Interventional Spine

Jonathan, A, Flug, MD, MBA
Douglas, Katz, MD, Non ASSR Member
A Orlando, Ortiz, MD, MBA, Non ASSR Member

Excerpta

Purpose

To report a case of a spinal plasmacytoma which resembled infectious osteomyelitis on imaging.

Methods & Materials

Case Report

Results

A 41 year old female with a history of hepatitis C, diabetes mellitus, intravenous heroin abuse and anemia presented to the emergency department with a several day history of worsening right lateral rib wall pain. The patient also reported a history of difficulty urinating and a 40-lb weight loss over a 7 month period. The patient was HIV negative, however was currently using intravenous heroin three times daily. The patientâ

General Spine

Sean, C., Chang, M.D.
Mark, Shiroishi, M.D., Non ASSR Member
Adrian, Correa, M.D., Non ASSR Member
Meng, Law, M.D., Non ASSR Member
Paul, E., Kim, M.D., Non ASSR Member
John, L., Go, M.D., Non ASSR Member

Excerpta

Purpose

To report a rare case of inflammatory pseudotumor involving the thoracic spine.

Methods & Materials

A 57 year old male presents with a one year history of gradual weakness of the bilateral lower extremities. At the time of presentation, the patient had rapid progression of leg weakness, urinary retention and bowel incontinence over a one week period. MR imaging of the thoracic spine demonstrated a dural based circumferential mass within the central canal extending from the C4 to T5 levels causing compression of the thoracic cord. The mass demonstrated isointensity on T1 weighted images and marked hypointensity on T2 weighted images with heterogenous, avid enhancement. A second area of involvement was also seen at the T8-T11 levels.

Results

The patient underwent emergency decompression of the thoracic spine, and tissue sample was obtained. Pathology demonstrated acute and chronic areas of inflammation and fibrosis with infiltration of a polyclonal population of lymphocytes and plasma cells diagnostic for inflammatory pseudotumor of the thoracic spine. The incidence of inflammatory pseudotumor of the spine is rare with a few isolated case report within the literature. This presentation will describe the imaging findings and frequency of inflammatory pseudotumor of the spine.

Conclusion

Inflammatory pseudotumor is a rare phenomenon, but should be included in the differential diagnosis of dural based lesions of the spine.

References/Financial Disclosures

1. Claude Gilliard, M.D., Beatrijs De Coene, M.D., Joseph Bou Lahdou, M.D., Yves Boutsen, M.D., Henri Noël, M.D., and Catherine Godfraind, M.D. Cervical epidural pseudotumor and multifocal fibrosclerosis-Case report and review of the literature. J Neurosurgery 2000;93:152-156
2. Mahjouba Boutarbouch MD, Yasser Arkha MD, Lobna Rifi MD, Said Derraz MD, Abdessamad El Ouahabi MD and Abdeslam El Khamlichi MD. Intradural cervical inflammatory pseudotumor mimicking epidural hematoma in a pregnant woman: case report and review of the literature. Surgical Neurology. 2008 69;3:302-305
3.Giovanni Liccardo, Pierpaolo Lunardi, Agazio Menniti, Roberto Floris, FrancescoSaverio Pastore and Bernardo Fraioli. Calcifying pseudo-tumor of the spine: description of a case and review of the literature. European Spine Journal;12:548-551

General Spine

Amish, H, Doshi, MD
Kapil, R, Desai, MD, Non ASSR Member
Sheeraz, Qureshi, MD, MBA, Non ASSR Member
James, C, Wittig, MD, Non ASSR Member

Excerpta

A 29-year-old male radiology resident presented with a several month history of lower back pain which was worse at night and improved with non-steroidal anti-inflammatories. A CT and MRI were performed which demonstrated the presence of a small ossific focus (black arrow) overlying the junction of the right L1 lamina with its respective spinous process. A small amount of reactive sclerosis and edema were identified within the lamina on the CT and MR (white arrow), respectively. This focus demonstrated significant uptake on technetium-labeled bone scan. It was unclear at this time whether this focus resided within bone or was centered in the ligamentous structures. Surgical exploration, resection and pathologic analysis demonstrated the presence of a subperiosteal osteoblastoma. Osteoblastomas are a rare, painful tumor of the spine. To our knowledge, there have been no reported cases of subperiosteal osteoblastoma within the spine. Though, osteoblastomas have a typical appearance on cross-sectional imaging, when it occurs in an subperiosteal location recognition and diagnosis can be confusing. Awareness of this entity and this unusual presentation can lend to accurate future diagnosis.

