THIS

PANELS, THE

EXHIBIT,

A SELECTION OF TUE NEURORADIOLOGY AND COMPUTED TOMOGRAPHY WAS EXHIBITED AT THE 67TH SCIENTIFIC ASSEMBLY AND ANNUAL MEETING RADIOLOGICAL SOCIETY OF NORTH AMERICA, NOVEMBER 15-20, 1981, CHICAGO, ILLINOIS.

OF

Computed

tomography

in the the sacrum

evaluation of lesions arising in and around

Solomon
Ian Errol Hilton Kelly Soye,

Batnitzky,
M.D. M.D., M.D. M.D.

M.D.

Levine, I. Price, Z. Hart,

Ph.D.

In general, the intraevaluation and

computed

tomography because

is superior

to other

studies to define

for the

of the sacrum extraosseous extent

of its ability precisely.

of a lesion

Introduction
stances, the

Primary
the sacrum

lesions
symptoms

of the
they

sacrum
produce bone

are
are and bowel and area tissue

relatively
nonspecific by inherent contents. conventional barium may involvement

infrequent.
and conventional curvature Using enema routine tomography, studies, In the may not vague.

In many
In addition, radiographic and because diagnostic

in-

is a difficult because

to examine

techniques of the nuclide of the lesions, demonstrated techniques, bone sacrum the

of its angulation of overlying as plain radiography, myelography its surrounding of bone these and soft techniques.

superimposition such and extent using scanning,

radiosmall lesions of large

be missed.

case

be accurately

Health

From the Department of Diagnostic Radiology, Sciences and Hospital, Kansas City, Kansas.
Address reprint requests to Solomon Batnitzky,

The University
M.D., Department

of Kansas

College
Radi-

of

of Diagnostic

ology, The University of Kansas College of Health at 39th Street, Kansas City, Kansas 66103.

Sciences

and Hospital,

Rainbow

Boulevard

500

RadioGraphics

November

1982

Volume

2, Number

Batnitzky,
CT of lesions

et at.

in the sacrum

With imaging around bone and of surgical

the modality

advent has

of computed become available

tomography for the

(CT), evaluation

an

important of lesions

new in and

Introduction

the sacrum.
soft and tissue radiation

CT can
involvement.

accurately
This In the

and
capability case

clearly

delineate
permits accurate

the extent
planning followup lesions,

of

therapy.

of malignant

CT
and

scans The

are extremely
and always

valuable
for

for assessing
tumor basis

the effects
recurrence.

of radiation and
findings

therapy tissue

chemotherapy

detecting on the

specificity
is not

of CT does
possible

not match media

its sensitivity,
of the CT

specific
alone.

diagnosis

The iodinated provides

use of various contrast additional

contrast and

(intrathecal regarding

metrizamide, with the extent

intravenous CT scanning of a lesion.

material, valuable

barium)

in conjunction

information

45 SACRAL

LESIONS

DEMONSTRATED

BY

COMPUTED

TOMOGRAPHY

A.

CONGENITAL 1.
2.

Sacral

Cyst

(3)

Perineural
Fracture Sacrococcygeal Chordoma Giant Cell (2)

Sacral

Cysts

(1)
S

B.
C.

TRAUMA 1. 1. 2. 3.
4. 5.

PRIMARY

TUMORS Teratoma (3) Tumor (2) (3)

Aneurysmal Extraspinal

Bone

Cyst

(1)
(2)

Ependymoma Schwannoma

6. Intrasacral
7. 8.

(1)

Hemangioma (1) Ewings Tumor (1)

Fibroma FROM RECURRENT LESIONS (1) (1) with Lesions Lipomatous (Tuberculosis) Infiltration (1) (2) Disease Ectasia Dysraphism (1) DISTANT RECTAL SITES (16) (3) CARCINOMA

9. Ossifying
D.
E. METASTASES LOCALLY 1. 2. 3. 4. Pagets Dural Spinal MISCELLANEOUS

F.

