Extradural inflammation associated with annular tears: demonstration with gadolinium-enhanced lumbar spine MRI.
Annular tears are manifest on MRI as the high-intensity zone (HIZ) or as annular enhancement. Patients with annular tears may experience low back pain with radiation into the lower limb in the absence of nerve root compression. Inflammation of nerve roots from leak of degenerative nuclear material through full-thickness annular tears is a proposed mechanism for such leg pain. The aim of this study is to illustrate the appearance of extradural enhancement adjacent to annular tears in patients being investigated for low back pain with radiation into the lower limb(s). Sagittal T1- and T2-weighted spin echo and axial T1-weighted spin echo sequences were obtained in eight patients being investigated for low back and leg pain. In all patients, the T1-weighted sequences were repeated following intravenous gadopentetate dimeglumine (Gd-DTPA). Annular tears were identified at 12 sites in eight patients. Extradural inflammation appeared as a region of intermediate signal intensity replacing the fat between the posterior disc margin and the theca, which enhanced following Gd-DTPA. The inflammatory change was always associated with an annular tear, and in four cases directly involved the nerve root. Enhancement of the nerve root was seen in two cases. The findings may be relevant in the diagnosis of chemical radiculopathy secondary to inflammation at the site of an annular leak from a degenerating disc. (+info)
Recurrent spinal epidural metastases: a prospective study with a complete follow up.
OBJECTIVES: Prospective studies with a complete follow up in patients with spinal epidural metastases (SEM) are rare, so little is known of the incidence and relevance of recurrent spinal epidural metastases (RSEM). This prospective study was undertaken as a part of a previously started and extended prospective study to determine the occurrence and details of RSEM. METHODS: Patients with SEM of various primary malignancies were followed up until death. The diagnosis was confirmed after neurological examination by imaging studies visualising not only the clinically suspected level, but also as much of the spinal canal as possible. RESULTS: Recurrent spinal epidural metastases (RSEM) occurred in 21 of the 103 patients (20%) after a median interval of 7 months and, after treatment, a second recurrence occurred in 11 patients (11%), a third recurrence in two patients (2%), and a sixth recurrence in one patient (1%). RSEM developed about as often at the initial level (55%) as at a different level (45%), did not occur more often in patients with initially multiple SEM, but, not surprisingly, occurred much more often in patients with longer survival. About one half of the patients surviving 2 years, and nearly all patients surviving 3 years or longer developed RSEM. Ambulatory state could be preserved in most patients, even after their second recurrence. CONCLUSION: RSEM are common and even several episodes of RSEM in the same patient are not rare. Patients with SEM who survive long enough have a high risk of RSEM and prompt treatment of RSEM to maintain the ambulatory state of the patient is valuable. (+info)
Cervical epidural lipoblastomatosis: changing MR appearance after chemotherapy.
Lipoblastomatosis is a locally infiltrative tumor of embryonic fat. We describe the MR appearance of cervical lipoblastomatosis with epidural extension. The initial MR study showed features of a soft-tissue mass; a subsequent MR examination, performed after chemotherapy, depicted the lesion as a typical lipoma of high signal intensity on T1-weighted images and of intermediate signal on T2-weighted sequences. (+info)
Pharmacokinetics and efficacy of epidurally delivered sustained-release encapsulated morphine in dogs.
BACKGROUND: We evaluated the epidural effects of a multivesicular liposome-based sustained-release preparation of morphine (C0401) on behavior and lumbar cerebrospinal fluid and serum kinetics of morphine. METHODS: Beagle dogs were prepared with lumbar epidural catheters with subcutaneous injection ports and lumbar intrathecal catheters. Each dog (n = 6) received the following by the epidural route: 5 mg/3 ml morphine sulfate in saline (MS-5), 10 mg/3 ml C0401 (C0401-10), and 30 mg/3 ml C0401 (C0401-30). Behavioral and physiologic parameters and nociceptive responses (skin twitch latency) were evaluated, and morphine concentrations were determined in lumbar cerebrospinal fluid and serum. RESULTS: All morphine treatments blocked the skin twitch response. Time to onset was 1.3 +/- 0.3 h for C0401-30; 2.6 +/- 0.6 h for C0401-10; and 0.4 +/- 0.2 h for MS-5. Duration of action was 62 +/- 0.3 h for C0401-30; 27 +/- 2 h for MS-5. All treatments produced a modest reduction in arousal, muscle tone, and coordination, with the duration of the C0401-30 preparation being longer lasting. Respiratory rate was mildly depressed by all treatments, and moderate hypotension was noted. Time to peak cerebrospinal fluid morphine concentration was 11 h for C0401-30; 3 h for C0401-10; and 5 min for MS-5. Peak lumbar cerebrospinal fluid level was 34,992 +/- 5,578 ng/ml for MS-5; 14,483 +/- 3,438 ng/ml for C0401-30; and 10,730 +/- 2,888 ng/ml for C0401-10. Morphine mean residence time in lumbar cerebrospinal fluid was 0.8 +/- 0.1 h for MS-5; 8.9 +/- 1.0 h for C0401-30. DISCUSSION: Kinetics studies showed that multivesicular liposome sequestration results in a restrained and persistent release of morphine from the epidural space. This extended release corresponded with an extended duration of analgesia without an attendant increase in the incidence of side effects. (+info)
Epidurography and therapeutic epidural injections: technical considerations and experience with 5334 cases.
