Imaging, 22 (2013), 20110023

MUSCULOSKELETAL IMAGING

Picture quiz: Musculoskeletal imaging

M JAVID,

FRCR,

M CALLEJA,

FRCR

and S SHETTY,

FRCR

Department of Radiology, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
doi: 10.1259/imaging.
20110023
2013 The British Institute of
Radiology

Cite this article as: Javid M, Calleja M, Shetty S. Picture quiz: Musculoskeletal imaging. Imaging 2013;22:20110023.

Case 1

Case 4

A 66-year-old female presented with a long history of lower back pain (see Figure 1). What is the
diagnosis?

A 59-year-old female complained of low back pain

radiating to the left leg (see Figure 4). What is the diagnosis?

Case 5
Case 2

A 61-year-old male complained of a left-sided sciatic

type of pain (see Figure 5). What is the diagnosis?

A 23-year-old female presented with a long history of

back pain, and recent worsening of symptoms (see
Figure 2). What is the diagnosis?

Case 6

Case 3
This 18-year-old male was involved in a high-speed
motorcycle accident (see Figure 3). What do the images
show?

A 28-year-old female presented with a long history of

back pain (see Figure 6). She was otherwise well. What is
the most likely diagnosis?

Case 7
A 57-year-old male presented with a slowly increasing
swelling of the thigh (see Figure 7). What is the diagnosis?

Address correspondence to: Dr Malika Javid, Department of

Radiology, University Hospitals Coventry and Warwickshire NHS
Trust, Clifford Bridge Road, Coventry CV2 2DX, UK. E-mail:
Malika.Javid2@uhcw.nhs.uk

imaging.birjournals.org

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M Javid, M Calleja and S Shetty

(a)

(b)

(c)

Figure 1. 66-year-old female with history of lower back pain. (a) CT scan on bone windows done at the time of presentation. (b,
c) Sagittal (b) T1 weighted and (c) T2 weighted images through the area.

(a)

(b)

(c)

Figure 2. 23-year-old female with history of back pain, and recent worsening of symptoms. (a) Sagittal T1 weighted, (b) short tau
inversion recovery and (c) axial T2 weighted images.

(a)

(b)

(c)

Figure 3. 18-year-old male involved in a high-speed motorcycle accident. (a) Sagittal T1 weighted, (b) T2 weighted and (c) axial T2
weighted images.

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Imaging 2013, 22, 20110023

Picture quiz: Musculoskeletal imaging

(a)

(b)

Figure 4. 59-year-old female who complained of low back pain radiating to the left leg. (a) T2 sagittal left paracentral image.
(b) T2 axial image through the upper half of the L5 vertebral body.

(a)

(c)

(b)

(d)

Figure 5. 61-year-old male who complained of left-sided sciatic type pain. (a, b) Sagittal (a) T1 and (b) T2 weighted images
through the left-sided pedicles. (c) Axial T2 weighted image through the L3/4 disc.

imaging.birjournals.org

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M Javid, M Calleja and S Shetty

(a)

(b)

(c)

Figure 6. 28-year-old female with a long history of back pain. (a, b) Sagittal (a) T1 weighted and (b) T2 weighted images.

(a)

(b)

(c)

Figure 7. 57-year-old male with a slowly increasing swelling of the thigh. (a) T1 weighted coronal image. (b) T1 and (c) short tau
inversion recovery axial images through the thigh.

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Imaging 2013, 22, 20110023

Picture quiz: Musculoskeletal imaging

Answers
Answer 1
Chordoma. The CT shows a destructive lesion in the
sacrum, it has a presacral soft tissue component and shows
matrix calcification. On MRI the lesion is of low to intermediate signal on T1 weighted images. On T2 weighted
images it is of heterogeneous high signal, and the capsule
and internal septa have uniform low signal. The lesion
extends both anteriorly and posteriorly. The anterior
extent displaces the rectosigmoid, but typically does not
invade it. On T1 weighted and T2 weighted images there
may also be areas of increased signal due to haemorrhage.
These are the appearances of a sacral chordoma.
Chordomas are the commonest primary malignant
tumour of the sacrum. Chordomas account for 24% of
primary malignant bone tumours [1].
5060% of these occur in the sacrococcygeal region. The
differential diagnoses of sacral tumour with soft tissue
mass include giant cell tumour, chondrosarcoma, plasmocytoma and metastasis.

Answer 2
Tuberculous spondylodiscitis. Sagittal T1 weighted
imaging shows a low signal mass involving the L4 and L5
lumbar vertebrae with extension anterior and posterior
to the vertebrae. The short tau inversion recovery (STIR)
images show high signal changes. The axial T2 weighted
images show an anterior abscess. The cauda equina is
compromised.
Tuberculous spondylodiscitis is the most common
extrapulmonary form of tuberculosis. The thoracolumbar
and lumbar regions are the most frequent sites of occurrence in the spine. Anterior vertebral erosion with relative
sparing of the discs is typical, in contradistinction to
pyogenic spondylodiscitis where less than 2% of discs
are not involved [2]. The pattern of vertebral involvement
may be paradiscal, anterior, central and posterior. A lack
of proteolytic enzymes in Mycobacteria infections in
comparison with pyogenic infections has been proposed
as the cause of the relative preservation of the intervertebral disk and of the subligamentous spread of
infection by the former organism. Non-contiguous lesions
can occur; therefore whole-spine imaging is recommended
[3]. Paraspinal and epidural abscesses are common.

