Structured approach to spine osseous (bone) lesions
Choose your own adventure

Spine osseous lesions can be a particular challenge to the radiologist or other physician seeing patients with spine disease. Sometimes these lesions can be symptomatic and other times they are found totally incidentally. They have a broad differential, and many times the role of the radiologist is simply to help determine the next management step. That is, does a next step in management need to be taken acutely or can the problem be managed conservatively with imaging follow-up.

The most important clinical question is whether a lesion is aggressive or nonaggressive. We use the word nonaggressive instead of benign because some locally nonagressive lesions can be malignant, and some aggressive lesions can be pathologically benign. However, this distinction drives the decisions about management.

In this section, Dr. Michael Hoch is going to walk us through a structured approach to osseous lesions of the spine based on making this distinction. This lecture has a unique format which mimics the “Choose Your Own Adventure” books that many of us read throughout elementary and middle school. This will give you a chance to make your own choices as we go though the cases.

The first section will be a brief overview which will be followed by 5 case presentations. At the end of each case, you need to decide whether you believe the lesion is aggressive or nonaggressive and choose the appropriate video. If you choose correctly, you will see the correct answer to the case presentation. If not, you should return, review the images, and select the other course.


In the introduction, Dr. Hoch walks us through some of the key features of aggressive and non-aggressive lesions and walks us through a flow-chart based approach that we can use to narrow our differential once we decide whether a lesion is aggressive or non-aggressive.


As described above, the following 5 cases use the structured approach that Dr. Hoch described in the introduction. Watch the introduction to each case and then choose which video you believe correctly answers the question of whether the lesion is aggressive or non-aggressive

Case 1

This is the first of five unknown cases. It shows a lesion in the lumbar spine with extension into the epidural space. There is T2 hyperintensity and avid enhancement.

 Case 1 – Do you believe this lesion is?



Case 2

This is the second of five unknown cases. It shows a lesion in the cervical spine. It is relatively well marginated without destruction of the adjacent bone. It is T2 heterogeneous/dark, T1 hypointense, and enhancing.

 Case 2 – Do you believe this lesion is?



Case 3

This is the third of five unknown cases. There is a lesion in the lower thoracic spine in a relatively young patient with back pain. There are areas of cortical destruction and loss of bone matrix. There is potentially a soft tissue component.

 Case 3 – Do you believe this lesion is?



Case 4

This is the fourth of five unknown cases. There is a destructive lesion in the posterior elements of the upper thoracic spine. There is a significant soft tissue component with epidural and adjacent soft tissue involvement.

 Case 4 – Do you believe this lesion is?



Case 5

This is the fifth of five unknown cases. There is an expansile lesion in the lumbar spine with bowing of the cortex of the vertebral body. The patient has a large right adrenal mass and a history of adrenal carcinoma.

 Case 5 – Do you believe this lesion is?




In summary, spine osseous lesions are challenging diagnoses to make. However, having a structured approach to their interpretation can help you differentiate what types of abnormalities you might be observing. We suggest you first make a determination about whether you are looking at an aggressive or nonaggressive lesion and then go from there.

Other resources

If you’d like to review more spine imaging, I recommend you check out the other spine cases on this web site. There aren’t a lot of great books about spine bone lesions, but you might consider the following case review book which is pretty good.

Spine Imaging: Case Review Series – Efrat Saraf-Lavi

Target audience: junior residents, senior residents, fellows

Detail level: medium

This is another in the popular case review series books. Like the brain book, the presentation is case style and divided into easy (“Opening Round”), moderate (“Fair Game”), and hard (“Challenge”) sections. Unfortunately, this book is not quite as high yield as the brain book. There is some repetitiveness to the diagnoses and the images are a little bit lower quality, although part of this is just because it’s hard to capture spine imaging in only a few images. This book remains useful because there aren’t that many other spine neuroradiology review books and it give you a nice case based review to peruse before the exam.