Tang et al.

M u s c ul o s kel et a l I m ag i n g • C l i n i c a l O b s e r v a t i o n s
MRI of Bone Marrow
Necrosis
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MRI Features of Bone

Marrow Necrosis
Yu Ming Tang1,2 OBJECTIVE. The purpose of this study was to illustrate and review the MRI appearance of
Susanne Jeavons1 histologically proven cases of bone marrow necrosis (BMN) and to review the literature on this
Stephen Stuckey1 clinicopathologic entity with emphasis on its distinction from avascular necrosis (AVN) of bone.
Helen Middleton3 CONCLUSION. BMN is a rare clinicopathologic entity separate from AVN and has a
Devinder Gill3 distinctive MRI appearance. As MRI comes to play an increasingly important role in the eval-
uation of bone marrow disease, BMN is likely to be more frequently encountered. Awareness
Tang YM, Jeavons S, Stuckey S, Middleton H, of BMN and its MRI appearance and appreciation of the frequent association between BMN
Gill D and underlying malignancy may assist in the early diagnosis of BMN and initiate an intensive
search for occult malignancy.

one marrow necrosis (BMN) is a best with the clinical features when necrosis is

B unique clinicopathologic entity

Keywords: bone, lymphoma, MRI, musculoskeletal
imaging, spine
DOI:10.2214/AJR.05.0656
Received April 16, 2005; accepted after revision
August 17, 2005.
1Department of Radiology, Princess Alexandra Hospital,
Ipswich Rd., Woolloongabba, Brisbane, Queensland 4102,
Australia. Address correspondence to Y. M. Tang.
2South Coast Radiology, Gold Coast, Queensland, Australia.
3Department of Haematology, Princess Alexandra Hospital,
Brisbane, Queensland, Australia.
AJR 2007; 188:509–514
0361–803X/07/1882–509
© American Roentgen Ray Society
distinct from avascular necrosis
(AVN) of bone and marrow apla-
sia. The histologic features of BMN are dis-
ruption of the normal marrow architecture
and necrosis of myeloid tissue and medullary
stroma with loss of fat spaces. Unlike in AVN,
in BMN the spicular architecture is preserved,
and unlike in aplastic anemia, in BMN the re-
ticular structure is destroyed [1]. In the early
stages of BMN, however, differentiation of
these entities may not be possible. BMN has
been associated with malignancy (usually he-
matologic), sickle cell disease, infection, and
medication. BMN can occur before the diag-
nosis of malignancy, after chemotherapy, or at
recurrence. Because BMN can occur before
the diagnosis of malignancy, an extensive
search for malignant disease is justified
whenever BMN is diagnosed in isolation.
Patients with BMN usually present with
bone pain (80% of cases), fever (70%), and fa-
tigue [1–3]. Pancytopenia, anemia, or throm-
bocytopenia may be present. Elevation of lac-
tate dehydrogenase, alkaline phosphatase, uric
acid, and alanine transferase levels is common
[1]. The diagnosis is usually made on the basis
of findings at bone marrow aspiration and bi-
opsy. Bone marrow aspirate may yield a dry
tap, but trephine biopsy characteristically
shows necrosis of the myeloid tissue on a back-
ground of amorphous eosinophilic material
[3]. The histologic diagnosis is said to correlate
extensive [1]. The prognosis of patients with
BMN depends greatly on the underlying disor-
der [1] but is generally considered poor, death
usually occurring within weeks or months [2].
The pathophysiologic mechanism of BMN
has not been clearly elicited, but failure of the
microcirculation is thought to be the critical
event [1]. This microcirculatory occlusion may
be the result of tumor emboli, tumor compres-
sion, fibrin thrombi, or cytotoxic injury [4]. In
the three cases in this series, the changes were
widespread and occurred either immediately
before or during chemotherapy for lymphoma
or at the time of relapse of lymphoma. Al-
though MRI is being used increasingly in the
evaluation of bone marrow disease, there have
been few reports in the English-language liter-
ature on the MRI features of BMN. We present
the MRI features of three histologically proven
cases of BMN in patients with lymphoma and
describe the MRI features of this entity.
Materials and Methods
We retrospectively reviewed the MR images of
three patients with BMN. The diagnosis was made
on the basis of clinical course and results of bone
marrow trephine biopsy. The clinical course, bio-
chemical values, and histologic findings in each
case were reviewed by a consultant hematologist
and a trainee hematologist. The MR images were
reviewed in conjunction with the clinical data by
two consultant radiologists and a senior trainee ra-
diologist. All MRI was performed on a 1.5-T unit

AJR:188, February 2007 509

 Tang et al.

