Devoted to diagnostic and interventional spine imaging and therapeutics

Library

  • February

    14 year old female with an insidious gait disturbance.

    14 year old female with an insidious gait disturbance.

    Primary Diagnosis

    Dermoid cyst of the filum terminale.

    Secondary Diagnosis

    N/A

    Diagnosis Discussion

    Dermoid cysts are rare developmental tumors associated with midline closure defects. They are common in the lower spine in the intradural extramedullary location. In the spinal canal, 60% occur in the lumbosacral region. Patients present with progressive lower extremity neurologic and bladder sphincter dysfunction because of cord tethering. The presence of a sinus tract, sacral dimple, tufts of hair, or spina bifida can be important clues leading to the diagnosis. An associated dermal sinus occurs approximately 20% of the time. A dermoid cyst typically has a heterogeneous appearance on MR images. T1-weighted images may show hyperintensity consistent with secretions of sebaceous glands, liquid lipid metabolites, and cholesterol from decomposed epithelial cells of the cyst wall. The solid cholesterol present in the dermoid cyst can cause prolonged T1 relaxation. Solid components of a dermoid cyst are slightly hypo- to isointense compared with the spinal cord. On T2-weighted images, the areas of T1 hyperintensity may show relatively decreased signal intensity. The solid portions of a dermoid cyst are hyperintense but often heterogeneous. On CT, a dermoid cyst appears as a well-defined, well-circumscribed lesion of low attenuation. The presence of calcification or teeth can be seen on CT. Reference AJR 2000; 174:874-875.

    General Anatomic Area:

    Lumbar

    Secondary Anatomic Area:

    N/A

    Disease Category:

    Congenital

    Contributor:

    Erin Simon, MD

    Date:

    02/01/2006

    Difficulty Level:

    Medium

    Pathology Confirmed?:

    Yes
    Click here for more info

    ACR Category Number:

    N/A

    Keywords:

    inclusion cyst, lipoma,dermoid
  • January

    Two different patients who are large for dates. Fetal MRI ordered in both cases.

    Two different patients who are large for dates. Fetal MRI ordered in both cases.

    Primary Diagnosis

    Sacrococcygeal Teratoma.

    Secondary Diagnosis

    N/A

    Diagnosis Discussion

    The four images provided are obtained from two different fetuses with the same condition; a sacrococcygeal teratoma. Sacrococcygeal teratoma usually present as a mass protruding between the coccyx and the rectum, nearly always arising from the tip of the coccyx. Benign teratomas usually produce no functional impairment. 15% of patients have associated congenital anomalies like imperforate anus, sacral bone defects, duplication of uterus or vagina, spina bifida, meningomyelocele. The tumor markers are AFP and b -HCG. In contrast to the SCT in infancy, presacral teratoma in adult are extremely rare. The presence of a teratoma in the fetus may be accompanied by polyhydramnios, a uterine size larger than the expected gestational age, elevated levels of alpha-fetoprotein in amniotic fluid and associated with increased risk of - stillbirths, fetal hydrops, high output cardiac failure presumably as a result of vascular shunting through the tumour. Neonatal sacrococcygeal teratoma is a rare tumor and it being potentially malignant tumor the early diagnosis helps in management. The diagnostic imaging studies help to confirm the diagnosis of a clinically palpable sacrococcygeal mass, determine its relationship to other structures and detect metastases. Although in our case it was an intrauterine fetal demise but neonatal sacrococcygeal teratomas can be associated with a very good prognosis by utilizing prenatal diagnosis, proper intrapartum management, detailed neonatal preoperative delineation, and complete surgical excision of the tumor.

    General Anatomic Area:

    Sacrum and Coccyx

    Secondary Anatomic Area:

    N/A

    Disease Category:

    Congenital

    Contributor:

    Erin Simon, MD

    Date:

    01/01/2006

    Difficulty Level:

    Medium

    Pathology Confirmed?:

    Yes
    Click here for more info

    ACR Category Number:

    N/A

    Keywords:

