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Anterior Lumbar Radiculopathy
KEY FACTS
Terminology
-
Uncommon complication following intrathecal chemotherapy
-
Transient or permanent paraplegia
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Initially described following intrathecal methotrexate (MTX) in pediatric acute lymphoblastic leukemia patients
-
Imaging
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Smooth linear enhancement of conus pia, anterior cauda equina nerve roots
-
Unenhanced T1W, T2W images normal
Top Differential Diagnoses
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Guillain-Barré syndrome
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Cerebrospinal fluid (CSF) disseminated metastases
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Postradiation radiculopathy
Pathology
-
Intrathecal MTX, arabinoside (Ara-C) standard prophylaxis, and treatment agents for pediatric CNS leukemia
-
MTHFR polymorphism affects folate homeostasis, may modify or predict CNS vulnerability to MTX
Clinical Issues
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Lower extremity flaccid weakness, most often without sensory deficit
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↑ CSF protein, mononuclear pleocytosis, CSF immunoglobulin G synthesis
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Most commonly occurs after > 1 intrathecal chemotherapy dose
-
Abnormal electrodiagnostic studies correlate with nerve root enhancement
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Most patients are children, but rare reports in adults
-
Extent of clinical recovery is variable
Diagnostic Checklist
-
Correlation with clinical information critical to establishing correct diagnosis
-
Contrast administration essential to detect cauda equina abnormality
Sagittal T1WI MR in a leukemia patient with leg weakness following intrathecal chemotherapy shows normal appearance of the conus
and cauda equina
. The unenhanced images may be normal in patients with anterior lumbar radiculopathy, so contrast should always be given.
and cauda equina . The unenhanced images may be normal in patients with anterior lumbar radiculopathy, so contrast should always be given.
Sagittal T1WI C+ MR in the same patient reveals abnormal smooth, thin, linear enhancement of the ventral conus pia
and cauda equina
. The diagnosis would have been missed without contrast administration.
and cauda equina . The diagnosis would have been missed without contrast administration.
Axial T1WI C+ MR through the conus medullaris confirms smooth, thin, linear enhancement of the ventral conus pia and cauda equina
.
.
At the level of the cauda equina, axial T1WI C+ MR demonstrates characteristic smooth thin linear enhancement of the ventral cauda equina nerve roots
but not the dorsal cauda equina nerve roots
.
but not the dorsal cauda equina nerve roots .
TERMINOLOGY
Abbreviations
-
Methotrexate (MTX), cytosine arabinoside (Ara-C)
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