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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6036_Библиотеки_им_академика_М_И_Перельмана.pdf
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S. K. Singh and S. H. Fung
Fig. 6.4 Case 3: 84-year-old male with cardiac pace-
maker was imaged with CT scan to evaluate for metastatic
disease. (a) Previous MRI obtained 12years ago showing
normal bone marrow at L1 and T11. (b) CT Sagittal bone
technique reconstruction. (c) CT Sagittal soft tissue tech-
scan did not reveal any metastatic disease activity. An intraosseous disc herniation can mimic a
neoplasm in the bone marrow [2]. Often on MRI,
disc fragments can be dark on T1W images and
intermediate to bright on T2W. They can even
show enhancement, typically marginal.
Case 4
This 73-year-old female presents with an unusual
abnormality. The T7 vertebral body lesion has
a predominantly sclerotic matrix that is nonspecic (Fig. 6.5a). The anterior bony margin
on axial CT image is fairly well-dened, but not
a sharp sclerotic line (Fig. 6.5b). MRI shows
extension across the disc into the upper T8 vertebral body (Fig.6.6). A process that involves the
disc always should bring to mind the possibility of infection. However the bulk of the abnor-
nique. Suspicious new lucent areas were identied in the
L1 and T11 vertebral bodies (arrows). Subtle endplate
defects (arrowheads) indicating that the disc has herniated
through the endplate into the vertebral body (Schmorl’s
node)
mality is in the vertebral body, is well-dened,
and does not enhance (Fig.6.6). There is no soft
tissue mass outside of the spine and adjacent to
the abnormality; the endplates around the disc
are sharp and well-dened. All of these features argue against infection. A neoplasm that
can involve the disc and is high signal on T2W
images is chordoma [27], but chordomas usually have some internal enhancement [2]. The
nal histopathologic diagnosis was benign notochordal neoplasm.
Case 5
The imaging evaluation of a 57-year-old female
with back pain relies on MRI scans. Abnormalities
(dark on T1W images and mostly bright on T2W
images) involve multiple vertebral bodies and in
the lower thoracic spine extend across disc spaces
6 Imaging Metastatic Spinal Disease
77
Fig. 6.5 Case 4: CT
scan in 73-year-old
female with unknown
spine lesion. (a) Coronal
CT scan reconstruction
in bone window shows
mostly sclerotic change
in T7 lesion with small
lytic component (white
arrow). (b) Axial CT
scan in bone window
shows mainly sclerotic
change (white arrow)
ab
Fig. 6.6 Case 4: MRI
in 73-year-old female
with unknown spine
lesion. (a) Sagittal T1W
image shows areas of
low signal in T7
vertebral body (white
arrowhead). (b) Sagittal
T2 STIR image very
bright signal in T7
vertebral body which
extends across disc into
superior T8 vertebral
body (white arrow). (c)
Sagittal T1W image
with fat saturation and
after intravenous
contrast shows no
enhancement
ab c
78
cd
ab
ab
S. K. Singh and S. H. Fung
Fig. 6.7 Case 5: MRI in 57-year-old female with mul-
tiple spine lesions. (a) Sagittal T1W image shows areas
of low signal in multiple thoracic vertebral bodies
(white arrows). Compression deformity at the lowest
arrow. (b) Sagittal T2W image demonstrates involvement across multiple intervertebral discs. (c) Sagittal T2
STIR image shows many of the lesions are bright/high
signal. The epidural involvement results in signal
change in the cord (dashed white arrow). (d) Sagittal
T1W image with fat saturation and after intravenous
contrast shows epidural extension, both ventrally and
dorsally (arrowheads)
Fig. 6.8 Case 5: MRI
in 57-year-old female
lesions. (a, b) Axial
T1W images after
intravenous contrast
show extensive
paravertebral enhancing
tissue (white arrows) in
addition to epidural
disease
(Fig.6.7). The multiple disc space involvement
argues against typical metastatic disease or multiple myeloma. The typical T2W very high signal
of chordoma is not present. There is prominent
paravertebral enhancing material as well as epi-
dural involvement (Fig. 6.8). One of the lower
thoracic vertebral bodies shows considerable
deformity. Unusually for neoplasms, different
areas show different enhancement characteristics: considerable enhancement of epidural
6 Imaging Metastatic Spinal Disease
79
and paravertebral disease (Fig. 6.8a), but little
enhancement in many of the vertebral body
lesions (Fig.6.7d).
The disc involvement again raises the concern for infection. However, in contrast to bacterial spinal infection, the amount of disc disease
(Fig.6.7d) is small (little contrast-enhanced disease) in relation to the degree of vertebral body or
paravertebral disease. This pattern suggests fungus or tuberculosis as the cause [30]. Indeed, the
nal diagnosis was tuberculosis.
