General Spine

Shehanaz, Ellika, MD, DM
Horia, Marin, MD, Non ASSR Member
Martin, Price, MD, Non ASSR Member
Beejal, Amin, MD, Non ASSR Member
Muwaffak, Abdulhak, MD, Non ASSR Member
Jorge, Gutierrez, MD, Non ASSR Member

Excerpta

Background

Pseudotumoral hypertrophy of the transverse ligament is a rare cause of spinal cord compression. We would like to present a case of severe compression of the craniocervical junction, related to an extraaxial mass arising from the C1-C2 joint.

Our patient is a 77 year old man, presenting with progressive neck pain, unsteady gait and spasticity. Physical examination was significant for sensory deficits to light touch and pinprick in all finger tips and toes, increased muscle tone and hyperreflexia in upper and lower extremities. CT myelography demonstrated severe extradural mass effect on the thecal sac at the craniocervical junction. MRI of the cervical spine revealed a T1 hypointense, heterogeneous, predominantly T2 hypointense extraxial mass, posterior to the odontod, compressing the thecal sac and spinal cord. Also, there are findings consistent with diffuse idiopathic skeletal hyperostosis (DISH) throughout the cervical spine. The patient underwent surgical trans-oral resection and posterior cervico-occipital fusion. Pathologic examination revealed degenerated fibrocartilage fragments, without inflammatory changes or crystal deposition.

Discussion

Differential diagnosis of degenerative pseudotumor of the atlanto-axial joint includes pannus associated with rheumatoid arthritis, calcium pyrophospate deposition disease and gout tophi. Imaging diagnosis of degenerative pseudotumor is favored in our case in the absence of bone erosions and enhancement. Also, the presence of changes of DISH is supporting the diagnosis. DISH causes limitation of motion in the lower cervical spine with potential for microinstability at the level of atlantoaxial joint with repetitive tear and repair of the transverse ligament leading to pseudotumoral hypertrophy. This association was previously reported with a total of 10 cases in the literature.

General Spine

Alex, B, Schabel, MD
Lubdha, M, Shah, MD, Non ASSR Member

Excerpta

A 53-year old male with a history of cocaine abuse, alcohol abuse, and hepatitis C developed acute onset lower back pain, bilateral lower extremity weakness, numbness to the level of T10, and urinary retention following an evening of cocaine use.

Upon arrival, MRI of the thoracolumbar spine was performed, which demonstrated cord expansion and increased T2 and STIR signal within the cord between T9 and T12. Axial images demonstrated an â

General Spine

Sasan, Karimi, MD
Vineet, Punia, MBBS, Non ASSR Member
Vaios, Hatzoglou, MD, Non ASSR Member
George, Krol, MD, Non ASSR Member
Eric, Lis, MD, Non ASSR Member

Excerpta

CSF dissemination from chordoma is rare. The non enhancing nature of leptomeningeal tumor deposits further adds to the rarity of this case. To the best of our knowledge macroscopic or gross leptomeningeal tumor without enhancement has never been described.

Purpose

To describe an unusual case of spinal chordoma with pathologically proven CSF dissemination.

Methods & Materials

The history and other relevant clinical information of a patient with pathologically proven lumbar chordoma will be presented

Results

The spinal imaging of the patient along with relevant review of literature will be presented and discussed.

Conclusion

Although non enhancing leptomeningeal disease is rare its presence should be sought when indicated. Its detection requires a high index of suspicion with careful analysis of routine imaging. Additional or modification of the routine spinal imaging may be necessary to well demonstrate leptomeningeal tumor.

References/Financial Disclosures

AJNR Am J Neuroradiol. 1989 Jan-Feb;10(1):193-5.

No Financial Disclosures

General Spine

Kenneth, l, Weiss, MD
Matthew, A, Fox, MD, Non ASSR Member
Robert, P, Baughman, MD, Non ASSR Member
Jane, L, Weiss, Non ASSR Member
Dongmei, Sun, PhD, Non ASSR Member

Excerpta

Worsening, generalized spine pain is a common clinical complaint. Ordering diagnostic imaging studies for patients with poorly localizing symptoms or systemic pathology presents the clinician with many choices and challenges: what level, what modality, and at what cost? We present such a case of progressive back pain in a patient referred to our investigational MRI lab for a rapid total spine survey. MRI results were compared to routine FDG PET-CT.