Inflammatory

Volume

2, Number

November

1982

RadioGraphics

501

Batnitzky,
CT of lesions

et at.
in the sacrum

Normal Anatomy
BASE OF SACRUM SUPERIOR ARTICULAR PROCESS

SACRAL CANAL

DORSAL PELVIC SURFACE SURFACE

PELVIC

VIEW SAGITTAL SECTION

SUPERIOR ARTJCULAR

PROCESS

ANTERIOR SACRAL FORAMEN

POSTERIOR SACRAL FORAMINA

...

I
HIATUS

SACRAL CANAL

POSTERIOR SACRAL FORAMEN

DORSAL

VIEW

COCCYGEAL CORNU

TRANSVERSE SECTION THROUGH

Si

PELVIC,

SAGITTAL, DORSAL, AND TRANSVERSE OF SACRUM AND COCCYX.

VIEWS

Figure
Pelvic, sacrum

i
sagittal, dorsal and coccyx. and transverse views of the

FILUM TERUINALE.

RECTUM

\\

SAGITTAL SECTION MID SACRUM AND

THROUGH PELVIS.

Figure 2 Sagittal section through mid sacrum and pelvis demonstrating the relationship of the sacrum and coccyx to the rectum and bladder.

502

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November

i982

Volume

2, Number

Batnitzky,
CT of lesions

et at.

in the sacrum

Normal Anatomy

Figure 3 Axial CT scans

1. First
2. 3. Ala Sacral

through
segment

the sacrum
(Si)

demonstrating

the normal
5.
6. 7.

anatomy
Posterior
Fifth Greater Piriformis sacral sciatic

of the sacrum.
sacral foramen
(S5) notch segment muscle

sacral
of sacrum canal

4.

Anterior

sacral

foramen

8.

Volume

2, Number

November

1982

RadioGraphics

503

Batnitzky,
CT of lesions

et at.
in the sacrum

Normal Anatomy

Figure 4 CT scans through the lower sacral Open arrow points to the bladder.

and coccygeal

area with

barium

in the rectum

(arrowhead)

and colon

(arrows).

+2

.,._.

Figure

5
of the are clearly lumbosacral seen. area. The spinal canal (arrowheads), sacral

Sagittal (A and B) and coronal (C) reconstruction ala (arrows) and sacroiliac joints (open arrow)

504

RadioGraphics

November

i982

Volume

2, Number

Batnitzky,
CT of lesions

et al.

in the sacrum

Intrasacral
and cating satile and sacral with nature, may reach extradural the

cyst,

anterior
cyst are

sacral
different

meningocele,
variants

intrasacral
of the same

meningocele
condition. They pulcanal

Sacrat Cyst

all are

basically
they

arachnoid
subarachnoid may a large

cysts
produce size. They

arising
erosion may

within
and extend

the
expansion into

sacrum
Because

and
of the

communiof their sacral producing

space

in most

instances.

the

pelvis,

bladder partial

or rectal symptoms. In some instances, agenesis of the sacrum (Figure 6).

they

may

be associated

with

Figure 6A CT scan of a 20 year old male within the sacrum, expanding

who

was admitted

for evaluation

of left

hip

pain,

demonstrates

a large

cystic

lesion

the sacral

canal.

The density

of this lesion

is that of spinal

fluid.

Figure 6B Metrizamide (arrowhead) communicates

Some contrast

myelography reveals the distal end of the to be effaced and displaced to the left. The with the sacral cyst via a thin channel material is seen in the lower portion of the

dural sac dural sac (arrows). cyst (open

arrows).

Volume

2, Number

November

i982

RadioGraphics

505

Batnitzky,
CT of lesions

et at.
in the sacrum

Perineural Sacral Cyst

the

Cysts root

of the sheath

nerve that may

root fill

sheaths with

appear the contrast

as localized, agent

distal during

dilatations myelography.

of

Although the lower

they lumbar

may and

be found upper

at other sacral roots.

levels, These

they cysts

most

commonly cause

occur multiple, localized

in

are frequently

and the majority are asymptomatic. thinning and erosion of the adjacent

They may, on occasion, bone (Figure 7).

