Wk 9, Case 4 - Review

Patient History
Patient with history of pancreatic adenocarcinoma status post Whipple surgery, presenting with progressive lower extremity weakness bilaterally and loss of bladder control.

Findings
There is extensive intramedullary T2/STIR hyperintensity compatible with edema, involving the spinal cord from the T4 level inferiorly to the conus medullaris. There is relative preservation of the cord periphery. Additionally, there are multiple small abnormal vascular flow-voids along the pial surface of the spinal cord throughout the thoracic spine,
extending inferiorly to the level of the conus medullaris. There is also ill-defined, diffuse enhancement of the distal spinal cord/conus medullaris.

There are degenerative changes within the visualized portions of the cervical spine with at least moderate neural foraminal narrowing at C6-C7 as seen on the sagittal images. In the thoracic spine, there is a small central disc protrusion at T8-T9 without significant narrowing of the spinal canal. There are mild facet and costovertebral degenerative changes without significant neural foraminal narrowing.

There are variable degrees of spinal canal and neural foraminal narrowing in the lumbar spine:

L1-L2: Mild facet degenerative changes without significant neural foraminal narrowing. The spinal canal is patent.

L2-L3: There is a disc bulge narrowing the spinal canal to 7 mm in AP dimension, compounded by thickening of the ligamenta flava. There is narrowing of the lateral recesses bilaterally and potential contact with the descending L3 nerve roots. There is crowding of the nerve roots at this level. There are mild to moderate facet generative changes bilaterally which contribute to moderate left and mild right neural foraminal narrowing.

L3-L4: There is a diffuse disc bulge which narrows the spinal canal to 9 mm in AP dimension and 6 mm in the transverse dimension. There is narrowing of the lateral recesses bilaterally compounded by moderate facet degenerative changes and thickening of the ligamenta flava, with potential compression of the descending L4 nerve roots. There is crowding of the nerve roots at this level. There is marked narrowing of the neural
foramina bilaterally.

L4-L5: There is a diffuse disc bulge narrowing the spinal canal to 9 mm in AP dimension. There is moderate narrowing of the transverse diameter of the spinal canal on the basis of moderate to marked hypertrophic facet degenerative changes, which also contributes to narrowing of the lateral recesses and possibly compression of the descending L5 nerve roots. There is crowding of the roots of the cauda equina at this level. There is marked narrowing of the neural foramina bilaterally, right greater than left.

L5-S1: There is a bulge/pseudodisc bulge in the setting of minimal retrolisthesis, without significant narrowing of the spinal canal. There are moderate to marked facet degenerative changes bilaterally and possibly displacement or compression of the descending S1 nerve roots. There is marked narrowing of the neural foramina bilaterally.

There is buckling of the roots of the cauda equina in the lower lumbar spine.

There is asymmetric enhancement and increased signal on the sagittal STIR sequences involving the paraspinal musculature on the left at the L5 and imaged upper sacral levels possibly related to recent trauma are nonspecific inflammation. Note is made of what appear to be cysts or hemangiomata in the visualized liver as seen on the sagittal and coronal localizers. Please refer to separate body MRI report. There is marked distention of the urinary bladder and hydronephrosis bilaterally. There are probable renal cysts.

There is a small amount of secretions in the trachea. There is edema in the subcutaneous tissues of the lower back and increased signal in the paraspinal muscles.

Impressions
Findings most consistent with a spinal vascular malformation with extensive spinal cord edema involving most of the thoracic spine and extending to the conus medullaris. Recommend neurointerventional radiology/neurosurgery consult. There are multilevel degenerative changes in the lumbar spine with crowding of the roots of the cauda equina and probably mass effect on the traversing nerve roots as detailed above.