Spontaneous ligamentum flavum hematoma in the lumbar spine

Lumbar or sacral nerve root compression is most commonly caused by intervertebral disc degeneration and/or herniation. Less frequently, other extradural causes may be implicated, such as infection, neoplasm, epidural hematoma, or ligamentum flavum pathology. We present the case of a patient with spontaneous ligamentum flavum hematoma compressing the L4 nerve root, without antecedent trauma. Although exceedingly rare, the diagnosis of ligamentum flavum pathology in general, and that of ligamentum flavum hematoma in particular, should be considered on those rare occasions when the etiology of lumbar or sacral nerve root compressions appears enigmatic on radiological studies. Usually surgical treatment produces excellent clinical outcome.     

MR imaging of epidural hematoma in the lumbar spine

OBJECTIVE: To bring attention to the MR imaging appearance of epidural hematoma (EDH) in the lumbar spine as a small mass often associated with disk herniation or an acute event. This paper will show our experience with this entity and describe criteria for its MR imaging appearance. DESIGN AND PATIENTS: Thirteen cases of prospectively diagnosed EDH of the lumbar spine were compared with 12 cases of prospectively diagnosed prominent epidural extrusion. Our criteria were retrospectively evaluated by the two authors for their presence or absence in each case. The chi-square test for nominal data was applied. MR imaging criteria utilized to distinguish EDH from disk herniation at our institution include: (1) signal different from disk, (2) high signal on T1-weighted images, either centrally or peripherally, (3) teardrop- or egg-shaped mass, in the sagittal plane, (4) size greater than half the vertebral body height in a craniocaudal dimension, (5) primarily retrosomatic epidural location, (6) plasticity - the mass is seen to conform closely to the contours of bone (e.g., in the lateral recess), (7) little or no disk space narrowing unless associated with disc herniation. RESULTS: Chi-square analysis demonstrated each criterion to significantly differentiate between EDH and extrusion. Only six of 13 EDH cases went to surgery in spite of their relatively large size. Two of six patients were diagnosed as having epidural clot consistent with hematoma at the time of surgery. The four patients who were not diagnosed at surgery revealed only small disk herniations or fragments of disk. CONCLUSIONS: The occurrence of EDH is more frequent than previously suspected. Spontaneous EDH is frequently associated with disk herniation and acute events such as sneezing or coughing. Most cases of spontaneous EDH will resolve prior to surgery with only the minority becoming chronic in order to be seen at surgery as an encapsulated mass. MR imaging can reliably identify EDH and distinguish between EDH and large disk extrusions.     

Chronic nontraumatic spinal epidural hematoma of the lumbar spine: MRI diagnosis

An uncommon case of chronic nontraumatic spinal epidural hematoma of the lumbar spine in a 75-year-old woman is reported. The patient presented with a 7-month history of low back pain and bilateral sciatica. Magnetic resonance imaging enabled a correct preoperative diagnosis revealing a nodular, well-circumscribed epidural mass with peripheral enhancement and signal intensities consistent with chronic hematoma, which extended from L2 to L3. Laminectomy of L2–L3 was performed and the hematoma was totally resected. Histological examination of the surgical specimen demonstrated a chronic encapsulated hematoma. No evidence of vascular malformation was found. The patient recovered fully after surgical treatment. Received: 23 August 1999; Revised: 13 January 2000; Accepted: 4 February 2000     

Epidural fibrosis and recurrent disk herniation in the lumbar spine: MR imaging assessment

Twenty patients were enrolled in a prospective study to evaluate MR imaging in the differentiation of epidural scar and herniated disk material. Fourteen patients had surgical verification of imaging findings. In 12 (86%) of these patients, the MR interpretations fully agreed with the observations at surgery. Careful integration of the findings on sagittal and axial T1-weighted images with more T2-weighted axial images was important for analysis. Anterior and lateral recess scars were hypo- or isointense on T1-weighted sequences and hyperintense on more T2-weighted sequences relative to the "parent" anulus intensity. Free fragments demonstrated a slightly hyperintense signal intensity on T1-weighted images relative to epidural fibrosis but had a similar hyperintense signal intensity on T2-weighted sequences. Prolapsed or extruded disk fragments were hypo- or isointense relative to the parent anulus on all sequences. Morphology, epidural location, mass effect, and often signal intensity were the important parameters by which scar and herniated disk could be differentiated with MR.     

Epidural abscess of the cervical spine: MR findings in five cases.

