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Spinal metastases from nonneural cancers are its cost-eective ability to scan the entire axial and
identied in 5% to 10% of cancer patients. appendicular skeleton at the same time, which is
Although these may be asymptomatic and in- useful to survey for overall metastatic disease
cidentally discovered during imaging for other burden [1]. Addition of the single photon emission
reasons, they are usually discovered during imag- computed tomography (SPECT) technique im-
ing evaluation for symptomatic spinal disease. proves sensitivity for metastatic lesions [2,3].
Imaging plays a crucial role in the pretreatment Positive bone scan ndings require correlation to
workup of spinal cancer as well as in the post- cross-sectional (CT or MRI) or plain radiography
treatment assessment of therapy ecacy. A prac- to exclude benign entities, such as degenerative
tical approach to performing and interpreting disease masquerading as neoplasm. The most
imaging studies to evaluate spinal metastatic important predictors for a positive bone scan are
cancer patients is discussed in this article. vertebral cortical involvement and lesion size; small
lesions, especially those conned to the medullary
cavity, may be occult on bone scanning [1].
Imaging techniques Myelography is an older imaging technique
that requires uoroscopically guided administra-
Plain radiography, myelography, computed tion of intrathecal iodinated contrast. Because it is
tomography (CT), nuclear scintigraphy, and mag- time-intensive and invasive, it is used considerably
netic resonance imaging (MRI) all play important less frequently since the advent of MRI. Currently,
roles in the imaging assessment of spinal cancer. myelography is used most often in conjunction
Plain radiography is readily available, easy to with CT, and its primary advantages include
perform, and inexpensive, and it provides a de- excellent depiction of osseous structures and good
tailed assessment of osseous structures. Disadvan- contrast resolution between hyperdense cerebro-
tages include its planar format, which results in spinal uid (CSF) and isodense nerve roots and
considerable overlapping of adjacent structures, soft tissue. Disadvantages of myelography include
inability to reformat the data in orthogonal planes, ionizing radiation (a relative disadvantage), its
and insensitivity to soft tissue abnormalities. invasive nature, and lower contrast resolution
Currently, its main utilization is for cost-eective than MRI. Current indications include evaluation
postoperative evaluation of spinal hardware and of patients with absolute MRI contraindications
assessment of dynamic stability using exion- and as an adjunct to nonconclusive MRI.
extension imaging. CT is useful for detailed assessment of osseous
Nuclear radiography (scintigraphy) after intra- structures and assessing hardware status, particu-
venous injection of technetium (Tc 99m) demon- larly in cases in which plain radiographs are
strates uptake in lesions inducing active bone inconclusive. At our institution, CT is used pri-
metabolism. A major advantage of scintigraphy is marily to characterize ambiguous lesions detected
on MRI and to assess pedicle and posterior element
E-mail address: Kevin.moore@hsc.utah.edu integrity and size before surgical resection and
(K.R. Moore). reconstruction. Because of its intrinsically lower
1042-3680/04/$ - see front matter 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.nec.2004.04.002
382 K.R. Moore / Neurosurg Clin N Am 15 (2004) 381389
contrast resolution and axial planeonly acquisi- T2WIs to conclude in which compartment(s)
tion, it has been largely supplanted by MRI for soft (extradural, intradural/extramedullary, or intra-
tissue characterization and denitive detection of medullary) the tumor resides. Correctly classifying
the presence and number of lesions. Nevertheless, tumor location in this way considerably limits the
modern multislice CT scanners reliably provide dierential diagnosis list. After delimiting loca-
excellent thin-section axial images that make rou- tion, I assess superior/inferior and anteroposterior
tine small-volume isovoxel multiplanar reconstruc- tumor extent, with specic attention to position
tion possible with excellent spatial resolution, and status of the spinal cord and presence or
albeit still with lower contrast resolution than absence of central osseous canal compromise.
MRI. CT may also be eectively used for charac- Axial images are used to quantify involvement
terization of possible pathologic vertebral fractures of the central canal and neural foramina and to
when MRI is impossible or contraindicated [1,4]. clarify the exact relation of the tumor to adjacent
MRI is currently the state-of-the-art imaging osseous, neural, and vascular structures. Intrave-
technique for assessing the spinal metastatic nous contrast administration is essential for initial
cancer patient [57] and has several strong advan- tumor patient assessment to conrm the diagnosis
tages over the other commonly available imaging and determine the extent and number of lesions.