. 4#{252}

#{149}t;,_5

Figure 7A CT scan at the Si level

posterior erosion aspect is more

demonstrates of the sacral canal marked on the right

scalloping posteriorly side.

and erosion (arrowheads);

of the the

Figure Lateral
ple,

7B myelogram
sacral

demonstrates
cysts

the multi-

perineural

(arrowheads).

Figure

7C

Lateral laminogram of the sacrum after the myelogram reveals accumulation and retention of the contrast material in the penneural cyst.

Figure 7D CT scan performed

cumulation the region

after

the myelogram
material

reveals

acin

of the contrast of the scalloping.

(arrowheads)

506

RadioGraphics

November

1982

Volume

2, Number

Batnitzky,
CT of lesions

et at.

in the sacrum

Many examination
8).

injuries by

of the conventional

sacrum

and methods

coccyx

are

elusive,

and

radiological (Figure

Trauma

is frequently

unrewarding

Figure 8A Antenopostenior demonstrates This fracture

of the sacrum.

roentgenogram of the sacrum a right-sided fracture (arrowheads). was not visible on the lateral view

.4

I.

0
V

Figure 8B The extent of the fracture is better appreciated with CT, which reveals an undisplaced fracture of the right sacral ala (arrowheads). In many instances, onstrated, an associated hematoma although it is not seen may be demin this case.

Volume

2, Number

November

1982

RadioGraphics

507

Batnitzky,
CT of lesions

et at.
in the sacrum

Sacrococcygeal Teratoma develop

The

Sacrococcygeal

teratomas

are

rare

lesions

found

in one

in 35,000

live They

births. They
from
majority

are, however, multipotential

are Rarely, noted they

the most cells

at birth, may present but

common in Hensens
they

sacral node
may

tumor that
They

in childhood. migrate
in infancy occur 4 times

caudally.
or even more

be found

childhood.

in adulthood.

frequently are visible not invariably,

with coccyx.

in females on plain benign. consists

Benign

than films, Cystic

solid

in males. and these tumors,

components

Sixty

percent

contain tumors often

calcifications are usually, benign,

that although

calcified
are

too, are most

usually

but tumors
Definitive

predominantly tumors

malignant.

treatment tential

of surgical
may

removal of the tumor and extirpation of the recur if incompletely removed and have a powhether 9). a teratoma of the is cystic greater

for malignant transformation. CT can be especially useful in determining important in solid lesions distinction (Figure

or predominantly solid-an likelihood of malignancy Figure 9A

old female reveals a well marginated,

in view

CT scan in a 32 year multiloculated cystic

mass.
w

Figure

9B (below)
--4.

CT scan of the pelvis of a 2 year old female demonstrates extension of a large, mainly solid, malignant teratoma (arrowheads) into the left buttock. The bladder (arrows) and rectum (open arrow) are displaced by the tumof.

.,,

2
1

Figure
2 year

9C
old male with a large, predominantly cystic teratoma extending into the pelvis. i-axial scan, 2 and 3-coronal

reconstruction

scans

and

sagittal

reconstruction

scan.

508

RadioGraphics

November

i982

Volume

2, Number

Batnitzky,
CT of lesions

et at.

in the sacrum

Giant 40 and These

benign, of the

cell tumors often even

capable is extremely

occur those that

rare.

mainly the long initially

in patients bones. appear

that

between histologically

the ages

of 20 and

Giant

Cell Tumor

most tumors,
are spine

involve

There

is a female
Giant most

predilection. to be completely
cell tumor seen commonly

of showing The

malignant few

characteristics. do occur are

in the sacrum,

but fewer

than

5% affect

the sacrum.

