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Differential Diagnosis of Skull and Spine Disorders

Increased T1 Signal Intensity of Spinal Bone Marrow!!navigator!!

= mostly benign

  1. FOCAL
    1. Hemangioma (11%)
    2. Modic type 2 endplate changes
    3. Lipoma
    4. Paget disease (later stage)
    5. Hemorrhage (with fracture)
    6. Melanoma
  2. DIFFUSE / MULTIFOCAL
    1. Normal variant
    2. S/P radiation treatment
    3. Osteoporosis
    4. Multiple hemangiomas
    5. Spondyloarthritis
    6. Anorexia nervosa

Decreased T1 Signal Intensity of Spinal Bone Marrow!!navigator!!

= equal to / lower than SI of muscle

  1. CENTERED ON ENDPLATE
    1. Modic type 1 + 3 endplate changes
    2. Osteomyelitis
    3. Amyloid
  2. CENTERED IN VERTEBRAL BODY
    1. Malignancy (metastasis, lymphoma, plasma cell dyscrasia, solitary plasmacytoma, multiple myeloma)
    2. Fracture
    3. Hemangioma (rare presentation)
    4. Fibrous dysplasia
  3. CENTERED IN POSTERIOR ELEMENTS
    metastases, myeloma, lymphoma, fracture, primary bone tumor
  4. DIFFUSE / MULTIFOCAL
    1. Hematopoietic hyperplasia
      1. chronic anemia: sickle cell disease, thalassemia, hereditary spherocytosis
      2. chronic illness: HIV
      3. heavy smoking
      4. obesity
      5. drugs: granulocyte-colony-stimulating factor, erythropoietin
    2. Neoplasm
      • avid enhancement
    3. Renal osteodystrophy
    4. Systemic inflammation: sarcoidosis, gout, spondyloarthropathy
    5. Hematologic malignancy: myelofibrosis. mastocytosis

Destruction of Vertebral Body!!navigator!!

  1. NEOPLASM
    1. Metastasis
    2. Primary neoplasm: chordoma, chondrosarcoma, lymphoma, multiple myeloma
  2. INFECTION
    1. Pyogenic vertebral osteomyelitis
    2. Tuberculous spondylitis
    3. Brucellosis
    4. Fungal disease
    5. Echinococcosis
    6. Sarcoidosis

Granulomatous Spondylitis

  1. TB
  2. Brucellosis
  3. Sarcoidosis

Gas in Vertebral Body!!navigator!!

  1. Osteonecrosis = Kümmell disease
    • linear collection
  2. Osteomyelitis
    • small gas bubbles ± extension into adjacent soft-tissues
  3. Intraosseous displacement of cartilaginous / Schmorl node
    • branching gas pattern
  4. Malignancy

Small Vertebral Body!!navigator!!

  1. Radiation therapy
    during early childhood in excess of 1,000 rad
  2. Juvenile rheumatoid arthritis
    Location: cervical spine
    • atlantoaxial subluxation may be present
    • vertebral fusion may occur
  3. Eosinophilic granuloma
    Location: lumbar / lower thoracic spine
    • compression deformity / vertebra plana
  4. Gaucher disease
    = deposits of glucocerebrosides within RES
    • compression deformity
  5. Platyspondyly generalisata
    = flattened vertebral bodies associated with many hereditary systemic disorders: achondroplasia, spondyloepiphyseal dysplasia tarda, mucopolysaccharidosis, osteopetrosis, neurofibromatosis, osteogenesis imperfecta, thanatophoric dwarfism
    • disk spaces of normal height

Vertebra Plana

mnemonic: FETISH

  • Fracture (trauma, osteogenesis imperfecta)
  • Eosinophilic granuloma (Langerhans cell histiocytosis)
  • Tumor (metastatic neuroblastoma, myeloma, leukemia, aneurysmal bone cyst, Ewing sarcoma)
  • Infection
  • Steroids (avascular necrosis)
  • Hemangioma

mnemonic: MELT

  • Metastasis / Myeloma
  • Eosinophilic granuloma
  • Lymphoma
  • Trauma / TB

Signs of Acute Vertebral Collapse on MR

  1. Osteoporosis
    • retropulsion of posterior bone fragment
  2. Malignancy
    • epidural soft-tissue mass
    • no residual normal marrow signal intensity
    • abnormal enhancement

Enlarged Vertebral Body!!navigator!!

  1. Paget disease
    • “picture framing”; bone sclerosis
  2. Gigantism
    • increase in height of body + disk
  3. Myositis ossificans progressiva
    • bodies greater in height than width
    • osteoporosis
    • ossification of ligamentum nuchae

Enlarged Intervertebral Foramen!!navigator!!