Case 6
The case illustrates the analysis of the imaging of an unknown spinal mass in a 42-year-old
male. The enhancing mass involves the spinal
canal, right neural foramen, and paravertebral
soft tissues (Figs.6.9 and 6.10). The ow void
of the right vertebral artery is displaced anteri-
orly (Fig.6.10b). There is involvement of the C4
vertebral body with a mild pathologic fracture
(Figs.6.10 and 6.11) as well as the right pedicle
and pars (Figs. 6.9d and 6.11c). In some areas
the bone cortex is completely gone (Fig.6.11c).
The margins of the mass in the bone are slightly
sclerotic in places (Fig.6.11) and have a narrow
margin or transition zone. CT scan does not identify an internal matrix of the mass either in the
bone or outside bone. The lack of disc involvement and the large, fairly solidly enhancing
appearance argue against infection and in favor
of neoplasm. A neoplasm that involves both bone
and adjacent soft tissues suggests an aggressive
process such as metastases, multiple myeloma,
or lymphoma [2]. The complete loss of cortical bone in areas also hints at a more aggressive
process. However, the areas of sclerotic margins
that seem well- dened or narrow favor a slowgrowing neoplasm [2]. The nal imaging diagnosis favored an aggressive neoplasm.
ab cd
Fig. 6.9 Case 6: MRI in 42-year-old male with large spine
mass. (a) Sagittal midline T1W image shows area of low signal in C4 vertebral body with epidural extension into spinal
canal (arrowhead). (b) Sagittal midline T2 STIR image
shows the lesion has bright/high signal including epidural
component (arrowhead) and mild deformity of C4 vertebral
body. (c) Sagittal right-sided T1W image shows lateral
extension and involvement of the pars interarticularis (arrow).
(d) Sagittal right-sided T2 STIR image shows lateral extension and involvement of the pars interarticularis (arrow)
80
S. K. Singh and S. H. Fung
Fig. 6.10 Case 6: MRI
in 42-year-old male with
large spine mass. (a)
Axial T1W image after
intravenous contrast
shows extensive right
spinal and paravertebral
enhancing tissue in
addition to vertebral
body and epidural
disease. (b) Axial T2W
image shows high signal
in mass with anterior
round dark ow void of
right vertebral artery. (c)
Sagittal T1W image
after intravenous
contrast shows
enhancement in the mass
a
c
b
abc
Fig. 6.11 Case 6: CT scan in 42-year-old male with large
spine mass. (a) Sagittal CT scan reconstruction in bone technique shows lytic lesion and mild deformity at C4 vertebral
body. (b) Coronal CT scan reconstruction in bone technique
shows lytic change in C4 vertebral body and in the right-sided
structures. (c) Axial CT scan image in bone technique shows
lytic change in C4 vertebral body and in the right-sided structures back to the edge of the lamina. (d) Axial CT scan image
in soft tissue technique shows the soft tissue mass extending
from within the canal to the right paravertebral region (arrows)
d
6 Imaging Metastatic Spinal Disease
81
However, the nal histopathologic diagnosis
was benign schwannoma which typically is a
soft tissue mass which can affect adjacent bone
due to slow growth including secondary benign
pressure erosion. However, schwannoma can
extend into bone or even arise within bone [31].
Case 7
In this case the imaging issues revolve around the
utility of myelography and CT scan with myelographic (intrathecal) contrast. The patient is a
60-year-old male with progressive back pain and
lower extremity weakness. He has had prior spine
stabilization with pedicle screws and rods from
T10 vertebral body to the sacrum. In such a case,
MRI is often nondiagnostic or of limited diagnos-
a b
tic value because of metallic artifact. The routine
radiographic images obtained during the myelogram show considerable epidural mass effect on
the subarachnoid space at T10 level and loosening
of T10 pedicle screws (Fig.6.12). The subsequent
CT scan (Figs.6.13, 6.14, and 6.15) demonstrates
fracture of the posterior T10 vertebral body and that
the epidural material is soft tissue density (rather
than bone or calcium). The axial CT images also
show the effects of metallic artifact on CT scans:
the details of the spinal canal are difcult to visualize at the level of the screws. The routine radiographic images obtained during the myelogram are
not as affected by the metal and clearly show the
compromise of the thecal sac (Fig.6.12).
Therefore, in cases of spinal instrumentation,
myelogram provides critical information that
may not be obtained by MRI.
