Presentation
Known case of metastatic renal cancer. Now presenting with new onset right leg paresthesia
Patient Data
There is a destructive lytic metastatic lesion involving almost the entire vertebral body of L1, extending into the pedicles, right worse than left, and into the right transverse process. It is associated with a pathologic compression fracture which demonstrates a maximum height loss of 55%. The lesion is causing cortical and endplate destruction.There is bulging of the mass to the spinal canal with soft tissue extension into the epidural space anteriorly and laterally causing severe central canal stenosis. There is also extraosseous soft tissue infiltration into the right paravertebral tissues and into the T12-L1 and L1-L2 neural foramen bilaterally, worse on the right. This is resulting in severe neural foraminal stenosis at L1-L2 on the right.
A left sided nephrectomy, pancreatic metastasis and retroperitoneal lymphadenopathy are noted.
Case Discussion
Pathological fractures occur when normal stresses cause abnormal bones to fracture, whether affected by malignancy, infection or metabolic bone disease.
The majority of bone metastasis affects the axial skeleton in a pattern reflecting the distribution of red marrow. CT signs of malignant vertebral compression fractures include the destruction of cortical or cancellous bone, or the pedicle and an associated epidural or focal paravertebral soft-tissue mass.
Remember that although CT delineates well the osseous integrity, lesions that do not cause significant bone destruction may be missed on CT. MRI better evaluates for these occult lesions and the central canal involvement.
Case co-author: Rehana Jaffer, MD, FRCPC
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