Magnetic resonance imaging of spinal involvement by hematopoietic malignancies requiring surgical decompression

"Wrap-Around Sign" in Non-Hodgkin Lymphoma of the Spine: A Common yet Overlooked Imaging Feature?

BACKGROUND

Anecdotal cases of the so-called "wrap-around" appearance in non-Hodgkin lymphoma (NHL) of the spine exist in the medical literature. In this paper, we looked at the prevalence of this imaging feature in our institutional cases.

MATERIALS AND METHODS

We screened our institutional database for biopsy-proven NHL. Our inclusion criteria were the histologically confirmed diagnosis of NHL involving any vertebra, available magnetic resonance imaging of the affected site, and a positive wrap-around sign. Exclusion criteria included lymphoma cases without the wrap-around sign and/or histology other than NHL. We subdivided the cases into 3 groups: 1) lymphoma wrapped around the vertebral body; 2) the posterior elements alone; or 3) both the vertebral body and posterior elements.

RESULTS

Our search identified 147 cases of NHL in which a confirmatory biopsy at the primary tumor site was available. Of those, 23 cases fulfilled the inclusion criteria (16 men and 7 women with average age at diagnosis of 63.3 years), yielding prevalence of 15.6% in our series. Most commonly the lymphoma involved the vertebral body with or without some involvement of the posterior vertebral elements (n = 20, 86.9%), followed by posterior vertebral elements (n = 2, 8.7%). One remaining case (4.4%) had lymphoma involving the anterior vertebral body and posterior elements.

CONCLUSIONS

Findings of our pilot study indicated that the wrap-around sign in cases of NHL could be helpful diagnostically. This sign may be frequently under-recognized, leading to potential for a diagnostic dilemma on imaging. Larger studies are necessary to obtain more precise information about the prevalence of the wrap-around sign.

Pyogenic Atlantoaxial Rotational Dislocation Representing Adult Torticollis with Vertebral Artery Occlusion: A Case Report and Review

BACKGROUND

Pyogenic atlantoaxial rotational dislocation is a rare but life-threatening condition. Disease progression damages the soft tissue and bony structure, resulting in spinal cord or brain stem compression. Rapid and correct diagnosis could enable successful treatment. However, few studies have been reported, and the characteristics of a successful treatment course are not well known. In addition, our case presented with vertebral artery (VA) occlusion. Here we present a report of successful treatment of pyogenic atlantoaxial rotational dislocation representing adult torticollis with VA occlusion.

CASE DESCRIPTION

A 67-year-old woman with neck pain and high fever was treated for suspected meningitis. Although her fever improved, pain persisted for several weeks. Examinations mostly showed characteristics of an infection with destructive atlantoaxial rotational dislocation; however, positive uptake with positron emission tomography, no anomalies with diffusion-weighted magnetic resonance imaging, and VA occlusion indicated the presence of a tumor lesion. After VA embolization and Halo reduction/stabilization, biopsy and blood culture revealed pyogenic infection. Antibiotics with rigid stabilization improved the inflammation and allowed definitive occipitocervical fixation, resulting in an uneventful postoperative course and painless bony fusion 2 years postoperatively.

CONCLUSIONS

VA involvement should be examined for safe treatment. Stabilization is warranted to improve chronic inflammation. Knowledge regarding the characteristic treatment course could enable successful treatment planning and may prove to be lifesaving.

Preliminary evaluation of a robotic apparatus for the analysis of passive glenohumeral joint kinematics

Background

The shoulder has the greatest range of motion of any joint in the human body. This is due, in part, to the complex interplay between the glenohumeral (GH) joint and the scapulothoracic (ST) articulation. Currently, our ability to study shoulder kinematics is limited, because existing models isolate the GH joint and rely on manual manipulation to create motion, and have low reproducibility. Similarly, most established techniques track shoulder motion discontinuously with limited accuracy.

Methods

To overcome these problems, we have designed a novel system in which the shoulder girdle is studied intact, incorporating both GH and ST motions. In this system, highly reproducible trajectories are created using a robotic actuator to control the intact shoulder girdle. High-speed cameras are employed to track retroreflective bone markers continuously.

