Elsevier

Magnetic Resonance Imaging

Volume 18, Issue 7, September 2000, Pages 819-824
Magnetic Resonance Imaging

Original contribution
Diagnosis of vertebral metastasis, epidural metastasis, and malignant spinal cord compression: are T1-weighted sagittal images sufficient?

https://doi.org/10.1016/S0730-725X(00)00181-8Get rights and content

Abstract

The objective of this study was to determine whether T1-weighted sagittal images alone are adequate in the diagnosis of vertebral metastasis, epidural metastasis, and malignant spinal cord compression. Ninety-four complete magnetic resonance (MR) studies of the spinal column (a complete study consisting of T1-weighted sagittal images, T2-weighted sagittal images, and T1- and/or T2-weighted axial images) and 94 T1-weighted sagittal images alone (a subset of the complete studies) from 57 consecutive cancer patients over the last 2 years with clinically suspected cord compression were blindly and independently evaluated by four radiologists. The complete MR studies were used as the standard. Overall, the sensitivity of T1-weighted sagittal images alone to vertebral metastasis (87%) was statistically greater than cord compression (70%) (p = 0.05), and statistically greater than epidural metastasis (46%) (p ≤ 0.02). The specificity for cord compression (97%) was greater than the specificity for epidural metastasis (89%) (p = 0.03), and greater than the specificity for vertebral metastasis (83%) (p ≤ 0.02). There was a strong trend for better detection of cord compression overall and better detection of vertebral metastasis in the cervical spine by the most experienced radiologist. Complete studies of the spine are necessary in the diagnosis of vertebral metastasis, epidural metastasis, and cord compression, particularly with less experienced radiologists.

Introduction

Magnetic resonance (MR) imaging is the best available modality for evaluating suspected metastatic spinal disease [1], [2], [3], [4], [5], [6], [7], [8], [9]. There is a lack of universal agreement on methods, and therefore, no standard series of MR sequences of the spine are used consistently from institution to institution [1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15]. While it seems that T1-weighted sagittal images are always included in the initial assessment of suspected spinal cord compression, the utilization of T2-weighted sequences, axial and coronal images, and gadolinium-enhanced images varies among institutions and radiologists [1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15].

Using T1-weighted images, vertebral metastases are well visualized by a reduction in signal of the tumor compared to the bright appearance of normal fatty marrow. The spinal cord, cerebrospinal fluid, and extradural masses are clearly distinguishable structures with this sequence alone. Hence, T1-weighted sagittal images are preferentially obtained in suspected metastatic spinal cord compression and are included with almost all protocols [1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12]. It has been proposed in the past that T1-weighted sagittal images alone are adequate in the routine screening for metastatic epidural tumors [3], [9], [10]; however, no published reports exist which statistically prove the value of using T1-weighted sagittal images alone.

If T1-weighted sagittal images alone can sufficiently provide the pertinent information in cancer patients with clinically suspected evidence of metastasis, then it would be unnecessary in most cases to obtain other images. Doing so would significantly reduce the time and thus the cost required to image the patient. Therefore, the present study was designed to determine the level of agreement between T1-weighted sagittal images alone and T1- and T2-weighted axial and sagittal images with respect to the detection of vertebral metastasis, epidural metastasis, and malignant spinal cord compression with T1-weighted sagittal images alone versus T1- and T2-weighted axial and sagittal images.

Section snippets

Materials and methods

Our study group included 57 consecutive patients examined over the last 2 years with clinically suspected malignant spinal cord compression who had MR evaluation at our institution. There were 31 males and 26 females ranging in age from 22–87 years with a mean age of 49 years. Twenty-three patients had more than one study (17 with 2 studies, 3 with 3 studies, 1 with 4 studies, 1 with 6 studies, and 1 with 7 studies). Gadolinum contrast enhancement was used in 11 of the 94 studies. Including

Results

Of the 94 studies reviewed, there were 72 cases (77%) of vertebral metastasis, 28 cases (30%) of epidural metastasis, and 22 cases (23%) of cord compression. Overall, the sensitivity of T1-weighted sagittal images alone for vertebral metastasis was 87%, for cord compression was 70%, and for epidural metastasis was 46% with the external standard. With the external standard (assume all data henceforth reflect the use of the external standard unless specifically stated otherwise), vertebral

