Bone marrow edema knee causes 2014,guide hunter pvp 4.3.4,ford edge alternator price range - Reviews

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Bone Marrow Edema, also known as Bone Marrow Edema Syndrome, or BMES, is a disorder that causes the marrow of the bones to swell up and take on fluid. Osteoarthritis is a chronic disease wherein the connective tissue of the joints is slowly eroded. In those situations where osteoarthritis is not present in the BMES sufferer, the patient usually sustained a broken bone shortly before the disorder's onset.
Bone marrow edema, or swelling, results from several conditions and is a relatively common disorder.
It is usually a symptom of some underlying disease, so treatments are focused on treating the cause of the edema. Bone marrow edema of the knee is a rare condition in which the main symptoms are bone and joint pain.
In this review we will discuss:Clinical and imaging features of stress fracturesCommon locations of stress fractures. Bone is constantly attempting to remodel and repair itself, especially when extraordinary stress is applied. When enough stress is placed on the bone, it causes an imbalance between osteoclastic and osteblastic activity and a stress fracture may appear. Bones are not made to withstand so much energy on their own and the muscles act as shock absorbers. Insidious onset of pain and swelling over the affected region is the most important complaint, initially during the activity.
With ongoing exposure, pain will last after the training, eventually causing the athlete to stop exercising. Stress fractures are most common in the weight-bearing bones of the lower extremity, especially the lower leg and the foot (Figure).
Typical stress fracture of the distal shaft of the second metatarsal not seen on initial radiograph (left). Radiographs have a sensitivity of 15-35% for detecting stress fractures on initial examinations, increasing to 30-70% at follow up due to more overt bone reaction.
Therefore, radiologists should not be comforted by negative radiographs and should initiate further state of the art imaging. After 4 weeks, a follow up radiograph clearly marks callus formation at the site of the stress fracture. On the left a 28-year old female with recent onset of pain over a region of the 2nd metatarsal bone. MRI has surpassed bone scintigraphy as the imaging tool for stress fractures, showing equal sensitivity (100%) but a higher specificity (85%), probably by giving better anatomical detail and more precisely depicting the tissues involved.
STIR (short tau inversion recovery), T1-weighted (T1WI) and T2-weighted images (T2WI) are used for characterization and grading.
On the left a 22-year old female, a professional athlete with a recent onset of forefoot pain, persisting after training. T1WI shows a definite fracture line in the navicular bone, indicating a grade 4 stress fracture.
Corresponding CT shows a fracture line and sclerosis on the axial images and coronal reconstructions. Although this is a low-risk fracture, the follow-up radiographs at 3 and 13 months did show poor healing tendency. The initial x-ray was reported as normal, but a T2-weigthed gradient echo of the knee shows bone marrow edema in the proximal tibia indicating the presence of a stress fracture.
X-ray and CT-scan showing a fissure at the insertion of the flexor digitorum longus muscle.
Initially the pain was only present during running, but finally it was present even in rest. A CT-scan was performed for further differentiation and revealed a vertically oriented fissure at the insertion of the flexor digitorum longus muscle. Medial malleolar stress fracture: Initial coronal STIR image and CT at 11 months follow-up. Bilateral stress fracture of the distal fibula: Initial radiographs and Bone scintigraphy at 2 weeks follow up. The radiograph at 6 weeks follow-up (not shown) confirmed bilateral stress fractures with healing tendencies. Stress fracture of 2th metatarsal: Radiograph at presentation and at 1 and 3 months follow up. A CT performed at presentation shows sclerosis of the medial sesamoid and confirms the diagnosis of stress fracture. Increased T2-weighted signal from the subchondral bone marrow is a frequent finding in acute traumatic osteochondral injury [86] as well as in the setting of chronic osteochondral injury, or osteoarthritis [87-89]. The characteristics of the MRI signal abnormality in the marrow are similar to those of water, which is dark on short TE sequences and bright on fluid-sensitive sequences such as fat-suppressed proton density or T2-weighted SE or FSE sequences, or STIR images [93]. Choice of appropriate MR pulse sequence is important for any research studies using imaging-derived data. Of 200 subchondral bone marrow edema-like lesions detected by IW fs sequence, 93 lesions (46.5%) were not depicted by the DESS sequence. In direct comparison the IW fs sequence depicts more subchondral bone marrow edema-like lesions and better demonstrate the extent of their maximum size.
