spine marrow: pathologic fractures and ditzels mark e. schweitzer, m.d. chair and professor of...
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Spine Marrow:Spine Marrow:Pathologic Fractures and Pathologic Fractures and
DitzelsDitzels
Mark E. Schweitzer, M.D.Mark E. Schweitzer, M.D.Chair and Professor of Radiology The University of Stony Chair and Professor of Radiology The University of Stony
BrookBrook
Editor in ChiefEditor in Chief
JMRIJMRI
MARROW SIGNALMARROW SIGNAL
DiffuseDiffuse MultifocalMultifocal Focal (as far as you can see)Focal (as far as you can see)
CML
Multiple myelomaMultiple myeloma
T1 and T2Low field
QUESTION:QUESTION: What is the probability What is the probability that this is malignant ?that this is malignant ?
a.a. 0% 0% b.b. 20%20%c.c. 40%40%d.d. 60%60%e.e. 80%80%
Vertebral Marrow: Low Vertebral Marrow: Low SignalSignal
T1 onlyT1 only Higher specificityHigher specificity
Diffuse or focal within vertebral Diffuse or focal within vertebral bodybody
Fracture?Fracture? Be carefulBe careful
T2 useful only if dark or haloT2 useful only if dark or halo
Multiple benign fractures
Is this a benign or Is this a benign or malignant fracture?malignant fracture?
BENIGN FRACTURESBENIGN FRACTURES
Trauma Trauma Cervical M > FCervical M > F
YoungerYounger
Thoracic Thoracic Slightly older Slightly older Usually below T7Usually below T7
Lumbar Lumbar Older yetOlder yet
OsteoporosisOsteoporosis A type of traumaA type of trauma Not cervicalNot cervical T7 and belowT7 and below
Most at T10-L4Most at T10-L4 Most common L2Most common L2 Most likely Most likely notnot to be to be
benign L5benign L5
T scoreT score > -2.5 > -2.5 Only 1/3 of fragilityOnly 1/3 of fragility
NO NOT IGNORE MORPHOLOGYNO NOT IGNORE MORPHOLOGY
Compression?
Is the marrow diffusely involved?
No
Fracture line?
Yes
NO
Sequential?
No
No drop
Drop > 16%
Follow up Bone Scan Biopsy
Benign
OUT OF PHASE
Vertebral Vertebral BodyBody
Yes
Yes
Benign Benign Benign
PATHOLOGIC FRACTURE: 2PATHOLOGIC FRACTURE: 2° SIGNS ° SIGNS (I)(I)
ExtensiveExtensive involvement posterior elements involvement posterior elements including pedicleincluding pedicle
Non-sequentialNon-sequential
LargeLarge soft tissue mass or periduralsoft tissue mass or peridural
Atypical locations:Atypical locations: L5L5 Dens Dens Upper to mid ThoracicUpper to mid Thoracic
Atypical appearance (one side worse, Atypical appearance (one side worse, ““irregularirregular””))
No fx line- or verticalNo fx line- or vertical
T1
Axial T1STI
R
Compression 2° mets
Fx line=benignT1 T2
No high signal in disc aboveNo high signal in disc above
Inferior > superior endplate Inferior > superior endplate ddx: metabolic bone diseaseddx: metabolic bone disease
No PLL avulsionNo PLL avulsion
Posterior bowingPosterior bowing
PATHOLOGIC FRACTURE: 2° PATHOLOGIC FRACTURE: 2° SIGNSSIGNS
T1 T2 fat satSequential
•Metastases•Posterior bowing•Multiple bodies•Posterior
T1 T2 fat sat
Lung CA mets
Soft tissue mass• especially peridural
Multiple Myeloma malignant fx
ALL FRACTURE LINES ARE NOT BENIGN Non horizontal
Gad
T1T2
Maligant inferior > superior
T1 T2
Look for metastases elsewhereLook for metastases elsewhere
Look for benign fractures elsewhereLook for benign fractures elsewhere Remember curse of epidemiologyRemember curse of epidemiology
PATHOLOGIC FRACTURE: 2° PATHOLOGIC FRACTURE: 2° SIGNSSIGNS
Pathologic fracture
T1 T2 Gado
*No enhancement
Fracture and Met
VERTEBRAL FACTURESVERTEBRAL FACTURESDO NOT IGNORE LOCATIONDO NOT IGNORE LOCATION
Risk of MalignancyRisk of Malignancy JeffersonJefferson Teardrop (cervical)Teardrop (cervical) ChanceChance OdontoidOdontoid BurstBurst PlanaPlana Anterior compressionAnterior compression Atypical compression (r > l side, Atypical compression (r > l side, upper to mid T)upper to mid T)
RRIISSK K
OOFF
MMEETT
REMEMBER:REMEMBER: Hyperacute Hyperacute traumatic/osteoporotictraumatic/osteoporotic
Fractures can look malignantFractures can look malignant
******Be cautious and follow-Be cautious and follow-upup******
Acute osteoporotic mimic mets
If I am not sure, what should If I am not sure, what should I do?I do?
