Vertebral body osteonecrosis: Evolving imaging features over time

We report the case of a 55-year-old woman with a history of multiple myeloma, osteoporosis, and long-term corticosteroid therapy, who presented with progressively worsening back pain. Imaging was pivotal for diagnosis and management. Magnetic resonance imaging (MRI) and computed tomography (CT) documented vertebral body osteonecrosis (VBON) occurring at different times and vertebral levels. In May 2024, MRI showed a fluid-filled intravertebral cleft within the L1 vertebral body, without collapse. Retrospective comparison with prior examinations (MRI and CT from 2019) demonstrated earlier VBON lesions at L4, progressing from fluid to gas phase, and a chronic collapse at T12. This case emphasizes the multifocal and temporal nature of VBON and highlights the teaching value of imaging, particularly MRI and CT, in distinguishing early osteonecrosis from neoplastic or purely osteoporotic fractures.