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 »  Introduction
 »  Case report
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Year : 2000  |  Volume : 48  |  Issue : 3  |  Page : 288-90

Diagnostic dilemma in a case of early spinal tumour fracture (Plasmacytoma) : a case report.


Vasant Kunj, 163/E, Dr. B.A. Road, Hindu Colony, Dadar, Mumbai, 400014, India.

Correspondence Address:
Vasant Kunj, 163/E, Dr. B.A. Road, Hindu Colony, Dadar, Mumbai, 400014, India.

  »  Abstract

MRI findings of D12 fracture were suspicious of a pathological fracture. However, biopsy did not show any evidence of tumour. This resulted in the patient following up after one and half years with an epidural mass lesion and neurological deterioration. This paper highlights some of the MRI features of fractures associated with underlying pathology over traumatic or osteoporotic fracture.

How to cite this article:
Kamat A, Velho V. Diagnostic dilemma in a case of early spinal tumour fracture (Plasmacytoma) : a case report. Neurol India 2000;48:288


How to cite this URL:
Kamat A, Velho V. Diagnostic dilemma in a case of early spinal tumour fracture (Plasmacytoma) : a case report. Neurol India [serial online] 2000 [cited 2020 Oct 20];48:288. Available from: https://www.neurologyindia.com/text.asp?2000/48/3/288/1517




   »   Introduction Top

Spinal fracture is a common problem tackled by spinal surgeons. Though trauma is a common cause of fracture, pathological spinal fracture should also be kept in mind while treating these patients. MRI is a sensitive diagnostic modality, however, the diagnosis may not always be obvious. Certain MRI features may help differentiate the two. This case report highlights some of the early MRI features of plasmacytoma, which will be useful in clinching the diagnosis over traumatic fractures.

   »   Case report Top

A 43 years old male had a fall from a height of four feet on his back in September 1995. He developed severe backache but had no neurological deficits at that time. X-ray showed compression fracture of the D12 body. He was treated conservatively with bed rest and brace. He, however, developed progressive weakness of lower limbs and was walking with support when he presented to us in April 1996. He had power grade 3 in dorsiflexion of the ankle joint and in the extensor hallucis longus, causing foot drop on the left side. MRI showed wedging of the D12 body with anterior compression of the cord. The possibility of pathological fracture was considered, as there was a hypointense mass involving the right side of vertebral body and right pedicle of D12 vertebra, which became nonhomogeneously hyperintense in the T2 weighted images. There was no epidural lesion.

Left thoracotomy with corpectomy of D12 body and decompression of the cord and autograft fusion from iliac crest bone was carried out. The bony fragments procured during corpectomy were sent for histopathology, which showed clear bone cells along with inflammatory infiltrate comprising of mononuclear cells and macrophages. There was no evidence of tumour. Post operatively, the patient showed complete neurological recovery within four months.

After a year and [eight] months, he developed gradually progressive backache and paraparesis with weakness, more in the left leg. On examination, he had power 'grade 3' at the hip and knee joints, while the power at the ankle and toes was 'grade 0'. The knee and ankle jerks were absent. MRI done at this stage showed an expansile lesion in the region of the D12 body with epidural extension and severe compression of the cord. The tumour was involving the pedicles and the facets of the D12 vertebra. The patient was again operated upon in April 1998. The involved facet was removed and the tumour was near totally excised by posterior transpedicular approach. The tumour was very vascular, brownish grey, fleshy and nonsuckable. Anterior interbody region between D11 and L1 were decorticated and this gap was packed with Gbone. Posterolateral fusion and fixation was done with Hartshill. The histo-pathology revealed it to be plasmacytoma. Local radiotherapy was subsequently given to the dorsal spine. The patient improved neurologically and had power 'grade 5' in both the lower limbs at one year follow-up.


   »   Discussion Top

Plasmacytoma represents a small subset of B-cell lymphocytic tumours.[1] It is a localised disease predominantly affecting the lumbar region, and may cause pathological fractures. Preoperatively, it may be very difficult, either by clinical features or even by imaging, to confirm the exact aetiology.

This patient first presented with paraparesis due to trauma. MRI was suspicious of pathological fracture, however histopathology did not show any evidence of tumour. The patient improved and went to his native place. He came back after more than one and half year with paraparesis. Repeat MRI revealed the tumour with its epidural extension. MRI is a sensitive investigation for spinal tumours.[2] Avrahami et al studied 40 cases with known primary and progressive back pain who underwent X-rays, CT scan and radionuclide bone scans, which were normal. They were subjected to MRI. Twenty one of these 40 patients showed lesions, which were then confirmed with needle biopsy.[2] Though MRI is a sensitive investigation, it may misdiagnose spinal lesions. Such a discrepancy between MRI findings and biopsy report has been reported by some workers.[3],[4],[5],[6] Tan et al presented four cases, who were diagnosed on MRI to have probable neoplastic involvement, but biopsies indicated a benign pathology.[6]

