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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6009_Библиотеки_им_академика_М_И_Перельмана.pdf
Meningeal Cyst
KEY FACTS
TERMINOLOGY
• Intraspinal extramedullary loculated CSF collection
IMAGING
• Nonenhancing extramedullary loculated CSF intensity
collection displacing cord or nerve roots
○ Solitary, multiple, or multiloculated
• Extradural or intradural extramedullary location
○ Extradural meningeal cyst (MC) may extend through
enlarged neural foramina
○ Presence of intradural MC suggested by mass effect on
spinal cord
• CSF intensity on T1WI, T2WI, STIR
Neoplasms, Cysts, and Other Masses
• Cyst wall may be imperceptible
○ No enhancement
• Cap sign: Extradural MC outlined by rostral and caudal
epidural fat
(Left) Sagittal graphic
demonstrates a type III
intradural meningeal cyst in
the mild dorsal thoracic canal
with moderate mass effect on
the spinal cord. (Right)
Sagittal T2WI MR depicts an
intradural dorsal meningeal
cyst causing mild spinal cord
compression. The cyst margins
can be visualized ſt adjacent
to areas of turbulent CSF flow.
This is a typical case of an
intradural meningeal cyst
presenting with myelopathy.
The cyst was treated with
surgical fenestration.
TOP DIFFERENTIAL DIAGNOSES
• Idiopathic spinal cord herniation
○ Focal cord atrophy and ventral deviation
• Dural ectasia
○ Spinal cord not distorted
• Spinal nerve root avulsion
○ Contiguous with subarachnoid space
PATHOLOGY
• Nabors classification of spinal MC
○ Type I: Extradural MC without spinal nerve root fibers
○ Type II: Extradural MC with spinal nerve root fibers
○ Type III: Intradural MC
CLINICAL ISSUES
• Most patients asymptomatic
• Other signs/symptoms
○ Pain, paraparesis, paresthesia
• Worsening neurologic deficits with enlarging cyst
300
(Left) Sagittal T2 TSE MR
shows a giant extradural
meningeal cyst ſt with high
signal, extensive bony
remodeling, and intracystic
septation . (Right) Axial
T2WI MR shows bilateral
extension of a giant extradural
meningeal cyst out along both
neural foramina ſt with bony
expansion and remodeling.
There is ventral cord
displacement and compression
.
Perineural Root Sleeve Cyst
KEY FACTS
Neoplasms, Cysts, and Other Masses
TERMINOLOGY
• Dilatation of arachnoid and dura of spinal posterior nerve
root sheath containing nerve fibers
IMAGING
• Occurs anywhere along spine
○ Most common in lower lumbar spine and sacrum
○ S2 and S3 nerve roots most commonly involved
• Thin-walled cyst mass
○ Contents follow CSF density/signal intensity
○ No enhancement
• ± neural foraminal widening (bone remodeling)
TOP DIFFERENTIAL DIAGNOSES
• Facet synovial cyst
• Nerve sheath tumor
• Spinal nerve root avulsion
• Metastases
• Meningocele
PATHOLOGY
• Nabors classification of spinal meningeal cyst (MC)
○ Type I: Extradural MC without spinal nerve root fibers
– IA: Extradural MC
– IB: Occult sacral meningocele (outdated term)
○ Type II: Extradural MC with spinal nerve root fibers
○ Type III: Intradural MC
CLINICAL ISSUES
• Majority asymptomatic: > 80%
• Symptoms may worsen with postural changes, Valsalva
maneuvers
• Cyst rupture → spontaneous intracranial hypotension
• Symptoms simulate disc herniation and spinal stenosis
DIAGNOSTIC CHECKLIST
• CSF intensity mass enlarging neural foramen or sacral canal
characteristic of perineural root sleeve cyst
(Left) Axial T2WI MR
demonstrates a focal, wellcircumscribed, hyperintense
perineural cyst ſt within the
left C6-C7 foramen. Subtle
linear low signal within the
cyst represents the exiting
nerve within it. (Right) Sagittal
T2WI MR confirms focal
expansion of the left C6-C7
foramen by a large perineural
root sleeve cyst ſt. Note the
hyperintense cyst signal
compared to the normal
dorsal root ganglia within
the adjacent level neural
foramina.
