General Spine

Peter Schramm, MD,
Saida Zoubaa, MD, Non ASSR Member
Paul Kremer, MD, Non ASSR Member

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A 22-year-old woman developed an increasing distal paraparesis, which resulted in a severe ataxic gait. MRI demonstrated a very large intramedullary tumour mass from D11 to L2, which could not be identified as one of the common neoplastic diseases of the spinal cord. The tumour was removed completely and the diagnosis of subependymoma confirmed. With respect to our patient and to the limited reports in the literature, we describe some typical features that may help in the diagnostic and preoperative assessment of this very rare spinal cord tumour.

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Interventional Spine

Avanti Ambekar, M.D.,
Cynthia Chin, M.D., ASSR Member

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A 45 year old woman presented with multiple post-traumatic sacral meningeal cysts from prior loculated CSF leak. Symptoms included worsening sacral pain on standing and Valsalva. CT myelogram (3/2007) and MRI (4/2007) demonstrated multiple intradural and extradural sacral meningeal cysts. The most posteroinferior cyst did not fill with contrast on myelogram and showed intermediate T1/high T2 MR signal without reduced diffusion. CT-guided cyst aspiration and fibrin glue injection was performed on 8/20/07. Two 13-gauge Jamshidi needles were advanced to the right and left S3 levels. 1.5 cc of serosanguinous fluid was aspirated from the left side. The right-sided needle was left open to air. Subsequently, one cc of fibrin glue (Tisseel) was administered via the left-sided needle with no pain induction. The injection was terminated upon observation of return of fibrin glue in the right-sided needle hub.

Cyst aspiration alone may allow fluid reaccumulation over time, due to the one-way valve communication with CSF. Fibrin glue injection results in durable obliteration of the cyst cavity. The two-needle injection technique has many advantages. Fibrin injection is typically very painful due to cyst distention. However, our patient experienced no pain during injection, since the second needle allowed control of cyst distention by equilibrating intracystic pressures with the atmosphere. The endpoint of injection is observation of fibrin in the second needle hub, that ensures complete filling of the potential cyst space for a more durable result. Also, the rate of chemical meningitis complications is lowered by allowing excess fibrin glue to flow out the second needle. The needles can be placed simultaneously under CT guidance with no increase in procedure time.

References

Zhang et al. "Percutaneous fibrin glue therapy for meningeal cysts of the sacral spine with or without aspiration of the cerebrospinal fluid." J Neurosurg Spine 7:145-150, 2007

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General Spine

Alexander Lerner, MD,
Soma Sahai, MD, Non ASSR Member
Deborah L Commins, MD, Non ASSR Member
John L Go, MD, ASSR Member

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Wagener Granulomatosis of the Cervical Spine.

Purpose

To describe an unusual case of Wegener Granulomatosis involving the cervical spine.

Methods & Materials

A 32 year old Hispanic female with no known primary neoplasm presented to our institution with a 3 year history of a dural based mass involving the left cavernous sinus, parasellar region, and tentorium. Brain biopsy of the mass at that time suggested a granulomatous, inflammatory mass. AFB cultures and ACE levels were negative for tuberculosis and sarcoidosis. The patient was treated with steroids and immunosuppressive medication (Imuran) with a mixed response. The patient now presented to the ER with occipital headache and extreme pain upon movement of the neck. MRI of cervical spine with and without IV contrast was obtained.

Results

MRI revealed an anterior extramedullary lesion extending from C1 to C6.
The lesion demonstrated isointense signal on T1-weighted images, isointense to hypointense signal on T2-weighted images, and avid homogeneous enhancement. There was no evidence of vertebral involvement. Due to the compression upon the thecal sac, an emergency decompression was performed. Final diagnosis was Wegener granulomatosis.

Conclusion

Wegener granulomatosis is a rare entity within the spine with a few isolated case reports in the literature. This paper will demonstrate the radiological manifestations of this entity in the spine with a demonstration of the pathology seen and a differential diagnosis for dural based lesions of the spine.

