D paraplegia. Myelography revealed an incomplete block at the level of T.12 vertebra, becoming complete at T.9. On decompression, hydatid cysts were found.
HYDATID
DISEASE
R. 0. Institute
of
Orthopaedics,
London
OF
MURRAY,
University,
THE
LONDON,
and
Royal
SPINE
ENGLAND
National
Orthopaedic
Hospital,
London
and
Stanmore
and FUAD
HADDAD,
American
Symptomless
hydatid
examination. but
occasionally
a cyst,
disease
Symptoms,
particularly
be
occur,
onset
in the liver
and
may
if they
a dramatic
BEIRUT,
University
are
Hospitals,
discovered usually
is associated
or lung.
LEBANON
Orient
Beirut
incidentally
caused with
the
in the relatively
infection rare
and pathological fractures predominate. sometimes diagnostic. With modern
may
where
be carried The
harbouring
the
sheep. may
weeks.
are
pass
these
and
may
suspected,
lead
In most
within ova are to
The
larva
develop. of these
caught
reach
human
parts
When
forms
embryos
a cyst
slowly,
1,000
incidence
of
and
be the
pelvis
VOL.
all cases 41 B,
3,
of
affects
examination the disease
of radiographs
thus
AUGUST
the intermediary
ovum
scolices an first
enters
the
grow
and
host
is commonly intestine of the of food or
intestinal
tract
of
an
migrate through the into larvae in about
within
ectocyst from filter, provided
which
connective by the
also
daughter
tissue. liver, and
About 15 per
lungs (Howorth 1945). The remainder developing in soft tissue are spherical
Death
bone, of
of the
destruction the
irregular relatively reaction
(bc.
College
found cent
and
however, to the 1959
Echinococcus. The from an intermediary
parasite
is often
followed
by
INVOLVEMENT
first
cit.),
involvement Out of 1,874 of
commonest per
of the Taenia by eating offal
occurs
rigidity and
not
exuberant of ectocyst
of
by
bone
mechanical
tissue,
spherical
the
as in other
growth formation
then may
pressure cyst
enlarges
tissues.
protrudes be observed.
Later, into
the Such
calcify.
Howorth
according NO.
and usual
cases with bone about 1 per cent.
was involved in 18 Woodland (bc. cit.),
in
is often
perforated, where the
the Royal Australasian Site of bone lesions-The
of
the
by the Cysts
Because
its shape
of
to
rupture
the disease
Radiological freedom of travel
released embryo may The embryos develop
centimetres. 1953).
deposited
may also, in time, of bone lesion’-Howorth
about
which
filter, provided settle elsewhere.
reaction.
the cortex may be adjacent soft tissues ectocysts Incidence
when
interpretation
world,
When
within
of several (Jidejian
are
inflammatory
unusually
an
of the
infestation.
BONE
that
the ova infested
The host reacts by forming embryos are trapped in the
a diameter the ectocyst
of
the
structures.
or spontaneous
the cysts develop into the mature worms in the then excreted in the faeces. Faecal contamination
the second and may
in
barriers
calcification
without
and
host, its envelope is dissolved. The wall to enter the portal venous system.
cysts often 75 per cent cent
cysts.
scolices Their
then
intermediary intestinal three
hydatid
The host.
definitive water
it is not
radiological
importance.
disease is caused by the ingestion of host is usually the dog, which becomes
definitive
host
to areas
particular
routine
on adjacent
instances
bone, pressure symptoms is usually of value and acquires
by
by pressure
in an
extensive
review
of the literature,
concluded
been recorded and that these represented cases of hydatid disease in the Hydatid Registry Surgeons, 24 per cent involved bone (Woodland 1949). site of bone lesions in hydatid disease is usually considered
this
to
had
be involved
the sacrum believed that
in about
in 11 per the spine
36 per
cent. Bellini is most often
cent
of cases.
(1946), Pugh affected-in
The (1951) 50 per
spine and cent
author. 499
500
R.
0.
MURRAY
AND
FIG.
Case I-Three large expanded throughout
Figure
1.
Figure 3-Seven
2-The months
cysts later,
HADDAD
I
hydatid cysts are present in the right lung. The right sixth rib most of its length, with cortical thinning and oval areas of translucency.