Radiologically,

the tumor There 10).

is characterized by a lytic process with little or no bone production. is a wide transition zone from pathological to normal bone (Figure

Figure 1OA CT scan of the sacrum

stroying most of the

of a 53 year old female

sacrum. The rectum

demonstrates
(arrowheads)

a large,
is pushed

expansile
forward

tumor
by

dethe

tumor.

Figure lOB CT scan of the sacrum of a 36 year old female the left posterior iliac wing.

demonstrates

a large,

expansile

mass involving

the left sacral

ala and

Volume

2, Number

November

1982

RadioGraphics

509

Batnitzky,
CT of lesions

et al.
in the sacrum

Chordomas

Chordomas the notochord Approximately and

primary coccygeal tumor group

are relatively and 50% may be found originate

sacrum.

uncommon at any

tumors. point from Chordoma

age

They area;

arise 35%,

from

rests

of

the clivus

to the coccyx. in the clivus common

sacroof the

in the sacrococcygeal column.

The average

15%, in the rest of the vertebral

of the is 56 years,

is the most ratio of two-to-one. or coccyx. cortex

at diagnosis

with and

a male-to-female lesion may soft along year

distant
with

The Later, in any exor

tumor it will direction,

tremely may spread

begins cause

as a locally bone expansion

destructive

of the sacrum through masses adjuvant

break issue with

the bone that may radiation

In one

producing extraosseous large. Surgical resection results

locally in 28%

become therapy The

metastatic (Figure

chemotherapy
recur occurred

in a five
develop
of patients

survival

of 66% of patients.
series, chordomas

tumor

or may

metastases.
sacrococcygeal

11).

:
-.
.S .S S -, N.

---n
:._...L

Figure

hA
old male had a chordoma resected This tiny i cm lesion (arrowheads) one year prior to this scan. Plain was seen on the CT scan and films and tomograms were normal proved to be a recurrent tumor.

This 28 year on followup.

Figure hhB The large size, solid nature

old patient. There is almost

and predominantly
complete destruction

midline

location

of a sacral

chordoma

is exemplified

in this 70 year

of the sacrum.

510

RadioGraphics

November

i982

Volume

2, Number

Batnitzky,
CT of lesions

et at.

in the sacrum

Chordomas
-4

4j:

Figure hlC This 63 year old male had a sacral chordoma diagnosed in i975. The tumor could not be completely removed, and his CT scan in 1979 demonstrates central destruction of the sacrum with extension of the tumor superiorly and laterally out of the sacrum into the right iliac wing (arrowheads).

5.

-:t-U.

,%

Ildi

4:
destruction
tissue mass.

Figure liD Two years later,

iliac wing

a repeat

CT scan demonstrates
along with a huge soft

of most of the right

side of the sacrum

and the superior

on the right

Volume

2, Number

November

1982

RadioGraphics

511

Batnitzky,
CT of lesions

et at.
in the sacrum

Aneurysmat Bone Cyst

subject plasms;

Aneurysmal
of much others

bone
debate believe

cysts
and this

are benign
controversy.

lesions
Some

whose
related

etiology
them

has been
to be The

the
neoage

consider

condition

to be always

to trauma.

group
occurring Although mately

affected
in the the

ranges
second majority

from
and

infancy
third

to the fourth
decades. arise in the There

decade

of life, the majority

predilection. bones, approxi-

is a female of long

of lesions

shafts

three

to four

percent

of cases

are

found

in the

spinal

column,

in-

cluding pansion are the more dural croachment

the sacrum. Radiologically, of the involved bone with commonly on the sac.
in spinal

there thinning the by the results

12).

is a localized rarefaction and exof the cortex. The neural arches bodies. resulting Radiotherapy There may is also be enof used, lesion, in cure. in compression

affected neural
lesions

than canal

vertebral

Curettage

usually

particularly

(Figure

:A

Figure Lateral
mass

i2A tomogram

of the sacrum

involving 52 and S3. This therapy. Histology confirmed

in an 1 1 year old female reveals an expansile lesion was curetted and then treated with radiation the diagnosis of an aneurysmal bone cyst.

