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A common pathology in an uncommon location: posterior migrated epidural disc herniation
ARTICLE IN PRESS
The Spine Journal ■■ (2016) ■■–■■
Images of Spine Care A common pathology in an uncommon location: posterior migrated epidural disc herniation A 56-year-old man presented with low back pain of 4 years’ duration and left leg pain. He was previously diagnosed with lumbar disc herniation. His pain improved with physical therapy. In the last 3 months his pain increased concomitantly with new onset right leg pain. His lumbar spine magnetic resonance imaging (MRI) revealed a mass lesion at the L4–L5 levels posterior to the dural sac (Figure A–C). The mass lesion had isointense signal intensity on
T1- and hypointense signal intensity on T2-weighted lumbar spine MRI. His contrast-enhanced lumbar spine MRI revealed homogenous attenuation. The preliminary diagnosis was meningioma. Beside the mass lesion, he also had a right-sided extruded disc herniation at the L2–L3 levels (Figure D). He underwent en bloc excision of the mass lesion via left L4 hemilaminectomy. His extruded disc fragment at the L2–L3 levels was extracted via right L2 hemilaminectomy and foraminotomy. His mass lesion was observed as a sequestered disc fragment (Figure E). Our patient had no pain after the surgery. Even though it is rare, posterior migrated epidural intervertebral disc fragment could be detected with contrast-enhanced MRI mimicking mass lesion.
Figure. Contrast-enhanced migrated free disc fragment at the L4–L5 levels in the left posterior epidural space with vivid enhancement mimicking extradural tumor (A–C). A concomitant herniated disc fragment has been observed at the L2–L3 levels (D). The mass lesion has been extracted en bloc (E). http://dx.doi.org/10.1016/j.spinee.2016.01.216 1529-9430/© 2016 Elsevier Inc. All rights reserved.
ARTICLE IN PRESS 2
R. Babayev et al. / The Spine Journal ■■ (2016) ■■–■■
Rasim Babayev, MDa Emel Ece Özcan Eks¸i, MDb Anar Kazımov, MDc Murat S¸akir Eks¸i, MDb a Department of Neurosurgery National Center of Oncology Milli Onkologiya Merkezi, 79B, H. Zardabi street, AZ1011 Baku, Azerbaijan b Department of Orthopedic Surgery-Spine Center University of California at San Francisco 500 Parnassus Ave. MU320 West San Francisco, CA 94143-0728, USA
c
Department of Radiology National Center of Oncology Milli Onkologiya Merkezi, 79B, H. Zardabi street, AZ1011 Baku, Azerbaijan
FDA device/drug status: Not applicable. Author disclosures: RB: Nothing to disclose. EEO: Nothing to disclose. AK: Nothing to disclose. MSE: Nothing to disclose. All the authors declare that there is no conflict of interest.
The Spine Journal ■■ (2016) ■■–■■
Images of Spine Care A common pathology in an uncommon location: posterior migrated epidural disc herniation A 56-year-old man presented with low back pain of 4 years’ duration and left leg pain. He was previously diagnosed with lumbar disc herniation. His pain improved with physical therapy. In the last 3 months his pain increased concomitantly with new onset right leg pain. His lumbar spine magnetic resonance imaging (MRI) revealed a mass lesion at the L4–L5 levels posterior to the dural sac (Figure A–C). The mass lesion had isointense signal intensity on
T1- and hypointense signal intensity on T2-weighted lumbar spine MRI. His contrast-enhanced lumbar spine MRI revealed homogenous attenuation. The preliminary diagnosis was meningioma. Beside the mass lesion, he also had a right-sided extruded disc herniation at the L2–L3 levels (Figure D). He underwent en bloc excision of the mass lesion via left L4 hemilaminectomy. His extruded disc fragment at the L2–L3 levels was extracted via right L2 hemilaminectomy and foraminotomy. His mass lesion was observed as a sequestered disc fragment (Figure E). Our patient had no pain after the surgery. Even though it is rare, posterior migrated epidural intervertebral disc fragment could be detected with contrast-enhanced MRI mimicking mass lesion.
Figure. Contrast-enhanced migrated free disc fragment at the L4–L5 levels in the left posterior epidural space with vivid enhancement mimicking extradural tumor (A–C). A concomitant herniated disc fragment has been observed at the L2–L3 levels (D). The mass lesion has been extracted en bloc (E). http://dx.doi.org/10.1016/j.spinee.2016.01.216 1529-9430/© 2016 Elsevier Inc. All rights reserved.
ARTICLE IN PRESS 2
R. Babayev et al. / The Spine Journal ■■ (2016) ■■–■■
Rasim Babayev, MDa Emel Ece Özcan Eks¸i, MDb Anar Kazımov, MDc Murat S¸akir Eks¸i, MDb a Department of Neurosurgery National Center of Oncology Milli Onkologiya Merkezi, 79B, H. Zardabi street, AZ1011 Baku, Azerbaijan b Department of Orthopedic Surgery-Spine Center University of California at San Francisco 500 Parnassus Ave. MU320 West San Francisco, CA 94143-0728, USA
c
Department of Radiology National Center of Oncology Milli Onkologiya Merkezi, 79B, H. Zardabi street, AZ1011 Baku, Azerbaijan
FDA device/drug status: Not applicable. Author disclosures: RB: Nothing to disclose. EEO: Nothing to disclose. AK: Nothing to disclose. MSE: Nothing to disclose. All the authors declare that there is no conflict of interest.