1990, The British Journal of Radiology, 63, 576-578
Case reports
sumably inducing structural weakening of the femoral shaft. In this case the joints are well maintained, although Langer and Langer (1981) described joint destruction in addition to trabecular and cortical bone involvement. Moulin et al (1977) demonstrated a consumptive coagulopathy in their case report of Servelle-Martorell syndrome involving the upper limb. A further clinical problem related to hypervascularity is the limitation of surgical intervention. An attempt at insertion of a tibial skeletal traction pin in the present case resulted in profuse haemorrhage forcing abandonment of the procedure. The contra-indications to open surgical procedure (Vollmar & Voss, 1978) and inability to control adequately the fracture on skin traction, unfortunately resulted in hypertrophic non-union 18 months after injury (Fig. 3). References KLIPPEL, M. & TRENAUNAY, P., 1900. Du naevus variquex
osteohypertrophique. Archives in General Medicine, 3, 641-672. LANGER, M. & LANGER, R., 1981. Radiologic analysis of bone structure in congenital angiodysplasia. European Journal of Radiology, 1, 195-199. LINDENAUER, S. M., 1971. Congenital arteriovenous fistula and the Klippel-Trenaunay Syndrome. Annals of Surgery, 174, 248-263. MARTORELL, F. & MONSERROT, J., 1962. Atresic iliac vein and Klippel-Trenaunay Syndrome. Angiology, 13, 265-267. MOULIN, G., DAVID, B., BOUCHET, D., MONIER, D. & LAMAUD,
Figure 3. Hypertrophic non-union left proximal femur.
M., 1977. Angiome veineux osteohypoplasique geant avec retentissment hemodynamique et coagulopathie. Annales de Dermatologie et Venereologie, 104, 479-481. PARKES WEBER, F., 1907. Angioma formation in connection with hypertrophy of limbs and hemi-hypertrophy. British Journal of Dermatology, 19, 231-235. SERVELLE, M., 1952. In Pathologie vasculaire, Vol. 1. (Masson, Paris), pp. 323-329. VOLLMAR, J. & Voss, E. U., 1978. Chirugie der kongenitalen angiodysplasen. Langenbecks Archiv fur Chirurgie, 347, 255-259.
Epidural abscess of the cervical spine: case report and literature review By J. W. Williams, FRCS and T. Powell, FRCR, FRCP Radiology Department, Royal Hallamshire Hospital, Sheffield (Received October 1989)
A 51-year-old fisherman with a centro-blastic centrocytic Grade 4B non-Hodgkin's lymphoma only partially responsive to combination chemotherapy over a period of 6 months received an endogenous bone marrow transplant following intensive chemotherapy. His white cell and platelet counts remained low post-operatively, requiring a number of transfusions and continuous antibiotic cover. Two weeks after the transplant he became febrile and developed neck pain which became gradually more severe. Plain radiographs of the cervical spine 576
were normal, as was an isotope bone scan, but the pain continued to increase. A computed tomographic (CT) scan with intravenous contrast medium showed a peripherally enhancing mass within the spinal canal, situated anteriorly between C3 and C6, displacing the thecal sac (Fig. 1). Examination of a sputum sample showed acid-alcohol fast bacilli (AAFB) and, with a provisional diagnosis of an epidural abscess, surgical exploration was undertaken. At laminectomy, no sign of an abscess or granulation tissue could be found, but The British Journal of Radiology, July 1990
Case reports
Figure 3. Scan from CT guided biopsy of the lesion.
mately 10 ml of thick pus, examination of which confirmed the presence of AAFB. The patient refused further surgery and, despite antituberculous chemotherapy, rapidly became quadriplegic and later died. Discussion
Figure 1. Computed tomographic scan showing a peripherally enhancing mass within the spinal canal, situated anteriorly between C3 and C6, displacing the thecal sac.
post-operatively there was reduced pain and the patient became apyrexial. Ten days later the pain recurred, now associated with weakness of the left arm. Repeat CT revealed a persisting anterior mass (Fig. 2) and CT guided biopsy of the lesion (Fig. 3) yielded approxi-
Figure 2. Repeat CT scan showing a persisting anterior mass.