    neoplasia, lipoma, teratoma,dermoid
  • September

    Progessive weakness in the left upper extremity

    Progessive weakness in the left upper extremity

    Primary Diagnosis

    Neurofibromatosis Type I

    Secondary Diagnosis

    N/A

    Diagnosis Discussion

    Neurofibromatosis (NF) is an autosomal dominant disorder, probably of neural crest origin, that affects all 3 germinal layers; therefore, it can involve any organ system. NF is not a single entity but a group of heterogeneous multisystemic neurocutaneous disorders involving both neuroectodermal and mesenchymal derivatives. Although 8 subtypes have been proposed to date, the National Institutes of Health (NIH) Consensus Development Conference has defined 2 distinct types: neurofibromatosis type 1 (NF1), or von Recklinghausen disease, which affects 85% of patients, and neurofibromatosis type 2 (NF2), or bilateral acoustic neuromas/schwannomas, which affects 10% of patients. Neurofibromas may affect any organ in the body. Discrete cutaneous and subcutaneous neurofibromas may develop at any time in life, but they occur infrequently before puberty. The total number of neurofibromas seen in adults with NF1 varies from a few to hundreds or even thousands. Additional cutaneous and subcutaneous neurofibromas continue to develop throughout life, although the rate of appearance may vary greatly from year to year. Although schwannomas and neurofibromas are histologically different, they exhibit similar MRI appearances. Both schwannomas and neurofibromas are hypointense or mildly hypointense compared to the spinal cord on T1-weighted images and heterogeneously hyperintense on T2-weighted images. The tumors may extend into the neural foramina. Within schwannomas, areas of hypointensity due to collagen deposition, hemorrhage, and densely packed Schwann cells frequently are seen. After the administration of contrast material, peripheral enhancement of schwannomas predominates. Neurofibromas enhance more homogeneously. Enhancement patterns and T2-weighted images can help differentiate schwannomas from meningiomas, but the same confidence cannot be transferred to differentiating schwannomas from neurofibromas. MRI allows noninvasive identification of intradural neurofibromas and helps determine their relationship to the neural foramina, canal, and thecal sac spinal cord. Paraspinal neurofibromas may be dumbbell shaped, fusiform, or spherical. They are slightly hyperintense relative to muscle on T1-weighted images, with a hyperintense periphery and a hypointense core on T2-weighted images. Source: www.emedicine.com/RADIO/topic474.htm.

    General Anatomic Area:

    Cervical

    Secondary Anatomic Area:

    N/A

    Disease Category:

    Neoplastic - primary

    Contributor:

    Erin Simon, MD

    Date:

    09/01/2005

    Difficulty Level:

    Easy

    Pathology Confirmed?:

    Yes
    Click here for more info

    ACR Category Number:

    N/A

    Keywords:

    neurofibroma, neurolemmomma, nerve sheath tumor, phakomatosis, elephant mans disease, von recklinghausens disease
  • August

    19 year old male with progressive neck pain.

    19 year old male with progressive neck pain.

    Primary Diagnosis

    Spondyloepiphyseal dysplasia with failed occipital cervical fusion

    Secondary Diagnosis

    N/A

    Diagnosis Discussion

    Spondyloepiphyseal dysplasia (SED) is a descriptive term for a group of disorders with primary involvement of the vertebrae and epiphyseal centers resulting in a short-trunk disproportionate dwarfism. Spondylo refers to spine, epiphyseal refers to the growing ends of bones, and dysplasia refers to abnormal growth. Dwarfing conditions are frequently referred to as short-limb or short-trunk types, according to whether the limbs or trunk is more extensively involved. SED, metatropic dysplasia, and Kniest syndrome are considered short-trunk dwarfing conditions. SED is a generalized dysplasia with primary involvement of the vertebrae and proximal epiphyseal centers. Other generalized dysplasias with significant vertebral involvement, like spondylometaphyseal dysplasia or spondyloepimetaphyseal dysplasia, affect the metaphyseal region of the long bone or metaphyseal and epiphyseal region of the long bone, respectively. The clinical and radiographic differences among the various spondylodysplasias are frequently age-related. SED congenita is a nonlethal form of congenital dwarfism characterized by typical skeletal dysplasias, vertebral changes, and ocular manifestations. It can be diagnosed at birth. In contrast, SED tarda is milder than SED congenita, late in onset, and appearance may be normal at birth. Source: e-medicine; Shital N Parikh, MBBS, Alvin H Crawford, Preeti Batra, MD.

    General Anatomic Area:

    Thoracic

    Secondary Anatomic Area:

    spine, skeleton

    Disease Category:

    Congenital

    Contributor:

    AE Flanders, MD

    Date:

    08/01/2005

    Difficulty Level:

    Medium

    Pathology Confirmed?:

    Yes
    Click here for more info

    ACR Category Number:

    N/A

    Keywords:

    dwarfism, short stature, atlanto-axial instability
  • June

    Young patient presenting with a myelopathy 2 years after a ‘stroke’.

    Young patient presenting with a myelopathy 2 years after a ‘stroke’.

    Primary Diagnosis

    Multiple spinal ‘arachnoid’ cysts following aneurysmal SAH.

