a journey down the canal: radiological assessment of spinal

A Journey Down The CanalA Journey Down The Canal

Radiological Assessment of Radiological Assessment of Spinal Cord MassesSpinal Cord Masses

John BerryJohn Berry--CandelarioCandelario HMS IIIHMS IIIGillian Lieberman, MD BIDMCGillian Lieberman, MD BIDMC

Objectives

Patient reviewPatient review

Anatomy of the spineAnatomy of the spine

Imaging techniquesImaging techniques

Classification of spinal massesClassification of spinal masses

Patients revisited!Patients revisited!

Let’s meet our 2 patients

Patient #1 – History and presentationHD is a 67 year old female who presents with HD is a 67 year old female who presents with

lower extremity weakness for the past six lower extremity weakness for the past six months It worsened in the last two months months It worsened in the last two months resulting in frequent nonresulting in frequent non--traumatic falls. traumatic falls.

Pertinent positive is urinary urgency.Pertinent positive is urinary urgency.PMH includes previous back surgery of unknown PMH includes previous back surgery of unknown

reasons.reasons.Received Received myelogrammyelogram, however results unavailable., however results unavailable.PE remarkable for decreased sensation from T7 PE remarkable for decreased sensation from T7

down.down.

Patient #2 – History and presentationCR is a 40 year old male who reported CR is a 40 year old male who reported

atypical leg soreness after riding of an allatypical leg soreness after riding of an all-- terrain vehicle. Soreness was greater than terrain vehicle. Soreness was greater than after similar episodes of riding. after similar episodes of riding. Progressive weakness developed in the Progressive weakness developed in the right leg.right leg.

Pertinent negatives are no difficulty with Pertinent negatives are no difficulty with bowel or bladder function.bowel or bladder function.

PMH and PE unremarkable.PMH and PE unremarkable.

Indications for imaging the spineIndications for imaging the spine

Increased weakness in the lower Increased weakness in the lower extremitiesextremities

Changes in bowel or bladder functionChanges in bowel or bladder function

Saddle anesthesia Saddle anesthesia –– Sensory loss Sensory loss occurring over the buttocks, posterioroccurring over the buttocks, posterior-- superior thigh and superior thigh and perianalperianal regionregion

Imaging TechniquesImaging Techniques

Imaging Modalities of the SpineImaging Modalities of the SpineIMAGING IMAGING MODALITYMODALITY

ADVANTAGESADVANTAGES DISADVANTAGESDISADVANTAGES

Plain filmPlain film Modest visualization of the Modest visualization of the vertebrae, low cost, fastvertebrae, low cost, fast

No clarity of the fluids and soft No clarity of the fluids and soft tissue, radiation exposuretissue, radiation exposure

CTCT Clear visualization of bony Clear visualization of bony structures, some visualization of structures, some visualization of soft tissue structuressoft tissue structures

Limited visualization of soft tissue, Limited visualization of soft tissue, radiation exposure,radiation exposure,

MRIMRI Best modality for soft tissue Best modality for soft tissue visualization, no radiation visualization, no radiation exposure. Test of choice for exposure. Test of choice for lower extremity weakness and lower extremity weakness and bowel/bladder dysfunction.bowel/bladder dysfunction.

Difficult to evaluate cortical bone Difficult to evaluate cortical bone and calcifications, expensive and calcifications, expensive relative to other modalitiesrelative to other modalities

CT CT MyelographyMyelography

Used when MRI is Used when MRI is contraindicated, allows contraindicated, allows visualization of spinal cord and visualization of spinal cord and nerve roots, can evaluate for nerve roots, can evaluate for lesions within the spinal canallesions within the spinal canal

Invasive, involves the injection of Invasive, involves the injection of contrast into the contrast into the thecalthecal sacsac

LetLet’’s review spine s review spine anatomy!anatomy!

Anatomy Review: Basics 31 Pairs of Spinal Nerves

8 cervical12 thoracic5 lumbar5 sacral1 coccygeal

Conus tapers at ~L1/2

Cauda equina falls freely at this level

Anatomy Review: Vertebrae and Spinal nerves

http://www.jefferson.edu/neurosurgery/documents/Spinal%20Cord%20Tumors.pdfhttp://www.backpain-guide.com/Chapter_Fig_folders/Ch05_Anatomy_Folder/

Ch5_Images/05-4_Overall_Spine.jpg

Anatomy Review: Axial view of vertebrae

Eisen, A. Anatomy and localization of spinal cord disorders. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2009

Anterior

Posterior

Anatomy Review: Cross section of Anatomy Review: Cross section of spinal cord spinal cord –– Spinal nervesSpinal nerves

Eisen, A. Anatomy and localization of spinal cord disorders. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2009

Anterior

Posterior

Anatomy Review: Cross section of spinal cord – White matter tracts

Eisen, A. Anatomy and localization of spinal cord disorders. In: UpToDate, Basow DS (Ed) UpToDate Waltham MA 2009

Posterior

Anterior

Spinal Cord MassesSpinal Cord Masses

Spinal Cord MassesAnatomic Classification

1. Extradural

Arise outside the dura

From the osseous spine, intervertebral disc and adjacent soft tissue

Relevant imaging findings: Focal, exophytic mass displacing the thecal sac

2. Intradural extramedullary

Arise inside the dura but outside the spinal cord

DISPLACES THE SPINAL CORD

3. Intradural intramedullary

Arise from the spinal cord

Most common lesions are malignant neoplasms in the form of glioma

IntraspinalIntraspinal MassesMasses

IntramedullaryIntradural

Extramedullary Extradural

http://www.mayoclinic.org/spinal-cord-tumors/types.html

Key:

3a-Develops outside spinal cord but potentially compresses nerves and blood vessels

3b-Invades from the bone. Typical of metastatic tumors

3c-Develops along soft tissue between the vertebrae.