General Spine

Jonathan, D, Steinberger, MD
Amish, Doshi, MD, Non ASSR Member
Aren, Gottlieb, MD, Non ASSR Member
Bradley, Delman, MD, Non ASSR Member
Puneet, Pawha, MD, Non ASSR Member

Excerpta

Case:

We present the case of a 26-year-old female G3P0, with history of infertility and 2 spontaneous abortions, who underwent clomid-assisted pregnancy, seen with twin gestation at 22 weeks. Patient presented to her Ob/Gyn with a ten day history of lower back pain. The patientâ

General Spine

Karuna, Shekdar, MD
Lucy, Rourke-Adams, MD, Non ASSR Member
Lee, Sutton, MD, Non ASSR Member
Erin, Schwartz, MD, Non ASSR Member

Excerpta

Central neurocytoma is a neuronal neoplasm that occurs supratentorially, with the most common location in the lateral or third ventricles. Although there have been few case reports of this in the cord, it is exceedingly rare. We present a rare case of an intra-medullary anaplastic neurocytoma of the spinal cord.

Purpose

To present a rare case of an intra-medullary anaplastic neurocytoma of the spinal cord.

Methods & Materials

A 11 year old boy presented to our institute for a CT evaluation of his thoracic spine following trauma. There was history of collision while playing football two weeks earlier, after which he complained of pain awakening him from sleep. He described pain between his shoulder blades. He was neurologically intact on examination.

Results

Unenhanced CT evaluation revealed abnormal expansion of the bony spinal canal from C4 to T4, and expansion of the cord with heterogenous density and mineralization worrisome for an intra-medullary cord neoplasm. The diagnostic considerations included an astrocytoma and ependymoma. Futher evaluation with MR imaging was recommended.

MR imaging without and with contrast, demonstrated an expansile, intra-medullary cord lesion with heterogeneous signal and enhancement extending from C4 to the T3 levels. This was felt to most likely represent an intra-medullary cord tumor such as an astrocytoma or ependymoma.

The patient underwent C4-T2 laminectomy and excision of intramedullary spinal tumor. At surgery, the frozen section evaluation was in favor of an ependymoma. The final histo-pathological evaluation revealed it to be an anaplastic neurocytoma.

Conclusion

Central neurocytoma is a neuronal neoplasm that occurs supratentorially, with the most common location in the lateral or third ventricles. Although there have been few case reports of this in the cord, it is exceedingly rare.

References/Financial Disclosures

1: Tatter SB, Borges LF, Louis DN. Central neurocytomas of the cervical spinal cord. Report of two cases. J Neurosurg. 1994 Aug;81(2):288-93.

2: Coca S, Moreno M, Martos JA, Rodriguez J, Barcena A, Vaquero J. Neurocytoma of spinal cord. Acta Neuropathol. 1994;87(5):537-40.

Nothing to disclose

General Spine

Sean, C, Chang, M.D.
Jesse, G. A., Jones, M.D., Non ASSR Member
Mark, S., Shiroishi, M.D., Non ASSR Member
Warren, L., Garner, M.D., Non ASSR Member
Lerner, Alexander, M.D., Non ASSR Member
Go, L., John, M.D., Non ASSR Member

Excerpta

Purpose

To present a rare case of spinal cord infarction following electrocution as demonstrated by MRI diffusion weighted imaging.

Methods & Materials

The clinical documents and imaging studies of a 43 year old man brought to the trauma center in a cervical collar after sustaining third degree burns of his scalp, torso and lower extremities following high-voltage electrocution were reviewed.

Results

On admission, the patient was observed to voluntarily move all four extremities. MRI of the cervical spine at that time demonstrated a normal cervical cord. He was subsequently intubated and sedated for several days for burn surgery and ICU care. Upon extubation, he was noted to have quadriparesis. Repeat MRI at this time revealed interval development of spinal cord infarction as evident by increased cord diameter, increased T2 signal of the substance of the cord, which restricts on diffusion weighted imaging.

