CASE 18
By: Dr. Sattam Lingawi and Dr. Alaa Al-Turkustani
HISTORY: 64-year-old male patient presented with back pain.
What are your findings?
What is the differential diagnosis?
FINDINGS:
Fig 1: Lateral radiograph of the lumbar spine demonstrates superior and inferior end plate compression fracture of T12 with anterior wedging, inferior end plate fracture of L1 & superior end plate fracture of L2 vertebrae.
Fig 2 & 3: Sagittal T2 WI and Sagittal post contrast T1 WI with fat saturation demonstrating diffuse heterogeneous bone marrow signal intensities which is predominantly low on T2 WI with multilevel vertebral bodies compression fracture at T12, L1 and L2 associated with enhancement within the partially collapsed T12 vertebral body and epidural enhancing soft tissue mass encasing the lower spinal cord and conus medullaris.
DIFFERENTIAL DIAGNOSIS:
Multiple myeloma with epidural metastasis.
Lymphoma and leukemia.
Secondary Bone and epidural metastasis.
DIAGNOSIS:
Multiple myeloma with epidural metastasis.
PEARLS AND DISCUSSION:
Multiple myeloma is a primary malignant bone neoplasm in the adults arising from red marrow due to monoclonal proliferation of the plasma cells. Marrow disease in the presence of multiple myeloma is identifiable at MR imaging as areas of decreased fat and increased signal intensity within the marrow on T1-weighted images. STIR and T2-weighted imaging are the most sensitive sequences for depicting these changes. When contrast-enhanced imaging is performed, untreated lesions demonstrate diffuse contrast enhancement. However, these changes in the appearance of marrow are nonspecific; therefore, other infiltrative processes, such as leukemia, lymphoma, and metastases, should be included in the differential diagnosis at MR imaging. The diagnosis of multiple myeloma has been based mainly on bone involvement (multiple bone marrow lesions, often with pain), hypercalcemia, anemia, chronic renal insufficiency, and the presence of M protein (monoclonal immunoglobulin) in samples of blood, urine, or both.
FURTHER READING:
Christopher J. Hanrahan, Current Concepts in the Evaluation of Multiple Myeloma with MR Imaging and FDG PET/CT. RadioGraphics 2010; 30:127–142.
C. F. Healy, J. G. Murray, Multiple Myeloma: A Review of Imaging Features and Radiological Techniques. Bone Marrow Research. 2011, 583439
