Discs masquerading as tumours remain a diagnostic challenge

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Deva S Jeyaretna, Southwest Neurosurgery Centre, Derriford Hospital, Plymouth, UK, presented a study at the British Association of Spine Surgeons annual meeting in February, Edinburgh, UK, on distinguishing between sequestered disc fragments and tumours.

Jeyaretna said, “Distinguishing between sequestered disc fragments and tumours remains a diagnostic challenge, but one of paramount importance given that the surgical management of these two clinical entities varies dramatically.”

 

When atypical clinical and imaging findings are present in patients referred for management of spinal tumours, sequestered disc fragments should be considered as a possibility, he told delegates.

 

Jeyaretna presented an analysis of Derriford Hospital’s experience over the last three years in managing this clinical challenge. “To our knowledge, this is the single largest series of patients who presenting as tumours that were later determined to be sequestered disc fragments,” he said

 

Investigators prospectively identified patients who were referred to the regional neurosurgical unit for evaluation of possible spinal tumours whose imaging and clinical findings were atypical. Then, the medical notes, operative records and MR imaging of these patients was reviewed and radiological findings were compared to 15 consecutive patients with nerve sheath tumours.

 

Seventeen patients (eight female, median age: 54 years [range 35–77]) were identified in the three-year period, mean follow-up was 20 months (2–32). All patients underwent MRI and twelve of these underwent contrast MRI. “From the patient’s perspective, they faced the stress associated with a possible diagnosis of a tumour, were referred out of area to the regional neurosurgical unit and had the possibility of an unnecessary operation associated with possible risks of morbidity,” he said.

 

Results

 

  • The most common location (16/17) for discs mimicking tumours in the series was in the lumbar spine.
  • The signal characteristics of the lesions and contrast enhancement were variable.
  • Thirty five per cent of patients were managed operatively and the diagnosis of intervertebral disc made intraoperatively, or on histology. The remainder was monitored clinically and with MR imaging, and required no surgical intervention in the follow up period.

 

The features that favoured a diagnosis of disc rather than tumour included a rapid onset of symptoms and abatement of pain with time. “Radiologically, sequestered disc was more likely if the lesion demonstrated contiguity with the disc space, the presence of other degenerate discs, no foraminal exit widening, and the absence of central enhancement,” said Jeyaretna.

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