Out of phaseOut of phase Follow-up/old filmsFollow-up/old films
Tumor does Tumor does notnot rapidly evolverapidly evolve Bone scanBone scan Thin slice CTThin slice CT X-rayX-ray ContrastContrast Diffusion/perfusion/spectroDiffusion/perfusion/spectro
CT signs of benignity (also treatment response):•Sclerotic margins•Central fat•Typical Ca++
Treated MM
Benign fracture uses of gadBenign fracture uses of gad
Fx f/u3 weeks later
initialTwo months later
When should I not worry When should I not worry about a vertebra plana?about a vertebra plana?
Leukemia
T1 T2
VERTEBRA PLANAVERTEBRA PLANA
>75% loss of height>75% loss of height
Usually equal posterior and anteriorUsually equal posterior and anterior
ddx: ddx: Eosinophilic granuloma Eosinophilic granuloma MetastasesMetastases Osteoporotic fracturesOsteoporotic fractures
No more common to be malignant than No more common to be malignant than more typical fracturesmore typical fractures
Look at the rest of the spineLook at the rest of the spine
plana
Lymphoma
T1
T2 Gad
Malignant planaMalignant plana
What do I do with a low What do I do with a low signal ditzel on a T1W signal ditzel on a T1W
image?image?
If a portion of the vertebral body,If a portion of the vertebral body,
different rules and lower thresholddifferent rules and lower threshold
Focal T1 low signalFocal T1 low signal
Is it low on T2?Is it low on T2?
No; Is there a halo?No; Is there a halo?
Yes =Bone island/Yes =Bone island/Endplate Endplate ΔΔ
Yes: probableYes: probablemetmet
Is there central fat?Is there central fat?
Yes: redYes: redmarrowmarrow
No and smaller than 1 cm No and smaller than 1 cm or multifocal = Bone scanor multifocal = Bone scan
1-2 cm1-2 cmCTCT
>2cm out >2cm out of phaseof phasedoes not does not ddx lesionsddx lesions
DitzeDitzell
ALL, treated with 2ALL, treated with 2ndnd necrosis necrosis
Bone island-does not dropIn phase is not a substitute for T1
Breast metBreast met
T1W T2W (halo) Diffusion out of phaseT1W T2W (halo) Diffusion out of phase
L5 ditzelSubtle halo
T1-halo= benignT2- central high signal indeterminate
Lung metsLung mets
Compression?
Is the marrow diffusely involved?
No
Fracture line?
Yes
NO
Sequential?
No
No drop
Drop > 16%
Follow up Bone Scan Biopsy
Benign
OUT OF PHASE
Vertebral Vertebral BodyBody
Yes
Yes
Benign Benign Benign
Focal T1 low signalFocal T1 low signal
Is it low on T2?Is it low on T2?
No; Is there a halo?No; Is there a halo?Yes =Bone island/Yes =Bone island/Endplate Endplate ΔΔ
Yes: probableYes: probablemetmet
Is there central fat?Is there central fat?