TABLE 1: Summary of Clinical Features

Feature Patient 1 Patient 2 Patient 3
Presenting symptoms Low back pain, pancytopenia, low- Back and abdominal pain, high-grade Back pain
grade fevers fevers,a thrombocytopeniaa
Time from chemotherapy to onset of 7 years from initial diagnosis Cycle 1, day –2; cycle 2, day +7 Two weeks after initial therapy
symptomsb
Time from symptoms until MRI (d) 26 65 2
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Underlying pathologic condition Diffuse large B-cell lymphoma Diffuse large B-cell lymphoma Polymorphic posttransplantation
lymphoproliferative disorder
Disease status at time of bone marrow Relapsed Present Remission
necrosis
Survival status (cause of death) Died (relapsed disease) Died (relapsed disease) Alive
a Possibly disease related.
b Day 1 is first day of chemotherapy for each repeat cycle. Minus sign [–] indicates days before commencement of chemotherapy; + = days after chemotherapy.

TABLE 2: Summary of MRI Findings The patient chose palliative management

Finding Patient 1 Patient 2 Patient 3 but returned 2 weeks later with urinary reten-
Central
tion, constipation, and a sensory level at T10
with features of spinal cord compression. MRI
T1 weighted Hypointense Hypointense Hyperintense
showed that the epidural abnormalities had
T2 weighted Hypointense Hypointense Hyperintense progressed, extending from T1 to T7 and L4 to
After gadolinium administration No enhancement NA No enhancement S1, resulting in marked compression on the
Fat suppression NA NA Signal suppression spinal cord and cauda equina. Marked retro-
STIR NA Hypointense NA
peritoneal lymphadenopathy also was present.
The geographic pattern of abnormalities was
Peripheral rim
stable, supporting the presence of a dual patho-
T1 weighted Hypointense Hypointense Hypointense logic condition: relapsed lymphoma and
T2 weighted Hyperintense Hyperintense Hypointense BMN. The patient received palliative radiation
Double line sign Present Present Nil therapy and steroids and died 2 weeks later as
After gadolinium administration Enhancement NA Enhancement
a consequence of progressive disease.
STIR NA Hyperintense NA
Case 2
Note—NA = not available. A 65-year-old woman presented with hyper-
calcemia, B symptoms (weight loss, fever, and
(Signa, GE Healthcare). Sagittal T1- and T2-weighted The presentation raised suspicion about re- night sweats), abdominal pain, and widespread
sequences of the entire spine were performed in all lapsed disease, and the patient underwent a rapidly enlarging lymphadenopathy. CT re-
cases. A third sagittal sequence, differing among number of diagnostic studies. CT of the neck, vealed extensive lymphadenopathy, a renal
the three cases but including gadolinium enhance- chest, abdomen, and pelvis revealed a 2.8-cm mass, and thickening of the small-bowel wall.
ment in two cases, also was performed. hypoechoic liver lesion and paraaortic and mes- Findings at biopsy of an inguinal lymph node
enteric lymphadenopathy as large as 2.5 cm. were consistent with those of diffuse large B-
Results Bone marrow aspiration and trephine biopsy of cell lymphoma. Staging bone marrow aspiration
The clinical course and MRI appearances the right posterior iliac crest revealed BMN and and trephine biopsy showed extensive involve-
are summarized in Tables 1 and 2. an infiltrate of large abnormal cells (Fig. 1A) ment with lymphoma. Combination chemo-
that stained with B-cell markers (CD20 and therapy with HyperCVAD (cyclophosphamide,
Case 1 CD79a), consistent with malignant lympho- doxorubicin hydrochloride, vincristine, and
An 80-year-old man presented with lower cytes. Because of focal sensory loss, MRI of the dexamethasone alternating with cytarabine and
back pain, pancytopenia, low-grade fever, and spine was performed (Figs. 1B–1D). The im- methotrexate) and rituximab was begun.
a markedly elevated lactate dehydrogenase ages showed extensive abnormalities of all ver- Severe back pain developed the day before
level of 2,470 U/L (normal, 110–250 U/L). He tebral bodies, the sternum, and the sacrum. the start of chemotherapy and persisted for 10
had a history of stage IIIE diffuse large B-cell There were irregular patchy geographic areas days. Bone marrow aspiration and trephine
lymphoma, which had been diagnosed and of low T1-weighted and low T2-weighted sig- biopsy from the right posterior iliac crest after
treated 7 years earlier. The initial therapy had nal intensity. Several of these lesions had an ir- the first cycle of chemotherapy showed BMN.
been six cycles of CHOP (cyclophosphamide, regular serpiginous enhancing rim, and some of Soon after the start of the second cycle of che-
doxorubicin hydrochloride, vincristine, and these had a T2-weighted hyperintense margin. motherapy, severe back pain again developed,
prednisolone) chemotherapy, and the disease Early anterior epidural extraosseous extension coinciding with administration of granulocyte
had been in complete remission since that time. of disease was present at L5 (not shown). colony-stimulating factor (G-CSF). The pain