    Secondary Diagnosis

    N/A

    Diagnosis Discussion

    Cysts may develop after hemorrhage, trauma & inflammation. Pre-existing or de novo? may have hemosiderin. Composed of single layer of meningothelial cells. May produce back pain/myelopathy that may be intermittent (syrinx). Arachnoid cysts also occur within the spinal canal, in which arachnoid cysts or arachnoid diverticula may be located subdurally or in the epidural space, respectively. Spinal arachnoid cysts are commonly located dorsal to the cord in the thoracic region. A cyst in this location is usually secondary to a congenital or acquired defect and is situated in an extradural location. Intradural spinal arachnoid cysts are secondary to a congenital deficiency within the arachnoid or are the result of adhesions resulting from previous infection or trauma. Microscopic examination shows that their walls are formed from a splitting of the arachnoid membrane, with an inner and outer leaflet surrounding the cyst cavity. Arachnoid cysts often are an incidental finding on imaging and, usually, patients are asymptomatic even if the cyst is quite large. The most commonly associated clinical features are headache, calvarial bulging, and seizures, with focal neurologic signs occurring less frequently. Controversy surrounds the treatment of arachnoid cysts. Some clinicians advocate treating only patients with symptomatic cysts while others believe that even in asymptomatic patients, cysts should be decompressed to avoid future complications. The most effective surgical treatment appears to be excision of the outer cyst membrane and cystoperitoneal shunting. Pathophysiology: Cystic lesions localized within the arachnoid membrane may be classified according to the location along the neural axis or by the histologic composition of the cyst wall, which is either arachnoid connective tissue or glioependymal tissue. Distribution of these two types of cysts differs along the neural axis. The cysts located along the cerebral convexity and in the spinal cord are mostly arachnoid while cysts found in the supracollicular or retrocerebellar region may be either arachnoid or glioependymal cysts. Microscopic examination of arachnoid cysts shows that the walls are formed from a splitting of the arachnoid membrane, with an inner and outer leaflet surrounding the cyst cavity. The cyst wall consists of fibrous connective tissue slightly denser than normal arachnoid tissue, with hyaline change at times. No epithelial lining is present. The outer wall of the cyst adheres loosely to the dura. The cyst wall is devoid of blood vessels, and changes of inflammation or hemorrhage seldom occur. Arachnoid cysts usually occur in association with normal arachnoid cisterns, and such cysts are congenital, arising from arachnoid clefts and arachnoid duplications. Glioependymal cysts are rare; only a few instances of interhemispheric glioependymal cysts are known. Glioependymal cysts may be associated with agenesis of the corpus callosum, heterotopia, and other dysplasias. Most likely, arachnoid cysts expand when hydrodynamic pulse waves of cerebrospinal fluid (CSF) become entrapped in arachnoid locations. The cysts may be unilocular or loculated by septations. The wall of the cyst is usually smooth. Most cysts are filled with clear colorless fluid of low protein content comparable to CSF. A few cysts may contain elevated protein content. Gross appearances of glioependymal cysts usually are indistinguishable from arachnoid cysts; however, their microscopic appearances vary. Glioependymal cysts are epithelial lined and may bear cilia, but only glial tissue is seen lining the lesion if the epithelial lining becomes dehiscent or lost. Glioependymal cysts are believed to derive from displaced neuroectodermal tissue. Histologic classification is only of systematic interest and has little bearing on prognosis. Acquired arachnoid cysts may develop following surgery, trauma, subarachnoid hemorrhage, neonatal infections and can occasionally occur in association with extra-axial neoplasm. Arachnoid cysts associated with tumors develop as a consequence of CSF loculation surrounded by arachnoid scarring, with expansion of osmotic filtration or via a ball-valve mechanism. These acquired arachnoid cysts have been described variably as acquired secondary or leptomeningeal cysts. The reason arachnoid cysts grow and become space occupying is far from clear. No inner lining is present through which active transport can take place. Neurosurgeons have observed ostia with pulsating fluid in exposed cysts suggesting a hydrodynamic flap-valve or ball-valve mechanism. Recently, cine MRI has shown abnormal fluid flow in intradural spinal arachnoid cysts presenting with cord compression. A common localization is in the floor of the middle cranial fossa, in particular, in the sylvian fissure and the parasagittal location in the interhemispheric fissure. Most cysts are unilateral, smoothly rounded, and adhere loosely to the dura. source: e-medicine Ali Nawaz Khan, MBBS, FRCP, FRCP.

    General Anatomic Area:

    Other

    Secondary Anatomic Area:

    subarachnoid space, intradural space, spinal canal

    Disease Category:

    Toxic

    Contributor:

    Maurice Castillo, MD, W. Kucharczyk MD

    Date:

    06/01/2005

    Difficulty Level:

    Difficult

    Pathology Confirmed?:

    No
    Click here for more info

    ACR Category Number:

    N/A

    Keywords:

    intraspinal cysts
  • May

    43-year-old male with a chronic history of dysesthesias and hypesthesias in all extremities. He has a chronic disease of which the most important findings are liver failure and decreased vision. Several members of his family had a similar history.

    43-year-old male with a chronic history of dysesthesias and hypesthesias in all extremities. He has a chronic disease of which the most important findings are liver failure and decreased vision. Several members of his family had a similar history.

    Primary Diagnosis

    Familial amyloid polyneuropathy.

    Secondary Diagnosis

    spinal canal, spinal cord, subarachnoid space

    Diagnosis Discussion

    Familial amyloid polyneuropathy: Deposition of amyloid in pial/subarachnoid arteries & arterioles results in destruction of the blood-cord-barrier sensory nerves & unmyelinated fibers most affected Precursors of FAP are metabolized by liver, thus liver transplantation is useful. Amyloidosis of the spinal cord predominantly involves the arteries in the subarachnoid space

    General Anatomic Area:

    Other

    Secondary Anatomic Area:

    spinal canal, spinal cord, subarachnoid space

    Disease Category:

    Metabolic

    Contributor:

    Maurice Castillo, MD

    Date:

    05/01/2005

    Difficulty Level:

    Difficult

    Pathology Confirmed?:

    Yes
    Click here for more info

    ACR Category Number:

    N/A

    Keywords:

    N/A
  • April

    10 year old with a gait disturbance.

    10 year old with a gait disturbance.