= NEUROFORAMINAL WIDENING = DUMBBELL-SHAPED / HOURGLASS LESION

  1. SOLID BENIGN
    1. Benign peripheral nerve sheath tumor (PNST):
      • Neurofibroma
      • Neurilemmoma = schwannoma
    2. Meningioma
    3. Extradural cavernous hemangioma
    4. Congenital absence / hypoplasia of pedicle
  2. SOLID MALIGNANT
    1. Metastatic destruction of pedicle: neuroblastoma
    2. Malignant PNST
    3. Ewing sarcoma / primitive neuroectodermal tumor
    4. Solitary bone plasmacytoma
    5. Chondrosarcoma
  3. CYSTIC
    1. Dural ectasia (Marfan syndrome, Ehlers-Danlos syndrome)
    2. Synovial cyst
    3. Traumatic pseudomeningocele
    4. Arachnoid cyst
    5. Hydatid cyst

Cervical Spine Fusion!!navigator!!

mnemonic: SPAR BIT

  • Senile hypertrophic ankylosis (DISH)
  • Psoriasis, Progressive myositis ossificans
  • Ankylosing spondylitis
  • Reiter disease, Rheumatoid arthritis (juvenile)
  • Block vertebra (Klippel-Feil)
  • Infection (TB)
  • Trauma

Vertebral Border Abnormality!!navigator!!

Straightening of Anterior Border

  1. Ankylosing spondylitis
  2. Paget disease
  3. Psoriatic arthritis
  4. Reiter disease
  5. Rheumatoid arthritis
  6. Normal variant

Anterior Scalloping of Vertebrae

  1. Aortic aneurysm
  2. Lymphadenopathy
  3. Tuberculosis
  4. Multiple myeloma (paravertebral soft-tissue mass)

Posterior Scalloping of Vertebrae

in conditions associated with dural ectasia

  1. INCREASED INTRASPINAL PRESSURE
    1. Communicating hydrocephalus
    2. Ependymoma
  2. MESENCHYMAL TISSUE LAXITY (dural ectasia)
    1. Neurofibromatosis
    2. Marfan syndrome
    3. Ehlers-Danlos syndrome
    4. Posterior meningocele
  3. BONE SOFTENING
    1. Mucopolysaccharidoses: Hurler, Morquio, Sanfilippo
    2. Achondroplasia
    3. Acromegaly (lumbar vertebrae)
    4. Ankylosing spondylitis (lax dura acting on osteoporotic vertebrae)

mnemonic: SALMON

  • Spinal cord tumor
  • AchondroPlasia
  • Mucopolysaccharidosis
  • Osteogenesis imperfecta
  • Neurofibromatosis

mnemonic: DAMN MALE SHAME

  • Dermoid
  • Ankylosing spondylitis
  • Meningioma
  • Neurofibromatosis
  • Marfan syndrome
  • Acromegaly
  • Lipoma
  • Ependymoma
  • Syringohydromyelia
  • Hydrocephalus
  • Achondroplasia
  • Mucopolysaccharidoses
  • Ehlers-Danlos syndrome

Bony Outgrowths from Vertebra!!navigator!!

  1. CHILDHOOD
    1. Hurler syndrome = gargoylism
      • rounded appearance of vertebral bodies
      • mild kyphotic curve with smaller vertebral body at apex of kyphosis displaying tonguelike beak at anterior half (usually at T12 / L1)
      • “step-off” deformities along anterior margins
    2. Hunter syndrome
      less severe changes than in Hurler syndrome
    3. Morquio disease
      • flattened + widened vertebral bodies
      • anterior “tonguelike” elongation of central portion of vertebral bodies
    4. Hypothyroidism = cretinism
      • small flat vertebral bodies
      • anterior “tonguelike” deformity (in children only)
      • widened disk spaces + irregular endplates
  2. ADULTS
    1. Spondylosis deformans
      • osteophytosis along anterior + lateral aspects of endplates with horizontal + vertical course ← shearing of outer annular fibers (Sharpey fibers connecting annulus fibrosus to adjacent vertebral body)
    2. Diffuse idiopathic skeletal hyperostosis (DISH)
      • flowing calcifications + ossifications along anterolateral aspect of >4 contiguous thoracic vertebral bodies ± osteophytosis
    3. Ankylosing spondylitis
      • bilateral symmetric syndesmophytes (= ossification of annulus fibrosus)
      • “bamboo spine”
      • “diskal ballooning” = biconvex intervertebral disks ← osteoporotic deformity of endplates
      • straightening of anterior margins of vertebral bodies ← erosions
      • ossification of paraspinal ligaments
    4. Fluorosis
      • vertebral osteophytosis + hyperostosis
      • sclerotic vertebral bodies + kyphoscoliosis
      • calcification of paraspinal ligaments
    5. Acromegaly
      • increase in anteroposterior diameter of vertebrae + concavity on posterior portion
      • enlargement of intervertebral disk
    6. Hypoparathyroidism
    7. Neuropathic arthropathy
    8. Sternoclavicular hyperostosis

