrast to pilocytic astrocytomas, which are found in a biphasic background. PMA usually lacks Rosenthal fibers, and rarely have eosinophillic granular bodies, unlike PA. Often the neoplastic cells radiate from vessels, thus producing an angiocentric pattern, and vaguely resemble perivascular rosettes (2,4,5,12). This is irregular and fibrillar when compared to the perivascular rosettes of ependymomas (12). There is occasional infiltration of the tumor into the surrounding normal parenchyma, with only a few described cases of mitotic figures (2, 12). Finally, a few cases have shown necrotic foci (12).

Tumor location has obvious implications for surgical management and outcome. Treatment options for PMA include tumor resection, radiation therapy, and chemotherapy. Resection can pose a challenge because of the extensive infiltration usually seen with PMA’s, and therefore, most cases result in subtotal resection. There is generally a poorer prognosis in patients who undergo more aggressive resection, versus those with less resection, specifically in patients with PA (7). This, however, is not reported in patients with PMA because of the rarity of this tumor subtype. Prognosis is therefore partially dependent on long-term behavior of the partially resected tumor. Unfortunately, PMA’s are more aggressive than PA’s, and can therefore have a worse prognosis, although better than that of infiltrating PA’s (4).

The median post operative follow-up is 14 months in infants and children, with the majority of cases presenting with local recurrence and a few with CSF dissemination of the tumor (12). PA has a lower rate of recurrence, with rare reports of CSF spread (2, 14). According to Komotar et al, patients with PMA have a shorter overall survival and progression free survival times than patients with PA.

From studies to date, PMA appears to be a more aggressive subtype of PA’s. Some reasons include: 1. they recur sooner and more frequently than PA’s (2,5,6,12); 2. CSF dissemination is more common (2,5,12); 3. Necrosis of the tumor, which occurs more frequently in rapidly growing tumors, occurs in PMA’s, as opposed to PA’s (6,12); 4. PMA’s are more likely to invade surrounding structures (2,6); 5. Patients with PMA’s experience a shorter progression free survival than patients with PA’s (2).

Another unusual finding in pilomyxoid astrocytomas, is anaplastic change of the initial or recurring tumor, after resection, chemotherapy, or radiation therapy. The anaplastic change results in a more benign tumor, although this has only been reported in a few cases (2,3,12). This may suggest maturation of the tumor, however, the clinical significance is unclear given the rarity of this finding.

This case is unusual for a variety of reasons. First, it is uncommon to find an astrocytoma in an intradural extramedullary location. Second, there are only 3 other reported cases of PMA within the spinal cord. Finally, none of the reported cases of PMA occur in patients over the age of 8, and this patient was 32 years old.

Conclusion

Pilomyxoid astrocytomas are a subtype of the more frequent pilocytic astrocytomas, with distinct histologic features and a more aggressive subtype, most commonly occurring in younger ages. Because it is a more aggressive tumor, surgical resection is often incomplete, and therefore requires adjuvant treatment. This neoplasm is generally associated with shorter progression free survival. Better identification and recognition of these tumors may help in improved understanding of treatment options and outcomes.