techniques. It combines excellent spatial resolu- Intravenous contrast has a less absolute role in the
tion and superb contrast resolution, is noninva- follow-up of known extradural spinal cancer,
sive, and does not expose patients to ionizing particularly if only a qualitative assessment for
radiation. MRI provides superior depiction of the presence or absence of cord compression is
soft tissues, particularly the spinal cord and tumor needed. This point has considerable practical
margins. Disadvantages include relatively long signicance; contrast administration frequently
acquisition times, insurmountable safety contra- adds at least 30 minutes to imaging time for a total
indications in some patients, and lower sensitivity spinal survey, which may be too much additional
to osseous structural abnormalities. Standard time for an ill patient to hold still and remain
MRI protocols obtain T1-weighted images acceptably comfortable after 45 minutes of prior
(T1WIs) without and with intravenous contrast imaging time to acquire the unenhanced images.
and T2-weighted images (T2WIs) in at least one As a general rule, however, contrast administra-
and usually two orthogonal planes. The sagittal tion is helpful for comprehensive postoperative
imaging plane is most useful for global assessment surveillance and is essential in cases with intra-
of the number and extent of lesions, tumor dural or intramedullary tumor burden.
margins, and spinal cord status. Axial images I approach CT similarly to MRI. Axial CT
provide the best assessment of tumor relation to scans are acquired via a bone and soft tissue
adjacent nonneoplastic structures. In addition, algorithm using thin-slice collimation (12.5 mm
MRI is usually the most useful tool for post- depending on superoinferior distance to be cov-
operative tumor bed surveillance. ered) and reviewed similarly to axial MRI scans.
Finally, although MRI is the single most useful Contrast is necessary whenever soft tissue charac-
imaging modality for spinal cancer patient assess- terization is needed. If only an assessment of
ment, complex problems may be best assessed osseous integrity is required, just bone algorithm
using a combination of MRI to dene soft tissue images without contrast are obtained, which
tumor margins and relation to adjacent soft tissue shortens examination time and precludes the risk
structures and CT to assess the osseous structures. of allergic contrast reaction. With modern multi-
planar scanners, sagittal and coronal reformatted
images can be constructed on-line at the time of
imaging or o-line on a dedicated workstation
Magnetic resonance imaging and computed
and provide anatomic information similar to that
tomography interpretation
provided by MRI.
After image acquisition, it is critical to dene
the tumor margins and tissue characteristics
accurately to facilitate construction of a tailored Compartmental approach to spinal cancer imaging
dierential list and for ecient preoperative
Extradural metastatic spinal cancer
assessment.
A practical MRI approach to spinal cancer The lumbar spine is more commonly aected
begins with review of the sagittal T1WIs and by extradural metastatic lesions than the thoracic
K.R. Moore / Neurosurg Clin N Am 15 (2004) 381389 383
Fig. 4. Axial bone algorithm CT of the L3 vertebra Fig. 6. Sagittal CT reformat shows typical cervical spine
shows subtle disruption of the posterior and lateral blastic metastatic lesions and a pathologic dense fracture
cortices with preservation of trabecular architecture in (arrow) in this patient with prostate cancer, who fell and
a patient with biopsy-proven metastatic colon cancer. struck his chin.
paraspinal soft tissue mass, or an epidural mass impossible to detect in blastic lesions. Uncom-
[4]. It is seldom possible to detect tumor en- monly, a blastic vertebral tumor shows diuse
hancement within a vertebral body, but a para- sclerosis without obvious destruction (ivory
spinal soft tissue mass may variably enhance. vertebral body).
