he Pediatric Vertebral Column: Alterations in Bone Structure

10.1055/b-0034-87916

The Pediatric Vertebral Column: Alterations in Bone Structure

Increased Density

Generalized Increased Density

Please note that humans are not densitometers; we are only recognizers of interfaces. Plain image recognition of increased or decreased density is only possible in relation to adjacent objects.

Sclerosis of the vertebrae can occur in all diseases in which generalized sclerosis of all bones occurs.

**Table 4.102 Generalized increased density**
Diagnosis	Findings	Comments
Physiologic “bony sclerosis of the neonate”	Apparent increased density of multiple bones, decreasing in the first weeks of life. One explanation is the difference from prenatal bone and the metaphyseal less dense bone created in the first weeks of life. See below for bone-in-bone appearance.	Can closely mimic osteopetrosis. True increased density is in relation to neighboring structures, such as zones of provisional calcification or tooth buds. Bones can be made more or less dense on picture archiving and communication system (PACS) with maneuvering.
Osteopetrosis Fig. 4.268, p. 468	Diffuse sclerosis systematically of all or part of the vertebral bodies and entire skeleton. “Rugger jersey” spine in some older children.	Anemia occurs when too much bone is involved. Increase bone fragility, even in vertebrae. Occasionally has multiple wormian bones. May have jaw osteomyelitis. Osteocytic osteolysis impairment may be a cause.
Bone marrow hyperplasia	Dense trabeculation. If severe, could show extramedullary hematopoiesis.	Chronic iron deficiency and hemolytic anemias, and particularly thalassemia major. MRI shows well the abnormal pattern vs. expected fat in marrow.
Pyknodysostosis	Generalized sclerosis.	Bone fragility. Multiple wormian bones. Short stature. Toulouse-Lautrec’s syndrome is a possible example.
Fluorosis	Generalized sclerosis is systematically laid down in bone during exposure.	Osteoporosis can also occur in chronic fluoride intoxication.
Engelmann disease, progressive diaphyseal dysplasia Fig. 4.269, p. 468	Diaphyseal vigorous periosteal reaction leads to sclerotic appearance. In vertebrae, mainly seen in the neural arch.	Also know as Camurati-Engelmann disease. Increased uptake in bone scintigraphy in a ctive stage. Similar pattern in mother-of-pearl industrial exposure.
Osteomesopyknosis	Density similar to osteopetrosis, but limited to trunk and the most proximal limbs.	May have back pain.

**Fig. 4.268 Osteopetrosis** in a neonate (compare to **Fig. 4.192** ). Denser than normal bones and prominent vascular clefts are noted.

**Fig. 4.269 Camurati-Engelmann disease.** The neural arches are dense compared to the bodies, as are regions in the ilium. These are analogous to the periosteal reaction of the dense femoral shafts (arrow). The density remains normal in femoral epiphysis (E) and metaphysis, as well as the vertebral bodies. All but the most posterior parts of the posterior ribs also dense.

**Table 4.103 Bandlike sclerosis**
Diagnosis	Findings	Comments
Bone-in-bone appearance	Normal growth pattern in the very young.	Normal in neonates and prematures in the first 2–8 wk. Evolves to normal spontaneously.
Healing osteoporosis	Newest normal density bone interfaces with osteoporotic bone.
Growth resumption lines after illness or injury Fig. 4.270	Dense lines parallel to growth plates in vertebral column are less conspicuous than in long bones.	Also known as Harris lines, Park lines, growth arrest lines, or growth recovery lines.
“Rugger jersey” vertebrae Fig. 4.271, p. 470	Denser bone along end plates than centrally.	A characteristic of osteopetrosis and osteomesopyknosis.
Healing renal osteodystrophy	Band of normal bone looks denser than earlier demineralized bone.
Chronic lead poisoning	Dense bands less conspicuous than those of long bones.	Also in bismuth poisoning.
Idiopathic hypercalcemia and hypervitaminosis D	Bands of increased density during the metabolically active period of the conditions.	Occasionally, hypervitaminosis D leads to less than normal density instead.

**Fig. 4.270 Harris lines.** Osteoporotic vertebral bodies show dense thin lines (growth arrest/recovery lines of Harris or Park) paralleling the end plates. This teenager with Duchenne muscular dystrophy has had a heart transplant and thus receives periodic metabolic jolts from immune therapy, resulting in the lines.

**Fig. 4.271 “Rugger jersey” in osteopetrosis** in a 1-year-old girl. The metaphyseal equivalents adjacent to the end plates are denser than the central (older) portions of the vertebral bodies. A dense 12th rib is noted (arrow).

**Table 4.104 Localized sclerosis**
Diagnosis	Findings	Comments
Bone island (s)	Homogeneous, often round, sclerotic, with hazy borders.	Also called osteomas. Of no clinical significance, except diagnostically if part of Gardner syndrome.
Sclerotic pedicle	Contralateral to spondylolysis. Possibly metastasis.	See the subsequent discussion of osteoid osteoma.
Osteoid osteoma Fig. 4.272 Fig. 4.273	Sclerotic region with sharp borders; has a predilection for pedicles. Reflex scoliosis common.	Often difficult to demonstrate. Skeletal scintigraphy or CT are best diagnostic methods (rather than MRI).
Compression fracture	Areas of increased density from significant vertebral body compression. Especially when callus occurs during healing phase.	Anterior compression best seen on lateral image; lateral compression best seen on frontal.
Healing phase of spondylitis-diskitis	Increased density at margins of disk material that intrudes through end plate.	Associated disk space narrowing.
Schmorl node margins	Increased density at margins of disk material that intrudes through end plate.
Healing phase of other lytic and steopenic processes	For example, LCH or rickets.	In healing rickets, the end plates (which are zones of provisional calcification) reappear first.
Melorheostosis	Could involve vertebral elements.	Endosteal in childhood.
Percutaneous vertebroplasty	Dense material injected into treated vertebral body.	After traumatic collapse or in eosinophic granuloma.
Sclerotic neoplasms
Hodgkin and non-Hodgkin lymphoma Fig. 4.274a–d, p. 472	Predominantly increased density of the affected vertebral bodies.	Marrow replacement on MRI.
Ewing sarcoma	Mostly sclerotic, arch or body.
Hemangioma	Dense and coarse trabeculae.	Often asymptomatic. Nicely shown on thin-section CT.
Metastases from medulloblastoma		Or retinoblastoma.
Osteogenic sarcoma		Unusual in vertebral location.
Chordoma		Mainly in clivus or sacrum.
Endosteal hyperostosis	Cortex of pedicles and other arch elements is thick at expense of medullary cavity; sclerotic calvarium and jaw.	Worth type is AD; van Buchem type is autosomal recessive.