Imaging of Normal and Abnormal Vertebral bone Marrow

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1 Imaging of Normal and Abnormal Vertebral bone Marrow Dr Philippa Tyler Consultant Radiologist The Royal National Orthopaedic Hospital, Stanmore

2 Systematic review marrow change (fat / oedema/ sclerosis/fibrosis/ infiltration) focal / diffuse? End plate related Vertebral morphology SPINE MARROW MRI: UKRC

3 Introduction variety of signal changes: 1. may be normal 2. abnormal and insignificant 3. abnormal and significant malignancy infection inflammation SPINE MARROW MRI: UKRC

4 Marrow Signal T1 T2 FAT BRIGHT BRIGHT OEDEMA/INFILTRATION DARK BRIGHT SCLEROSIS/FIBROSIS DARK DARK SPINE MARROW MRI: UKRC

5 Associated vertebral morphology MORPHOLOGY FOCAL END PLATE DEFECT SCHMORL S NODE EXAMPLE VERTEBRAL BODY COLLAPSE OSTEOPOROTIC / PATHOLOGICAL VERTEBRAL ENLARGEMENT PAGET S Marrow abnormalities may be focal or diffuse SPINE MARROW MRI: UKRC

6 1. Marrow Fat SPINE MARROW MRI: UKRC

7 1. Marrow Fat increased T1W SI increased T2W SI normal marrow SI on fat suppressed sequences mostly insignificant aplastic anaemia SPINE MARROW MRI: UKRC

8 Red to yellow marrow conversion SPINE MARROW MRI: UKRC

9 Normal Marrow Fat dependent upon ratio of fatty : haemopoietic increases with age SPINE MARROW MRI: UKRC

10 Normal marrow fat: elderly heterogeneous increased fat content SPINE MARROW MRI: UKRC

11 Normal Marrow fat: healed collapse healed L1 osteoporotic collapse SPINE MARROW MRI: UKRC

12 Increased marrow fat: Normal morphology T1 and T2 hyperintense diffuse T12 haemangioma SPINE MARROW MRI: UKRC

13 Increased marrow fat: Normal morphology PMH B-cell lymphoma Healed lesion T11 markedlyt1 and T2 hyperintense marrow following healing of neoplastic lesions inflammatory lesions SPINE MARROW MRI: UKRC

14 Increased marrow fat: Normal morphology PMH L4 plasmacytoma RT L3-L5 Fatty marrow post RT SPINE MARROW MRI: UKRC

15 Increased marrow fat: Vertebral enlargement end-stage Paget s disease SPINE MARROW MRI: UKRC

16 Focal fatty Marrow Normal vertebral morphology related to basivertebral vein children/young adults SPINE MARROW MRI: UKRC

17 Focal fatty Marrow Normal vertebral morphology islands of fatty marrow older individuals SPINE MARROW MRI: UKRC

18 Focal fatty Marrow Normal vertebral morphology Haemangioma extremely common frequently multiple SPINE MARROW MRI: UKRC

19 Focal fatty marrow Related to the end plate Modic Type 2 associated with DDD SPINE MARROW MRI: UKRC

20 Focal fatty marrow: Enthesis healed/sub-clinical enthesopathy disc normal or degenerate SPINE MARROW MRI: UKRC

21 Focal fatty marrow: Focal end plate defect Schmorl s node very common SPINE MARROW MRI: UKRC

22 Focal fatty marrow: Focal end plate defect anterior limbus lesion disc prolapse deep to ring apophysis young adolescents Thoraco-lumbar SPINE MARROW MRI: UKRC

23 2. Marrow Fibrosis SPINE MARROW MRI: UKRC

24 2. Marrow Fibrosis characterised by reduced T1W SI reduced T2W SI normal marrow SI on fat suppressed sequences mostly insignificant focal-do not mistake for sclerotic metastasis diffuse-myelofibrosis SPINE MARROW MRI: UKRC

25 Focal marrow fibrosis: Normal vertebral morphology focal mild T1W and T2W SI reduction differential diagnosis: sclerotic metastasis no surrounding reactive change scintigraphy/ct normal SPINE MARROW MRI: UKRC

26 Diffuse marrow fibrosis: Normal vertebral morphology Myelofibrosis Diffuse, patchy Reduction of marrow SI SPINE MARROW MRI: UKRC

27 Diffuse marrow fibrosis: vertebral enlargement Paget s disease patchy reduction of marrow SI late stage of disease fibrosis and sclerosis NB: reduced T1W SI with ST mass Paget s sarcoma SPINE MARROW MRI: UKRC

28 3. Marrow Sclerosis SPINE MARROW MRI: UKRC

29 3. Marrow Sclerosis characterised by reduced T1W SI reduced T2W SI reduced marrow SI on fat suppressed sequences may be significant sclerotic metastasis osteitis (CRMO/SAPHO) SPINE MARROW MRI: UKRC

30 Marrow Sclerosis: Related to end plate Modic Type 3 advanced DDD SPINE MARROW MRI: UKRC

31 Marrow Sclerosis: Related to end plate Visible on CT and xrays SPINE MARROW MRI: UKRC

32 Marrow Sclerosis Multiple lesions - metastases Sclerotic metastases breast or prostate commonly mixed lytic sclerotic SPINE MARROW MRI: UKRC

33 Marrow Sclerosis Multiple lesions - metastases halo sign on T2W sensitivity 75% specificity 99.5% SPINE MARROW MRI: UKRC