Conclusion

Spinal cord injury is thought to be a rare complication of electrocution. Thermal coagulation of small vessels supplying the spinal cord leading to infarction appears to play a major pathophysiologic role. Contributing factors such as direct nerve injury from electrical current have also been proposed. Patients who suffer immediate neurological symptoms typically recover over several days, whereas delayed onset heralds lasting injury. Further studies are needed to predict the subpopulation of electrocution victims prone to develop spinal cord injury and devise preventative strategies. To the best of our knowledge this is the first example in the literature documenting the use of diffusion weighted imaging to confirm spinal cord infarct following electrocution.

References/Financial Disclosures

1.Silversides J. The neurological sequelae of electrical injury. Can Med Assoc J 1964;91:195â

Interventional Spine

Hyung-Seok, Kim, M.D.
Jin-Hee, Park, M.D., Non ASSR Member
Pyung-Jin, Kim, M.D., Non ASSR Member
Ji-Youn, Yu, M.D., Non ASSR Member
Sang-Ho, Lee, M.D., Non ASSR Member

Excerpta

Subdural fluid collection after the lumbar spinal surgery is a rare complication. Subdural space in the spine is not a potential space since the creation of a cleft in this area of the meninges is the result of tissue damage.

Purpose

To introduce the clinical symptom, MR findings and the CT-guided percutaneous aspiration of a patient of subdural fluid collection after lumbar fusion surgery.

Methods & Materials

A 70-year-old female patient with severe radiating leg pain ten days after the lumbar fusion surgery. The MR images on 13 days after the operation showed posterior intradural fluid collection from T-L junction to S2 level with ventral shifting of the conus medullaris and nerve roots. Axial images demonstrated lobulating biconcave fluid collection in the subdural space not subarchonid or epidural spaces. We performed percutaneous aspiration under the CT-guidance.

Results

We aspirated about 14 cc thin bloody colored fluid at L3 and L5 level under the CT-guidance technique. The MR images after the aspiration demonstrated decreased intradural fluid and dorsal shifting of the conus medullaris and the roots. The patient’s symptom was partially improved immediately, and more improved gradually. There was no growth of the organism in the aspirated fluid.

Conclusion

The subdural fluid collection in the spine is a rare complication after the lumbar surgery. But it could induce severe pain of the patient. CT-guided percutaneous aspiration is the good method of the treatment of the subdural fluid collection.

References/Financial Disclosures

1. On the Question of a Subdural space. D.E.Haines. The Anatomical Record 1991;230:3-21
2. Acute Spinal Subdural Hematoma: MR and CT Findings with Pathologic Correlates. M.Judith Donovan Post, Jose L.Becerra, Parley W. Madsen et al. AJNR 1994;15:1895-1905
3. Traumatic Spinal Subdural Hematoma with Spontaneous Resolution. KS Hung, CC Liu, CH Wang et al. Spine 2002;27:E534-538
4. Acute Nontraumatic Spinal Subdural Hematomas in Three Patients.X Morandi,L Riffaud, E Chabert, G Brassier. Spine 2001;26:E547-551
5. The Importance of MRI Findings for the Diagnosis of Nontraumatic Lumbar Subacute Subdural Hematomas. PJ Johnson, HJ McConnnel, EG Graham, LG Leibrock. Acta Neurochirurgica 1991;113:186-188

General Spine

Hyung-Seok, Kim, M.D.
Jin-Hee, Park, M.D., Non ASSR Member
Pyung-Jin, Kim, M.D., Non ASSR Member
Ji-Youn, Yu, M.D., Non ASSR Member
Sang-Ho, Lee, M.D., Non ASSR Member

Excerpta

Symptomatic vertebral hemangomas are extremely rare and, when they occur, are predominantly in the thoracic spine. Less than 1% of the vertebral hemangiomas caused neurologic symptoms from spinal cord or nerve root compression and they can lead to serious neurologic deficits if not treated immediately.

Purpose

To introduce a symptomatic cavernous hemangioma of L3 vertebra with epidural extraosseous extension, which was proved pathologically after operation.

Methods & Materials

The patient is a 58-year-old woman who had slowly aggravating back pain, right leg pain with numbness and tingling sensation for ten months. Her symptom was aggravated in a standing position, and it was subsided when she was in the supine position. Plain radiographs, CT and MRI were performed before surgery.

