Teaching Case

A 12-year-old female patient is brought to the emergency room due to a fall. She is referred for further evaluation due to some findings in his clinical examination in the emergency and orthopedic evaluation.

Figure 1. Scalloping is seen in lower lumbar vertebrae on lateral lumbosacral radiography.

Figure 2. In the sagittal T2 MRI images, the enlarged dural sac (dural ectasia) and concavity in the posterior parts of the lumbar vertebra is visible.

Figure 3. CT shows bony structure changes, similar to MRI.

Background One of the reasons for dural sac widening is dural ectasia and it can be associated with Marfan syndrome, Ehlers-Danlos syndrome, Loeys-Dietz syndrome, neurofibromatosis type 1, ankylosing spondylitis, osteogenesis imperfecta, acromegaly, trauma, surgery, tumors, and scoliosis. In Marfan syndrome, dural ectasia can observe 60-90% of patients [1]. In neurofibromatosis type 1, plexiform neurofibromas are thought to cause local infiltration of the dura that leading to the widening of the dura [2].

Clinical Perspective Many of the patients are asymptomatic. The most common symptoms are low back pain, headaches, and radicular pain in the involved limb and sometimes there can be urinary incontinence [1]. We should be aware of the radiological findings of dural ectasia in patients who underwent imaging for such complaints, and we should inform the requesting physician for further investigations on the etiologies that mentioned above.

Imaging Perspective Widening of the anteroposterior diameter of the dural sac and vertebral scalloping usually in the lumbar region can be observed in each of the MRI, CT, and radiographic examinations. But every part of the spinal canal can be affected. Spine MRI is the best imaging modality to evaluate the bony structures and spinal canal [3].

Outcome Most of the dural ectasia can be treated conservatively and do not require surgery.

Take Home Message We should be aware of this structural disorder which has typical radiological findings and guide clinicians in investigating etiologies.

Written informed patient consent for publication has been obtained.