Pediatric Imaging Pearl of the Week

The illustrated DDX can be found here.

School ager with back pain and fevers

MRI of transverse myelitis — Sagittal and axial T2 MRI of the thoracic spine shows centrally located continuous bright signal through the thoracic spinal cord that ends just above the conus medullaris.

The diagnosis was transverse myelitis.

School ager with back pain when bending over

MRI of tethered cord — Sagittal T1 (left) and T2 (right) MRI of the lumbar spine shows a low-lying conus medullaris of the spinal cord which terminates at S1. The T11/T12 vertebral body areas of low signal intensity on T1 and high signal intensity on T2 were felt to be due to aggressive Schmorl nodes as the patient had no clinical signs of infection.

The diagnosis was tethered cord.

Teenager with back pain

Radiograph and bone scan of spondylosis — Lateral radiograph of the lumbar spine shows a lucency through the pars interarticularis of the L5 vertebral body (pars defect). Axial and coronal images from a nuclear medicine bone scan show increased radiotracer localization in the right L5 pars interarticularis.

The diagnosis was L5 spondylosis.

Teenager with chronic back pain and acute abdominal pain

Radiograph and CT of Scheuermann disease — Lateral scout radiograph and 2D sagittal reconstruction of the lumbar spine from a CT of the abdomen shows anterior wedging and Schmorl nodes deformities of the T8, T9 and T10 vertebral bodies along with disc space narrowing at those levels.

The diagnosis was Scheuermann disease.

School ager with left flank pain and back pain with fever and increased white blood cell count

CT of acute pyelonephritis — Immediate (above) and delayed (below) axial CT with contrast of the abdomen shows multiple low density wedge-shaped lesions in the left kidney and a striated nephrogram on the delayed images.

The diagnosis was acute pyelonephritis.

Teenager with back pain

Radiograph and CT of osteosarcoma of spine — AP and lateral radiographs of the lumbar spine taken during a CT myelogram show loss of height of the L3 vertebral body and sclerosis of its posterior elements. Axial CT myelogram through the L3 vertebral body shows lytic lesions in the vertebral body and an expansile sclerotic appearance of the posterior elements with periosteal reaction.

The diagnosis was osteosarcoma of the spine.

Preschooler with back pain

MRI of osteomyelitis of the spine — Coronal T1 MRI without contrast of the lumbar spine (left above) shows areas of low signal intensity on the right side of the L4 and L5 vertebral bodies and a right-sided paraspinal mass all of which enhance after the administration of contrast (right above). Axial T2 MRI through the L5 vertebral body (below) shows high signal intensity in the right side of the vertebral body and in the right paraspinal mass. The disk spaces are not involved.

The diagnosis was osteomyelitis.

Teenager with back pain and scoliosis

Radiograph and CT of osteoid osteoma of the spine — AP radiograph of the thoracic spine shows an indistinct margin of the left T10 pedicle and mild scoliosis convex right. Axial CT without contrast of the T10 vertebral body with coronal and sagittal 2-D reconstructions shows a small round lucent nidus with central calcification in the left T10 pedicle surrounded by sclerosis.

The diagnosis was osteoid osteoma.

Preschooler with back pain, limited right hip motion, and a limp

Radiograph and CT of osteoblastoma of the sacrum — AP and lateral radiographs of the lumbar spine show an expansile lesion in the right side of the S3 vertebral body. Axial CT without contrast through this level shows a large round lucent nidus with central calcification in the right S3 pedicle surrounded by sclerosis.

The diagnosis was osteoblastoma of the sacrum.

Toddler with back pain

MRI of neuroblastoma invading the spinal canal — Coronal T1 MRI without contrast of the chest shows a right paraspinal mass in the region of the right adrenal gland that on axial sequences was seen to extend into the spinal canal.

The diagnosis was neuroblastoma.

School ager with back pain

Radiographs of mechanical back pain — AP, lateral and both oblique radiographs of the lumbar spine are unremarkable and show no evidence of a scotty dog deformity, thus ruling out spondylolysis.

The diagnosis was mechanical back pain.

Toddler with back pain

Radiograph of leukemia of the spine — Lateral radiograph of the thoracic spine shows diffuse osteopenia in the vertebral bodies with loss of height (vertebra plana) in all of the vertebral bodies.

The diagnosis was acute lymphoblastic leukemia involving the spine.

