Management of Tarlov cysts: an uncommon but potentially serious spinal column disease-review of the literature and experience with over 1000 referrals

Tarlov cysts were thought to be anatomic variants of uncertain etiology and clinical significance when initially described over 80 years ago. They are often detected in routine lumbosacral imaging and generally not reported in a differential diagnosis. There is increasing evidence that at least some Tarlov cysts are symptomatic and can have a significant adverse impact on patients' health and well-being. Women are disproportionately affected with this condition, often presenting with long-standing pain and neurological dysfunctions. Significant gender bias has been a concern in the management of these patients. Unfortunately, there is no consensus on patient selection or management approaches for symptomatic Tarlov cysts. This review article updates information on the prevalence, diagnosis, clinical significance, and treatments of these cysts. Based on these findings and experience with over 1000 patient referrals, a treatment decision algorithm for symptomatic Tarlov cysts was constructed to provide guidance for appropriate management of patients with these complex cysts.

What Is the Prevalence of Clinically Important Findings Among Incidentally Found Osseous Lesions?

BACKGROUND

Patients with incidentally found musculoskeletal lesions are regularly referred to orthopaedic oncology. Most orthopaedic oncologists understand that many incidental findings are nonaggressive and can be managed nonoperatively. However, the prevalence of clinically important lesions (defined as those indicated for biopsy or treatment, and those found to be malignant) remains unknown. Missing clinically important lesions can result in harm to patients, but needless surveillance may exacerbate patient anxiety about their diagnosis and accrue low-value costs to the payor.

QUESTIONS/PURPOSES

(1) What percentage of patients with incidentally discovered osseous lesions referred to orthopaedic oncology had lesions that were clinically important, defined as those receiving biopsy or treatment or those found to be malignant? (2) Using standardized Medicare reimbursements as a surrogate for payor expense, what is the value of reimbursements accruing to the hospital system for the imaging of incidentally found osseous lesions performed during the initial workup period and during the surveillance period, if indicated?

METHODS

This was a retrospective study of patients referred to orthopaedic oncology for incidentally found osseous lesions at two large academic hospital systems. Medical records were queried for the word "incidental," and matches were confirmed by manual review. Patients evaluated at Indiana University Health between January 1, 2014, and December 31, 2020, and those evaluated at University Hospitals between January 1, 2017, and December 31, 2020, were included. All patients were evaluated and treated by the two senior authors of this study and no others were included. Our search identified 625 patients. Sixteen percent (97 of 625) of patients were excluded because their lesions were not incidentally found, and 12% (78 of 625) were excluded because the incidental findings were not bone lesions. Another 4% (24 of 625) were excluded because they had received workup or treatment by an outside orthopaedic oncologist, and 2% (10 of 625) were excluded for missing information. A total of 416 patients were available for preliminary analysis. Among these patients, 33% (136 of 416) were indicated for surveillance. The primary indication for surveillance included lesions with a benign appearance on imaging and low clinical suspicion of malignancy or fracture. A total of 33% (45 of 136) of these patients had less than 12 months of follow-up and were excluded from further analysis. No minimum follow-up criteria were applied to patients not indicated for surveillance because this would artificially inflate our estimated rate of clinically important findings. A total of 371 patients were included in the final study group. Notes from all clinical encounters with orthopaedic and nonorthopaedic providers were screened for our endpoints (biopsy, treatment, or malignancy). Indications for biopsy included lesions with aggressive features, lesions with nonspecific imaging characteristics and a clinical picture concerning for malignancy, and lesion changes seen on imaging during the surveillance period. Indications for treatment included lesions with increased risk of fracture or deformity, certain malignancies, and pathologic fracture. Diagnoses were determined using biopsy results if available or the documented opinion of the consulting orthopaedic oncologist. Imaging reimbursements were obtained from the Medicare Physician Fee Schedule for 2022. Because imaging charges vary across institutions and reimbursements vary across payors, this method was chosen to enhance the comparability of our findings across multiple health systems and studies.

RESULTS

Seven percent (26 of 371) of incidental findings were determined to be clinically important, as previously defined. Five percent (20 of 371) of lesions underwent tissue biopsy, and 2% (eight of 371) received surgical intervention. Fewer than 2% (six of 371) of lesions were malignant. Serial imaging changed the treatment of 1% (two of 136) of the patients, corresponding to a rate of one in 47 person-years. Median reimbursements to work up the incidental findings analyzed was USD 219 (interquartile range USD 0 to 404), with a range of USD 0 to 890. Among patients indicated for surveillance, the median annual reimbursement was USD 78 (IQR USD 0 to 389), with a range of USD 0 to 2706.

CONCLUSION

The prevalence of clinically important findings among patients referred to orthopaedic oncology for incidentally found osseous lesions is modest. The likelihood of surveillance resulting in a change of management was low, but the median reimbursements associated with following these lesions was also low. We conclude that after appropriate risk stratification by orthopaedic oncology, incidental lesions are rarely clinically important, and judicious follow-up with serial imaging can be performed without incurring high costs.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Sacral Tarlov cysts: Neurophysiology abnormalities and correlation with pelvic sensory and visceral symptoms

BACKGROUND AND PURPOSE

Recent studies suggest a possible association between Tarlov cysts (TCs), usually considered as incidental radiological findings, and neurological symptoms such as pain, numbness and urogenital complaints. The aim was to explore the relationship between TCs and sacral nerve root functions using pelvic neurophysiology tests, and to correlate changes with clinical symptoms and magnetic resonance imaging (MRI) findings.

METHODS

Consecutive patients with sacral TCs, referred for pelvic neurophysiology testing and presenting with at least one symptom related to the pelvic area, participated in a cross-sectional review of symptoms using validated questionnaires. Findings of pelvic neurophysiology (pudendal sensory evoked potentials, sacral dermatomal sensory evoked potentials, external anal sphincter electromyography) and urodynamics testing were collected retrospectively. The relationship between neurophysiology, MRI findings and patients' symptoms was assessed using Fisher and ANOVA tests.

RESULTS

Sixty-five females were included (mean age 51.2 ± 12.1 years). The commonest symptom was pain (92%). Urinary (91%), bowel (71%) and sexual (80%) symptoms were also frequently reported. Thirty-seven patients (57%) had abnormal neurophysiology findings reflecting sacral root dysfunction. No association was seen between MRI findings (size, location of the cysts, severity of compression) and neurophysiology. A negative association was observed between neurophysiology abnormalities and occurrence of urgency urinary incontinence (p = 0.03), detrusor overactivity (p < 0.01) and stress urinary incontinence (p = 0.04); however, there was no association with voiding difficulties.

CONCLUSIONS

Contrary to current understanding, TCs are associated with injury to the sacral somatic innervation in the majority of patients with presumed symptomatic cysts. However, urinary incontinence is unlikely to be related to TC-induced nerve damage.