Yes: redYes: redmarrowmarrow
No and smaller than 1 cm No and smaller than 1 cm or multifocal = Bone scanor multifocal = Bone scan
1-2 cm1-2 cmCTCT
>2cm out >2cm out of phaseof phase
DitzeDitzell
DISC SPACE INFECTIONDISC SPACE INFECTION Majority hematogenous spreadMajority hematogenous spread
Also post-opAlso post-op
Xray:Xray: Loss of disc height and erosions Loss of disc height and erosions Look for paraspinal mass in T spineLook for paraspinal mass in T spine
MR: MR: Loss of disc space height, but increased T2W signalLoss of disc space height, but increased T2W signal Endplate erosions or edemaEndplate erosions or edema Epidural abcess, may look like phlegmonEpidural abcess, may look like phlegmon Dark on T2 or have vacuum phenomenon- o/w DDDDark on T2 or have vacuum phenomenon- o/w DDD
Nuclear: gallium preferred Nuclear: gallium preferred
ADVANCED IMAGINGADVANCED IMAGING
Infections begin in endplateInfections begin in endplate Just beneath subchondral boneJust beneath subchondral bone
Concomitant osteomyelitis frequentConcomitant osteomyelitis frequent
Use overtness on T1Use overtness on T1
Epidural abscesses can look different Epidural abscesses can look different than abscesses elsewherethan abscesses elsewhere Have more of a phlegmon appearanceHave more of a phlegmon appearance
Infection
ORGANISMSORGANISMS
Usually mono-except 1/3 of TBUsually mono-except 1/3 of TB
Blood culturesBlood cultures positive in positive in 50%50%
Staph > 76%Staph > 76%
Strep 2Strep 2ndnd most common most common
TB: 5%TB: 5%
DISC SPACE INFECTIONDISC SPACE INFECTIONDDXDDX
Should not be anterior, skip, or show Should not be anterior, skip, or show extensive spread to psoas- o/w TBextensive spread to psoas- o/w TB
Should not spread to facets, or show new Should not spread to facets, or show new bone formation- o/w chronic or NP spinebone formation- o/w chronic or NP spine
Should not be dark on T2 or have vacuum Should not be dark on T2 or have vacuum phenomenon- o/w DDD or instabilityphenomenon- o/w DDD or instability
Other ddx:amyloid, subacute fractures, Other ddx:amyloid, subacute fractures, ank spondank spond
Instability
DISC SPACE INFECTIONDISC SPACE INFECTIONDDXDDX
Should not be anterior, skip, or show Should not be anterior, skip, or show extensive spread to psoas- o/w TBextensive spread to psoas- o/w TB
Should not spread to facets, or show new Should not spread to facets, or show new bone formation- o/w chronic or NP spinebone formation- o/w chronic or NP spine
Should not be dark on T2 or have vacuum Should not be dark on T2 or have vacuum phenomenon- o/w DDDphenomenon- o/w DDD
Other ddx: amyloid, subacute fractures, ank Other ddx: amyloid, subacute fractures, ank spondspond
Bright Bright T2 T2 endplateendplatessDisc Disc darkdark
Modic Modic II
Disc Disc BrightBright
GE for GE for vacuumvacuum
YesYes = = DDDDDD
Listhesis Listhesis = = InstabilityInstability
Abnl facetsAbnl facets== NPNP
O/W O/W infectioninfection
T2T2
SPREAD OF DISC SPREAD OF DISC INFECTIONSINFECTIONS
Adjacent disc Adjacent disc spacesspaces Most often TBMost often TB
FacetsFacets Atypical in Atypical in
infectionsinfections
PsoasPsoas
Through greater Through greater sciatic notchsciatic notch
Lumbar plexusLumbar plexus
Iliopsoas bursaIliopsoas bursa
Hip Hip
TB and ATYPICALTB and ATYPICAL Immigrants/HIV:Immigrants/HIV:
Massive worldwide frequencyMassive worldwide frequency Lung disease present but seeding site usually Lung disease present but seeding site usually
GI/GUGI/GU Looks like chronic/smoldering osteo difficult Looks like chronic/smoldering osteo difficult
ddxddx May be osteo, articular or spondyliticMay be osteo, articular or spondylitic In spine:In spine:
AnteriorAnterior Psoas abscessesPsoas abscesses May skip levels May skip levels May result in Gibbus deformityMay result in Gibbus deformity
Common superimposed pyogenicCommon superimposed pyogenic Often mimics typical discitisOften mimics typical discitis
Parasites and ST TB- ca++Parasites and ST TB- ca++
Lower than disc on T1Lower than disc on T1
Salt and pepperSalt and pepper== myeloma myeloma
Drops on Drops on out of phase out of phase == red red marrowmarrow
Check acetabulumCheck acetabulumand for bullseyesand for bullseyes
o/w carcinomatosis, leukemiao/w carcinomatosis, leukemia
Look for Look for nodes nodes ==lymphomalymphoma
If yes If yes benignbenign
if noif no
Diffuse marrowDiffuse marrow
MMMMSalt nSalt n’’peppapeppa
T1 T2
Early MMEarly MM Two years laterTwo years later
out
in in out
CMLCMLCML
T1 T2
Is this just weird normal Is this just weird normal marrow or multiple marrow or multiple
myeloma?myeloma?
