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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
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MARROW SIGNAL Diffuse Multifocal Focal (as far as you can see)
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CML cml
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Multiple myeloma
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T1 and T2 Low field QUESTION: What is the probability
that this is malignant ? 0% 20% 40% 60% 80% pagets
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Vertebral Marrow: Low Signal
T1 only Higher specificity Diffuse or focal within vertebral body Fracture? Be careful T2 useful only if dark or halo
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Multiple benign fractures
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Is this a benign or malignant fracture?
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breast met
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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
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Osteoporotic fractures
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Path fracture mm
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Compression? No Vertebral Body Yes No drop No Out-of-phase No Yes
Follow up Bone scan Biopsy Yes No Is the marrow diffusely involved? No drop Is fx line present? No Out-of-phase No Yes Sequential? Drop >16% Benign Benign Benign Benign
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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
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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
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Compression 2° mets T1 Axial T1 STIR
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Fx line= benign T1 T2
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PATHOLOGIC FRACTURE: 2° SIGNS
Extensive involvement posterior elements including pedicle Non-sequential Large soft tissue mass or peridural Atypical locations: L5 Dens Upper to mid Thoracic No fx line or vertical
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PATHOLOGIC FRACTURE: 2° SIGNS
No high signal in disc above Inferior > superior endplate ddx: metabolic bone disease No PLL avulsion Posterior bowing
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PATHOLOGIC FRACTURE: 2° SIGNS
No high signal in disc above Inferior > superior endplate Ddx: metabolic bone disease No PLL avulsion Posterior bowing Look for metastases elsewhere Look for benign fractures elsewhere
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Korn
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Benign fracture
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Path fracture
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T1 T2 fat sat Sequential
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T1 T2 fat sat Metastases Posterior bowing Multiple bodies Posterior
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Lung CA mets
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Soft tissue mass especially peridural
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Multiple Myeloma ALL FRACTURE LINES ARE NOT BENIGN Non horizontal
malignant fx T1 T2 Gad ALL FRACTURE LINES ARE NOT BENIGN Non horizontal
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Maligant inferior > superior
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PATHOLOGIC FRACTURE: 2° SIGNS
Look for metastases elsewhere Look for benign fractures elsewhere Remember curse of epidemiology
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Pathologic fracture
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lymphoma
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T1 T1 in out Mets and malignant fx
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T1 T2 Gad PLL avulsion Sequential location Complete fat/
degenerated disc T1 T2 Gad
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Fracture and Met *No enhancement T1 T2 Gado
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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)
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Breast path fracture
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REMEMBER: ***Be cautious and follow-up***
Hyperacute traumatic/osteoporotic Fractures can look malignant ***Be cautious and follow-up***
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Burst fracture mimking met
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Acute osteoporotic mimic mets
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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
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T1 T2 in out Xrt with out of phase
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(also treatment response):
CT signs of benignity (also treatment response): Sclerotic margins Central fat Typical Ca++ Treated mm with sclerotic rims
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Treated MM
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Benign fracture uses of gad
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T GAD T CT
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Kummel’s
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3 weeks later Fx f/u
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Two months later initial
See scan 2 months before-acute fracture in feb Two months later initial
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When should I not worry about a vertebra plana?
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Leukemia T2 T1
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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
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plana
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T1 T2 Gad Lymphoma
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plana
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T1 T2
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Malignant plana
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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
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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
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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
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ALL, treated with 2nd necrosis
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LOW SIGNAL DITZEL Single ditzel: Multiple ditzels: <1cm: CT
>1cm: in and out of phase +/- thin slice MR >2cm: x-ray vs bone scan Multiple ditzels: <1cm: halo/ bullseye consider bone scan >1cm: bone scan vs. biopsy IF indeterminate, still low probability and f/u Moderate to High probability, need biopsy
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Bone island-does not drop
In phase is not a substitute for T1
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T1W T2W (halo) Diffusion out of phase
Breast met
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L5 ditzel Subtle halo
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T2- central high signal indeterminate
T1-halo= benign
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Lung mets
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Rim bright on T1W Center bright on T2W
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Lung mets
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T2W gad Is there a role for contrast In short no Only to see
epidural component T2W gad
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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
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T1 Bone island T2 T1
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mets Malig schorl’s T1 Gad T2
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T1 T2 Sclerotic mets
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Sclerotic breast mets
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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
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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
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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
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T1 T2 Question: What is the probability that this is malignant? 20%
50% 75% 90% Lymphoma contiguous
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Breat met
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HALO AND BULLSEYE SIGNS periphery/center of a focal lesion
HALOs T1: Benign T2: Malignant Bullseye sign = focal central fat Also benign Bullseye sign = central fluid Usually benign
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in out Halo on out only