Results

We evaluated this automated system’s capacity to reproducibly capture GH translation in intact and pathologic shoulder conditions. A pair of shoulders (left and right) were tested during forward elevation at baseline, with a winged scapula, and after creation of a full thickness supraspinatus tear.

Discussion

The system detected differences in GH translations as small as 0.5 mm between different conditions. For each, three consecutive trials were performed and demonstrated high reproducibility and high precision.

Spinal epidural abscess mimicking lymphoma: a case report

We describe a case of epidural thoracic abscess presenting similar to epidural lymphoma on imaging and review the imaging findings and clinical characteristics of both to help differentiate the two. Typical magnetic resonance imaging characteristics for epidural abscess are a heterogeneously enhancing epidural collection, which is isointense/hypointense on T1 images and hyperintense on T2 images with granulation tissue typically having a rim of enhancement with gadolinium. In contrast, typical imaging characteristics for an epidural lymphoma include an isointense/hypointense appearance on T1-weighted magnetic resonance imaging (MRI) and a hyperintense or even hypointense appearance on T2 images. Lymphomas tend to enhance uniformly and diffusely with contrast. The patient's MRI revealed a compressive thoracic epidural mass at T8-T10. The mass was hypointense on T1- and T2-weighted images and enhanced intensely and uniformly on T1 images after gadolinium injection. Additionally, abnormal hyperintense signal within the left T9-T10 facet joint was identified on T2 images. The imaging findings were felt to be most consistent with lymphoma, but the possibility of epidural abscess, and less likely, epidural hematoma were also considered. Although the patient's abscess presented similar to lymphoma on MRI, possibly the most revealing clue on imaging that infection was the likely diagnosis was hyperintense signal within the left facet joint seen on T2-weighted images. This is important as primary radiation treatment based on imaging characteristics alone, without a tissue diagnosis, is often suggested in cases of lymphoma. This mode of treatment would be contraindicated in the setting of infection. A diagnosis that is not conclusive by needle biopsy or imagine may require an open procedure for definitive diagnosis.

Epidural malignant lymphomas of the spine: collected experiences with epidural malignant lymphomas of the spinal canal and their treatment

STUDY DESIGN

Retrospective study of 13 patients treated by the authors.

OBJECTIVE

To examine the course of the disease of malignant lymphoma (ML) presenting in the epidural area of the spine.

SETTING

Department of Neurosurgery, Third Department of Internal Medicine, Medical and Health Science Center, University of Debrecen, Debrecen, Hungary.

SUBJECTS AND METHODS

The epidural presentation in eight patients was heralded by motor signs (paraparesis and plegia), in one by a lesion of the posterior columns of the spinal cord (ataxia), and in three by pain. One patient was free of complaints and symptoms. The affected epidural area was diagnosed previously by myelography and computerized tomography (CT), and later by magnetic resonance (MR), over the course of which the location was verified as thoracic in eight patients, cervical in one, and lumbar in four. The authors recommended surgical intervention in 9 out of 13 cases, in seven cases of Hodgkin's and six cases of non-Hodgkin's lymphoma. Seven patients were treated for recognized manifestations of malignant lymphoma while six were diagnosed by intraoperative-histological examination.

RESULTS AND CONCLUSION

The decompression operations for tumors resulted in limited improvement in seven patients (reduction in pain and return of ability to walk). Four patients were not operated on, two of which had significant improvement in their neurological symptoms. Paraparesis remained unchanged in one patient. One patient remained symptom-free. The authors emphasize the importance of interdisciplinary consultation and weighing individual priorities in the indications for operation on epidural ML.

Imaging of the Lumbar Spine Neoplasms

The most common lumbar spine tumors are metastatic disease, myeloma, and hemangioma. Primary osseous lesions of the lumbar spine are unusual. When encountered, they often exhibit characteristic imaging properties, aiding the radiologist to provide a short list of differential diagnoses. We provide a discussion of imaging appearance of lumbar spine neoplasms. Emphasis of this review is on osseous lesions. Few common neurogenic intradural, extraaxial lesions are also discussed.