BackgroundSubchondral bone marrow edema-like lesions (BML) are defined as non-cystic areas of ill-delineated hyperintensity on fluid-sensitive fast spin echo (FSE) fat suppressed (fs) pulse sequences and of hypointensity on T1-weighted (T1W) spin echo (SE) images [1]. MethodsStudy subjectsSubjects included in the present study were participants in the Joints On Glucosamine (JOG) cohort. Schematic illustration of semiquantitative scoring system for subchondral bone marrow edema-like lesions and subchondral cysts using the Whole Organ Magnetic Resonance Imaging Score (WORMS). In a second consensus reading by two experienced musculoskeletal radiologists (FWR, AG) with 7 and 9 years experience in standardized semiquantitative MR assessment of knee OA, these 200 subregions were re-evaluated using the sagittal 3D DESS and sagittal IW fs TSE sequences only. The distribution of the confidence ratings for the differentiation of subchondral BMLs and cysts varied between the sequences (Table 4), but by the Wilcoxon sign-rank test, the sequences were not different (p = 0.93). DiscussionSummarizing our results, we found that subchondral BMLs were more conspicuous and appeared larger when using the sagittal IW fs TSE sequence, compared with the sagittal DESS sequence.
ConclusionsSummarizing our findings, the maximum extent of subchondral BMLs seems to be depicted on the IW fs sequence when compared directly to the DESS.
Funding SourcesThe JOG study is funded by a grant from the Coca-Cola Company Beverage Institute for Health & Wellness. 2 clicks for more privacy: On the first click the button will be activated and you can then share the poster with a second click.
This is extremely painful, as it puts pressure against the interior of the bones and is found to reduce the marrow's ability to produce new blood cells. This occurs through the buildup of waste minerals around the joints as well as by wear and tear over time. BMES is different from normal edema in that, while it does include an increase in the fluid mass of the bone marrow, it also involves an inflammatory response from the immune system. The use of MR imaging in the assessment and clinical management of stress reactions of bone in high-performance athletes. Similar alteration in bone marrow signal intensity are observed following high intensity exercise or with altered joint biomechanics [90,91]. Because the abnormal signal closely follows water, this finding has been erroneously termed bone marrow edema [94]. The aim of this study was to compare semiquantitative assessment of subchondral bone marrow edema-like lesions and subchondral cysts using intermediate-weighted (IW) fat-suppressed (fs) spin echo and Dual Echo Steady State (DESS) sequences on 3 T MRI. 3T MRI was performed with the same sequence protocol as in the Osteoarthritis Initiative (OAI).
The DESS sequence helps in the differentiation of subchondral bone marrow edema-like lesions and subchondral cysts.
They are one of the features of osteoarthritis (OA) detected on MRI and are observed regularly in conjunction with structural alterations of adjacent cartilage. The JOG study is a 6-month double-blind randomized controlled trial to examine the efficacy of oral glucosamine supplementation. The femur and tibia are divided into lateral (L) and medial (M) regions, with the trochlear groove of the femur considered part of the M region.
Readings for both sequences were performed separately with a time interval of 4 weeks to avoid recognition bias.
This includes presence of subchondral BMLs on the IW fs sequence and absence on the DESS sequence. The DESS sequence helps in the differentiation of subchondral BMLs and cysts, as it depicts cysts as being larger than on the IW fs sequence. The sponsor did not have any role in the study design, analysis and interpretation of data, writing of the manuscript, or the decision to submit the manuscript for publication. Unless a systematic approach is followed, it may cause confusion in the differential diagnosis. Useful internal standards for distinguishing infiltrative marrow pathology from hematopoietic marrow at MRI.
In-phase and out-of-phase MR imaging of bone marrow: Prediction of neoplasia based on the detection of coexistent fat and water. Value of opposed-phase gradient-echo technique in distinguishing between benign and malignant vertebral lesions. Whole-body diffusion-weighted MR imaging in cancer: Current status and research directions.