510 AJR:188, February 2007

 MRI of Bone Marrow Necrosis

Fig. 1—80-year-old man with bone marrow necrosis and relapse of lymphoma. History included diagnosis of
diffuse large B-cell lymphoma diagnosed and managed with chemotherapy 7 years earlier. Early anterior epidural
extraosseous extension of disease (not shown) was present at L5. MR images show extensive geographic pattern
of signal abnormality of vertebral bodies. At follow-up MRI (not shown) 2 weeks after imaging, geographic
abnormalities were stable, and epidural abnormalities had progressed, suggesting dual pathologic conditions.
A, Photomicrograph of bone marrow trephine biopsy specimen shows extensive necrosis of hemopoietic and
stromal elements (arrowhead) with loss of normal fat spaces and preservation of bone trabeculae (arrow). (H and
E, ×100)
B, Sagittal T2-weighted MR image shows central areas of irregular patchy areas of low signal intensity (arrows).
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Margins of several lesions show irregular serpiginous rim of high signal intensity (arrowheads).
C, Sagittal T1-weighted MR image shows central areas of irregular patchy areas of low signal intensity (arrows).
D, Sagittal T1-weighted gadolinium-enhanced MR image shows central areas of irregular patchy areas of low
signal intensity (arrows). Margins of several lesions show irregular serpiginous rim (arrowheads).

B C D

did not resolve with cessation of G-CSF ad-
ministration. Febrile neutropenia developed,
and blood cultures grew coagulase-negative
staphylococci. CT of the lumbar spine did not
reveal collections or diskitis. Pain and fever
persisted, and MRI was performed.
MRI showed extensive bone abnormality
involving the entire spine (Figs. 2A–2C).
Geographic areas of low T1 and low T2 signal
intensity were present in the posterior aspect
of the vertebral bodies. These areas were sur-
rounded by a peripheral rim of T2 and STIR
hyperintensity and a further external rim of
intermediate signal intensity. The appear-
ances were considered atypical of lymphoma-
tous involvement and similar to those of bone
infarcts seen at other sites.
Findings at repeated bone marrow aspira-
tion and trephine biopsy from both posterior
iliac crests confirmed the presence of persis-
tent BMN (Fig. 2D). Restaging CT did not
show evidence of recurrent or residual dis-
ease. MRI performed 2 months later because
of persistent bone pain showed no marked in-
terval deterioration. After the fifth cycle of
chemotherapy (cycle 3A), the patient experi-
enced rapid and aggressive relapse and died
of fulminant disease soon afterward.
Case 3
A 19-year-old woman presented 2 years af-
ter cadaveric renal transplantation because of
medullary cystic disease with a short history of
headaches, vomiting, and deteriorating level of
consciousness. CT and MRI showed multifo-
cal enhancing lesions in the right cerebral
hemisphere with surrounding edema and mass
effect. Stereotactic biopsy was performed, and
the histopathologic findings confirmed a diag-
nosis of polymorphic posttransplantation lym-
phoproliferative disorder. Further staging, in-
cluding bone marrow aspiration and trephine
biopsy from the right posterior iliac crest, CT

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 Tang et al.
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A B C

Fig. 2—65-year-old woman with bone marrow necrosis after chemotherapy for diffuse large B-cell lymphoma.
Images show extensive signal abnormality involving entire spine. Imaging appearance is atypical of lymphomatous
involvement and similar to that of bone infarcts seen at other sites.
A, Sagittal T2-weighted MR image shows geographic areas of low intensity in posterior aspect of vertebral bodies
(arrows) surrounded by peripheral rim of hyperintensity and external rim of low signal intensity (arrowheads).
B, Sagittal T1-weighted MR image shows geographic areas low signal intensity in posterior aspect of vertebral
bodies (arrows).
C, Sagittal STIR MR image shows geographic areas of low signal intensity in posterior aspect of vertebral bodies
(arrows) surrounded by peripheral rim of hyperintensity and further external rim of low signal intensity
(arrowheads).
D, Photomicrograph of bone marrow trephine biopsy specimen shows extensive necrosis of bone marrow stromal
and hemopoietic elements with loss of normal fat spaces (arrow) and preservation of bony trabeculae. Arrowhead
indicates region of preserved fat spaces. (H and E, ×20)
D