Spine Ossification

  1. Syndesmophyte = ossification of annulus fibrosus
    • thin slender vertical outgrowth extending from margin of one vertebral body to next
      Associated with: ankylosing spondylitis, ochronosis
  2. Osteophyte
    = ossification of anterior longitudinal ligament
    • initially triangular outgrowth several millimeters from edge of vertebral body
      Associated with: osteoarthritis
  3. Flowing anterior ossification
    = ossification of disk, anterior longitudinal ligament, paravertebral soft tissues
    Associated with: DISH
  4. Paravertebral ossification
    • initially irregular / poorly defined paravertebral ossification eventually merging with vertebral body
      Associated with: psoriatic arthritis, Reiter syndrome

Vertebral Endplate Abnormality!!navigator!!

  1. Cupid's bow vertebra
    Cause: ? (normal variant)
    Location: 3rd–5th lumbar vertebra
    • two parasagittal posterior concavities on inferior aspect of vertebral body (best viewed on AP)
  2. Osteoporosis (senile / steroid-induced)
    1. “fish vertebra / fish-mouth vertebra”


      Cause: osteoporosis, osteomalacia, Paget disease, osteogenesis imperfecta, multiple myeloma, hyperparathyroidism, Gaucher disease
      • biconcave vertebra
      • bone sclerosis along endplates
    2. wedge-shaped vertebra
      • anterior border height reduced by >4 mm compared to posterior border height
    3. “pancake” vertebra
      • overall flattening of vertebra
  3. “H-vertebra”
    = compression of central portions ← subchondral infarcts
    Cause: sickle cell + other anemias, Gaucher disease
  4. Schmorl / cartilaginous node
    = intraosseous herniation of nucleus pulposus at center of weakened endplate
    Cause: Scheuermann disease, trauma, hyperparathyroidism, osteochondrosis
  5. Butterfly vertebra
    Cause: congenital defect
  6. Limbus vertebrae
    = intraosseous herniation of disk material at junction of vertebral bony rim of centra + endplate (anterosuperior corner)
  7. “Rugger-jersey spine”
    Cause: hyperparathyroidism, myelofibrosis
    • horizontal sclerosis subjacent to vertebral endplates with intervening normal osseous density (resembling the stripes on rugby jerseys)
  8. “Sandwich” / “Hamburger” vertebra
    Cause: osteopetrosis, myelofibrosis
    • sclerotic endplates alternate with radiolucent midportions of vertebral bodies
  9. “Ring” epiphysis

Ring Epiphysis

= normal small steplike recess at corner of anterior edge of developing vertebral body that calcifies ~ 6 years of age, ossifies ~ 13 years of age, and fuses with vertebral body ~ 17 years of age

  1. Severe osteoporosis
  2. Healing rickets
  3. Scurvy

Bullet-shaped Vertebral Body!!navigator!!

mnemonic: HAM

  • Hypothyroidism
  • Achondroplasia
  • Morquio syndrome

Bone-within-bone Vertebra!!navigator!!

= “ghost vertebra” following stressful event during vertebral growth phase in childhood

  1. Stress line of unknown cause
  2. Leukemia
  3. Heavy metal poisoning
  4. Thorotrast injection, TB
  5. Rickets
  6. Scurvy
  7. Hypothyroidism
  8. Hypoparathyroidism

Ivory Vertebra!!navigator!!

= increase in opacity of vertebral body retaining its size and contours

Cause: stimulation of osteoblasts, coarsening of trabeculae, reactive bone formation

  1. in adults: metastasis (prostate, breast), lymphoma (Hodgkin disease), Paget disease, osteosarcoma, carcinoid
  2. in children: Hodgkin disease >>osteosarcoma, metastatic neuroblastoma, medulloblastoma, osteoblastoma

mnemonic: LOST FROM CHOMP

  • Lymphoma
  • Osteopetrosis
  • Sickle cell disease
  • Trauma, Tuberculous spondylitis
  • Fluorosis
  • Renal osteodystrophy
  • Osteoblastic metastasis
  • Myelosclerosis
  • Chronic sclerosing osteomyelitis, Chordoma
  • Hemangioma
  • Osteosarcoma
  • Myeloma
  • Paget disease

Sclerotic Pedicle!!navigator!!

  1. Osteoid osteoma
  2. Unilateral spondylolysis
  3. Contralateral congenitally absent pedicle

Outline