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Ellenberg, Maury MD; Ilechukwu, Ifeyinwa MD
From the Department of Physical Medicine and Rehabilitation (ME) and the Division of Occupational and Environmental Medicine, Department of Family Medicine (II), Wayne State University, Detroit, Michigan.
A 52-yr-old woman was awakened from her sleep with the abrupt onset of severe left buttock and anterior thigh pain associated with right anterior thigh numbness. She received a corticosteroid Dosepak with considerable improvement in her pain, which then recurred several days after discontinuation of the steroids. Physical examination 2 wks after the initial onset showed 4/5 strength in the left hip flexors and a positive femoral stretch test. Reflexes were 2+ and symmetric, and other muscle strength was intact. Magnetic resonance imaging revealed an L2-3 anterior and left extradural defect with superior migration encroaching on the left L2-3 neural foramina (Fig. 1). The unusual location and configuration of the lesion prompted a gadolinium-enhanced magnetic resonance examination (Fig. 2). With the gadolinium scan, the lesion enhanced intensely and homogeneously, leading to primary diagnostic consideration of a benign spinal tumor such as a schwannoma or meningioma. She underwent a lumbar laminectomy with removal of the mass. Pathology revealed hyaline and fibrocartilage with myxomatous degeneration compatible with intervertebral disc. No tumor tissue was found. The patient improved and became completely asymptomatic during the following 4 wks.
Gadolinium enhancement is used to distinguish postoperative scar or tumor from disc herniation on magnetic resonance imaging. Disc material is avascular and, consequently, does not generally enhance with gadolinium. When enhancement occurs, it is almost always ring enhancement. 1 There are very few reported cases of homogeneous lumbar disc enhancement with gadolinium on magnetic resonance imaging. 2,3 This case demonstrates that homogeneous enhancement can result from acute disc herniation and not only from tumor tissue.
This report emphasizes that, despite recent technical advances, clinical and course presentation and repeated careful examination are often the best guides for directing the management of patients with spine-related problems.
© 2004 Lippincott Williams & Wilkins, Inc.
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