Diffuse vertebral body edema due to calcified intraspongious disk herniation

Calcified Thoracic Disc - A descriptive classification with clinical and management implications

Introduction and Objective

Thoracic disc calcification is a radiological finding which may be incidental or diagnosed in patients presenting with myelopathy due to spinal cord compression. We performed a study to analyze the imaging patterns of calcified thoracic discs (CTDs).

Patients and Methods

A retrospective review of the spinal and radiology database of a tertiary referral orthopedic hospital was conducted for the incidence of CTDs between 2007 and 2020. Patients' demographics and radiological findings were recorded. The relationship between disc size, morphology, spinal cord compression, and management was assessed.

Results

Fifty-one cases of CTDs were identified. The mean size of CTD was 806.2 mm3 (range: 144-2340). The most common level of disc calcification was T9-T10 (24%) in 12 patients. Thoracic disc calcifications in our series commonly involved disc "protrusion" in 67% (34 patients), followed by "mushroom" type in 31% (16 patients) and "extrusion" in 2% (1 patient). 37% (19 patients) had spinal cord compression with 12% (6 patients) undergoing surgical interventions. There was no statistically significant difference in the mean sizes of CTD between the groups with and without spinal cord compression (P = 0.566, independent sample t-test). Patients with "mushroom" type calcification were more likely to have surgical intervention (P = 0.01, Fisher's exact test).

Conclusion

Thoracic disc calcifications, while common, can still be underdiagnosed till late myelopathic deterioration. Care of the elderly physicians, spinal surgeons, and radiologists need to be aware of them to guide diagnosis and management. Our study demonstrates that disc morphology plays a vital role in myelopathic presentation and therefore determines the need for surgical intervention instead of the absolute size of disc calcification.

A Rare Cause of Acute Back Pain in a Young Adult: Case Report and Discussion of Calcific Discitis

Calcific discitis in the adult population is very rare, with fewer than 40 cases reported in the literature. Most cases thus far have involved patients presenting with mid to upper back pain of acute to subacute onset. As it is a condition that is self-resolving with rare exception, the true incidence is likely underestimated. Another factor contributing to the underestimation of individuals with back pain in general is that many patients will treat themselves before presenting for care. Back pain is one of the most common presenting symptoms to primary care physician offices and represents an economic burden of billions of dollars annually. The utilization of MRI imaging and other diagnostic work-up amount to an important component of this cost and one that could possibly be reduced with early radiological identification of this condition. We present a case in which an adult patient presented with subacute lumbar back pain, eventually diagnosed as calcific discitis.

Acute Symptomatic Calcific Discitis Mimicking a Septic Spondylodiscitis

Acute symptomatic calcific discitis is a poorly understood condition that has been mostly reported in children. Cases in adults have been scarcely reported and may mimic an infectious process. Imaging, including computed tomography, can show the disc calcification but might fail to show it because its resorption can occur early after the onset of symptoms. We report the case of an adult patient presenting with severe cervical-dorsal junction pain, fever, high C-reactive protein (CRP) levels, and imaging findings mimicking an infectious spondylodiscitis, including an erosion of the anterior part of the vertebral endplate. However, the patient improved spontaneously and rapidly, with pain and fever disappearing and C-reactive protein (CRP) returning to normal within a week.

Acute Calcific Discitis or Symptomatic Calcified Schmorl's Node of the Upper Thoracic Spine in an Adult: A Case Report and Literature Review

We describe a patient with acute calcific discitis following symptomatic Schmorl's node (SN) of upper thoracic spine. A 28-year-old female suffered from sudden severe pain in mid-thoracic, left scapular area, radiating to her chest. Plain radiography of the thoracic spine showed calcification in T3–4 intervertebral disc space. Computed tomography (CT) scan and magnetic resonance imaging (MRI) of the spine demonstrated calcification of the T3–T4 nucleus pulposus, migrating into the inferior of T3 vertebral body with reactive bone marrow edema. By conservative treatment with multidrug therapy, the pain subsided and disappeared in 3 months. Follow-up CT scan and MRI of the thoracic spine confirmed complete resolution of calcified SN and reactive bone marrow edema.

Lumbar intravertebral disc herniation secondary to idiopathic calcific discitis

Calcific discitis is a well recognized entity in the paediatric population but more recently has been increasingly reported in adults. It typically involves the lower thoracic vertebrae and is of unknown aetiology. Herniation of the calcified fragment is rare but typically occurs out through the annulus fibrosus into the canal space. Herein we describe the first reported case of calcific discitis involving the lumbar vertebrae with subsequent herniation of the calcified disc into and through the anterior aspect of the L5 vertebra. The patient first presented with a history of right back pain and leg sciatica. Radiographic imaging demonstrated calcification within the L4/5 interspace, which was managed with simple analgesia. She subsequently re-presented 24-months later with worsening sciatica, right leg weakness and faecal incontinence. No evidence of cord or root compression was noted on MRI. However, an abnormality was noted at the anterior body of L5 with evidence of superior endplate depression and marrow signal change. Subsequent radionucleide bone studies confirmed a solitary focus of increased linear activity extending across the width of the L4-L5 interspace. Her symptoms were managed medically. Serial radiographic imaging demonstrated regression of the disc space calcification and healing of the L5 fracture. Despite its sinister presentation this condition was self-limiting. We describe the radiographic evolution of this pathology and postulate a putative hypothesis through which it may have arisen.