FIG. Case
F.
2
3
FIG.
in the lung T.4 vertebra
and
developed
the
shows
rib lesion partial
in T.6
and
are collapse,
again visible, but and non-specific
is
the spine destructive
appears changes
normal. have
7 vertebrae. THE
JOURNAL
OF
BONE
AND
JOINT
SURGERY
HYDATID
DISEASE
OF
RADIOLOGICAL
The
radiological
changes
the stage at which Early bone lesions
they
are
are
in skeletal
THE
501
SPINE
CHANGES
hydatid
disease
may
be
considered
in relation
to
observed. by ill defined
characterised
areas
of translucency,
without
sclerotic
or
resembling a bunch of grapes. If observed at this stage, the condition barely be differentiated from other cystic lesions, such as simple or aneurysmal bone osteoclastoma, fibrous dysplasia or osseous tuberculous foci. periosteal
Developed oval
bone
lesions
in the long
when
show
well
defined
areas
axis of the affected bone. daughter cysts are present.
adjacent
of translucency,
The pattern, The margins
which
however, are always
tend
to be circular
highly
a
The
stage
the
cortex
vascularised is now and
Advanced associated considerable
area
set for
the
of spongiosa,
a further
tend
eventually
development,
namely
or
may be less regular, especially smooth and show surrounding
sclerosis. This sclerosis indicates bone reaction and, although usually attributed infection, is more likely a simple response to pressure. At this stage the bone with thinning of the cortex. The cysts having once begun to develop in a bone, with for
can cysts,
reaction,
to spread
rupture
to secondary may expand, a predilection
throughout
of the
hydatid
its length. tissue
through
periosteum.
bone lesions soft-tissue size and
are thus accompanied by a break in the cortex and the development shadows with smooth and rounded margins. Such lesions may have been described by Bellini (bc. cit.) as ossifluent abscesses.”
of attain
“
Lesions
in the spine-These deserve special consideration. In the early stages a cystic area may arouse suspicion, in addition to the conditions mentioned above, of a primary or secondary neoplasm, including vertebral angioma. In the late stages, which develop slowly, the areas of translucency in the affected vertebrae are partly masked by reactive sclerosis. Ossifluent “
abscesses
“
involved.
may
be visible
In oblique
exclude spaces
tuberculosis. in hydatid
developed. A more
views
the laminae
may
be seen
differentiation
is to of the tumour
be
although
even
in
extensive
made
case
heads
to be affected.
from
tumour through does not provoke
this
the
of the This
bone
adjacent
has been
in this differentiation are not narrowed unless
caused by hydatid cysts in the lungs Phemister and Brunschwig 1941).
involvement,
and
hardly be expected if such
masses, formed by growth appearance. Moreover, this shadows (Hodges,
shadows,
Much more important disease remain intact and
That would difficult
as soft-tissue
is that the secondary
a plasmacytoma,
transition
to
may
be
to tend
intervertebral infection
were
to has
tuberculous.
in which
soft-tissue
may present a very similar sclerotic reaction. Rounded
may dispel doubt, practically Another differentiating factor the
stated
involvement
the cortex, a marginal
ribs
multiple
excluding is probably
myeloma the rib
myelomatosis
may
be
suspected. CLINICAL
This
paper
three cases
reports
skeletal hydatid disease Hospital, Beirut, during symptoms
two
years
Jidejian (bc.
Hospital
without
from
1-A
duration, Tenderness
man
aged
has
recently
reported
a
series
been
190
of
are
the
only
examples
of
called
to this
presenting cases was a high
cases
from
feature during refused,
incidence
the
by Mills
(1956).
this period could but is estimated of
bone
American
lesions,
University
involvement.
thirty-six
was admitted
REPORTS in
March
1946 with back
pain
of
three
years’
radiating from just below the angle of the right scapula to the axilla and nipple. was found over the right sixth rib, and radiological changes affecting the rib were
ascribed
to plasmacytoma.
VOL.
NO.
41 B,
which
University Hospital and the Orient In each of these cases cord pressure
hydatid disease of all types because operation in some should not be taken to indicate
CASE
Case
involvement,
the American October 1954.
of
cit.)
skeletal
at
Attention
The total number of cases not be determined accurately at forty-five. These figures because
of spinal
encountered
were prominent.
