What is the hidden finding in this spine case?

This 77-year-old woman presents with longstanding back and left hip pain. This case is a good reminder that we are responsible for everything and we need to make sure to look at all of the images. With that in mind, what is the unexpected finding you might miss?

SURVEY

Axial T2

Coronal STIR

Make sure you noted the mixed signal cystic and solid mass of the right kidney in image 3 (green arrow). This is the unexpected finding and it resulted in partial nephrectomy for clear cell subtype of renal cell carcinoma. The spine findings, which are expected, demonstrate degenerative spondylosis with recess stenosis greatest at L3-4 level. But in the name of providing optimum patient care, we need to be vigilant for unexpected findings like the kidney findings in this case. On the other hand, incidentalomas in the kidneys are very common when imaging the lumbar spine. If such lesions are round, less than 4-5 cm, smooth, homogenous and bright on T2 without internal nodules, we will report them as statistically most compatible with renal cysts and not follow them further. For more case review, check out MRI Online.

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