Results

Plain lateral radiographic film demonstrates the coarse vertical striations in L3 body. Axial and sagittal reconstructed CT images show the â

General Spine

Asif, Abdullah, M.D.
Husam, Semaan, M.D., Non ASSR Member
Hassan, Semaan, M.D., Non ASSR Member
Haitham, Elsamaloty, M.D., Non ASSR Member
Ahmad, Aouthmany, M.D., Non ASSR Member
Yogesh, Patel, M.D., Non ASSR Member

Excerpta

Coccidioides immitis is a dimorphic fungus that resides as a saprophyte in arid, alkaline soils. It is endemic to the American Southwest and Central and South America. Its reported disease prevalence is increasing. There are approximately 100,000 new infections diagnosed each year, of which one-third are symptomatic. Of the symptomatic individuals approximately 5-10% will develop a serious pulmonary infection and of those that have a serious infection less than 1% will develop chronic pulmonary disease and/or extrapulmonary dissemination. The main organs of involvement disseminated coccidioidomycosis are the skin, lymphoid tissue, the central nervous system, and the musculoskeletal system. Imaging plays a central role in defining the extent of dissemination. We describe an extremely rare case of disseminated coccidioidomycosis of the spine in a 26-year old immunocompetent patient.

Purpose

To report a rare case of disseminated coccidioidomycosis in an immunocompetent patient.

Methods & Materials

Patient was a 26-year old man, who had lived in Arizona previously, presented with facial lesions as well as neck and back pain. He noticed a skin lesion six months ago that has been getting worse. Physical examination showed marked spinal stiffness and tenderness to palpation at C2, C5 spinous processes as well as at thoracic and lumbar levels. The remainder of the physical examination including the neurological evaluation was within normal limits. Laboratory tests showed elevated C-reactive protein and white blood cell count. Magnetic resonance imaging studies demonstrated extensive paravertebral abscesses involving the cervical, thoracic, and lumbar spine as well as involvement of the vertebral bodies and posterior elements.
A CT-guided drainage of the left paravertebral C6 level fluid collection was performed and the cultures confirmed coccidioidomycosis. Patient was treated with radical surgical debridement, spinal stabilization with corpectomy at C5 level with concomitant local and systemic chemotherapy.

Results

An initial x-ray of cervical spine showed C5 vertebral plana with prevertebral soft tissue swelling. Subsequent CT of cervical spine demonstrated near complete destruction of C5 vertebral body, severe kyphosis, epidural as well as retropharyngeal soft tissue involvement.
MR imaging demonstrated a pathologic fracture with the complete destruction of the C5 vertebral body and inflammatory involvement of adjacent C4-C5 intervertebral disc. C5 retropulsion with mass effect on the spinal cord with cord edema was seen. Extensive prevertebral soft tissue involvement was seen at C4 through C6 levels. C1 through C4 posterior elements as well adjacent soft tissue demonstrated an abscess cavity with adjacent inflammatory changes. Extensive involvement of thoracic vertebral bodies as well as paravertebral soft tissue was noted. The right scapula demonstrated high signal intensity lesion on T2W images consistent with inflammatory involvement. Mediastinal adenopathy was also appreciated. Osseous involvement of multiple lumbar vertebral bodies as well multiple paraspinous fluid collection was seen. Extensive involvement of the sacrum and iliac bones was also appreciated.
A whole body nuclear medicine scan demonstrated multiple areas of increased activity in the cervical, thoracic, upper lumbar spine, right ischium, and the left acetabulum. In light of patient’s history, these findings were most consistent with multiple foci of infection.

Conclusion

The prevalence and distribution of Coccidioidomycosis is increasing as is the likelihood of seeing its often unique and bizarre clinical manifestations and complications. Most patients are asymptomatic and disseminated form of disease is rare. The symptoms of disseminated disease develop insidiously and delay in diagnosis of several months is not a rarity. If included in the differential diagnosis, the disease can be recognized earlier and the likelihood of numerous complications can be avoided. Once spinal involvement is diagnosed, a regimen of aggressive surgical debridement as well as consistent chemotherapy must be employed if remission and/or eradication of the illness are sought.

Lesions are usually well-circumscribed but may present with an ill-defined border and permeative type of bone destruction, especially in the spine. Plain radiographs are useful in the initial evaluation, nuclear medicine bone scan can identify disseminated disease, and CT and MRI are effective in determining soft tissue involvement and spinal abnormalities.