Why Should Radiologists Evaluate MR Localizer Sequences?

AIM

This study aimed to assess the diagnostic accuracy of magnetic resonance (MR) localizer sequences in the detection of spinal incidental findings.

MATERIALS AND METHODS

MR localizer sequence findings from 384 patients were reviewed retrospectively. The images were evaluated by an experienced radiologist. T2-weighted diagnostic sagittal and coronal images included in the abdominal images were taken as references.

RESULTS

Of the 384 patients, 170 were female and 214 were male. Pathology was detected in 63 of the patients. The findings were more common in male groups. These pathologies were spinal discopathy, metastases, hemangioma, angulation in the coccyx, and hemivertebra.

CONCLUSIONS

Although often overlooked, MR localizer images enable diagnosing additional pathologies in the spine. These are unsuspected but can be critical for patient management, reducing patient morbidity and mortality.

Percutaneous Biportal Endoscopic Fenestration for Symptomatic Foraminal Tarlov Cyst

Perineural (Tarlov) cysts are a common benign pathology in the lumbosacral area but are rarely symptomatic, even when compressing the spinal root. Despite the rarity of Tarlov cyst formation in the foramen of the spine, this type is more symptomatic than those in other sites due to the narrow space. We introduce a biportal endoscopic fenestration for symptomatic foraminal Tarlov cysts. We present the case of a 40-year-old woman experiencing radiating pain in her right lower leg for 4 years. On seeking treatment, her great toe and ankle plantar flexion power had decreased. Magnetic resonance imaging revealed a cystic mass located in the L5-S1 intervertebral foramen that compressed the lumbar nerve root. Partial laminotomy was performed using a percutaneous biportal endoscopic system with a far lateral approach. An oval cystic mass of 2.6×1.1 cm was identified on high-definition images. Partial bone and foraminal ligament removal and cystic membrane fenestration were performed for nerve decompression. After decompression, the patient's motor weakness and radiating pain improved. Due to high-definition images and the minimally invasive laminotomy procedures associated with percutaneous biportal endoscopic fenestration, a foraminal Tarlov cyst was fenestrated safely, and weakness arising from radiculopathy was resolved in the current case. [Orthopedics. 2023;46(2):e125-e128.].

Added value of coronal-T1W sequence to the lumbar MR imaging protocol for low back pain

Introduction:

Magnetic resonance imaging (MRI) is the most appropriate imaging method to investigate low back pain. As low back pain is very common, a large number of MRI scans are performed.

Objective:

To evaluate the extraspinal findings and clinical effect of the T1-weighted spin echo (T1 W SE) coronal sequence added to the lumbar MRI protocol for low back pain.

Materials and methods:

In 2015, we added a T1-weighted (T1W) coronal sequence to our routine lumbar MRI protocol. We retrospectively evaluated 969 lumbar MRI images for low back pain performed with this protocol. The extraspinal MRI findings obtained from them were then grouped as associated with low back pain (Category 1) and not associated with low back pain (Category 2). We also evaluated whether the recorded incidental extraspinal findings could be detected on conventional sagittal and axial images.

Results:

Ninety-six (63%) of the extraspinal findings were associated with low back pain (Category 1) and 56 (37%), Category 2. Seventy-eight percent of the extraspinal findings were detected only on coronal-T1W images and not on conventional images.

Conclusion:

Adding coronal-T1W sequence to the routine protocol of lumbar MRI can help to identify extraspinal findings and guide clinical treatment.

Prevalence and clinical potential of extraspinal incidental findings in lumbosacral spine MRI of patients with suspected disc diseases

BACKGROUND Incidental findings could be observed in organs close to the spine while reporting lumbosacral spine magnetic resonance imaging (MRI). This study aimed to report the prevalence and clinical potential of extraspinal incidental findings in lumbosacral MRI of patients with suspected disc diseases. METHODS This single-centered cross-sectional study was carried out on 420 consecutive adult patients who underwent lumbar spine MRI for suspected disc disease from January to July 2019. The MRI was checked for the presence of extraspinal incidental findings, and each finding was categorized according to the body organ and its clinical significance. Each MRI plane that best displayed the findings was recorded, and the association between the findings and patient's age and sex was determined. RESULTS Of 420 samples, 135 cases showed extraspinal findings (32.1%), and 7.6% of the patients displayed suspicious lesions. The urinary tract was the most common system (18.6%) to display both clinically significant (5.0%) and benign findings (13.6%), and the axial MRI section was the plane which showed most of the incidental findings. Incidental findings in any body system were rarely found in the younger patients. Females had significantly higher benign findings than males (p = 0.002). CONCLUSIONS The prevalence of extraspinal findings in lumbosacral spine MRI is high, and some are significant. Most findings are related to the urinary tract and best displayed in the axial plane.

Tarlov cysts in back pain patients: prevalence, measurement method and reporting points

OBJECTIVE

Determining the prevalence of Tarlov cysts in low back pain patients.

METHODS AND MATERIALS

The picture archiving & communication system (PACS) & hospital information system (HIS) of a corporate hospital were retrospectively analyzed to determine the percentage of Tarlov cysts among patients undergoing spinal MRI for back pain over 3 years (January 2017 to December 2019).

RESULTS

384 patients had undergone spinal MRI for back pain over the study period, and 25 of them (6.51%) had Tarlov cysts. Vast majority (15 cases) showed cysts located at S2/S3 level, and few were found at S1/S2 and other levels. Single cysts were found in most (=18) of the cases, while 7 cases of multiple / bilateral cysts were found. Cyst dimensions were higher in craniocaudal than anteroposterior or transverse directions. In case of multiple cysts, one or two cysts were noted as dominant, having higher dimensions than the others. The study data revealed no gender or age predilection.

CONCLUSIONS

We conclude that including the entire sacrum with a T2 sagittal sequence in all MRI for low back pain can increase detection of Tarlov cysts, and thereby provide more data for further analysis.

ADVANCES IN KNOWLEDGE

We propose the concept of one "dominant" cyst when there are multiple Tarlov cysts. We recommend that diameter or size of Tarlov cysts be specified to their craniocaudal dimension. We also suggest reporting points for contextual structured reporting, viz. presence or absence of bony scalloping, neural foraminal narrowing, nerve root compression or extraforaminal extension.

High Prevalence of Perineural Cysts in Patients with Fibromyalgia and Chronic Fatigue Syndrome

OBJECTIVE

Pain in fibromyalgia (FM) and chronic fatigue syndrome (CFS) is assumed to originate from central sensitization. Perineural cysts or Tarlov cysts (TCs) are nerve root dilations resulting from pathologically increased cerebrospinal fluid pressure. These cysts initially affect sensory neurons and axons in dorsal root ganglia and produce sensory symptoms (pain and paresthesia). Symptomatic TC (STC) patients often complain about widespread pain and fatigue. Consequently, STC patients may initially be diagnosed with FM, CFS, or both. The objective of this study was to document the prevalence of TCs in patients diagnosed with FM or CFS.

