INDICATIONS: Compression fracture, eight months postpartum
FINDINGS: The bone marrow is very heterogeneous on the T2-weighted images with multiple areas of markedly high intensity outlining nearly geographic contours in the vertebral bodies and more punctate areas in the lamina and spinous processes. On T1, the overall intensity is moderately diminished, still slightly higher than the adjacent psoas muscles. On T1, there is one particularly low intensity area in the posterior right side of the L2 vertebral body with slight target configuration on T2 on series 3, image 6. The lesion measures 11 mm in diameter. There is a second possible focus of similar low signal in the left iliac crest on series 7, image 34 measuring 7 mm in diameter. After contrast, the marrow enhances heterogeneously with most of the bright areas corresponding to the T2 bright regions. The areas of low signal do not appear to enhance significantly. The overall appearance of the bone marrow may reflect a fairly aggressive decalcification and/or recalcification. However other more common marrow processes must be considered such as malignancy, hemolysis or multiple bone marrow infarcts; close clinical follow up and correlation with DEXA, peripheral smear and reticulocyte count is recommended. A bone marrow biopsy should be considered, the left iliac crest should provide a representative sample. The leading alternate possibilities are leukemia, lymphoma, multiple myeloma, breast cancer, recovering red marrow from hemolysis, multiple bone marrow infarcts as seen in SLE, Gaucher's, and many other conditions. Note that there is no evidence of retroperitoneal adenopathy.
The L3 vertebral body shows a mild chronic compression fracture. There is a fracture line extending obliquely almost in the axial plane from the superior anterior endplate into the mid posterior vertebral body. This vertebral body has lost approximately 10% of vertical height. There is a slight posterior retropulsion slightly indenting the dural sac. No marrow edema is seen within the vertebral body. However, there is slight edema in the surrounding paraspinal soft tissues with slight increased enhancement as seen on series 9, image 13. The paraspinal soft tissue changes suggest a late subacute fracture.
The vertebral body alignment is normal. The spinal canal is normal size. The lower thoracic cord and cauda equina appear normal. No abnormal enhancement is seen within the spinal canal. The disc heights are preserved with no disc desiccation. No disc bulges or disc protrusions. No joint or foraminal changes. The SI joints appear normal. The retroperitoneal soft tissues appear normal.
OPINION: 1. Heterogeneous appearing bone marrow on T2 and post contrast T1 images with much more homogenous moderately decreased T1 signal and two foci of markedly decreased T1 signal aggressive severe osteoporosis probably in the healing phase possible with very heterogenous appearing marrow. Close clinical follow up is recommended. Correlation with CBC and peripheral smear plus reticulocyte count is recommended. I do not have plain films at this time; correlation with the DEXA values is recommended to confirm that this is osteoporosis. Bone marrow biopsy should be considered if there is no significant radiographic or DEXA confirmation of osteoporosis or if there are signs of a malignant process. As there is back pain currently in view of an essentially healed L3 compression fracture perhaps this is a sufficient sign to warrant a bone marrow biopsy.
[ Note that the patient has a remote family history of aggressive adenocarcinomas (breast and colon) and breast cancer accelerated by pregnancy is a worry.]
2. Late subacute to chronic milt L3 vertebral body compression deformity and fracture. No bone marrow edema is seen currently.
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