BACKGROUND AND PURPOSE: Even in experienced hands, blind epidural steroid injections result in inaccurate needle placement in up to 30% of cases. The use of fluoroscopy and radiologic contrast material provides confirmation of accurate needle placement within the epidural space. We describe our technique and experience with contrast epidurography and therapeutic epidural steroid injections, and review the frequency of systemic and neurologic complications. METHODS: Epidural steroid injections were performed in 5489 consecutive outpatients over a period of 5 1/2 years by three procedural neuroradiologists. In 155 cases (2.8%), the injections were done without contrast material owing to either confirmed or suspected allergy. The remaining 5334 injections were performed after epidurography through the same needle. Patients and referring clinicians were instructed to contact us first regarding complications or any problem potentially related to the injection. In addition, the referring clinicians' offices were instructed to contact us regarding any conceivable procedure-related complications. RESULTS: Only 10 patients in the entire series required either oral (n = 5) or intravenous (n = 5) sedation. Four complications (0.07%) required either transport to an emergency room (n = 2) or hospitalization (n = 2). None of the complications required surgical intervention, and all were self-limited with regard to symptoms and imaging manifestations. Fluoroscopic needle placement and epidurography provided visual confirmation of accurate needle placement, distribution of the injectate, and depiction of epidural space disease. CONCLUSION: Epidurography in conjunction with epidural steroid injections provides for safe and accurate therapeutic injection and is associated with an exceedingly low frequency of untoward sequelae. It can be performed safely on an outpatient basis and does not require sedation or special monitoring. (+info)
Cervical epidural rhabdomyosarcoma with a leukemia-like presentation in an aged patient--case report.
A 77-year-old female presented with rhabdomyosarcoma manifesting as leukemia-like indications. Neuroimagings detected cervical and paravertebral masses. Immunohistochemical study of the surgically excised mass lesion from the cervical spine established the correct diagnosis. This leukemia-like presentation of rhabdomyosarcoma requires a multidisciplinary approach to establish the correct diagnosis and treatment. (+info)
Paravertebral arteriovenous malformations with epidural drainage: clinical spectrum, imaging features, and results of treatment.
BACKGROUND AND PURPOSE: Arteriovenous malformations (AVMs) of the spine or spinal cord can be characterized as spinal cord AVMs, spinal cord and dural arteriovenous fistulas, and AVMs occurring outside the dura but draining into the epidural veins. The purpose of this study was to review the clinical spectrum, imaging features, and results of treatment of paravertebral arteriovenous malformations (PVAVMs) with epidural drainage. METHODS: The clinical records and images of 10 patients with PVAVMs were analyzed retrospectively for clinical presentation, MR findings, angioarchitecture, pathophysiology, treatment efficacy, and clinical follow-up. RESULTS: Seven patients had myelopathy. The MR findings for three of these patients showed spinal cord hyperintensity on T2-weighted sequences and prominent perimedullary vessels. Angiography, performed in two of the three patients, showed evidence of reflux into the perimedullary veins from the PVAVMs. Each of these two patients underwent surgical clipping of the radicular vein leading to the perimedullary veins. In three of the seven patients, there were large epidural veins compressing the cord. Angiography performed in these patients showed large PVAVMs with multiple feeders, which were treated by a combination of transarterial and transvenous embolization. One of the seven patients had an associated spinal cord arteriovenous malformation. In three patients with incidental PVAVMs, cure was achieved by using a combination of coils and liquid adhesives by the endovascular route. CONCLUSION: The clinical presentation of PVAVMs is variable, and symptomatic lesions are the result of compression by epidural veins or of congestive myelopathy. A clear understanding of the anatomy and pathophysiology is necessary to plan treatment. Endovascular techniques are capable of curing the malformation, alleviating the symptoms, or both in a significant proportion of these lesions. (+info)
Lumbosacral extradural arachnoid cysts: diagnostic and indication for surgery.
No critical discussion of the indication for the surgical treatment of lumbosacral extradural arachnoid cysts is found in the literature. Therefore, we want to compare the results in patients with operative and conservative treatment to define standards for a good surgical result. Over a period of 9 years, we operated on eight patients with a lumbosacral extradural arachnoid cyst and treated eight others conservatively. Only three of the operated patients experienced a postoperative relief of pain, but none was symptom free. The only one with continuing success had a preoperative history of 1 year only. MRI scans without contrast agent were misinterpreted in one included and one excluded case. The results of conservative treatment were nearly the same as those of operative treatment. MRI is the best diagnostic tool, but a variety of sequences must be used. Patients with a short pain history and a clear neurological deficit profited most from surgery. Patients with slight and not clearly related uncharacteristic symptoms should be excluded from surgery. (+info)