DESIGN

A retrospective study.

SETTING

An outpatient clinic for musculoskeletal disorders.

SUBJECTS

Patients diagnosed with FM according to the 1990 American College of Rheumatology criteria or with CFS according to the 1994 Centers for Disease Control criteria were selected.

METHODS

Review of lumbar and sacral magnetic resonance imaging scans including TCs ≥5 mm in size.

RESULTS

In total, 197 patients with FM, CFS, or both underwent magnetic resonance imaging. Ninety-one percent were women. The mean age was 48.1 (±11.9) years. TCs were observed in 39% of patients, with a mean size of 11.8 (±5.2) mm. In males, the prevalence was 12%, vs. 42% in females.

CONCLUSIONS

In patients diagnosed with FM or CFS, the prevalence of TCs was three times higher than that in the general population. This observation supports the hypothesis that STCs, FM, and CFS may share the same pathophysiological mechanism, i.e., moderately increased cerebrospinal fluid pressure, causing irritation of neurons and axons in dorsal root ganglia.

Statement of the German Roentgen Society, German Society of Neuroradiology, and Society of German-speaking Pediatric Radiologists on Requirements for the Performance and Reporting of MR Imaging Examinations Outside of Radiology

BACKGROUND

 Magnetic Resonance Imaging (MRI) is a very innovative, but at the same time complex and technically demanding diagnostic method in radiology. It plays an increasing role in high-quality and efficient patient management. Quality assurance in MRI is of utmost importance to avoid patient risks due to errors before and during the examination and when reporting the results. Therefore, MRI requires higher physician qualification and expertise than any other diagnostic imaging technique in medicine. This holds true for indication, performance of the examination itself, and in particular for image evaluation and writing of the report. In Germany, the radiologist is the only specialist who is systematically educated in all aspects of MRI during medical specialty training and who must document a specified, high number of examinations during this training. However, also non-radiologist physicians are increasingly endeavoring to conduct and bill MRI examinations on their own.

METHOD

 In this position statement, the following aspects of quality assurance for MRI examinations and billing by radiologists and non-radiologist physician specialists are examined scientifically: Requirements for specialist physician training, MRI risks and contraindications, radiation protection in the case of non-ionizing radiation, application of MR contrast agents, requirements regarding image quality, significance of image artifacts and incidental findings, image evaluation and reporting, interdisciplinary communication and multiple-eyes principle, and impact on healthcare system costs.

CONCLUSION

 The German Roentgen Society, German Society of Neuroradiology, and Society of German-speaking Pediatric Radiologists are critical with regard to MRI performance by non-radiologists in the interest of quality standards, patient welfare, and healthcare payers. The 24-month additional qualification in MRI as defined by the physician specialization regulations (Weiterbildungsordnung) through the German state medical associations (Landesärztekammern) is the only competence-based and quality-assured training program for board-certified specialist physicians outside radiology. This has to be required as the minimum standard for performance and reporting of MRI exams. Exclusively unstructured MRI training outside the physician specialization regulations has to be strictly rejected for reasons of patient safety. The performance and reporting of MRI examinations must be reserved for adequately trained and continuously educated specialist physicians.

KEY POINTS

· MR imaging plays an increasing role due to its high diagnostic value and serves as the reference standard in many indications.. · MRI is a complex technique that implies patient risks in case of inappropriare application or lack of expertise.. · In Germany, the radiologist is the only specialist physician that has been systematically trained in all aspects of MRI such as indication, performance, and reporting of examinations in specified, high numbers.. · The only competence-based and quality-assured MRI training program for specialist physicians outside radiology is the 24-month additional qualification as defined by the regulations through the German state medical associations.. · In view of quality-assurance and patient safety, a finalized training program following the physician specialization regulations has to be required for the performance and reporting of MRI examinations..

CITATION FORMAT

· Hunold P, Bucher AM, Sandstede J et al. Statement of the German Roentgen Society, German Society of Neuroradiology, and Society of German-speaking Pediatric Radiologists on Requirements for the Performance and Reporting of MR Imaging Examinations Outside of Radiology. Fortschr Röntgenstr 2021; 193: 1050 - 1060.

Spinal Perineural Cysts among European Patients

BACKGROUND

 A perineural (Tarlov) cyst is a fluid-filled lesion occurring between the perineurium and the endoneurium of spinal nerve roots. The aim of the study was to evaluate the prevalence and morphology of perineural cysts, detected incidentally in patients with symptomatic degenerative disk disease.

MATERIALS/METHODS

 The study was based on the retrospective data gathered during magnetic resonance imaging (MRI) examinations.

RESULTS AND CONCLUSIONS

 Out of 3,128 spinal MRI examinations, perineural cysts were detected in 286 patients (9%). The cysts were most commonly observed in the sacral region, followed by thoracic, cervical, and lumbar regions. Cysts were more common in women than in men and the average age of patients was 54.8 years. In the majority, a single cyst was found. The average longest dimension of the lesion was 11.72 mm.

Transcatheter arterial embolization for a symptomatic Tarlov cyst with hemorrhage due to an underlying arteriovenous fistula

Symptomatic sacral perineural cysts (Tarlov cysts) accompanied by intra-cyst hemorrhage are rare. The treatment strategies have not been established. We report a 57-year-old woman with severe back pain due to a Tarlov cyst accompanying intracyst hemorrhage. Computed tomography angiography revealed an arteriovenous fistula (AVF) at the area surrounding the cyst. The patient underwent transcatheter arterial embolization for the AVF. Thereafter, the hematoma and cyst decreased in size, and clinical symptoms markedly improved with no additional surgery. Transcatheter arterial embolization may be an effective alternative to surgery for Tarlov cysts with vascular disease, including AVF.

Global incidence of spinal perineural Tarlov's cysts and their morphological characteristics: a meta-analysis of 13,266 subjects

BACKGROUND

Spinal perineural Tarlov's cysts (TCs) are considered incidental findings that occasionally might exert pressure upon nerve roots and correspond with patients' signs and symptoms. Purpose of this meta-analysis is to deliver global incidence and characteristics (location, size, and shape) of TCs.

METHODS

Following PRISMA checklist, all major databases were searched by two authors for radiologic studies reporting incidence and morphologic features (location, size, and shape) of TCs. Anatomical Quality Assessment tool was applied for risk of bias evaluation. Meta-analysis of random-effects model was employed. Subgroup analysis for regional distribution, gender, sacral levels, age, correspondence with symptoms, and persistent genital arousal disorder (PGAD) were planned ahead.