Spinal Cord Masses Spinal Cord Masses -- SubcategoriesSubcategories

BenignBenign

Cystic (and other Cystic (and other tumorliketumorlike masses)masses)

MalignantMalignant

MetastasesMetastases

LetLet’’s identify a list of s identify a list of specific masses in these specific masses in these

subcategories.subcategories.

Spinal TumorsSpinal TumorsExtraduralExtradural IntraduralIntradural

ExtramedullaryExtramedullaryIntraduralIntraduralIntramedullaryIntramedullary

Benign HemangiomaHemangiomaOsteoidOsteoid osteomaosteomaOsteochondromaOsteochondroma

MeningiomaMeningiomaNerve sheath tumorsNerve sheath tumors

RareRare

Cystic Synovial cystSynovial cystArachnoidArachnoid cystcystEosinophilicEosinophilic granulomagranuloma

EpidermoidEpidermoidDermoidDermoid

Multiple SclerosisMultiple SclerosisSyringomyeliaSyringomyeliaTransverse Transverse myelitismyelitis

Malignant ChordomaChordomaLymphomaLymphomaSarcomaSarcoma

RareRare EpendymomaEpendymomaAstrocytomaAstrocytomaHemangioblastomaHemangioblastoma

Metastases BreastBreastLungLungProstateProstate

Seeding from the CNSSeeding from the CNS BreastBreastLungLungLymphomaLymphomaLeukemiaLeukemia

ExtraduralExtradural

Benign

HemangiomaHemangioma

OsteoidOsteoid osteomaosteoma

OsteochondromaOsteochondroma

PACS, BIDMC

Companion Patient #1: Hemangioma on CT

CT with IV and oral contrast – Revealed a mass with low attenuation. Further work up only necessary if the patient was symptomatic.

Cysts and others tumorlike masses

Synovial cysts

Arachnoid cysts

Eosinophilic granuloma

Companion Patient #2: Arachnoid on MRI

Produced by URMC Radiology

http://www.urmc.rochester.edu/SMD/rad/Hollar_HTML/sld028.htm

T1-weighted – Revealed a hypointense signal of a well-circumscribed mass that was compressing the spinal cord.

T2-weighted – Revealed a hyperintense signal of the same lesion.

Malignant

ChordomaChordoma

LymphomaLymphoma

SarcomaSarcoma–– OsteosarcomaOsteosarcoma–– ChondrosarcomaChondrosarcoma–– Multiple MyelomaMultiple Myeloma

Companion Patient #3: Chondrosarcoma on MRI

T2 Sagittal with contrast– Demonstrates a large, well- circumscribed mass compressing the spinal cord. It enhances with a mixed signal but is mostly hyperintense.

Produced by URMC Radiology


Metastases

MOST COMMON EXTRADURAL MOST COMMON EXTRADURAL MALIGNANT CANCERMALIGNANT CANCER

Breast, lung, and prostate cancer are the Breast, lung, and prostate cancer are the most prevalentmost prevalent

Initial site of lesion are the vertebral Initial site of lesion are the vertebral bodiesbodies

MetastasesMetastases

T2 Sagittal with contrast – Demonstrates an enhancing hyperintense signal. It is a poorly-marginated mass compressing the spinal cord.

Produced by URMC


IntraduralIntradural ExtramedullaryExtramedullary

Benign

MeningiomaMeningioma

Nerve sheath tumorsNerve sheath tumors–– NeurofibromaNeurofibroma–– SchwannomaSchwannoma

Meningioma

Produced by URMC


T1 AXIAL with contrast – Demonstrates displacement of the spinal cord

T1 SAGITTAL with contrast – Demonstrates a moderately enhancing, well-circumscribed mass.

Cysts and other masses

EpidermoidEpidermoid

DermoidDermoid

Dermoid

T2 Sagittal T1 SagittalProduced by URMC


Metastases

Can arise from inside or outside the CNSCan arise from inside or outside the CNS

Usually findings are discovered in the Usually findings are discovered in the lumbosacrallumbosacral regionregion

IntraduralIntradural IntramedullaryIntramedullary

Cysts and other masses

Multiple SclerosisMultiple Sclerosis

SyringomyeliaSyringomyelia

Transverse Transverse MyelitisMyelitis

Syringomyelia

Produced by URMC


T1 Sagittal with contrast T2 Sagittal

Malignant

EpendymomaEpendymoma

AstrocytomaAstrocytoma

HemangioblastomaHemangioblastoma

Astrocytoma

Produced by URMC


T2 Sagittal T2 Sagittal T1 Sagittal

Metastases

RareRare

Primary malignancies include: breast, Primary malignancies include: breast, lung, lymphoma, leukemia, and malignant lung, lymphoma, leukemia, and malignant melanomamelanoma

Metastases

Produced by URMC


T1-weighted with contrast

Patients RevisitedPatients Revisited

Patient HDPatient HD

T1 Sagittal Pre-contrast T2 Sagittal Pre-contrast

PACS, BIDMC

1.6x2.4cm mass lesion in the thoracic spinal canal at T6-T7.