Purpose

To apply a recently developed 2-D color-encoded sub-minute automated total spine MRI screening technique with improved tissue contrast through optimized fat-water separation[1-5] in a patient with generalized spine pain.

Methods & Materials

57 year old female, five years post liver transplant for hepatitis C, was referred to the investigational image laboratory for worsening back pain. Imaging was performed on a 3.0 T GEHDx MR scanner with 8-channel spine array coil and manufacturer supplied investigational pulse sequences (GE Healthcare (GEHC), Waukesha, WI). A dual-echo automated spine survey iterative scan technique (ASSIST DE) protocol was employed, wherein the skull base to sacrum, was auto-imaged in two contiguous 21 sec, 35 cm FOV breath-hold prompted sagittal acquisitions, yielding a composite superior-inferior (SI) field-of-view (FOV) of 70 cm and anterior-posterior (AP) FOV of 35 cm. 3D fast spoiled gradient (FSPGR) dual echo (DE) 2-point Dixon sequencing was performed with auto calibrating reconstruction for Cartesian sampling (ARC)[6] and surface coil intensity correction (SCIC), [TR = 5.6 msec, TE1 = 1.4 msec, TE2 ~ 2.6 msec, flip angle = 12, BW = +/- 167 khz, SI frequency encoding = 336, AP phase encoding =284, zero interpolation (ZIP 2) and slice thickness = 3mm with 1.5 mm overlap, 40 slices providing 58.5 mm right to left coverage. Fat-water separation was performed by the host computer using Maâ

General Spine

Cameron, Evans, MD
Lubdha, Shah, MD, Non ASSR Member

Excerpta

Purpose

To report a chondrosarcoma mimicking as a nerve sheath tumor in the lumbar spine

Methods & Materials

A 32 y.o. previously healthy male presented with a 3 year history of chronic back pain, progressively worsening and radiating to his left hip and upper thigh over the last 4 months.

Results

Initial radiographs showed an amorphous calcific density at the L4-L5 nerve root foramen with scalloping of the undersurface of the left L4 pedicle. The adjacent cortex was otherwise intact. The findings were concerning for a neoplastic process and MRI was subsequently performed. Enhanced MRI of the lumbar spine demonstrated a large extradural mass centered in the left L4-L5 neural foramen and extending into the thecal was severe and left neural foraminal canal narrowing. The osseous margins of the left L4 pedicle were smoothly scalloped and marrow signal intensities were preserved. The mass had a lobular peripheral contour and avid patchy enhancement. Given its location and imaging characteristics the differential diagnosis included a nerve sheath or possibly a meningioma. Given its internal enhancement, lack of facet arthropathy and no communication with the facet joints a synovial cyst was excluded. Given the minimal changes to the adjacent bone the mass did not appear to be arising from the bone and a primary bone tumor was not initially included in the differential. Given the patientâ

General Spine

Rihan, Khan, M.D.
Rihan, Khan, M.D., Non ASSR Member
Bruce, Dean, M.D., Non ASSR Member

Excerpta

Purpose: To present a striking case of infected pseudoarthrosis of the lumbar spine in an eighteen year old paraplegic female with a history of long segment spinal fusion, multiple decubitus ulcers and abscesses.

Case Report: Patient is an eighteen year old female who suffered a gunshot wound at the age of three, with resultant T9 paraplegia and T7 anesthesia. She underwent posterior spinal fusion of the thoracic and lumbar spine at the age of twelve for instability with subsequent anterior fusion for persistent deformity. She would develop multiple abscesses, requiring removal of the posterior hardware at the age of fifteen.

