Spinal infection. Outline ANATOMY 6/2/2017. Anatomy Pathogen

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Outline Spinal infection Pramot Tanutit, M.D.

Faculty of Medicine, Prince of Songkla University

Tuberculous spondylitis Mimicking disease ANATOMY

Hematogenous spread Contiguous source Direct

aureus(55-90%), Streptococcus, Pneumococcus,

Pseudomonas, Klebseilla Resnick, Bone and joint

1 Outline Spinal infection Pramot Tanutit, M.D. Department of Radiology, Songklanagarind Hospital Faculty of Medicine, Prince of Songkla University Anatomy Pathogen Pyogenic spondylodiscitis Tuberculous spondylitis Mimicking disease ANATOMY Pyogenic spondylodiscitis Route of spreading Hematogenous spread Contiguous source Direct impaction Postoperative infection Pathogen: S. aureus(55-90%), Streptococcus, Pneumococcus, Enterococcus, Escherichia coli, Salmonella, Pseudomonas, Klebseilla Resnick, Bone and joint imaging, 2005 Radiographics 2009; 29: Pyogenic spondylodiscitis Location: Lumbar(48%)>Thoracic(35%)>Cervical(6.5%) Usually one segment Onset: acute to subacute period Clinical: back pain, fever, focal neurological manifestation(late) 1

2 Stage of infection Location: Lumbar Disc and end plate: Destroyed Marrrow: Extensive edema Paraspinal involvement: Small abscess with thick, irregular rim enhancement Epidural involvement: Positive Radiol Clin N Am 50(2012) T2W T1W-Gd Location: Lumbar Disc and end plate: Destroyed Epidural involvement Paraspinal involvement: Small abscess with thick, irregular rim enhancement Marrow: extensive edema Tuberculous spondylitis Tuberculous spondylitis Onset: subacute to chronic Route of spreading: mainly hematogenous route Clinical: lack of symptom in early phase Location: Mid-thoracic or thoracolumbar> lumbar, cervical Possible isolated posterior element involvement Lamina> pedicle> spinous process> transverse process Resnick, Bone and joint imaging,

3 Disc and end plate: Early spared Tuberculous spondylitis Location: Midthoracic/ thoracolumbar Marrow: Ill-defined marrow alteration Paraspinal involvement: Large abscess, thin smooth rim enhancement Epidural involvement: Positive Other: Gibbus(advanced), subligamentous spreading, multiple involvement, skip lesion Imaging Radiol Clin N Am 50(2012) Subligamentous spreading Large right psoas abscess Paraspinal involvement: Large abscess(+/- calcify), thin smooth rim enhancement 3

Pyogenic Tuberculous Location Lumbar Mid-thoracic/ thoracolumbar Calcified nodes Disc & endplate Destroyed Early spared Bony part Body involvement Anterior body, isolated posterior element Paraspinal

multiple involvement Radiol Clin N Am 50(2012) 777-789 Our study, 2011 The Combination of Magnetic Resonance Findings in Differentiation between Pyogenic Spondylitis and Tuberculous spondylitis

4 Pyogenic Tuberculous Location Lumbar Mid-thoracic/ thoracolumbar Calcified nodes Disc & endplate Destroyed Early spared Bony part Body involvement Anterior body, isolated posterior element Paraspinal involvement Small abscess with thick, irregular rim enhancement large abscess(+/- calcify), thin smooth rim enhancement Epidural + + Other Leukocytosis Gibbus(advanced), subligamentous spreading, multiple involvement Radiol Clin N Am 50(2012) Our study, 2011 The Combination of Magnetic Resonance Findings in Differentiation between Pyogenic Spondylitis and Tuberculous spondylitis Population: 150 patients( ) Parameters TB Pyogenic Sig. C-spine level / Thoracic spine level / Lumbar spine level / / Sacrum level / / Skip lesion / Subligamentous spreading >2 levels / / Intraosseous abscess / / Para/perispinal abnormal signal / / Para/perispinal abscess formation / / Table: MRI findings of TB and pyogenic spondylitis Probability of pyogenic spondylitis Intraosseous abscess para/ perispinal abnormal signal Subligamentouos spreading > 2 levels Sacral spine involvement Probability (%) Enhancing lung nodule with central necrosis at left apical lung Left paravertebral abscess 4

5 Rim-enhancing mediastinal node (Tbc lymphadenitis) Prevertebral abscess Penumbra sign*** Mycotic aortic aneurysm, TB Warning*** TB spondylitis with collapse mimic TUMOR Differential diagnosis Spondyloarthropathies Degenerative endplate change(modic I) Spondyloarthropathies Romanus lesion 5

6 Spondyloarthropathies Degenerative disc disease Romanus lesion Andersson lesion Girl 4 YO, neck pain and low grade fever for 3 days Take home point Infected spondylitis Pyogenic: lumbar, extensive marrow edema, small abscess TB: T or TL spine, involve posterior element, intraosseous abscess, subligamentous spreading(>3 levels), large abscess, calcification, calcified nodes 6

7 Take home point Contrast enhancement: bioactivity, extension of disease Plain film or CT scan: calcification, ossification Difficult case: 2 wks follow up IVR: vertebral biopsy or aspiration Thank you 7

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