References

Financial Disclosures: None

1. Houten JK, Cooper PR. Spinal cord astrocytomas: presentation, management and outcome. J Neurooncol. 2000 May;47(3):219-24. Review.
2. Komotar RJ, Burger PC, Carson BS, Brem H, Olivi A, Goldthwaite PT, Tihan T. Pilocytic and Pilomyxoid Hypothalamic/Chiasmatic Astrocytomas, Neurosurgery. 2004; 54: 72-9.
3. Zhongxin Yu, M.D., M.S.1, Gregory N. Fuller, M.D., Ph.D.2 An 18 month-old girl with a hypothalamic tumor. E-Reference: Case 503-1 Department of Pathology, University of Oklahoma Health Science Center
4. Komotar RJ, Carson BS, Rao C, Chaffee S, Goldthwaite PT, Tihan T. Pilomyxoid astrocytoma of the spinal cord: report of three cases. Neurosurger. 2005; 56:191.
5. Komotar RJ, Mocco J, Jones JE, Zacharia BE, Tihan T, Feldstein NA, Anderson RC. Pilomyxoid astrocytoma: diagnosis, prognosis, and management. Neurosurg Focus. 2005 Jun 15;18(6A):E7.
6. Fernandez C, Figarella-Branger D, Girard N, Bouvier-Labit C, Gouvernet J, Paz Paredes A, Lena G. Pilocytic astrocytomas in children: prognostic factors–a retrospective study of 80 cases. Neurosurgery. 2003; 53: 544-53.
7. Minehan KJ, Shaw EG, Scheithauer BW, Davis DL, Onofrio BM. Spinal cord astrocytoma: pathological and treatment considerations. J Neurosurg. 1995 Oct;83(4):590-5.
8. Epstein FJ, Farmer JP, Freed D. Adult intramedullary spinal cord ependymomas: the result of surgery in 38 patients. J Neurosurg. 1993 Aug;79(2):204-9.
9. Innocenzi G, Salvati M, Cervoni L, Delfini R, Cantore G. Prognostic factors in intramedullary astrocytomas. Clin Neurol Neurosurg. 1997 Feb;99(1):1-5.
10. Houten JK, Weiner HL. Pediatric intramedullary spinal cord tumors: special considerations. J Neurooncol. 2000 May;47(3):225-30. Review.
11. Giannini C, Scheithauer BW, Burger PC, Christensen MR, Wollan PC, Sebo TJ, Forsyth PA, Hayostek CJ. Cellular proliferation in pilocytic and diffuse astrocytomas. J Neuropathol Exp Neurol. 1999 Jan;58(1):46-53.
12. Tihan T, Fisher PG, Kepner JL, Godfraind C, McComb RD, Goldthwaite PT, Burger PC. Pediatric astrocytomas with monomorphous pilomyxoid features and a less favorable outcome. J Neuropathol Exp Neurol. 1999; 58:1061-8.
13. Arslanoglu A, Cirak B, Horska A, Okoh J, Tihan T, Aronson L, Avellino AM, Burger PC, Yousem DM. MR imaging characteristics of pilomyxoid astrocytomas. Am J Neuroradiol. 2003; 24:1906-1908.

General Spine

Suresh C Patel, M.D., ASSR Member
Horia Marin, M.D., Non ASSR Member

Excerpta Extraordinaire

Excerpta

This is a case Report of an 87-year-old female presenting with throbbing headache, radiating from the retro-orbital region to the vertex, then to her occiput on the right side, progressively getting worse over the last 3 weeks. The pain is continuous and is partially relieved by Tylenol. Neurologic examination is unremarkable. The headache has the characteristics of cervicogenic headache secondary to right occipital neuralgia. Past medical history is significant for degenerative joint disease and Calcium Pyrophosphate Dihydrate (CPPD) crystal deposition arthritis involving knee, shoulder and hand joints. There is no history of malignancy or renal disease. Laboratory values are unremarkable. There was a remote history of weakly positive rheumatoid factor (35 units (normal = 30u)). Large joint synovial fluid analysis showed presence of CPPD crystals and no evidence of inflammation to favor rheumatoid arthritis. Hand radiographs demonstrate extensive changes consistent with both ostheoarthritis and CPPD.

|MRI of the cervical spine demonstrates an enhancing soft tissue within the atlantoaxial articulation, resulting in widening of the predental space and extension into the spinal canal with mild compression of the cervicomedullary junction. CT of the cervical spine demonstrates enlargement of the predental space with anterior displacement of C1 relative to C2. There are extensive Calcium deposits both in the atlantoaxial joint and at the level of the transverse ligament. There is minimal focal bony erosion of the left side of base of dens. There is marked degenerative disc disease involving the entire cervical spine.