Vol. 63, No. 751
Spinal epidural abscess is a rare condition, especially in the cervical spine, forming 12% of 241 cases reported during the antibiotic era (Lasker & Harter, 1987). Cervical epidural abscess is usually associated with osteomyelitis of underlying vertebral bodies, although this may not be detectable at the time of diagnosis. Delayed diagnosis leads to increased morbidity and mortality from cord compression and venous thrombosis, and septicaemia may occur. Treatment more than 36 h after the development of motor weakness or paralysis is associated with a poor prognosis; in a review of 188 cases of spinal epidural abscess only 39% made a complete recovery (Danner & Hartman, 1987). Predisposing factors include recent spinal surgery, trauma or instrumentation (a case has been recorded after chemonucleolysis), or by metastatic spread of infection from septic foci in the skin, genitourinary tract or lung. Diabetics, immuno-suppressed patients and intravenous drug abusers are more susceptible. Twenty-five per cent of cases in the Western hemisphere are a result of tuberculous infection (Werner & M usher, 1985) and are thought to follow reactivation of an old primary focus, which may remain hidden. Most cases are a result of S. aureus, although infection by other Gram positive and Gram negative organisms, anaerobes and fungi have been reported (Lasker & Harter, 1987). Most cases, though not all, have spinal pain at the abscess site. Pyrexia may be absent in chronic cases. Signs of root compression usually appear during the course of the condition. Progression from motor weakness to paraparesis can be rapid. Blood cultures, 577
Case reports
1990, The British Journal of Radiology, 63, 578-580
cerebro-spinal fluid (CSF) examination and erythrocyte sedimentation rate are often informative, but white cell count tends to be unhelpful (Danner & Hartman, 1987). In the presence of osteomyelitis, plain film abnormalities are found in 82% of cases. Radionuclide bone scans are highly sensitive but lack specificity (Modic et al, 1985). Myelography has proved extremely reliable in most series and will demonstrate extra-dural compression or a block in almost 100% of cases of epidural abscess, also providing CSF for examination. Computed tomographic scanning with intravenous or intra-thecal contrast media is a sensitive and informative technique. Using intravenous contrast media, the abscess is shown as a soft-tissue mass with peripheral enhancement replacing the normal fat planes around the thecal sac and displacing it. Gas may be present within the abscess (Kirzner et al, 1988). Osteomyelitis and paravertebral extension can also be recognized and aspiration-biopsy undertaken (Burke & Brant-Zawadski, 1985). Similarly, magnetic resonance imaging (MRI) can demonstrate the abscess and extensions of the septic process using suitable sequences and differentiate these into liquid content and infectious oedema or granulation tissue; this can be difficult or impossible on CT. Osteomyelitis can be detected with a sensitivity equivalent to that of radionuclide bone scan (Modic et al, 1985; Angtuaco et al, 1987). Following intravenous administration of Gadolinium-DTPA, MRI can define the extent of active inflammation more clearly (Sze, 1988). Ultrasound has been used intra-operatively to locate an abscess prior to surgical drainage and to assess the adequacy of surgical decompression (Feldenzer et al, 1986).
Conclusion
The optimum treatment of spinal epidural abscess depends on early diagnosis and treatment. The use of enhanced CT and of MRI allows non-invasive diagnosis with the possibility of guided aspiration-biopsy and the instillation of antibiotics prior to surgical, or medical treatment in selected cases (Leys et al, 1985). References ANGTUACO, E. J. C , MCCONNELL, J. R., CHADDUCK, W. M. &
FLANIGAN, S., 1987. MR imaging of spinal epidural sepsis. American Journal of Roentgenology, 149, 1249-1253. BURKE, D. R. & BRANT-ZAWADSKI, M., 1985. CT of pyogenic
spine infection. Neuroradiology, 27, 131-137. DANNER, R. L. & HARTMAN, B. J., 1987. Update of spinal
epidural abscess: 35 cases and review of the literature. Reviews of Infectious Diseases, 9, 265-21 A. FELDENZER, J. A., WATERS, D. C , KNAKE, J. E. & HOFF, J. T.,
1986. Anterior cervical epidural abscess: the use of intraoperative spinal sonography. Surgical Neurology, 25, 105-108. KIRZNER, H., YOUN, K. O. H. & LEE, S. H., 1988. Intraspinal
air: A CT finding of epidural abscess. American Journal of Roentgenology, 151, 1217-1218. LASKER, R. B. & HARTER, D. H., 1987. Cervical epidural
abscess. Neurology, 37, 1747-1753. LEYS, D., LESOIN, F., VIAUD, C , PASQUIER, F., ROUSSEAUX, M.,
JOMIN, M. & PETIT, H., 1985. Decreased morbidity from acute bacterial spinal epidural abscesses using Computed Tomography and non-surgical treatment in selected patients. Annals of Neurology, 17, 350-355. MODIC, M. T., FEIGLIN, D. H., PIRAINO, D. W., BOUMPHREY, S., WEINSTEIN, M. A., DUCHESNEAU, P. M. & REHM, S., 1985.