Diffusion-weighted MR imaging of bone marrow: Differentiation of benign versus pathologic compression fractures.
Femoral head avascular necrosis: Correlation of MR imaging, radiographic staging, radionuclide imaging, and clinical findings.
Longitudinal assessment of bone marrow edema-like lesions and cartilage degeneration in osteoarthritis using 3 T MR T1rho quantification.
Meniscal pathology on MRI increases the risk for both incident and enlarging subchondral bone marrow lesions of the knee: The MOST Study.


Strong association of MRI meniscal derangement and bone marrow lesions in knee osteoarthritis: data from the osteoarthritis initiative. Subchondral cystlike lesions develop longitudinally in areas of bone marrow edema-like lesions in patients with or at risk for knee osteoarthritis: Detection with MR imaging--the MOST study.
Bone marrow edema pattern in osteoarthritic knees: correlation between MR imaging and histologic findings. Idiopathic bone marrow edema lesions of the femoral head: predictive value of MR imaging findings.
Vertebral neoplastic compression fractures: Assessment by dual-phase chemical shift imaging. Benign and malignant processes: Normal values and differentiation with chemical shift MR imaging in vertebral marrow. Acute vertebral body compression fractures: Discrimination between benign and malignant causes using apparent diffusion coefficients. Diffusion-weighted MR imaging of metastatic disease of the spine: Assessment of response to therapy.
MR detection of iliac bone marrow involvement by malignant lymphoma with various MR sequences including diffusion-weighted echo-planar imaging.
Diffusion MR imaging features of skull base osteomyelitis compared with skull base malignancy. Role of diffusion-weighted MR imaging in assessing malignant versus benign skull-base lesions. Characterization of bone and soft-tissue tumors with in vivo 1H MR spectroscopy: Initial results.
Quantification of vertebral bone marrow fat content using 3 Tesla MR spectroscopy: Reproducibility, vertebral variation, and applications in osteoporosis. MR image analysis of pedal osteomyelitis: Distribution, patterns of spread, and frequency of associated ulceration and septic arthritis. MRI signal changes of the bone marrow in HIV-infected patients with lipodystrophy: Correlation with clinical parameters. It quite literally doesn't have the room that it needs to fulfill its function, though the initial onset of the excess fluid serves to help blood cells that were already created in circulation. A correlation is present that in almost 80% of BMES cases, the patient also had osteoarthritis. It is possible, though not proven, that BMES is part of the immune system's self defense mechanism.
They have a low risk of complicated healing with conservative therapy, because the fracture parts are pressed together.
Correlation of clinical symptoms and scintigraphy with a new magnetic resonance imaging grading system.
It is a nonspecific MRI finding, but can be associated with pain [88], and with internal derangement in the knee [91,92].
Correlation studies with histology indicate that a mixture of tissue types contribute to the abnormal marrow signal. In a primary reading subchondral bone marrow edema-like lesions were assessed according to the WORMS system.
Confidence scores for differentiation of the two types of lesions were not significantly different between the two sequences. The IW fs sequence should be used for determination of lesion extent whenever the size of subchondral bone marrow edema-like lesions is the focus of attention. Higher prevalence and greater volume of concomitant BMLs has been reported to associated be with higher grades of cartilage loss [2].As OA progresses, an increase in BML volume is seen in the subchondral bone in many patients, and this is positively correlated with an increase in cartilage loss in the same region [2, 3]. Two hundred and one participants, aged 35 to 65, with mild to moderate chronic, frequent knee pain (Western Ontario and McMaster Universities (WOMAC) score a‰? 25 [10]) were recruited at the University of Pittsburgh, Pittsburgh, PA. The score is based on the extent of regional marrow involvement by areas of free water signal with ill-defined margins.
In addition, there is a grade 1 subchondral bone marrow edema-like lesion at the posterior medial femur (short white arrows show the approximate location of the ill-defined margin of the lesion).
Within this lesion, there is a small subchondral cyst (grade 1) directly adjacent to the subchondral plate (black arrowhead). Confidence ratings for the differentiation of subchondral BMLs and cysts were not significantly different between the two sequences.Choice of appropriate pulse sequences is a very important issue in MRI-based OA research.
