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