RESULTS

22 radiologic studies of level 3 evidence involving 13,266 subjects were included. Global pooled prevalence of TCs was 4.18% (95% CI 2.47-6.30). Mean pooled sagittal diameter was 11.86 mm (95% CI 10.78-12.93). Sacral cysts strongly prevailed over the other segments. Of the sacral, S2 level was the most common (46.7% [95% CI 29.4-60.5]). Geographically, the highest incidence was found in Europe (6.07% [95% CI 1.49-13.00]), followed by North America (3.82% [95% CI 0.49-9.44]), and Asia (3.33% [95% CI 1.52-5.75]). TCs were more common in women than in men (5.84% vs 3.03%, p < 0.001, test of homogeneity, χ²). Subjects with PGAD had incidence of 37.87% (95% CI 2.45-81.75). TCs in pediatric population are rare-0.53% (95% CI 0.02-1.51). 15.59% of TCs corresponded with symptoms.

CONCLUSIONS

Spinal perineural (Tarlov) cysts are found in a minority of population. S2 level of the sacral bone is affected most frequently. There is female predominance. Correspondence with symptoms is seen in less than one-fifth of TCs. Studies with stronger evidence level are needed to corroborate the results. The purported high incidence in PGAD requires confirmation in case-control studies for the risk-ratio calculation.

Identification of perineural cysts during ultrasound-guided caudal anaesthesia

An 8-year-old boy was scheduled for urethral fistula correction under general anaesthesia with an ultrasound-guided caudal block. During scanning of the caudal area, we noticed two cystic structures in the caudal space in the region of the intended needle endpoint so we decided against performing the caudal block. Surgery was conducted uneventfully and a penile block was administered as an alternative for analgesia postoperatively. Radiological evaluation of the child 3 weeks later revealed the presence of perineural cysts in the sacral region. Routine use of ultrasound for caudal anaesthesia procedures may reveal unexpected anomalies in the sacral area, which could have implications for optimal patient management.

Spinal cord stimulation for the treatment of chronic pelvic pain after Tarlov cyst surgery in a 66-year-old woman: A case report

Tarlov cysts are extradural meningeal cysts with collections of cerebrospinal fluid within the nerve sheath. These cysts are uncommon but tend to present more often in women. Symptomatic Tarlov cysts can lead to a variety of neurologic symptoms and painful conditions, including chronic pelvic pain. There is no consensus regarding the best treatment for symptomatic cysts. Surgical management has high rates of complication, including chronic pain, but better long-term results for symptom and cyst resolution. We describe a patient who developed worsening pelvic pain and lumbar radiculopathy after surgical management of her Tarlov cysts. Medication failed to relieve the pain, as did a variety of other procedures, before the patient ultimately received significant pain relief from high-frequency spinal cord stimulation. This case may provide guidance for physicians when managing patients suffering from symptomatic Tarlov cysts, or worsening pain symptoms after surgical management of these cysts.

Evaluating the discordant relationship between Tarlov cysts and symptoms of pudendal neuralgia

BACKGROUND

Pudendal neuralgia is a painful neuropathic condition involving the pudendal nerve dermatome. Tarlov cysts have been reported in the literature as another potential cause of chronic lumbosacral and pelvic pain. Notably, they are often located in the distribution of the pudendal nerve origin at the S2, S3, and S4 sacral nerve roots and it has been postulated that they may cause similar symptoms to pudendal neuralgia. Literature has been inconsistent on the clinical relevance of the cysts and if they are responsible for symptoms.

OBJECTIVE

To evaluate the prevalence of S2-S4 Tarlov cysts at the pudendal nerve origin (S2-S4 sacral nerve roots) in patients specifically diagnosed with pudendal neuralgia, and establish association of patient symptoms with location of Tarlov cyst.

STUDY DESIGN

A retrospective study was performed on 242 patients with pudendal neuralgia referred for pelvic magnetic resonance imaging from January 2010 to November 2012. Dedicated magnetic resonance imaging review evaluated for presence, level, site, and size of Tarlov cysts. Among those with demonstrable cysts, subsequent imaging data were collected and correlated with the patients' clinical site of symptoms. Statistical analysis was performed using χ², Pearson χ², and Fisher exact tests to assess significance.

RESULTS

Thirty-nine (16.1%) patients demonstrated at least 1 sacral Tarlov cyst; and of the 38 patients with complete pain records, 31 (81.6%) had a mismatch in findings. A total of 50 Tarlov cysts were identified in the entire patient cohort. The majority of the Tarlov cysts were found at the S2-S3 level (32/50; 64%). Seventeen patients (44.7%) revealed unilateral discordant findings: unilateral symptoms on the opposite side as the Tarlov cyst. In addition, 14 (36.8%) patients were detected with bilateral discordant findings: 11 (28.9%) had bilateral symptoms with a unilateral Tarlov cyst, and 3 (7.9%) had unilateral symptoms with bilateral cysts. Concordant findings were only demonstrated in 7 patients (18.4%). No significant association was found between cyst size and pain laterality (P = .161), cyst volume and pain location (P = .546), or cyst size and unilateral vs bilateral pain (P = .997).

CONCLUSION

The increased prevalence of Tarlov cysts is likely not the etiology of pudendal neuralgia, yet both could be due to similar pathogenesis from part of a focal or generalized condition.

Prevalence of benign osseous lesions of the spine and association with spinal pain in the general population in whole body MRI

Background

Benign osseous lesions of the spine are common but precise population prevalence estimates are lacking. Our study aimed to provide the first population-based prevalence estimates and examine association with back and neck pain.

Materials and methods

We used data from the population-based Study of Health in Pomerania (SHIP). Whole-body MRI examinations (1.5 Tesla: T1, T2, and TIRM weightings) were available from 3,259 participants. Readings of the spinal MRI images were conducted according to a standardized protocol by a single reader (JS). The intra-rater reliability was greater than Kappa values of 0.98. Pain measures included the seven-day prevalence of spine pain and neck pain, and average spine pain intensity due to spine pain during the past three months.

Results

We found 1,200 (36.8%) participants with at least one osseous lesion (2,080 lesions in total). Osseous lesions were less common in men than in women (35.5% vs 38.9%; P = .06). The prevalence of osseous lesions was highest at L2 in both sexes. The prevalence of osseous lesions increased with age. Up to eight osseous lesions were observed in a single subject. Hemangioma (28%), and lipoma (13%) occurred most often. Sclerosis (1.7%), aneurysmal bone cysts (0.7%), and blastoma (0.3%) were rare. Different osseous lesions occurred more often in combination with each other. The association with back or neck pain was mostly negligible.

Conclusion

Osseous lesions are common in the general population but of no clinical relevance for spinal pain. The prevalence of osseous lesions varied strongly across different regions of the spine and was also associated with age and gender. Our population-based data offer new insights and assist in judging the relevance of osseous lesions observed on MRIs of patients.