(Left) Axial CT myelography
shows multiloculated bilateral
T1 nerve root contrast-filled
cysts ſt, confirming contiguity
with the contrast-filled dural
sac. Only part of the right cyst
contains contrast. (Right) Axial
T2WI MR of the thoracic spine
demonstrates bilateral, wellcircumscribed CSF intensity
perineural cysts ſt extending
through the neural foramina.
There is enlargement of the
right neural foramen by the
cyst.
301
Syringomyelia
KEY FACTS
TERMINOLOGY
• Hydromyelia = cystic central canal dilatation
• Syringomyelia = cystic spinal cord cavity not contiguous
with central cord canal
• Syringobulbia = brainstem syrinx extension
IMAGING
• Expanded spinal cord due to dilated, beaded, or sacculated
cystic cavity
TOP DIFFERENTIAL DIAGNOSES
• Ventriculus terminalis
• Cystic spinal cord tumor
Neoplasms, Cysts, and Other Masses
• Myelomalacia
PATHOLOGY
• Hydrocephalus, Chiari 1 or 2 malformation,
myelomeningocele or other spinal dysraphism, tethered
cord, congenital scoliosis, spinal cord injury
(Left) Sagittal graphic
demonstrates a large,
sacculated, beaded spinal cord
syrinx extending to the conus.
Despite the loculated
appearance of large syringes,
the individual fluid spaces are
contiguous and drainable
using a single shunt catheter.
(Right) Sagittal T1WI MR
(Chiari 2 malformation, not
shown) depicts a large
sacculated spinal cord syrinx
that extends the entire length
of the spinal cord into the lowlying terminal spinal cord that
inserts into the dural closure
at L4.
CLINICAL ISSUES
• Cloak-like pain and temperature/sensory loss with
preservation of position sense, proprioception, light touch
• Distal upper extremity weakness, gait instability
• Cranial neuropathy (2° to syringobulbia)
• Etiologies
○ Primary syrinx usually in young patients
– ↑ prevalence with basilar invagination, Chiari 1 or 2
malformation
○ Secondary syrinx at any age
– 25% of spinal cord injury patients develop syrinx
DIAGNOSTIC CHECKLIST
• Despite septated appearance, large syrinx cavities usually
contiguous
• Contrast administration essential to exclude tumor in
complicated cavitary lesions
302
(Left) Sagittal T2WI FS MR
(Chiari 1 malformation) shows
inferior displacement of
pointed ectopic cerebellar
tonsils ſt below the foramen
magnum. Note associated
cervical syringohydromyelia
. (Right) Axial T2WI MR
(Chiari 1 malformation, not
shown) reveals typical cervical
spinal cord
syringohydromyelia
characterized by smooth
dilation of the central spinal
cord canal and absence of
nodularity, eccentric
cavitation, or myelomalacia.