Various studies have, hence, tried to point out the features, which may detect tumour fracture without an obvious tumour mass. Distinctive features of pathological fractures were depicted by Moulopoulos et al[7] and by Cuenod et al.[8] In a study of 98 compression fractures, Moulopoulos et al defined certain criteria on the basis of which accuracy of the diagnosis of malignant and benign lesions may reach 94%. They suggested that diffuse and homogeneous decrease in signal intensity on T1-weighted images, convex vertebral contour, involvement of pedicle and lumbar location were more frequently observed in malignant fractures. Enhancement does not help in establishing the diagnosis.[7] Cuenod et al studied 30 patients with malignant vertebral collapse and suggested six findings suggestive of malignancy. These include convex posterior border, epidural mass, diffuse low signal intensity within the vertebral body on Tl weighted images and in the pedicles, high or nonhomogeneous signal intensity after gadolinium injection and on T2-weighted images.[8] However, the distinction between traumatic and pathological spinal fractures may not always be obvious if it is based only on the change of signal intensity. Though MRI can detect malignant vertebral lesions early, acute healing compression fractures may mimic them. The MRI findings of traumatic vertebral fracture show different sequential signal intensity changes in post-traumatic vertebral compression fractures of varying ages, making it very difficult to differentiate between traumatic and pathological spinal fracture. Hence, An et al recommended correlation with clinical findings and serial MRIs to rule out pathological aetiology of the fracture.[9],[10]

In a study of 34 cases of atraumatic compression fractures comprising 18 tumours and 16 osteoporosis fractures, Rupp et al concluded that decreased signal intensity on Tl and increased signal intensity on T2 weighted images was sensitive but not specific for tumour involvement. Even gadolinium enhancement, multiple level involvement, and posterior vertebral expansion are not useful for differentiation of tumour fracture. However, pedicle involvement and/or associated soft tissue mass clinches the diagnosis, as they are specific for a tumour compression fracture or vertebral lesion.[4]
In the present case, the first MRI had shown wedging of the body of D12 vertebra along with a hypointense mass, which became nonhomogeneously hyperintense in the T2 weighted images involving the right side of vertebral body. However, it was the involvement of the right pedicle, which was specific of tumour, even though there was no epidural lesion. We conclude that the involvement of the pedicle on MRI, even in the absence of any obvious epidural mass, goes strongly in favour of a tumour. If the histopathology does not show tumour tissue, the patient needs to be closely followed up with regular neurological assessment and follow up MRI to look for progression of the disease.[9]

 

  »   References Top

1.Camins MB, Oppenheim JS, Perrin RG : Tumours of the vertebral axis: benign, primary malignant, and metastatic tumors In: Neurological Surgery Youmans Julian eds. 4 : 3134-3167.   Back to cited text no. 1    
2.Avrahami E, Tadmor R, Dally O et al : Early MR demonstration of spinal metastases in patients with normal radiographs and CT and radionuclide bone scan. J Comput Assist Tomogr 1989; 13 : 589-602.   Back to cited text no. 2    
3.Lecouvet FE, Vande Berg BC, Maldague BE : Vertebral compression fracture in multiple myeloma. Part I. Distribution and appearance at MR Imaging. Radiology1997; 204 : 195-199.   Back to cited text no. 3    
4.Rupp RE, Ebraheim NA, Coombs RJ : Magnetic resonance imaging differentiation of compression spine fractures or vertebral lesions caused by osteoporosis or tumour. Spine 1995; 1, 20 : 2499-2503.   Back to cited text no. 4    
5.Libshitz HI, Malhouse SR, Cunningham D et al : Multiple myeloma: appearance at MR imaging. Radiology 1992; 182 : 833-837.   Back to cited text no. 5    
6.Tan SB, Kozak JA, Mawad ME : The limitations of magnetic resonance imaging in the diagnosis of pathologic vertebral fractures. Spine 1991; 16 : 919-923.   Back to cited text no. 6    
7.Moulopoulos LA, Yoshimitsu K, Johnston DA et al : MR prediction of benign and malignant vertebral compression fractures. J Magn Reson Imaging 1996; 6 : 667-674.   Back to cited text no. 7    
8.Cuenod CA, Laredo JD, Chevret S et al : Acute vertebral collapse due to osteoporosis or malignancy: appearance on unenhanced and gadolinium-enhanced MR images, Radiology 1996; 2 : 541-549.   Back to cited text no. 8    
9.An HS, Andreshak TG, Nguyen C et al : Can we distinguish between benign versus malignant compression fractures of the spine by magnetic resonance imaging? Spine 1995; 20 : 1776-1782.   Back to cited text no. 9    
10.Sung MS, Park SH, Lee JM et al : Sequential changes of traumatic vertebral compression fracture on MR imaging. J Korean Med Sci 1995; 10 : 189-194.   Back to cited text no. 10    

 

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