Vertebral osteomyelitis: Assessment using MR. Radiology, 157, 157-166. SZE, G., 1988. Gadolinium-DTPA in spinal disease. Radiologic Clinics of North America, 26, 1009-1024. WERNER, E. F. & MUSHER, D. M., 1985. Spinal epidural
abscess. Medical Clinics of North America, 69, 375-384.
Primary osteosarcoma of the uterus By *Michael G. Caputo, MD, Karen L Reuter, MD and tFrank Reale, MD Departments of Radiology and tPathology, University of Massachusetts Medical Center, 55 Lake Avenue North, Worcester, MA 01655, USA {Received October 1989 and in revised form January 1990)
Post-menopausal vaginal bleeding is a common clinical problem. Often, the clinician will call upon the radiologist to perform and interpret studies such as ultrasound or computed tomography (CT), to aid in the diagnosis or to evaluate further a pelvic mass. The following case illustrates an unusual cause of postmenopausal vaginal bleeding, with ultrasound and CT images of the pelvic mass. Certainly, the radiologist, in *Author for correspondence. 578
interpreting scans and correlating them with clinical data, must always consider common etiologies first; but one must also remember the uncommon and even rare entities that may radiologically mimic a more common pathologic process and, if appropriate, might be included in the differential diagnosis. Case report The patient was a 58-year-old gravida 0, para 0, white woman who presented with a history of progressively worsen-
The British Journal of Radiology, July 1990
Case reports
sumably inducing structural weakening of the femoral shaft. In this case the joints are well maintained, although Langer and Langer (1981) described joint destruction in addition to trabecular and cortical bone involvement. Moulin et al (1977) demonstrated a consumptive coagulopathy in their case report of Servelle-Martorell syndrome involving the upper limb. A further clinical problem related to hypervascularity is the limitation of surgical intervention. An attempt at insertion of a tibial skeletal traction pin in the present case resulted in profuse haemorrhage forcing abandonment of the procedure. The contra-indications to open surgical procedure (Vollmar & Voss, 1978) and inability to control adequately the fracture on skin traction, unfortunately resulted in hypertrophic non-union 18 months after injury (Fig. 3). References KLIPPEL, M. & TRENAUNAY, P., 1900. Du naevus variquex
osteohypertrophique. Archives in General Medicine, 3, 641-672. LANGER, M. & LANGER, R., 1981. Radiologic analysis of bone structure in congenital angiodysplasia. European Journal of Radiology, 1, 195-199. LINDENAUER, S. M., 1971. Congenital arteriovenous fistula and the Klippel-Trenaunay Syndrome. Annals of Surgery, 174, 248-263. MARTORELL, F. & MONSERROT, J., 1962. Atresic iliac vein and Klippel-Trenaunay Syndrome. Angiology, 13, 265-267. MOULIN, G., DAVID, B., BOUCHET, D., MONIER, D. & LAMAUD,
Figure 3. Hypertrophic non-union left proximal femur.
M., 1977. Angiome veineux osteohypoplasique geant avec retentissment hemodynamique et coagulopathie. Annales de Dermatologie et Venereologie, 104, 479-481. PARKES WEBER, F., 1907. Angioma formation in connection with hypertrophy of limbs and hemi-hypertrophy. British Journal of Dermatology, 19, 231-235. SERVELLE, M., 1952. In Pathologie vasculaire, Vol. 1. (Masson, Paris), pp. 323-329. VOLLMAR, J. & Voss, E. U., 1978. Chirugie der kongenitalen angiodysplasen. Langenbecks Archiv fur Chirurgie, 347, 255-259.