Given the clinical picture, history and radiologic findings, the diagnosis was cervicogenic headache secondary CPPD crystal deposition arthritis of the atlantoaxial joint.

References

1. Y Kakitsubata, RD Boutin, DJ Theodorou, RM Kerr, LS Steinbach, KK Chan, MN Pathria, P Haghighi, D Resnick:
2. Calcium Pyrophosphate Dihydrate Crystal Deposition in and around the Atlantoaxial Joint: Association with Type 2 Odontoid Fractures in Nine Patients. Radiology July 2000; 213-218.

Financial Disclosures: None

General Spine

Reono - Bertagnolli, BS, MD, Non ASSR Member
Gregory W Petermann, MD, ASSR Member

Excerpta Extraordinaire

Excerpta

We present a case of irreversible lower extremity paraplegia in a young male patient. The subject first experienced symptoms while surfing off the island of Oahu, Hawaii in less than 3 foot waves. His symptoms rapidly progressed from bilateral lower extremity paresthesia to paraplegia. MRI was performed demonstrating extensive high signal within the spinal cord at the thoracic vertebral levels. Computed tomography, angiogram, and plain radiographs were also obtained. There were small, multilevel disc herniations present adjacent to the cord abnormality.

There have been multiple cases of spinal cord infarction after surfing over the last decade. Images from this case will be presented, demonstrating spontaneous spinal cord infarction in a previously healthy individual. Presumed factors for this condition may include preexisting causes of canal stenosis (congenital, degenerative, or associated disc herniation). The occurrence in beginning surfers raises the possibility this may also be related to positioning. Many beginning surfers lie prone with their head and thorax extended while searching for waves while experience surfers will sit upright on the board.

General Spine

Megan E Deacon-Casey, MD, Non ASSR Member
Deborah A Lee, MD, PhD, Non ASSR Member
Daniel F Broderick, MD, Non ASSR Member

Excerpta Extraordinaire

Excerpta

A 2 day old neonate was delivered to an 18 year old woman G1P0. Her pregnancy was complicated by multiple sclerosis and she delivered via C-section secondary to failure to progress and prolonged rupture of membranes after attempt with vacuum extraction. At the time of birth the patient was noted to have macrosomia, meconium stained amniotic fluid and respiratory distress. Initially the patient was floppy and unresponsive at birth requiring resuscitated. Within the first 24 hours the patient was able to move all four extremities; 48 hours later the neonate presented with seizures, minimal movement of the right upper extremity and decreased tone, which later progressed to bilateral upper extremity hypotonicity.

The neonate was initially evaluated with Computed Tomography (CT) of the head revealing no definite abnormality and probably a subtle hypodense region in the brainstem. Further evaluation with Magnetic Resonance Imaging (MRI) revealed a heterogeneous, T1 hypointense and T2 hyperintense, expansile mass in the cervical spinal cord. The mass demonstrated heterogeneous enhancement and contained several well-defined loculated components. There was contiguous cephalad extension of the lesion with involvement of the medulla. A surgical biopsy was performed revealing a histologic diagnosis of an extrarenal rhabdoid cervical spinal cord tumor.

Atypical teratoid/rhabdoid tumor (ATRT) is a highly aggressive primitive central nervous system (CNS) neoplasm of infancy. The reported cases in the literature are commonly seen in the posterior fossa and upper cervical spinal cord. To our knowledge, this is the first reported case of ATRT presenting in a neonate. The imaging characteristics are not specific. The differential diagnosis includes other more common malignant tumors such as primitive neuroendocrine tumors (PNET). Rhabdoid tumor (RT) was first described as an aggressive neoplasm of unknown histogenesis affecting the kidneys of infants and young children, but has since been reported in all ages and in many other primary sites, including the central nervous system. The most common extrarenal location involves the posterior fossa. Although malignant ATRT are rare and the imaging features are nonspecific, it should be included in the differential diagnosis of childhood intracranial and spinal neoplasms.