What is happening to the spinal cord?

Displacement

PACS, BIDMC

T2 Axial No Contrast – This image demonstrates the intradural, extramedullary location of the mass.


PACS, BIDMC

What is that?

T2 Axial Post-gadolinium contrast


PACS, BIDMC

DURAL TAIL

T2 Axial Post-gadolinium contrast – Indicates an enhancing lesion with a dural tail.


CT Sagittal Reformatted – Calicifed component of the intradural mass. Notice the lack of bone involvement above and below the lesion.

PACS, BIDMC


Differential Diagnosis includes:Differential Diagnosis includes:–– Nerve Sheath TumorNerve Sheath Tumor–– MeningiomaMeningioma–– MetastasesMetastases

WhatWhat’’s next?s next?–– Biopsy specimensBiopsy specimens


Pathology ReportPathology Report–– Multiple fragments of soft tissue in one Multiple fragments of soft tissue in one

sectionsection–– Multiple fragments of white and Multiple fragments of white and erythematouserythematous

soft and bony tissuesoft and bony tissue–– No atypical featuresNo atypical features

Patient HD Patient HD -- definitive diagnosisdefinitive diagnosis

MENINGIOMAMENINGIOMA

Patient HD - Epilogue

SY was discharged home after surgery SY was discharged home after surgery under normal instructions. under normal instructions.

Appointment made for surgical follow up Appointment made for surgical follow up visit in 7visit in 7--10 days.10 days.

Brain tumor clinic visit set for July.Brain tumor clinic visit set for July.

Patient CRPatient CR

PACS, BIDMC

T2 Sagittal without contrast – Indicates an intramedullary mass at ~T11/T12 that is nodular yet irregular, measuring 2.1x1.0cm AP x 1.3 cm transverse.


PACS, BIDMC

T1 Axial and Sagittal with contrast – Indicates an enhancing intramedullary mass at ~T11/T12.


Differential Diagnosis includes:Differential Diagnosis includes:–– Primary Spinal Primary Spinal intramedullaryintramedullary massesmasses

EpendymomaEpendymoma

AstrocytomaAstrocytoma

HemangioblastomaHemangioblastoma

WhatWhat’’s next?s next?–– Biopsy specimenBiopsy specimen


Pathology ReportPathology Report–– IntraoperativeIntraoperative smears revealed a smears revealed a gliomaglioma

producing many producing many glialglial processes. processes. –– Nuclear Nuclear pleomorphismpleomorphism–– Permanent Section revealed infiltration and Permanent Section revealed infiltration and

significant significant anaplasiaanaplasia–– Mitotic figures identifiedMitotic figures identified

Patient CR Patient CR -- definitive diagnosisdefinitive diagnosis

ANAPLASTIC ASTROCYTOMAANAPLASTIC ASTROCYTOMA

Patient CR - Epilogue

RBRB’’ss diagnosis resulted in nonsurgical diagnosis resulted in nonsurgical management management –– chemotherapy.chemotherapy.

Despite a stable recovery and no growth to the Despite a stable recovery and no growth to the masses at 3 month follow up, masses at 3 month follow up, RBRB’’ss condition condition began to deteriorate. Neurological deficits began to deteriorate. Neurological deficits increased. Numerous increased. Numerous comorbiditiescomorbidities developed.developed.

RB was discharged from BIDMC to palliative care; RB was discharged from BIDMC to palliative care; therapy was ceased.therapy was ceased.

RB receives pain management.RB receives pain management.

Recap

Review of the anatomy of the spine and Review of the anatomy of the spine and its functional correlatesits functional correlates

Explored the different anatomical Explored the different anatomical classification of spinal massesclassification of spinal masses

Identified MRI with IVIdentified MRI with IV--contrast as the test contrast as the test of choice for spinal massesof choice for spinal masses

Utilized this imaging modality to Utilized this imaging modality to demonstrate spinal masses for patients demonstrate spinal masses for patients reporting lower extremity weakness reporting lower extremity weakness and/or bowel/bladder dysfunctionand/or bowel/bladder dysfunction

Acknowledgments

JeanJean--Marc Marc GauguetGauguet, MD PhD, MD PhD

Alice Fisher, MDAlice Fisher, MD

Jay Jay PahadePahade, MD, MD

NagamaniNagamani PeriPeri, MD, MD

Rafael Rojas, MDRafael Rojas, MD

Gillian Lieberman, MDGillian Lieberman, MD

Maria Maria LevantakisLevantakis

a journey down the canal: radiological assessment of spinal

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