Lumbar Soft Tissue Mass
Kevin R. Moore, MD
DIFFERENTIAL DIAGNOSIS
Common
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Lipomyelomeningocele
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Myelomeningocele
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Spinal Lipoma
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Traumatic Spinal Muscle Injury
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Scoliosis
Less Common
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Plexiform Neurofibroma
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Ewing Sarcoma
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Lymphoma
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Venous Vascular Malformation
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Lymphatic Malformation
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Paraspinal Abscess
Rare but Important
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Lytic Osseous Metastases
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Hemangiopericytoma
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Dorsal Spinal Meningocele
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Pseudomeningocele
ESSENTIAL INFORMATION
Key Differential Diagnosis Issues
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Appearance of overlying skin, pertinent clinical information helps limit differential list
Helpful Clues for Common Diagnoses
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Lipomyelomeningocele
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Lipomyelocele = neural placode-lipoma complex contiguous with subcutaneous fat through dysraphic defect, attaching to and tethering spinal cord
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Lipomyelomeningocele = lipomyelocele + meningocele, enlargement of subarachnoid space, displacement of neural placode outside of spinal canal
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Myelomeningocele
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Lumbosacral (44%) > thoracolumbar (32%) > lumbar (22%) > thoracic (2%)
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Low-lying cord on postoperative MR imaging does not always = clinical tethering
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Spinal Lipoma
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Arise from premature separation (dysjunction) of cutaneous ectoderm from neuroectoderm during neurulation
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Profound hypodensity on CT and T1WI hyperintensity characteristic of fat
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Use chemical fat saturation or inversion recovery MR techniques to confirm fat content
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Traumatic Spinal Muscle Injury
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Most commonly from MVA; also athletic injuries, blow from falling objects, direct injury
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Scoliosis
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General term for any lateral curvature of spine
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Dextroscoliosis: Curve convex to right
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Levoscoliosis: Curve convex to left
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Kyphoscoliosis: Scoliosis with component of kyphosis
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Rotoscoliosis: Scoliosis which includes rotation of vertebrae
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Short-curve scoliosis usually has underlying abnormalities; consider congenital, neoplasm, or inflammation
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Helpful Clues for Less Common Diagnoses
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Plexiform Neurofibroma
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Long, bulky, multinodular nerve enlargement is pathognomonic for NF1
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Often affects sacral or brachial plexi
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Ewing Sarcoma
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5% of all Ewing tumors in spine (sacrum > rest of spine)
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Usually in adolescents or younger adults
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Permeative lytic lesion of vertebral body or sacrum involving vertebral body before neural arch
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Contiguous spread along peripheral nerves from spine or sacral primary but may originate in soft tissues
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Lymphoma
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Lymphoreticular neoplasms with wide variety of specific diseases and cellular differentiation
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Multiple types demonstrate variable imaging manifestations
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Venous Vascular Malformation
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Lymphatic Malformation
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Congenital trans-spatial vascular malformation of lymphatic channels present from birth
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Typically minimal to no enhancement, although septations may enhance, especially if previously inflamed
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Fluid-fluid levels strongly suggest diagnosis
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May grow rapidly if hemorrhage or concurrent viral infection
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