A 56-year-old female patient presented with low-back and hip pain radiating down to her left leg for 12 months. She did not respond to initial management with conservative therapy of non-steroidal anti-inflammatory medications.
MRI (magnetic resonance imaging) of the lumbar spine (3T scanner) was performed using T2-weighted, T1-weighted, SPAIR, and fat-saturated contrast-enhanced T1-weighted sequences.
Figure 1. T2-weighted sagittal MRI of lumbar spine showing bone-based malignancy from L3 to L5 causing severe canal stenosis and infiltrating anteriorly into the retroperitoneal space.
Figure 2. T2-weighted axial magnetic resonance image show very high signal intensity of the tumour, which infiltrating posteriorly into the paraspinal musculature and expanding into the abdomen and psoas muscles bilaterally. The tumour causes severe spinal stenosis with compression of the nerves.
Figure 3. Sagittal T1-weighted image shows a low-intensity lesion penetrating from vertebral bodies to the retroperitoneum.
Figure 4. Sagittal T2-SPAIR image shows a well-circumscribed high-intensity lesion.
Figure 5. T1-weighted image with gadolinium contrast demonstrates heterogenous contrast-enhancement of the tumour.
MRI exam presented the mass exhibited homogeneous low-intensity on T1-weighted images; hyperintensity in the intraosseous and extraosseous component on T2-weighted images, compared with the normal vertebral body. The mass extended into the spinal canal posteriorly and perivertebral space anterolaterally infiltrating the psoas muscles and penetrating to the retroperitoneal space with surrounding the abdominal aorta for less than half the circumference. After intravenous administration of contrast material, the heterogeneous enhancement was observed.
Background: Chordoma is a rare tumour that arises from notochord remnants in the vertebral column and base of the skull, and presented as slow-growing, locally-invasive malignant tumours. It most commonly occurs in the base of the cranium or the sacrococcygeal region but around 15-20% affect the vertebral body. Chordomas typically affect those in the 40-60-year-old age group but have been reported in children and the very elderly. [1,2,3]
Clinical perspective: It is a slow-growing tumour, which makes it difficult to diagnose and follow up after treatment. Affected patients usually have a poor prognosis because of the extensive nature of the disease at the time of diagnosis, which may make it difficult to perform a radical resection. [1,3,4]
Imaging perspective: On CT, chordoma appears as a well-circumscribed lytic lesion with, sometimes with marginal sclerosis and central calcifications. It may exhibit moderate to marked enhancement following contrast administration. Currently, MRI is the preferred imaging modality for pre-operative diagnosis and assessment. Chordomas have lower signal intensity on T1-weighted imaging and may show foci of hyperintensity which represents intratumoural haemorrhage. T1-weighted imaging with gadolinium contrast demonstrates heterogenous contrast-enhancement of the tumour with a honeycomb appearance. On T2-weighed imaging chordomas tend to be hyperintense. Gradient-echo MRI/SWI imaging can confirm intratumoural haemorrhage. [2,3,4,5]
Outcome: The treatment which provides the longest survival is complete en bloc resection of the tumour with clean margins. In the majority of cases, margin-free excision is difficult due to surrounding neurovascular structures and extensive tumour size. Most physicians advocate for radiation therapy after any type of chordoma resection and recommend lifelong surveillance with magnetic resonance imaging due to the high local recurrence rate. Chordomas are relatively radioresistant necessitating high-dose radiation therapy. [1,3,4,5,6]
Teaching points: Most of the chordomas exhibit very high signal on T2-weighted imaging.
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Chordoma of the vertebral bodies
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Based on the provided lumbar spine MRI images, a localized destructive lesion is visible within the vertebral body. The signal characteristics are as follows:
• On T1-weighted images (axial and sagittal), the lesion appears predominantly low to intermediate in signal intensity, with patchy inhomogeneous areas;
• On T2-weighted images, the lesion shows high signal intensity with relatively well-defined margins, and certain regions demonstrate even brighter areas, suggesting possible mucinous or liquefactive components inside the lesion;
• Following contrast administration, significant or heterogeneous enhancement is noted in the lesion, and in some sequences, a “honeycomb-like” enhancement pattern is observed;
• The lesion involves the vertebral body and extends partially into the spinal canal, showing signs of compression or invasion of adjacent vertebrae or paravertebral soft tissue;
Overall, the findings are consistent with features of a primary spinal tumor. In particular, chordoma (Chordoma) often exhibits “expansile destruction” and a high T2 signal.
Therefore, based on the imaging findings and the patient’s clinical age group, chordoma is the primary consideration.
Combining the imaging characteristics (T2 hyperintensity, pronounced and heterogeneous enhancement after contrast, localized destructive lesion) with the clinical presentation (chronic lumbogluteal pain radiating to the lower limbs), the most likely diagnosis is
Chordoma.
For definitive confirmation, a biopsy with pathological and immunohistochemical analysis is recommended.
Treatment Strategy:
1. Surgical Treatment: If the patient meets surgical criteria and an en bloc resection with clear margins is feasible, it significantly reduces the risk of local recurrence.
2. Radiotherapy: Although chordoma is relatively radioresistant, high-dose radiotherapy can aid in local control, particularly when complete surgical resection is not possible or margins are not clear.
3. Pharmacotherapy: No definitive chemotherapy protocols are established. Some targeted therapies may help control advanced or recurrent disease.
4. Long-Term Follow-Up: Chordomas have a high recurrence rate, necessitating regular MRI evaluations.
Rehabilitation and Exercise Prescription (FITT-VP Principle):
1. Frequency: 2–3 rehabilitation sessions per week are recommended, initially under professional guidance.
2. Intensity: Begin with low-intensity exercises (e.g., trunk stability exercises while seated or lightly supported standing), avoiding high impact or heavy loads. Gradually increase core strength training intensity.
3. Time: Each session should last 20–30 minutes, including warm-up and cool-down.
4. Type: Focus on core stability exercises and light resistance training for the lower extremities, supplemented by low-impact aerobic activities (elliptical or level walking).
5. Progression: As tolerance improves, extend session duration to 30–45 minutes and moderately increase resistance for strength training. Pain levels, neurological symptoms, and vital signs should be closely monitored.
Notes:
• During the pre- and post-operative period or during radiotherapy, follow medical and rehabilitation professional advice strictly. Avoid increasing load arbitrarily.
• If pain significantly worsens or new neurological symptoms appear, seek prompt medical attention.
Sample Training Program: 2–3 sessions per week, about 30 minutes each, including:
• Warm-Up: 5 minutes of level walking or seated cycling, along with gentle stretching of the lumbar and dorsal regions;
• Core Stability Exercises: Modified plank with knees on the ground, hold for 10–15 seconds, rest for 15 seconds, for 3 sets;
• Lower Extremity Resistance Training: Light seated leg extension or ankle exercises, 8–10 repetitions per set, 2–3 sets;
• Cool-Down: Lumbar-sacral relaxation and decompression exercises (e.g., supine knee flexion, side-to-side leg rocking) for 5 minutes.
Disclaimer: This report is a reference analysis based on the available imaging and medical history information. It is not a substitute for an in-person consultation or professional medical advice. If you have any concerns or if symptoms worsen, please seek medical attention promptly.
Chordoma of the vertebral bodies
