Sacral Cyst

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    T HIS E XH IB IT , A SELECT ION O F TU E NEURORAD IO LO GY AND COM PU TED TOMOGRAPHYPAN EL S , W A S EXH IB IT ED A T THE 67TH SC IEN TIF IC A SSEM BLY AND ANNUAL M EETIN G OF

    T HE RA DIO LO GIC AL SOC IETY O F NO RTH AM ER ICA , N OVEM BER 15-20 , 1 981 , C H ICAGO ,ILL INOIS .

    C om pu ted tom ography in th eeva lua tion o f le s ion sa r is in g in and around th e sa crum

    So lomon Ba tn i t zky , M .D .Ian Soy e , M .D .E rro l L ev ine , M .D ., P h .D .H ilton I. P ric e , M .D .K elly Z . H art, M .D .

    In gen era l, com pu ted tom ography is su perio r to o th er stud ies fo rth e eva lua tion o f th e sa crum becau se o f its a b ility to defin e th ein tra - an d ex tra osseou s ex ten t o f a les ion p rec ise ly .

    In trod uc tion P rim ary le sion s o f the sac rum are re la tive ly in freq uen t. In m any in -stances, the sym ptom s they p ro duce a re n onsp ec if ic an d vagu e. In add itio n ,the sac rum is a d ifficu lt b one to exam ine by conv en tiona l rad io g rap h ictechn iq ues b ecause o f its ang u la tion an d inh eren t cu rva tu re and becau seo f the su pe rim pos itio n of ove rly ing b ow e l con ten ts . U s ing ro u tine d iagn ostictechn iq ues, such as p la in rad iog raph y , co nven tio na l tom og raph y , rad io -n uc lide bon e scann in g , m ye log raphy and b arium enem a stud ies , sm all le sion so f th e sac rum and its su rro und ing a rea m ay be m issed . In the case o f largele sion s, the ex ten t o f bon e an d so ft tissue invo lvem en t m ay no t be accu rate lydem on stra ted us ing th ese techn iques.

    F rom the D epa rtm en t o f D iag nos tic R ad io log y , T he U nive rs ity o f K ansas C o lleg e o fH ea lth S ciences an d H o sp ita l, K ansas C ity , K an sas.

    A ddress rep rin t requests to S o lom on B atn itzk y , M .D ., D ep ar tm en t o f D iagnos tic R ad i-o lo gy , The U niv ersity o f K an sas C o llege o f H ea lth S c iences and H osp ital, R a inbow Bou lev arda t 39 th S tree t, K ansas C ity , K ansas 66 103 .

    500 R ad ioG rap h ic s N ov em ber 1982 Volum e 2 , N um ber 4

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    B atn itzky , e t a t .CT of le sion s in th e sacrum

    W ith the adven t o f com pu ted tom ograp hy (C T ), an im portan t new In trodu c tionim ag in g m oda lity h as becom e ava ilab le fo r the eva lua tion o f le sion s in andaround th e sac rum . C T can accu ra te ly and c lea rly d el ineate the ex ten t o fbone and so ft tissue inv o lvem en t. T h is capab ility p erm its accu rate p lann in gof su rg ica l and rad ia tio n th erapy . In th e case o f m alig nan t les ions, fo llow upCT scans are ex trem e ly v alu ab le fo r a sse ss ing the e ffec ts o f rad ia tio n th erapyan d chem o the rapy and fo r de tectin g tum or recu rren ce .

    The sp ecific ity o f C T do es n o t m atch its sen si tiv i ty , an d sp ec ific tissued iagno sis is no t alw ays po ssib le on th e basis o f th e CT fin d ing s alo ne .

    The u se o f va riou s co n tra s t m ed ia (in tra thecal m etriz am id e , in trav en ou siod ina ted con tras t m ateria l, and ba rium ) in con ju nc tion w ith CT scan n in gp rov ide s ad d itio na l v a luab le in fo rm a tio n rega rd in g the ex ten t o f a les io n .

