Age / Sex : 43 / F

Age / Sex :  43/F

Chief complaint :  Back Pain

gossypiboma

Discussion

Findings:

Simple radiograph shows right side eccentric bone destructive lesion in L1 and L2 vertebral bodies without marginal sclerosis.

MR images show lobulating-contoured, multiseptated, right-side posterior paravertebral mass with an intermediate signal intensity and fluid-fluid level appearance from T12 to L3 level. There are bone destruction of right side pedicle, lamina, transverse and spinous processes of T12 and L1

Additional elongated-shape lesion with subtle low signal intensities in posterior epidural space from T10 to L1 suggested hematoma. There is compression of spinal cord.

Differential Diagnosis:  
 Infectious spondylitis with hematoma 

 Sarcomatous lesion with hemorrhage

Diagnosis: Gossypiboma with bone destruction and intraspinal hematoma

Discussion:  

 A paraverterbal retained surgical sponge (textiloma) is rare and mostly asymptomatic in chronic cases but can be confused with other soft-tissue masses. “Gossypiboma” is a term used to describe a mass within the body that comprises a cotton matrix surrounded by a foreign-body reaction, which is extremely rare after spinal surgery.The incidence of retained foreign bodies following surgery varies from 0.01% to 0.001%.

 The non-absorbable materials of the retained surgical foreign bodies induce 2 types of reactions. One reaction is exudative reaction in nature and leads to the formation of an abscess with or without secondary bacterial infection. The differential diagnosis in such cases includes postoperative collection, hematoma, and non-foreign body abscess. The other type of reaction is a aseptic fibrinous response, which creates adhesions and encapsulation and eventually results in the development of a foreign-body granuloma. Asymptomatic forms are sometimes discovered fortuitously. A delayed presentation may develop months or even years after the initial surgery.

 Adhesions and encapsulation are common features of gossypiboma, and the lesion may present as a mass. In such cases, the differential diagnosis typically includes tumor, such as schwannoma, fibromatosis, MFH, and other soft tissue sarcoma. The exudative type of gossypiboma causes symptoms earlier than the fibrinous type. Gossypibomas typically have an inconsistent radiologic appearance, which depends on the amount of time that the foreign body has been in situ, the type of material, and the anatomic location. Diagnosis of gossypiboma is difficult because patients with gossypiboma range from being asymptomatic to presenting with severe life-threatening illness.

 On CT scans, gossypibomas appear as circumscribed masses with thick walls; these masses might contain gas bubbles and may exhibit calcification or enhancement of the wall after administration of contrast medium. The internal structure may appear to be whirl-like or spongiform because of the presence of gas trapped within the mesh of the sponge.

 In contrast, MR images can be difficult to interpret because radiopaque filaments cannot be visualized: The radiopaque filament is impregnated with barium sulfate, which is neither magnetic nor paramagnetic and therefore causes no artifacts on MR images. The differential diagnosis should include other postoperative changes such as scar formation and paraspinal abscess. MR imaging was used to examine gossypibomas indicated that T1-weighted images typically reveal a well-circumscribed mass with a low signal intensity, whereas T2-weighted images reveal a very high signal intensity. The capsule is typically dark on T1- and T2-weighted images. The presence of low-signal- intensity stripes suggesting gauze fiber on T2-weighted images may be a characteristic MR imaging appearance of gossypiboma.

Clinical symptoms associated with gossypiboma can be exhibited for several years or even for decades. If the gossypiboma remains asymptomatic, the therapeutic approach must balance the potential risk of evolution of the foreign body and the risk of surgical removal. The clinical history can help to differentiate these 2 alternatives because the onset of complaints is usually much earlier in patients with postoperative scar formation compared with those with gossypiboma.

References:

1.        Kim HS, Chung T-S, Suh SH, Kim SY, MR imaging findings of paravertebral gossypiboma. AJNR 2007;28:709-713

2.        Aydosan M, Mirzanli C, Ganiyusufoglu K, Tezer M, Ozturk I. A 13-year-old testiloma(gossypiboma) after discectomy for lumbar disc herniationa:a case report and review of the literature Spine J 2007;7:618-621