MATERIAL
3, AUGUST
1959
Five
months
later, the
patient
was
readmitted
with
partial
502
R. 0.
Case
2-Bilateral
level.
Expansion
FIG.
Case
2.
Figure
Antero-posterior
MURRAY
paravertebral and
destruction
5
5-Antero-posterior
tomograph
tomograph (4 centimetres)
shadows
AND
4 with
F.
HADDAD
smooth,
of head of right pedicle of T.9.
ninth
rounded rib.
margins Thinning
at T.9 of
right
1G. B (64 centimetres) showing the paravertebral shadows. showing expansion and destruction of the right THE JOURNAL
OF BONE
AND
Figure
ninth JOINT
6-
rib. SURGERY
HYDATID
paraplegia.
Myelography
complete followed, were
removed operation little
were
complete
the
the
from
first
function
below
cortex
length
of
laminectomy
the
fourth
by
oval
of T.6
and
its
vertebra the lower
of hydatid Operation
disease. The was followed
it seemed
sclerosis, which Comment-This
circular
areas
the
vertebrae,
likely
and
that
appearance, by frank
these
Case
2-A
progressive
in the
right
VOL.
41 B, D
collapse
aged
man
and inability the thoracic
to walk
3,
AUGUST
of
forty-five,
numbness region.
NO.
relief.
examination
vertebra,
numbers. 1955 In
becoming Improvement hydatid cysts
six
1957
June
further
mediastinum. later the paralysis
and
of translucency.
partial
chest
round was
This
collapse
destructive
of hydatid involvement
sixth
cysts
After this became
expanded,
process
T.9 The
vertebra, disc spaces
admitted weakness
of T.4.
changes
above, with the
October 1947 in the right with thinning
in
opacities involved
the
of the chest, destructive The
represented
disc
spaces
early
whole
taken after changes in were
well
manifestations
was not diagnostic at this stage. development of much deformity
disease in subsequent radiographs of the thoracic spine. Incidentally,
and
of the spine. advanced
rib.
with are
7 some irregular well preserved.
in December of both
for three months. At For one month before 1959
the
of
but three large the right sixth rib
FIG. 2-Partial
with
some
and the posterior extremities, and
as indicated osteomyelitis
masked the changes case illustrates early present
Case
of T.12
end. A further lateral radiograph hydatid cysts in the lung, showed
anterior of
T.7
and
were
thoracic to
at the level
found in large In November
with
vertebra,
findings-Radiological no spinal abnormality, cysts. In addition, and
preserved
changes
block cysts were operations.
thoracic
returned
the rib except and removal
bodies
hydatid further
503
SPINE
THE
this level.
of the radiological 1 and 2) revealed represented hydatid
lung of
the
from
OF
an incomplete
at T.9. On decompression, but recurrences necessitated
removed
Review (Figs.
revealed
DISEASE
1955,
lower
the same admission
sclerosis
had
within
the
complained
extremities
time he noticed he had suffered
for
one
body.
of and
kyphosis difficulty
back
a half
pain years,
developing in in urination
504
R. 0.
and
had
become
vertebrae
constipated. T.6 and
between
liver
was
not
reflexes,
Vibration
sense
was
the
right
smooth larger
tomograph
(Fig.
changes in the The appearance
head
was
partly
in the abdomen.
and
touch
been
eroded.
antero-posterior
rounded than that
destructive the cortex. also
palpable Pain
the
with being
64-centimetre
had
were
kyphosis with a bulge of the thoracic Chest examination was negative. The
5),
and
the
of the right was very like
The
lateral
view
margins on the
(Fig.
After
laminectomy
and slightly
paresis
still
examination
the
the
patient
disappearance exaggerated. of
diagnosis
material
3-A
woman
pain
since
January
she
suffered
an
the
from
ninth
had The
7) confirmed
(Fig.
the
recovery,
vertebra
fourth,
abdomen
revealed
examination
fifth
and
sixth
4) para-
6) demonstrated
body
with
of T.9
vertebra
The disc of T. 12.
spaces
were
complete
relief
of the
and
the
right
ninth
rib
confirmed
disease.
aged thirty was admitted 1948, which radiated a severe bout of pain in the
and
(Fig.
in the lower extremities were in April 1958. Pathological
in June 1956 complaining ofrecurrent mid-thoracic into her shoulders. Six months before admission mid-thoracic region which radiated into both legs.