    Primary Diagnosis

    Intradural dermoid cyst with fatty filum terminale and tethered spinal cord.

    Secondary Diagnosis

    spinal canal

    Diagnosis Discussion

    There is a large intradural mass at the L3-4 level which is only mildly hyperintense on T1 weighted images. Note that the mass is contained by the thickened, fat containing filum terminale. The conus medullaris is low lying.

    General Anatomic Area:

    Lumbar

    Secondary Anatomic Area:

    spinal canal

    Disease Category:

    Congenital

    Contributor:

    Erin Simon, M.D.

    Date:

    04/01/2005

    Difficulty Level:

    Easy

    Pathology Confirmed?:

    Yes
    Click here for more info

    ACR Category Number:

    N/A

    Keywords:

    liporaschisis, dysraphic states, lipoma
  • March

    A 14 year old who had lower extremity weakness after being tackled in a pick-up football game.

    A 14 year old who had lower extremity weakness after being tackled in a pick-up football game.

    Primary Diagnosis

    Pathologic fractures and ventral epidural hematoma secondary to previously undiagnosed acute leukemia.

    Secondary Diagnosis

    marrow space disease

    Diagnosis Discussion

    Note the loss of stature of the upper thoracic vertebral bodies with the associated marrowspace signal abnormality throughout the thoracic spine on sagittal T1WI. There is a prominent anterior epidural soft tissue mass which spans multiple levels related to an associated epidural hematoma. The spinal cord is damaged showing a long segmental area of edema.

    General Anatomic Area:

    Thoracic

    Secondary Anatomic Area:

    marrow space disease

    Disease Category:

    Hematologic

    Contributor:

    Erin Simon, M.D.

    Date:

    03/01/2005

    Difficulty Level:

    Medium

    Pathology Confirmed?:

    Yes
    Click here for more info

    ACR Category Number:

    N/A

    Keywords:

    epidural hematoma,myeloproliferative condition, leukemia, marrow space disorder, trauma
  • February

    47 y/o male after a motor vehicle accident, complains of neck pain. Abnormality detected on plain radiographs.

    47 y/o male after a motor vehicle accident, complains of neck pain. Abnormality detected on plain radiographs.

    Primary Diagnosis

    Congenital absence of the right cervical pedicle. (producing a developmental facet dislocation)

    Secondary Diagnosis

    pedicle, posterior elements

    Diagnosis Discussion

    Congenital absence of a cervical pedicle is an unusual disorder with potentially confusing clinical and radiologic manifestations. The typical radiologic triad of findings included (1) the false appearance of an enlarged neural foramen owing to the absent pedicle; (2) a dysplastic, dorsally displaced ipsilateral articular pillar and lamina; and (3) a dysplastic ipsilateral transverse process. Note that the MRI supports the absence of an acute injury as there is no edema in the ligamentous structures nor is there evidence of subluxation at the involved level, (an expected finding with a UID or DFS1 type injury).

    General Anatomic Area:

    Cervical

    Secondary Anatomic Area:

    pedicle, posterior elements

    Disease Category:

    Congenital

    Contributor:

    AE Flanders, MD

    Date:

    02/01/2005

    Difficulty Level:

    Difficult

    Pathology Confirmed?:

    No
    Click here for more info

    ACR Category Number:

    N/A

    Keywords:

    congenital spine anomalies
  • January

    64 y/o male with intermittant leg weakness and incontinence. No pain or radicular complaints.

    64 y/o male with intermittant leg weakness and incontinence. No pain or radicular complaints.

    Primary Diagnosis

    Cavernous malformation of the spinal cord, aka cavernoma.

    Secondary Diagnosis

    N/A

    Diagnosis Discussion

    Intramedullary cavernomas of the cord are quite uncommon and account for between 3 and 12% of all vascular lesions of the spinal cord. Little is known of their natural history, although their tendency to produce hemorrhage and episodic symptomatic worsening is recognized. These are very uncommon; estimated incidence is 0.02-4% of the population with 3-5% occuring in the spinal cord. They are congenital and enlarge with time. There is slow flow within these cavernomas with no arterial-venous shunting. Unlike cavernomas in the brain, there is a 70% prediliction for spinal cord cavernomas in females. Can be solitary or multiple. Single lesion is usually sporadic, multiple lesions think of the familial (autosomal dominant) form. Typically present clinically in the fourth decade. Four type of presentations, acute episode with stepwise decline, acute onset with rapid deterioration, acute onset with mild deficit and gradual deterioration and slowly progressive neurologic decline. Acute symptoms attributed to hemorrhage, with back pain and delayed neurologic deterioration. Hemorrhage rate is unknown but is likely less than cerebral cavernomas (0.5 - 1.0% per year). Appearance on imaging is typical. Lobulated mass with a low signal peripheral hemosiderin rim. Variable degree of internal enhancement. When edema is present, it is likely produced by microhemorhage into parenchyma. Treatment is conservative initially. Microsurgical resection may be necessary in instances where neurologic deterioration occurs.

