Paraspinal Mass Research Articles

Castleman disease of the spine mimicking a nerve sheath tumor

Castleman disease is a rare lymphoproliferative disease of unknown cause. In most cases, afflicted patients present with a mediastinal mass although the disease may manifest in numerous other sites, including intracranially and rarely intraspinally. The authors report on the case of a 19-year-old woman who presented with a large paraspinal mass emanating from the T7-8 neural foramen. The morphological and signal characteristics revealed on magnetic resonance imaging were similar to those of nerve sheath tumors. The patient underwent open biopsy sampling of the lesion, and results of a pathological evaluation revealed hyaline-vascular type Castleman disease. She underwent radiotherapy and remains symptom-free with a radiographically stable lesion 1 year later. Although the disease has been reported to mimic a meningioma when encountered in intracranial locations, to the authors' knowledge, this is the first case of the disorder mimicking a nerve sheath tumor. When the diagnosis of Castleman disease is made, good results can be obtained with partial resection and radiotherapy.

Cervical radiculopathy secondary to Hodgkin's lymphoma

Background Spinal cord/root compression is a rare complication of HL and usually seen in the setting of progressive, advanced disease. It is extremely rare to occur as an initial presentation of HL. We report a case of HL presented with bilateral cervical radiculopathy. Methods A case report of a 42-year-old woman who presented with C8 cervical radiculopathy and paraspinal mass with extradural extension in C7-T1. Biopsy revealed HL. This case report represents a case of HL presenting with epidural disease, with nerve root compression as the only apparent site of clinical involvement. A review of the literature of patients with HL presenting with spinal cord/root compression is presented. Result Our patient received chemotherapy and external beam radiation therapy. She achieved good recovery of her symptoms and complete response by radiologic criteria. Based on a review of the literature, Hodgkin's disease involving the spinal epidural space is very responsive to chemoradiotherapy with good prognosis for both functional recovery and complete response. Conclusion Chemoradiotherapy is a successful treatment for Hodgkin's disease presenting with spinal root compression. Surgery should be reserved for urgent decompression, if needed; palliation; and maintenance of function and stability.

Use of isotopes in the diagnosis of hematopoietic disorders

Isotopes of iron have been paramount in clinical tracer studies of hematopoiesis. Kinetics of disappearance from plasma, appearance in circulating erythrocytes, and localization in general areas of bone marrow, spleen, and liver were early revealed by gamma-/beta-emitting Fe-59 with note of characteristic differences of kind and degree of dysfunction among various anemias. Findings have helped in management (e.g., decisions about splenectomy). Positron/gamma-emitting Fe-52 (better for imaging) has provided more detail on marrow expansion and erythropoietic relocation. Other gamma-emitting tracers of hematopoiesis have been In-111 (linked to transferrin) and technetium 99m (Tc-99m) colloids (localizing to reticuloendothelial cells, which have close association with blood cell progenitors), but Fe-52 has proved to be more accurate for recognition of erythropoiesis. Occasional diverse heterotopic sites of hematopoiesis beyond spleen and liver in states of bone marrow disease have posed diagnostic challenges and also raised questions about migration and/or activation of stem cells. Studies of granulopoiesis utilize Tc-99m--labeled leukocytes or Tc99m-labeled antibodies to circulating and progenitor white cells. Iron-deficiency anemias due to malnutrition, malabsorption, blood loss, or special need are explored by dual study (oral vs intravenous) with radioactive (Fe-59, Fe-55) or stable (Fe-54, Fe-57) iron isotopes, which can guide dietary supplementation. Tests for B-12 deficiency in pernicious anemia or malabsorption with radioisotopes of cobalt (Co-57, Co-58) have been upgraded in sensitivity and scope. Rates of oxidation to expired carbon dioxide from particular carbon (radioactive C-14 or stable C-13)--labeled compounds can test B-12 or folic acid deficiencies or gastric infestation as causes of megaloblastic anemias.

