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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