References

Mentzel, Hans-J., Neumann, Thomas, Fitzek, Clemens, Sauner, Dieter, Reichenbach, Jurgen R., Kaiser, Werner A.
MR Imaging in Wegener Granulomatosis of the Spinal Cord
AJNR Am J Neuroradiol 2003 24: 18-21

Provenzale JM, Allen NB. Wegener granulomatosis: CT and MR findings. AJNR Am J Neuroradiol 1996; 17:785-792

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General Spine

Sangit B Malliah, MD,
Todd Siegal, MD, Non ASSR Member
Brown Michelle, MD, Non ASSR Member
Cyrus Khorrami, MD, Non ASSR Member

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Summary: A 47 year old male presented for a lumbar spine MRI after a fall directly on his back from an elevation of a few feet. An MRI of the lumbar spine demonstrated a fluid intensity signal encircling the lumbar spine spanning over multiple lumbar vertebral levels. This fluid was in a subdural location interposed between the dura and arachnoid layers of the thecal sac with both meningeal layers identified. There was no neural foraminal extension. There was no infiltration of the epidural fat. The signal intensity of the fluid followed CSF signal intensity on all imaging sequences. Post contrast imaging was performed four weeks later which demonstrated no enhancement and no change in the imaging findings. Overall, findings were compatible with a post-traumatic subdural hygroma of the lumbar spine. Hematoma was considered less likely as there was no change in the imaging findings over a four week period.
This abnormality appears to be on the spectrum of various types of CSF leaks. These include true meningeal diverticulum which may be due to congenital weakness of the meninges as seen in various connective tissue disorders. Pseudomeningoceles are another form of CSF leak due to tears of the dura-arachnoid mater resulting in epidural CSF collections. Although CSF leaks are often asymptomatic, they may cause low-back pain, headaches, nerve root entrapment and intracranial hypotension. After consultation with orthopedic surgery, conservative management was decided upon with symptomatic treatment. The patient will be followed clinically and repeat MRI will be performed if clinical symptoms persist or worsen.
Our review of the literature found no prior cases of this entity.

Reference

Review of spinal pseudomeningoceles and cerebrospinal fluid fistulas.
Neurosurg Focus. 2000 Jul 15:9(1):e5. Review Hawk MW, Kim KD.

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General Spine

Christopher P Petrie, DC,
Jean-Nicolas Poirier, DC, DACBR, Non ASSR Member

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We present an educational retrospective case study of a patient suffering from chronic low back pain and lumbar spine vertebral sarcoidosis.

A 64 year-old male presented with chronic low back pain with radiation down the left leg to the calf. He rated his pain level at 10/10. He had severe ambulatory limitations and complained that he could not sit. A plain film radiographic examination demonstrated extensive degenerative changes at the vertebral endplates, discs and facet joints predominantly in the lower lumbar spine. No destructive osseous lesions were seen involving the lumbar vertebrae. A disc herniation was clinically suspected at L5-S1. A period of conservative treatment failed to resolve the patient’s symptoms, and a magnetic resonance imaging (MRI) evaluation of the lumbar spine was recommended to evaluate the lumbosacral disc changes. Multiple lesions ranging from 4mm to 2cm in largest diameter were seen scattered throughout the vertebral bodies from L1-S2. The lesions appeared sharply delineated and demonstrated homogeneous low signal intensity on T1 and T2- weighted sequences. Conversely, two small lesions involving L4 and L5 demonstrated high signal intensity on fluid-sensitive sequences. A small rim of high signal intensity was also seen on T2-weighted sequences incompletely surrounding the largest lesions at L3 and L4. There was no evidence of pathological fracture or soft tissue or epidural extension of the disease. A large disc bulge was seen at L5-S1, accompanied by advanced facet arthrosis and ligamentum flavum hypertrophy, leading to spinal canal stenosis and bilateral neural foraminal encroachment. Fat suppression and contrast-enhanced sequences were not performed.

A biopsy sample of the lesions revealed the presence of a noncaseating granulomatous disease. The patient was diagnosed with vertebral sarcoidosis. A chest radiographic examination failed to demonstrate any mediastinal or pulmonary involvement of the disease. The patient denied treatment for sarcoidosis and no follow-up MRI examination was performed. He continued a period of conservative care that eventually improved his low back pain. The true etiology of the pain (mechanical low back vs. osseous sarcoidosis) was never established.

This unusual case of provided an opportunity to learn more about the clinical and imaging presentation of vertebral sarcoidosis, a rare and usually painful condition. The imaging findings are variable and nonspecific and may simulate metastatic disease. Biopsy is required for accurate diagnosis.

