Age / Sex : 66 / M

Chief complaint : Right hip and leg pain for 5 months

                Accidentally discovered spine abnormality in L4

What is your diagnosis?

Two weeks later, you can see the final diagonosis with a brief discussion of this case (Please submit only one answer).

Courtesy : Sunghoon Park, Ajou University School of Medicine

Discussion

Answer: 

Hematopoietic marrow hyperplasia

Findings:

Radiographs of lumbar spine has no specific findings on the L4.

Sagittal reformatted CT images of lumbar spine shows suspicious sclerotic change of L4 body without definite mass lesion and cortical destruction.

MR Imaging showed moderated decrease signal intensities on T2- and T1-weighted image and homogeneous enhancement in L4 body without epidural and paravertebral soft tissue mass formation.

There was no interval change of bone marrow lesion on L4 in the MR images taken three months later.

The vertebral bone marrow lesion was pathologically confirmed hematopoietic marrow by imaging guided biopsy.

Differential Diagnosis:

Myeloma

Discussion:

The most extreme pattern of focal hypertrophy of the red marrow component

Hematopoietic cell proliferation triggered by increased peripheral demand or blood cell hypofunction

MR - compatible with that of normal hematopoietic marrow

: moderate decrease in signal intensity on T1-weighted SE images

• similar or slightly lower than that of the adjacent intervertebral disk.

: intermediate to low signal intensity of T2 fast SE images

: moderate increase in signal intensity on fat-saturated intermediate- or T2-weighted fast SE images

: no or moderate enhancement after gadolinium injection

CT – normal

PET imaging : limited, but these areas may show a slight increased hypermetabolic uptake in comparison with adjacent red marrow.

References:

1. Shigematsu Y, Hirai T, Kawanaka K, et al. Distinguishing imaging features between spinal hyperplastic hematopoietic bone marrow and bone metastasis. AJNR Am J Neuroradiol. 2014;35:2013–20.

2. Vande Berg BC, Lecouvet FE, Galant C, Simoni P, Malghem J. Normal variants of the bone marrow at MR imaging of the spine. Semin Musculoskelet Radiol. 2009;13:87–96.