Outline and learning objectives Primary bone tumors - to review the anatomy/pathology of the epidural space Filip M. Vanhoenacker - to learn about imaging signs of primary tumors of the osseous spine University Hospital Antwerp General Hospital St-Maarten Mechelen - to review the most frequent benign and malignant tumors of the osseous spine 1 2 Essential anatomy of the epidural space Essential anatomy of the epidural space Anterior epidural space “Virtual” space between dural sac and vertebral walls Posterior longitudinal ligament at disk space Extent: foramen magnum- • broad sacrum • tight adherence Anterior epidural space Posterior longitudinal ligament at vertebral Posterior (posterolateral) body epidural space • lateral fibrovascular complex (veins): loose neurographics.org • septum medium: tight 3 4 Essential pathology of the epidural space Essential pathology of the epidural space Anatomic barrier of Anatomic barrier of septum medium and septum medium and lateral expansions lateral expansions Curtain sign on imaging Curtain sign on imaging • tumors • tumors • infections • infections • preferential lateral • preferential lateral migration of disk migration of disk extrusions extrusions • trauma: lateral • trauma: lateral fragments fragments 5 6 1 Essential pathology of the epidural space Essential pathology of the epidural space Anatomic barrier of Anatomic barrier of septum medium and septum medium and lateral expansions lateral expansions Curtain sign on imaging Curtain sign on imaging • tumors • tumors • infections • infections • preferential lateral • preferential lateral migration of disk migration of disk extrusions extrusions • trauma: lateral • trauma: lateral fragments fragments 7 8 Essential pathology of the epidural space Imaging strategy Anatomic barrier of • (Clinical information (age!)) septum medium and lateral expansions • Multiplicity? Curtain sign on imaging • Topography • tumors • infections • Matrix • preferential lateral migration of disk • Contour (borders) extrusions • trauma: lateral • Other signs fragments 9 10 Imaging strategy Imaging strategy •Clinical information • Age! - young (osteoid osteoma, ABC, Ewing sarcoma) - middle-aged (GCT) - elderly (chordoma) • Other symptoms - benign lesions: mostly asymptomatic - malignant lesions: often symptomatic - more frequent in children - depending on location and extension - depending on type of tumor: osteoid osteoma, aggressive hemangioma, malignancies 11 12 2 Imaging strategy Imaging strategy • Topography: body vs posterior elements •Multiplicity: think of mets, MM, Lymphoma, systemic disease Malignant Exceptions mets hemangioma myeloma EG lymphoma enostosis chordoma GCT Benign Exceptions OO chondrosarc osteoblastoma osteosarc ABC Ewing’s sarc exostosis 13 14 Imaging strategy Imaging strategy • Topography: body vs posterior elements • Topography: body vs posterior elements Osteoid Osteoma 15 16 Imaging strategy Imaging strategy • Topography: preferential segmental location • Topography: cervical spine -cervical spine: osteoblastoma, ABC, osteochondroma (C2) -thoracic spine: hemangioma, enostosis (T1-T7), ABC, chondrosarcoma -lumbar spine: enostosis (L2-L3), osteoid osteoma - sacral spine: chordoma, GCT, Ewing’s sarcoma, plasmocytoma, lymphoma Osteoblastoma 17 18 3 Imaging strategy Imaging strategy • Topography: thoracic spine • Topography: sacral spine hemangioma chordoma 19 20 Imaging strategy Imaging strategy • Topography: sacral spine • Topography: sacral spine plasmocytoma GCT 21 22 Imaging strategy Imaging strategy • Matrix • Matrix -osseous -osseous enostosis enostosis osteoid osteoma osteoid osteoma osteoblastoma osteoblastoma a b -cartilaginous -cartilaginous chondrosarcoma