References

Fisher AJ, Gilula LA, Kyriakos M, Holzaepfel CD. MR imaging changes of lumbar vertebral sarcoidosis. AJR Am J Roentgenol. 1999;173:354-6.

Rua-Figueroa I, Gantes MA, Erausquin C, Mhaidli H, Montesdeoca A. Vertebral sarcoidosis: clinical and imaging findings. Semin.Arthritis Rheum. 2002;31:346-52.

Waanders F, van HP, Krikke A, Wesseling J, Nieboer P. Sarcoidosis mimicking metastatic disease: a case report and review of the literature. Neth.J Med 2006;64:342-5.

Lisle D, Mitchell K, Crouch M, Windsor M. Sarcoidosis of the thoracic and lumbar spine: imaging findings with an emphasis on magnetic resonance imaging. Australas.Radiol 2004;48:404-7.

This case was previously presented at the American College of Chiropractic Radiology (ACCR) 2007 Annual Workshop, October 17-20 in Denver, CO.

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General Spine

Bradley P Thomas, MD,
Thomas S Dina, MD, ASSR Member

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Remote cerebellar hemorrhage (RCH) is a rare occurrence associated with cranial, and less commonly, spinal surgery when there is significant CSF loss. This intraparenchymal hemorrhage pattern is very characteristic and hypothesized to be the result of cerebellar venous compression (Figure 1).

We present a case of a 34 year-old male post-resection of a chondrosarcoma located at the left T3-4 costovertebral junction without intraoperative evidence of dural violation. On post-operative day 2, new neurologic symptoms led to a head CT and subsequent MRI exams that revealed RCH along with diffuse dural enhancement with sagging of the pons and brainstem indicative of CNS hypotension. Following the removal of a peri-operative chest tube, repeat thoracic imaging was suggestive of a complex pseudomeningocele at the operative site (Figures 2 and 3). Surgical exploration revealed what appeared to be loculated CSF collections and presumed spontaneous resolution of a CSF leak.

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Peter Kalina, MD,

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A 5 month old presented with a 2 month history of not extending her legs or pushing off surfaces. She would not support weight on her lower extremities and cried when placed on her stomach. Her parents noticed decreased lower extremity movement. MRI suggested a large enhancing T12 to L2 intramedullary tumor, likely astrocytoma or ependymoma. At surgery, the lesion was completely extramedullary/ intradural. The pathology revealed Adrenal Cortical tumor. Ectopic adrenal cortical neoplasms of the spine are extremely rare. This patients adrenal glands were normal. The tumor presumably developed from congenital ectopic rests of intraspinal adrenal tissue.

General Spine

Peter Kalina, MD,

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The imaging features of Limbus avulsion fractures in children will be reviewed based on three post-traumatic cases. This will include plain films, CT, MRI and myelography.

General Spine

Richard Silbergleit, M.D.,
Ahmad Haidary, M.D., Non ASSR Member

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Juvenile xanthogranuloma is a rare histiocytic disorder that typically presents in childhood and occasionally in adults. A 46 year old female preented with several months of decreased rectal tone and right lower extremity weakness. CT demonstrated an expansile mass involving the L2 vertebral body and posterior elements extending deep into the paraspinal muscles. The imaging findings and pathology of this unusual lesion are reviewed.

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Gregory E Punch, MD,
Daniel J Donovan, MD, Non ASSR Member
Gregory W Petermann, MD, ASSR Member

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Chiari II malformations are reported in association with myelomeningoceles, although these are infrequently located in the cervical level. The concomitant findings of two other intramedullary lesions is even less common.

We present a case of a 19 month old male with global developmental delay, no verbal skills, and inability to stand or walk. MRI imaging demonstrated low lying tonsils with small posterior fossa and tectal beaking of the brain. A C3-C5 posterior spinal defect was present with a skin covered CSF collection and no neural elements within the sac. A small dorsal lipoma and adjacent syringohydromyelia occurred just above this abnormality. Finally, intramedullary fat containing mass also occurred at T5-T6 level with an associated dorsal dermal sinus. These imaging findings of a Chiari II malformation with a cervical meningocele, dorsal lipoma of the cord, and an intramedullary dermoid with associated dorsal dermal sinus will be reviewed.

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