Preliminary Diagnosis: Spinal metastases
I. What imaging technique is first-line for this diagnosis?
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MRI imaging of the spine with IV contrast.
II. Describe the advantages and disadvantages of this technique for diagnosis of spinal metastases.
Advantages
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Able to localize the exact area of metastatic involvement and predict any neurological abnormalities (sensory, motor, and autonomic).
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Able to evaluate for secondary complications, such as intraspinal hemorrhage, syrinx formation, adjacent osseous spread of disease, etc.
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Does not utilize ionizing radiation, unlike radiographs.
Disadvantages
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Expensive.
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Time-consuming.
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Requires significant patient cooperation to limit motion artifact.
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IV contrast requires that the patient have good renal function (i.e., a GFR at least > 30)
III. What are the contraindications for the first-line imaging technique?
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MR imaging is contraindicated in patients with non-MR compatible metallic hardware or foreign bodies.
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Gadolinium contrast is contraindicated in patients with a GFR ≤ 30.
IV. What alternative imaging techniques are available?
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CT with and without contrast
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CT spinal myelography
V. Describe the advantages and disadvantages of the alternative techniques for diagnosis of spinal metastases.
CT with and without contrast
Advantages
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Much faster imaging modality than MR and may be performed on more sick, less responsive patients.
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Requires less patient cooperation and is less susceptible to motion artifact.
Disadvantages
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Exposure to ionizing radiation.
CT myelography
Advantages
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Can be used in patients with contraindications to MRI.
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Provides a more detailed evaluation of the spinal cord than CT.
Disadvantages
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Exposes a patient to the risks associated with an invasive procedure.
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Exposes the patient to ionizing radiation.
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May miss some lesions (40-50%).
VI. What are the contraindications for the alternative imaging techniques?
CT with and without contrast
Contraindicated in pregnant patients, especially during the first two trimesters.
Relative contraindication for contrast in patients with renal failure.
Relative contraindication for contrast in patients with contrast allergy.
CT myelography
Contraindicated in pregnant patients, especially during the first two trimesters.
Contraindicated in patients with a hypercoagulable state, i.e., platelets < 50,000; INR > 2.0.
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