Stuart R. Pomerantz CAQ Prep 2004 Intramedullary Edema DDx 1. 2. 3. 4. 5. 6. 7. 8. 9.

9. Transverse myelitis idiopathic, viral, MS Sarcoid SLE Dural AV fistula Astrocytoma Ependymoma Post-traumatic edema Mets Spinal Cord Infarct

Cystic Masses within Spinal Canal DDx

1. Hydrosyringomyelia 2. Ependymoma 3. Astrocytoma 4. Hemangioblastoma 5. Spinal Cord Herniation 6. Arachnoid Cyst 7. Meningeal diverticulum/Cyst 8. Cysticercosis 9. Neuroepithelial Cyst 10. Neuroenteric Cyst 1. Drop Metastases (Primary CNS or systemic malignancy) 2. Schwannomas 3. Meningioma 4. Exophytic glial neoplasm 5. Filar ependymoma 6. PNET 1. 2. 3. 4. 5. 6. 7. Leptomenigneal Metastases Arachnoiditis Nerve root compression Meningitis (Chemical, infectious, carcinomatous) CMV radiculitis guillain-Barre Syndrome AV Fistula

Enhancing Intradural Extramedullary Masses DDx

Enhancing Intradural Nerve Roots DDx

Intramedullary Lesion

1. Tumor a. Ependymoma 60% b. Astrocytoma 25% c. Oligodendroglioma - 3% d. Epidermoid, dermoid, teratoma (1-2%)

e. Lipoma 2. Cystic Lesion a. Syringomyelia b. Hydromyelia c. Reactive Cyst d. Hemangioblastoma 3. Vascular a. Cord concussion b. Hemorrhagic contusion c. Cord transection d. AVM 4. Chronic Infection a. Sarcoid b. Transverse Myelitis c. MS Intramedullar Cord Lesion IM ASHAMED 1. Inflammation MS, transverse myelitis, sarcoidosis) 2. Medulloblastoma 3. Astrocytoma 4. syringomyelia, hydromyelia 5. Hematoma, Hemangioblastoma 6. AVM 7. Mets 8. Ependymoma 9. Dermoid 1. 2. 3. 4. Neurofibroma 25-35% Meningioma Lipoma Dermoid commonly conus/cauda, a/w spinal dysraphism 5. Ependymoma 6. Drop mets from CNS tumors 7. Mets from extra-CNS tumors 8. Arachnoid cyst 9. neurenteric cyst 10. Hemangioblastoma MAMA N 1. Mets 2. Arachnoiditis 3. Meningioma 4. AVM, arachnoid cyst

Intradural Extramedullary Mass

Intradural Extramedullar Mass

5. Neurofibroma Epidural Extramedullary Lesion 1. Benign Tumor a. Dermoid, epidermoid b. Lipoma c. Fibroma d. Neurinoma/schwannoma with intradural component e. Meningioma with intradural component f. Ganglioneuroblastoma, ganglioneuroma 2. Malignant Tumor a. Hodgkin Disease b. Lymphoma dorsally c. Mets breast, lung, from VB d. Paravertebral Neuroblastoma e. Chordoma 3. Disk Disease a. Bulging disk, herniated disc, sequestered disc fragment 4. Osseous spinal stenosis, spondylosis 5. Inflammation epidural abscess 6. Hematoma 1. Arising from nerve sheath a. Schwannoma antoni A (cellular) and B (myxoid), most sporadic, 15-20% NF2 b. Neurofibroma NF1, potential for malignant transformation, 2. Originating from Nerve a. Neuroma posttraumtic lesion at end of severed nerve b. Neurilemoma 1. 2. 3. 4. 5. 6. 7. MS Amyotrophic Lateral sclerosis Cervical spondylosis Sequela of trauma Ischemia Rtx AVM

Neurogenic Tumor (Neurinoma) types

Cord Atrophy DDX

Lumbosacral Post-surgical Syndrome

1. Biomechanical Failure a. Primary disc herniation b. Recurrent disc herniation (1 week 1 month) 2. Failure of Treatment

a. b. c. d.

residual disc herniation (onset < 1 week) perioperative intraspinal hemorrhage spinal/meningeal/neural inflammation Intraspinal scar formation - > 1month i. Epidural fibrosis ii. Fibrosing arachnoiditis