Based on the type and relative proportion of signal alterations on conventional T1-weighted (TIW) and T2-weighted (T2W) MR images, various etiologies of bone marrow lesions can be divided into three categories [Table 1].
Functional interrelationships of vascular and hematopoietic compartments in experimental hemolytic anemia: An electron microscopic study.
Thankfully, BMES is a self-limiting disorder which fades an average of three weeks after the initial onset. It would prevent infection of the broken bone and bone marrow by inflaming the bone marrow, increasing its internal temperature to a point which would discourage the reproduction of bacteria and viruses, just like a fever. In the setting of acute trauma, areas of fluidlike signal are associated with regions of trabecular microfracture, hemorrhage, necrosis, and edema [95]. The femoral and tibial surfaces are further subdivided into anterior (A), central (C) and posterior (P) regions. For subregions in which subchondral BMLs were depicted in both sequences, the corresponding numbers for one grade and two grade differences (i.e. As we have shown, the extent of subchondral BMLs will be underestimated, or lesions might be completely missed by using the DESS sequence. Both sequences appear to be complementary and, based on our results, clear superiority of one sequence over the other could not be demonstrated.
This article outlines a systematic approach using this categorization, typical imaging features of various pathologies based on available literature, and prudent use of problem-solving imaging techniques, such as chemical shift imaging (CSI) and diffusion-weighted imaging (DWI). The extent of subchondral bone marrow edema-like lesions was re-evaluated separately using sagittal IW fs and DESS sequences according to WORMS. They are identified as foci of markedly increased signal in the subchondral bone with well delineated margins and no evidence of internal marrow tissue or trabecular bone. Region A of the femur corresponds to the patellofemoral articulation; region C the weight bearing surface and region P the posterior convexity that articulates only in extreme flexion. The score is based on the extent of focal bone loss through individual cysts (illustrated in the central region) or multiple cysts (illustrated in the posterior region) subchondrally.
Wilcoxon signed-rank tests for paired comparisons of clustered data were used to examine if there were statistically significant differences between the two sequences, and clustering by person was controlled [13]. Subchondral BMLs are an important feature of knee OA that is associated with pain [14] and cartilage damage [2].
However, if the main focus of any study is evaluation of subchondral BMLs, assessment should be performed on FSE fs sequences that depict these lesions to their maximum extent.
The body could be trying to reduce the mineral deposits in the joints by swelling the bone marrow with fluid, which has the side effect of pushing newly produced blood cells (red and white) out of the bone and into immediate use throughout the body.
Lesion size and confidence of the differentiation between subchondral bone marrow edema-like lesions and subchondral cysts located within or adjacent to them was rated from 0 to 3. Semiquantitative assessment of subchondral BMLs and cysts is commonly performed on FSE sequences such as T2-weighted (T2W), intermediate-weighted (IW) or proton density-weighted (PDW) fs sequences [5] or short-tau inversion recovery (STIR) sequence [6].
Region C of the tibial surface corresponds to the uncovered portion between the anterior and posterior horns of the meniscus centrally and the portion covered by the body of the meniscus peripherally. Consequently, the margin of the cyst is more clearly delineated when compared to IW fs sequence. Multiple publications have utilized MRI-assessment of subchondral BMLs, with most of these applying semiquantitative approaches [2, 4, 7, 15] and others applying quantitative methodology [16a€“18]. Red marrow contains 40% fat cells, 40% water, and 20% hematopoietic cells, whereas yellow bone marrow is composed of 80% fat cells, 15% water, and 5% hematopoietic cells.
Wilcoxon signed-rank tests and chi-square statistics were used to examine differences between the two sequences.
However, BMLs have also been assessed on gradient recalled echo (GRE)-type sequences such as Fast Low Angle Shot (FLASH) or Spoiled Gradient Recalled (SPGR) [7] that are commonly used for quantitative assessment of cartilage volume and thickness due to their high contrast of cartilage to subchondral bone [8]. Due to previous total knee arthroplasty or the presence of radiographic end-stage OA, eight participants had only one knee scanned, leaving 346 knees that were included in the analyses.