    General Anatomic Area:

    Thoracic

    Secondary Anatomic Area:

    conus medullaris

    Disease Category:

    Vascular

    Contributor:

    Adam Flanders, MD

    Date:

    01/01/2005

    Difficulty Level:

    Easy

    Pathology Confirmed?:

    No
    Click here for more info

    ACR Category Number:

    N/A

    Keywords:

    cavernous malformation, OCVM, cavernoma,vascular malformation, occult
  • December

    61 year old male with severe low back pain radiating into the right leg.

    61 year old male with severe low back pain radiating into the right leg.

    Primary Diagnosis

    "Classic" synovial cyst arising from facet joint.

    Secondary Diagnosis

    N/A

    Diagnosis Discussion

    A synovial cyst is a relatively uncommon cause of spinal stenosis in the lumbar spine. It is a benign condition, and the symptoms and level of pain or discomfort may remain stable for many years. Synovial cysts are benign, fluid-filled sacs that develop in the facet joints of the lumbar spine as a result of degeneration. If large enough, these sacs can cause spinal stenosis - a narrowing of the spinal canal that places pressure on spinal nerves and causes pain. A synovial cyst is a fluid-filled sac that develops as a result of degeneration in the spine. Because a synovial cyst develops from degeneration it is not often seen in younger patients. The pre-requisite is advanced degeneration of the facet articulation. The fluid-filled sac creates pressure inside the spinal canal and this in turn can give a patient all the symptoms of spinal stenosis.

    General Anatomic Area:

    Lumbar

    Secondary Anatomic Area:

    N/A

    Disease Category:

    Degenerative

    Contributor:

    AE Flanders, MD

    Date:

    12/01/2004

    Difficulty Level:

    Easy

    Pathology Confirmed?:

    Yes
    Click here for more info

    ACR Category Number:

    N/A

    Keywords:

    spine degeneration, facet joint, periarticular cyst, ganglion cyst
  • November

    73 year old female with sudden onset of neck and back pain with weakness.

    73 year old female with sudden onset of neck and back pain with weakness.

    Primary Diagnosis

    Spontaneous epidural hematoma secondary to warfarin therapy.

    Secondary Diagnosis

    N/A

    Diagnosis Discussion

    Spontaneous bleeding from anticoagulation is a known complication of coumadin (warfarin) therapy. Although it is uncommon, spontaneous epidural hematomas have been reported in the epidural space. In some instances they can cause spinal cord compression and myelopathy. The hematomas are often in the dorsal epidural space compared to traumatic spinal epidural hematomas which are usually ventral. Fluid levels are present in the hematoma in this case providing a clue that the patient has an intrinsic coagulopathy. Spontaneous hemorrhages are more commonly reported intracranially and in the retroperitoneal space.

    General Anatomic Area:

    Cervical

    Secondary Anatomic Area:

    Thoracic

    Disease Category:

    Iatrogenic

    Contributor:

    AE Flanders, MD

    Date:

    11/01/2004

    Difficulty Level:

    Medium

    Pathology Confirmed?:

    Yes
    Click here for more info

    ACR Category Number:

    N/A

    Keywords:

    anticoagulation, epidural hematoma, complications
  • October

    68 year old female with constant back pain after a fall.

    68 year old female with constant back pain after a fall.

    Primary Diagnosis

    Tuberculous osteomyelitis (spondylitis).

    Secondary Diagnosis

    N/A

    Diagnosis Discussion

    Tuberculous spondylitis or osteomyelitis (Potts disease) is usually secondary to an extraspinal source of infection. Usually, more than one vertebra is involved. The area usually affected is the anterior aspect of the vertebral body adjacent to the subchondral plate. Tuberculosis may spread from that area to adjacent intervertebral disks. In adults, disk disease is secondary to the spread of infection from the vertebral body. In children, because the disk is vascularized, it can be a primary site. Progressive bone destruction leads to vertebral collapse and kyphosis. The spinal canal can be narrowed by abscesses, granulation tissue, or direct dural invasion. This leads to spinal cord compression and neurologic deficits. Kyphotic deformity occurs as a consequence of collapse in the anterior spine. Lesions in the thoracic spine have a greater tendency for kyphosis than those in the lumbar spine. A cold abscess can occur if the infection extends to adjacent ligaments and soft tissues. Abscesses in the lumbar region may descend down the sheath of the psoas, and the abscesses are typically calcified. In this case, there is a calcified paraspinal mass (abscess) with epicenter at the destroyed endplate extending into the paraspinal region, the psoas musculature and epidural space. It is not uncommon for the patient to exhibit minimal constitutional symptoms.

    General Anatomic Area:

    Lumbar

    Secondary Anatomic Area:

    N/A

    Disease Category:

    Infectious

    Contributor:

    AE Flanders, MD

    Date:

    10/01/2004

    Difficulty Level:

    Easy

    Pathology Confirmed?:

    Yes
    Click here for more info

    ACR Category Number:

    N/A

    Keywords:

    infectious spondylitis, cold abscess, TB, Potts disease
  • September

    54 year old female with long history of left chest wall discomfort.

    54 year old female with long history of left chest wall discomfort.

    Primary Diagnosis

    Congenital thoracic arachnoid diverticulum.