Fibrous Dysplasia
KEY FACTS
Neoplasms, Cysts, and Other Masses
TERMINOLOGY
• McCune-Albright syndrome: Polyostotic fibrous dysplasia
(FD), precocious puberty, café au lait skin lesions
IMAGING
• Most spine lesions occur with polyostotic disease
• Often causes scoliosis
• Neural arch > vertebral body
• Fusiform expansion of bone
• Cortical thinning
• Commonly ground-glass matrix
○ However, matrix may range from purely lytic to purely
sclerotic lesion
• Narrow zone of transition ± sclerotic margin
• Low to intermediate signal intensity on T1WI,
heterogeneous on T2WI and STIR with variable
enhancement
• Mild to marked increase in radionuclide uptake
TOP DIFFERENTIAL DIAGNOSES
• Aneurysmal bone cyst
• Paget disease
• Osteoblastoma
• Osteosarcoma
• Tuberous sclerosis
PATHOLOGY
• Sporadic mutation in GNASgene
CLINICAL ISSUES
• Growth disturbance, pathologic fracture
• Rarely undergoes sarcomatous transformation
DIAGNOSTIC CHECKLIST
• Do not confuse with Paget disease on imaging
○ Paget disease thickens cortex and trabeculae
○ FD thins cortex and replaces trabeculae
(Left) Sagittal bone CT shows
severe polyostotic fibrous
dysplasia (FD) involving the
skull, facial bones, and cervical
spine. Some areas are ground
glass st, others are purely
lytic ſt, and there are a few
foci of calcified cartilage .
(Right) Coronal bone CT in the
same patient shows loss of
normal trabeculae in the
majority of the included bones
replaced by FD matrix.
Thinning of tables of skull is a
characteristic finding.
(Left) Axial bone CT shows
variation in density ſt in a
single vertebra with nearly
complete marrow
replacement. This variability is
common and should not raise
suspicion for malignant
degeneration. (Right) Axial
bone CT shows lytic FD st in
the posterior elements. The
narrow zone of transition
(sometimes sclerotic) helps to
distinguish FD from more
aggressive processes.
Vertebral bodies tend to be
less severely involved than the
posterior elements.
303
Kümmell Disease
KEY FACTS
TERMINOLOGY
• Posttraumatic avascular necrosis of vertebral body
IMAGING
• Radiographs, CT
○ Loss of height, sclerosis of vertebral body
○ Narrow, horizontally oriented band of gas in vertebral
body
○ Filling cleft in vertebral body due to fracture nonunion
• MR
○ Vertebral body collapse
○ Gas-filled cleft is low signal intensity on all sequences
Neoplasms, Cysts, and Other Masses
(unless fluid-filled)
○ Fracture line may or may not be visible
○ Less well seen than on CT scan
TOP DIFFERENTIAL DIAGNOSES
• Infection
• Nontraumatic bone infarction
(Left) Coronal bone CT shows
gas within a collapsed,
sclerotic vertebral body. Gas is
also present in the adjacent
disc spaces ſt. The gas seen in
Kümmell disease probably
migrates into the vertebral
body from a degenerated disc.
(Right) Sagittal T1WI MR
shows gas in an
osteoporotic burst fracture
and adjacent discs ſt. Gas
could easily be mistaken for
calcification on the MR.
• Gas within degenerated intervertebral discs
• Calcium pyrophosphate dihydrate deposition
PATHOLOGY
• Radiographically occult vertebral body clefts common in
patients with fracture
• Nonunited vertebral body fracture cleft undergoes 2°
necrosis, collapse
• Nitrogen accumulates in fracture cleft
CLINICAL ISSUES
• Presents with pain, kyphosis
• Usually occurs in elderly, osteoporotic patients
• Progressive vertebral body collapse if untreated
DIAGNOSTIC CHECKLIST
• Kümmell disease may be rarely associated with pathologic
fracture
304
(Left) Sagittal T2WI MR
reveals band-like gas in the
vertebral body and gas in
the intervertebral discs ſt.
The findings are less
conspicuous and less specific
than demonstrated with bone
CT. (Right) Sagittal bone CT
shows gas in a collapsed
vertebral body. This unusual
case has occurred in a patient
with metastatic disease ſt.
Kümmell disease should not be
presumed to always indicate a
benign compression fracture.
This patient had blastic
metastases from prostate
carcinoma.