A 13-year-old textiloma (gossypiboma) after discectomy for lumbar disc herniation: a case report and review of the literature

Background context A paraspinal retained surgical sponge (textiloma) is rare and mostly asymptomatic in chronic cases but can be confused with other soft-tissue masses. Therefore, it is important to be aware of patients with a paraspinal soft-tissue mass with unusual or atypical symptoms. Purpose A patient with asymptomatic chronic paraspinal textiloma who was operated on 13 years ago for lumbar disc herniation is presented. Study design Case report. Methods A patient presented with complaints of back pain radiating to leg and neurogenic claudication. Computed tomography imaging revealed canal stenosis at L3–L5 levels and a soft-tissue mass at the paraspinal muscles of the L5–S1 level. Results Surgical treatment was performed for both to excise or obtain biopsy from the soft-tissue mass and to treat spinal stenosis. During the operation, a retained surgical sponge was found and excised completely with fibrous capsule surrounding it and decompression and posterior spinal instrumentation performed without fusion for spinal stenosis with dynamic pedicle screws (Cosmic Pedicle Screw System; Ulrich AG, Germany). Recovery was uneventful, and the patient's stenosis symptoms were resolved soon after surgery. Conclusion Retained surgical sponges do not show mostly any specific clinical and radiological signs. They should be included in differential diagnoses of soft-tissue masses at the paraspinal region with a history of a previous spinal operation.

CT Perfusion in Spinal Disease: An Adjunct Tool to Vertebral Body Biopsy

Routine diagnostic techniques are inadequate for diagnosis of spinal diseases. The purpose of this study was to determine whether CT perfusion can differentiate inflammatory diseases like tuberculosis from neoplastic diseases of spine. Thirty-two patients with vertebral body lesions associated with paraspinal mass underwent CT guided bone biopsy and histopathological evaluation. CT perfusion was done in all patients before doing biopsy. Perfusion parameters like blood volume (BV), blood flow (BF) and time to peak (TTP) were calculated and correlated with histopathology. Statistical analysis was done using Mann-Whitney test. p value <0.05 was considered significant. Of 32 cases, 20 had tuberculous osteomyelitis and 12 neoplastic disease (seven metastasis, three plasmacytoma, one each lymphoma and chordoma). Mean rBF was [inflammatory lesions, 1.459 and neoplastic lesions, 18.080 (p<0.000). Mean rBV was (inflammatory disease, 2.8589 and neoplastic lesions, 12.2133 (p<0 .000)). Mean rTTP was [inflammatory pathology, 1.041 and neoplastic pathology, 0.703(p<0.079)]. This shows the deconvolution-based CTP technique's potential for noninvasive diagnosis of at least all inflammatory lesions affecting the spine that are associated with paraspinal mass. Validation of the use of deconvolution CTP parameters for differentiation of inflammatory from neoplastic pathology may permit this technique to be used as an adjunct tool when biopsy when routine imaging findings are inconclusive.

Entzündliche Wirbelsäulenerkrankungen

Regardless of the compartment involved, imaging of spinal infections and other spinal inflammatory diseases must be performed by magnetic resonance imaging (MRI). This allows early detection of changes in disk space or vertebral bodies. Associated paraspinal and epidural masses are depicted. However, in spinal cord inflammation MRI has a very limited specificity and cannot usually differentiate between the wide array of possible causes of intramedullary lesions. This article covers a spectrum of inflammatory lesions of the spinal cord.

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The goals of this study were to 1.) Compare IMRT treatment techniques for a para-spinal mass located in the thoracic spine of an anthropomorphic phantom, and 2.) Measure the accuracy of Megavoltage-CT (MVCT) images for localizing spinal anatomy in the T-Spine region.