Failed Back Surgery Syndrome 1. Definition 2. Causes

1. Failure of improvement following back surgery (515%), difficult in immediate postop pd, stabilization of findings over 2-6 moths 2. DDx a. Osseous Causes i. Spondylisthesis ii. Central Stenosis iii. Foraminal stenosis iv. Pseudoarthrosis b. Soft Tissue Causes i. Adhesive arachnoiditis ii. Infection iii. Hemorrhage iv. Epidural fibrosis (scarring) v. Recurrent disc herniation c. Surgical Errors i. Wrong level/side of surgery ii. Direct nerve Injury ABCDEFG 1. Arachnoiditis 2. Bleeding 3. Contamination (infection) 4. Disc (residual/recurrent/new level) 5. Error (level) 6. Fibrosis (scar) 1. displaced disc fragment 2. intra/extramedullar tumor 3. Osseous: paget dz, osteomyelitis, osteoarthrosis of facet joint, ank spon 1. 2. 3. 4. 5. 6. Epidural Lipomatosis Metastases AVMs Extramedullary hematopoiesis OPLL Lymphoma

Failed Back Surgery Syndrome DDx

Cauda Equina Syndrome DDx

Long Epidural Lesions of the Spine DDx

7. Neuroblastoma 8. Epidural Abscess 9. Epidural Hematoma Sacral/Presacral Masses DDx 1. 2. 3. 4. 5. 6. 7. 8. 9. Chordoma Giant Cell Astroctyoma Mets Sacrococcygeal teratoma Tarlov Cysts Plasmacytoma Neuroblastoma Ganglioneuroma Plexiform Neurofibroma

Osteolytic Lesion of Skull

1. Normal variant a. Emissary vein b. Venous Lake c. Pacchionian granulations d. Parietal foraminae (normal or giant) 2. Trauma a. Surgical burr hole b. Leptomeningeal cyst 3. Infection a. Osteomyelitis b. Hydatid disease c. Syphilis d. Tb 4. Congenital a. Dermoid/Epidermoid b. NF (asterion defect) c. Meningoencephalocele d. Osteoporosis circumscripta of Paget Dz e. Fibrous Dysplasia 5. Benign Tumor a. Hemangoma b. Brown Tumor c. EG 6. Malignant Tumor a. Solitary/multiple mets b. Multiple myeloma c. Plasmacytoma d. Leukemia e. Neuroblastoma

Solitary Lytic Lesion in Skull

HELP MFT HOLE 1. Hemangioma 2. Epidermoid/Dermoid 3. Leptomeningeal Cyst 4. Postop/Paget Dz 5. Mets, Myeloma 6. Fibrous dysplasia 7. Tb 8. Hyperparathyroidism 9. Osteomyelitis 10. Lambdoig defect (NF) 11. Eosinophilic Granuloma BAMMAH 1. Brown Tumor 2. AVM 3. Myeloma 4. Mets 5. Amyloidosis 6. Histiocytosis 1. 2. 3. 4. 5. 6. 7. 1. 2. 3. 4. Asomia Hemivertebra Coronal cleft Butterfly vertebra Block vertebra Hypoplastic vertebra Klippel-Feil syndrome

Multiple Lytic Lesions in Skull

Spinal Segmentation Anomalies

Small Vertebral Body DDx

RTx Juvenile rheumatoid arthritis cspine EG vertebra plana Gaucher dz compression deformity (deposits of glucocerebrosides within RES) 5. Plastyspondyly generalisata (hereditary disorders inc. achondroplasia, mucopolysacharidosis, osteopetrosis, NF, OI) FETISH 1. Fracture (trauma, OI) 2. EG 3. Tumor Lymphoma, Leukemia, mets) 4. Infection 5. Steroids (avascular necrosis) 6. Hemangioma

Vertebral Plana

Enlarged Vertebral Body DDx

1. Pagets DZ picture framing 2. Gigantism 3. Myositis ossificans progressive

Vertebral Border Abnormalities Straightening of Anterior Border 1. 2. 3. 4. 5. 6. 1. 2. 3. 4. Ankylosing Spondylitis Paget Dz Psoriatic arthritis Reiter disease RA Normal Variant Aortic Aneurysm Lymphadenopathy Tb Multiple Myeloma