Kümmell Disease
TERMINOLOGY
Definitions
• Posttraumatic avascular necrosis of vertebral body
IMAGING
General Features
• Best diagnostic clue
○ Gas-filled cleft in flattened vertebral body
• Location
○ Thoracic or lumbar vertebral body
Radiographic Findings
• Radiography
○ Loss of height, sclerosis of vertebral body
○ Narrow, horizontally oriented band of gas in vertebral
body
○ Filling cleft in vertebral body due to fracture nonunion
CT Findings
• Bone CT
○ Horizontal band of gas-filling cleft in vertebral body
○ Gas often in adjacent disc space
MR Findings
• Vertebral body collapse
• Fracture line may or may not be visible
○ Horizontal low signal intensity line on T1WI
○ Band-like high signal intensity on T2WI, STIR
• Gas-filled cleft
○ Low signal intensity on all sequences
– May occasionally be fluid-filled, follow fluid signal
intensity
○ Less well seen than on CT scan
Nuclear Medicine Findings
• Bone scan
○ Positive 3-phase bone scan
Imaging Recommendations
• Best imaging tool
○ CT scan
• Protocol advice
○ MDCT with sagittal, coronal reformations
DIFFERENTIAL DIAGNOSIS
Infection
• Small bubbles of gas sometimes present, but not cleft
• Endplate destruction
• Heterogeneous enhancement of disc and vertebral body
• Fluid collections in paraspinous soft tissues
Nontraumatic Bone Infarction
• Serpentine contour of infarction with peripheral
enhancement
• Associated with steroids, sickle cell disease, pancreatitis,
vasculitis, emboli, and caisson disease
Gas Within Degenerated Intervertebral Discs
• Gas forms in degenerated discs, may enter Schmorl nodes
Calcium Pyrophosphate Dihydrate Deposition
(CPPD)
• Calcifications appear similar to gas on MR
PATHOLOGY
General Features
• Etiology
○ Kyphoplasty data suggests radiographically occult
vertebral body clefts are common in patients with
fracture
○ Nonunited vertebral body fracture undergoes secondary
necrosis and collapse
○ Nitrogen accumulates in fracture cleft
CLINICAL ISSUES
Presentation
• Most common signs/symptoms
○ Pain, kyphosis
Demographics
• Age
○ Usually elderly, osteoporotic patients
• Epidemiology
○ Uncommon
Natural History & Prognosis
• Progressive vertebral body collapse if untreated
Treatment
• Options, risks, complications
○ Vertebroplasty or kyphoplasty relieves pain
DIAGNOSTIC CHECKLIST
Image Interpretation Pearls
• Kümmell disease rarely can occur in pathologic fracture due
to tumor
• Gas may be seen in infection
○ Usually small bubbles, not linear cleft
SELECTED REFERENCES
1. Wang Q et al: Pathomechanism of intravertebral clefts in osteoporotic
compression fractures of the spine: basivertebral foramen collapse might
cause intravertebral avascular necrosis. Spine J. 14(6):1090-1, 2014
2. Lin CL et al: MRI fluid sign is reliable in correlation with osteonecrosis after
vertebral fractures: a histopathologic study. Eur Spine J. 22(7):1617-23, 2013
3. Voulgari PV et al: Avascular necrosis in a patient with systemic lupus
erythematosus. Joint Bone Spine. 80(6):665, 2013
4. Wu AM et al: Vertebral compression fracture with intravertebral vacuum
cleft sign: pathogenesis, image, and surgical intervention. Asian Spine J.