Inflammatory pseudotumor of the spinal nerve complicated by paraneoplastic pemphigus

We describe finding an inflammatory pseudotumor (IPT) in the thoracic spinal nerve, a previously unreported location, in combination with paraneoplastic pemphigus (PNP). This 48-year-old woman presented with a 1-month history of progressive dyspnea and pleuritic pain in the right lower chest region, as well as a 1-month history of thoracic back pain. Physical examination revealed multiple oral ulcers, multiple blisters, and erythematous papules on the skin of the trunk. These lesions were diagnosed as pemphigus vulgaris based on the results of biopsy examination. All laboratory tests, plain chest radiographs, and plain spine radiographs showed normal findings. Thoracic magnetic resonance (MR) imaging studies showed an extradural paraspinal ellipsoidal mass exhibiting regular boundaries; and contrast enhancement was homogeneous in the right costodiaphragmatic recess at the T-12 level and extended into the spinal foramen (Fig. 1 left). Because of the patient’s progressive symptoms, a costotransversectomy was performed via a paramedian incision. Intraoperatively, we observed a well-circumscribed 5 3 3 3 4‐cm tumor originating from the proximal part of T-12 spinal nerve, which was not grossly infiltrated; the lesion bulged into the right thoracic cavity. The final histological diagnosis was an IPT (Fig. 1 right). The patient’s chest pain progressively resolved after surgery, but dyspnea persisted and progressive pulmonary compromise developed. She was transferred to the department of internal medicine, and a repeated biopsy sample of an oral ulcer was obtained. Direct tissue immunofluorescence demonstrated intracellular immunoglobulin G (IgG) and complement C3 deposition within the epidermis (Fig. 2). The final diagnosis was PNP combined with fibrosa obliterans, which was caused by the underling IPT. During the following months, the progressive dyspnea improved slightly after intravenous Ig therapy, as did the skin and mucosal lesions. Three months after the operation, however, the patient was readmitted to the intensive care unit for progressive dyspnea, and she died of pulmonary failure. In the present case the IPT’s origin from the spinal nerve in the paravertebral region was unique.4 In such cases involving an IPT diagnosis is seldom confirmed preoperatively, and the treatment of choice is resection. 2

Solitary Fibrous Tumors of the Head and Neck

To describe the clinicopathologic and radiologic features of solitary fibrous tumors of the head and neck. Retrospective analysis. Tertiary referral center that performs head and neck surgical oncology. Twelve patients with solitary fibrous tumors of the head and neck identified from the pathology and soft tissue tumor databases at Memorial Sloan-Kettering Cancer Center, New York, NY, from 1990 to 2004. All cases were reviewed by 3 experienced pathologists, 1 of whom is an experienced soft tissue tumor pathologist. The diagnosis was confirmed by microscopic features on hematoxylin-eosin staining and by positive staining for CD34 and Bcl2 on immunohistochemical analysis. Tumors were scored for mitotic activity, cellularity, nuclear pleomorphism, necrosis, and the presence of a malignant component. Details on patient characteristics, tumor characteristics, previous treatment and surgery, adjuvant treatment, and outcome were recorded from clinical records. Solitary fibrous tumors occurred in patients over a wide age range (27-78 years; median age, 52 years). Seven patients (58%) were women, and 5 (42%) were men. Most tumors presented as a slow-growing painless mass with a duration ranging from 2 months to 5 years. The tumors ranged from 1 x 1 cm to 6 x 5 cm. Patients presented with a subcutaneous mass of the scalp or face in 4 cases, intraoral mass in 4, sinonasal mass in 3, and paraspinal mass in 1. Computed tomographic and/or magnetic resonance imaging scans of 7 of the 12 patients showed well-circumscribed tumors that enhanced strongly with contrast. Treatment for all of the patients was surgical resection. Pathologic findings showed that 9 tumors were benign and 3 were malignant. Three patients had a positive surgical resection margin. All patients were alive at a median follow-up of 8 months (range, 1-76 months). Local recurrence occurred in 1 patient who had positive surgical margins 3 years after the initial surgery. Solitary fibrous tumors of the head and neck region are rare and most commonly benign. The diagnosis depends on microscopic and immunohistochemical features, although imaging may help. Patients with these tumors can be safely treated with local excision, but tumors with positive margins require close follow-up over several years owing to the potential for late local recurrence.