Anterior Scalloping of Vertebrae

Posterior Scalloping of Vertebrae

Dural Ectasia 1. Increasing Intraspinal Pressure a. Communicating hydrocephalus b. Ependymoma 2. Mesenchymal tissue laxity a. NF b. Marfan Syndrome c. Ehlers-Danlos d. Posterior Meningocele 3. Bone Softening a. Mucopolysaccharidoses: Hurler, Morqui, Sanfilippo b. Acromegaly (lumbar vertebrae) c. Ankylosing spondylitis (lax dura acting on osteoporotic vertebrae) d. Achondroplasia 1. LOWER 1/3 ANTERIOR BEAK a. Hurler syndrome LOWER 1/3 anterior beak, mild kyphotic curve b. Achondroplasia c. Cretinism (hypothyroidism) d. Down syndrome e. Neuromuscular diseases 2. CENTRAL ANTERIOR BEAK a. Morquio disease flat/wide vbs 3. Spondylosis Deformans osteophytes along

Bony Projections from Vertebra

anterior and lateral endplstes with horizontal/vertical course (sharpeys) 4. DISH Diffuse idiopathic skeletal hyperostosis, Forrestier disease, flowing Ca+/ossification alaong anterolateral aspect of >= 4 contiguosu thoracic vertebral bodies 5. Ankylosing Spondylitis bil symmetric syndesmophytes (ossification of annulus fibrosus), bamboo spine, discal ballooning (biconvex discs) 2 osteoporotic endplate deformity 6. Fluorosis Spine Ossification Patterns and associations 1. Syndesmophyte ossification of annulus fibrosus, ankylosign sponydilitis, ochronosis 2. Osteophyte - ossification of ALL, osteoarthritis 3. Flowing Anterior Ossification DISH 4. Paravertebral ossification psoriatic arthritis, Reiter syndrome 1. Osteoporosis senile, steroids, fish vertebrae 2. Sickle Cell Disease H vertebrae central compression due to subchondral infarcts 3. Schmorl Node 4. Limbus vertebrae (anteriosuperior corner 5. Ring epiphysis normal b/w 6-12 yo, small steplike recess at corner of anterior vb edge 6. Renal Osteodystrophy rugger jersey spine 7. Myelofibrosis rugger-jersey spine thick bands 8. Osteopetrosis sandwich vertebrae thin sclerotic endplates SHOOT 1. Scheurmann disease 2. Hyperparathyroidism 3. Osteoporosis 4. Osteomalacia 5. Trauma CHOW 1. CPPD 2. Hemochromatosis 3. Ochronosis 4. Wilson Disease HAM 1. Hypothyroidism

Vertebral endplate Abnormality

Schmorl Node DDx

Intervertebral Disc Calcification

Bullet-shaped Vertebral Body

2. Achondroplasia 3. Morqui syndrome Bone-within-bone Vertebra 1. 2. 3. 4. 5. 6. 7. 8. Stress line Leukemia Heavy metal poisoning Thorotrast injection , TB Rickets Scurvy Hypothyroidism Hypoparathyroidism

EXPANSILE LESION OF VB EXPANSILE LESION OF VB: Multiple VB Involvement 1. 2. 3. 4. 5. 6. 7. 1. 2. 3. 4. Mets Multiple Myeloma lymphoma hemangioma Paget disease angiosarcoma EG Osteochondroma chordoma aneurismal bone cyst myeloma

EXPANSILE LESION OF VB: Involvement of Two/More Contiguous Vertebrae

EXPANSILE LESION OF VB: Benign lesions

1. Osteochondroma 2. Osteoblastoma posterior elements, cervical, calcified tumor matrix 3. Giant Cell Tumor sacrum, malignant degen 1520% 4. Osteoid osteoma 5. Aneurysmal Bone cyst arise from primary bone lesion (GCT, fibrous dysplasia) 6. Hemangioma 7. Hydatid Cyst 8. Paget disease picture framining, enlargement 9. EG 10. Fibrous Dysplasia ground glass 1. Chordoma 2. Metastases pedicles often destroyed 3. Multiple Myeloma/Plasmacytoma pedicles usually spared 4. angiosarcoma

EXPANSILE LESION OF VB: Malignant Lesions

5. Osteosarcoma, chondrosarcoma 6. Lymphoma Bone Tumors Favoring Vertebral Bodies CALL HOME 1. Chordoma 2. ABC 3. Leukemia 4. Lymphoma 5. Hemangioma 6. Osteobastoma, osteoid, osteoma 7. Myeloma, Mets 8. EG 1. 2. 3. 4. Osteoid Osteoma Benign Osteoblastoma ABC Ewing sarcoma

