Spinal Lesions Differential Overview

See Spinal Lesions Differential Imaging

Spinal Masses
- Extradural
  - Neoplastic
    - Secondary
      - Metastasis
        Multiple lesions, associated with known primary malignancy:
        Breast, prostate, lung, kidney, thyroid, lymphoma/myeloma.
    - Primary
      - Malignant
        
        Chondrosarcoma
        Arising from bone, may see calcifications.
        
        Osteosarcoma
        Aggressive bone destruction, soft tissue extension.
      - Benign
        
        Osteochondroma
        Bony protrusion with cartilaginous cap.
  - Trauma
    - Post-traumatic haematoma
      History of trauma, acute onset of symptoms.
  - Infection
    - Spinal epidural abscess
      Associated with fever, elevated WBC, midline posterior location.
- Intradural Extramedullary
  - Neoplastic
    - Secondary
      - Extra-CNS
        
        Rare compared to extradural metastases:
        Melanoma, breast, lung, lymphoma.
      - CNS
        
        High-grade astrocytoma, medulloblastoma, germ cell tumours, choroid plexus neoplasm, ependymomas.
    - Primary
      - Malignant
        
        Malignant peripheral nerve sheath tumor (MPNST)
        Arising from nerve sheath, aggressive appearance.
      - Benign
        
        Neurofibroma
        Well-circumscribed, may be multiple in neurofibromatosis type 1.
        
        Schwannoma
        Well-circumscribed, homogeneous enhancement.
        
        Meningioma
        Dural tail sign, intense homogeneous enhancement.
  - Autoimmune
    - Chronic adhesive arachnoiditis
      Clumping or “beading” of nerve roots on MRI.
  - Infection
    - Leptomeningitis
      Diffuse leptomeningeal enhancement, often with associated hydrocephalus or cranial nerve involvement.
- Intradural Intramedullary
  - Neoplastic
    - Secondary
      - Rare
    - Primary
      - Potentially Malignant
        
        Ependymoma
        Most common
        
        Astrocytoma
        Diffuse, expansile, often involves multiple vertebral segments.
      - Benign
        
        Myxopapillary ependymoma
        Located in the filum terminale, cystic.
        
        Haemangioblastoma
        Often cystic with a mural nodule, associated with Von Hippel-Lindau disease when multiple.
        
        Lipoma
        
        Epidermoid Cyst
  - Demyelinating
    - Multiple sclerosis
      Patchy, ovoid lesions, especially in cervical cord; may see other typical MS plaques in the brain.
    - Acute Disseminated Encephalomyelitis (ADEM)
      Monophasic; follows viral infection or vaccination.
  - Vascular
    - Cavernous malformation
      Popcorn appearance with mixed signal intensities, representing different ages of haemorrhage.
  - Trauma
    - Cord contusion
      Secondary findings of spinal fractures, marrow oedema, ligamentuous and soft-tissue injury.
  - Metabolic
    - Subacute combined degeneration
      B12 deficiency and pernicious anaemia or malabsorption (Corhn disease).

Explanatory notes

Extradural (or Epidural) Space: This is the space between the inner surface of the vertebral bones and the outermost dural covering of the spinal cord. It contains fat, blood vessels, and the spinal nerve roots. It’s bounded by the bony vertebrae externally and the dura mater internally.
Intradural Extramedullary Space: Located within the dura but outside the spinal cord. It houses the cerebrospinal fluid (CSF) and cauda equina nerves in the lumbar spine. This space is between the dura mater and the pia mater, which tightly adheres to the spinal cord.
Intradural Intramedullary Space: This doesn’t refer to a “space” in the traditional sense. Instead, it denotes lesions that are within the substance of the spinal cord itself. The spinal cord is enveloped by the pia mater, and any lesion inside this boundary is intramedullary.

Updated on 5 February 2024

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