Figure 1
Abdomen and pelvis CT topogram
Topogram shows collapse of the D12 vertebral body, with intervertebral spaces spared.
Young female atraumatic vertebral fracture
SectionNeuroradiology
Case TypeClinical Cases
AuthorsMario Zerega Ruiz, MD1, Alvaro Salas Zuleta, MD2, Iván Gallegos Méndez, MD3, Facundo Las Heras, MD3.
Connected authors
22 years, female
Clinical History
A 22-year-old female presented to the emergency department with intense thoracic-lumbar pain, refractory to NS-AIDS and no history of trauma. The pain started 3 months ago and augmented the last day. Physical exam revealed localised pain at mid-line D12 palpation and no neurological signs. Laboratory tests were normal.
Imaging Findings
In contrast enhanced abdomen and pelvis CTs (Figures 1 and 2), there was a D12 vertebral body burst fracture, with vertebral body collapse, convex abutment of the posterior wall and medullar canal stenosis at that level. There was an enhancing soft tissue mass with involvement of the right pedicle and lamina. The adjacent vertebral discs were spared.
At dorso-lumbar MRI the findings were similar (Figure 3), and there was compression of the dural sac by the lesion and bone fragments, but the medulla signal was normal. The lesion was heterogeneous, isointense in T1 and hyper-intense in T2, with some lineal areas and a peripheral rim hypo-intense in both sequences. After gadolinium the lesion exhibited intense enhancing.
At dorso-lumbar MRI the findings were similar (Figure 3), and there was compression of the dural sac by the lesion and bone fragments, but the medulla signal was normal. The lesion was heterogeneous, isointense in T1 and hyper-intense in T2, with some lineal areas and a peripheral rim hypo-intense in both sequences. After gadolinium the lesion exhibited intense enhancing.
Discussion
Vertebral fractures can be benign (osteoporotic, traumatic) or malignant (due to neoplasms). The imaging characteristics of a malign vertebral fracture are the presence of soft tissue enhancing mass, an ill-defined fracture line, irregularity of vertebral plates, retropulsion of the posterior vertebral wall with an obtuse angle, hypo-intensity of bone medulla in T1, involvement of pedicles, posterior elements or intervertebral discs, among others. This case shows a number of these elements and additionally exhibits a typical vertebra plana morphology. This is collapse of the vertebral body, without involvement of intervertebral discs or neurologic symptoms.
The etiology of malignant vertebral fractures includes bone tumours. Tumours can be secondary (most commonly, like metastases, myeloma and lymphoma) or primary bone tumors (like hemangioma, eosinophilic granuloma, chordoma) [1, 2].
The etiology of vertebra plana comprises various entities among wich the most frequent is probably eosinophilic granuloma, but there are reports in the literature of cases of metastases, lymphoma or giant cell tumuors with the same morphology.
Tumours that compromise the vertebral body are generally malignant, with the exception of hemangioma, eosinophilic granuloma and giant cell tumour (this last one has common extension in the neural arch). Tumours that primarily involve posterior elements are usually benign, like osteoid osteoma, osteoblastoma, osteochondroma, except for Ewing sarcoma (this last one is a malign tumour, and it has common extension into the vertebral body).
The matrix, localisation, aggression pattern, signal intensity and topographic features of this case were non specific, but vertebra plana morphology narrowed differential diagnosis and suggested eosinophilic granuloma as first possibility.
The patient underwent tumorectomy of right pedicle and lamina, with posterior fixation. In a second surgery, ten days later, vertebral body tumorectomy was carried out, and another 10 days later vertebral replacement. The biopsy revealed a giant cell bone tumour of D12.
Giant cell bone tumour is common, accounting for 4-9% of primary bone tumours, and nearly 20% of benign bone tumours. It is usually solitary and benign, though multiple lesions have been described, and 5-10% are malignant. It affects more frequently females, especially when it is localised in the spine (female to male relation 2. 5 to 1) [3]. The vast majority of patients have mature skeleton, with 60% between 20 and 50 years. The most frequent symptom is pain of several months duration, that alleviates in rest, local inflammation and functional impotence. It can be associated with pathologic fracture and cause exacerbation or acute onset of symptoms. Its more common localisation is around the knee (50-65%) and spinal compromise is rare (3-6%), with 90% of these cases affecting sacrum.
The etiology of malignant vertebral fractures includes bone tumours. Tumours can be secondary (most commonly, like metastases, myeloma and lymphoma) or primary bone tumors (like hemangioma, eosinophilic granuloma, chordoma) [1, 2].
The etiology of vertebra plana comprises various entities among wich the most frequent is probably eosinophilic granuloma, but there are reports in the literature of cases of metastases, lymphoma or giant cell tumuors with the same morphology.
Tumours that compromise the vertebral body are generally malignant, with the exception of hemangioma, eosinophilic granuloma and giant cell tumour (this last one has common extension in the neural arch). Tumours that primarily involve posterior elements are usually benign, like osteoid osteoma, osteoblastoma, osteochondroma, except for Ewing sarcoma (this last one is a malign tumour, and it has common extension into the vertebral body).