A Child with a Rare Extraosseous Extension and Pathologic Fracture from a Vertebral Hemangioma: A Case Report

CASE

We present a case of a pathologic vertebral fracture and encroachment into the spinal canal from a vertebral hemangioma in a 13-year-old boy. The original approach of embolization followed by an anterior-posterior resection and stabilization through a costotransversectomy had to be converted intraoperatively to a combined anterior and posterior approach secondary to excessive bleeding.

CONCLUSION

Because of the hypervascularity and the extensive nature of aggressive vertebral hemangiomas, surgeons attempting procedures similar to the case described herein must be prepared to adapt to the circumstances when preoperative embolization is not totally effective. Surgical technique, proper anesthesia, and patient clotting capacity are important factors to consider.

Symptomatic Tarlov cysts are often overlooked: ten reasons why-a narrative review

PURPOSE

Tarlov cysts (TCs) are dilations of nerve roots arising from pathologically increased hydrostatic pressure (HP) in the spinal canal. There is much controversy regarding whether these cysts are a rare source of pain or often produce symptoms. The aim of this review was to identify the reasons that symptomatic TCs (STCs) are easily overlooked.

METHODS

The literature was searched for data regarding pathogenesis and symptomatology.

RESULTS

TCs may be overlooked for the following reasons: (1) STCs are considered clinically irrelevant findings; (2) it is assumed that it is clinically difficult to ascertain that TCs are the cause of pain; (3) MRI or electromyography studies only focus on the L1 to S1 nerves; (4) TCs are usually not reported by radiologists; (5) degenerative alterations of the lumbosacral spine are almost always identified as the cause of a patient's pain; (6) it is not generally known that small TCs can be symptomatic; (7) examinations and treatments usually focus on the cysts as an underlying mechanism; however, essentially, increased HP is the main underlying mechanism for producing symptoms. Consequently, STCs may relapse after surgery; (8) bladder, bowel and sphincter dysfunction are not inquired about during history taking. (9) Unexplained pain is often attributed to depression, whereas depression is more likely the consequence of debilitating neuropathic pain. (10) The recognition of STCs is subject to gender bias, confirmation bias and cognitive dissonance and unconscious bias in publishing.

CONCLUSION

There are several reasons STCs are underdiagnosed, mostly due to persistent misconceptions and biases. These slides can be retrieved under Electronic Supplementary Material.

A Giant Tarlov Cyst Presenting with Hydronephrosis in a Patient with Marfan Syndrome: A Case Report and Review of the Literature

BACKGROUND

Giant Tarlov cysts are always symptomatic and mimic many serious pathologic entities. We present the largest, to our knowledge, reported Tarlov cyst.

CASE DESCRIPTION

A 33-year-old woman with Marfan syndrome suffered from right kidney hydronephrosis because of ureter obstruction, for which she was treated with nephrostomy. Her neurologic examination was unremarkable. The role of magnetic resonance imaging in the management of this case is described. Absence of intractranial hypotension symptoms after cerebrospinal fluid (CSF) overdrainage suggested the presence of a valve-like mechanism. The patient was planned for surgical cyst remodeling by the application of titanium clips. The cyst's neck was exposed through an L5-S2 laminectomy. L5 and S1 laminae were severely eroded. CSF leaked out of the underlying, bulging, and thinned dura at each attempt for clip application. Intraoperatively, multiple responses from the S1, S2, and S3 roots were simultaneously recorded at each stimulation. Therefore, we decided to abandon this technique and performed a nonwatertight duroplasty followed by a layered wound closure instead. A week later, the patient received a lumbar-peritoneal shunt. The patient remained neurologically intact, the cyst shrunk, and the nephrostomy was removed.

CONCLUSIONS

Indirect evidence was helpful to assess for the presence of a valve-like mechanism. Intraoperatively, the surgeon must keep on high alert for sacral erosion to avoid inadvertent dural tear and rootlet injury. Finally, lumboperitoneal diversion remains a valid alternative in the management of our giant Tarlov cyst because it reduced the intracystic pressure that resulted in cyst regression.

An initial experience with the use of whole body MRI for cancer screening and regular health checks

OBJECTIVES

We evaluated the utility of whole-body MRI (WB MRI) for cancer screening and other regular health evaluations.

METHODS

This retrospective study included 229 patients who underwent whole-body MRI as part of a routine health examination and cancer screening. The WB MRIs and radiologic reports were evaluated by a musculoskeletal radiologist, a neuroradiologist, and an abdominal radiologist. The consensus of their findings was characterized into three categories, as follows: suspicion of malignancy (category I); need for follow-up (category II); and no need for follow-up (category III). Any correlations between the abnormal findings and each study group were evaluated using the Mann-Whitney U test and chi-square test.

RESULTS

There were six category I lesions, among which two cases were found to involve malignancy. The most common category II findings were annular tears of the disc (14% of category II findings) and severe disc bulging or protrusion, followed by shoulder bursitis and uterine myoma. The most common category III finding was mild disc bulging or protrusion (47% of category III findings).

CONCLUSIONS

WB MRI can be used in cancer screening and for regular health evaluations. WB MRI not only provides information about potential malignancy, but also provides information regarding nonmalignant abnormalities that require further evaluation.

Two Cases with Incidental Finding of Large Asymptomatic Intradural Lumbar Tumors

Benign lumbar intradural tumors are statistically uncommon and usually present with complaints of back pain with or without radicular neurological complaints. This report involves two separate patients that were found incidentally to have large intradural tumors without any neurologic complaints. In both cases the tumors were discovered when having magnetic resonance imaging (MRI) after minor auto accidents. Neither patient had any pre-existing lumbar or neurologic complaints. The report will review the different regions and types of incidental findings commonly seen on lumbar MRI scans and the need for close follow-up in patients with incidental lesions such as tumors.

Incidental extraspinal findings in the lumbar spine during magnetic resonance imaging of intervertebral discs

Purpose

To calculate the frequencies of incidental extraspinal findings and incidentally detected congenital anomalies or anatomical differences in the lumbar spine on magnetic resonance imaging (MRI) scans of intervertebral discs.

Materials and methods

A total of 379 lumbar spine MRI cases were prospectively investigated in the period spanning from August 2016 to January 2018. Both 1.5 and 0.35 Tesla MRI units (Toshiba and Siemens Medical Systems) were used to examine patients with clinically suspected intervertebral disc abnormalities at three MRI diagnostic centers in Khartoum State, Sudan.

Results

Of the 379(100%) patients, 90(23.7%) patients were presented with incidental findings. Among the incidental findings, 39(10.3%) were renal cysts, 10(2.6%) were retroverted uteri, 5(1.3%) were Nabothian cysts, 4(1.1%) were ovarian cysts, 10(2.6%) were uterine fibroids, 3(0.8%) were endometrial thickening, 11(2.9%) were indicative of hydronephrosis, 4(1.1%) were uncovered prostatic enlargement, 2(0.5%) were atrophic kidney, and 1(0.3%) each was of an ectopic kidney and bladder wall thickening, respectively.