ATRT is a rare, high grade tumor occurring most commonly in children younger than 2 years. It is generally found in the cerebellum. These tumors tend to be aggressive and frequently spread through the central nervous system. This diagnosis of ATRT has only been classified in the last three to five years; the tumor is a subset of medulloblastomas. They occur in about 1-2 percent of children with brain tumors. These tumors are often mistaken for medulloblastoma (MB) or central primitive neuroectodermal tumor (PNET) due to similar imaging features. It is important to distinguish ATRT from MB and PNET, since ATRT is associated with a particularly poor prognosis and an unrelenting clinical course when conventional therapies for MB and PNET are used. Treatment generally involves surgical removal of the tumor followed by chemotherapy. Radiation therapy may be considered depending on the age of the child and whether the tumor has recurred.

Images

General Spine

John P Fantauzzi, MD, Non ASSR Member
A Orlando Ortiz, MD, MBA, FACR, ASSR Member
Douglas S Katz, MD, Non ASSR Member

Excerpta Extraordinaire

Excerpta

A 70-year-old female underwent sequential CT scans to monitor a previously discovered descending thoracic aortic aneurysm. In November 2004, the aneurysm measured slightly more than 6 cm in maximum AP and transverse dimensions. In June 2005 the aneurysm was much larger, measuring 9.1 cm in the AP dimension x 10.1 cm in the transverse dimension. There was interval development of marked erosive changes of the left lateral aspects of the T8 and T9 vertebral bodies, which were adjacent to the aneurysm.

Vertebral body erosion is an unusual complication of an enlarging aortic aneurysm, with only a few reported cases in the literature.

References

Thanila A. Macedo, Anthony W. Stanson, Gustavo S. Oderich, C. Michael Johnson, Jean M. Panneton, and Mark L. Tie
Infected Aortic Aneurysms: Imaging Findings
Radiology 2004 231: 250-257

Images

General Spine

Bruno A Policeni, MD, Non ASSR Member
Wendy R.K. Smoker, MD FACR, ASSR Member
Toshio Moritani, MD PhD, Non ASSR Member

Excerpta Extraordinaire

Excerpta

Diastematomyelia is a rare form of spinal dysraphism characterized by the presence of an osseous, cartilaginous, or fibrous septum that sagittally clefts the spinal cord and/or filum terminale into two hemicords. The partitioning may be complete or incomplete and, although it may be an isolated finding, diastematomyelia is often associated with vertebral segmentation anomalies.

We present a case of three-level (triple) diastematomyelia in a 3 year-old boy demonstrated on plain radiographs, CT with 3D reconstructions, and MRI. The highest level was a partial osseous cleft at T6, the middle level was a large complete osseous cleft extending from T8 to T10 associated with vertebral segmentation anomalies, and the lowest level was also completely osseous at L3-4. The cord was tethered, divided over a long segment. In addition, multiple other congenital spinal anomalies were present.

To our knowledge, triple diastematomyelia has not been previously reported in the English literature. In a paper by McClelland et al (Radiology, 1977), mention of such a case by personal communication was made but not documented. Our review indicates that seven cases of two-level (double) diastematomyelia have been previously described.

General Spine

Chirstopher J Friend, MD, Non ASSR Member
Robert L Williams, MD, ASSR Member
Melanie B Fukui, MD, Non ASSR Member

Excerpta Extraordinaire

Excerpta

Patient 1

A 53-year-old woman presented to our emergency room with a gait instability, lower extremity numbness and incontinence. She had had a long history of chronic back pain and fibromylagia as well as a two-month history of more severe midback pain refractory to anti-inflammatory agents. Six weeks prior to presentation, pain management had administered epidural injections. Approximately two weeks following the injection, she had an episode of fever and chills that was thought to be due to a UTI. On admission exam, she had decreased pinprick sensation below T8 and decreased rectal sensation and tone. With a history of fever and prior epidural injection, an epidural abscess was the working diagnosis.