Nonoperative Treatment of Vertebral Blastomycosis Osteomyelitis Associated with Paraspinal Abscess and Cord Compression: A Case Report

Fungal infections of the spine are uncommon and usually result from hematogeneous spread of a primary focus1. Blastomyces dermatitidis has been described as a causative agent in cases of vertebral osteomyelitis2,3. Most cases of blastomycosis osteomyelitis begin as primary fungal infections of the lungs3. However, traumatic innoculation, local extension, and lymphatic spread also have been described as possible mechanisms of introduction of the fungi to bone2. The long bones are more commonly affected than the vertebral column is4. Primary cutaneous blastomycosis can occur5, and many other organ systems, including the genitourinary and central nervous systems, can be affected6. Blastomyces dermatitidis is a dimorphic fungus endemic to the southeastern and south central portions of the United States4. Primary pulmonary blastomycosis is acquired by inhalation of airborne conidia1. The spores then develop into the yeast form, producing an acute illness stage that is clinically indistinguishable from a bacterial pneumonia. In as many as 50% of cases of disseminated blastomycosis, osseous involvement may occur2,7. We report the case of a patient in whom vertebral blastomycosis osteomyelitis was successfully treated nonoperatively. The patient was informed that information concerning this case would be submitted for publication. Asixty-four-year-old South American woman who had recent-onset midthoracic spinal pain with left scapular radiation presented to us in February 2001. The patient had no history of trauma or recent illness and no history of exposure to farm animals or pets. The medical history included chronic hypertension, arthritis, and depression. Physical examination revealed normal findings. A computerized tomography scan demonstrated a paraspinal mass with rim …

Unusual Presentation of a Paraspinal Mass With Involvement of a Lumbar Facet Joint and the Epidural Space

Unusual Presentation of a Paraspinal Mass With Involvement of a Lumbar Facet Joint and the Epidural Space

Musculoskeletal Coccidioidomycosis

Coccidioidomycosis is a primary pulmonary infection, endemic to the southwestern United States, caused by inhalation of spores in an immunocompetent host. When systemic spread occurs, the dissemination of infection to musculoskeletal sites might account for 20% to 50% of cases. The musculoskeletal manifestations are well recognized by physicians in endemic areas. We report 2 cases encountered in metropolitan Chicago in which morphologically typical, large, yeast-like, encapsulated, endosporulating organisms were identified in tissue samples and Coccidioides immitis was cultured. One patient had a degenerative-type radiographic picture thought to be related to a sports injury. A second patient with skin lesions and a paraspinal mass required emergency decompressive spinal surgery. A history consistent with exposure to Coccidioides organisms was apparent only for the first patient. Although the diagnosis can be established morphologically by identifying the large endospores in tissue samples, the submission of samples for culture and subsequent microbiologic confirmation requires the diagnosis to be considered clinically. This report emphasizes the rarity of the organism in nonendemic areas and the redundant value of using both morphologic and microbiologic modalities.

Musculoskeletal Coccidioidomycosis

Coccidioidomycosis is a primary pulmonary infection, endemic to the southwestern United States, caused by inhalation of spores in an immunocompetent host. When systemic spread occurs, the dissemination of infection to musculoskeletal sites might account for 20% to 50% of cases. The musculoskeletal manifestations are well recognized by physicians in endemic areas. We report 2 cases encountered in metropolitan Chicago in which morphologically typical, large, yeast-like, encapsulated, endosporulating organisms were identified in tissue samples and Coccidioides immitis was cultured. One patient had a degenerative-type radiographic picture thought to be related to a sports injury. A second patient with skin lesions and a paraspinal mass required emergency decompressive spinal surgery. A history consistent with exposure to Coccidioides organisms was apparent only for the first patient. Although the diagnosis can be established morphologically by identifying the large endospores in tissue samples, the submission of samples for culture and subsequent microbiologic confirmation requires the diagnosis to be considered clinically. This report emphasizes the rarity of the organism in nonendemic areas and the redundant value of using both morphologic and microbiologic modalities.

