A 62-year-old male, with a history of recurrent vertebral echinococcal cysts, presented to the Emergency Department with a 14-day decline in lower limb function, gait instability, and bowel and bladder incontinence. Lumbar spine tenderness and neurological deficits in both lower limbs were noted during the examination, with no reported trauma history.
X-ray of the thoracolumbar spine revealed signs of multiple spinal surgeries with inserted surgical materials, yet no apparent cause for acute deterioration (Figures 1a and 1b). MRI revealed an extensive multicystic mass extending from Th12 to L2 with prominent cystic changes in the posterior elements of the L2 vertebra, which significantly indented the dural sac dorsally (Figures 2a and 2b). Over the course of one year, progressive cystic changes in the posterior part of the L2 vertebra led to the development of severe spinal stenosis, resulting in the complete displacement of cerebrospinal fluid and compression of the spinal cord at the level of the L2 vertebra (Figure 3).
Human echinococcosis (hydatid disease) is a zoonotic ailment resulting from tapeworm parasites transmitted by domestic dogs, particularly prevalent in the Mediterranean region [1].
Hydatid disease is primarily hepatic; spinal involvement is rare, constituting 0.2–1% of cases [2]. The spinal disease typically extends beyond the vertebral bodies, manifesting as an extraosseous soft tissue cystic mass that affects the paravertebral soft tissues, intervertebral discs, spinal canal with its spinal cord, and posterior spinal elements [3]. Based on the anatomical location, Braithwaite and Lees classified spinal echinococcosis into five types: intramedullary (type 1), intradural, extramedullary (type 2), extradural, intraspinal (type 3), vertebral (type 4), and paravertebral (type 5); however, multiple types can co-exist [3].
Diagnosing hydatid disease requires a comprehensive approach, considering clinical symptoms and radiological imaging for accurate detection [1]. Symptoms may manifest as back pain, limb weakness, radiculopathy, myelopathy, or pathological fractures [3,4].
Plain radiographs and CT scans are effective for visualising bony destruction, while MRI is the preferred diagnostic modality, due to its high sensitivity in detecting cysts and providing detailed anatomical insights [2,3,5].
Key MRI findings of spinal disease include multiple fluid-filled cystic lesions with thin-walled septations, resembling a cluster of grapes, with large, spherical cystic lesions within paravertebral muscles. These cysts typically manifest as hypointense on T1-weighted images and hyperintense on T2-weighted images, exhibiting subtle peripheral enhancement on post-contrast imaging. Multilocular cysts may indicate daughter cysts, which grow slowly, so the surrounding bone appears capsular and distensible with smooth and often sclerotic circumscription. These MRI findings are crucial for differentiating echinococcus from other pathologies, as biopsy or cyst aspiration is discouraged due to the high risk of disease spread and/or anaphylactic reaction. When diagnosis remains uncertain, serology can be employed to strengthen diagnostic accuracy. Our patient’s medical history and MRI findings strongly supported the progression of previous hydatid disease, further reinforced by positive serology for echinococcus. Subsequently, the diagnosis was confirmed through histopathological examination of the excised tissue [2,3,5].
Current treatment involves surgical excision for neural decompression and cyst removal, often combined with antihelminthic drugs. Despite available treatments, spinal echinococcosis has a high recurrence rate, attributed to cyst infiltrative nature and high intraoperative risk of rupture, emphasising the importance of early, pre-operative recognition and long-term surveillance, preferably with MRI [3,5,6].
Take Home Message
In endemic regions, clinicians should consider spinal echinococcosis in patients with back pain and neurological symptoms, especially when MRI reveals cystic lesions.
All patient data have been completely anonymised throughout the entire manuscript and related files.
Spinal compression due to progression of hydatid cyst disease
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Based on the provided imaging (including X-ray and MRI) and the history of previous surgery, internal fixation devices and interbody fusion cages are observed in the lumbar spine segments, indicating that the patient has undergone lumbar spine surgery. The images show multiple cystic lesions in the local lumbar region, partially involving the paravertebral soft tissues, with the following characteristics on MRI sequences:
Considering the patient’s long-term recurrent lumbar discomfort and functional impairment, X-ray shows certain changes in the bony structure around the fixation device. The local vertebral lesion does not present with typical extensive bone destruction or new bone formation. However, the cystic lesion covers a large area, suggesting a possible recurrence or progression of the original disease.
Given the patient’s history of vertebral echinococcosis (hydatid) infection, and the multiple cystic lesions on imaging that align with the typical features of spinal echinococcosis, the following diagnoses or differential diagnoses are considered:
Based on the patient’s history of vertebral echinococcosis, current neurological deficits (lower limb dysfunction, unstable gait, urine and fecal incontinence), imaging findings of multilocular cystic lesions, and supportive serological, intraoperative, or pathological evidence, the most likely diagnosis is:
Spinal Echinococcosis (Vertebral Hydatid Disease) Recurrence.
The main treatments for spinal echinococcosis include:
During the pre- and post-operative phases and throughout medication treatment, rehabilitation should follow a gradual, individualized, and safety-focused approach. Below are illustrative guidelines:
Throughout rehabilitation, symptoms and imaging changes must be closely observed. If new or worsening neurological symptoms appear, seek medical evaluation promptly. For patients with other chronic conditions (e.g., cardiovascular disease or osteoporosis), attention to exercise intensity adjustments and protective measures is necessary.
Disclaimer: This report is a reference analysis based on the provided medical information and does not replace in-person consultation by a qualified physician. The actual treatment plan should be determined by a clinician with appropriate qualifications, according to the patient’s specific circumstances.
Spinal compression due to progression of hydatid cyst disease