Figure
CT scan

i2B
of the sacrum 9 months later demonstrates a lytic cyst. lesion in the left side of the sacrum,

extending
features

across
are those

the midline.
of a healing

There

is considerable
bone

reactive

sderosis

around

the lesion.

The

aneurysmal

512

RadioGraphics

November

i982

Volume

2, Number

Batnitzky,
CT of lesions

et al.

in the sacrum

Hemangioma
often

is a benign, area, age.

involving into do not

vascular is the sacrum,

neoplasm. site however, may portion

The

spinal

column, particularly

most in The and

Hemangioma

the

thoracolumbar middle appearance

pattern extending

of predilection, rarely is characterized

women radiological
medullary frequently disease,

over

The

be involved.
body

of spinal the 13).

hemangioma neural arch.

by a coarse, to Pagets and no cortical

all or the malor

result in vertebral

of a vertebral

In contradistinction
enlargement,

these

tumors

thickening

occurs

(Figure

Figure h3A Conventional tomography of the sacrum of a 58 year old female shows the typical radiological appearance pattern of bone of a right-sided

hemangioma.
trabecular

Note the characteristic

coarse
of

in the region

the tumor.

5 #{149}4

.5

-I
Figure
CT

h3B
also reveals the typical appearance of a hemangioma.

of the sacrum

Volume

2, Number

November

i982

RadioGraphics

513

Batnitzky,
CT of lesions

et al.
in the sacrum

Extraspinal Ependymoma the

the

Spinal

ependymomas

originate

either

from present

the
either

ependymal cell
region.

lining clusters
The latter

of of

central
filum

canal
terminale.

of the spinal
They of the in this may conus area.

cord

or from
always

the ependymal
equina

almost

as intramedullary

tumors

or as tumors

medullaris-cauda

location
ependymomas

is the most
arise

commonly

involved, be found
locations. are found

and

nearly

90%

of primary as well

spinal as in
may locations:

Ependymal heterotopic rarely occur Extraspinal

cells positions. in extraspinal

in the coccygeal
not surprising in two that

ligament

It is, therefore,

ependymomas

ependymomas posterior

characteristic

in the soft tissue

to the sacrum,

or in the pelvis arising

to the lesion the picture

anterior
seen with

to the sacrum location may inthe common ependymoma on the dural

(in
vade

the retrorectal
and destroy cauda

space).
the sacrum. equina

Ependymomas
In contrast ependymoma, as an extradural

in either
extraspinal impinging

subarachnoid appears

on myelography

sac

from

below Complete

(caudad) surgical
survival they tend

either
tends

anteriorly should
to be long,

or posteriorly. be attempted
these systemically tumors more

removal
to metastasize

in all cases.
characteristically frequently

Although
recur than the

postoperative

locally,

and

intradural

variety

(Figure

14).

Figure

h4A

Conventional tomogram of the sacrum in a Si year old female demonstrates destruction of the anterior wall of the sacrum. The posterior sacral wall is thinned but intact. There is also destruction of the inferoposterior portion of the body of Si. Note residual pantopaque in the distal thecal sac outlining the upper pole of the tumor.

Figure

h4B
pole

Lumbar myelogram reveals an extradural defect produced by the upper of the tumor indenting the inferior aspect of the dural sac.

514

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November

i982

Volume

2, Number

Batnitzky,
CT of lesions

et al.

in the sacrum

Extraspinal Ependymoma

5-

.i,,.

Figure

h4C
a large anterior sacral mass destroying the rectum to the right (arrowheads). the anterior wall of the sacrum.

CT scan at the level of Si and 52 demonstrates The mass extends into the pelvis, displacing

,5

5-4

,S

,-

V;

5-

_5_,__..__l...............