Conclusions

A high percentage of extraspinal pathological findings were detected during MRI lumbar spine scans of intervertebral discs. Thus, it is important to be aware of the high percentage of patients who undergo further evaluation given the presence of unexpected findings, but for whom clinical confirmation of these abnormalities is not obtained.

Management of symptomatic sacral perineural cysts with microsurgery and a vascularized fasciocutaneous flap

Background

The optimal treatment of symptomatic perineural (Tarlov) cysts is controversial. Numerous surgical techniques have been proposed with conflicting results. A series of Tarlov cysts treated with a novel surgical approach is presented.

Methods

Patients with surgically treated symptomatic perineural cysts during 2013-2016 were included. The main indications for surgery were persistent radicular symptoms, pelvic pain, urinary and/ or bowel disturbances. At surgery, the cyst was opened and fenestrated. The cyst wall was then closed with packing, fibrin glue and a pedicled vascularized fasciocutaneous flap rotated into the area for obliteration of the dead space. Patients were followed-up with clinical visits and repeat magnetic resonance imaging (MRI) scans.

Results

Seven consecutive patients were included. The mean age was 50.3 years (range, 25-80 years) and the mean duration of symptoms was 49.3 months (range, 3-130 months). With one exception, all patients had urine and/or bowel problems (incontinence) preoperatively. A lumbar drain was inserted in five patients. The mean follow-up period was 15.4 months. Symptoms improved in 4/7 patients, in two cases no clinical difference was noted while one patient deteriorated. In two cases, a spinal cord stimulator was eventually implanted. In all seven cases, a significantly decreased cyst size was noted on MRI.

Conclusions

Cyst fenestration and the use of a vascularized fasciocutaneous flap successfully obliterated all cysts, with satisfactory clinical efficacy. Larger and comparative studies are warranted to clarify the long-term effects of this surgical technique in patients with symptomatic Tarlov cysts.

Is the routine use of magnetic resonance imaging indicated in patients with scoliosis?

Background

To assess the reliability of the indicators for performing magnetic resonance imaging in patients with scoliosis and assess the incidence of neural axis anomalies in a population with scoliosis referred to a specialist centre.

Methods

A retrospective review of magnetic resonance imaging (MRI) reports of all patients under the age of 18 who underwent a pre-operative MRI for investigation of their scoliosis between 2009 and 2014 at a single institution was performed.

Results

There were 851 patients who underwent an MRI scan of their whole spine with a mean age of 14.08 years. There were 211 males and 640 females. One hundred and fourteen neural axis abnormalities (NAA) were identified. The presence of a left sided thoracic curve, a double thoracic curve, being male nor being diagnosed before the age of 10 were found to be statistically significant for the presence of a NAA. Furthermore, 2.34% of patients were also found to have an incidental finding (IF) of an extraspinal abnormality.

Conclusions

From our series, the reported indications for performing an MRI scan in the presence of scoliosis are not reliable for the presence of an underlying NAA. We have demonstrated that there is a number of intra and extra dural anomalies found on MRI without clinical symptoms and signs. This acts as normative information for this group.

Keywords

Scoliosis; magnetic resonance imaging (MRI); neural axis abnormalities (NAA); adolescent idiopathic scoliosis (AIS).

Urogenital symptoms in women with Tarlov cysts

AIM

To describe the clinical findings and urogenital symptoms associated with sacral perineural cysts (Tarlov cysts).

METHODS

A retrospective chart review including 65 female patients with Tarlov cysts was completed. Clinical findings were collected from a database of subjects seen in our institution's urogynecology and neurosurgery clinics between 2004 and 2015. A statistical analysis was performed to test for any correlation between cyst size or location, and patient symptoms or examination findings.

RESULTS

Tarlov cysts were most commonly located from S2 to S3 (73%), and ranged in size from 1 to 2 cm (55%). Frequently reported symptoms included lower back pain (83%, 95% confidence interval [CI] 0.71-0.91), lower extremity radiculopathy (75%, CI 0.63-0.85), positional pain (62%, CI 0.50-0.73), urinary urgency (54%, CI 0.41-0.66) and urinary frequency (48%, CI 0.35-0.61). Common urodynamic findings included an early sensation of filling (70%), involuntary detrusor contractions (33%), urethral instability (33%) and stress urinary incontinence (33%). A statistical analysis comparing cyst size and location to clinical findings was significant for a correlation between an S2 location and central nervous system symptoms (P = 0.02), larger cyst size and urinary dysfunction (P = 0.05) and smaller cyst size and an early sensation of filling (P = 0.05).

CONCLUSION

Patients with symptomatic sacral Tarlov cysts frequently report pain and neuropathy related to the lower back, pelvis and urogenital system. As compared to the general population, urinary urgency and urodynamic findings associated with urgency were more frequent in our patient sample. These findings suggest that Tarlov cysts may have a clinically significant impact on urogenital function.

Clinical impact of coronal-STIR sequence in a routine lumbar spine MR imaging protocol to investigate low back pain

Aim of this study is to assess the clinical impact of coronal short tau inversion recovery (STIR)-weighted magnetic resonance (MR) sequence, when acquired in a lumbar spine MR imaging protocol, in detecting significant extraspinal imaging findings in patients with low back pain (LBP).We retrospectively evaluated 931 lumbar spine MR examinations of patients with LBP. Extraspinal MR imaging findings were categorized as: probably related to LBP (Category 1), not related to LBP but with relevant implications on patient's care (Category 2), and not related to LBP without significant implications on patient's care (Category 3). For each MR imaging finding was also assessed if it was detectable or not on the conventional sagittal and axial acquisition planes.Of the 931 evaluated MR examinations, 60 (6.4%) showed additional extraspinal MR imaging findings, categorized as follows: 55% (33/60) probably related to LBP (Category 1), 22% (13/60) not related to LBP but with relevant implications on patient's care (Category 2), and 23% (14/60) not related to LBP and without significant implications on patient's care (Category 3). Among categories 1 and 2 (n = 46), the 72% (33/46) of imaging findings were detected only on coronal plane. Coronal-STIR sequence significantly changed patients' diagnostic work-flow in 3.5% (33/931) of cases.Coronal STIR sequence, acquired in a lumbar spine MR imaging protocol to investigate LBP, may aid radiologists in detecting additional extraspinal MR imaging findings that could be related to LBP, addressing to the most appropriate clinical management.

The Prevalence of Incidental and Symptomatic Lumbar Synovial Facet Cysts

STUDY DESIGN

This was a retrospective cohort study from 2 affiliated tertiary care referral centers for spine disease.

OBJECTIVE

The purpose of this article was to assess the prevalence of incidental (ie, asymptomatic) and symptomatic lumbar synovial facet cysts on magnetic resonance imaging. Secondarily, we assessed whether the prevalence increases with age. In addition, we assessed differences in patient and cyst characteristics between asymptomatic and symptomatic facet cysts.