of the neck, chest, abdomen, and pelvis, and
whole-body gallium scanning, showed no dis-
ease outside the central nervous system.
The patient started therapy with high-dose
cytarabine and methotrexate followed by the
Memorial Sloan-Kettering protocol for cen-
tral nervous system lymphoma. Two weeks
after starting therapy, the patient presented
with severe lower back pain after a single
dose of G-CSF. Findings on CT of the abdo-
men, pelvis, and lumbosacral spine were
normal. The pain largely resolved with the
use of narcotics over the next week. Approx-
imately 3 weeks later, pain returned in the
absence of G-CSF. Findings on bone scan
were normal. MRI showed extensive abnor-
malities with a geographic pattern of signal
abnormalities throughout the spine, a central
region of T1 and T2 hyperintensity sur-
rounded by a hypointense rim, and marked
peripheral enhancement (Figs. 3A–3C).
Bone marrow aspiration and trephine biopsy
(Fig. 3D) from the right posterior iliac crest
revealed BMN.
Pain developed in the right hip and but-
tocks, and MRI showed a small effusion in
the right hip joint (not shown) and surround-
ing muscle edema. The extensive signal ab-
normalities within the spine on the previous
scan were also present in the pelvis and
proximal aspects of the femurs (Figs. 3E
and 3F). The effusion was surgically
drained, and cultures grew Clostridium ca-
daveris. The patient completed chemother-
apy and radiation therapy and was in com-
plete remission.

512 AJR:188, February 2007

 MRI of Bone Marrow Necrosis
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A B C

D E F
Fig. 3—19-year-old woman with bone marrow necrosis after chemotherapy for central nervous system lymphoproliferative disorder after renal transplantation. Extensive
signal abnormality involved vertebral bodies.
A, Sagittal T2-weighted MR image shows geographic central areas of high signal intensity (arrows) surrounded by well-defined rim of low signal intensity (arrowheads).
B, Sagittal T1-weighted MR image shows geographic central areas of high signal intensity (arrows) surrounded by well-defined rim of low signal intensity (arrowheads).
C, Sagittal T1-weighted fat-suppressed gadolinium-enhanced MR image shows geographic central areas of low signal intensity (arrows) surrounded by intensely enhanced
rim (arrowheads).
D, Photomicrograph of bone marrow trephine biopsy specimen shows hypocellular bone marrow (treatment related) with preservation of fat spaces (black arrow) and area
of necrosis of hematopoietic and stromal elements (arrowhead). Preservation of bone trabeculae (red arrow) is evident. (H and E, ×100)
E, Coronal T1-weighted MR image obtained because of right hip and buttock pain shows extensive signal abnormalities in spine in A–C also present in pelvis (arrowheads)
and proximal aspect of femur (arrow). Small effusion in right hip joint (not shown) with surrounding muscle edema was also present.
F, Coronal T2-weighted fat-suppressed MR image corresponding to E shows abnormalities in pelvis (arrowheads) and proximal aspects of femur (arrow).

Discussion
MRI is being used increasingly in evalua-
tion of disease of the bone marrow because it is
a noninvasive method of imaging large por-
tions of the marrow in a short time. MRI can be
used to complement bone marrow aspiration
and biopsy in establishing the diagnosis of and
in staging and follow-up of hematologic ma-
lignancies. The MRI appearances of marrow
disorders often are nonspecific and reflect
changes in the amount of trabecular bone, fat,
and water within the marrow cavity [5].
There have been few reports in the English-
language literature on the MRI features of
BMN. Our literature search revealed six reports