Discussion

Overall, the sensitivity for vertebral metastasis was only 87% with T1-weighted sagittal images alone. T1-weighted sagittal images failed to detect 13% of the metastases that were detectable with the complete image. This low sensitivity is clinically unacceptable, especially considering that the complete image may not show evidence of vertebral metastasis despite biopsy or autopsy positive evidence. It has been cited in the literature that greater than 70% of dying cancer patients examined have

Conclusion

Our study has found that complete studies of the spine, which include both T1-weighted sagittal images and T1- and/or T2-weighted axial images, are necessary in the detection of vertebral metastasis, epidural metastasis, and cord compression. T1-weighted sagittal images alone are not sufficient in detecting these life-threatening and debilitating consequences of malignancy. In this regard, axial images are invaluable.[16], [17], [18], [19], [20], [21]

References (26)

  • M.P Williams et al.

    Magnetic resonance imaging in suspected metastatic spinal cord compression

    Clin Radiol

    (1989)
  • P.M Colletti et al.

    Spinal MR imaging in suspected metastasescorrelation with skeletal scintigraphy

    Magn Reson Imaging

    (1991)
  • H.H Lien et al.

    Magnetic resonance imaging of malignant extradural tumors with acute spinal cord compression

    Acta Radiol

    (1990)
  • R.F Carmody et al.

    Spinal cord compression due to metastatic diseasediagnosis with MR imaging versus myelography

    Radiology

    (1989)
  • E.M Larsson et al.

    Emergency magnetic resonance examination of patients with spinal cord symptoms

    Acta Radiol

    (1988)
  • C.K Colman et al.

    Early diagnosis of spinal metastasis by CT and MR studies

    J Comput Assist Tomogr

    (1988)
  • U Heldmann et al.

    Low-field MR imaging (0.1 T) in patients with clinically suspected acute spinal cord compression

    Acta Radiol

    (1995)
  • U Heldmann et al.

    Frequency of unexpected multifocal metastasis in patients with acute spinal cord compression

    Acta Radiol

    (1997)
  • M.H Li et al.

    MRI of extradural spinal tumors at 0.3 T

    Neuroradiology

    (1993)
  • W.R.K Smoker et al.

    The role of MR imaging in evaluating metastatic spinal disease

    Am J Roentgenol

    (1987)
  • G Sze et al.

    Malignant extradural spinal tumorsMR imaging with GD-DTPA

    Radiology

    (1988)
  • G Sze et al.

    Gadolinium-DPTA in the evaluation of intradural extramedullary spinal disease

    Am J Roentgenol

    (1988)
  • S Sarpel et al.

    Early diagnosis of spinal-epidural metastasis by magnetic resonance imaging

    Cancer

    (1987)
  • Cited by (31)

    • ESTRO ACROP guidelines for external beam radiotherapy of patients with complicated bone metastases

      2022, Radiotherapy and Oncology
      Citation Excerpt :

      MRI can also help to differentiate benign from malignant causes of cord compression [7]. Both T1 and T2 weighted MR images, where possible without and with contrast are recommended [13]. Unenhanced T1 weighted images will demonstrate vertebral and epidural masses, contrast enhanced images are best to demonstrate intradural extramedullary disease and T2 weighted imaging is optimal to detect intramedullary disease [14].

    • Epidural metastasis and spinal cord compression

      2022, Neurological Complications of Systemic Cancer and Antineoplastic Therapy
    • The clinical utility of fluoroscopic versus CT guided percutaneous transpedicular core needle biopsy for spinal infections and tumours: a randomized trial

      2020, Spine Journal
      Citation Excerpt :

      Early accurate diagnosis for spinal tumors and infections has been found to reduce patient morbidity and mortality and to be cost effective [1–4].

    • The Dutch national guideline on metastases and hematological malignancies localized within the spine; a multidisciplinary collaboration towards timely and proactive management

      2018, Cancer Treatment Reviews
      Citation Excerpt :

      MRI is superior to all other imaging modalities when it comes to demonstrating spinal metastases and the compression of the myelum or cauda [31–36]. Both T1- and T2-weighted images are required to demonstrate spinal metastases and, in particular, spinal epidural metastases and/or MESCC [31,37,38]. The deadline for MRI scanning depends on the nature of the patient’s complaints (Table 3); an MRI should be performed within two weeks when the patient has only local back pain, or within 12 h if there is a clinical suspicion of MESCC, to enable treatment to start promptly.

    • Brain and Spinal Cord

      2013, Clinical Imaging: With Skeletal, Chest, & Abdominal Pattern Differentials: Third Edition
    View all citing articles on Scopus
    View full text