1	Benign versus malignant non-traumatic vertebral collapses * Laurence BELLAICHE * ***Jean-Denis LAREDO Clinique Bachaumont - Paris INSEP - Paris Hôpital Lariboisière - Paris ***UPENN - Philadelphia
2	Vertebral collapses (VC) History Clinical findings Imaging Simple biological tests
3	Vertebral collapses (VC) Plain X rays Bone scan CT scan MRI
4	Check-list for X-Rays Localisation and number of VC Shape of VC on AP and lateral X rays Antero-lateral cortex of the vertebral body (VB) Pedicle cortex Soft tissue mass Intravertebral vacuum phenomenon
5	X-rays Number and Location: Single collapse above T7 à Suspicion of malignancy
6	"2 . Shape of the..." 2 . Shape of the VC on lateral X rays: à No diagnostic value
7	"2 . Shape of the..." 2 . Shape of the VC on AP views: Very helpful
8	XRays 2 . Shape of the VC on AP views
9	"3." 3. Anterolateral cortex of the VB Benign VC : Fracture but no destruction Malignant VC : Cortical destruction
10	"3." 3. Anterolateral cortex of the VB Benign VC : Fracture but no destruction Malignant VC : Cortical destruction
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13	"3." 3. Anterolateral cortex of the VB
14	"3." 3. Anterolateral cortex of the VB Benign VC: Fracture but no destruction
15	"3." 3. Posterior cortex of the VC -Benign VC: Retropulsion of a VB corner -Malignant VC: Destruction / Bulging of the posterior cortex
16	"3." 3. Posterior cortex of the VB
17	"3." 3. Posterior cortex of the VB -Benign VC: Retropulsion of a VB corner
18	"4." 4. Pedicle cortex Benign VC: Normal or fractured Malignant VC: Cortical destruction
19	"4." 4. Pedicle cortex Benign VC: Normal or fractured Malignant VC: Cortical destruction
20	"5." 5. Soft tissue mass = Malignant VC
21	"5." 5. Soft tissue mass = Malignant VC
22	"6." 6. Intravertebral vacuum phenomenon Almost specific of a benign origin
23	"7." 7. Intravertebral vacuum phenomenon à Value of lateral views with spine extension
24	Bone Scan
25	Check-list for CT-Scan Anterolateral VB cortex Posterior VB cortex Pedicles and neural arch Soft tissue mass
26	Anterolateral VB cortex
27	"Anterolateral VB cortex" Anterolateral VB cortex Benign VC: ‘the puzzle sign’ à No piece is missing !
28	"Anterolateral VB cortex" Anterolateral VB cortex Malignant VC: some degree of cortical destruction à Some pieces of the puzzle are missing!
29	"2." 2. Posterior VB cortex Fracture and retropulsion of a VB corner Benign VC: 35% Malignant VC: 3%
30	CT Scan 2. Posterior VB cortex Cortical destruction - Benign VC: 0% - Malignant VC: 69%
31	CT Scan 3. Pedicle and neural arch Benign VC: Normal or fracture at VB/pedicle junction
32	CT Scan 3. Pedicle and neural arch Malignant VC: Destruction
33	CT Scan 4. Prevertebral soft tissue mass
34	4. Prevertebral soft tissue mass Benign VC: Absent or diffuse Malignant VC: Focal soft tissue mass
35	4. Spinal canal soft tissue mass Benign VC: 3% Malignant VC: 62%
36	MRI Adjacent vertebral metastases Morphological findings Signal Intensity (SI) abnormalities
37	MRI 1. Adjacent vertebral metastases: 60% of malignant VC
38	MRI 2. Morphological findings: - Posterior cortex - Neural arch - Soft tissue mass
39	MRI 2. Morphological findings Benign VC: Retropulsed corner
40	MRI 2. Morphological findings Malignant VC: Convex posterior cortex
41	MRI 2. Morphological findings Malignant VC: - Neural arch involved
42	MRI 2. Morphological findings Malignant VC: - Soft tissue mass
43	MRI 3. Signal Intensity (SI) abnormalities: SE T1 Gado - SE T1 Fat Sat FSE T2 or STIR
44	MRI Low SI
45	MRI 3. SI abnormalities SE T1: Partial preservation of fatty marrow Benign VC: 68% Malignant VC: 7%
46	MRI 3. SI abnormalities SE T1: Partial preservation of fatty marrow 4 suggestive patterns
47	MRI 3. SI abnormalities Gado - SET1: In Benign VC Diffuse homogeneous enhancement Return to normal SI Linear enhancement Fracture line
48	MRI 3. SI abnormalities Gado – SE T1 In Benign VC: à Return to normal SI
49	MRI 3. SI abnormalities Do not use Gado Fat-Sat SE T1 Impossibility to check for return to normal SI
50	MRI 3. SI abnormalities Gado – SET1 Malignant V.C. Heterogeneous enhancement Focal/nodular enhancement
51	MRI 3. SI abnormalities Fat Sat - T2 Benign VC Normal SI 37% Diffuse high SI 18% Linear high SI 45%
52	MRI: Difficult cases Follow-up MRI: You can check Return to fatty SI within 1 or 2 months
53	MRI 3. SI abnormalities Fat-Sat T2 Malignant VC Normal SI: 6% Nodular high SI: 94%
54	‘Pseudo-malignant VC’ Radiographs: à Cortical destruction à Bone bursting
55	‘Pseudo-malignant VC’ Radiographs: à Progressive bone destruction
56	‘Pseudo-malignant VC’ Extension radiographs: à Vacuum phenomenon
57	’Pseudo-malignant VC’ CT Scan: à Cortical destruction Bone fragmentation Retropulsed fragment
58	’Pseudo-malignant VC’ Atypical MRI à Fluid-like intravertebral collection
59	Benign versus malignant non-traumatic vertebral collapses: Diagnostic strategy Clinical findings Biological findings Radiographs Dynamic radiographs Bone scan CT scan MRI à Follow-up or Biopsy
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