c-1917 tuberculous spondylitis: what every radiologist should know

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Tuberculous Spondylitis: What every Radiologist shouldknow

Poster No.: C-1917

Congress: ECR 2011

Type: Educational Exhibit

Authors: J. Kavanagh, R. Dunne, J. Keane, A. M. Mc Laughlin; Dublin/IE

Keywords: MR, Bones, Spine, Musculoskeletal bone, Musculoskeletal spine,CT, Infection

DOI: 10.1594/ecr2011/C-1917

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Learning objectives

• To outline the Radiological features of Tuberculous (TB) Spondylitis usingcases from a National TB Referral centre.

• To review the imaging modalities involved in assessment of disease andcompare and contrast them using varied examples.

• To illustrate the classic radiological features of TB Spondylitis and thedifferential diagnoses.

Background

TB Spondylitis is one of the oldest diseases of mankind having been found in EgyptianMummies dated as far back as 4000BC. Bone and Joint infection account for 10-35%of extrapulmonary TB but only 2% of overall TB worldwide.This ancient disease hasexperienced a recent resurgence most notably in the immunocompromised host and thedevelopment of multidrug resistant strains. Prevalence is highest in Africa and lowest inThe Americas but due to better transport links and increasing population TB is a globalproblem.

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Fig.References: The antiquity of tuberculosis in Hungary: the skeletal evidence AntóniaMarcsikI,1; Erika MolnárI; László SzathmáryII

The vertebral bodies are vunerable to seeding from Primary TB bacillemia due to theconsistent vascular supply throughout adulthood. The Lower Thoracic and upper lumbarvertebrae are affected most commonly (80-90%), cervical spine involvement being bothrarer (10%) and causing more morbidity.Infection starts anteroinferiorly and spreadsdown behind the anterior or posterior ligaments to involve the adjacent vertebral bodycausing local bone destruction and abscess formation.

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Fig.: Mycobacterium TuberculosisReferences: J. Kavanagh; Department of Respiratory Medicine, St James Hospital,Dublin, IRELAND

Back Pain, fever and weight loss are the most common presenting symptoms but dueto the indolent nature of the disease and low index of suspicion in developed countries,diagnosis is often delayed. Intrathoracic disease can be absent in up to 50% of TBSpondylitis as well as false negative tuberculin skin test rates of up to 14%. Becauseof this,Radiologists often make the diagnosis leading to prompt anti microbial therapy toprevent serious neurological consequences. Once the diagnosis is made Radiologists areonce again key in obtaining microbial evidence of TB infection using CT or Fluoroscopicguided procedures.

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Imaging findings OR Procedure details

Plain Film, CT and MRI all have roles in diagnostic imaging of TB Spondylitis.

Plain Film

Non specific plain film abnormalities such as osteopenia and soft tissue swelling can pointthe Radiologist towards the right diagnosis in the appropriate clinical setting. Examplesbelow Demonstrate bony abnormalities from the cervical spine down to the lumbar spinein our patient cohort. In all cases plain film was the first investigation performed.

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Fig.: Increase in Atlanto-Axial distance andParavertebral soft tissueswellingReferences: J. Kavanagh;Department of RespiratoryMedicine, St JamesHospital, Dublin,IRELAND

Fig.: Gibbous Deformitywith CollapseReferences: J. Kavanagh;Department of RespiratoryMedicine, St JamesHospital, Dublin, IRELAND

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Fig.: Loss of Right Pedicleof T5References: J. Kavanagh;Department of RespiratoryMedicine, St JamesHospital, Dublin, IRELAND

CT vs MRI

CT is superior to MRI in the evaluation of the degree of bony destruction, deformity andcalcification. The degree of destruction of the vertebra is seen much more clearly in the

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second example below on CT compared to MRI. CT can be very useful in a paraspinal"cold abscess". Calcification within this can virtually diagnose TB infection as well asindentify a small area of lytic bone disease.