Imaging Findings: CT scan shows a pseudoarthrosis at L4/5 with a large overlying decubitus ulcer and fluid tracking to the spine. CT four weeks later shows interval osseous destruction at L4 and L5 with enlargement of the fluid collection and the patient underwent removal of anterior fusion hardware for chronic staphylococcus aureus abscess. MRI was performed three and a half months later for chronic non-healing ulcer. This showed the pseudoarthrosis with increased osseous destruction of the L4 and L5 vertebral bodies with a large intervening cavity measuring up to 13cm, containing enhancing debris, and a large sinus tract draining to the overlying chronic decubitus ulcer.

Summary: This case shows an extensive pseudoarthrosis of the lumbar spine in a paraplegic patient status post long segment spinal fusion complicated by infection from a large overlying chronic decubitus ulcer. Lack of mechanical instability in spinal infections will retard or prevent healing, predisposing to pseudoarthrosis. It has been suggested in the literature that postoperative infection after fusion increases the likelihood of pseudoarthrosis from 11.5% to 30%. More common causes of pseudoarthrosis include long segment spinal fusion, post-operative infection, neuropathic joint, and ankylosing spondylitis. It has also been suggested that female sex, long segment fusion specifically to the sacrum, and use of allograft material all increase the risk of pseudoarthrosis.

References/Financial Disclosures

No financial disclosures.

General Spine

Rishi, Agrawal, MD
Suresh, Patel, MD, Non ASSR Member

Excerpta

Spontaneous resolution of calcification of the ligamentum flavum.

Purpose

1. To present a case of spontaneous resolution of calcification of the ligamentum flavum.
2. To discuss the pathophysiology of calcification of the ligamentum flavum.

Methods & Materials

A 63-year-old female presented to the emergency department for an acute exacerbation of neck pain for the past week. She has had chronic neck pain that she attributes to a motor vehicle accident 5 years prior. The pain is sharp and radiates to the right arm.

CT was performed demonstrating a focal nodular calcification in the right ligamentum flavum, impressing upon the dorsal cord at the C4-C5 interspace. MRI was performed which showed thickening and enhancement of the dura adjacent to the calcified nodule. She was also shown to have elevated serum ESR and CRP levels.

She improved clinically in the hospital and was discharged. Follow-up MRI approximately 2 months later revealed complete resolution of the calcified nodule of the ligamentum flavum and diminished enhancement of the overlying dura.

Results

Calcification of the ligamentum flavum is a rare entity, reported more commonly in patients from Japan and the French Antilles. It is usually seen in middle-aged women and most commonly affects the cervical spine. It is thought to be due to deposition of calcium pyrophosphate within the ligamentum flavum. The calcium pyrophosphate is later transformed to hydroxyapatite. The calcification may be symptomatic if it abuts the spinal cord, and surgery is usually helpful for symptomatic patients.

Conclusion

Calcification of the ligamentum flavum is a rare entity caused by calcium pyrophosphate deposition. To our knowledge, there has been only one other case report in the literature of spontaneous resolution of calcification of the ligamentum flavum.

References/Financial Disclosures

1. Giulioni M, Zucchelli M, Damiani S. Thoracic myelopathy caused by calcified ligamentum flavum. Joint, Bone, Spine 2007; 74: 504-505
2. Saliou G, Theaudin M, Grados F, Clavel G, Lehmann P, Rutgers DR, Vallee JN. Cervico-brachial neuralgia caused by spontaneous resorption of ligamentum flavum calcification. Rheumatology 2008; 47; 107-109
3. Kawano N, Matsuno T, Miyazawa S et al. Calcium pyrophosphate dihydrate crystal deposition disease in the cervical ligamentum flavum. J Neurosurg 1988; 68: 613-20.

Interventional Spine

Matthew, T, Whitehead, MD
Nikdokht, Farid, MD, Non ASSR Member
Bassem, A, Georgy, MD, Non ASSR Member
R Sean, Pakbaz, MD, Non ASSR Member

Excerpta

Vertebral augmentation procedures for painful vertebral and sacral compression fractures have been readily described in the literature. We conducted a literature review of reported vertebral augmentation at the time of biopsy for suspected pathologic compression fractures related to metasteses. The prospective benefits of this procedure are many, including acute pain relief, osseous stabilization and prevention of fracture fragement retropulsion, cost savings, convienence, and elimination of secondary augmentation procedures at a later time. Notably, vertebral augmentation does not preclude future radiation therapy for metastases.