SUMMARY OF BACKGROUND

The prevalence of symptomatic and asymptomatic synovial facet cysts in the lumbar spine has been incompletely established, and, although many studies demonstrate an association with degenerative spine disease, no cumulative increase in prevalence of synovial facet cysts with increasing age has been presented.

METHODS

We included 19,010 consecutive patients who underwent a dedicated lumbar spine magnetic resonance imaging between 2004 and 2015. Our outcome measures were symptomatic and asymptomatic facet cysts. A symptomatic cyst was defined as a cyst with symptoms of radiculopathy on the same side as the cyst.

RESULTS

The overall synovial facet cyst prevalence was 6.5% [95% confidence interval (CI), 6.1-6.8]; 46% of the facet cysts were incidental and 54% were symptomatic. Increased age was independently associated with a higher likelihood of having a synovial facet cyst [odds ratio (per 10 y), 1.24, 95% CI, 1.20-1.29; P<0.001]. Large cyst size (odds ratio, 1.64; 95% CI, 1.23-2.20; P=0.001) and anterior location (odds ratio, 1.39; 95% CI, 1.08-1.79; P=0.010) of the synovial facet cyst were the only factors independently associated with having radiculopathy.

CONCLUSIONS

Approximately 1 in 15 patients have at least 1 synovial facet cyst. Having a facet cyst-symptomatic and asymptomatic-is strongly associated with increased age supporting the theory that degenerative disease underlies its development. Large cyst size and anterior location of the cyst are associated with an increased likelihood of having neurological symptoms.

LEVEL OF EVIDENCE

Level III, diagnostic study.

Symptomatic Tarlov Cysts: Surgical Treatment by Subcutaneous Infusion Port

BACKGROUND

The treatment of Tarlov cysts is challenging and difficult. The objective of our study was to describe the security and efficacy of the subcutaneous infusion port for drainage of symptomatic Tarlov cysts.

METHODS

The authors executed a retrospective review of data from 5 symptomatic Tarlov cysts patients who were treated using a subcutaneous infusion port from June 2014 to July 2017. Numerical Rating Scale scores and the Japanese Orthopedic Association scores of back pain were analyzed. Complications and adverse effects on postoperative days 1, 7, 14, and 28 were also analyzed. The mean follow-up was 12.6 months.

RESULTS

Five adults (3 females and 2 males) who had been symptomatic received a subcutaneous infusion port. After treatment, all patients experienced pain relief and pain alleviation lasted from 1 day to 3 years without complications and adverse effects.

CONCLUSIONS

A subcutaneous infusion port is a useful treatment option for symptomatic Tarlov cysts. When the patients' symptoms returned and the cysts repressurized, we quickly and simply drained the cysts by using the infusion port.

A New Classification for Pathologies of Spinal Meninges, Part 1: Dural Cysts, Dissections, and Ectasias

BACKGROUND: The clinical significance of pathologies of the spinal dura is often unclear and their management controversial.

OBJECTIVE: To classify spinal dural pathologies analogous to vascular aneurysms, present their symptoms and surgical results.

METHODS: Among 1519 patients with spinal space-occupying lesions, 66 patients demonstrated dural pathologies. Neuroradiological and surgical features were reviewed and clinical data analyzed.

RESULTS: Saccular dural diverticula (type I, n = 28) caused by defects of both dural layers, dissections between dural layers (type II, n = 29) due to defects of the inner layer, and dural ectasias (type III, n = 9) related to structural changes of the dura were distinguished. For all types, symptoms consisted of local pain followed by signs of radiculopathy or myelopathy, while one patient with dural ectasia presented a low-pressure syndrome and 10 patients with dural dissections additional spinal cord herniation. Type I and type II pathologies required occlusion of their dural defects via extradural (type I) or intradural (type II) approaches. For type III pathologies of the dural sac no surgery was recommended. Favorable results were obtained in all 14 patients with type I and 13 of 15 patients with type II pathologies undergoing surgery.

CONCLUSION: The majority of dural pathologies involving root sleeves remain asymptomatic, while those of the dural sac commonly lead to pain and neurological symptoms. Type I and type II pathologies were treated with good long-term results occluding their dural defects, while ectasias of the dural sac (type III) were managed conservatively.

Prevalence of simple and complex sacral perineural Tarlov cysts in a French cohort of adults and children

OBJECTIVE

To determine the prevalence of simple and complex sacral perineural Tarlov cysts (TCs) in a cohort of children and adults.

MATERIAL AND METHODS

Retrospective observational epidemiological study assessing 1100 consecutive sacral magnetic resonance (MR) studies, including 100 children and adolescents. All patients underwent 1.5T MR imaging with T1 and T2 weighted image acquisitions in sagittal and axial planes. All perineural cysts affecting the sacral nerve roots S1-S4 were quantitatively and qualitatively assessed.

RESULTS

Two hundred and sixty-three sacral TCs were found in 132 adult patients (13.2%), with a female predominance (68%). None was found in children. The prevalence of TCs increased with age. The average number of cysts per patient was 2.0±1.2 with a maximum of 6 cysts in a single patient. Most of the cysts (87.5%) showed a homogenous central fluid collection and a parietal course of the nerve fibers. Complex patterns were present in 33 cysts (12.5%) within which 28 cysts showed endocystic crossing of nerve fibers and 5 cysts contained internal septations. Seventy cysts (26.6%) eroded the adjacent bone and 13 cysts (4.9%) extended to the pelvis.

CONCLUSION

The prevalence of sacral TCs in our cohort corresponded to 13%, with a female predominance. Interestingly no TCs were found in children or adolescents (<18 years). In relation to the non-negligible percentage of complex cysts with internal septations, or endocystic crossing of nerve fibers, pre-interventional characterization of sacral TCs might help to choose an appropriate procedure in the treatment of rare symptomatic variants.

Ten Important Tips in Treating a Patient with Lumbar Disc Herniation

Lumbar disc herniation is a common spinal disorder that usually responds favorably to conservative treatment. In a small percentage of the patients, surgical decompression is necessary. Even though lumbar discectomy constitutes the most common and easiest spine surgery globally, adverse or even catastrophic events can occur. Appropriate patient selection and effective neural decompression constitute the most important points for better surgical outcomes and avoidance of unpleasant complications. Other important tips include timely performance of magnetic resonance imaging, correct interpretation of scan data, preoperative detection of underlying instability, exclusion of non-discogenic sciatica, determination of the main cause of clinical pathology, avoidance of the wrong side or level, and being sure that the more detailed procedure does not necessarily mean the more effective procedure.