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Mets variable sizes
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SUBSETS OF METS Large soft tissue mass Calcification Isolated
Thyroid, renal, hepatoma Calcification GI, usually colon Isolated Renal, breast Skeletal carcinomatosis Breast, prostate Distal Breast, renal If femur, lung Soft tissue Breast, lymphoma Cortical Lung Across joints/disc MM, prostate, lymphoma
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MM across (around) disc space
T1 Gad MM across (around) disc space
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DISC SPACE INFECTIONS Usually bad luck Only a fraction immune function
Only slight increase in DM Usually goes to only slightly degenerated disc vs. septic arthritis 2 º to transient bacteremia from skin or dental Often partially treated May result in peculiar appearances
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Post op infection
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DISC SPACE INFECTION Majority hematogenous spread Xray: MR:
Also post-op Xray: Loss of disc height and erosions Look for paraspinal mass in T spine MR: Loss of disc space height, but increased T2W signal Endplate erosions or edema Epidural abcess, may look like phlegmon Dark on T2 or have vacuum phenomenon- o/w DDD Nuclear: gallium preferred
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infection
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Infection indium and sulfa colloid
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ADVANCED IMAGING Infections begin in endplate
Just beneath subchondral bone Concomitant osteomyelitis frequent Use overtness on T1 Epidural abscesses can look different than abscesses elsewhere Have more of a phlegmon appearance
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Disc infection s/p tx
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Infection
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ORGANISMS Usually mono-except 1/3 of TB Blood cultures positive in 50%
Staph > 76% Strep 2nd most common TB: 5%
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disciits
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Np spine no ghost sign
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Atypical myco
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Disc space infection
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DISC SPACE INFECTION DDX
Should not be anterior, skip, or show extensive spread to psoas- o/w TB Should not spread to facets, or show new bone formation- o/w chronic or NP spine Should not be dark on T2 or have vacuum phenomenon- o/w DDD or instability Other ddx:amyloid, subacute fractures, ank spond
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tb
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Disc space infection
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Facet effusion with cyst
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Midic/isstabil Instability
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DISC SPACE INFECTION DDX
Should not be anterior, skip, or show extensive spread to psoas- o/w TB Should not spread to facets, or show new bone formation- o/w chronic or NP spine Should not be dark on T2 or have vacuum phenomenon- o/w DDD Other ddx: amyloid, subacute fractures, ank spond
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Ank spond
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amyloid
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Is this infection or… Segmental instability Bad Modic I change
Neuropathic spine
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Instability occult on MR
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Bright T2 endplates T2 Listhesis = Instability Disc dark Disc Bright Abnl facets= NP GE for vacuum Modic I O/W infection Yes = DDD
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SPREAD OF DISC INFECTIONS
Adjacent disc spaces Most often TB Facets Atypical in infections Psoas Through greater sciatic notch Lumbar plexus Iliopsoas bursa Hip
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Facet infection
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TB and ATYPICAL Immigrants/HIV:
Massive worldwide frequency Lung disease present but seeding site usually GI/GU Looks like chronic/smoldering osteo difficult ddx May be osteo, articular or spondylitic In spine: Anterior Psoas abscesses May skip levels May result in Gibbus deformity Common superimposed pyogenic Often mimics typical discitis Parasites and ST TB- ca++
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Pott’s
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tb
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tb
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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
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MM Salt n’ peppa T2 T1
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Two years later Early MM in out in out
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CML CML T1 T2
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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)
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T1 T2 Multiple myeloma almost nl Except for plasmacytoma
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T1 T2 out MM normal except out-of-phase
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Patchy Marrow on T1/T2-ignore T2
neither – in/out phase Check location Peripherally based = Benign Drop <16% = Benign Less or not drop – Bone Scan or BX Patchy Acetab also = Benign
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Why is there fluid in that facet joint?
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No, still likely OA vs. Instability
Facet Fluid Focal Bilat Multifocal OA NP < lower = OA Focal Nl Geodes?/Spurs? Yes = OA No, still likely OA vs. Instability
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Septic facet joint
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Why is the marrow diffusely dark on T1W images?
Skeletal carcinomatosis Too much normal red marrow Lymphoma Gauchers and other infiltrative Myelofibrosis Transfusions Multiple myeloma
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Skeletal carcinomatosis
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Red marrow
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Carcinomatatous lowt2
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WHY IS THE MARROW SO BRIGHT ON A T1 WEIGHTED IMAGE?
Normal Too little normal red marrow Prior radiation therapy or other injury Aplastic anemia
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Normal distribution of red/fatty marrow Normal fatty mimiking rt
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Aplastic anemia
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Increased fatty with red above s/p rt
RT and Mets outside field
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Why is the marrow so dark on T2W images?
Normal Too much normal red marrow Anemia Transfusions Diffuse mets Lymphoma
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Red marrow
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CML cml
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Transfusions
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Why is there edema about the pedicle?
OA Pars Met Extension of endplate reactive change
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Pedicale edema from facet OA
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Facet edema from OA
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Thyroid ca with large soft tissue mass
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Is this a met or an aggressive hemangioma?
atypical hemangiomas often ST mass often subtle T1 multifocality
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Could that be a vacuum in the vertebral body? And what does that mean?
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charcot
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AVN KUMMEL’S Fx Collapse Delayed collapse 2o to AVN
Vacuum accentuated on extension
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Kummel’s
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Is that Paget’s or a Met?
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PAGET’S Cortical thickening Double horizontal line sign Expansion
Peculiar T1/T2 patterns
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met
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Could that Schmorl’s node be symptomatic?
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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
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Malignant Schmorl’s
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Neuropathic spine
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