Fig.: Collapse of T11/T12 withretropulstion of bone fragmentsposteriorlyReferences: J. Kavanagh; Department ofRespiratory Medicine, St James Hospital,Dublin, IRELAND

Fig.: T2 Weighted MRI showing T11/T12involvement and spinal cord compressionReferences: J. Kavanagh; Department ofRespiratory Medicine, St James Hospital,Dublin, IRELAND

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Fig.: Axial Bone windows demonstratingdegree of bony destruction C1References: J. Kavanagh; Department ofRespiratory Medicine, St James Hospital,Dublin, IRELAND

Fig.: Axial T2 weighted imageshowing extension through foramentransversarium and paraspinal abscessReferences: J. Kavanagh; Department ofRespiratory Medicine, St James Hospital,Dublin, IRELAND

MRI

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MRI is the Gold standard of imaging in TB Spondylitis due to its superior soft tissueresolution and multiplanar capability. The Classic pattern of spread starting anteriorlyand moving to involve opposing vertebrae via subligamentous spread is clearly seen onMRI. The most common findings on MRI are decreased signal intensity on T1 weightedimages and increased signal intensity on T2. Paraspinal abscesses and disk herniationthreatening the spinal cord can diagnosed accurately and quickly treated.

In contrast to pyogenic infections such as S. Aureus, TB generally spares theintravertebral disc due to the absence of proteolytic enzymes. In rare cases when thedisc is involved there will be increased signal intensity on T2 weighted imaging. There isminimal periosteal reaction and sclerosis with TB and the anterior vertebral elements arepreferentially involved, which can be useful in differentiating it from metastatic disease.In general, however, TB Spondylitis has many mimics such as fungal infection andsarcoidosis, the clinical picture and obtaining tissue samples being vital in accuratediagnosis.

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Fig.: T1 Sagittal Pre Contrast ImageReferences: J. Kavanagh; Department ofRespiratory Medicine, St James Hospital,Dublin, IRELAND

Fig.: T1 Para-Sagittal Pre ContrastReferences: J. Kavanagh; Department ofRespiratory Medicine, St James Hospital,Dublin, IRELAND

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Fig.: T1 Post Contrast image withenhancing soft tissue mass extendingthrough the posterior endplate into theintrathecal space displacing the spinalcordReferences: J. Kavanagh; Department ofRespiratory Medicine, St James Hospital,Dublin, IRELAND

Fig.: T1 post contrast para-saggitalimage showing TB extending laterally intoright paraspinal spaceReferences: J. Kavanagh; Department ofRespiratory Medicine, St James Hospital,Dublin, IRELAND

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Fig.: Saggital T2 weighted imageReferences: J. Kavanagh; Department ofRespiratory Medicine, St James Hospital,Dublin, IRELAND

Fig.: Parasaggital T2 showing paraspinalabscessReferences: J. Kavanagh; Department ofRespiratory Medicine, St James Hospital,Dublin, IRELAND

MRI

Conclusion

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The total number of cases of TB is rising globally due to rising population in developedcountries. Although a post primary manifestation, over half the cases of TB Spondyltispresent with no active pulmonary disease. For a clinician in an area of low incidence itcan be difficult to diagnose due to its insidious nature and low index of suspicion.

Radiologists play a vital role in disease assessment and diagnosis. Subtle plain filmfindings on routine exams in the right clinical scenario can make the diagnosis. CT andMRI have a synergistic role in TB Spondylitis in evaluation of the bony and soft tissuespread respectively. This can lead to prompt medical or surgical intervention to preventpotentially serious neurological sequelae.

Personal Information

J Kavanagh¹, R Dunne², J Keane¹, A Mc Laughlin¹

Department of Respiratory¹, Department of Radiologyl²,

University of Dublin Teaching Hospital, St James Hospital,

James Street, Dublin 8, www.stjames.ie

Mail: [email protected]

References

Daniel, TM, Bates, JH, Downes, KA. History of tuberculosis. In: Tuberculosis:Pathogenesis, Protection, and Control, Bloom, BR (Ed), American Society forMicrobiology,Washington, 1994, p. 13.

Martini M, Ouahes M. Bone and joint tuberculosis:a review of 652 cases. Orthopedics1988;11(6):861-866.Martini M, Ouahes M. Bone and joint tuberculosis:a review of 652cases. Orthopedics 1988;11(6):861-866.

Jain R, Sawhney S, Berry M. Computed tomography of vertebral tuberculosis: patternsof bone destruction.Clin Radiol 1993;47(3):196-199.48.

Weaver P, Lifeso R. The radiological diagnosis of tuberculosis of the adult spine. SkeletalRadiol 1984;12(3):178-186.

Floyd K, Lienhardt C WHO - The global plan to stop TB 2011-2015: transforming the#ght towards elimination of tuberculosis

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Resnick D. Tuberculous infection. In: Resnick D,ed. Diagnosis of bone and jointdisorders. 3rd ed. London, United Kingdom: Saunders, 2002;2524-2545.

c-1917 tuberculous spondylitis: what every radiologist should know

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