AJR:188, February 2007 513


[3, 6–10] describing the MRI features of BMN
in conjunction with the histologic features. In
these articles, the unifying MRI feature in all
cases was the characteristic diffuse, extensive,
and geographic pattern of signal abnormalities.
The pattern of signal abnormalities is similar to
that of AVN and bone infarcts [3, 6], which
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have been well described in periarticular loca-
tions and long bones, especially the femoral
head, but rarely in the vertebrae [11]. However,
the imaging features differentiating these two
entities are site and distribution. BMN is ana-
tomically more extensive, diffusely involving
the marrow of the spine and pelvis [3], whereas
AVN is usually more focal and found in a peri-
articular distribution or in the appendicular
skeleton. Furthermore, the lesions of BMN do
not progress to vertebral body collapse, a fea-
ture often seen in vertebral AVN [11].
In all of our cases, the central region was sur-
rounded by a peripheral band of low signal in-
tensity. In both cases in which gadolinium was
administered, this peripheral rim became en-
hanced. In two cases the peripheral rim con-
sisted of an inner hyperintense line and an outer
hypointense line on T2-weighted images, simi-
lar to the double line sign considered pathogno-
monic of AVN. This pattern has been well de-
scribed in periarticular AVN, especially of the
femoral head, but rarely in AVN of vertebrae
[11]. The enhancing peripheral band is thought
to represent reactive granulation tissue at the in-
terface between necrotic and viable bone.
The central region of signal abnormality
had varying signal characteristics. In two
cases, central hypointensity was evident on
T1- and T2-weighted images. In the third
case, the central area was diffusely hyperin-
tense on T1- and T2-weighted images and
showed suppression of signal on T1 gadolin-
ium-enhanced fat-suppressed images, a find-
ing consistent with fat. In no case was en-
hancement found in the central area.
The varying appearances of the central area
may reflect different stages of BMN, similar to
those described by Mitchell and colleagues [12]
for AVN. This classification was based on the
qualitative assessment of alterations in MR sig-
nal intensity within the central region in AVN.
In the earliest stage (class A), the signal is anal-
ogous to fat with hyperintensity on T1 and
isointensity to mild hyperintensity on T2 im-
ages. This finding was seen in one of our cases,
and the patient was well and in remission. The
next stage (class B) shows signal characteristics
of blood and hemorrhage with T1 and T2 hy-
perintensity. Chim et al. [3] described a similar
pattern of T1 and T2 hyperintensity with en-
514
Tang et al.
hancement in the central area. They attributed
the pattern to the presence of blood and protein-
aceous material within hyperemic marrow. The
next stage (class C) exhibits signal characteris-
tics of fluid with T1 hypointensity and T2 hy-
perintensity. This pattern was described by
Weissman et al. [6] in two of three cases but was
not seen in our patients. The fourth and presum-
ably most advanced stage (class D) shows sig-
nal characteristics of fibrous tissue with hy-
pointensity on all sequences. This appearance
was found in two of our three patients and in
one of the three patients described by Weiss-
man et al. A similar appearance was found by
Thuerl et al. [7] in a patient with antiphospho-
lipid syndrome. Bone marrow fibrosis may de-
velop in prolonged cases of BMN [2, 10]. In
two of our cases and in the cases described by
Weissman et al., the patients died soon after this
appearance was found on MRI.
The imaging appearances of BMN may not
necessarily follow the aforementioned stages or
reach the final stage. Necrotic bone marrow can
heal and become repopulated by normal he-
matopoietic tissue, leaving small fibrotic scars.
BMN also is associated with development of
bone marrow fibrosis and is a predisposing fac-
tor for idiopathic myelofibrosis [2, 10]. An al-
ternative and perhaps more likely hypothesis is
that different relative preexisting populations of
marrow (hematopoietic and fatty) may cause
the varying MRI appearances of BMN. We
postulate that the extensive patterns of BMN in
cases 2 and 3 were in some way related to cyto-
toxic injury from chemotherapy, whereas in
case 1 there was evidence of recurrent hemato-
logic malignancy. In case 2, the onset of BMN
may have occurred on the day before chemo-
therapy (when severe back pain developed), al-
though bone marrow aspiration and trephine bi-
opsy and MRI were performed only after the
start of chemotherapy. BMN may also have
been associated with the underlying hemato-
logic malignancy in this case.
BMN is a rare clinicopathologic entity that is
distinct from AVN, having a different clinical
course, risk factors, and histologic findings.
BMN has a distinctive MRI appearance, unlike
most marrow disorders, which often have non-
specific findings. BMN characteristically has an
extensive, diffuse, geographic pattern of signal
abnormality consisting of a central area of vari-
able signal intensity surrounded by a distinct pe-
ripheral enhancing rim. These changes are sim-
ilar to those of AVN in the periarticular areas
and osteonecrosis of long bones but are differ-
entiated on imaging on the basis of the site, ex-
tensive distribution, and natural history of the le-
sions. In the early stages, however, these entities
can be indistinguishable on the basis of histo-
logic and possibly of imaging findings.
In conclusion, as MRI comes to play an in-
creasingly important role in the evaluation of
bone marrow disease, BMN is likely to be
more frequently encountered. Awareness of
this entity and its MRI appearance and appre-
ciation of its frequent association with under-
lying malignancy may assist in the early diag-
nosis of BMN and initiate an appropriate
search for occult malignancy.
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