Microsurgical treatment of sacral perineural (Tarlov) cysts: case series and review of the literature

OBJECTIVE

Tarlov cysts (TCs) occur most commonly on extradural components of the sacral and coccygeal nerve roots. These lesions are often found incidentally, with an estimated prevalence of 4%–9%. Given the low estimated rates of symptomatic TC and the fact that symptoms can overlap with other common causes of low-back pain, optimal management of this entity is a matter of ongoing debate. Here, the authors investigate the effects of surgical intervention on symptomatic TCs and aim to solidify the surgical criteria for this disease process.

METHODS

The authors performed a retrospective review of data from consecutive patients who were surgically treated for symptomatic TCs from September 2011 to March 2013. Clinical evaluations and results from surveying pain and overall health were used. Univariate statistical analyses were performed.

RESULTS

Twenty-three adults (4 males, 19 females) who had been symptomatic for a mean of 47.4 months were treated with laminectomy, microsurgical exposure and/or imbrication, and paraspinous muscle flap closure. Eighteen patients (78.3%) had undergone prior interventions without sustained improvement. Thirteen patients (56.5%) underwent lumbar drainage for an average of 8.7 days following surgery. The mean follow-up was 14.4 months. Univariate analyses demonstrated that an advanced age (p = 0.045), the number of noted perineural cysts on preoperative imaging (p = 0.02), and the duration of preoperative symptoms (p = 0.03) were associated with a poor postoperative outcome. Although 47.8% of the patients were able to return to normal activities, 93.8% of those surveyed reported that they would undergo the operation again if given the choice.

CONCLUSIONS

This is one of the largest published studies on patients with TCs treated microsurgically. The data suggest that patients with symptomatic TCs may benefit from open microsurgical treatment. Although outcomes seem related to patient age, duration of symptoms, and extent of disease demonstrated on imaging, further study is warranted and underway.

Sacral perineural cyst mimicking inflammatory low back pain

This case describes a 46-year-old woman with local pelvic and perineal pain, persisting for 2 years at presentation. The pain worsened during the night and morning and was alleviated during daily activities. Low back pain was associated with morning stiffness lasting longer than 2 h. Sometimes, she felt pain and numbness along her left S1 dermatome, without overt bladder or bowel incontinence. Lasegue's sign was negative. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were elevated (35 mm/h and 9.4, respectively) and Mennel's sign was present on both sides, indicating possible inflammation of the sacroiliac joints. However, radiographs of the lumbosacral spine and sacroiliac joints were normal. Magnetic resonance imaging (MRI) revealed a large spinal meningeal cyst in the sacrum (60 × 37 × 22 mm) consisting of multiple perineural cysts. The cyst eroded the surrounding sacral bone structures, narrowed several sacral foramina, and compressed neighboring nerve fibers. MRI findings on sacroiliac and hip joints were normal.

Chemical shift MRI can aid in the diagnosis of indeterminate skeletal lesions of the spine

OBJECTIVES

To evaluate the role of chemical shift MRI in the characterisation of indeterminate skeletal lesions of the spine as benign or malignant.

METHODS

Fifty-five patients (mean age 54.7 years) with 57 indeterminate skeletal lesions of the spine were included in this retrospective study. In addition to conventional MRI at 3 T which included at least sagittal T1WI and T2WI/STIR sequences, patients underwent chemical shift MRI. A cut-off value with a signal drop-out of 20 % was used to differentiate benign lesions from malignant lesions (signal drop-out <20 % being malignant).

RESULTS

There were 45 benign lesions and 12 malignant lesions. Chemical shift imaging correctly diagnosed 33 of 45 lesions as benign and 11 of 12 lesions as malignant. In contrast, there were 12 false positive cases and 1 false negative case based on chemical shift MRI. This yielded a sensitivity of 91.7 %, a specificity of 73.3 %, a negative predictive value of 97.1 %, a positive predictive value of 47.8 % and a diagnostic accuracy of 82.5 %.

CONCLUSIONS

Chemical shift MRI can aid in the characterisation of indeterminate skeletal lesions of the spine in view of its high sensitivity in diagnosing malignant lesions. Chemical shift MRI can potentially avoid biopsy in a considerable percentage of patients with benign skeletal lesions of the spine.

KEY POINTS

• Differentiating benign from malignant skeletal lesions of the spine can be challenging. • Utility of chemical shift MRI in characterising indeterminate spinal lesion is unreported. • This study demonstrates sensitivity 91.7 %, specificity 73.3 %, diagnostic accuracy 82.5 % for CSI. • CSI is useful in differentiating benign from malignant skeletal spine lesions. • Biopsy can potentially be avoided in some patients with benign skeletal lesions.

Chronic Pain in Older Adults

This review summarizes existing evidence relevant to the epidemiology of chronic pain in older adults, age-related differences relevant to pain, pain assessment, and important considerations regarding pain management in later life. Features unique to pain assessment in older adults include the likelihood of multiple diagnoses contributing to chronic pain, the ability of older adults to self-report, including those with mild to moderate cognitive impairment, and recognition that some older adults with cognitive impairment may demonstrate various behaviors to communicate pain. Management is best accomplished through a multimodal approach, including pharmacologic and nonpharmacologic treatments, physical rehabilitation, and psychological therapies. Interventional pain therapies may be appropriate in select older adults, which may reduce the need for pharmacologic treatments.

Extraspinal Incidental Findings on Routine MRI of Lumbar Spine: Prevalence and Reporting Rates in 1278 Patients

Objective

The aim of the present study was to determine the prevalence and reporting rate of incidental findings (IF) in adult outpatients undergoing lumbar magnetic resonance imaging (MRI).

Materials and Methods

Re-evaluation of a total of 1278 lumbar MRI images (collected from patients with a mean age of 50.5 years, range 16-91 years) captured between August 2010-August 2011 was done by a neuroradiologist and a musculoskeletal radiologist. IFs were classified according to organ or system (liver, gallbladder, kidney, bladder, uterus, ovary, lymph node, intestine and aorta). The rate of reporting of a range of IF was examined. The outcome of each patient's treatment was evaluated based on review of hospital records and by telephone interviews.

Results

A total of 253 IFs were found in 241 patients (18.8% of 1278). Among these, clinically significant IFs (n = 34) included: 2 renal masses (0.15%), 2 aortic aneurysms (0.15%), 2 cases of hydronephrosis (0.15%), 11 adrenal masses (0.86%), 7 lymphadenopathies (0.55%), 6 cases of endometrial or cervical thickening (0.47%), 1 liver hemangioma (0.08%), 1 pelvic fluid (0.08%) and 2 ovarian dermoid cysts (0.15%). Overall, 28% (71/253) of IFs were included in the clinical reports, while clinically significant findings were reported in 41% (14/34) of cases.

Conclusion

Extraspinal IFs are commonly detected during a routine lumbar MRI, and many of these findings are not clinically significant. However, IFs including clinically important findings are occasionally omitted from formal radiological reports.