Figure
CT scan

i4D
in a 54 year old male with recurrent ependymoma demonstrates a large mass destroying the left sacral ala

( arrowheads).

The posterior

laminectomy

defect

from

the previous

surgery

is also seen.

Volume

2, Number

November

1982

RadioGraphics

515

Batnitzky,
CT of lesions

et at.
in the sacrum

Sacrat Schwannoma
spinal

Although
canal,

schwannomas

are common of these but they into

neoplasms

found

throughout

the of

They

are

the occurrence benign tumors, and may extend

tumors in the sacral canal is uncommon. may produce expansion and erosion space (Figure 15).

the sacrum

the retrorectal

Figure
Lateral a large,

h5A
view of the sacrum of a 28 year expansile lesion of the sacrum. old male demonstrates

Figure

i5B filled thecal

and

CT scan at the L4 and L5 levels demonstrates an extradural mass displacing the metrizamide the right side (arrowheads). At L5 there is a complete block to the flow of the metrizamide, is seen at this level. The spinal canal is also markedly widened at this level.

sac towards

no metrizamide

516

RadioGraphics

November

1982

Volume

2, Number

Batnitzky,
CT of lesions

et at.

in the sacrum

Sacral Schwannoma

Figure i5C CT scan at the Si and S2 levels reveals cortex.

a large,

destructive

mass

within

the upper

sacrum

with erosion

of the posterior

Figure i5D CT scan of the lower

is displaced anteriorly

sacral area demonstrates

to the right side. The

extension
right ureter

of the tumor
is displaced

(arrowheads)
laterally.

into the pelvis.

The rectum

(arrow)

Volume

2, Number

November

1982

RadioGraphics

517

Batnitzky,
CT of lesions

et al.
in the sacrum

Ewings Tumor
between

Ewings
five

tumor and of age.

is a highly 30 years The tumor occur 16).

malignant

bone

neoplasm being predilection extremities

that greatest

affects between for males.

patients five More

five

of age;

the incidence has a distinct in the lower

The

and than
any
percent

13 years 50%
bone
of

tumors of the body may

cases

of these

or pelvis,

although

be involved.

sacrum

is involved

in about

(Figure

:_

Figure i6A Anteroposterior radiograph of a 15 year old male reveals

the right meative side of margins. the

of the sacrum

a lytic lesion in sacrum with per-

Figure h6B CT of the sacrum

medially involves into

demonstrates on the right

aspect

the destructive
There

lesion arising
is an associated

in the right
soft tissue

sacral
mass

ala. The lesion extends

(arrowheads) involving

the body

of the sacrum.

the iliopsoas

muscle

and displacing
joint

the right
(open

ureter
arrowhead).

medially

(arrow).

The

tumor

also

the posterior

of the sacroiliac

518

RadioGraphics

November

i982

Volume

2, Number

Batnitzky,
CT of lesions

et al.

in the sacrum

Ossifying
sinuses, face

fibromas
and mandible.

are

rare
The

lesions
sacrum

involving
is a most

primarily
unusual site

the
for

paranasal
this tumor

Ossifying Fibroma

(Figure

17).

Figure i7A Anteroposterior radiograph of the sacrum of a 49 year old female reveals an irregular, expansile mass in the right side of the sacrum.

SN::.:

Figure

i7B
demonstrate the extent of this lesion, Its sclerotic border is well margin of the spinal canal. No soft tissue component is identified. seen. Note that Histologically the tumor this mass

Computed tomograms has destroyed the right

proved

to be an ossifying

fibroma.

Volume

2, Number

November

1982

RadioGraphics

519

Batnitzky,
CT of lesions

et at.
in the sacrum

Metastatic Neoplasms

Metastatic (16 patients).

neoplasms The Breast Lung Kidney

Colon Cervix

formed of the primary

the largest tumors

group were:

of lesions

in this series

sites

3 2 2 2 2

Unknown Uterus Thyroid

Striated

primary

1 1
muscle

All of the

observed

metastatic

lesions

were

lytic,

with

varying

degrees

of bone

destruction

and

expansion

(Figure

18).