7(2):148-55, 2013
5. van der Schaaf I et al: Percutaneous vertebroplasty as treatment for
Kummell's disease. JBR-BTR. 92(2):83-5, 2009
6. Swartz K et al: Kümmell's disease: a case report and literature review. Spine
(Phila Pa 1976). 33(5):E152-5, 2008
7. Jang JS et al: Efficacy of percutaneous vertebroplasty in the treatment of
intravertebral pseudarthrosis associated with noninfected avascular necrosis
of the vertebral body. Spine. 28(14):1588-92, 2003
8. Lane JI et al: Intravertebral clefts opacified during vertebroplasty:
pathogenesis, technical implications, and prognostic significance. AJNR Am J
Neuroradiol. 23(10):1642-6, 2002
9. Young WF et al: Delayed post-traumatic osteonecrosis of a vertebral body
(Kummell's disease). Acta Orthop Belg. 68(1):13-9, 2002
10. Chou LH et al: Idiopathic avascular necrosis of a vertebral body. Case report
and literature review. Spine. 22(16):1928-32, 1997
Neoplasms, Cysts, and Other Masses
305
Hirayama Disease
KEY FACTS
TERMINOLOGY
• Synonyms: Hirayama flexion myelopathy, juvenile spinal
muscular atrophy, monomelic amyotrophy, juvenile
asymmetric segmental spinal muscular atrophy
• Definition: Cervical myelopathy related to anterior
displacement of posterior cervical dura with flexion
IMAGING
• Asymmetric cord atrophy
• Flexion study shows increased posterior epidural space
with ventral dural displacement, cord compression
• T1WI C+ shows enhancing enlarged posterior epidural
Neoplasms, Cysts, and Other Masses
space with flexion
TOP DIFFERENTIAL DIAGNOSES
• Motor neuron disease
• Chronic radiculopathy
(Left) Sagittal T2WI MR shows
the classic appearance of
Hirayama disease. The neutral
position of the MR shows mild
cord atrophy at the C5-C6
level ſt but is otherwise
normal. (Right) Flexion T2WI
MR shows marked ventral
displacement of the posterior
dural margin with cord
compression . A
hypointense T2 signal filling
the dorsal epidural space is a
distended venous plexus,
which will homogeneously
enhance with contrast (not
shown).
PATHOLOGY
• Tight dural canal during flexion related to disproportionate
length between vertebral column and dural canal
• Generally sporadic but familial cases have been reported
• Anterior horn cells of spinal cord levels C5-T1 show
shrinkage, degeneration, and necrosis with mild gliosis
CLINICAL ISSUES
• Nonprogressive muscular atrophy confined to hand and
forearm (2nd-3rd decades)
• Usually unilateral but can be bilateral
• Avoidance of neck flexion can stop progression
• May treat with posterior decompression/duraplasty
DIAGNOSTIC CHECKLIST
• Asymmetric atrophy of lower cervical cord on routine MR in
patient with distal upper limb weakness is highly suspicious
for Hirayama
○ Flexion cervical MR recommended
306
(Left) Flexion T1WI MR shows
marked ventral displacement
of the posterior dural margin
with a long segment of cord
compression. A slightly
heterogeneous signal filling
the dorsal epidural space
reflects a distended venous
plexus st. (Right) Axial T2WI
MR in flexion shows a
markedly distended posterior
epidural plexus . There is
ventral displacement of the
posterior dura with
asymmetrical cord
compression, worse on the
right ſt.
