Spine Marrow: Pathologic Fractures and Ditzels Mark E. Schweitzer, M.D. Chief of Radiology Hospital The Ottawa Hospital Professor of Radiology The University of Ottawa

The most likely to be metastatic is A B C D Breast met a more than D since D is cervial spine The most likely to be metastatic is A B C D

MARROW SIGNAL Diffuse Multifocal Focal (as far as you can see)

This is a child with congenital anemia This is a normal child This is a child with congenital anemia This could be indolent multiple myeloma This is skeletal carcinomatosis

Diffuse marrow Lower than disc on T1 Drops on Salt and pepper out of phase = red marrow Salt and pepper = myeloma Look for nodes = lymphoma Check acetabulum and for bullseyes If yes benign if no o/w carcinomatosis, leukemia

This could be sickle cell All the above This could be anemia This could be CML This could be gauchers This could be sickle cell All the above

CML CML T1 T2

This could be skeletal carcinamatosis This is normal marrow This patient is anemic This could be skeletal carcinamatosis This is multiple myeloma and of low grade

Is this just weird normal marrow or multiple myeloma? MULTIPLE MYELOMA MR PATTERNS Multiple nearly similar sized Small areas  T2W Apparently red marrow (infiltration) Salt and pepper May have too many or atypical location of fxs Focal lesion (plasmacytoma)

Two years later Early MM in out in out

T1 T2 out MM normal except out-of-phase

MM Salt n’ peppa T2 T1

T1 T2 Multiple myeloma almost nl Except for plasmacytoma

Multiple myeloma

Focal Vertebral Marrow: Low Signal T1 only Higher specificity Diffuse in a vertebrae or portion of marow Fracture? Be careful T2 useful only if dark or halo

T1 and T2 Low field pagets

The probability that this is malignant 30% 50% 66% 85% d

Is this a benign or malignant fracture?

BENIGN FRACTURES NO NOT IGNORE MORPHOLOGY Osteoporosis Trauma T score Cervical M > F Younger Thoracic Slightly older Usually below T7 Lumbar Older yet Osteoporosis A type of trauma Not cervical T7 and below Most at T10-L4 Most common L2 Most likely not to be benign L5 T score > -2.5 Only 1/3 of fragility NO NOT IGNORE MORPHOLOGY

Compression? Yes No Benign Benign Benign Benign Vertebral Body Is the marrow diffusely involved? Follow up Bone Scan Biopsy Yes No Fracture line? OUT OF PHASE No drop NO Sequential? Yes Drop > 16% Benign Benign Benign Benign

Osteoporotic fractures

PATHOLOGIC FRACTURE: 2° SIGNS (I) Extensive involvement posterior elements including pedicle Non-sequential Large soft tissue mass or peridural Atypical locations: L5 Dens Upper to mid Thoracic Atypical appearance (one side worse, “irregular”) No fx line- or vertical

Compression 2° mets T1 Axial T1 STIR

Fx line= benign T1 T2

PATHOLOGIC FRACTURE: 2° SIGNS No high signal in disc above Inferior > superior endplate ddx: metabolic bone disease No PLL avulsion Posterior bowing

Benign fracture

Path fracture

T1 T2 fat sat Sequential

T1 T2 fat sat Metastases Posterior bowing Multiple bodies Posterior

Lung CA mets

Soft tissue mass especially peridural

Maligant inferior > superior

T1 T2 Gad Probability that this is malignant 30% 50% 65% 90% c

PATHOLOGIC FRACTURE: 2° SIGNS Look for metastases elsewhere Look for benign fractures elsewhere Remember curse of epidemiology

Pathologic fracture

lymphoma

T1 T2 Gad PLL avulsion Sequential location Complete fat/ degenerated disc T1 T2 Gad

Fracture and Met *No enhancement T1 T2 Gado

This is a malignant fx This is a benign, acute fx I can’t tell Show me a plain film before I decide

VERTEBRAL FACTURES DO NOT IGNORE LOCATION Risk of Malignancy Jefferson Teardrop (cervical) Chance Odontoid Burst Plana Anterior compression Atypical compression (r > l side, upper to mid T)

Breast path fracture

Probability that this is malignant 25% 40% 65% 85% c Probability that this is malignant 25% 40% 65% 85%

