Download presentation
Presentation is loading. Please wait.
1
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
2
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
3
MARROW SIGNAL Diffuse Multifocal Focal (as far as you can see)
4
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
5
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
6
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
7
CML CML T1 T2
8
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
9
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)
10
Two years later Early MM in out in out
11
T1 T2 out MM normal except out-of-phase
12
MM Salt n’ peppa T2 T1
13
T1 T2 Multiple myeloma almost nl Except for plasmacytoma
14
Multiple myeloma
15
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
16
T1 and T2 Low field pagets
17
The probability that this is malignant 30% 50% 66% 85%
d
18
Is this a benign or malignant fracture?
20
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
21
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
23
Osteoporotic fractures
25
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
26
Compression 2° mets T1 Axial T1 STIR
27
Fx line= benign T1 T2
28
PATHOLOGIC FRACTURE: 2° SIGNS
No high signal in disc above Inferior > superior endplate ddx: metabolic bone disease No PLL avulsion Posterior bowing
30
Benign fracture
33
Path fracture
34
T1 T2 fat sat Sequential
35
T1 T2 fat sat Metastases Posterior bowing Multiple bodies Posterior
36
Lung CA mets
37
Soft tissue mass especially peridural
38
Maligant inferior > superior
39
T1 T2 Gad Probability that this is malignant 30% 50% 65% 90% c
40
PATHOLOGIC FRACTURE: 2° SIGNS
Look for metastases elsewhere Look for benign fractures elsewhere Remember curse of epidemiology
41
Pathologic fracture
42
lymphoma
43
T1 T2 Gad PLL avulsion Sequential location Complete fat/
degenerated disc T1 T2 Gad
44
Fracture and Met *No enhancement T1 T2 Gado
45
This is a malignant fx This is a benign, acute fx I can’t tell Show me a plain film before I decide
46
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)
47
Breast path fracture
48
Probability that this is malignant 25% 40% 65% 85%
c Probability that this is malignant 25% 40% 65% 85%
49
REMEMBER: ***Be cautious and follow-up***
Hyperacute traumatic/osteoporotic Fractures can look malignant ***Be cautious and follow-up***
50
Acute osteoporotic mimic mets
51
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
52
T1 T2 in out Xrt with out of phase
53
(also treatment response):
CT signs of benignity (also treatment response): Sclerotic margins Central fat Typical Ca++ Treated mm with sclerotic rims
54
Treated MM
55
Benign fracture ues of gad
56
T GAD T CT
57
Kummel’s
58
3 weeks later Fx f/u Probability that this is malignant 25% 45% 65%
85% b 3 weeks later Fx f/u
59
Two months later initial
See scan 2 months before-acute fracture in feb Two months later initial
60
This is a vertebra plana This is subacute This patient must have
osteoporosis D. All the above d
61
When should I not worry about a vertebra plana?
62
Leukemia T2 T1
63
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
64
plana
65
T1 T2 Gad Lymphoma
66
plana
67
T1 T2
69
Malignant plana
70
THE CHANCE THAT THIS IS BENIGN 10% 30% 60% 85%
d THE CHANCE THAT THIS IS BENIGN 10% 30% 60% 85%
71
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
73
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
74
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
75
ALL, treated with 2nd necrosis
76
T In Out MM
78
Bone island-does not drop
In phase is not a substitute for T1
79
T1W T2W (halo) Diffusion out of phase
Breast met
80
L5 ditzel Subtle halo
81
T1 T2
82
Lung mets
83
Rim bright on T1W Center bright on T2W
85
Lung mets
86
T2W gad Is there a role for contrast In short no Only to see
epidural component T2W gad
87
Sclerotic mets can mimic bone islands
Sclerotic mets infrequently fracture PET has few false negatives Cannot be seen after treatment c
88
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)
89
T1 Bone island T2 T1
91
mets Malig schorl’s T1 Gad T2
92
T1 T2 Sclerotic mets
93
Sclerotic breast mets
94
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
95
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
96
Breat met
97
This happened to this patient in adolescence
This patient has osteoporosis This patient may have metasases All the above
98
Could that Schmorl’s node be symptomatic?
100
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
104
Malignant Schmorl’s
105
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
106
Neuropathic spine
Similar presentations