However some of the results presented in these studies should be interpreted carefully, since GRE-type sequences that may not fully depict subchondral BMLs were used [7].GRE-type sequences, even with robust fat suppression or water excitation, are notoriously insenstitive to bone marrow abnormalities due to trabecular magnetic susceptibility of T2* effects, which may result in underestimation of the size of subchondral BMLs [19, 20]. Kwoh receives research grant funding from the Beverage Institute for Health & Wellness, The Coca-Cola Company. There is an ongoing discussion regarding the choice of MR pulse sequences that would optimize BML assessment [9].
Recent studies have demonstrated that these sequences are also less sensitive in the detection of subchondral BMLs when using FSE sequences as the reference standard [21, 22]. None of the other authors have declared any possible conflict of interest.Authors' contributionsGuarantors of integrity of the entire study are AG and FWR. In light of this debate, a head-to-head comparison of FSE and GRE sequences for semiquantitative assessment of BMLs is needed to objectively appreciate potential differences. The identical pulse sequence protocol used for the OAI was applied in the JOG study, excluding the FLASH sequence and the Multi-Echo Spin Echo T2 mapping sequence. These results were summarized and published in a consensus statement by Outcome Measures in Rheumatology Clinical Trials (OMERACT) and Osteoarthritis Research Society International (OARSI) in 2006 [5]. In long bones, such as humerus and femur, crescentic subchondral area of residual red marrow is commonly present.
The Osteoarthritis Initiative (OAI) MRI protocol with sagittal IW fs and DESS (Dual Echo Steady State, which is a T2-weighted gradient echo sequence) sequences acquired at 3 T MRI allows such a comparison.The aim of our study was a comparison of semiquantitative assessment of subchondral BMLs and subchondral cysts using the DESS and IW fs sequences at 3 T MRI.
Details of the full OAI pulse sequence protocol and the sequence parameters have been published [11]. In an adult, the red marrow is mainly located in the appendicular skeleton in the metaphysis and near the vertebral endplate (the methaphyseal equivalent), due to well-developed vascularity. Due to lack of a definitive reference standard, this study is primarily aimed at demonstrating how visualization of subchondral BMLs and cysts differs by sequence and at highlighting the strengths and weaknesses of each sequence for assessment of those lesions. Since this study demonstrated their appearance may vary depending on the MRI pulse sequence used, one should be cautious when evaluating BMLs even if they are non-degenerative in origin.Subchondral cysts are better delineated by the DESS sequence.


The MRI evaluation in JOG included the joint features of subchondral BMLs, subchondral cysts, cartilage, meniscus, effusion and synovitis using the Whole Organ Magnetic Resonance Imaging Score (WORMS) method [12]. In this situation, the insensitivity of GRE-type sequences to subchondral BMLs is actually advantageous [5], and the borders between subchondral BMLs and cysts are more clearly delineated than by FSE sequences. The IW fs sequence usually delineates less clearly the sclerotic rim of the cyst when compared to the DESS sequence, and thus a peripheral portion of the cyst might be attributed to be ill-defined on the IW fs sequence. This may be the reason why the cysts appear larger on the DESS sequence.Thus far, studies have shown no association between the presence of subchondral cysts and pain in subjects with knee OA [24, 25], and thus clinical research efforts tend to be more focused on subchondral BMLs, whose association with pain has been clearly demonstrated [14, 26].
Ideally, all research protocols should include both a GRE-type sequence and a FSE fs sequence [5], but if practical reasons (e.g. Post-contrast (intravenous gadolinium) fat-suppressed T1W imaging should always include pre-contrast baseline fat-suppressed T1W imaging in at least one plane, with subtraction manipulation if possible. Thus, the WORMS score for subchondral BMLs and cysts is a sum of percentage of subregion for each type of lesion and does not give information on the number of lesions.
Problem-solving techniques are performed in a suspected or known marrow lesion in a short period of time.