The matrix, localisation, aggression pattern, signal intensity and topographic features of this case were non specific, but vertebra plana morphology narrowed differential diagnosis and suggested eosinophilic granuloma as first possibility.
The patient underwent tumorectomy of right pedicle and lamina, with posterior fixation. In a second surgery, ten days later, vertebral body tumorectomy was carried out, and another 10 days later vertebral replacement. The biopsy revealed a giant cell bone tumour of D12.
Giant cell bone tumour is common, accounting for 4-9% of primary bone tumours, and nearly 20% of benign bone tumours. It is usually solitary and benign, though multiple lesions have been described, and 5-10% are malignant. It affects more frequently females, especially when it is localised in the spine (female to male relation 2. 5 to 1) [3]. The vast majority of patients have mature skeleton, with 60% between 20 and 50 years. The most frequent symptom is pain of several months duration, that alleviates in rest, local inflammation and functional impotence. It can be associated with pathologic fracture and cause exacerbation or acute onset of symptoms. Its more common localisation is around the knee (50-65%) and spinal compromise is rare (3-6%), with 90% of these cases affecting sacrum.
Differential Diagnosis List
Giant cells bone tumour of D12
Final Diagnosis
Giant cells bone tumour of D12
References
[1] Rodallec, M.H., et al. (2008) Diagnostic imaging of solitary tumors of the spine: what to do and say. Radiographics 28(4): p. 1019-41. (PMID: 18635627)
[2] Murphey, M.D., et al. (2001) From the archives of AFIP. Imaging of giant cell tumor and giant cell reparative granuloma of bone: radiologic-pathologic correlation. Radiographics 21(5): p. 1283-309. (PMID: 11553835)
[3] Jung, H.S., et al. (2003) Discrimination of metastatic from acute osteoporotic compression spinal fractures with MR imaging. Radiographics 23(1): p. 179-87. (PMID: 12533652)
Case information
| URL: | https://www.eurorad.org/case/8828 |
| DOI: | 10.1594/EURORAD/CASE.8828 |
| ISSN: | 1563-4086 |
Figure 2
Abdomen and pelvis contrast enhanced CT
Figure 3
Dorso-lumbar contrast enhanced MRI
Sagital plane T2 shows collapse of D12 with convex abutment of the posterior vertebral wall.
Coronal plane T2 that exhibits mild right vertex angulation of the spine in D12.
Sagital T1. There is posterior vertex angulation in D12. The lesion was heterogeneous, isointense in T1 and hyper-intense in T2, with some lineal areas and a peripheral rim hypo-intense in both sequences.
Axial T1. Note the intensity signal, for comparison with contrast enhanced sequences.
Axial T2. Note that although there is dural sac compression, there is not medullar signal intensity alteration.
Axial plane fat saturation T1 post gadolinium. After gadolinium the lesion exhibited intense enhancement.
Sagital T1 with fat saturation post-gadolinium.
Sagital T1 with fat saturation post-gadolinium through right pedicle shows expansion by an enhancing soft tissue mass.
Figure 4
Pathology
Panoramic 40X hematoxylin eosin (H&E) technique, that shows tumor infiltrating osseous trabecules.
100X hematoxylin eosin (H&E) technique, that shows a biphasic tumor composed of giant cells with abundant nuclei, more than 50 in some of them, interspersed between mononucleated cells.
400X hematoxylin eosin (H&E) technique. The giant and mononucleated cells show the same characteristics. They are ovoid, with fine chromatin, and visible non prominent nucleoli.
Abdomen and pelvis CT topogram
Topogram shows collapse of the D12 vertebral body, with intervertebral spaces spared.
Abdomen and pelvis contrast enhanced CT
Dorso-lumbar contrast enhanced MRI
Sagital plane T2 shows collapse of D12 with convex abutment of the posterior vertebral wall.
Coronal plane T2 that exhibits mild right vertex angulation of the spine in D12.
Sagital T1. There is posterior vertex angulation in D12. The lesion was heterogeneous, isointense in T1 and hyper-intense in T2, with some lineal areas and a peripheral rim hypo-intense in both sequences.
Axial T1. Note the intensity signal, for comparison with contrast enhanced sequences.
Axial T2. Note that although there is dural sac compression, there is not medullar signal intensity alteration.
Axial plane fat saturation T1 post gadolinium. After gadolinium the lesion exhibited intense enhancement.
Sagital T1 with fat saturation post-gadolinium.
Sagital T1 with fat saturation post-gadolinium through right pedicle shows expansion by an enhancing soft tissue mass.
Pathology
Panoramic 40X hematoxylin eosin (H&E) technique, that shows tumor infiltrating osseous trabecules.
100X hematoxylin eosin (H&E) technique, that shows a biphasic tumor composed of giant cells with abundant nuclei, more than 50 in some of them, interspersed between mononucleated cells.
400X hematoxylin eosin (H&E) technique. The giant and mononucleated cells show the same characteristics. They are ovoid, with fine chromatin, and visible non prominent nucleoli.