    45 SACRAL LES ION S D EM ONSTRA TED BY COM PU TEDT OMOGRA PHY

    A . CONGEN ITAL1. S acra l C y st (3 )2. Pe rineu ral S acra l C ys ts (1 )

    B . T RAUMA S1 . F rac tu re (2 )

    C . PR IM ARY TUMORS1. S ac ro co ccyg ea l T e ra tom a (3 )2 . C hordom a (3 )3 . G ian t C e ll Tum or (2 )4. A neu ry sm a l B one C y st (1 )5. Ex trasp ina l E pendym om a (2 )6 . In trasacra l S chw annom a (1 )7. H em ang iom a (1 )8. Ew in gs T um o r (1 )9 . O ssify ing F ib rom a (1 )

    D . M ETA STA SES FROM D ISTANT S ITES (1 6)E . LO CALLY RECURREN T RECTA L CARC INOM A (3)F . M ISC ELLANEOU S LES ION S

    1 . P age ts D isease (1 )2 . D ura l E c ta sia (1 )3 . S p ina l D y sraph ism w ith L ipom ato us In filtra tion (2 )4. In f lam m ato ry L esions (Tube rcu lo sis) (1 )

    V o lum e 2 , N um ber 4 N ov em ber 19 82 R ad ioG rap h ic s 501

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    Ana t omyBASE O F SACR UM

    PELV IC V IEW

    S U P E R I O RAR TJ C UL AR P RO C ES S

    SUPERIORA RT IC ULAR PRO CESS

    SACRALCANAL

    DORSALP EL VI C SU R FA CESURFACE

    SAGITTALSECTION

    ANTERIORSACRALFORAMEN

    SACRAL POSTERIORC AN A L SA CR A L

    FORAMENTRANSVERSESECT IONTHROUGH S i

    POSTERIORSACRAL FORAMINA ..

    DORSAL V IEW

    I H I A T U SC O C C Y G E A LC O R N U

    R ad ioG raph ics N ov em be r i98 2 V olum e 2 , N um ber 4

    No rma l

    502

    B a tn itzk y , e t a t.CT o f le sion s in th e sacrum

    PELV IC , SAG ITTA L, DORSAL , AND TRANSVERSE V IEW SOF SACRUM AND COCCYX .

    F igu re iPe lv ic , s ag ittal, do rsa l an d transve rse v iew s o f thesac rum and coccyx .

    FILUMTERU INALE.

    R ECTUM \\ S

    SAG ITTAL SECTION THROUGHM ID SACRUM AND PELV IS .

    Figu re 2S ag ittal s ec tion th roug h m id sac rum and pe lv isdem on stra tin g the re la tionsh ip o f the sac rumand coccyx to th e rectum and b lad de r.

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    B atn itzky , e t a t .

    V o lum e 2 , N um ber 4 N ovem ber 1982 R ad ioG raph ics 503

    CT o f le sion s in th e sacrum

    F igu re 3A x ia l C T scans th ro ug h th e sac rum dem onstra tin g the n o rm al an atom y o f the sac rum .1. F irst sac ra l segm en t (S i) 5 . P o ster io r sacra l fo ram en2 . A la of sac rum 6. F ifth sac ra l segm ent (S5 )3 . Sacra l cana l 7 . G rea te r sc iatic no tch4 . A n te r io r sac ra l fo ram en 8 . P irifo rm is m usc le

    No rma lAn a t omy

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    A

    a 2

    .,._.

    b+- V

    C

    R ad ioG raph ics N ovem be r i98 2 V olum e 2 , Num ber 4

    No rma lAn a t omy

    B a tn itzk y , e t a t .C T of lesio ns in the sa crum

    F igu re 4C T scans th ro ug h the low er sac ra l and co ccy geal are a w ith b arium in the re c tum (arrow h ead ) an d co lon (arrow s).O pen a rrow po in ts to the b ladd er.

    F ig u re 5Sag itta l (A and B ) and co ro na l (C ) reco nstruc tion o f the lum bosac ral a rea . Th e sp in al can al (arrow h ead s), s ac rala la (a rrow s) an d sac ro ilia c jo in ts (open a rrow ) a re clea rly seen .