Four months later she noticed difficulty in walking and rapidly admission she was unable to pass urine and was severely constipated. with a complete sensory level at T.5 vertebra, was demonstrated. the chest Radiological
spine
The nature.
level of T.9 vertebra, clearly shown in the
within it. at the level
The reflexes until last seen
thoracic
with intact.
expanded the rib and eroded right pedicle of T.9 vertebra
that
visible block
uneventful
of sensory changes. He remained well
of hydatid
Case
made
thoracic
tomograph
.
paraplegia, everywhere
in the lower extremities. cord of undetermined
of the
4-centimetre
collapsed, and some irregular density was preserved. Myelography revealed an incomplete
well
were
were evident at the left. They were more
ninth rib. These that in Case 1
view
Spastic
sensations
well as the sense of position were equivocal was that of a compressive lesion of the spinal was negative and eosinophilia was not found.
shadows
on
F. HADDAD
revealed tenderness.
demonstrated.
examination-In
vertebral
that
no masses
AND
as
clinical diagnosis The Casoni test Radiological
Examination without
T.lO,
and
enlarged
increased
MURRAY
no
the
of
thoracic
became bedridden. On Paraplegia in flexion, Clinical examination of
abnormality.
thoracic
spine
vertebrae.
revealed
widely
destructive
In the antero-posterior
view
changes
(Fig.
in
8) marked
the
erosion
of the left sides of these vertebral bodies was evident. The corresponding left pedicles had been destroyed. The posterior part of the left fifth and sixth ribs showed gross destruction and adjacent oval cavities; these indicated intrinsic bone disease in addition to any changes of
pressure
chest,
that might be present. and in contact with the
erosion
posteriorly
In the lateral radiograph vertebrae. The destruction
intact.
affected were
again
operation
of
about
in ten
1956
June
centimetres
costo-vertebral cysts, was
angle accidentally daughter cysts
small
body
of
completely
eroded. hospital, the
from
T.5
vertebra.
of
from
their
large
left
necks.
circular
soft-tissue
lesions.
9) central the pedicles
This case illustrates the fifth and sixth
demonstrated.
At
(Fig.
A bone
The
areas
of
and
under
the
The
dura
was
seen
from
its
lateral
disc
lay in the left spaces were
seen within the soft-tissue mass
were
presence
the very advanced ribs were found
Just
No significant improvement patient failed to return for
destruction
the
a large degenerate hydatid cyst filled opened. The area was thoroughly were seen to extrude through small
opacity
intervertebral
of the
stage of the to be eroded
disease. along a length
muscles and in the left with a great number of daughter cleaned. During this procedure holes in the lateral aspect of the
intercostal
aspect
because
followed the operation, follow-up examination.
the
pedicle
and,
had
been
discharge
after
DISCUSSION
The most
radiological
important
among
findings
in this
them
malignant
disease disease
can
be mistaken of
for a number In Case
bone. THE
JOURNAL
1 the OF
of other diagnosis BONE
AND
conditions, was JOINT
known SURGERY
HYDATID
DISEASE
OF
THE
505
SPINE
I
‘: -,
I 8 the left sides of the bodies of T.4, T.5 and with the posterior parts of the left fifth and FIG.
Case have
3-The pedicles and been eroded, together
association
with
these
changes,
a large
hemithorax.
circular
The
soft-tissue
disc spaces
mass
T.6 vertebrae sixth ribs. In is present in the left
are intact.
1
9
FIG. Case
VOL.
41 B,
NO.
3-Central
3,
AUGUST
areas of the pedicles
1959
destruction
and
are
visible
the soft-tissue
in affected mass is again
bodies. shown.
The
erosion
of
506
R.
when
we
first
saw
plasmacytoma
the
patient.
progressing
to
myelographic
blockage
tumour
within
tissue
hydatid cysts. both favoured but,
in two
MURRAY
In Case multiple
well the
0.