chondrosarcoma osteochondroma osteochondroma -ground glass -ground glass c d fibrous dysplasia fibrous dyplasia Image courtesy of prof. Ladeb M.F. 23 24 4 Imaging strategy Imaging strategy • Matrix • Matrix -osseous -osseous enostosis enostosis osteoid osteoma osteoid osteoma osteoblastoma osteoblastoma -cartilaginous -cartilaginous chondrosarcoma chondrosarcoma osteochondroma osteochondroma chordoma -ground glass -ground glass Chordoma with ring-and-arc-like fibrous dyplasia fibrous dyplasia enhancement 25 26 Imaging strategy Imaging strategy • Matrix • Contour (borders) and soft tissue extension -osseous -Geographic:benign enostosis • hemangioma osteoid osteoma • enostosis osteoblastoma • osteoid osteoma • osteoblastoma -cartilaginous • ABC chondrosarcoma -moth-eaten or permeative : malignant osteochondroma • Ewing sarcoma -ground glass -Soft tissue extension: malignant (mets, ES, chordoma) and some “aggressive” benign (osteoblastoma, GCT, aggressive fibrous dyplasia hemangioma) 27 28 Imaging strategy Imaging strategy • Contour (borders) and soft tissue extension • Contour (borders) and soft tissue extension Metastasis ABC Ewing’s sarcoma Agressive hemangioma 29 30 5 Imaging strategy Imaging strategy • Other signs -Fluid-fluid levels: ABC, teleangiectatic osteosarcoma • Fluid-fluid levels -Nidus: osteoid osteoma -Vertical striations: hemangioma -Brush border: enostosis -Expansion: ABC, osteoblastoma, aggressive hemangioma, osteochondroma -Signal intensity and enhancement pattern on MRI -Attenuation on CT: enostosis vs osteoblastic metastasis -Relative sparing of the disc space: EG, chordoma 31 32 Imaging strategy Imaging strategy • Nidus • Vertical striations/polka dot Hemangioma Osteoid osteoma 33 34 Imaging strategy Imaging strategy • Brush border and CT density • Expansion Ulano A, et al. AJR 2016; 207:362–368 Aggressive haemangioma 35 36 6 Imaging strategy Imaging strategy Signal intensity Signal intensity and enhancement pattern on MRI . SI . high SI on T1: hemangioma (fat within the lesion), EG . low SI on T2-WI: GCT, enostosis . Ring-and-arc-like enhancement: chondroid Hemangioma GCT 37 38 Imaging strategy Imaging strategy Signal intensity Signal intensity Giant cell tumor NHL 39 40 Imaging strategy Imaging strategy • Preserved disk • Preserved disk Eosinophilic granuloma GCT Chordoma 41 42 7 Most frequent Primary Tumors of Osseous Spine Benign Malignant Hemangioma Myeloproliferative tumors: Enostosis (bone island) multiple myeloma Osteoid osteoma lymphoma Osteoblastoma Non-myeloproliferative Aneurysmal bone cyst tumors: (ABC) Chordoma Giant cell tumor (GCT) Ewing sarcoma Eosinophilic granuloma Chondrosarcoma Osteochondroma 43 44 Frequent benign Primary Tumors of Osseous Spine Differential diagnosis Pans S, et al. JBR-BTR 2005 Osteoporotic fracture (Kümmel) 45 46 Differential diagnosis Conclusion Extradural tumor: first think of metastasis, myeloma and lymphoma Characterization • different parameters • multimodality approach MRI useful for staging Avoid unnecessary work-ups of benign lesions and facilitate treatment and management of aggressive lesions Multifocal TB Consider other Ddx (infection,osteopo…) 47 48 8 References • Vidal JA, Murphey MD. Primary Tumors of the Osseous Spine. MRI Clinics. 2007;15(2):239-253 • Rossi A, Gandolfo C, Morana G, Tortori-Donati P. Tumors of the Spine in Children. Neuroimaging Clinics of North America. 2007;17(1):17-33 • Drapé JL, Anract P, Rodali MH, et al. Tumeurs Spécifiques du Rachis: Aspects Diagnostiques et Thérapeutiques. In: Le Rachis; Getroa-Gel, Opus XXXV. 2008; pp 257-281 •Kahn SHM, De Schepper AM. Primary Tumors of the Osseous Spine. In: Van Goethem J, et al. Spinal Imaging. Sprineger-Verlag. 2007; pp 475-500 49 9.