Hirayama Disease
TERMINOLOGY
Synonyms
Hirayama flexion myelopathy, juvenile spinal muscular
•
atrophy, monomelic amyotrophy, juvenile asymmetric
segmental spinal muscular atrophy
Definitions
• Cervical myelopathy related to anterior displacement of
posterior cervical dura with flexion
IMAGING
General Features
• Best diagnostic clue
○ Anterior displacement of posterior cervical dura on MR
• Location
○ Cervical
• Size
○ Variable
• Morphology
○ Anterior displacement of linear posterior dura
CT Findings
• Myelography shows unilateral cord atrophy
• Flexion studies difficult due to contrast movement
MR Findings
• T1WI
○ Asymmetric cord atrophy
○ Flexion study shows increased posterior epidural space
with ventral dural displacement, cord compression
• T2WI
○ Asymmetric cord atrophy, cord hyperintensity at
atrophic area
○ Flexion study shows increased posterior epidural space
with ventral dural displacement, cord compression
• T1WI C+
○ Enhancing enlarged posterior epidural space with flexion
Imaging Recommendations
• Best imaging tool
○ Flexion MR
DIFFERENTIAL DIAGNOSIS
Motor Neuron Disease
• Diagnosis of exclusion without spinal imaging findings
Chronic Radiculopathy
• Disc disease
PATHOLOGY
General Features
• Etiology
○ Controversial
○ Dynamic spinal cord compression with neck flexion
○ Tight dural canal during flexion related to
disproportionate length between vertebral column and
dural canal
– Length of cervical canal increases with flexion
Neoplasms, Cysts, and Other Masses
– Dural sac compensates for this lengthening in normal
subjects
– Imbalance of growth of vertebrae and dura in
Hirayama causes tight dural canal with flexion with
anterior shift
• Genetics
○ Generally sporadic but familial cases have been reported
Gross Pathologic & Surgical Features
• Anterior horn cells of spinal cord levels C5-T1 showed
shrinkage, degeneration, and necrosis with mild gliosis
○ Suggested circulatory insufficiency in these areas related
to chronic trauma of cord compression
• Abnormal posterior dura with few elastic fibers
CLINICAL ISSUES
Presentation
• Most common signs/symptoms
○ Muscular atrophy confined to hand and forearm
○ Usually unilateral but can be bilateral
○ Disease onset insidious
○ No sensory or pyramidal tract involvement
Demographics
• Age
○ 2nd to 3rd decades
• Gender
○ M > F
Natural History & Prognosis
• Clinical course characterized by steady progression with
eventual stabilization
Treatment
• Avoidance of neck flexion can stop progression
○ Cervical collar for 3-4 years
• Selected patients treated with posterior decompression
with duraplasty, rarely anterior fusion
DIAGNOSTIC CHECKLIST
Image Interpretation Pearls
• Asymmetric atrophy of lower cervical cord on routine MR in
patient with distal upper limb weakness suspicious for
Hirayama
○ Flexion MR recommended
SELECTED REFERENCES
1. Paredes I et al: A severe case of Hirayama disease successfully treated by
anterior cervical fusion. J Neurosurg Spine. 20(2):191-5, 2014
2. Lehman VT et al: Cervical spine MR imaging findings of patients with
Hirayama disease in North America: a multisite study. AJNR Am J
Neuroradiol. 34(2):451-6, 2013
3. Patel TR et al: Lack of epidural pressure change with neck flexion in a patient
with Hirayama disease: case report. Neurosurgery. 64(6):E1196-7; discussion
E1197, 2009
4. Zhou B et al: Clinical features of Hirayama disease in mainland China.
Amyotroph Lateral Scler. Epub ahead of print, 2009
5. Misra UK et al: A clinical, magnetic resonance imaging, and survival motor
neuron gene deletion study of Hirayama disease. Arch Neurol. 62(1):120-3,
2005
6. Chen CJ et al: Hirayama flexion myelopathy: neutral-position MR imaging
findings--importance of loss of attachment. Radiology. 231(1):39-44, 2004
307
Paget Disease
KEY FACTS
TERMINOLOGY
• Osteitis deformans
• Chronic metabolic disorder of abnormal bone remodeling
in adult skeleton
IMAGING
• Enlarged vertebra with trabecular coarsening and cortical
thickening
○ Both vertebral body and neural arch involved
• Lumbar spine most common
• Picture frame vertebra
○ Central osteopenia
Neoplasms, Cysts, and Other Masses
○ Coarse and sclerotic peripheral trabecular pattern
• Diffusely dense ivory vertebra
• Fibrovascular marrow in active phase
• Fatty marrow in mixed phase
• Blastic inactive phase
○ Marrow space low T1/T2 signal representing sclerosis-
fibrosis
(Left) Axial graphic of pagetic
vertebrae demonstrates an
enlarged vertebral body,
pedicles, and left facet with
trabecular thickening and
increased fatty marrow. Paget
disease is a chronic metabolic
disorder of abnormal bone
remodeling and may virtually
affect every bone in the
skeleton. (Right) Axial T1WI
MR through a lumbar vertebra
shows coarse and irregular
trabeculae with mild vertebral
expansion. The pagetic bone
marrow contains fatty areas
with a heterogeneous
distribution.
