Bony Lesion, Aggressive

Bony Lesion, Aggressive
Lubdha M. Shah, MD
DIFFERENTIAL DIAGNOSIS
Common
  • Metastases, Lytic Osseous
  • Metastases, Blastic Osseous
  • Lymphoma
  • Multiple Myeloma
  • Osteomyelitis, Pyogenic
  • Osteomyelitis, Granulomatous
Less Common
  • Degenerative Endplate Changes
  • Accelerated Degeneration
  • Schmorl Node
  • Langerhans Cell Histiocytosis
Rare but Important
  • Spondyloarthropathy, Hemodialysis
  • Neurogenic (Charcot) Arthropathy
ESSENTIAL INFORMATION
Key Differential Diagnosis Issues
  • Bone destruction (tumor, infection) vs. remodeling, short transition zone (degenerative disc disease)
Helpful Clues for Common Diagnoses
  • Metastases, Lytic Osseous
    • Lytic, permeative diffusely enhancing lesion destroys posterior cortex & pedicle
    • T1 hypointense/T2 hypo ⇒ hyperintense, T2 hyperintense rim surrounding hypointense met
  • Metastases, Blastic Osseous
    • Sclerotic lesion destroys posterior cortex & pedicle
    • T1/T2 hypointense with variable enhancement depending on degree of sclerosis
  • Lymphoma
    • Lytic, permeative bone destruction may cross disc spaces
    • T1 hypointense, T2 iso-/hyperintense, & diffuse uniform enhancement
    • ± Soft tissue mass
  • Multiple Myeloma
    • Multifocal lytic lesions with cortical disruption & extraosseous soft tissue component
      • Pedicle involvement is late
    • Compression fractures with variable canal narrowing
      • 67% appear benign
  • Osteomyelitis, Pyogenic
    • Ill-defined T1 hypointensity in vertebral marrow with loss of adjacent endplate delineation
    • T2/STIR hyperintense marrow
    • Endplate osteolytic/osteosclerotic changes on CT & vertebral collapse
    • Disc space narrowing & enhancement
    • ± Paraspinal/epidural infiltrative soft tissue with loculated fluid (75%)
  • Osteomyelitis, Granulomatous
    • Tuberculous spondylitis shows vertebral collapse & large paraspinal abscess (± calcification)
      • ± Destruction of disc
      • Isolated posterior element involvement
    • Brucellar spondylitis shows anterosuperior epiphysitis (L4) with associated sacroiliitis
      • Intervertebral disc destruction & relatively intact vertebrae
    • Multiple (non)contiguous vertebrae with endplate irregularity & osteolysis
    • Enhancement of epidural soft tissue mass, marrow, disc, dura, subligamentous soft tissues
    • Chronically shows fusion across disc space
Helpful Clues for Less Common Diagnoses
  • Degenerative Endplate Changes
    • Loss of disc space height, loss of horizontal nuclear cleft on T2WI, linear disc enhancement
      • No bone destruction
      • Vacuum phenomenon (low T1/T2 signal)
    • Type 1: T1 hypo-/T2 hyperintense, may show prominent enhancement
      • Inflammatory in orgin, but association with lower back pain controversial
      • Associate with segmental instability with good clinical outcome following fusion
    • Type 2: T1/T2 hyperintense
    • Type 3: T1/T2 hypointense, sclerosis on CT & radiographs
  • Accelerated Degeneration
    • Degenerative changes of disc space/facets at levels adjacent to surgical fusion & congenital segmentation anomalies
      • Most common finding at adjacent segment is disc degeneration
      • No bone destruction
    • Response to altered biomechanical stresses
      • ↑ Intradiscal pressure, ↑ facet loading, & ↑ mobility occur after fusion implicated in causing adjacent segment disease
      • Rate of symptomatic adjacent segment disease ↑ with transpedicular instrumentation (12.2-18.5%)
      • Fusion with other forms of instrumentation or with no instrumentation (5.2-5.6%)
      • Risk factors: Instrumentation, fusion length, sagittal malalignment, facet injury, age, & pre-existing degenerative changes
  • Schmorl Node
    • Focal invagination of vertebral endplate by disc material
      • Low T1/high T2 signal in adjacent marrow if acute
      • Diffuse marrow enhancement if acute, marginal enhancement if subacute
      • Most commonly seen at the T8 through L1 levels & always contiguous with parent disc
Helpful Clues for Rare Diagnoses
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Aug 7, 2016 | Posted by in NEUROLOGY | Comments Off on Bony Lesion, Aggressive

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