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