Figure 18A Metastatic anaplastic

thyroid

carcinoma.

520

RadioGraphics

November

1982

Volume

2, Number

Batnitzky,
CT of lesions

et at.

in the sacrum

Metastatic Neoptasms

5_i_.

I
Figure h8B Metastatic squamous cell carcinoma from cervix.

-5

Figure
Metastatic

h8C
renal cell carcinoma.

Volume

2, Number

November

1982

RadioGraphics

521

Batnitzky,
CT of lesions

et at.
in the sacrum

Recurrent Rectal Carcinoma

were The

Three found tumors

patients to have recurred

who

had

previously disease soft tissues

had with of the

resections sacral invasion presacral

of rectal on CT space

carcinomas scanning. invaded and

recurrent in the

the

sacrum

(Figure

19).

;;_S

.#{149}

;,..

Figure
This

19

62 year

old male

had

had

an abdominoperineal

resection

for carcinoma

of the rectum.

CT demonstrates

a large,

expansile,

destructive

lesion

of the lower

sacrum,

secondary

to local recurrence

of the rectal

carcinoma.

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Batnitzky,
CT of lesions

et at.

in the sacrum

Pagets

disease

is a common

disease

of bone

of unknown

etiology

in

Pagets Disease

which and femur,

most

the new tibia,

normal bone spine or may

bone and

architecture The skull. lumbar bones

is greatly most

altered

by bone affected

resorption

apposition.
in the

commonly

are the pelvis, disease occurs may affect only (Figure

commonly

Spinal involvement spine and sacrum. and haphazard

by Pagets The disease

one 20).

bone,

be widespread

in distribution

*
:f

Figure 20A Anteroposterior

male reveals

radiograph
sclerosis and

of the sacrum
thickened

of a 62 year

trabeculae

old fecharacteristic

of Pagets

disease.

i4
S!_#{149}

...

--

...

-S..

#{149}#{149}

S_5

Figure 20B A computed

tomogram

of the sacrum

demonstrates

marked

bony

sclerosis

and thickening

of the cortex.

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November

1982

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523

Batnitzky,
CT of lesions

et at.
in the sacrum

Spinal Dysraphism with Lipomatous Infiltration

Spinal errations. sacrum dysraphism They is the may represents be associated a widespread with myelodysplasia, spectrum of vertebral a congenital disorder ab-

of the formation Fatty monly extend

minale

of the spinal

cord

and

nerves.

The

lower and

lumbar canal

spine

and

commonest tissue in the with intradural

21 and

site of involvement. extradural compartment spinal

22).

spinal cord

is commay terfilum

associated into the

(Figures

dysraphism.

This and into

lipomatous the

material and

compartment

1..

,:
S 4 . ..

Figure
Computed elements.

21A
tomograms show marked widening of the sacral canal with thinning and absence of fusion of the posterior

Figure

2hB
injection of metrizamide, displacement of the dural sac anteriorly and toward the left side is

After an intrathecal demonstrated.

524

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Batnitzky,
CT of lesions

et al.

in the sacrum

Spinal Dysraphism

:-

Figure ZiC CT of the lower

ment.

lumbar

spine

demonstrates

extension

of the lipomatous

material

into

the

intradural

compart-

,S,.&

Figure Sagittal

2iD reconstruction of the lower lumbar and sacral region demonstrates the lipomatous mass in the sacrum, with extension
into the intradural compartment in the lower lumbar area. The

Figure

22

intrathecal metrizamide can be clearly bosacral region (arrowheads).

seen in the lower

lum-

CT scan at the level of Si in a newborn female demonstrates widening of the sacral canal and absence of the posterior elements of the sacrum. Note the density (arrowheads) in the left posterior aspect of the sacral canal representiong lipomatous material. The CT scan is reversed to black on white. This is helpful in distinguishing bone and soft tissue detail.