Epidural abscess of the cervical spine: case report and literature review By J. W. Williams, FRCS and T. Powell, FRCR, FRCP Radiology Department, Royal Hallamshire Hospital, Sheffield (Received October 1989)
A 51-year-old fisherman with a centro-blastic centrocytic Grade 4B non-Hodgkin's lymphoma only partially responsive to combination chemotherapy over a period of 6 months received an endogenous bone marrow transplant following intensive chemotherapy. His white cell and platelet counts remained low post-operatively, requiring a number of transfusions and continuous antibiotic cover. Two weeks after the transplant he became febrile and developed neck pain which became gradually more severe. Plain radiographs of the cervical spine 576
were normal, as was an isotope bone scan, but the pain continued to increase. A computed tomographic (CT) scan with intravenous contrast medium showed a peripherally enhancing mass within the spinal canal, situated anteriorly between C3 and C6, displacing the thecal sac (Fig. 1). Examination of a sputum sample showed acid-alcohol fast bacilli (AAFB) and, with a provisional diagnosis of an epidural abscess, surgical exploration was undertaken. At laminectomy, no sign of an abscess or granulation tissue could be found, but The British Journal of Radiology, July 1990
Case reports
Figure 3. Scan from CT guided biopsy of the lesion.
mately 10 ml of thick pus, examination of which confirmed the presence of AAFB. The patient refused further surgery and, despite antituberculous chemotherapy, rapidly became quadriplegic and later died. Discussion
Figure 1. Computed tomographic scan showing a peripherally enhancing mass within the spinal canal, situated anteriorly between C3 and C6, displacing the thecal sac.
post-operatively there was reduced pain and the patient became apyrexial. Ten days later the pain recurred, now associated with weakness of the left arm. Repeat CT revealed a persisting anterior mass (Fig. 2) and CT guided biopsy of the lesion (Fig. 3) yielded approxi-
Figure 2. Repeat CT scan showing a persisting anterior mass.
Vol. 63, No. 751
Spinal epidural abscess is a rare condition, especially in the cervical spine, forming 12% of 241 cases reported during the antibiotic era (Lasker & Harter, 1987). Cervical epidural abscess is usually associated with osteomyelitis of underlying vertebral bodies, although this may not be detectable at the time of diagnosis. Delayed diagnosis leads to increased morbidity and mortality from cord compression and venous thrombosis, and septicaemia may occur. Treatment more than 36 h after the development of motor weakness or paralysis is associated with a poor prognosis; in a review of 188 cases of spinal epidural abscess only 39% made a complete recovery (Danner & Hartman, 1987). Predisposing factors include recent spinal surgery, trauma or instrumentation (a case has been recorded after chemonucleolysis), or by metastatic spread of infection from septic foci in the skin, genitourinary tract or lung. Diabetics, immuno-suppressed patients and intravenous drug abusers are more susceptible. Twenty-five per cent of cases in the Western hemisphere are a result of tuberculous infection (Werner & M usher, 1985) and are thought to follow reactivation of an old primary focus, which may remain hidden. Most cases are a result of S. aureus, although infection by other Gram positive and Gram negative organisms, anaerobes and fungi have been reported (Lasker & Harter, 1987). Most cases, though not all, have spinal pain at the abscess site. Pyrexia may be absent in chronic cases. Signs of root compression usually appear during the course of the condition. Progression from motor weakness to paraparesis can be rapid. Blood cultures, 577
Case reports
1990, The British Journal of Radiology, 63, 578-580
cerebro-spinal fluid (CSF) examination and erythrocyte sedimentation rate are often informative, but white cell count tends to be unhelpful (Danner & Hartman, 1987). In the presence of osteomyelitis, plain film abnormalities are found in 82% of cases. Radionuclide bone scans are highly sensitive but lack specificity (Modic et al, 1985). Myelography has proved extremely reliable in most series and will demonstrate extra-dural compression or a block in almost 100% of cases of epidural abscess, also providing CSF for examination. Computed tomographic scanning with intravenous or intra-thecal contrast media is a sensitive and informative technique. Using intravenous contrast media, the abscess is shown as a soft-tissue mass with peripheral enhancement replacing the normal fat planes around the thecal sac and displacing it. Gas may be present within the abscess (Kirzner et al, 1988). Osteomyelitis and paravertebral extension can also be recognized and aspiration-biopsy undertaken (Burke & Brant-Zawadski, 1985). Similarly, magnetic resonance imaging (MRI) can demonstrate the abscess and extensions of the septic process using suitable sequences and differentiate these into liquid content and infectious oedema or granulation tissue; this can be difficult or impossible on CT. Osteomyelitis can be detected with a sensitivity equivalent to that of radionuclide bone scan (Modic et al, 1985; Angtuaco et al, 1987). Following intravenous administration of Gadolinium-DTPA, MRI can define the extent of active inflammation more clearly (Sze, 1988). Ultrasound has been used intra-operatively to locate an abscess prior to surgical drainage and to assess the adequacy of surgical decompression (Feldenzer et al, 1986).