    Secondary Diagnosis

    N/A

    Diagnosis Discussion

    Arachnoid diverticula are congenital outpouchings of arachnoid membrane more often found at the level of the nerve root sleeve at the cervico-thoracic junction or thoraco-lumbar junction. Rarely, as in this case, the diverticulum occurs from congenital thinning of the posterior dura resulting in herniation of arachnoid into the epidural space. Transmission of CSF pulsation produces remodeling of the adjacent bone. In some instances, these cysts are a cause of intracranial hypotension.

    General Anatomic Area:

    Thoracic

    Secondary Anatomic Area:

    N/A

    Disease Category:

    Congenital

    Contributor:

    AE Flanders, MD

    Date:

    09/01/2004

    Difficulty Level:

    Medium

    Pathology Confirmed?:

    No
    Click here for more info

    ACR Category Number:

    N/A

    Keywords:

    pseudomeningocele, epidermoid cyst,arachnoid cyst
  • August

    Constant neck pain.

    Constant neck pain.

    Primary Diagnosis

    Osteopetrosis.

    Secondary Diagnosis

    N/A

    Diagnosis Discussion

    Osteopetrosis, (Albers-Schonberg Disease or marble bone disease) is a congenital disease that prevents formation of bone marrow and results in abnormal bone development, blindness, stunted growth, abnormal dental development and fragile bones. It occurs because there is a defect in cells called osteoclasts, which are necessary for the formation of bone marrow. In patients with osteopetrosis, osteoclasts don't work correctly and the cavity for bone marrow does not form. Few blood cells form because of the absence of bone marrow. Other blood-forming organs, particularly the spleen and liver, take over in blood production. As a result, these organs become greatly enlarged. Bones look solid on X-ray, but are actually brittle. Abnormal growth results. Patients usually stop growing at age 8 or 10. Differential diagnosis includes phyknodysostosis, Pagets disease, renal osteodystrophy, osteomalacia, hypervitaminosis D, fluorosis, Hyper and hypo parathyroidism, sickle cell, myelofibrosis, mastocytosis and others.

    General Anatomic Area:

    Cervical

    Secondary Anatomic Area:

    N/A

    Disease Category:

    Metabolic

    Contributor:

    AE Flanders, MD

    Date:

    08/01/2004

    Difficulty Level:

    Easy

    Pathology Confirmed?:

    No
    Click here for more info

    ACR Category Number:

    N/A

    Keywords:

    osteosclerosis
  • July

    Back pain.

    Back pain.

    Primary Diagnosis

    Myxopapillary Ependymoma.

    Secondary Diagnosis

    N/A

    Diagnosis Discussion

    N/A

    General Anatomic Area:

    Lumbar

    Secondary Anatomic Area:

    N/A

    Disease Category:

    Neoplastic - primary

    Contributor:

    Gregory Peterman M.D.

    Date:

    07/01/2004

    Difficulty Level:

    Easy

    Pathology Confirmed?:

    Yes
    Click here for more info

    ACR Category Number:

    N/A

    Keywords:

    ependymoma, glial cell neoplasms.,intradural spine tumors
  • June

    4 y/o male pedestrian struck by car.

    4 y/o male pedestrian struck by car.

    Primary Diagnosis

    C6-7 distraction with intraspinal hematoma on CT. Expired shortly after scanning.

    Secondary Diagnosis

    N/A

    Diagnosis Discussion

    N/A

    General Anatomic Area:

    Cervical

    Secondary Anatomic Area:

    N/A

    Disease Category:

    Traumatic

    Contributor:

    Erin Simon, MD

    Date:

    06/01/2004

    Difficulty Level:

    Easy

    Pathology Confirmed?:

    Yes
    Click here for more info

    ACR Category Number:

    N/A

    Keywords:

    spine fractures, spine injury,spinal cord injury
  • May

    Teenage boy presents with Horner's Syndrome.

    Teenage boy presents with Horner's Syndrome.

    Primary Diagnosis

    Calcified extruded cervical disc compresses cord. Managed conservatively and resolved on follow up, as is most commonly the case.

    Secondary Diagnosis

    N/A

    Diagnosis Discussion

    N/A

    General Anatomic Area:

    Cervical

    Secondary Anatomic Area:

    N/A

    Disease Category:

    Traumatic

    Contributor:

    Erin Simon, MD

    Date:

    05/01/2004

    Difficulty Level:

    Easy

    Pathology Confirmed?:

    Yes
    Click here for more info

    ACR Category Number:

    N/A

    Keywords:

    disc herniation, degenerative disc disease, sympathetic plexus
  • April

    23 y/o F presented with bilateral lower extremity paraparesis after a fall.

    23 y/o F presented with bilateral lower extremity paraparesis after a fall.

    Primary Diagnosis

    Sacral lipomyeloschisis with tethered cord. Had a hemangioma superficially removed from this site as a child. No urinary s/sx.

    Secondary Diagnosis

    N/A

    Diagnosis Discussion

    Note the T2 prolongation in the spinal cord, likely ischemic from the long term tethering. The fat-placode interface is located within the spinal canal, distinguishing the lipomyeloschesis from the lipomyelomeningocele, the latter having an expanded subarachnoid space that results in the fat-placode interface being outside of the spinal canal.

