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Imaging in spinal posterior epidural space lesions: A pictorial essay

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ABSTRACT

Spinal epidural space is a real anatomic space located outside the dura mater and within the spinal canal extending from foramen magnum to sacrum. Important contents of this space are epidural fat, spinal nerves, epidural veins and arteries. Due to close proximity of posterior epidural space to spinal cord and spinal nerves, the lesions present with symptoms of radiculopathy and/or myelopathy. In this pictorial essay, detailed anatomy of the posterior epidural space, pathologies affecting it along with imaging pearls to accurately diagnose them are discussed. Various pathologies affecting the posterior epidural space either arising from the space itself or occurring secondary to vertebral/intervertebral disc pathologies. Primary spinal bone tumors affecting the posterior epidural space have been excluded. The etiological spectrum affecting the posterior epidural space ranges from degenerative, infective, neoplastic - benign or malignant to miscellaneous pathologies. MRI is the modality of choice in evaluation of these lesions with CT scan mainly helpful in detecting calcification. Due to its excellent soft tissue contrast, Magnetic Resonance Imaging is extremely useful in assessing the pathologies of posterior epidural space, to know their entire extent, characterize them and along with clinical history and laboratory data, arrive at a specific diagnosis and guide the referring clinician. It is important to diagnose these lesions early so as to prevent permanent neurological complication.

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Miscellaneous: Hirayama's disease: Sagittal T2-weighted (A) image in the flexion position shows atrophy of the cervical cord with hyperintense signal from C4-6 levels (arrowhead) and forward migration of the posterior dura (arrow). Axial T2-weighted (B, C) images at C5-6 level shows asymmetric atrophy of the left side of the cord with myelomalacic changes along with widened posterior epidural space (elbow arrow)
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Figure 42: Miscellaneous: Hirayama's disease: Sagittal T2-weighted (A) image in the flexion position shows atrophy of the cervical cord with hyperintense signal from C4-6 levels (arrowhead) and forward migration of the posterior dura (arrow). Axial T2-weighted (B, C) images at C5-6 level shows asymmetric atrophy of the left side of the cord with myelomalacic changes along with widened posterior epidural space (elbow arrow)

Mentions: MRI is the imaging modality of choice to diagnose Hirayama's disease. Since the pathology is brought about by flexion of the cervical spine; presence of subtle signs on imaging in neutral position should prompt consideration of dynamic study.[646566] Imaging features in a neutral position include loss of attachment of dura to lamina,[64] asymmetric lower cervical cord atrophy with increase in T2 signal, and loss of cervical lordosis.[646566] Loss of dural attachment has been ranked with 100% specificity, and its presence in a young male with distal upper extremity weakness makes the diagnosis of Hirayama's disease likely.[64] However, the caveat is the presence of this sign in approximately half of normal healthy volunteers.[67] Further, this finding may be absent once the disease enters a stable phase.[65] Flexion MRI reveals forward migration of dura with enlargement of posterior epidural space seen as a crescentic region of high signal both on T1 and T2.[64656667] There may be congested vessels in posterior epidural space (flow voids) better appreciated on constructive interference in steady state images.[66] Following contrast administration, the space shows uniform enhancement [Figures 26 and 27].


Imaging in spinal posterior epidural space lesions: A pictorial essay
Miscellaneous: Hirayama's disease: Sagittal T2-weighted (A) image in the flexion position shows atrophy of the cervical cord with hyperintense signal from C4-6 levels (arrowhead) and forward migration of the posterior dura (arrow). Axial T2-weighted (B, C) images at C5-6 level shows asymmetric atrophy of the left side of the cord with myelomalacic changes along with widened posterior epidural space (elbow arrow)
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC5036327&req=5

Figure 42: Miscellaneous: Hirayama's disease: Sagittal T2-weighted (A) image in the flexion position shows atrophy of the cervical cord with hyperintense signal from C4-6 levels (arrowhead) and forward migration of the posterior dura (arrow). Axial T2-weighted (B, C) images at C5-6 level shows asymmetric atrophy of the left side of the cord with myelomalacic changes along with widened posterior epidural space (elbow arrow)
Mentions: MRI is the imaging modality of choice to diagnose Hirayama's disease. Since the pathology is brought about by flexion of the cervical spine; presence of subtle signs on imaging in neutral position should prompt consideration of dynamic study.[646566] Imaging features in a neutral position include loss of attachment of dura to lamina,[64] asymmetric lower cervical cord atrophy with increase in T2 signal, and loss of cervical lordosis.[646566] Loss of dural attachment has been ranked with 100% specificity, and its presence in a young male with distal upper extremity weakness makes the diagnosis of Hirayama's disease likely.[64] However, the caveat is the presence of this sign in approximately half of normal healthy volunteers.[67] Further, this finding may be absent once the disease enters a stable phase.[65] Flexion MRI reveals forward migration of dura with enlargement of posterior epidural space seen as a crescentic region of high signal both on T1 and T2.[64656667] There may be congested vessels in posterior epidural space (flow voids) better appreciated on constructive interference in steady state images.[66] Following contrast administration, the space shows uniform enhancement [Figures 26 and 27].

View Article: PubMed Central - PubMed

ABSTRACT

Spinal epidural space is a real anatomic space located outside the dura mater and within the spinal canal extending from foramen magnum to sacrum. Important contents of this space are epidural fat, spinal nerves, epidural veins and arteries. Due to close proximity of posterior epidural space to spinal cord and spinal nerves, the lesions present with symptoms of radiculopathy and/or myelopathy. In this pictorial essay, detailed anatomy of the posterior epidural space, pathologies affecting it along with imaging pearls to accurately diagnose them are discussed. Various pathologies affecting the posterior epidural space either arising from the space itself or occurring secondary to vertebral/intervertebral disc pathologies. Primary spinal bone tumors affecting the posterior epidural space have been excluded. The etiological spectrum affecting the posterior epidural space ranges from degenerative, infective, neoplastic - benign or malignant to miscellaneous pathologies. MRI is the modality of choice in evaluation of these lesions with CT scan mainly helpful in detecting calcification. Due to its excellent soft tissue contrast, Magnetic Resonance Imaging is extremely useful in assessing the pathologies of posterior epidural space, to know their entire extent, characterize them and along with clinical history and laboratory data, arrive at a specific diagnosis and guide the referring clinician. It is important to diagnose these lesions early so as to prevent permanent neurological complication.

No MeSH data available.


Related in: MedlinePlus