MRI with nerve sheath thickening - anyone seen this before?

[oneforfighting]

50+yo with new axial only low back pain of several months. Born in Southeast Asian country.
I treated for facetogenic pain. Did MBBs and had ~70% relief but self-report limited by language/cultural barrier. In any case, pt decided to not move forward with RFA since was still "doing good".

MRI L-spine showed nonspecific nerve sheath thickening. Tried a lit search, couldn't come up with much. Radiologist said it could be seen in mixed connective tissue diseases.
Anyone seen this before? Would appreciate general thoughts and necessary workup.

ETA - hypothetically, would you do an epidural on this patient?

MRI L-spine:

T1

T2

STIR

T1 axial

T2 Axial

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[SSdoc33]

 

[SSdoc33]

never seen it so diffuse like this. i have seen bilateral or at 1 or 2 levels. just axial, though, so nothing to be done

 

[MitchLevi]

Not sure I'd work this up TBH. If his back is better and he's otherwise doing okay, I'd forget about this.

 

[ErrantWhatever]

I saw that once but the pt had a hx of Neurofibromatosis.

 

[oneforfighting]

I saw that once but the pt had a hx of Neurofibromatosis.

only has h/o high cholesterol so this was incidental

 

[lobelsteve]

O epidural for axial low back pain. looks genetic. Get mri on his siblings. (Just kidding)

 

[Orin]

I've seen some peripheral nerve sheath tumors but they've generally got NF history. Sometimes NF isn't diagnosed until late, and there are some folks with "schwannomatosis" which just shows off as multiple schwannomas without skin findings.

I would consider evaluating them with a repeat MRI w/ and w/o contrast, but your radiologist should be able to tell you what to do here.

 

[oneforfighting]

I've seen some peripheral nerve sheath tumors but they've generally got NF history. Sometimes NF isn't diagnosed until late, and there are some folks with "schwannomatosis" which just shows off as multiple schwannomas without skin findings.

I would consider evaluating them with a repeat MRI w/ and w/o contrast, but your radiologist should be able to tell you what to do here.

How would MRI w/ & w/o guide management?
Now that I think about it, I think I saw something around his sacrum/buttock area that could be consistent with a neurofibroma. Never asked him in detail regarding other areas of skin lesions.
Is there a specialist I should be sending this patient to for workup? Neurologist? Academic center?

 

[oneforfighting]

I saw that once but the pt had a hx of Neurofibromatosis.

Is there a specialist I should be sending this patient to for workup? Neurologist? Academic center?

 

[Orin]

How would MRI w/ & w/o guide management?
Now that I think about it, I think I saw something around his sacrum/buttock area that could be consistent with a neurofibroma. Never asked him in detail regarding other areas of skin lesions.
Is there a specialist I should be sending this patient to for workup? Neurologist? Academic center?

Yes, a neurologist can normally be of help but some of them aren't familiar with this stuff. Academic centers tend to have someone.

If your radiologist has specialized neuroradiology expertise, that's also fair to get their insights, but generally these are watched over the course of months early on to years later.

Contrast I'm told can help to identify the malignant vs benign nature of a PNST, although there are other ways to do it based on MRI sequences too.

 

[CB1Antagonist]

d/dx also includes CMT and CIDP

 

[Clean7795]

Probably CMT/CIDP or less likely a peripheral nerve sheath tumor syndrome as you have already all mentioned.

The patient should probably have a tertiary center referral for neurology to monitor it, and also so the MRIs are interpreted by a neuroradiologist. Ordering another MRI is probably a waste since the neurologist will order one from their own radiology department anyway.

 

[oneforfighting]

Thank you all for your input. I will refer him out to a tertiary care center for evaluation and monitoring.

 

[JBM16BYU]

Very interesting case. My first thought was peripheral nerve sheath tumor, but with it being widespread it is likely something more systemic I agree, like CIDP/CMT which was brought up above. There are other causes of hypertrophic nerve roots too that can be sorted out by Neurology. Referral to Neurology (more likely in a tertiary referral center) would be beneficial for patient. Will likely be followed up with EMG/NCS, potential peripheral nerve biopsy (likely sural nerve), and maybe genetic screening.

 

[maxxor]

MSK rad.

This looks like NF1.

Radiology Quiz 5474 | Radiopaedia.org

radiopaedia.org

 

[oneforfighting]

MSK rad.

This looks like NF1.

Radiology Quiz 5474 | Radiopaedia.org

radiopaedia.org

Definite resemblance