Interesting Spine Cases
M. Castillo, MD, FACR
University of North Carolina
Chapel Hill
Case # 1
• 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.
Case # 1
Case # 1
Case # 1. Which of the following
is/are cause(s) of pial enhancement?
•
•
•
•
•
1. Metastases
2. Sarcoidosis
3. Amyloidosis
4. Lymphoma
5. All of the above
Case # 1. Regarding amyloidosis
involving the spinal cord, which is
true:
1. It predominantly involves the intramedullary veins
2. It predominantly involves the arteries in
the subarachnoid space
3. It never results in cord contrast enhancement
4. It affects heavy myelinated fibers
Case # 1. Dx: Amyloidosis involving
the pia.
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
» AJNR 2004; 25: 1599
Spine involvement, amyloidosis.
CNS Amyloidosis.
CNS Amyloidosis.
Infiltrative lesion
Case # 2
Young patient
presenting with a
myelopathy 2
years after a
‘stroke’.
Case # 2
Case # 2. The following may result
in spinal ‘cysts’:
•
•
•
•
•
A.
B.
C.
D.
E.
Cysticercosis
Exophytic syrinxes
Post trauma arachnoid tears
Post SAH arachnoid cysts
All of the above
Case # 2. Which is the most likely
diagnosis in this patient?
•
•
•
•
•
A.
B.
C.
D.
E.
Cysticercosis
Exophytic syrinxes
Post trauma arachnoid cysts
Post SAH arachnoid cysts
None of the above
Case # 2
Case courtesy of W. Kucharczyk, Toronto
Case # 2. Dx: Multiple spinal
‘arachnoid’ cysts following aneurysmal
SAH.
• 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)
Other extramedullary ‘cysts’
‘Idiopathic’ subarachnoid cyst
Other extramedullary ‘cysts’
Extradural cysts
Case # 3
Young male with a history of
melanoma presents with
lower back pain.
Case # 3
Case # 3. The most likely
diagnosis is related to which
category of disease:
•
•
•
•
•
A.
B.
C.
D.
E.
Metastasis
Infection
Degenerative disease
Congenital
None of the above
Case # 3. Which is false regarding
the abnormality shown here:
• A. Trauma is a predisposing factor
• B. Disc herniation is a part of it
• C. Weakening of the end-plate may be a
secondary factor
• D. Contrast enhancement may occur
• E. Infection plays a role
Case # 3. Dx: Acute enhancing
Schmorl node.
• Pre-requisites: soft end-plate/bone trabeculae
– Congenital: nutrient blood vessels
– Metabolic diseases, tumors
– Scheuermann disease
• May appear ‘cystic’ due to:
– Intra-nodal hemorrhage, mucous degeneration
• Contrast enhancement: granulation tissues
• Cause pain before MRI findings, pain
disappears by 3 years & node ‘stabilizes”
Cystic Schmorl Nodes
Giant cystic Schmorl;s nodes. AJR 2001; 176: 969
CASE # 4
11-year-old boy with back pain of 2-months
duration.
CASE # 4
Case # 4.
The most likely diagnosis is:
•
•
•
•
•
A.
B.
C.
D.
E.
Aneurysmal bone cyst
Osteoid osteoma
Osteoblastoma
Giant cell tumor
Fibrous dysplasia
Case # 5. Which is false regarding
spinal osteoblastoma:
• A. If predominantly affects the posterior
elements
• B. It may occasionally cross intervertebral
space
• C. It is a benign process
• D. It is a lesion found in middle age and
older individuals
Case # 4. Dx: Osteoblastoma.
• Rare tumor (0.5-2%) comprised of osteoid,
primitive woven bone amidst fibrovascular
connective tissues
• Chronic pain, salicylates not helpful
• Sclerotic or lucent lesion, 25% have
aggressive features
• Choice of Tx: en bloc resection, curettage
with bone packing, XRT for malignant
ones
Case # 5
A 10-year-old child
with a longstanding
right hemiparesis now
with progressive left
lower extremity
weakness.
Case courtesy H. Alvarez, Paris
Case # 5. The findings shown are
due to:
•
•
•
•
1. Spinal AVM
2. Hematomyelia
3. Spinal AVF
4. Spinal cavernous
malformation
Case # 5. Imaging of the brain in
this patient may show:
•
•
•
•
•
1. old infarctions
2. one or more AVM’s
3. Wallerian degeneration
4. hemiatrophy
5. all of the above
Case # 6. The diagnosis in this
patient is:
• 1. moyamoya disease
• 2. spinal arterial
malformation syndrome
(SAMS)
• 3. Rendu-Osler-Weber
disease
• 4. Von Hippel Lindau
disease
Case # 5. Dx: ROW.
• Abnormalities in
chromosomes 9 & 12
• Defect in synthesis of
‘endoglin’ which is needed
for growth/remodelling of
capillaries
• > common in males
• Multiple skin/mucosa
telangiectasias
Case # 6.
A 30-year-old
male presents
with a subacute
onset of a
myelopathy.
Case # 6. The differential
diagnosis in this case includes:
•
•
•
•
•
1. Multiple sclerosis
2. Acute disseminated encephalomyelitis
3. Vasculitis
4. Sarcoidosis
5. All of the above
Case # 6. Primary Angiitis of the
CNS.
• Spinal cord vasculitis: idiopathic,
associated with Hodgkin, thyroiditis, drug
allergy, Sjogren, viral-induced, hepatitis
• Perivascular (artery & vein) infiltration by
lymphocytes, cavitation, pial inflammation
• Prognosis is very poor, some temporary
symptom relief with steroids, necrosis of
spinal cord
CASE # 7
45-year-old man with a chronic disorder now with
a cauda equina syndrome.
Courtesy M, Thurnher, Vienna
Case # 7. The most likely diagnosis
is:
• A. Neurofibromatosis I with dural ectasia
• B. Marfan syndrome with dural ectasia
• C. Ankylosing spondylitis with erosive
dural ectasia
• D. Epidermoid with bone scalloping
Case # 7.All but one of the following
are complications of ankylosing
spondylitis:
• A. “Banana” type fractures
• B. Erosive dural ectasia w/cauda equina
syndrome
• C. Epidural hematomas
• D. Infectious diskitis/osteomyelitis
• E. Non-infectious diskitis/osteomyelitis
(amyloidosis?)
Case # 7.Ankylosing Spondylitis,
Newer Concepts
• B27 gene:
– 95% of Europeans, only 25% in Middle East
– Antiviral properties
high in American Indians
who survived European viruses during conquest
• Bowel infection is a predisposing factor
– Antibodies with cross reaction to joints
• Spine disease is not improved with antiinflammatory drugs or methotrexate, need
blockers of TNF