Presentation
Sudden worsening of upper thoracic back pain which radiates to the chest. No extremity weakness. Background history of chronic anemia.
Patient Data
Multiple lobulated paravertebral soft tissue masses at thoracic region.
A few discrete lobulated extradural spinal soft tissue lesions at the posterior aspect of thoracic spinal canal, compressing onto the thoracic spinal cord, worst at T5/T6 levels.
Coarse trabeculated bony skeleton.
Splenomegaly.
Multiple discrete extradural spinal lesions along the posterior aspect of the thoracic spinal canal, which compress onto the thoracic spinal cord and displaces the cord anteriorly. No high signal intensity within the spinal cord on T2 to suggest spinal cord myelopathy. These extradural lesions have similar intensities to the vertebral bone marrow. Minimal enhancement post contrast. No extension of these lesions into the neural foraminae.
Multiple paravertebral lesions (similar intensities to the spinal epidural lesions in all sequences).
Diffuse lower bone marrow signal intensities on both T1WI and T2WI in the vertebrae likely due to iron deposition from repeated blood transfusion. Trabecular pattern of the vertebral body.
Splenomegaly.
Case Discussion
Extradural spinal lesions result in moderate to severe spinal canal stenosis, consistent with clinical history of thoracic radiculopathy. The classical paravertebral masses with the ancillary signs (splenomegaly, coarse trabeculated bony skeleton sclerosis) support the underlying chronic hemolytic anemia. The presence of extradural spinal lesions which have similar intensities to the paravertebral masses and the vertebral bone marrow suggest the diagnosis of extramedullary hematopoiesis. Spinal canal is not the usual typical common sites for extramedullary hematopoiesis.
This patient has thalassemia major disease which requiring regular blood transfusion. They went on to have 10 cycles of radiotherapy and more regular blood transfusions with improving thoracic radiculopathy.
Extramedullary hematopoiesis should be considered as one of the differential diagnosis for spinal epidural lesion in the correct patient groups (chronic hemolytic anemia) in order to avoid unnecessary and risky biopsy.
*Image courtesy of radiologist Dr Norhaslinda Bt Kamiso.
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