DOI:10.2214/AJR.07.7028
AJR 2007; 189:S58-S60
© American Roentgen Ray Society
AJR Teaching File: Lumbar Radiculopathy and Intraspinal Mass
Scott Drummond1,
Kevin P. Banks2 and
Stephen Brown2
1 Lake Erie College of Osteopathic Medicine, Erie, PA.
2 All authors: Department of Radiology, Brooke Army Medical Center, MCHE-DR,
3851 Roger Brooke Dr., Fort Sam Houston, TX 78234.
Received November 9, 2005;
accepted after revision May 8, 2006.
The opinions and assertions contained herein are the private views of the
authors and are not to be construed as official or as reflecting the views of
the Department of the Army or the Department of Defense.
Address correspondence to K. P. Banks
(kevin.banks{at}amedd.army.mil).
Keywords: astrocytoma • ependymoma • hemangioblastoma • intraspinal mass • lumbar radiculopathy • lymphoma
Clinical History
A 49-year-old man presents to his primary care physician complaining of a
24-month history of gradually worsening lower back pain with right lower
extremity pain and weakness. Physical examination reveals pain with hip
flexion, as well as brisk deep-tendon reflexes.
Radiologic Description
A sagittal T1-weighted MR image (Fig.
1A) reveals a well-defined iso- to hyperintense intradural mass at
the level of the L4–L5 vertebrae with several surrounding nerves
adhering to the margin. A fat-saturated T2-weighted fast spin-echo image
(Fig. 1B) shows a nearly
uniform hyperintense mass in the lumbosacral spine. A contrast-enhanced
fat-saturated T1-weighted image (Fig.
1C) depicts marked heterogeneous enhancement of the lesion. Flow
voids are viewed on axial T2-weighted images
(Fig. 1D) through the
intrathecal mass.
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Fig. 1A —49-year-old white man with 24-month history of gradually
worsening lower back pain, right lower extremity pain, and weakness.
T1-weighted sagittal image of lumbosacral spine shows well-defined isointense
intradural mass at level of L4–L5 vertebrae. Note investment of several
surrounding nerves and vessels as well as lateral displacement of remaining
nerves.
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Fig. 1B —49-year-old white man with 24-month history of gradually
worsening lower back pain, right lower extremity pain, and weakness.
Fat-saturated T2-weighted fast spin-echo sagittal image of lumbosacral spine
shows lesion to be almost uniformly hyperintense.
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Fig. 1C —49-year-old man with 24-month history of gradually worsening
lower back pain, right lower extremity pain, and weakness. Contrast-enhanced
fat-saturated T1-weighted sagittal image of lumbosacral spine shows marked
enhancement of mass. Venous congestion was noted both superiorly and
inferiorly (images not shown).
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Fig. 1D —49-year-old man with 24-month history of gradually worsening
lower back pain, right lower extremity pain, and weakness. Axial T2-weighted
image through intrathecal mass shows presence of flow voids in lesion.
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Differential Diagnosis
The differential diagnosis for gradually worsening lower back pain with
right lower extremity pain and weakness includes hemangioblastoma, ependymoma
(myxopapillary), astrocytoma, lymphoma, and metastasis.
Diagnosis
The diagnosis is hemangioblastoma.
Commentary
Spinal cord hemangioblastomas constitute 1–7% of all spinal cord
neoplasms, have no gender predilection, are slow-growing lesions (clinical
symptoms average almost 4 years), and involve the thoracic cord most commonly
(50% of cases), followed closely by the cervical cord (40%). Most (80%) cord
hemangioblastomas are solitary and occur in patients younger than 40 years,
and three quarters are intramedullary.
Multiple lesions of the spinal cord are noted only in patients with von
Hippel-Lindau disease [1].
Spinal cord swelling not confined to the tumor margins or syrinx, which is
seen with hemangioblastoma, is attributed to local venous congestion or
arteriovenous shunting [2].