Fig. 6.12 Case 7:
Myelogram in 60-yearold male with back pain
and metallic spinal
instrumentation. (a)
Frontal view of lower
thoracic spine after
subarachnoid injection
of myelographic
contrast. Loosening of
T10 pedicle screws
(arrowheads) and
epidural compromise of
the subarachnoid space
(small black arrows). (b)
Lateral view of lower
thoracic spine during
myelogram.
Circumferential epidural
compromise of the
subarachnoid space
(small black arrows) at
T10 level
82
ab
Fig. 6.13 Case 7: CT
scan with myelographic
contrast in 60-year-old
male with back pain and
metallic spinal
instrumentation. (a, b)
Coronal CT scan
reconstructions in bone
technique after
myelogram. Loosening
of T10 pedicle screws
(arrowheads)
S. K. Singh and S. H. Fung
Case 8
This example shows how the metabolic information provided by FDG-PET can help increase
specicity of imaging. A 41-year-old male with
history of lymphoma underwent MRI for back
pain. There is subtle abnormality in the dor-
sal epidural space best appreciated on the axial
images (Figs.6.16 and 6.17). However, no bone
lesion is noted. Lymphoma or metastasis in the
epidural space is most often the result of a spinal
bone mass with secondary extension into the epidural compartment. The same issue arises when
considering epidural infection: usually the result
cd
6 Imaging Metastatic Spinal Disease
83
Fig. 6.14 Case 7: CT
scan with myelographic
contrast in 60-year-old
male with back pain and
metallic spinal
instrumentation. (a–c)
Sagittal CT scan
reconstructions in bone
technique after
myelogram. Epidural
material compromising
thecal sac (white
arrowheads). Fracture of
posterior T10 vertebral
body (black arrows)
abc
ab
Fig. 6.15 Case 7: CT scan with myelographic contrast
in 60-year-old male with back pain and metallic spinal
instrumentation. (a–d) Inferior to superior axial CT
scan images at T10 after myelogram. Epidural material
of secondary spread from discitis/osteomyelitis.
Another consideration is that the epidural space
can enlarge due to venous engorgement in the
setting of intracranial (CSF) hypotension. The
clinical setting can help exclude infection and
compromising thecal sac (white arrowheads). Fracture
of posterior T10 vertebral body (black arrows). Metallic
artifact obscures details especially at level of pedicle
screws
intracranial hypotension. In this case, a subsequent 18F-FDG PET scan (Fig. 6.18) conrmed
active neoplasm as the cause of the epidural
abnormality. Lymphoma can arise secondarily or
even primarily in the epidural space [32].
84
ab
S. K. Singh and S. H. Fung
Fig. 6.16 Case 8: MRI
in 41-year-old male with
lymphoma. (a) Sagittal
midline T1W image
shows subtle low signal
in posterior epidural
space where there is
usually high signal fat
(arrows). (b) Sagittal
midline T2W image
without fat suppression
shows subtle low signal
in posterior epidural
space where there is
usually high signal fat
(arrows). (c) Sagittal
T1W image with fat
suppression after
intravenous contrast
shows enhancement in
posterior epidural space
(arrows)
abc
Fig. 6.17 Case 8: MRI
in 41-year-old male with
lymphoma. (a) Axial
T2W image shows
subtle low signal in
posterior epidural space
which is slightly
enlarged (arrows). (b)
Axial T1W image low
signal in posterior
epidural space (arrows)
Case 9
in Fig. 6.19b). However, recent fractures usually
enhance (Fig. 6.19c) which should not be con-
The nal examples demonstrate the appearances
of benign, acute fractures. The typical vertebral
body acute osteoporotic fracture has band-like,
almost linear edema (Fig. 6.19). A collection or
cleft of uid may be present (upper vertebral body
fused with neoplasm. Edema or signal abnormality
involving the pedicles is not exclusive to neoplasms but can occur in acute fractures (Fig.6.20).
In uncertain cases, the options include biopsy, 18FFDG PET scan, and follow-up imaging.
6 Imaging Metastatic Spinal Disease
Fig. 6.18 Case 8:
18
F-FDG PET in
41-year-old male with
lymphoma. Axial images
show high metabolic
activity in posterior
thoracic epidural space
(arrows)
85
Fig. 6.19 Case 9:
70-year-female with
acute back pain from
benign fracture. (a)
Sagittal midline T1W
image shows low signal
in deformed upper T11
vertebral body where
there is usually high
signal fat (arrow). (b)
Sagittal midline STIR
image shows high signal
in deformed upper T11
vertebral body (arrow).
(c) Sagittal T1W image
with fat suppression
after intravenous
contrast shows
enhancement in T11
vertebral body (arrow)
abc