High-Resolution Imaging of the Spine Using Multidetector-Row Computed Tomography

The purpose of this study was to investigate the ability of high-resolution computed tomography (CT) images to distinguish between benign and malignant vertebral compression fractures. Computed tomography images of 45 benign compression fractures in 40 patients and 33 malignant compression fractures in 33 patients were evaluated. A 16-slice multidetector-row CT scanner was used for data acquisition, and axial images with a slice thickness of 1 mm and sagittal and coronal multiplanar reconstruction images with a slice thickness of 0.7 to 1 mm were used for interpretation. The following findings were significantly more frequent in malignant fractures: destruction of the anterolateral and/or posterior cortex of the vertebral body, destruction of the cancellous bone of the vertebral body, destruction of the end plate, destruction of the pedicle, a paraspinal soft tissue mass, and an epidural mass. The extremely reliable signs of malignancy were destruction of the anterolateral and/or posterior cortex of vertebral body (100% accuracy) and destruction of the cancellous bone of the vertebral body (97.4% accuracy). High-resolution CT can provide many useful signs for differentiating between benign and malignant vertebral compression fractures, and its diagnostic ability is sufficient for clinical use.

Extranodal Rosai-Dorfman Disease with Multifocal Bone and Epidural Involvement Causing Recurrent Spinal Cord Compression

Sinus histocytosis with massive lymphadenopathy, or Rosai-Dorfman disease, is a rare histiocytic disorder that typically presents with chronic, self-limiting, cervical lymphadenopathy. We present a case, a diagnostic dilemma for multiple consultation services, of an otherwise well 17-year-old boy without lymphadenopathy who, 8 months after excision of a T9 lytic vertebral lesion and epidural mass that caused cord compression, again presented with cord compression from progressive vertebral disease, recurrent epidural mass, and development of a paraspinal mass and tibial lesion. The excised vertebral and epidural lesions, 2 paraspinal biopsies, and tibial biopsy were interpreted as chronic inflammation until large histiocytes were noted, which were positive for CD68, S100 protein, fascin, and MAC387, and demonstrated characteristic emperipolesis (lymphophagocytosis) that was diagnostic of Rosai-Dorfman disease. This atypical clinical behavior and sites of involvement of multiple bones but not of lymph nodes is unusual and constitutes the aggressive end of the clinical spectrum and a rare cause for cord compression.

Cytopathologic analysis of paraspinal masses: A study of 59 cases with clinicoradiologic correlation

Paraspinal masses (PSM) are uncommon and present a wide spectrum of differential diagnoses on fine-needle aspiration (FNA). We analyzed 59 cases of PSM on FNA in a 15-yr period, in the context of clinicoradiologic correlation. Radiologic findings, clinical data, and tissue biopsies were reviewed. Patients were 14-83 yr of age (mean 54.7) with a M:F ratio of 1.36:1. Of the 59 cases, 39 (66%) were deemed diagnostic. Of these, 8 (21%) revealed nonneoplastic lesions and 31 (79%) yielded neoplasms: 2 (6%) benign and 29 (94%) malignant. Of the malignant cases, 22 (76%) were metastatic tumors from various sites, while 7 (24%) were cancers from local spread, which included non-Hodgkin's lymphoma (NHL, 5) and myeloma (2). Benign neoplasms were nerve sheath tumors. Metastatic tumors consisted of adenocarcinoma, 9; squamous-cell carcinoma, 3; renal-cell carcinoma, 1; and non-small-cell carcinoma/not otherwise specified (NOS), 9. Twenty-four (41%) cases received further studies: immunoperoxidase (IPOX) alone, 17 (71%); special stains for microorganisms, 2 (8%); IPOX/other special stains, 4 (17%); and flow cytometry analysis, 1 (4%). Eight (14%) cases received follow-up biopsies. Half of these biopsies added information to previously "nondiagnostic" FNAs. Of the previously "diagnostic" FNAs, tissue biopsy yielded no additional information. Cytopathologic diagnoses were consistent with the pre-FNA radiology analyses in 13 (39%) cases. In instances of radiologic and cytopathologic discrepancy (4 cases, 12%), diagnoses made by FNA reversed the initial radiologic impression of neoplasm to infection, and vice versa. PSMs are rare lesions (0.26% of total FNAs done in 15 yr at our institution). The most common lesion encountered is metastatic adenocarcinoma, followed by NHL. Ancillary studies are helpful in difficult cases. In cases of radiologic/cytopathologic discrepancy, FNA diagnoses are more accurate and decisive for patient management. The sensitivity and specificity of a PSM FNA are 88% and 75% respectively.

