From: Primary myelofibrosis: spectrum of imaging features and disease-related complications
Differential diagnosis of sclerotic vertebral lesions | |||
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Focal/multifocal lesions | Diffuse osteosclerosis | ||
Diagnosis | Helpful features | Diagnosis | Helpful features |
Bone infarction | • Typically serpiginous or patchy geographic appearances. | Sclerotic metastases | • May have known history of cancer (e.g. breast, prostate, gastric, neuroendocrine). |
• The ‘Double Line Sign’ of hyperintense inner ring and hypointense outer ring is a classic feature. | • Usually solitary lesion, T1 isointense or hypointense compared to red marrow, and minimally brighter on T2/STIR. | ||
• H-shaped vertebrae and absence of the spleen may be a clue to sickle cell anaemia as a cause. | |||
• A ‘Halo sign’ of rim hyperintensity and marked enhancement are highly suggestive. | |||
Chronic granulomatous infection | • Often also associated with longitudinal ligament oedema and enhancement, vertebral destruction and intraosseous, and epidural and paraspinal abscesses. | Myeloproliferative neoplasms | • Diffuse, homogenous T1 hypointense but with variable T2 hypo- or hyperintensity depending on phase of disease. |
• In late myelofibrosis, depletion of haematopoietic elements results in markedly hypointense marrow appearances on all sequences. | |||
Chronic recurrent multifocal osteomyelitis (CRMO) | • Typically children or young adults. | Sclerotic multiple myeloma | • Uncommon, occurring in 3% of myeloma cases. Appears hypointense on all sequences. |
• Clavicle involvement is a characteristic finding. | |||
• Clinical features may help with diagnosis. CRMO is associated with psoriasis, inflammatory bowel disease, or skin conditions including SAPHO syndrome. | • May be associated with POEMS syndrome—clinical or radiological features of polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes may be present. | ||
Bone islands | • Generally oval-shaped and spiculated, and orientated to long axis of bone. | Osteosarcoma | • Predominantly hypointense on all sequences (T1, T2, STIR). |
• Lack bone marrow oedema, periostitis, soft tissue mass, or other aggressive features. | • Associated with large areas of new bone formation. | ||
Lymphoma/leukaemia | • May present as a focal bone lesion or ‘ivory vertebra’ with diffuse T1 hypointense but homogenously T2 hyperintense appearances. | Lymphoma/leukaemia | • May present as a focal bone lesion or ‘ivory vertebra’ with diffuse T1 hypointense but homogenously T2 hyperintense appearances. |
• Tumour extension into soft tissues is a common feature of lymphoma. | • Tumour extension into soft tissues is a common feature of lymphoma. | ||
• Leukaemia more typically presents as a diffuse process rather than focal/multifocal lesion, with diffuse slight T1 hypointensity and T2 hyperintensity appearance compared to the intervertebral disks. | • Leukaemia more typically presents as a diffuse process rather than focal/multifocal lesion, with diffuse slight T1 hypointensity and T2 hyperintensity appearance compared to the intervertebral disks. | ||
Osteoid osteoma | • Usually under 30 years of age. | Mastocytosis | • Variable appearances—may be both lytic and sclerotic, diffuse, or focal. |
• A T1 isointense and T2 hyperintense nidus is usually present in the neural arch. | |||
• Typically T1 hypointense with mixed T2 and STIR signal intensity and multifocal or diffuse enhancement. | |||
• Clinical history is often helpful: severe pain and scoliosis, improving with non-steroidal anti-inflammatory analgesics. | • Multifocal bubbly lesions may be identified. | ||
Osteoblastoma | • Usually under 30 years of age. | Renal osteodystrophy | • The ‘Rugger-Jersey’ appearances of T1 and T2 hypointensity along the endplates are classic findings. |
• Similar appearances to osteoid osteoma but larger (2–6 cm) and with more aggressive features (local growth and distant metastases). | |||
• Renal atrophy, scarring, renal cysts, or lipomatosis may also provide clues to the underlying aetiology. | |||
Giant cell tumour | • Usually young to middle-aged patient. | Paget’s disease | • Demonstrate fibrofatty change, trabecular disorganisation, and cortical involvement and expansion. |
• More common in sacrum than elsewhere in the spine. | |||
• Usually located in the vertebral body rather than neural arch, and has heterogenous, isointense T1 signal with enhancement. | • Variable T2 appearances depending on the stage of disease. | ||
• The ‘Picture-Frame’ vertebra is a classic appearance at the mixed phase of disease. | |||
• Areas of T1 hyperintensity may be present from intralesional haemorrhage. | |||
• Fluid-fluid levels may be present if associated with an underlying aneurysmal bone cyst. | |||
 |  | Fibrous dysplasia | • Appears T1 isointense to hypointense and T2 hypointense. Typically a well-marginated lesion with cortical thickening, and often with a clear halo of perilesional fat on T1. |
 |  | Osteopetrosis | • Diffuse T1 and T2 hypointensity with vertebral thickening and spinal canal stenosis. |
• The ‘Sandwich Vertebra’ appearance is a classic description. | |||
 |  | Pyknodysostosis | • Patients often have a known history. |
• Associated with short stature and scoliosis. |