MULTIPLE MYELOMA MR PATTERNSMULTIPLE MYELOMA MR PATTERNS
Multiple nearly similar sizedMultiple nearly similar sized
Small areas Small areas T2W T2W
Apparently red marrow (infiltration)Apparently red marrow (infiltration)
Salt and pepperSalt and pepper
May have too many or atypical location of May have too many or atypical location of fxsfxs
Focal lesion (plasmacytoma)Focal lesion (plasmacytoma)
Multiplemyelomaalmost nlExcept forplasmacytoma
T1
T2
MM normal except out-of-phase
T1
T2
out
Patchy Marrow on Patchy Marrow on T1/T2-ignore T2T1/T2-ignore T2
Check Check locationlocation
Peripherally Peripherally based =based = BenignBenign
Patchy Patchy Acetab Acetab also =also = BenignBenign
neither – in/out neither – in/out phasephase
Drop Drop <16%<16%
= Benign= BenignLess or not drop Less or not drop – Bone Scan or – Bone Scan or BXBX
Why is the marrow diffusely Why is the marrow diffusely dark on T1W images?dark on T1W images?
Skeletal carcinomatosisSkeletal carcinomatosis Too much normal red marrowToo much normal red marrow LymphomaLymphoma Gauchers and other infiltrativeGauchers and other infiltrative MyelofibrosisMyelofibrosis TransfusionsTransfusions Multiple myelomaMultiple myeloma
Skeletalcarcinomatosis
Red marrowRed marrow
WHY IS THE MARROW SO WHY IS THE MARROW SO BRIGHT ON A T1 WEIGHTED BRIGHT ON A T1 WEIGHTED
IMAGE?IMAGE? NormalNormal
Too little normal red marrowToo little normal red marrow
Prior radiation therapy or other Prior radiation therapy or other injuryinjury
Aplastic anemiaAplastic anemia
Normal distributionof red/fattymarrow
Aplastic anemia
RT andRT andMets outside fieldMets outside field
Why is the marrow so dark Why is the marrow so dark on T2W images?on T2W images?
NormalNormal Too much normal red marrowToo much normal red marrow AnemiaAnemia TransfusionsTransfusions Diffuse metsDiffuse mets LymphomaLymphoma
Red marrow
CML
Transfusions
Why is there edema about Why is there edema about the pedicle?the pedicle?
OAOA ParsPars MetMet Extension of endplate reactive Extension of endplate reactive
changechange
Is this a met or an Is this a met or an aggressive hemangioma?aggressive hemangioma?
atypical hemangiomasatypical hemangiomas
often ST massoften ST mass
often subtle T1often subtle T1
multifocalitymultifocality
Could that be a vacuum in Could that be a vacuum in the vertebral body? And the vertebral body? And what does that mean?what does that mean?
AVN AVN KUMMEL’S KUMMEL’S
FxFx CollapseCollapse Delayed Delayed collapse 2 collapse 2oo to AVN to AVN Vacuum accentuated on Vacuum accentuated on
extensionextension
Is that PagetIs that Paget’’s or a Met?s or a Met?
PAGET’SPAGET’S
Cortical thickeningCortical thickening Double horizontal line signDouble horizontal line sign ExpansionExpansion Peculiar T1/T2 patternsPeculiar T1/T2 patterns
Could that SchmorlCould that Schmorl’’s node s node be symptomatic?be symptomatic?
TYPES OF SCHMORL’STYPES OF SCHMORL’S
Juvenile: low T1/T2Juvenile: low T1/T2 Vascularized-adj edemaVascularized-adj edema Acute/Traumatic- also edemaAcute/Traumatic- also edema
Usually subacuteUsually subacute Neoplastic-usu. Inferior endplates/ Neoplastic-usu. Inferior endplates/
“chronic/slow growing” tumors “chronic/slow growing” tumors prostate/breastprostate/breast
Malignant Schmorl’s
Neuropathic spine