1991, The British Journal of Radiology, 64, 763-764
Case of the month A soldier with recurrent back pain By P. G. Barker, FRCR and N. D. Raby, MRCP, FRCR Department of Diagnostic Radiology, Queen Elizabeth II Military Hospital, London SE18 4QH, UK (Received February 1990 and in revised form May 1990)
A 39-year-old man presented with acute lower back pain referred down the back of the right leg to the knee. Address correspondence to Dr P. G. Barker, 9 Bagshot Court, Prince Imperial Road, London SE18 4JS, UK.
Figure 1. Lumbar radiculogram. Antero-posterior and lateral views.
Vol. 64, No. 764
There were no abnormal neurological findings and clinical examination was unremarkable. He had a longstanding history of recurrent back pain, which had required hospitalization in the past. Lumbar spine radiographs 3 months previously appeared normal. In view of these symptoms and past history, a radiculogram (Fig. 1) and subsequently a computed tomographic (CT) myelogram of the lumbar spine were performed (Fig. 2). What are the abnormal findings and what is the most likely diagnosis?
Figure 2. Computed tomographic myelogram of the lumbar spine (L4 level).
763
Case of the month
Figure 3. Computed tomographic scan of the upper abdomen showing a large retroperitoneal soft-tissue mass with associated hydronephrosis.
The radiculogram shows the theca being compressed anteriorly by a large soft-tissue mass within the spinal canal extending from L2 to L5. There has also been partial destruction of the vertebral body of L3. The CT myelogram confirms the radiculogram findings but also shows obliteration of the normal retroperitoneal structures anterior to the vertebral body. In particular, the aorta and inferior vena cava cannot be identified. Abdominal CT (Fig. 3) reveals a large retroperitoneal soft-tissue mass with associated hydronephrosis. Chest CT showed retrosternal lymphadenopathy. Blood samples taken on admission showed abnormal liver function with a Gamma Glutamyl transferase of 176 i.u./l and alkaline phosphatase of 214 i.u./l. His erythrocyte sedimentation rate was raised at 56 mm/h. These findings are most likely to be due to a nonHodgkin's lymphoma and subsequent lymph node biopsy confirmed the diagnosis. Discussion
Spinal epidural involvement is an uncommon initial presentation of non-Hodgkin's lymphoma occurring in only 2.2-3.4% of cases (Levitt et al, 1980; Epelbaum et al, 1986). Although primary spinal epidural
lymphoma has been reported, the majority have disseminated disease (Green et al, 1987). Local back pain, often appearing months before cord compression, occurs as a prodromal symptom in 80% of cases (Epelbaum et al, 1986). Spinal epidural lymphoma has been described in children but 80% occur in adults aged above 40 years of age (Epelbaum et al, 1986). The commonest site for initial presentation as spinal epidural lymphoma is the thoracic spine. Cord compression at the cervical level has not been reported as an initial presentation probably because cervical lymphadenopathy is noted prior to the spinal canal becoming involved. Plain radiography shows associated vertebral involvement in between 40 and 60% of cases (Verda, 1944; Bucy & Jerva, 1962; Haddad et al, 1976; Rao et al, 1982). The features are either of pedicle erosion or vertebral destruction with associated compression fracture and para vertebral soft-tissue mass. Myelography in spinal epidural lymphoma usually shows complete obstruction to the flow of intrathecal contrast medium at the level of the tumour. This case is unusual in this respect, the tumour causing no such obstruction and only anterior thecal displacement. References BUCY, P. C. & JERVA, M. J., 1962. Primary epidural spinal lymphosarcoma. Journal of Neurosurgery, 19, 142-152. EPELBAUM, R.,
HAIM, H.,
BEN-SHAHAR, M.,
BEN-ARIE,
Y.,
FEINSOD, M. & COHEN, Y., 1986. Non-Hodgkin's lymphoma
presenting with spinal epidural involvement. Cancer, 58, 2120-2124. GREEN, S. T.,
N G , J.-P., HART, I. K.
& BONE, I.,
1987.
Non-Hodgkin's lymphoma presenting with isolated cauda equina compression. Quarterly Journal of Medicine, 65, 1005-1007. HADDAD, P., THAELL, J. F., KIELY, J. M., HARRISON, E. G. &
MILLER, R. H., 1976. Lymphoma of the spinal extradural space. Cancer, 38, 1862-1866. LEVITT, L. J., DAWSON, D., ROSENTHAL, D. S. & MALONEY, W.
C , 1980. CNS involvement in lymphomas. Cancer, 45, 545-552. RAO,
T. V.,
NARAYANASWAMY, K.
S.,
the
non-Hodgkin's
SHANKAR, S. K.
&
DESHPANDE, D. H., 1982. Primary spinal epidural lymphomas: a clinico-pathological study. Ada Neurochirurgica, 62, 307-317. VERDA, D. J., 1944. Malignant lymphomas of the spinal extradural space. Surgical Clinics of North America, 24, 1228-1243.
