Interesting Spine Cases

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Interesting Spine Cases

• M. Castillo, MD, FACR
• University of North Carolina
• Chapel Hill

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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.

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Case 1
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Case 1
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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

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Case 1. Regarding amyloidosis involving the
spinal cord, which is true

• 1. It predominantly involves the intrame-
• dullary veins
• It predominantly involves the arteries in
• the subarachnoid space
• It never results in cord contrast enhance-
• ment
• 4. It affects heavy myelinated fibers

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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

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Spine involvement, amyloidosis.
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CNS Amyloidosis.
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CNS Amyloidosis.
Infiltrative lesion
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Case 2
Young patient presenting with a myelopathy 2
years after a stroke.
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Case 2
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Case 2. The following may result in spinal
cysts

• A. Cysticercosis
• B. Exophytic syrinxes
• C. Post trauma arachnoid tears
• D. Post SAH arachnoid cysts
• E. All of the above

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Case 2. Which is the most likely diagnosis in
this patient?

• A. Cysticercosis
• B. Exophytic syrinxes
• C. Post trauma arachnoid cysts
• D. Post SAH arachnoid cysts
• E. None of the above

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Case 2
Case courtesy of W. Kucharczyk, Toronto
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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)

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Other extramedullary cysts
Idiopathic subarachnoid cyst
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Other extramedullary cysts
Extradural cysts
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Case 3
Young male with a history of melanoma presents
with lower back pain.
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Case 3
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Case 3. The most likely diagnosis is related
to which category of disease

• A. Metastasis
• B. Infection
• C. Degenerative disease
• D. Congenital
• E. None of the above

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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

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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

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Cystic Schmorl Nodes
Giant cystic Schmorls nodes. AJR 2001 176 969
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CASE 4
11-year-old boy with back pain of 2-months
duration.
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CASE 4
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Case 4. The most likely diagnosis is

• A. Aneurysmal bone cyst
• B. Osteoid osteoma
• C. Osteoblastoma
• D. Giant cell tumor
• E. Fibrous dysplasia

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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

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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

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Case 5
A 10-year-old child with a longstanding right
hemiparesis now with progressive left lower
extremity weakness.
Case courtesy H. Alvarez, Paris
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Case 5. The findings shown are due to

• 1. Spinal AVM
• 2. Hematomyelia
• 3. Spinal AVF
• 4. Spinal cavernous malformation

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Case 5. Imaging of the brain in this patient
may show

• 1. old infarctions
• 2. one or more AVMs
• 3. Wallerian degeneration
• 4. hemiatrophy
• 5. all of the above

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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

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Case 5. Dx ROW.

• Abnormalities in chromosomes 9 12
• Defect in synthesis of endoglin which is needed
  for growth/remodelling of capillaries
• gt common in males
• Multiple skin/mucosa telangiectasias

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Case 6. A 30-year-old male presents with a
subacute onset of a myelopathy.
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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

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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

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CASE 7
45-year-old man with a chronic disorder now with
a cauda equina syndrome.
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Courtesy M, Thurnher, Vienna
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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

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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?)

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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
  anti-inflammatory drugs or methotrexate, need
  blockers of TNF

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