TOP DIFFERENTIAL DIAGNOSES
• Osteoblastic metastases
• Vertebral hemangioma
PATHOLOGY
• Sites of osseous involvement
○ Pelvis = spine > femur > skull > tibia > clavicle > humerus
> ribs
○ Polyostotic, asymmetric > monostotic
• Possible viral etiology
○ Measles virus of Paramyxovirus family found in
osteoclasts
CLINICAL ISSUES
• 20% asymptomatic
• Deep, dull bone pain
• Sarcomatous transformation: < 1%
• Myelopathy, cauda equina syndrome from canal narrowing
308
(Left) Anteroposterior
radiograph depicts an
enlarged L3 vertebral body ,
pedicles ſt, and transverse
processes st. Increased
density gives the ivory
vertebra appearance. The
coarse and sclerotic peripheral
trabecular pattern and central
osteopenia gives the picture
frame appearance. (Right)
Anteroposterior bone scan
reveals ↑ uptake in the L3
vertebra ſt. Increased uptake
in the sternum st is suspicious
for Paget disease. Bone pain is
common in the lumbar spine.
Bone Infarction
KEY FACTS
Neoplasms, Cysts, and Other Masses
TERMINOLOGY
• Infarction of vertebral body cancellous bone and marrow
secondary to systemic disease or aortic pathology
○ Not osteonecrosis (Kümmell disease)
IMAGING
• Well-defined, geographic signal abnormality, which tends
to involve anterior 1/3 to 1/2 of vertebral body
• T2WI shows increased signal in multiple bodies with abrupt
transition to normal marrow signal
• T1WI C+ shows markedly diminished enhancement of
affected vertebral body areas
○ No associated epidural or paravertebral soft tissue
○ Rare to involve posterior elements
TOP DIFFERENTIAL DIAGNOSES
• Infarction secondary to underlying systemic disease
○ Sickle cell
○ Acute leukemia (ALL or AML)
○ SLE
○ Lymphoma
○ Transplantation with graft-vs.-host disease
• Infarction secondary to aortic disease
○ Dissection
○ Abdominal aortic surgery
• Metastatic disease marrow infiltration
• Leukemia or lymphoma marrow tumor infiltration
• Granulomatous or fungal infection
CLINICAL ISSUES
• Nonspecific back pain in setting of systemic illness
DIAGNOSTIC CHECKLIST
• Infarction as sign of systemic illness or malignancy, such as
leukemia
• Associated with spinal cord infarction; useful as a
confirmatory sign that nonspecific T2 hyperintensity in cord
reflects infarction
(Left) Sagittal T1WI C+ MR in a
patient with a new diagnosis
of lymphocytic leukemia
shows multiple, well-defined,
geographic foci of diminished
enhancement ſt in multiple
vertebral bodies with a rim of
increased enhancement. There
is no associated soft tissue
mass and no disc involvement.
(Right) Axial T1WI C+ MR in a
patient with multiple
vertebral infarcts and a new
diagnosis of acute leukemia
(ALL) shows sharply
marginated lesions in both
right and left sides of the
vertebral body ſt with mild
peripheral enhancement.
(Left) Sagittal T1WI MR shows
multiple infarcts in a patient
with ALL status post
chemotherapy. Note welldefined low signal present in
the anterior 1/2 of multiple
vertebral bodies. (Courtesy M.
Pathria, MD.) (Right) Sagittal
T2WI FS MR in a patient with
ALL status post chemotherapy
shows focal, well-defined
hyperintensity in the anterior
1/2 of multiple vertebral
bodies, which also involves the
sacrum. (Courtesy M. Pathria,
MD.)
309