Effective imaging of the tumor depends on lesion size. Large lesions are
readily seen on unenhanced studies, whereas small tumors may remain illusive
even after the administration of contrast material
[2]. Frequently, vascular foci
are imaged and interpreted as flow voids on MRI. MR angiography is helpful in
surgical evaluation of the tumor vasculature for intraoperative hemostatic
control [1,
3].
At pathology, gross examination revealed a well-demarcated reddish mass
with associated vessels. At histologic examination, a richly vascular neoplasm
with large pale stromal cells was seen packed among blood vessels. These
morphologic features are representative of a hemangioblastoma.
Correctly discerning the extradural versus intradural location of this
mass, as well as identifying the vascular characteristics associated with a
well-circumscribed lesion, is paramount to the development of a concise
differential diagnosis. Lesions of the lumbosacral spinal cord and cauda
equina include hemangioblastoma, ependymoma (myxopapillary), astrocytoma,
lymphoma, and metastasis.
Lumbosacral lesions typically cause radicular symptoms in the lower
extremities. Pain, sensory deficits, and loss of motor function commonly
manifest as a mass in this area. Patients present at a range of ages,
depending on the specific type of lesion.
The evaluation of each patient should include comprehensive radiologic
examination of the CNS to rule out multiple lesions and other disorders. Also,
systemic involvement should be considered, such as that seen in von
Hippel-Lindau disease. Physical examinations should also include complete
neurologic evaluation, including a full ophthalmic examination. Retinal
findings, which are suggestive of von Hippel-Lindau disease, should be
validated or discounted.
Ependymomas, the most common lumbosacral neoplasms, generally become
manifest in the young adult. Myxopapillary ependymomas are subtypes usually
found in the filum terminale and, rarely, in the subcutaneous tissues.
Scoliosis and canal widening are often present as well as vertebral scalloping
[4]. Cord edema, the presence
of nontumoral cysts, and an associated "cap sign" are also common
features of ependymomas
[4].
Astrocytoma, the second most common lumbosacral neoplasm, is characterized
by evidence of bone erosion, scoliosis, interpedicular distance widening, and
eccentric disposition. T1-weighted MRI reveals a lesion with multiple
vertebral involvement and poorly defined margins
[4]. Cysts, also common to
astrocytomas, present without a cap sign
[4].
Metastasis of the intradural spine, although extremely rare, is often
illusive in conventional radiography. Cystic structures are rarely associated
with spinal metastasis, whereas bone erosion is common
[3,
4]. Notably, cord edema with
mild cord expansion over several vertebral segments, disproportionate to
lesion size, is correlated to spinal metastasis. The theory of hematogenous
spread via the Batson's venous plexus or lymphatic ducts has been postulated
[4].
Lymphoma of the spinal cord accounts for fewer than 1% of all lymphomas in
the body. Patients commonly present with ambulatory difficulties and muscle
weakness. All lymphomas of the spinal cord have shown high signal intensity on
T2-weighted images. Contrast-enhanced studies reveal potential irregular
enhancement [4].
Objective
The educational objective of this article is to review the common neoplasms
that may present as a mass of the filum terminale and cauda equina.
Conclusion
Although these neoplasms often appear nonspecific, knowledge of their
imaging characteristics and their typical clinical presentation can allow
practicing radiologists to create an accurate and focused differential
diagnosis.
References
- Chu BC, Terae S, Hida K, et al. MR findings in spinal
hemangioblastoma: correlation with symptoms and with angiographic and surgical
findings. AJNR 2001;22
: 206–217[Abstract/Free Full Text]
- Baker KP, Moran CJ, Wippold FJ 2nd, et al. MR imaging of spinal
hemangioblastoma. AJR 2000;174
: 377–382[Free Full Text]
- Gläsker S, Berlis A, Pagenstecher A, Vouqioukas VI, van
Velthoven V. Characterization of hemangioblastomas of spinal nerves.
Neurosurgery 2005;56
: 503–509[CrossRef][Medline]
- Koeller KK, Rosenblum RS, Morrison AL. Neoplasms of the spinal cord
and filum terminale: radiologic–pathologic correlation.RadioGraphics
2000;20
:1721
–1749[Abstract/Free Full Text]
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Clinical History
Radiologic Description