    504

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    CT o f le sio ns in the sacrum

    In tra sac ra l cy st , an terio r sa c ra l m en in go ce le , in trasacra l m en ing oceleand sac ral ex tradu ra l cys t a re d iffe ren t v a rian ts o f the sam e cond ition . T heya ll are b a sica lly ara ch no id cys ts aris in g w ith in th e sac rum and com m un i-ca ting w ith th e suba rachn o id space in m o st in s tan ces. B ecau se o f the ir pu l-sa tile na tu re, they m ay prod uce erosio n and ex pansio n of the sac ra l cana lan d m ay reach a la rge size . T hey m ay ex tend in to the p elv is , p rod uc ingb lad de r o r re cta l sym p tom s. In som e in s tan ce s , th ey m ay b e asso cia ted w ithp art ia l ag en es is o f th e sac rum (F igu re 6 ).

    Sac ra tCys t

    B atn itzky , e t a l.

    V o lum e 2 , N um ber 4 N ov em ber i9 82 R ad ioG raph ic s 505

    F ig u re 6ACT scan o f a 20 yea r o ld m a le w ho w as adm itted fo r eva lua tion of lef t h ip pa in , d em onstra tes a la rg e cy stic le sio nw ith in th e sac rum , exp an d in g the sacra l c an al . T h e dens ity o f th is le s ion is th at o f sp ina l flu id .

    F igu re 6BM etrizam ide m yelo g raph y reveals the d is ta l en d o f the d u ra l sac(a rrow h ead ) to be effa ced and d isp la ced to th e le ft. T he d ura l sa ccom m un ica te s w ith th e sac ra l cy st v ia a th in ch an ne l (a rrow s).Som e con tra st m a te ria l is seen in the low e r po rtion o f th e cys t (o pena r rows ) .

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    .

    4 # {252 }

    #{14 9}t;,_ 5

    F igu re 7CL ate ral lam in og ram o f the sac rum afte r them ye log ram rev ea ls accum ula tion and re-ten tio n of the con tras t m a te ria l in th e pen-neu ra l cyst.

    506 R ad ioG raph ics N ovem be r 1 982 V olum e 2 , N um be r 4

    B a tn itzk y , e t a t .CT o f le sions in the sa crum

    Pe r ineu ra lSac ra lCys t

    Cysts o f the ne rve roo t shea ths ap pear a s localized , d is ta l d ila ta tions o fthe ro o t shea th tha t m ay fill w ith th e con tra st ag en t du ring m ye log raph y .A ltho ugh they m ay be fo und a t o the r leve ls , th ey m o st comm on ly occu r inthe low e r lum ba r an d upp er sac ra l roo ts. T h ese cys ts a re freq uen tly m ultip le ,and th e m a jo rity a re a sym ptom a tic . T hey m ay , on occas io n , c au se localizedth inn ing and ero sion o f th e ad ja cen t bo ne (F ig u re 7) .

    F igu re 7ACT scan at the S i lev el d em ons tra te s scallo p ing and e rosio n o f thepos ter io r a spec t o f the sac ra l cana l p oste rio rly (a rrow heads); thee ro sion is m o re m arked on the righ t side .

    F igu re 7BL a tera l m y elo g ram dem on stra te s the m u lti-p le , pe rin eu ra l s ac ral cys ts (arrow head s).

    F igu re 7DCT scan pe rfo rm ed a fte r the m yelo g ram revea ls a c -cum ula tion of the co n tras t m ate r ial (a rrow heads) inth e reg io n of th e sca llop in g .

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    .4

    I.

    S 0V

    V olum e 2 , N um ber 4 N ovem ber 1982 R ad ioG raph ics 507

    B a tn itzk y , e t a t.CT of le sio ns in the sacrum

    M any in ju r ie s o f the sacrum and coccyx are e lusiv e, and rad io lo g ica lex am ina tion by conv en tiona l m e thod s is frequen tly unrew ard ing (F ig u re8).

    T r a uma

    F igu re 8AA nten o