2 one
the
site
canal.
cases,
HADDAD
of us favoured
malignant
He
of
This
In Case 3 hydatid disease the former. In the advanced of these
F.
myelomatosis.
below
neural
AND
the
was,
was
bone
hydatid
disease;
influenced
by
lesion,
in fact,
suggesting
caused
by the
and neurofibroma were stage it is less difficult
disease
was
seriously
the
disease,
rounded
but
is a common
globular
finding
shadows
in
in intestinal
the
lung,
considered.
with
other
a
presence
of
presence
of
of numerous
possible, but we a correct diagnosis,
The
greatest
difficulty
pre-operative diagnosis be may rupture the cysts, with positive Casoni or positive may give an indication of
infestations.
together
the
presence
considered to make
arises in early disease. Nevertheless it is important that a correct made because treatment depends upon it, and ill advised biopsy consequent recurrences. The differential diagnosis will rest on Weinberg tests, but these are often falsely negative. Eosinophilia
the the
A chest
involvement
radiograph of
the
showing
vertebrae,
may
suggest multiple metastases, and the patient might be left to become paralysed on the assumption that the condition was inoperable. In metastatic carcinoma adjacent vertebral bodies are not
affected,
usually
The presence spaces, should
and
costal
lesions
of soft-tissue shadows bring this condition
affect
only
part
of a rib,
which
is not
besides a destructive vertebral into the differential diagnosis.
often
lesion,
expanded.
with
intact
disc
SUMMARY
1
The
.
in about
filters
radiological features of skeletal hydatid disease are discussed. 1 to 2 per cent of cases, bone being involved only after the provided firstly by the liver and secondly by the lungs. At
translucency appear a surrounding
sclerotic
which
and
throughout
with
tend
to spread
and exuberant ectocyst forms, disease
2.
hydatid which
is very
Three
areas We
should
and
of the
like
from
bone.
In advanced
clear-cut thin and stages
in the adjacent death of the
destructive expand the
the
cortex
areas, cortex
is ruptured,
soft tissue. Around parasite. The progress
this an of the
the
spine
are
travel
in the
described,
and
modern
and
the
neurofibroma. and
relieved these most advanced
world
hydatid
helpful
advice,
differential
Each
disease
case
diagnosis
presented
totally case.
in
is liable
to
with
one be
case, seen
in
endemic.
to thank
to
thoracic
plasmacytoma
Operative decompression and not at all in the third
easy
it is not
Photographer
an affected
of affection
symptoms. in another,
rapid
where
In developed lesions, visible. The cysts
become
cyst growth takes place may later calcify, indicating
particularly
cord pressure incompletely With
reaction,
slow.
cases
is considered,
3.
are not diagnostic.
Osseous lesions occur embryos have passed the first, ill defined areas of
Mr
H. Jackson
Institute
Burrows
for
of Orthopaedics,
his
Royal
National
and
Mr
Orthopaedic
F.R.P.S.,
R. J. Whitley,
Hospital,
for
preparing
Chief the
illustrations.
REFERENCES ARIAS
R.
Golden.
HOWORTH,
M. (1946):
BELLINI,
HODGES,
P. C.,
Osteohydatidosis:
PHEMISTER,
New York:
D.
Thomas
M. B. (1945):
B.,
and
Nelson
Echinococcosis
Its
Radiological
and
Sons.
of
Bone.
Y. (1953):
Hydatid
Disease.
Surgery,
(1941):
Journal
155. MILLS, T. J. (1956): Paraplegia due to Hydatid Disease. PUGH, D. G. (1951): Roentgenologic Diagnosis of Diseases WOODLAND, L. J. (1949): Hydatid Disease of Vertebrae. JIDEJIAN,
Features.
A.
BRUNSCHWIG,
of
Radiology,
In Diagnostic Bone
and
47, Radiology,
Joint
Surgery,
569. p. 543. 27,
Edited
by
401.
34,
Journal of Bone and Joint Surgery, 38-B, 884. of Bones, p. 172. New York: Thomas Nelson & Sons. Medical Journal of Australia, ii, 904.
THE JOURNAL
OF BONE
AND
JOINT
SURGERY