REMEMBER: ***Be cautious and follow-up*** Hyperacute traumatic/osteoporotic Fractures can look malignant ***Be cautious and follow-up***

Acute osteoporotic mimic mets

If I am not sure, what should I do? Out of phase Follow-up/old films Tumor does not rapidly evolve Bone scan Thin slice CT X-ray Contrast Diffusion/perfusion/spectro

T1 T2 in out Xrt with out of phase

(also treatment response): CT signs of benignity (also treatment response): Sclerotic margins Central fat Typical Ca++ Treated mm with sclerotic rims

Treated MM

Benign fracture ues of gad

T1 GAD T2 CT

Kummel’s

3 weeks later Fx f/u Probability that this is malignant 25% 45% 65% 85% b 3 weeks later Fx f/u

Two months later initial See scan 2 months before-acute fracture in feb Two months later initial

This is a vertebra plana This is subacute This patient must have osteoporosis D. All the above d

When should I not worry about a vertebra plana?

Leukemia T2 T1

VERTEBRA PLANA >75% loss of height Usually equal posterior and anterior ddx: Eosinophilic granuloma Metastases Osteoporotic fractures No more common to be malignant than more typical fractures Look at the rest of the spine

plana

T1 T2 Gad Lymphoma

plana

T1 T2

Malignant plana

THE CHANCE THAT THIS IS BENIGN 10% 30% 60% 85% d THE CHANCE THAT THIS IS BENIGN 10% 30% 60% 85%

What do I do with a low signal ditzel on a T1W image? If a portion of the vertebral body, different rules and lower threshold

Ditzel Focal T1 low signal Is it low on T2 is there a halo Yes probable met Bone island/ Endplate ^ >2cm out of phase Is there central fat Yes, red marrow 1-2 cm CT No and smaller then 1 cm or multifocal = Bone scan

Ditzel Focal T1 low signal Is it low on T2? Yes: probable met No; Is there a halo? Yes: probable met Yes =Bone island/ Endplate Δ >2cm out of phase does not ddx lesions Is there central fat? Yes: red marrow 1-2 cm CT No and smaller than 1 cm or multifocal = Bone scan

ALL, treated with 2nd necrosis

T1 In Out MM

Bone island-does not drop In phase is not a substitute for T1

T1W T2W (halo) Diffusion out of phase Breast met

L5 ditzel Subtle halo

T1 T2

Lung mets

Rim bright on T1W Center bright on T2W

Lung mets

T2W gad Is there a role for contrast In short no Only to see epidural component T2W gad

Sclerotic mets can mimic bone islands Sclerotic mets infrequently fracture PET has few false negatives Cannot be seen after treatment c

Is that a bone island or a sclerotic met? Many sclerotic mets are not that low on T2W √ for reactive interface and homogeneity Size also, but helps to a lesser degree One way mets heal is with sclerosis (vs fatty conversion)

T1 Bone island T2 T1

mets Malig schorl’s T1 Gad T2

T1 T2 Sclerotic mets

Sclerotic breast mets

Compression? Yes No Benign Benign Benign Benign Vertebral Body Is the marrow diffusely involved? Follow up Bone Scan Biopsy Yes No Fracture line? OUT OF PHASE No drop NO Sequential? Yes Drop > 16% Benign Benign Benign Benign

Ditzel Focal T1 low signal Is it low on T2? Yes: probable met No; Is there a halo? Yes =Bone island/ Endplate Δ Is there central fat? >2cm out of phase Yes: red marrow 1-2 cm CT No and smaller than 1 cm or multifocal = Bone scan

Breat met

This happened to this patient in adolescence This patient has osteoporosis This patient may have metasases All the above

Could that Schmorl’s node be symptomatic?

TYPES OF SCHMORL’S Juvenile: low T1/T2 Vascularized-adj edema Acute/Traumatic- also edema Usually subacute Neoplastic-usu. Inferior endplates/ “chronic/slow growing” tumors prostate/breast

Malignant Schmorl’s

This is a diffuse marrow disorder This is Paget’s This is lymphoma osteopetrosis This is a diffuse marrow disorder This is Paget’s This is lymphoma This is Multiple Myeloma

Neuropathic spine