References/Financial Disclosures

Amar AP, Larsen DW, Esnaashari N, et al. Percutaneous transpedicular polymethylmethacrylate vertebroplasty for the treatment of spinal compression fractures. Neurosurgery 2001;49:1105â

General Spine

Charles, T, Cash, M.D.
Richard, Silbergleit, M.D., Non ASSR Member
Ay-Ming, Wang, M.D., Non ASSR Member

Excerpta

We present a case of anterior herniation of a calcified intervertebral disc at C7/T1 in an 11 year old boy. He initially presented in December of 2000 with neck pain, and was diagnosed with idiopathic disc calcification of childhood at multiple cervical levels. Subsequently, in 2006, a cervical spine radiograph demonstrated calcification only at the C7-T1 disc space. In 2009, the patient then presented with acute symptoms of pain and dysphagia following trauma in a swimming pool. Radiographs demonstrated anterior herniation of the calcified disc material with prevertebral soft tissue prominence. MRI performed the next day redemonstrated the herniation, and also showed significant mass effect and compromise of the posterior wall of the esophagus. There was no posterior herniation.

Pediatric idiopathic intervertebral disc calcification is a rare but well described entity, the incidence of which is unknown as most cases are asymptomatic. It most commonly occurs in the cervical spine. Patients can develop pain, thought to be due to fragmentation of the calcification, which is then followed by its disappearance. Management is usually conservative, with surgery reserved for those who develop posterior herniation and significant neurologic symptoms. Symptomatic anterior herniation is extremely rare, with only a few cases reported in the literature. It is speculated that C7-T1 may be particularly vulnerable due to the fixed nature of T1 compared to the more mobile C7.

General Spine

Puneet, S., Pawha, MD
Daniel, Lerner, MD, Non ASSR Member
Amish, H., Doshi, MD, Non ASSR Member

Excerpta

Medullary infarctions in the appendicular skeleton are commonly surrounded by a curvilinear border of hypointense signal on T1 and T2 weighted imaging, reflecting the reactive interface between reparative and necrotic bone (1). This appearance is well recognized in the metaphyses and epiphyses of long bones, but is rarely appreciated in vertebral body infarction (also known as vertebral osteonecrosis or avascular necrosis).

We present a 63 year old female with Gaucher disease who has deep medullary vertebral body infarction at the L4 level, sharply outlined by a hypointense border on MR imaging in the absence of vertebral collapse or cleft (Figs. 1 and 2). MRI demonstrates triangular geographic regions of signal abnormality adjacent to the central portions of both the inferior and superior endplates of a single vertebral body, a distribution known to be particularly vulnerable to ischemia. These geoqraphic abnormalities are sharply outlined by a peripheral hypointense border on both T2 weighted and T1 weighted imaging. Given the high incidence of bone infarction in patients with Gaucher disease, the presence of multiple extensive medullary bone infarctions in both lower extremities of this patient (Fig. 3), and the characteristic distribution of the abnormality, these findings are consistent with deep medullary vertebral body infarction. The patient has a surgical history significant for splenectomy and right total hip arthroplasty, with no prior spine intervention.

To our knowledge, this appearance has been reported twice in the vertebral body. One of these cases. was secondary to delayed radionecrosis of the vertebral body and spinal cord and the other case presented by Javier et al. was of uncertain etiology in a patient with lymphoma and osteoporosis (2,3). Subclinical deep medullary infarcts of the vertebral body are known to occur in patients with Gaucher disease often resulting in vertebral collapse (4).