Preschooler with worsening back pain for 3 weeks and then refusal to walk

Radiograph and MRI of Langerhans cell histiocytosis of the spine — Lateral radiograph of the lumbar spine shows loss of height of the L1 vertebral body. Coronal and sagittal T1 MRI with contrast of the lumbar spine shows flattening (vertebra plana) and enhancement of the L1 vertebral body with a small enhancing right sided paravertebral mass.

The diagnosis was Langerhans cell histiocytosis of the spine.

Teenager with low back pain and bilateral radicular pain for 5 months

MRI of disc herniation — Sagittal and axial (at the L5 level) T1 MRI without contrast of the lumbar spine shows central and posterior displacement of the L5 intervertebral disk.

The diagnosis was disc herniation.

School ager with worsening back pain after minor fall

Radiograph and CT of Ewing sarcoma of the spine — Lateral radiograph of the spine shows collapse of the T12 vertebral body. Sagittal 2D reconstruction and axial CT without contrast of the T12 vertebral body in bone windows shows a permeative destructive process affecting it. Axial CT without contrast of the abdomen at the T12 level shows a large left-sided paraspinal soft tissue mass.

The diagnosis was Ewing sarcoma.

Toddler with limp who won’t bear weight on right leg

Radiograph and MRI of diskitis / osteomyelitis — Lateral radiograph of the lumbar spine shows loss of height of the L3-L4 intervertebral disc space. Sagittal T2 MRI of the lumbar spine shows (right top) loss of normal bright signal of the L3-L4 intervertebral disc and an epidural mass just posterior to the L4 vertebral body. Axial T1 MRI with contrast at the L4 level shows the epidural mass to be right sided and to also involve the right psoas muscle.

The diagnosis was osteomyelitis / diskitis.

Toddler with back pain and scoliosis

MRI of astrocytoma of spinal cord — Sagittal T1 (left), T2 (middle) and T1 with contrast (right) MRI of the thoracic spine shows an expansile lesion of the lower thoracic spinal cord that is isointense on T1, hyperintense on T2, and which enhances avidly with contrast.

The diagnosis was an astrocytoma of the spinal cord.

School ager with lower back and left buttock pain and a limp

Radiograph and MRI of aneursymal bone cyst — Lateral radiograph of the lumbar spine shows an expansile lesion in the S2 vertebral body. Axial and sagittal T2 MRI of the lumbar spine shows the S2 expansile lesion to be well defined and to have fluid-fluid levels within it.

The diagnosis was aneurysmal bone cyst of the sacrum.

Our DDX For This Week Is

Pediatric Imaging Pearl of the Week

The illustrated DDX can be found here.

Teenager with abnormal pleural-based nodules on CXR who had sustained blunt abdominal trauma in the remote past

CXR and CT and Tc-99m sulfur colloid scan of diaphragmatic rupture — CXR AP shows a left-sided large pleural nodule just beneath the clavicle. Axial CT with contrast of the chest shows multiple pleural nodules throughout the left hemithorax and absence of the spleen. Tc-99m sulfur-colloid scan shows normal radiotracer uptake in the liver with no uptake in the region of the spleen (lower left), and nodular uptake throughout the left hemithorax (lower middle) and abdomen (lower right).

The diagnosis was diaphragmatic rupture and post-traumatic splenosis.

Teenager in a motor vehicle accident with chest pain

CXR and CT and angiogram of thoracic aortic injury — CXR AP shows widened mediastinum. Axial CT with contrast of the chest shows dilated caliber of the thoracic aorta at the level of the diaphragm with surrounding mediastinal fluid (above) and normal caliber of the abdominal aorta with evidence of retrocrual hemorrhage tracking into the abdomen (below). Angiogram shows a pseudoaneurysm of the aorta at the level of the diaphragm.

The diagnosis was thoracic aortic injury.

Teenager shot by sibling with pellet gun one day ago with progressive dyspnea and chest pain

CXR and CT of pericardial effusion — CXR AP shows an enlarged cardiac silhouette, bilateral pleural effusions and radioopaque pellets in the right thorax near the hilum and left axilla. Axial and coronal CT with contrast of the chest shows a large amount of fluid in the pericardial space.

The diagnosis was traumatic pericardial effusion.

School ager in a motor vehicle accident with respiratory distress

CXR of tracheobronchial injury of left mainstem bronchus — CXR AP shows air in the superior mediastinum and neck, airspace disease in the left upper lobe, and a small amount of air in the left pleural space.

The diagnosis was tracheobronchial injury of the left mainstem bronchus with pneumomediastinum and a small left pneumothorax.