Spine Marrow: Pathologic Fractures and Ditzels

1. Spine Marrow:Pathologic Fractures and Ditzels Mark E. Schweitzer, M.D.Chair and Professor of Radiology The University of Stony Brook Editor in Chief JMRI

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

3. CML

4. Multiple myeloma

5. T1 and T2 Low field • QUESTION: • What is the probability • that this is malignant ? • 0% • 20% • 40% • 60% • 80%

6. Vertebral Marrow: Low Signal • T1 only • Higher specificity • Diffuse or focal within vertebral body • Fracture? • Be careful • T2 useful only if dark or halo

7. Multiple benign fractures

8. Is this a benign or malignant fracture?

10. Trauma 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 BENIGN FRACTURES NO NOT IGNORE MORPHOLOGY

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

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

17. Compression 2° mets T1 Axial T1 STIR

18. Fx line= benign T1 T2

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

24. T1 T2 fat sat Sequential

25. T1 T2 fat sat • Metastases • Posterior bowing • Multiple bodies • Posterior

26. Lung CA mets

27. Soft tissue mass • especially peridural

28. Multiple Myeloma malignant fx T1 T2 Gad ALL FRACTURE LINES ARE NOT BENIGN Non horizontal

29. Maligant inferior > superior T1 T2

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

31. Pathologic fracture

33. Fracture and Met *No enhancement T1 T2 Gado

34. VERTEBRAL FACTURESDO NOT IGNORE LOCATIONRisk of Malignancy R I S K O F M E T • Jefferson • Teardrop (cervical) • Chance • Odontoid • Burst • Plana • Anterior compression • Atypical compression (r > l side, upper to mid T)

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

38. Acute osteoporotic mimic mets

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

40. CT signs of benignity • (also treatment response): • Sclerotic margins • Central fat • Typical Ca++

41. Treated MM

42. Benign fracture uses of gad

43. 3 weeks later Fx f/u

44. Two months later initial

45. When should I not worry about a vertebra plana?

46. Leukemia T2 T1

47. 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

48. plana

49. T2 T1 Gad Lymphoma