Conclusion
The optimum treatment of spinal epidural abscess depends on early diagnosis and treatment. The use of enhanced CT and of MRI allows non-invasive diagnosis with the possibility of guided aspiration-biopsy and the instillation of antibiotics prior to surgical, or medical treatment in selected cases (Leys et al, 1985). References ANGTUACO, E. J. C , MCCONNELL, J. R., CHADDUCK, W. M. &
FLANIGAN, S., 1987. MR imaging of spinal epidural sepsis. American Journal of Roentgenology, 149, 1249-1253. BURKE, D. R. & BRANT-ZAWADSKI, M., 1985. CT of pyogenic
spine infection. Neuroradiology, 27, 131-137. DANNER, R. L. & HARTMAN, B. J., 1987. Update of spinal
epidural abscess: 35 cases and review of the literature. Reviews of Infectious Diseases, 9, 265-21 A. FELDENZER, J. A., WATERS, D. C , KNAKE, J. E. & HOFF, J. T.,
1986. Anterior cervical epidural abscess: the use of intraoperative spinal sonography. Surgical Neurology, 25, 105-108. KIRZNER, H., YOUN, K. O. H. & LEE, S. H., 1988. Intraspinal
air: A CT finding of epidural abscess. American Journal of Roentgenology, 151, 1217-1218. LASKER, R. B. & HARTER, D. H., 1987. Cervical epidural
abscess. Neurology, 37, 1747-1753. LEYS, D., LESOIN, F., VIAUD, C , PASQUIER, F., ROUSSEAUX, M.,
JOMIN, M. & PETIT, H., 1985. Decreased morbidity from acute bacterial spinal epidural abscesses using Computed Tomography and non-surgical treatment in selected patients. Annals of Neurology, 17, 350-355. MODIC, M. T., FEIGLIN, D. H., PIRAINO, D. W., BOUMPHREY, S., WEINSTEIN, M. A., DUCHESNEAU, P. M. & REHM, S., 1985.
Vertebral osteomyelitis: Assessment using MR. Radiology, 157, 157-166. SZE, G., 1988. Gadolinium-DTPA in spinal disease. Radiologic Clinics of North America, 26, 1009-1024. WERNER, E. F. & MUSHER, D. M., 1985. Spinal epidural
abscess. Medical Clinics of North America, 69, 375-384.
Primary osteosarcoma of the uterus By *Michael G. Caputo, MD, Karen L Reuter, MD and tFrank Reale, MD Departments of Radiology and tPathology, University of Massachusetts Medical Center, 55 Lake Avenue North, Worcester, MA 01655, USA {Received October 1989 and in revised form January 1990)
Post-menopausal vaginal bleeding is a common clinical problem. Often, the clinician will call upon the radiologist to perform and interpret studies such as ultrasound or computed tomography (CT), to aid in the diagnosis or to evaluate further a pelvic mass. The following case illustrates an unusual cause of postmenopausal vaginal bleeding, with ultrasound and CT images of the pelvic mass. Certainly, the radiologist, in *Author for correspondence. 578
interpreting scans and correlating them with clinical data, must always consider common etiologies first; but one must also remember the uncommon and even rare entities that may radiologically mimic a more common pathologic process and, if appropriate, might be included in the differential diagnosis. Case report The patient was a 58-year-old gravida 0, para 0, white woman who presented with a history of progressively worsen-
The British Journal of Radiology, July 1990