In the following, we will use the term subchondral BML and subchondral cyst interchangeably for "percentage of the area occupied by BML and cyst within a subregion" as defined in WORMS. One might potentially argue that an IW fs sequence overestimates the extent of the lesion relative to the DESS sequence. Two-point Dixon technique (~5 min) takes longer than CSI (2-3 min); however, one can obtain a number of images from the same acquisition, "water only," "fat only," and "both water and fat" images. Two hundred subregions exhibiting subchondral BMLs from 63 knees of 42 subjects in the primary reading were randomly chosen for the consequent direct sequence comparison. Although this cannot be ruled out completely, based upon current knowledge, we believe it is more likely that IW fs depicts the maximum extent of subchondral BMLs [6].
No study has confirmed if the extent of subchondral BMLs as seen on GRE-type sequences matched that seen on histological examination. Another limitation that must be noted is that the imaging evaluation occurs at only one time point, and thus we are unable to comment on each sequence's sensitivity to change in a longitudinal study. STIR or fat-suppressed T2W MR (fsT2-W) imaging techniques are most sensitive for the detection of bone marrow lesions due to increased dynamic range of contrast. Lastly, we did not evaluate the state of hyaline cartilage and their appearances in the two types of pulse sequences because it was deemed outside the scope of the present study. With increasing use of proton density sequence instead of T1W sequence in routine joint imaging, it should be noted that the normal or reconverted red marrow may appear isointense to the muscle. However, interested readers are directed to a recently published article which compared semiquantitative assessment of focal cartilage damage using the DESS and IW fs sequences [27]. They demonstrated that the IW fs sequence detected more and larger focal cartilage defects than the DESS, but more intrachondral signal changes were observed with the DESS.
In those cases, simple looking back at the planning scout images (generally performed as gradient echo images) may be helpful. The focal islands of normal marrow always have some amount of microscopic fat and, therefore, tend to lose signal on these images (technically out-of-phase). However, if the scout image is performed as an in-phase image or if the lesion is not covered on the scout image, additional CSI would confirm that the lesion does not replace the bone marrow by demonstrating 20% signal loss on the out-of-phase images. It is important to emphasize that CSI does not differentiate between benign and malignant lesions but between bone marrow replacing and non bone marrow replacing lesions.
In fact, a benign bone marrow replacing lesion, such a bone cyst would show a drop of signal in out-of-phase images less than 20% compared to in-phase images. The enhancement of the normal marrow in adults is usually less than 35% from baseline on intravenous gadolinium administration. Benign compression fractures were iso- to hypointense to normal vertebral body, whereas malignant fractures were hyperintense. The lesions show homogenous bone marrow edema and usually they do not have associated soft tissue component or solid enhancement. Conventional radiography is usually negative in marrow-centric stress or microtrabecular injuries.
Histologically, the traumatic bone marrow lesion is the result of hemorrhage and inter-trabecular microfractures.
Fatigue fractures are the result of abnormal stress on normal bone structure, whereas insufficiency fractures are the result of a normal stress on an abnormal bone, such as in osteoporosis and osteomalacia.
The former are more common in young athletes and military recruits and the latter in older patients. The fracture line is commonly visible as a linear, solid or broken T1 and T2 hypointensity surrounded by a cloud of edema. Several reports on stress fracture in athletes are available and virtually every bone can be involved depending on the type of activity.
Typical location for stress fractures are the pelvis with lesser trochanter, femoral neck, tibia, and sacrum from running; and shoulder in athletes involved in throwing and lifting, such as in baseball players. T1-weighted fat-suppressed gadolinium-enhanced MRI of bone marrow edema of the knee: computer-assisted quantitative comparison and influence of injected contrast media volume and acquisition parameters.
There is homogenous ill-defined bone marrow lesion, appearing mildly hyperintense to muscle on T1W and moderately hyperintense on STIR images (arrows). Chemical shift imaging (CSI) shows more than 20% loss of signal intensity (SI) on the out-of-phase image (C) compared to the in-phase image (D). Bone marrow lesions category I (stress reaction)Click here to view Insufficiency fractures affect mainly elderly patients with osteoporosis. Most subjects with subchondral insufficiency injuries experience sudden pain and do not, in general, have any systematic disease, whereas patients with osteonecrosis present with insidious onset of pain and have underlying systemic disease. AVN is commonly seen as a half-moon-shaped lesion or a serpiginous lesion with a "double line" sign on T2W images, which is characterized by a peripheral low-intensity rim and inner high-intensity line.