Volume

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November

1982

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525

Batnitzky,
CT of lesions

et at.
in the sacrum

Dural Ectasia

Dural commonly, are the most

ectasia multiple

with

enlargement may involved

of the spinal The

canal dorsal 23).

is a common and lumbar

finding but more regions

in neurofibromatosis. commonly

This

be localized are involved. sites

to one or two segments,

segments

(Figure

Figure

23A
.-

radiograph of the sacrum in a 12 year old female with neurofibromatosis shows marked widening of the sacral foramina (arrowheads) and widening of the interpediculate distance at L4 and L5.
Anteroposterior

Figure 23B Myelography

of the dural

reveals

dural

ectasia
into two

with the distal

large, laterally

end
sit-

sac widening

uated sacral meningoceles that are responsible plain film findings above.

for the

526

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November

1982

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Batnitzky,
CT of lesions

et at.

in the sacrum

Dural Ectasia

S____S_(

Figure 23C CT at the L5, Si and 52 levels

sacral foraminal enlargement.

demonstrates
Also, note the

widening
large,

of the spinal
pelvic neurofibroma

canal,

together
(arrowheads)

with

the marked
involving the

bladder wall. The open arrow seen in the buttocks area.

points

to the uterus.

Multiple

cutaneous

neurofibromas

(arrows)

are also

Volume

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November

i982

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527

Batnitzky,
CT of lesions

et at.
in the sacrum

Summary These

A wide spectrum examples have by CT important CT and new

it is the

of lesions involving been selected from radiographic that could not extent modality permit
technique

the sacrum has been a series of 45 patients

presented. who were

examined provided Although

diagnosis,
traosseous

and other information does

most valuable

techniques. In many cases, CT not be obtained by other methods. to make

for

usually

one

an exact

pathological
both the in-

demonstrating

extraosseous imaging

of a lesion.

CT has established of lesions

itself in and

as an around

important
the sacrum.

for the evaluation

References

1. Dahlin DC. Bone Tumors: General Aspects and Data on 6221 Cases. Charles C Thomas, Springfield, Illinois, 1978. 2. DeSantos LA, Goldstein HM, Murray JA, Wallace S. Computed tomography in the evaluation of musculoskeletal neoplasms. Radiology 1978; 128:89-94. 3. Morantz RA, Kepes JJ, Batnitzky S, Masterson BJ. Extraspinal ependymomas: Report of three cases. J Neurosurg 1979; 51:383-391. 4. Naidich DP, Freedman MT, Bowerman JW, Siegelman SS. Computerized tomography in the evaluation of the soft tissue component of bony lesions of the pelvis. Skel Radiol 1978; 3:144-148. 5. Rengachary SS, OBoynick P, Karlin CA, Batnitzky S, Price HI. Intrasacral extradural communicating arachnoid cyst: Case report. Neurosurgery 1981; 8:236-240. 6. Rengachary SS, OBoynick P, Batnitzky S, Kepes JJ. Giant intrasacral schwannoma: Case report. Neurosurgery 1981; 9:573-577. 7. Schey WL, Shkolnik A, White H. Clinical and radiographic considerations of saccrococcygeal teratomas: Analysis of 26 new cases and review of the literature. Radiology 1977; 125:189-195. 8. Smith J, Wixon D, Watson RC. Giant cell tumor of the sacrum: Clinical and radiological features in 13 patients. J Canad Assoc Radiol 1974; 30:34-39. 9. Turner ML,. Mulhern CB, Dalinka MK. Lesions of the sacrum: Differential diagnosis and radiological evaluation. JAMA 1981; 245:275-277.

Figure

6B previously

appeared

in Neurosurgery

1981; 8:236-240;

Figures iSA, B
& C

14A, C & previously

D previously appeared in Neurosurgery 1981; 9:573-577, and Figures appeared in The Journal of Neurosurgery 1979; 51:383-391.

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