0:00

This was a patient who had a curious MRI scan.

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On the pre-gad T1-weighted scan, we noticed that there

0:09

was soft tissue in the anterior epidural

0:11

space adjacent to the L2 vertebra.

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But in addition,

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on the T1-weighted scan, behind the L5-S1 levels

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we also saw soft tissue which extended

0:25

even to the sacral region.

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And you'll notice along the posterior sacral S3

0:31

level, there was similar gray tissue here.

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What are we looking at?

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We're looking at the soft tissue posterior

0:38

to the vertebral body here.

0:39

We're looking at the tissue at the L5-S1 level,

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as well as extending inferiorly.

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And then we see a similar area lower down in the sacral

0:51

region. So this is spanning multiple levels.

0:53

Normally, I'd be concerned about this being a disc herniation

0:57

with some minimal epidural hematoma.

1:00

But in this case,

1:01

with it being more diffuse in the

1:04

lumbar level at multiple levels,

1:07

I have to consider a differential diagnosis.

1:10

Let's look at the post-gadolium enhanced

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scan and see whether that helps us.

1:15

So here we find the pre-gad T1, and

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the post-gad T1-weighted scan.

1:21

There's just a little bit of faint enhancement

1:24

of this tissue in the epidural space.

1:27

It's not very dramatic.

1:29

We have a CT scan also on the patient,

1:32

and that shows similar process in the thoracic

1:35

spine posteriorly. In this case,

1:38

I think it's most important to check the electronic

1:42

medical record for the scenario

1:45

in which the patient is in.

1:47

It happened that this case had acute myelogenous leukemia.

1:51

And given that history,

1:53

we would suggest that this most likely represents

1:56

leukemic infiltration with extraosseous extension, and/or the presence

2:04

of lymphoma. And in point of fact,

2:07

that is what was the final diagnosis on biopsy.

2:11

However, in a different scenario,

2:15

such as a myelodysplastic syndrome or

2:19

a patient who has severe anemia,

2:23

the differential diagnosis would include extramedullary

2:26

hematopoiesis. And in point of fact, despite the clinical history,

2:33

the chest CT was read as extramedullary hematopoiesis

2:38

and the lumbar spine MRI read as leukemia,

2:42

which led to the definitive biopsy showing that,

2:47

yay! The neuroradiologist won and the thoracic

2:51

radiologist was incorrect. So again,

2:54

a differential diagnosis including leukemia, lymphoma,

2:58

extramedullary hematopoiesis.

3:00

And in a different scenario,

3:01

you might even consider, in a patient with multiple

3:04

myeloma, plasmacytoma, for example.