34 Marrow Sclerosis: Metastases differentiation from marrow fibrosis CT will be abnormal SPINE MARROW MRI: UKRC

35 Marrow Sclerosis Vertebral enlargement End-stage Paget s disease SPINE MARROW MRI: UKRC

36 Marrow Sclerosis Vertebral enlargement End stage Paget s disease PF: ivory vertebra CT: osteitis Scintigraphy: intense activity SPINE MARROW MRI: UKRC

37 Marrow Sclerosis Osteitis (CRMO/SAPHO) Chronic Recurrent Multifocal Osteomyelitis non-bacterial inflammatory bone condition children back pain SPINE MARROW MRI: UKRC

38 Marrow sclerosis SAPHO SAPHO osteitis optimally demonstrated on CT may see vertebral collapse SPINE MARROW MRI: UKRC

39 4. Marrow Oedema SPINE MARROW MRI: UKRC

40 4. Marrow Oedema characterised by reduced T1W SI normal or increased T2W SI increased marrow SI on fat suppressed sequences mostly significant infection inflammation-spondyloarthropathy reactive-tumour (OO/OB) SPINE MARROW MRI: UKRC

41 Marrow Oedema vertebral collapse acute osteoporotic collapse residual oedema in VB SPINE MARROW MRI: UKRC

42 Marrow Oedema vertebral collapse Benign vs pathological: residual fatty marrow no ST mass other OPC fluid sign: 40% of OP# 6% of path# P<0.001 SPINE MARROW MRI: UKRC

43 Marrow oedema related to end plate Modic Type 1 associated with DDD progresses with time to Type 2 SPINE MARROW MRI: UKRC

44 Marrow oedema focal end plate defect Schmorl s node SPINE MARROW MRI: UKRC

45 Marrow oedema focal end plate defect Schmorl s node diffusely oedematous VB SPINE MARROW MRI: UKRC

46 Marrow oedema centered on the intervertebral disc pyogenic discitis extensive vertebral oedema end-plate destruction hyperintense disc epidural mass SPINE MARROW MRI: UKRC

47 Marrow oedema: multifocal Gad TB discitis/osteomyelitis multilevel noncontiguous disease isolated VB lesions not uncommon SPINE MARROW MRI: UKRC

48 Marrow oedema: multifocal SAPHO hyperostosis optimally demonstrated on CT multilevel involvement common look for anterior chest wall involvement costo-vertebral arthropathy SPINE MARROW MRI: UKRC

49 Marrow oedema related to enthesis earliest sign of seronegative spondyloarthropathy Romanus lesion SPINE MARROW MRI: UKRC

50 Marrow oedema reactive OO/OB: diagnose with CT scintigraphy SPINE MARROW MRI: UKRC

51 5. Marrow infiltration SPINE MARROW MRI: UKRC

52 5. Marrow infiltration reduced T1W SI normal or increased T2W SI increased marrow SI on fat suppressed sequences mostly significant malignant-metastasis/myeloma/lymphoma reconversion-chronic anaemia SPINE MARROW MRI: UKRC

53 Marrow infiltration: abnormal morphology malignant marrow replacement metastasis Renal Ca SPINE MARROW MRI: UKRC

54 Marrow infiltration: abnormal morphology and ST mass malignant marrow replacement Metastasis Myxoid liposarcoma SPINE MARROW MRI: UKRC

55 Marrow infiltration: normal morphology or collapse malignant marrow replacement myeloma SPINE MARROW MRI: UKRC

56 Marrow infiltration: normal morphology malignant marrow replacement myeloma Variegated pattern SPINE MARROW MRI: UKRC

57 Marrow infiltration: normal morphology primary vertebral tumours vascular haemangioma characterise with CT SPINE MARROW MRI: UKRC

58 Marrow infiltration: vertebral collapse primary vertebral tumours aggressive haemangioma SPINE MARROW MRI: UKRC

59 Marrow infiltration: vertebral collapse primary vertebral tumours GCT consider when profound T2W hypointensity SPINE MARROW MRI: UKRC

60 Marrow infiltration: soft tissue mass primary vertebral tumours chordoma hyperintense T2W lobular contour posterior VB SPINE MARROW MRI: UKRC

61 Marrow Infiltration diffuse marrow replacement bright disc sign on T1W malignancy metastasis myeloma lymphoma/leukaemia severe marrow reconversion chronic anaemias SPINE MARROW MRI: UKRC

62 CONCLUSIONS a large variety of marrow SI changes are seen on lumbar spine MRI majority have classical appearances fatty change or marrow infiltration oedematous VB when not degenerative or infective, look for cause CT accurate diagnosis is essential for correct management SPINE MARROW MRI: UKRC

63 ? Schmorl s node SPINE MARROW MRI: UKRC

64 Infective spondylodiscitis SPINE MARROW MRI: UKRC

65 Pre-sacral mass SPINE MARROW MRI: UKRC

66 No biopsy needed SPINE MARROW MRI: UKRC

67 ? Diagnosis SPINE MARROW MRI: UKRC

68 Check T1 SPINE MARROW MRI: UKRC

69 Additional modalities SPINE MARROW MRI: UKRC

70 Diffusion weighted MRI: spinal met or benign collapse? On the b800 DWI image the increased signal intensity (restricted diffusion) in the T11, L1 and L2 vertebral bodies is consistent with metastatic lesions absence of high signal intensity in the collapsed L4 vertebral body indicates a benign vertebral collapse. SPINE MARROW MRI: UKRC

71 SPINE MARROW MRI: UKRC

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