Bone edema of the whole vertebral body: an unusual case of spondyloarthritis

Spondyloarthritis (SpA) is usually characterized by early inflammatory involvement of the sacroiliac joints (SI), which constitutes one of the most important classification criteria according to the SpondyloArthritis International Society (ASAS). These criteria do not include inflammatory spine lesions which can be detected on MRI, although spine involvement is very common in axial SpA. This is because spine MRI lesion often retrieved in SpA are not very specific, and can be found in many other diseases such as malignancy and osteoarthritis. Here we present the case of a 33-year old woman who presented a worsening low back pain, with a thoracic spine MRI showing bone marrow edema (BME) of the whole T8 vertebral body. Owing to this peculiar presentation, together with the unresponsiveness of the pain to nonsteroidal anti inflammatory drugs (NSAIDs) and a slight increase of the biomarker CA19-9, a malignancy was suspected. Therefore, the patient underwent bone scintigraphy, Single positron emission computed tomography (SPET/TC), positron emission tomography and repeated MRI without reaching a diagnosis. Finally, when SI joints MRI was performed, BME of the SI joints emerged: this was fundamental to formulate the diagnosis of axSpA.

Acute symptomatic calcific discitis in adults: a case report and review of literature

Symptomatic calcific discitis has been reported in the paediatric population but is a rare entity in adults with only eight cases reported in the English literature. We present a case of adult calcific discitis presenting with acute onset back pain. Radiographs and CT demonstrated central T11-T12 disc calcification with diffuse marrow oedema on subsequent MRI. The patient was referred to our spinal oncology unit due to the extensive marrow oedema as a possible underlying primary bone tumour. Review of the CT confirmed an end-plate defect with herniated calcific nucleus pulposus with no underlying bone lesion. Features were in keeping with acute calcific discitis. The patient was treated symptomatically and made an uneventful recovery. We discuss the characteristic imaging features seen on radiograph, CT and MRI and review the current literature. Calcific discitis is a self-limiting pathology requiring symptomatic management only. Radiologists need to be aware of this rare entity as it can occur in adults and may be mistaken for a more sinister pathology such as infective discitis or a bone tumour and lead to further unnecessary imaging or invasive procedures.

Calcific discitis in an adult patient with intravertebral migration and spontaneous remission

Symptomatic disc calcifications have been reported, especially in the pediatric population, and remain of unknown etiology. Such a condition has been very rarely reported in adults. The aim of this paper is to present a case report of calcific discitis in an adult patient with intravertebral migration and spontaneous calcification resorption. The clinical presentation was that of back pain with an abrupt onset, not related to trauma or to physical activity. No fever or neurological deficits were present. Blood count, erythrocyte sedimentation rate, routine urine, and urine culture were negative. The pain regressed in 20 days with analgesic therapy. Findings of thoracic calcific discitis are illustrated with X-rays, CT, MRI, and bone scintigraphy.

Image-guided percutaneous spinal biopsy

The purpose of this article is to discuss the role of imaging in the diagnosis and management of spinal disorders, with particular attention to that of image-guided percutaneous spinal biopsy. We discuss the indications, general principles, pre-procedural steps and specific techniques used for image-guided percutaneous spinal biopsy in the context of our experience and the wider literature. Percutaneous spinal biopsy is a safe and diagnostically accurate procedure when appropriately selected for further evaluation in the multidisciplinary team setting.

Magnetic resonance imaging characterization of vertebral endplate changes in the dog

Spinal MR images acquired from canine patients over a 7-year period were reviewed for the presence of vertebral endplate changes. Seventy-five dogs with 76 distinct lesions were identified. Presumptive diagnoses fell into five categories: reactive endplate changes (10 dogs/13.2%), discospondylitis (29 dogs/38.2%), vertebral osteochondrosis (7 dogs/9.2%), intravertebral disc herniation (Schmorl's nodes) (4 dogs/5.3%), and fatty infiltration (26 dogs/34.2%). Fatty infiltration occurred significantly more often in small breed dogs (P < 0.001) and tended to be multifocal. The following features were observed in discospondylitis as well as in other nonfatty endplate pathologies: irregular endplates, endplate hyperintensity in T2w or STIR images, reduced endplate signal intensity in T1w SE, variable T1w GRE signal intensity, and endplate contrast enhancement. Overlap between MR characteristics of nonfatty endplate changes should prompt cautious evaluation of adjacent structures.

Tumoral calcinosis presenting as a deformity of the thoracic spine

The authors describe a rare case of tumoral calcinosis (TC) of the thoracic spine in a 13-year-old boy with thoracic scoliosis. The patient presented with a 2-year history of back pain. He had no personal or family history of bone disease, deformity, or malignancy. Magnetic resonance imaging revealed a heterogeneously enhancing mass involving the T-7 vertebral body and the left pedicle. Computed tomography findings suggested that the mass was calcified and that this had resulted in scalloping of the vertebral body. The lesion was resected completely by using a left T-7 costotransversectomy and corpectomy. The deformity was corrected with placement of a vertebral body cage and pedicle screw fixation from T-5 to T-9. Pathological analysis of the mass demonstrated dystrophic calcification with marked hypercellularity and immunostaining consistent with TC. This represents the third reported case of vertebral TC in the pediatric population. Pediatric neurosurgeons should be familiar with lesions such as TC, which may be encountered in the elderly and in hemodialysis-dependent populations, and may not always require aggressive resection.