The pattern in these patients is mainly localized in the foot, tibia, and femur in descending order. In those cases, an asymmetric larger confluent area of more T2 brightness should be looked for the diagnosis of pathologies such as superimposed bone contusion or fracture or infection. Therefore, the findings should be clinically correlated for appropriate diagnosis.Bone marrow edema is very common in osteoarthritis (OA) as well as in both seropositive and seronegative inflammatory arthropathies.
Most of these patients have an underlying subchondral insufficiency fracture or stress response. Similar to other category I lesions, the bone marrow edema is more pronounced on T2W imaging than on T1W imaging. Conventional radiography plays an important role in the identification and characterization of these lesions, especially the presence of benign or malignant periostitis, focal lytic or sclerotic lesions, and cortical destruction or permeation.
In infectious cases, Brodie's abscess may be seen as a confluent oval or elongated lesion approaching the physeal plate. The use of in-phase and out-of-phase imaging is probably the best known problem-solving technique for bone marrow pathologies. Several research articles have documented that restrictive diffusion with high signal intensity on DWI is observed in neoplastic (pathologic) fractures as compared to osteoporotic fractures.
According to their study, malignant vertebral fractures showed high signal intensity on DWI, whereas benign lesions showed low signal intensity. On the contrary, literature on osteomyelitis and tumors of the peripheral skeleton is very scant compared to that on spine. CSI confirms the marrow replacement due to lack of drop in signal intensity on the out-of-phase image (C) compared to in-phase image (D). Post intravenous gadolinium axial T1W subtraction imaging (E) at the level of the proximal tibia shows diffuse enhancement (large arrow) similar to adjacent vessels (small arrow). There are diffuse and inhomogeneous bone marrow lesions with hypointense signal intensity of the femurs on T1W and moderately hyperintense on STIR images with bilateral epiphyseal involvement. Corresponding coronal pre- (C) and post-gadolinium (D) 3D T1W images show diffuse enhancement of the lesions.
DWI (G) image at the level of the proximal right femoral shaft shows restricted diffusion (arrow).
Bone marrow lesions category IIClick here to view Having discussed both conventional and advanced MR techniques, one of the most important MRI indications in this category is the assessment of osteomyelitis in the adult population with diabetic foot. Diabetic pedal osteomyelitis is almost always the result of spread of infection from a skin ulcer and occurs most frequently around the fifth and first metatarso-phalangeal joints and calcaneocuboid joint.
Reactive edema shows bone marrow edema similar to category I lesions, with  predominantly high signal intensity on fluid-sensitive sequence and either a normal bone marrow or a hazy subcortical reticular distribution of hypointensity on T1W sequence.
One challenging differential diagnosis for the radiologist is to distinguish osteomyelitis from neuropathic joint. In the acute stage, the imaging findings of the neuropathic joint are very similar to those of osteomyelitis, with features such as subchondral T1 low signal intensity, T2 high signal intensity, and joint effusion. Additionally, "ghost sign," referring to a low signal intensity bone structure on T1W sequence that "reappears" as high signal intensity on fluid-sensitive sequence, suggests superimposed osteomyelitis. However, there are usually small islands of microscopic fatty marrow in successfully treated lesions.
Sagittal T1W (B) and coronal STIR (C) images show patchy marrow replacement with epiphyseal involvement of the proximal humerus. Associated subcutaneous soft tissue mass shows marked T2 hyperintensity and intense enhancement (arrows) on post-contrast subtracted 3D T1W image (D).
Restricted diffusion was seen in the acromion and soft tissue mass, reflecting high cellularity (arrow in E), and there was >20% signal loss on the out-of-phase (F,G) image. Bone marrow lesions category IIIClick here to viewTo conclude, bone marrow lesion can be seen as a non-specific finding in a variety of conditions.
A systematic approach to its evaluation by categorization is essential with prudent use of both conventional and problem-solving techniques, such as CSI and DWI, for accurate diagnosis and appropriate patient management.



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