Priamry Vertebral Tumors Peds

Blow Lesion of Posterior Elements

GO APE 1. GCT 2. Osteoblastoma 3. ABC 4. Plasmacytoma 5. EG A HOG 1. ABC 2. Hydatid Cyst, Hemangioma 3. Osteoblastoma, Osteoid Osteoma 4. GCT SPAR BIT 1. Senile hypertrophic ankylosis (DISH) 2. Psoriasis, progressive myositis ossificans 3. Ank Spon 4. reiters disease, RA (juvenile) 5. Block vertebra (Klippel-Feil) 6. Infection (Tb) 7. Trauma 1. 2. 3. 4. 5. 6. Isolated congenital (References only) Klippel-Feil syndrome (References only) Rheumatoid arthritis Ankylosing spondylitis Tuberculosis Operative fusion

Primary Tumor of Posterior Elements

Cervical Spine Fusion

Fused Vertebrae

7. Post traumatic (References only) Odontoid Erosion P LARD 1. Psoriasis 2. Lupus 3. Ankylosis Spondylitis 4. RA 5. Down syndrome 1. 2. 3. 4. 5. 6. 7. Occult spina bifida occulta meningocele myelocele myelomeningocele lipomyelomeningocele myelocystocele myeloschisis

Spina Dysraphism types

Atlantoaxial Subluxation Causes

1. Congenital occipitalization of atlas, congenital insufficiency of transverse ligament, os odontoideum/dens aplasia, down syndrome (20%)_, morqui syndrome, bondy dysplasia 2. Arthritis laxity or transverse ligament, dens erosion a. RA, psoriatic, Reiter, anklyosing spondyltiis, SLE 3. Inflammatory Process pharyngeal infection, retropharyngeal abscess, Otitis media, mastoiditis, cervical adenitis, parotitis, alveolar abscess 4. Trauma (very rare without dens fx) 5. Marfan disease JAP LARD 1. Juvenile RA 2. Ank spon 3. Psoriatic 4. Lupus 5. Accident (trauma) 6. Retropharyngeal abscess, RA 7. Down

Atlantoaxial Subluxation

Sacral Neoplasms

SPACEMON 1. Sarcoma 2. Plasmacytoma 3. ABC

4. 5. 6. 7. 8. Complications of Cervical Spine Fixation Surgery

Chordoma ependymoma Metastasis (breast, kidney, cervix, colon) osteomyelitis Neuroblastoma

1. Soft tissue complications a. Wound Infection b. Seroma and epidural scar c. Epidural hematoma - CT d. Epidural hematoma - MRI 2. Bone/Bone graft complications a. Nonunion b. Endplate Fracture c. Graft Collapse d. Graft Reabsorption e. Displaced Strut Graft f. Instability 3. Hardware complications a. Screw in disc space b. Screw displacement c. Screw backing out d. Screw in spinal canal e. Screw loosening f. Screw loosening and hematoma g. Broken screw h. Slipped rod

Multiple Collapsed Vertebrae

1. 2. 3. 4. 5. 6. 7.

Osteoporosis Neoplastic Disease Trauma Scheurmanns Disease Infection EG Sickle Cell anemia

Erosion, destruction or absence of a pedicle

1. Metastasis 2. Multiple myeloma 3. Intraspinal mass (References only)

4. 5. 6. 7. 8. Squaring of one or more vertebral bodies 1. 2. 3. 4. 5. Conditions producing disc space narrowing 1. 2. 3. 4. 5. 6. 7. 8. Intervertebral disc calcifications

Aneurysmal bone cyst Giant cell tumor Congenital abscence (References only) Tuberculosis Benign bone Alkylosing spondylitis Paget's disease Psoriatic arthropathy Reiter's syndrome Rheumatoid arthritis Infection Mastocytosis Myelofibrosis Lymphomas Paget's disease Fluorosis Renal osteodystrophy Axial osteomalacia

1. Degenerative spondylosis 2. Alkaptonuria 3. CPPD 4. Ankylosing spondylitis 5. Juvenile chronic arthritis 6. Hemochromatosis 7. Diffused idiopathic skeletal hyperostosis 8. Gout 9. Idiopathic 10. Post spinal fusion Anterior scalloping of the sacrum 1. Metastasis 2. Multiple myeloma 3. Posterior soft tissue pelvic tumors Ivory vertebrae 1. 2. 3. 4. Metastases Paget's disease Lymphoma Low-grade infection