Cervical epidural abscess is an uncommon infectious process of the spinal epidural space. Although this disorder is often unsuspected clinically, the patient's signs and symptoms may suggest other diagnoses that frequently lead to an MR examination. We retrospectively reviewed the MR examinations of five patients with surgically proved cervical epidural abscess in order to assist in the diagnosis of this clinically elusive disorder. Each epidural abscess was evaluated for MR signal intensity, location, extent, delineation, and enhancement pattern. We assessed the spinal cord for compression and signal intensity and analyzed the vertebrae, intervertebral disks, and paraspinal soft tissue. Compared with the spinal cord, the abscess was isointense or hypointense on T1-weighted spin-echo images and hyperintense on T2-weighted images. The abscess was hyperintense or isointense relative to the cord on T2* gradient-echo images. Enhancement of the abscess occurred in the two patients given an IV injection of gadopentetate dimeglumine. The epidural abscess was located anteriorly in three patients, posteriorly in one, and was circumferential in one. The abscess extended from two to nine vertebral bodies in length. In each case, the abscess caused some degree of spinal cord compression, and one patient had bright signal intensity within the cord on T2-weighted images. Three patients had MR changes of accompanying osteomyelitis and paravertebral abscess. MR imaging is useful in diagnosing cervical epidural abscess and in evaluating associated abnormality of the spinal cord, vertebral bodies, intervertebral disks, and paraspinal soft tissue.     

Intradural nerve root hematoma in the lumbar spine. A case report

Intradural nerve root hematoma of the lumbar spine is extremely rare and can cause compression of the cauda equina. This case, which presented with low back pain and radiation to both lower extremities, diagnosed as an intradural hematoma of nerve root by magnetic resonance imaging (MRI) and was totally removed successfully. Intradural nerve root hematoma can present with or without a history of trauma or blood dyscrasia, where MRI is the best imaging modality, and can be well treated by surgery.     

Fluorine-18 fluorodeoxyglucose PET in infectious bone diseases: results of histologically confirmed cases

The aim of this study was to evaluate the clinical use of fluorine-18 fluorodeoxyglucose positron emission tomography (FDG-PET) in acute and chronic osteomyelitis and inflammatory spondylitis. The study population comprised 21 patients suspected of having acute or chronic osteomyelitis or inflammatory spondylitis. Fifteen of these patients subsequently underwent surgery. FDG-PET results were correlated with histopathological findings. The remaining six patients, who underwent conservative therapy, were excluded from any further evaluation due to the lack of histopathological data. The histopathological findings revealed osteomyelitis or inflammatory spondylitis in all 15 patients: seven patients had acute osteomyelitis and eight patients had chronic osteomyelitis or inflammatory spondylitis. FDG-PET yielded 15 true-positive results. The tracer uptake correlated with the histopathological findings in each case. Bone scintigraphy performed in 11 patients yielded ten true-positive results and one false-negative result. Follow-up carried out on two patients revealed normal or clearly reduced tracer uptake, which correlated with a normalisation of clinical data. In early postoperative follow-up it was impossible to differentiate between postsurgical reactive changes and further infection using FDG-PET. It is concluded that acute and chronic osteomyelitis of the peripheral as well as the central skeleton can be detected using FDG-PET. Osteomyelitis can be differentiated from soft tissue infection surrounding the bone. Unlike computed tomography and magnetic resonance imaging, FDG-PET is not affected by metal implants used for fixing fractures. FDG-PET demonstrated promising initial results with respect to treatment monitoring. Nevertheless, in the early postoperative phase FDG-PET seems to be of limited value owing to unspecific tracer uptake.     

Focal fatty change of the liver adjacent to the falciform ligament: CT and sonographic findings in five surgically confirmed cases

Five cases of surgically confirmed focal fatty infiltration of the liver were detected by CT and sonography. In all five cases, the abnormality was located at the anterolateral edge of the medial segment of the liver. It was seen as a small area of low attenuation adjacent to the falciform ligament on CT and as an echogenic area next to the ligamentum teres on sonography. Dynamic CT performed during infusion of contrast medium via the superior mesenteric artery (arterial portography) showed portal blood flow within the lesion and was useful for excluding the presence of a hepatic tumor. Focal fatty infiltration of the liver adjacent to the falciform ligament constitutes a diagnostic pitfall on CT and sonography.     

Pseudogout of the lumbar spine

Calcium pyrophosphate deposition involves deposition of calcium pyrophosphate dihydrate crystals in various joints throughout the body. The term “pseudogout” refers to an acute attack of calcium pyrophosphate crystal-induced arthritis. Though clinical presentation and joint involvement vary, involvement of the lumbar spine is rare. We present the case of a 61-year-old male who presented with 3 days of worsening lower back pain. He had elevated inflammatory markers, leukocytosis, and spinal tenderness on exam. Magnetic resonance imaging of the lumbar spine showed likely L4-L5 osteomyelitis; however, biopsy of the disk space revealed extensive calcium pyrophosphate crystal deposition. The patient was treated with prednisone taper with alleviation of symptoms. Though pseudogout of the spine is rare, our report supports literature urging clinicians to consider pseudogout when assessing elderly patients with back pain for prompt and appropriate treatment.     

Magnetic resonance imaging of the lumbar spine with axial loading: a review of 120 cases

Purpose

To evaluate the imaging findings of patients with clinical symptoms of lower back pain who underwent magnetic resonance imaging (MRI) of the lumbar spine with axial loading.

Materials and methods

We examined 120 patients by MRI, before and after axial loading, using a compression device that applied 50% of their body weight for a load time of 5 min. The dural sac cross area (DSCA) was examined by two experienced radiologists before and after axial load, and their findings were compared. Degenerative abnormalities within and adjacent to the spinal canal were also analyzed.