    General Anatomic Area:

    Sacrum and Coccyx

    Secondary Anatomic Area:

    N/A

    Disease Category:

    Congenital

    Contributor:

    Erin Simon, MD

    Date:

    04/01/2004

    Difficulty Level:

    Medium

    Pathology Confirmed?:

    Yes
    Click here for more info

    ACR Category Number:

    N/A

    Keywords:

    meningocele, dysraphism, tethered cord
  • March

    Chronic neck pain for years.

    Chronic neck pain for years.

    Primary Diagnosis

    Multifocal chordoma.

    Secondary Diagnosis

    N/A

    Diagnosis Discussion

    Chordomas are relatively rare tumors arising from the primitive notochord remanants of the spine, therefore, they occur in predictable locations. The most common locations are at the sacrococcygeal (50%), skull base/clivus (35%) followed by the spine (15%). There is a predeliction for the C2 vertebral body. On imaging, these are well marginated, multiloculated tumors with minimal internal enhancement. In this case, the tumor is multifocal, with lesions at the level of the clivus and the lower cervical spine (C5). While the tumor is well marginated, its unrelenting propensity to invade normal anatomic spaces (e.g. the epidural space and the vertebral artery) makes treatment difficult and recurrence is common.

    General Anatomic Area:

    Cervical

    Secondary Anatomic Area:

    N/A

    Disease Category:

    Neoplastic - primary

    Contributor:

    AE Flanders, MD

    Date:

    03/01/2004

    Difficulty Level:

    Medium

    Pathology Confirmed?:

    Yes
    Click here for more info

    ACR Category Number:

    N/A

    Keywords:

    chordoma, osteocartilagenous tumors, chondrosarcoma
  • February

    Carcinoma (unknown primary) with cerebral and spinal metastases in addition to carcinomatosis. Intrinsic coagulopathy.

    Carcinoma (unknown primary) with cerebral and spinal metastases in addition to carcinomatosis. Intrinsic coagulopathy.

    Primary Diagnosis

    Spontaneous intradural hemorrhage secondary to coagulopathy.

    Secondary Diagnosis

    N/A

    Diagnosis Discussion

    Spontaneous subdural hematoma in the spinal canal is a relatively rare entity compared to the intracranial process. In many instances, the etiology remains elusive, however, some underlying processes have been associated with this syndrome. This includes spinal-dural arterio-venous fistulas, carcinomatosis with vascular/hemorrhagic primary, traumatic lumbar puncture and intrinsic coagulopathy. In this patient, intrinsic coagulopathy and carcinomatosis are both present.

    General Anatomic Area:

    Lumbar

    Secondary Anatomic Area:

    N/A

    Disease Category:

    Hematologic

    Contributor:

    AE Flanders, MD

    Date:

    02/01/04

    Difficulty Level:

    Difficult

    Pathology Confirmed?:

    Yes
    Click here for more info

    ACR Category Number:

    N/A

    Keywords:

    spontaneous hemorrhage, intradural space, subdural space,coagulopathy
  • January

    46 year old male with lumbar radiculopathy thought to be related to a disc herniation.

    46 year old male with lumbar radiculopathy thought to be related to a disc herniation.

    Primary Diagnosis

    Nerve sheath tumor, schwannoma

    Secondary Diagnosis

    Intradural Space

    Diagnosis Discussion

    This is an intradural-extramedullary neoplasm. Meningiomas and nerve sheath tumors (schwannomas and neurofibromas) comprise the overwhelming majority this subset of spinal tumors. Meningiomas arise from the arachnoid mater (a thin covering layer of the spinal cord which is located inside the dura), and are most common in middle aged and elderly women. Schwannomas and neurofibromas arise from the nerve roots which come off the spinal cord. Meningiomas and nerve sheath tumors are usually benign. Filum terminale ependymomas arise at the base of the spinal cord and may be large and adherent to many nerves, making total removal sometimes difficult. Spinal tumors may cause a variety of symptoms depending on their type, location, and rate of growth. In general pain in the neck or back followed by neurological problems, such as weakness or numbness of the arms or legs or a change in the normal bowel or bladder habits, is most common. In patients already diagnosed with cancer of another area of the body, the new onset of spinal pain may indicate a spinal fracture caused by weakening of the vertebrae by metastatic tumor. Tumors which arise inside the dura are rarely metastatic and are usually slow growing. Patients with these types of tumors may have pain for years before any neurological problems occur. The imaging characteristics; solitary mass with uniform enhancement favors schwannoma as the primary diagnosis. Meningioma and myxopapillary ependymoma should also be entertained.

    General Anatomic Area:

    Lumbar

    Secondary Anatomic Area:

    Intradural Space

    Disease Category:

    Neoplastic - primary

    Contributor:

    AE Flanders, MD

    Date:

    01/01/2004

    Difficulty Level:

    Easy

    Pathology Confirmed?:

    Yes
    Click here for more info

    ACR Category Number:

    N/A

    Keywords:

    perineural fibroblastoma, neurofibroma, phakomatosis,nerve sheath tumor
  • December

    42 year old vagrant with 2 week history of neck pain. Recently developed weakness in upper and lower extremities.

    42 year old vagrant with 2 week history of neck pain. Recently developed weakness in upper and lower extremities.