Due to the patient’s symptoms, an emergent MRI was ordered which showed enhancing extradural soft tissue extending from T1 to L1 with several levels of canal compromise. Additionally, the marrow signal in the vertebral bodies was uniformly low, consistent with diffuse marrow infiltration. A differential diagnosis of lymphoma was given with extramedullary hematopoiesis felt less likely.

The patient was taken to the operating room where a partial T4-T5 laminectomy and biopsy of the epidural mass was performed. Frozen section suggested lymphoma and further exploration was terminated. Final pathologic diagnosis was plasmacytoma. Subsequent bone marrow biopsy showed hypercellular bone marrow with 80% plasma cells consistent with multiple myeloma.

Patient 2

A 74-year-old male presented with bilateral leg weakness, decreased proprioception, and urinary retention. He denied any numbness or paresthesias. Due to his leg weakness, an MRI was ordered which demonstrated a large enhancing extradural soft tissue mass at T5 and T6 with displacement of the thecal sac. The mass extended through the right neural foramen with compression of the superior endplate of T5 and inferior endplate of T6. Evaluation of the bone marrow demonstrated scattered abnormal enhancement throughout the spine with areas of more focal involvement and osseous destruction. A diagnosis of multiple myeloma verse metastatic disease was suggested. Serum electrophoresis showed an IgG kappa monoclonal gammopathy. Urine chemistry showed similar results. A Tc-99 MDP bone scan was negative consistent with the patients presumed diagnosis of multiple myeloma.

Multiple myeloma is caused by a malignant proliferation of plasma cells, which usually affect the bone marrow. Other symptoms can include bone pain, impaired renal function, and hypercalcemia. With the increase in imaging utilization, incidental detection has become more common. Spinal compromise is a well-known complication of MM, which is often caused by vertebral fracture. The cases we present are unusual in that the spinal compromise is being caused by an extensive extradural soft tissue mass. This is a much less common cause of spinal compromise in multiple myeloma.

These cases also demonstrate the differing patterns of vertebral involvement in multiple myeloma. Three different marrow patterns have been described: focal, diffuse, and variegated. The focal pattern consists of multiple lesions on a normal background. The diffuse pattern demonstrates a homogenous decrease in marrow signal on a T1 basis. The variegated pattern shows multiple small foci of low T1 signal that enhance post contrast. A normal pattern has also been defined as biopsy proven marrow infiltration with a normal MRI appearance. The differing patterns may have a correlation with tumor burden. Patient 1 illustrates a diffuse pattern of involvement while Patient 2 illustrates a more focal involvement.

We present these cases illustrate an unusual presentation of multiple myeloma as well as the differing patterns of marrow involvement in multiple myeloma.

Interventional Spine

Natasha Acosta, MD, Non ASSR Member
Naveed Akhtar, MD, Non ASSR Member
Veronika McDonald, DO, Non ASSR Member
Thomas Grobelny, MD, Non ASSR Member
Jorge A Vidal, MD, Non ASSR Member

Scientific Poster

Purpose

The poster provides a review of the most common complications encountered after Vertebroplasties. The management of these complications is also addressed in this presentation

Methods & Materials

Over 400 vertebroplasties were reviewed retroactively in to assess their complications, their outcome and the management. The patient’s medical records and radiological images were evaluated and the data was consequently analyzed.

Results

Vertebroplasties as a spinal intervention for pain have a relatively low complication rate. However, complications do occur and include, but are not exclusive of: extravasation of cement into the spinal canal, veins, or disc space, radiculopathy, and/or increased pain. An algorithm is provided for the management of these complications which include nerve blocks, Neurontin, steroid use, and conservative therapy.

Conclusion

Vertebroplasties carry a very low risk of complications. Nonetheless, these must be properly recognized and promptly addressed in order to maintain a low level of morbidity and a high level of patient comfort and satisfaction.