Answer 3
Burst fracture. Sagittal T1 weighted and T2 weighted
images show compression of the L1 vertebra with retropulsion of bone into the central canal causing central
canal stenosis. The posterior ligamentous complex is
ruptured; there is a high signal cleavage plane between
T12 and L1 involving the ligamentum flavum, and the
interspinous and supraspinous ligaments. Burst fractures
involving all three columns are unstable. High signal
changes within the conus, demonstrated on the T2
weighted imaging, are likely to be haemorrhagic. Additional fractures are present at the T12, T11 and T10 levels.
At the T12 there is collapse of the superior end plate,
a small anterosuperior vertebral body corner fracture and
some angulation of the posterior vertebral body cortex
imaging.birjournals.org

inferiorly, indicative of a posteroinferior vertebral body

corner fracture. High signal oedema with a faint line
paralleling the superior end plates of T11 and T12 vertebral bodies also suggest fractures.
Burst fractures result from a combination of flexion and
axial loading. The morphological changes seen include
anterior wedging, end plate disruptions and disruption of
the posterior vertebral body line. Posterior column fractures usually involve the laminar or spinous process.
Intact posterior longitudinal ligament is an important
finding. Imaging of the whole spine is necessary with at
least a sagittal T2 weighted SFE FS/STIR image to rule
out non-contiguous fractures [4].

Answer 4
Synovial facet joint cyst. The T2 images show a lesion
in the left lateral recess at the L4/5 level. The appearances
are typical of a facet joint cyst. These cysts are quite
common and are associated with degeneration of the
facet joint. The cysts may compress the nerve root in the
lateral recess or contribute towards central spinal stenosis. They sometimes show high signal on the T1 images
due to proteinacious content of the cyst. The lesions may
be treated by facet joint injection, direct puncture or
surgery [5].

Answer 5
Lateral disc hernia. The sagittal images show obliteration of the fat within the L3 foramen by disc. The L3
nerve roots cannot be visualized as they are compressed
within the foramen. On the axial image the lesion is seen
lying in a lateral position (arrow in Figure 5d). The lateral
recess is not involved.

Answer 6
Osteopetrosis. Sagittal T1 weighted and T2 weighted
images both show low signal changes at the superior and
inferior end plates.
On plain radiography, the vertebrae show alternating
sclerotic and radiolucent transverse bands, known as the
rugger-jersey sign or sandwich vertebrae (Figure 2c),
which correspond with the MRI findings. These appearances are consistent with osteopetrosis. Another appearance is bone within bone. The vertebrae can also be
extremely radiodense.
Osteopetrosis (marble bone disease, Albers-Schonberg
disease) was first described by the German radiologist
Albers-Schonberg in 1904. It is a rare hereditary disease
where there is a defect in the osteoclasts, resulting in
failure of proper bone resorption. This results in very
dense but brittle bones. It is classified clinically into three
types:
1. Infantile. This has autosomal recessive inheritance. It is
the most severe form, with bone marrow failure and
a poor prognosis. Death is usually in the first decade of
life.
2. Delayed (adult). This is autosomal dominant. It is not
associated with bone marrow failure and has a good
prognosis. It is further divided into Types 1 and 2 [6].
Adults are usually asymptomatic.
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M Javid, M Calleja and S Shetty

3. Intermediate. This is autosomal recessive. It is not

associated with bone marrow failure, but has a poor
prognosis.

the appendicular site is good following a complete

excision.

References
Answer 7
Low-grade liposarcoma. There is a large tumour
showing mainly high signal on T1 and low signal on
the fat suppression sequence (Figure 7a, b). This indicates that this is a lipomatous lesion. The size and
deep position indicates that this is a liposarcoma. In
addition there are minor non-fatty components.
Lipomatous lesions deep to the muscle fascia have
a high chance of being malignant compared with
their superficial counterparts [7]. Simple deep lipomas
are smaller and suppress completely on the fat suppression sequences. Atypical lipoma, a very lowgrade lesion, usually suppresses completely, but tends
to be larger than simple lipoma. When there are
non-fatty components, as in this case, then a confident
diagnosis of liposarcoma can be made [7]. The higher
the proportion of non-fatty tissue in the lesion, the
higher the tumour grade is likely to be. Biopsy is not
usually undertaken as there is the risk of sampling
error and, in any case, the result does not influence
management. The prognosis for low-grade tumours in

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1. Llauger J, Palmer J, Amores S, Bague S, Camins A. Primary

tumors of the sacrum: diagnostic imaging. AJR Am J Roentgenol 2000;174:41724.
2. Ledermann HP, Schweitzer ME, Morrison WB, Carrino JA.
MR imaging findings in spinal infections: rules or myths?
Radiology 2003;228:50614.
3. Kaila R, Malhi AM, Mahmood B, Saifuddin A. The incidence
of multiple level noncontiguous vertebral tuberculosis
detected using whole spine MRI. J Spinal Disord Tech 2007;
20:7881.
4. Green RA, Saifuddin A. Whole spine MRI in the assessment
of acute vertebral body trauma. Skeletal Radiol 2004;33:
12935.
5. Apostolaki E, Davies AM, Evans N, Cassar-Pullicino VN. MR
imaging of lumbar facet joint synovial cysts. Eur Radiol 2000;
10:61523.
6. el-Tawil T, Stoker DJ. Benign osteopetrosis: a review of 42
cases showing two different patterns. Skeletal Radiol 1993;22:
58793.
7. Murphey MD, Arcara LK, Fanburg-Smith J. From the archives
of the AFIP: imaging of musculoskeletal liposarcoma with
radiologic-pathologic correlation. Radiographics 2005;25:
137195.

Imaging 2013, 22, 20110023