Paraspinal Mass in a Seven-Year-Old Girl

Paraspinal Mass in a Seven-Year-Old Girl

Bronchopleural cutaneous fistula due to &amp;lt;i&amp;gt;Eikenella corrodens&amp;lt;/i&amp;gt;

The aim of this paper is to review the subject and to report on and discuss a case of bronchopleural cutaneous fistula due to Eikenella corrodens. A 16-year-old girl was brought to our hospital with fever and blood-tinged sputum 2 weeks prior to her admission. She suffered from neurologic sequelae of herpetic encephalitis and had been bed-ridden since 5 years of age. A longitudinal paraspinal soft mass had been noted in the previous week by her mother. She had been given oral feeding despite frequent choking for the past few years. On palpation, the mass can be squeezed to follow the least resistance of subcutaneous space longitudinally extending to the lower thoracic region. Chest computed tomography scan revealed right lower lobe necrotizing pneumonitis and a pleuro-cutaneous fistula leading to the subcutaneous air locules. A protracted course of antibiotics was prescribed and subcutaneous air trapping decreased in size over 8 weeks. Eikenella corrodens has increasingly been implicated as a potential causative pathogen in pleuropulmonary infections. Pleuro-cutaneous fistula and abscess formation complicating empyema and necrotizing pneumonitis due to E. corrodens infection have not been reported. A bulging thoracic subcutaneous lesion waxes and wanes with respiration suggest the possibility of a pleruo-cutaneous fistula. Treatment of Eikenella empyema using antibiotics without surgical decortication requires a prolonged course of antibiotic therapy.

Diffusion-Weighted Magnetic Resonance Imaging of Spinal Infection and Malignancy

Pyogenic and tuberculous spondylitis can mimic malignancy. The purpose of this study was to deter mine the efficacy of diffusion-weighted magnetic resonance imaging in differentiating spinal infection and malignancy. Fifty-one consecutive patients with suspected spinal infection or malignancy were enrolled in the study. Apparent diffusion coefficients (ADCs) of paraspinal soft tissue mass and normal and abnormal vertebral bone marrow were determined on the diffusion-weighted magnetic resonance images of the spine. The mean ADCs of normal and abnormal vertebral bodies in patients with confirmed infection or malignancy were compared using nonparametric tests. ADCs of 69 tuberculous, 9 pyogenic, and 50 malignant vertebral marrow lesions were significantly higher than ADCs of normal marrow. ADCs of malignant bone marrow and 5 paraspinal soft tissue lesions were significantly lower than tuberculosis and pyogenic infection. There was no significant difference between the ADCs of 44 adult and 25 pediatric tuberculous bone lesions or between tuberculosis and pyogenic infection. Using the cutoff ADC of 1.02x10(-3)mm2/s for bone marrow, the sensitivity, specificity, and accuracy were 60.26%, 66.00%, and 62.50%, respectively, for distinguishing infection from malignancy. The sensitivity, specificity, and accuracy increased to 94.12%, 82.35%, and 90.20%, respectively, when the ADCs of associated soft tissue lesions were higher than 1.17x10(-3)mm2/s. Diffusion-weighted magnetic resonance imaging has limited usefulness for differentiating spinal infection and malignancy.

Vertebral osteomyelitis in an infant presenting with pseudotumor and narrowing of the spinal canal

In an 8-week-old infant, kyphosis caused by destruction of the 7th thoracic vertebra was observed. A paraspinal mass and narrowing of the spinal canal due to vertebral osteomyelitis were present. Treatment with antibiotics and bracing was carried out with no evidence of neurologic disturbances over a follow-up period of 24 months.