Results

A reduction in DSCA greater than 15 mm² after axial load was defined as significant, and was found in 81 patients (67.5%) and 138 disc spaces (38.3%). Reduction was most frequent at L4-L5 (n = 55). For other disorders, a 9% increase in cases of bulging disc was seen during axial loading, and seven disc spaces showed protrusion/extrusion only after load. Facet joint synovial cysts, foraminal stenosis, and hypertrophy of the flavum ligaments showed almost no differences, pre- and post-load.

Conclusion

For adequate evaluation of lumbar symptoms, examination should be performed with axial loading, especially in cases of suspected spinal stenosis.     

X-ray computed tomography of hydatid cyst of the liver: symptomatology and classification. Apropos of 157 cases including 146 surgically confirmed

Computed tomography (CT) and in most cases ultrasonography imaging was carried out in 157 patients with suspected hydatid cyst of liver (HCL), and the diagnosis was confirmed on operation in 146 cases. Findings enabled enrichment of CT semiology, proposals for a classification of HCL and precision concerning the value of CT for diagnosis of this affection. The CT scan was observed to provide data on the lesions and to establish the diagnosis of HCL in almost all patients (only one false positive in the 146 cases operated upon). It appeared to be a more reliable method than other exploratory examinations, particularly ultrasonography, in a good number of cases. The indications for CT are defined and the place of this examination in overall investigatory procedures discussed.     

Epidural lipomatosis with lumbar radiculopathy: CT appearance

Epidural lipomatosis is a relatively uncommon clinical entity in which large amounts of fat are deposited in the epidural space. In most of the previously reported cases of this entity an associated myelopathy has been reported. We describe a patient who presented with lumbar radiculopathy, which was probably caused by epidural lipomatosis.     

Fluorine-18 fluorodeoxyglucose positron emission tomography in infectious bone diseases: results of histologically confirmed cases

The aim of this study was to evaluate the clinical use of fluorine-18 fluorodeoxyglucose positron emission tomography (FDG-PET) in acute and chronic osteomyelitis and inflammatory spondylitis. The study population comprised 21 patients suspected of having acute or chronic osteomyelitis or inflammatory spondylitis. Fifteen of these patients subsequently underwent surgery. FDG-PET results were correlated with histopathological findings. The remaining six patients, who underwent conservative therapy, were excluded from any further evaluation due to the lack of histopathological data. The histopathological findings revealed osteomyelitis or inflammatory spondylitis in all 15 patients: seven patients had acute osteomyelitis and eight patients had chronic osteomyelitis or inflammatory spondylitis. FDG-PET yielded 15 true-positive results. The tracer uptake correlated with the histopathological findings in each case. Bone scintigraphy performed in 11 patients yielded ten true-positive results and one false-negative result. Follow-up carried out on two patients revealed normal or clearly reduced tracer uptake, which correlated with a normalisation of clinical data. In early postoperative follow-up it was impossible to differentiate between postsurgical reactive changes and further infection using FDG-PET. It is concluded that acute and chronic osteomyelitis of the peripheral as well as the central skeleton can be detected using FDG-PET. Osteomyelitis can be differentiated from soft tissue infection surrounding the bone. Unlike computed tomography and magnetic resonance imaging, FDG-PET is not affected by metal implants used for fixing fractures. FDG-PET demonstrated promising initial results with respect to treatment monitoring. Nevertheless, in the early postoperative phase FDG-PET seems to be of limited value owing to unspecific tracer uptake. Received 4 November 1999 and in revised form 20 January 2000     

MRI of the post-discectomy lumbar spine

Laminectomy and discectomy are common procedures in the management of symptomatic lumbar disc herniation. Complications of such surgery include recurrent/residual disc herniation, epidural scar formation, discitis, arachnoiditis and pseudo-meningocele. Gadolinium-enhanced MRI is the technique of choice for investigating recurrent symptoms following discectomy. This article reviews the normal early and late post-laminectomy MR appearances, as well as the pathological findings associated with the above-mentioned complications.     

Ligamentum flavum hematoma in the thoracic spine

We report a case of a hematoma of ligamentum flavum at T11-12 in a 66-year-old man who presented with progressive weakness of the right foot and numbness of both legs. Past history was negative and no precipitating episode of lower back sprain or trauma. The resected T11 and T12 laminas showed old hematoma with degenerative changes in the ligamentum flavum. Hematoma occurring in the thoracic spine has never been reported previously.     

Traction osteophytes of the lumbar spine: radiographic-pathologic correlation

Previous reports have emphasized two types of osteophytes on the anterior aspects of the lumbar vertebral bodies: the common claw osteophyte and the less common but more significant traction osteophyte, which is indicative of spinal instability. To delineate the importance of the traction osteophyte, a radiographic-pathologic study was conducted. The results indicate that claw osteophytes are more frequent than traction osteophytes, that both may coexist in a single vertebral body, and that, in most cases, these osteophytes appear to represent different stages of the same pathologic process.