Radionuclide scanning can identify disseminated lesions that are clinically unsuspected. False-negative bone scans in disseminated disease have not been reported. Therefore, when disseminated disease is suspected, skeletal scintigraphy should be the initial mode of examination, followed by magnetic resonance imaging.

References/Financial Disclosures

1. Galgiani J, 2005. Coccidioides species in: Principals and practices of infectious disease by Mandell, Bennett, and Dolin: Philadelphia: Elservier 2005; 3040-3050.

2. Crum, NF, Lederman, ER, Stafford, CM, et al. Coccidioidomycosis: A descriptive survey of a reemerging disease. Clinical characteristics and current controversies. Medicine (Baltimore) 2004; 83:149

3. DiCaudo DJ. Coccidioidomycosis: a review and update. J Am Acad Dermatol 2006;55:929â

General Spine

Asif, Abdullah, M.D.
Hassan, Semaan, M.D., Non ASSR Member
Kristan, Jenkins-Mosure, M.D., Non ASSR Member
Haitham, Elsamaloty, M.D., Non ASSR Member
Terrence, Lewis, M.D., Non ASSR Member

Excerpta

Neurothekeomas are distinctive benign predominantly cutaneous tumors that most often occur in the skin of the face and arms of young adults. Intraspinal neurothekeomas are extremely rare. We report CT Myelogram and MR imaging findings of an extremely rare case of neurothekeoma of the cauda equina, which is a very unusual tumor of probable nerve sheath origin.

Purpose

To report an extremely rare case of intraspinal neurthekeoma.

Methods & Materials

We describe MR and CT Myelogram findings of an intraspinal neurothekeoma occurring in a 49 year-old white female who presented with back pain.

Results

A 49-year old white female presented with severe low back pain radiating into right hip and leg for one month. Patient also had complains of numbness and tingling in her right leg. The pain was exacerbated by activity. She had some difficulty initiating micturition. Physical examination revealed a flexed posture. No additional abnormalities were illicited. Laboratory values were within limits of normal.
MR imaging of the lumbar spine was performed which showed a well-circumscribed intradural extramedullary mass at the L1-L2 level which measured 2.1cm x 1.3cm x 1.3cm nearly filling the entire thecal sac with mass effect on adjacent nerve roots. It showed predominantly high signal on T2W imaging (Figs.1B & 2A) with internal areas of low signal intensity and isointense signal to muscle on T1W imaging (Figs. 1A & 2C). Post contrast enhanced T1W MR images showed avid enhancement (Figs. 1D & 2D) with subtle areas of internal non-enhancement (Fig. 1C). Differential considerations at this point included an epyndymoma, schwanoma, neurofibroma, and paraganglioma. Neurosurgical consultation requested a preoperative CT Myelogram examination which demonstrated a well circumscribed soft tissue density mass at L1-L2 level filling the thecal sac with small rim of intrathecal contrast along the periphery of the mass (Figs. 3A & 3B).
Gross analysis of the lesion showed a dark brown and tan mass with smooth consistency. Microscopically, tumor demonstrated a lobulated appearance with a peripheral capsule. The lobules were primarily composed of delicate spindle cells separated by a myxoid matrix. In addition to the myxoid nodules, areas of spindled cells without myxoid change and areas of loose stellate cells were seen. There was no convincing palisading of tumor cells. Ultrastructural examination showed long, intertwined cell processes lined by basal lamina, and numerous Luse bodies. These findings were consistent with a mixed cellular and myxomatous form of neurothekeoma. Patient remained asymptomatic at 6-month and 2-year clinical follow-up without evidence for recurrence on MR imaging follow-up

Conclusion

Intraspinal neurothekeomas mimic ependymoma, schwanoma, and paragangliomas in radiologic appearance and may be included in the differential diagnosis of soft-tissue masses of cauda equina. Clinically, neurothekeomas exhibit benign behavior and are successfully treated in most cases with complete excision. Local recurrence is extremely uncommon when there are wide surgical margins Additionally, neurosurgeons and neuroradiologists should be familiar with the benign nature of these masses.

References/Financial Disclosures

Kim H-J, Baek CH, Ko YH, and Choi JY. Neurothekeoma of the Tongue: CT, MR, and FDG PET Imaging Findings. Am J Neuroradiol. 2005; 27:1823â