Keywords: Spinal, Epidural, Extradural, Lymphoma
764
The British Journal of Radiology, August 1991
Case of the month A soldier with recurrent back pain By P. G. Barker, FRCR and N. D. Raby, MRCP, FRCR Department of Diagnostic Radiology, Queen Elizabeth II Military Hospital, London SE18 4QH, UK (Received February 1990 and in revised form May 1990)
A 39-year-old man presented with acute lower back pain referred down the back of the right leg to the knee. Address correspondence to Dr P. G. Barker, 9 Bagshot Court, Prince Imperial Road, London SE18 4JS, UK.
Figure 1. Lumbar radiculogram. Antero-posterior and lateral views.
Vol. 64, No. 764
There were no abnormal neurological findings and clinical examination was unremarkable. He had a longstanding history of recurrent back pain, which had required hospitalization in the past. Lumbar spine radiographs 3 months previously appeared normal. In view of these symptoms and past history, a radiculogram (Fig. 1) and subsequently a computed tomographic (CT) myelogram of the lumbar spine were performed (Fig. 2). What are the abnormal findings and what is the most likely diagnosis?
Figure 2. Computed tomographic myelogram of the lumbar spine (L4 level).
763
Case of the month
Figure 3. Computed tomographic scan of the upper abdomen showing a large retroperitoneal soft-tissue mass with associated hydronephrosis.
The radiculogram shows the theca being compressed anteriorly by a large soft-tissue mass within the spinal canal extending from L2 to L5. There has also been partial destruction of the vertebral body of L3. The CT myelogram confirms the radiculogram findings but also shows obliteration of the normal retroperitoneal structures anterior to the vertebral body. In particular, the aorta and inferior vena cava cannot be identified. Abdominal CT (Fig. 3) reveals a large retroperitoneal soft-tissue mass with associated hydronephrosis. Chest CT showed retrosternal lymphadenopathy. Blood samples taken on admission showed abnormal liver function with a Gamma Glutamyl transferase of 176 i.u./l and alkaline phosphatase of 214 i.u./l. His erythrocyte sedimentation rate was raised at 56 mm/h. These findings are most likely to be due to a nonHodgkin's lymphoma and subsequent lymph node biopsy confirmed the diagnosis. Discussion
Spinal epidural involvement is an uncommon initial presentation of non-Hodgkin's lymphoma occurring in only 2.2-3.4% of cases (Levitt et al, 1980; Epelbaum et al, 1986). Although primary spinal epidural
lymphoma has been reported, the majority have disseminated disease (Green et al, 1987). Local back pain, often appearing months before cord compression, occurs as a prodromal symptom in 80% of cases (Epelbaum et al, 1986). Spinal epidural lymphoma has been described in children but 80% occur in adults aged above 40 years of age (Epelbaum et al, 1986). The commonest site for initial presentation as spinal epidural lymphoma is the thoracic spine. Cord compression at the cervical level has not been reported as an initial presentation probably because cervical lymphadenopathy is noted prior to the spinal canal becoming involved. Plain radiography shows associated vertebral involvement in between 40 and 60% of cases (Verda, 1944; Bucy & Jerva, 1962; Haddad et al, 1976; Rao et al, 1982). The features are either of pedicle erosion or vertebral destruction with associated compression fracture and para vertebral soft-tissue mass. Myelography in spinal epidural lymphoma usually shows complete obstruction to the flow of intrathecal contrast medium at the level of the tumour. This case is unusual in this respect, the tumour causing no such obstruction and only anterior thecal displacement. References BUCY, P. C. & JERVA, M. J., 1962. Primary epidural spinal lymphosarcoma. Journal of Neurosurgery, 19, 142-152. EPELBAUM, R.,
HAIM, H.,
BEN-SHAHAR, M.,
BEN-ARIE,
Y.,
FEINSOD, M. & COHEN, Y., 1986. Non-Hodgkin's lymphoma
presenting with spinal epidural involvement. Cancer, 58, 2120-2124. GREEN, S. T.,
N G , J.-P., HART, I. K.
& BONE, I.,
1987.
Non-Hodgkin's lymphoma presenting with isolated cauda equina compression. Quarterly Journal of Medicine, 65, 1005-1007. HADDAD, P., THAELL, J. F., KIELY, J. M., HARRISON, E. G. &
MILLER, R. H., 1976. Lymphoma of the spinal extradural space. Cancer, 38, 1862-1866. LEVITT, L. J., DAWSON, D., ROSENTHAL, D. S. & MALONEY, W.
C , 1980. CNS involvement in lymphomas. Cancer, 45, 545-552. RAO,
T. V.,
NARAYANASWAMY, K.
S.,
the
non-Hodgkin's
SHANKAR, S. K.
&
DESHPANDE, D. H., 1982. Primary spinal epidural lymphomas: a clinico-pathological study. Ada Neurochirurgica, 62, 307-317. VERDA, D. J., 1944. Malignant lymphomas of the spinal extradural space. Surgical Clinics of North America, 24, 1228-1243.
Keywords: Spinal, Epidural, Extradural, Lymphoma
764
The British Journal of Radiology, August 1991
