Spine lesion

[Son Nguyen]

Hi Birdies!

21yr old female presented today right lower/mid back pain FI. Asked the patient to show me where she was symptomatic. At the level of right L1 there was a paraverterbal cystic lesion with surrounding echogenicity. She was focally tender over this location with probe pressure. I had a quick look at the CT images, couldn’t see anything too obvious at this location. Any ideas what this may be?

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[Stephen Bird]

It is an interesting appearance and you have eagle eyes to find it.

The para spinal muscles are ugly on ultrasound and look very fibrous, but you have done well.

Anatomically it is in the multifidus muscle.

I am not sure what the appearance represents,

Could it be some oedema in the muscle, partial tear injury ?

What was the clinical scenario (acute onset, trauma, stretching injury, sport, occupation etc)

I will ask Ray Chen to take a look at this case as he is the master of spine ultrasound.

I will be interested in his comments.

Steve.

[Son Nguyen]

No hx of trauma or physical activities to explain injury.

She’s is reproducibly tender right on this location. I was thinking there was possible oedema. Like most I’m quite foreign to back ultrasound. The referral did say right back pain ?iliopsoas bursitis, so I wasn’t expecting too much to be honest.

She does have a slight curvature of the spine (see x-ray)

Ct results showed nothing at L1:
Conclusion:
* There is a broad-based posterior disc bulge at L4-5 impinging upon the thecal sac and the preemergent L5 nerve roots.

The patient did mention the GP was thinking about doing an MRI as well.

I will chase up the MRI result if she ends up getting scanned.

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[Ray Chien-Hsing Chen]

I agree this Steve that it might be muscle lesions, but relative rare.

Another idea is there might be a cystic lesion from facets joint, secondary to trauma or degeneration.

Sometimes, it cause symptoms.

MRI scan will prove the answer.

[Stephen Bird]

Thanks Ray,

Yes, a good thought about a facet joint lesion.

I wonder if we can organise an MRI,

I have not seen anything quite like this before.

I will keep you posted.

Steve

[Stephen Bird]

Yes, not too much there, just some mild scoliosis.

Keep your eye out for the MRI,

Some muscle oedema is looking like the best option.

Steve

[Son Nguyen]

Patient finally had an MRI the other day.

Conclusion:
There is a paraspinal mass at the level of T12 and L1 with probable intra-osseuous involvement. This is a resulting in compression of the conus to a significant degree. It extends over a length of 6.5cm in its epidural length. Another focus with likely bony involvement is seen in the epidural posteriorly to L4/5. Anterior mediastinal mass. Impression of marrow replacement ?red marrow ?infiltrative. A lymphoproliferative process seems most likely.

I’ll try to chase up images at some point.

Son

[Stephen Bird]

You have done very well Son,

Just goes to show the value of listening to your patient and always putting the transducer on exactly the location of the symptoms even if you are sceptical that you will see anything.
In the end it sounds like a serious pathology, especially at the very young age of 21.
I think you have done this patient a great service as it is unlikely it would have been escalated to an MRI without your excellent observation and recommendation.
This gives the patient the earliest possible diagnosis and best outcome probability.
This is pure ultrasound at its best.

You are to be congratulated.

Great work Son,

Steve.

[Son Nguyen]

Thanks Steve,

Doesn’t sound great for the patient. I appreciate the words of encouragement.
You’re an important role model for me.

Son

[Stephen Bird]

You have done well here,

This is the sort of pathology that sees the sonographer but the sonographer doesn’t see the pathology.

I have never seen a pathology like this one.

Wonder how many have seen me !!

Keep up the great work,

Steve.

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