Discussion

The double-line sign is a well known and specific MR imaging appearance of skeletal infarction typically seen in the metaphyses and epiphyses of long bones (5). This sign refers to an outer rim of low signal surrounding an inner parallel line of high signal on T2 weighted imaging. The peripheral hypointense line reflects sclerotic reparative bone, while the inner high signal is thought to represent hyperemic granulation tissue. In our case, the internal T2 hyperintensity was more diffuse rather than linear and may reflect a more longstanding appearance.

The posterior central arteries of the vertebral body supply the posterior and central portions, while the anterior central arteries supply the antero-lateral portions of the vertebral body, with the end-arterial branches of both arteries supplying the superior and inferior endplates. The watershed regions are in the center (deep medullary portion) of the vertebral body. The watershed zones and end-arterial zones of the vertebral bodies overlap in triangular (conical) regions based along the central portions of both the superior and inferior endplates (6). These regions are particularly susceptible to infarction, and correlated well with the distribution of abnormality in our case.

Gaucher disease is an autosomal recessive lysosomal storage disease caused by deficiency of the enzyme glucocerebrosidase. This leads to the accumulation of lipid-laden macrophages (Gaucher cells) with associated inflammatory response and results in chronic multi-organ damage particulary affecting the spleen, liver and bone marrow (7). Skeletal manifestations, and particularly bone infarctions, are a significant cause of morbidity in these patients. Analysis of the Gaucher registry of patients revealed that most have some degree of skeletal involvement and 25% of patients have bone infarcts (8). Infiltration with Gaucher cells may result in diffuse bone marrow infiltration replacing the normal marrow signal on MR imaging (9). The mechanism of bone infarction in these patients is incompletely understood, but may relate to direct occlusion of the microvasculature by Gaucher cells, or to marrow infiltration and resultant increased intraosseous pressure causing vascular compression and ischemia (10).

More commonly recognized imaging signs of vertebral body infarction include triangular areas of T2 hyperintensity along the endplates, vertebral body collapse, and vertebral body clefts filled with air or fluid. Sclerotic outlining of a geographic vertebral body lesion in the appropriate clinical setting should alert the radiologist to consider the diagnosis of vertebral body infarction.

References/Financial Disclosures

No financial disclosures.

1. Mitchell DG, Kressel HY, Rao VM, et al. The unique MRI appearance of the reactive interface in avascular necrosis: the double-line sign. Magn Reson Imaging. 1987; 5(suppl 1):41.
2. Warscotte L, Duprez T, Lonneux M, et al. Concurrent spinal cord and vertebral bone marrow radionecrosis 8 years after therapeutic irradiation. Neuroradiology 2002;44:245e8.
3. Javier RM, Moser T, Dietemann JL, Sparsa L, Natarajan-Ame S, Chenard MP, Kuntz JL. Multiple vertebral osteonecrosis. Joint Bone Spine. 2008 May;75(3):341-4. Epub 2007 Aug 31.
4. Wiesner L, et al. Severe pathologic compression of three consecutive vertebrae in Gaucher’s disease: a case report and review of the literature. Eur Spine J. 2003 Feb;12(1):97-9. Epub 2002 May 24.
5. Zurlo J. The Double-Line Sign. Radiology 1999; 212: 541-2.
6. Yuh WT., et al. MR imaging of spinal cord and vertebral body infarction. AJNR Am J Neuroradiol. 1992 Jan-Feb;13(1):145-54.
7. Cox TM. Gaucher disease: understanding the molecular pathogenesis of sphingolipidoses. J Inherit Metab Dis 2001;24 Suppl 2:106-21; discussion 87-8.
8. Charrow J, Andersson H et al. The Gaucher Registry: Demographics and Disease Characteristics of 1698 Patients With Gaucher Disease. Arch Intern Med. 2000 Oct 9;160(18):2835-43.
9. Maas M, Poll LW, Terk MR. Imaging and quantifying skeletal involvement in Gaucher disease. Br J Radiol. 2002;75 Suppl 1:A13-24.
10. Wenstrup RJ, et al. Skeletal aspects of Gaucher disease: a review. The British Journal of Radiology, 75 (Suppl. 1) (2002), A2â