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Case Challenge: Spine MRI Cases

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Spine MRI Case Challenge Pre-Course Activities
2 topics

20b - Answer: Cauda Equina Syndrome in a 22-year-old. Prior intracranial tumor resection

David Yousem MBA, MD
David M Yousem, MBA, MD
Professor of Radiology, Vice Chairman and Associate Dean
Includes DICOM files

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Case Report

HISTORY: Cauda Equina Syndrome in a 22-year-old. Prior intracranial tumor resection.

TECHNIQUE:
Outside Institution MRI of cervical, thoracic and lumbar spine from diagnostic imaging service HF dated 10/13/2017 were submitted for second opinion interpretation.

FINDINGS:

MRI cervical spine:

Postoperative changes of a C1 laminectomy are seen with prominent CSF space at this site. Comparison made with the MRI of the brain dated 10/12/2016. The nonenhancing T2 hyperintense tissue seen within the left foramen of Luschka on the prior MRI of the brain is not appreciated on these images.

There is however evidence of a small new enhancing nodules seen dorsal to the cervicomedullary junction at the level of the foramen magnum measuring 7 mm in the craniocaudal dimension and 5 mm in the AP dimension (series 36
image 5) that is concerning for recurrent neoplasm. There are no axial images through this region.

There is a small 3 mm nodule seen along the right anterolateral aspect of the cervical cord at the C3-4 level with nodular enhancement (series 8 image 9 and series 37 image 7). This is new since the prior MRI 5/24/2016.

There is degenerative change within the cervical disks, with mild disc bulges at C4-5, C5-6 and a left central disc protrusion at C6-C7 levels indenting the ventral aspect of the cervical subarachnoid space with no evidence of significant spinal canal stenosis or foraminal compromise.


MRI thoracic spine:

Thoracic vertebrae show normal height, alignment and marrow signal characteristics. No significant spinal canal stenosis is present at any level. There is a minimal disc bulge at T8-9, and a small central disc protrusion at T9-10 indenting the ventral aspect of the thoracic subarachnoid space.

There is a small focal 3 x 2 mm area of T2 hyperintensity along the left paramedian dorsal aspect of the cord at the T11 vertebral level (sagittal series 15 image 8, axial series 18 image 23 ). There is focus of nodular enhancement seen on axial series 38 image 29, but adjacent curvilinear, likely vascular enhancement seen dorsal to the cord extending superiorly towards the T10 vertebra.

No other enhancing lesions present in the rest of the thoracic spine or thoracic cord.


MRI of the lumbar spine:

These images show evidence of extensive nodular enhancing metastatic disease throughout the cauda equina and in the sacral thecal sac. Enhancing nodules are present within the cauda equina just below the tip of the conus at the L1 vertebral level to the right of midline, with a prominent 8 x 5 mm nodule in a left paramedian dorsal location at the L3 level. Most prominently, there is evidence of significant enhancing soft tissue nodular lesions present within the sacral spinal canal and filling up as well as expanding the nerve root sleeves of the left more than right S2 and S3 nerve roots. Minimal but symmetric enhancement of the S1 nerve roots within the neural foramina could be related to the dorsal root ganglia. The enhancing nodules are best visualized on the axial fat-suppressed T1 images (series 33, images 31-36), with the most prominent left S1-2 lesion measuring 2.3 cm in the craniocaudal dimension.

There is evidence of disc degenerative change with a posterior central and left central disc protrusion at C3-4 and C4-C5 levels, mildly indenting the ventral aspect of the thecal sac. There is facet degeneration at L4-L5. No evidence of significant central spinal canal stenosis is seen.

IMPRESSIONS:
Second Opinion Consultation on Outside hospital studies.

Evidence of recurrent disease is present with metastatic CSF seeding from medulloblastoma.

Small enhancing nodule is present along the dorsal aspect of the cervicomedullary junction to the right of midline measuring 7 x 5 mm at the level of the foramen magnum.

Small 3 mm enhancing nodule is present along the right anterolateral aspect of the cervical spinal cord at C3-C4.

Subtle 3 mm enhancing nodule is seen along the dorsal aspect of the cord at the T10-11 level.

Multiple enhancing nodules present within the cauda equina at the L1 and L3 levels, with most bulky intraspinal/thecal sac seeding from CSF spread seen at the S1-S3 levels, the largest lesion involving the left S2 nerve
root sleeve measuring 2.3 cm in craniocaudal dimension.

LESSON 5, TOPIC 15

Case Challenge: Spine MRI Cases

Case Challenge

last updated: 2022-03-08 19:55:15

created: 2022-03-08 19:55:15

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