MMODICODIC TTYPEYPE 11 VSVS TTUBERCULOUSUBERCULOUS SSPONDYLITISPONDYLITIS

Modic Type 1 Tuberculous SpondylitisDefinition Degenerative vertebral endplate

and subchondral bone marrow changes which can be seen in MRI

Presentation of extrapulmonary tuberculosis that affects the spine

Predilection Mostly affect the lumbar spine Most commonly involves the thoracic spine and less often the lumbar spine

Etiology Normal age-related degenerative process

Hematogenous spread of tuberculosis infection from the lung

Pathogenesis Disruption and fissuring of endplates and formation of a fibrovascular granulation tissue within the adjacent marrow

Represent the inflammatory stage of degenerative disk disease and indicate an ongoing active degenerative process

In most cases starts in the anterior spine and soft tissues and progresses posteriorly.

Osteomyelitis and arthritis progressive bone destruction vertebral collpase and kyphosis

The spinal canal can be narrowed by abscesses, granulation tissue, or direct dural invasion, leading to spinal cord compression and neurologic deficits

Clinical Manifestation

Chronic and constant low back pain Chronic back pain, fever, weight loss, neurologic deficits

Imaging Rö: Lumbar fusion Segmental instability (sagittal

translation of 3 mm or more on dynamic flexion-extension films)

Rö: Lytic destruction of anterior portion

of vertebral body Increased anterior wedging Collapse of vertebral body

MRI (best method): Hypointense on T1-weighted

imaging (T1WI) and hyperintense on T2-weighted imaging (T2WI)

Areas of enhancement on contrast-enhanced images (show bone marrow edema and inflammation)

Lack of abnormally increased signal intensity of an associated disk on T2

No soft-tissue involvement Vacuum phenomenon within

severely degenerated disks

Reactive sclerosis on a progressive lytic process

Enlarged psoas shadow with or without calcification

CT Scan (best method): Irregular lytic lesions Sclerosis Disk collapse Soft-tissue abscesses and

calcification important because they are rarely present in nontuberculous abscesses

MRI: Relatively hypointense on T1-

weighted imaging (T1WI) and relatively hyperintense on T2-weighted imaging (T2WI) show inflammatory tissue esp. abscesses

Large abscess (often bilateral) with thin and smooth wall mainly involve the psoas muscle can spread subligamentously

Well-defined paraspinal region with abnormal signal intensity

Skip lesions Treatment Symptomatic (e.g. analgesic) and

physiotherapyAntituberculosis drugs and surgery

Modic Type 1 Modic Type 1 TuberculousTuberculous SSpondylitispondylitis

Modic type 1 degeneration in a 55-year-old man. (a) Sagittal T1-weighted MR image (450/11) shows decreased signal intensity of the vertebral body bone marrow (arrows) and disk (arrowhead) at the L4-5 level. (b) Sagittal T2-weighted MR image (3066/121) shows increased bone marrow signal intensity and a multilayer pattern (arrows). No fluidlike signal intensity is seen in the disk (arrowhead). (c) Corresponding sagittal contrast-enhanced fat-suppressed T1-weighted MR image (550/11) shows marked bone marrow enhancement (arrows) and an intradiskal vacuum phenomenon (arrowhead).

Tuberculous spondylitis in a 44-year-old woman. (a) Sagittal T2-weighted MR image (3000/120) shows severe diskovertebral destruction, formation of epidural abscesses (arrowhead), and compression of the spinal cord at the T11-12 level. The anterior paraspinal abscess is confined by the anterior longitudinal ligament (arrow) and extends vertically through four levels of the thoracolumbar spine (T10 through L1). (b) Sagittal contrast-enhanced fat-suppressed T1-weighted MR image (446/10) clearly shows a rim-enhancing subligamentous abscess (arrow) that does not encase the intercostal arteries (arrowheads). (c, d) Axial T2-weighted (3000/96) (c) and contrast-enhanced fat-suppressed T1-weighted (979.1/10) (d) MR images show a well-defined paraspinal abscess (arrowhead) with a thin,

smooth wall. The spinal cord is slightly compressed (arrow in d) by the anterior epidural abscess.Reference:Reference:Rahme R and Moussa R. The Modic Vertebral Endplate and Marrow Changes: Pathologic Significance and Relation to Low Back Pain and

Segmental Instability of the Lumbar Spine. Am J Neuroradiol 29:838–42. May 2008Hong SH, et al. MR Imaging Assessment of the Spine: Infection or an Imitation? RadioGraphics 2009; 29:599–612http://emedicine.medscape.com/article/226141 Audrey (2011-061-

115)