    Primary Diagnosis

    C5-6 discitis, osteomyelitis and paraspinal/epidural phlegmon resulting in spinal cord compression.

    Secondary Diagnosis

    C5-6 disc, cervical vertebral body

    Diagnosis Discussion

    Discitis is inflammation of an intervertebral disk or disk space which may lead to disk erosion. Until recently, discitis has been defined as a nonbacterial inflammation and has been attributed to aseptic processes (e.g., chemical reaction to an injected substance). However, recent studies provide evidence that infection may be the initial cause, but perhaps not the promoter, of most cases of discitis. Discitis has been diagnosed in patients following discography, myelography, lumbar puncture, paravertebral injection, and obstetrical epidural anesthesia. Discitis following chemonucleolysis (especially with chymopapain) is attributed to chemical reaction by some and to introduction of microorganisms by others. In this case, there was no history of spinal intervention. The most likely source of the infection is a hematogeneous etiology from sepsis. The pathogen in this case was s. aureus, although e. coli and other common bacteria are known to produce this condition. As the infection progressed, it caused destruction of both adjacent endplates as well as the intervertebral disc. The infected material is then allowed access to the paraspinal soft tissues and epidural space. The large inflammatory mass in the paraspinal soft tissues did not force this patient to seek treatment. However, once the epidural component reached sufficient size to compress the cervical spinal cord, the resultant weakness produced in the lower and upper extremities finally forced the patient to seek care. Note that despite the large size of the enhancing inflammatory mass (phlegmon), there is no frank abscess formation. The patient responded to antibiotic therapy and did not require surgical decompression initially.

    General Anatomic Area:

    Cervical

    Secondary Anatomic Area:

    C5-6 disc, cervical vertebral body

    Disease Category:

    Infectious

    Contributor:

    AE Flanders, MD

    Date:

    12/01/2003

    Difficulty Level:

    Easy

    Pathology Confirmed?:

    Yes
    Click here for more info

    ACR Category Number:

    N/A

    Keywords:

    infection, spondylitis, osteomyelitis
  • November

    29 year old female with constant unrelenting back pain. Prior lumbar laminectomy 5 years prior with re-operation 2 years ago.

    29 year old female with constant unrelenting back pain. Prior lumbar laminectomy 5 years prior with re-operation 2 years ago.

    Primary Diagnosis

    Adhesive arachnoiditis.

    Secondary Diagnosis

    N/A

    Diagnosis Discussion

    One of the causes of the so called "failed-back syndrome" is the condition of adhesive arachnoiditis. This iatrogenic condition was more frequent with the use of the intrathecal contrast agent known as Pantopaque. This material, when mixed with a small of amount of the patients blood (from a traumatic lumbar puncture) would frequently produce an inflammatory reaction which resulted in scarring and tethering of the intradural contents resulting in aggregation of nerve roots. In more severe cases, the matted cauda equina adheres to the inner surface of the thecal sac, resulting in the "empty sac" sign on myelography and MRI. While Pantopaque is no longer in use, arachnoiditis is still a potential complication of lumbar laminectomy and diskectomy, especially when the thecal sac is inadvertantly violated. There are no successful methods to treat arachnoiditis. It is important to recognize the pattern of arachnoiditis to exclude other potential causes of chronic back pain.

    General Anatomic Area:

    Skull Base

    Secondary Anatomic Area:

    N/A

    Disease Category:

    Iatrogenic

    Contributor:

    AE Flanders, MD

    Date:

    11/01/2003

    Difficulty Level:

    Easy

    Pathology Confirmed?:

    No
    Click here for more info

    ACR Category Number:

    N/A

    Keywords:

    scarring, granulation tissue, failed back syndrome.,dwarfism, short stature, atlanto-axial instability.,intraspinal cysts
  • October

    33 y/o male with progressive loss of motor power and sensory disturbance in arms and legs for 6 months. Now is unable to ambulate or voluntarily control bowel or bladder.

    33 y/o male with progressive loss of motor power and sensory disturbance in arms and legs for 6 months. Now is unable to ambulate or voluntarily control bowel or bladder.

    Primary Diagnosis

    Melorheostosis.

    Secondary Diagnosis

    N/A

    Diagnosis Discussion

    N/A

    General Anatomic Area:

    Thoracic

    Secondary Anatomic Area:

    N/A

    Disease Category:

    Metabolic

    Contributor:

    Adam E. Flanders, MD

    Date:

    10/01/2003

    Difficulty Level:

    Difficult

    Pathology Confirmed?:

    No
    Click here for more info

    ACR Category Number:

    N/A

    Keywords:

    hyperostosis,Dysplasias,chordoma, osteocartilagenous tumors, chondrosarcoma,meningocele, dysraphism, tethered cord,disc herniation, degenerative disc disease, sympathetic plexus, spine fractures, spine injury,spinal cord injury, ependymoma, glial cell neoplasms.,osteosclerosis, pseudomeningocele, epidermoid cyst,arachnoid cyst,infectious spondylitis, cold abscess, TB, Potts disease,anticoagulation, epidural hematoma, complications,spine degeneration, facet joint, periarticular cyst, ganglion cyst,intradural spine tumors