Uncommonly, a lytic lesion may demonstrate a MRI is useful for assessing impact on the
sclerotic rim that erroneously suggests benignity. marrow space as well as adjacent bones and soft
Blastic extradural metastatic lesions (Fig. 6) show tissues. The single most useful sequence for
a similar distribution to lytic lesions but demon- detecting extradural spine metastases is the un-
strate higher density than the adjacent surround- enhanced sagittal T1WI, which demonstrates
ing marrow cavity. Enhancement is virtually a relatively hypointense tumor within a back-
ground of higher signal intensity nonneoplastic
marrow (Fig. 7). Lesions may be solitary or
multiple and may show focal or diuse fatty
marrow replacement. When there is diuse in-
volvement, it may be more dicult to diagnose
metastatic disease, but it is always prudent to
search for diuse reduction of marrow signal
resulting in vertebral bodies showing lower T1
signal intensity than disks, which is the opposite
of normal (Fig. 8). In extradural metastases,
cortical destruction is usually apparent and the
disks spared, in contrast to infectious spondylitis,
the primary dierential diagnostic entity. Contrast
administration demonstrates soft tissue extent and
helps to distinguish tumor from adjacent epidural
venous plexus, disks, or veins. Postenhanced
T1WIs are most useful with fat saturation to
accentuate tumor conspicuity; failing to use fat
Fig. 5. Sagittal CT reformat shows typical malignant saturation may obscure visualization of tumors
ndings, including anterolateral destruction of C4 (white after contrast (Fig. 9). T2WIs are useful for
arrow) and posterior cortical disruption with cancellous assessing cord status and degree of canal narrow-
bone destruction of the C3 marrow cavity (black arrow). ing but are the least useful sequence for detecting
K.R. Moore / Neurosurg Clin N Am 15 (2004) 381389 385
Intradural/extramedullary metastases
Intradural/extramedullary lesions are quite
rare as isolated entities compared with their
benign mimics (eg, nerve sheath tumor, meningi-
Fig. 8. Sagittal T1-weighted image in a patient with oma) and usually show involvement of adjacent
diuse metastatic breast cancer. It is dicult to detect soft tissue and osseous structures that belies their
the marrow replacement unless one appreciates that the malignancy. Denitive imaging diagnosis is di-
vertebral marrow is darker than the adjacent disks, cult without demonstrated involvement of the
a nding that is always abnormal. vertebral body or epidural venous structures but
386 K.R. Moore / Neurosurg Clin N Am 15 (2004) 381389
Fig. 9. Sagittal T1-weighted image after intravenous contrast administration without (A) and with (B) fat saturation
demonstrates the utility of fat saturation in a patient with metastatic colon cancer. (A) There is rounded displacement of
the L3 posterior cortical line (arrow) on the image without fat saturation that belies the malignant nature of the lesion,
but the tumor signal intensity is indistinguishable from adjacent fatty marrow, a common pitfall. (B) Fat saturation
darkens the fatty marrow, making the metastatic lesion conspicuous.
would be more likely in the context of lesion mon in children than extradural metastases, a re-
multiplicity or a known history of preexisting ection of the higher proportion of brain tumors
malignancy. with a propensity to spread by means of the CSF
In adults, intradural metastases are much less and the relative rarity of malignant cancers
common than extradural metastases and most predisposed to bone metastasis within this pop-
commonly manifest as leptomeningeal disease. ulation compared with adults.
Conversely, intradural metastases are more com- Leptomeningeal disease is also known as
either carcinomatous meningitis or lympho-
matous meningitis and results from CSF dis-
semination of an intracranial neoplasm or
systemic spread of a non-central nervous system
(CNS) primary tumor. The classic MRI appear-
ance is smooth or nodular enhancement along
the spinal cord and nerve roots in a sheet-like
distribution (Fig. 13). Nodules along these sur-
faces are common and are more often found in
dependent locations, particularly at the bottom
of the thecal sac or between the roots of the
cauda equina (Fig. 14). T2WIs may show edema
of adjacent spinal cord, but the metastases are
often isointense to spinal cord on T1WIs and
T2WIs. The CSF may appear cloudy, and the
nerve roots may be blurry or smudged in
appearance. Recommended MRI sequences are
the same as for extradural metastatic survey,
with intravenous contrast essential. CT is con-
Fig. 10. T2-weighted images (T2WIs) are frequently
insensitive for detecting vertebral metastatic lesions
siderably less sensitive for intradural metastases
because the lesions show similar signal intensity to than MRI; CT is often normal, even after
marrow. The L1 metastasis is barely detectable (arrows) contrast administration, and osseous destruction
on this T2WI but quite visible on a T1-weighted image is frequently not apparent. Sensitivity for CT
(see Fig. 7). is greatly increased by combination with
K.R. Moore / Neurosurg Clin N Am 15 (2004) 381389 387
Fig. 11. (A) Sagittal T1-weighted image in a prostate cancer patient shows diuse metastases to all ve lumbar and S1
vertebral bodies/posterior elements. (B) Sagittal diusion-weighted imaging displays expected hyperintense signal
intensity of the metastases within the aected vertebra.
Fig. 12. Anterior and posterior planar whole-body bone Fig. 13. Sagittal T1-weighted image after intravenous
scan in a patient with known metastatic breast cancer contrast with fat saturation shows thick smooth pial
shows typical increased uptake within the many axial enhancement of the terminal cord and conus correlating
skeleton, calvarial, and rib metastases. with leptomeningeal breast cancer metastasis.
388 K.R. Moore / Neurosurg Clin N Am 15 (2004) 381389
Fig. 15. (A) Sagittal T2-weighted image shows an isointense signal intensity rounded intramedullary renal cell carcinoma
metastasis in the conus (arrow) with surrounding hyperintense edema. (B) Sagittal contrast-enhanced T1-weighted image
conrms a faintly enhancing intramedullary metastasis (arrow).
K.R. Moore / Neurosurg Clin N Am 15 (2004) 381389 389