Juvenile spondylodiscitis : the value of magnetic resonance imaging A report of two cases
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1 Act Orthop. Belg., 2004, 70, CASE REPORT Juvenile spondylodiscitis : the vlue of mgnetic resonnce imging A report of two cses Herbert PLASSCHAERT, Kristof DE GEETER, Guy FABRY From the Deprtment of Orthopedic Surgery, U.Z. Pellenberg, Lubbeek (Pellenberg), Belgium Two boys presenting with reluctnce to sit stright nd stnd were dignosed with spondylodiscitis of the lumbr spine. After confirmtion of the dignosis on plin rdiogrphs, computed tomogrphy nd mgnetic resonnce imging, they were successfully treted with ntibiotics nd in one cse lumbr orthosis. The use of mgnetic resonnce imging is discussed nd compred to the other rdiologicl techniques. Mgnetic resonnce imging seems to be the most sensitive nd specific imging technique used in the dignostic process of spondylodiscitis. Computed tomogrphy nd technetium bone scn both ply specific prt in the process of dignosis nd follow-up. INTRODUCTION Juvenile spondylodiscitis is n infection of the intervertebrl disc destroying the djcent vertebrl endpltes ; it mkes up for 2% of ll juvenile bone infections (4). The pthology nd loction re probbly fcilitted by the typicl involution of the vsculristion of the immture intervertebrl disc in children, thus creting stsis nd even n inversion of the blood flow (1, 3, 5, 7). Depending on the systemic presenttion of the disese nd the severity of the bony destruction, differentition is mde between pure discitis, without bony destruction, spondylodiscitis nd vertebrl osteomyelitis with mssive bone destruction nd severe systemic repercussions (4). Two ge groups show high incidence of the disese : 0.5 to 4 nd 10 to 14 yers (1, 3, 7). Symptoms re generlly non-specific nd re determined by the ge of the child nd the level of the lesion, which is minly lumbr (6, 9). The use of severl dignostic techniques nd the vrious options in the tretment of spondylodiscitis re still subject of discussion. CASE 1 A Cucsin boy, ged 13 months, ws seen t the out-ptient clinic becuse of whinging nd crying for one week, dirrhoe for two dys nd reluctnce to sit stright nd stnd. From his recent history we withheld n episode of fever one month erlier nd twice fll on his bck during the lst month. At clinicl exmintion, mobilising the child s lumbr region seemed to evoke pin. The Herbert Plsschert, MD, Registrr. Guy Fbry, MD, Professor of Orthopedics. Orthopedic Surgery, U.Z. Pellenberg, Weligerveld 1, B-3212 Lubbeek (Pellenberg), Belgium K. De Geeter, Orthopedic Surgeon. St.-Mri-Roos der Koningin, Ziekenhuisln 100, 1500 Hlle, Belgium. Correspondence : G. Fbry, Orthopedic Surgery, U.Z. Pellenberg, 1 Weligerveld, B-3212 Lubbeek (Pellenberg), Belgium. E-mil : Guy.Fbry@uz.kuleuven.c.be. 2004, Act Orthopædic Belgic.
2 628 H. PLASSCHAERT, K. DE GEETER, G. FABRY b c d Fig. 1. -b. Initil rdiogrphs : nrrowing of the intervertebrl spce L3-L4 nd irregulr borders of the djcent vertebrl endpltes ; c-d. Rdiogrphs fter one yer show slight dextroconvex scoliosis nd reduced lumbr lordosis. c Fig. 2. -b. sgittl nd frontl CT imge, showing the extent of the bony destruction t L3-L4 ; c. MRI-T2 sgittl imge, showing hypointense signl t the L3-L4 intervertebrl disk spce 6 months fter dignosis ; d. MRI-T1 frontl imge, showing little difference in signl intensity between the vertebre. boy ws hving fever of 38.3 C, but further clinicl exmintion showed no possible entrnce portl. The erythrocyte sedimenttion rte (ESR) nd C rective protein (CRP) were elevted, while b d investigtion of the urine reveled non significnt culture of Enterococcus Feclis. Blood nd feces cultures were negtive. Plin rdiogrphs of the lumbr spine showed signs of spondylodiscitis t L3-L4 (fig 1 nd b). This ws confirmed by computed tomogrphy (fig 2 nd b). A technetium 99 m bone scn ws highly positive. The tuberculin skin test ws negtive, pleding ginst tuberculous spondylodiscitis. Finlly mgnetic resonnce imging scn (fig 2c nd d) confirmed the extended bone destruction s seen on the CT scn nd reveled no dmge to the surrounding soft tissue. Tretment initilly consisted of intrvenous (IV) cefotxim nd flucloxcillin t respectively mg/dy nd mg/dy. After confirmtion of the dignosis by MRI, doses were incresed to respectively nd mg/dy. CRP nd ESR dropped immeditely. After one week of therpy the fever lso disppered. Becuse of persistent pin nd reluctnce to sit, lumbr brce ws pplied with n obvious ntlgic effect : the child immeditely strted to stnd nd sit stright gin. After three weeks of fvourble evolution, the child developed pustulr rsh on his torso nd limbs, combined with fever up to 39.7 C nd oedem. His body weight incresed with 10% in just three dys. The suspicion of n llergic vsculitis ws confirmed by high blood levels of CRP, Lctte Dehydrogense (LDH) nd eosinophilic leukocytes, combined with leuko- nd thrombocytopeni. This is known side effect of the longterm use of cefotxim nd flucloxcillin. Therpy
3 JUVENILE SPONDYLODISCITIS 629 ws switched to clindmycine mg/dy, cetirizinedihydrochloride, 2 10 mg solumedrol nd 5mg furosemide IV per dy. The beneficil effect ws immedite. After totl of 4 weeks of IV therpy, ntibiotic therpy ws continued orlly for nother 4 weeks. After totl of 8 weeks of ntibiotic tretment nd 4 months of brce support, the boy ws cliniclly considered cured nd showed no more signs of illness or functionl disbility. Rdiogrphs tken fter 1 yer (fig 1c nd d), showed slight dextroconvex scoliosis nd lumbr kyphosis of no functionl significnce. CASE 2 b An 18-month-old Cucsin boy presented with difficulties to wlk nd sit stright for more thn six weeks. Mobilistion of the pelvis seemed pinful. During the first weeks, the focus of pin ws thought to be in the hip, but erlier exmintions in nother clinicl orthopedic prctice did not revel ny obvious clinicl signs or rdiologicl bnormlities t the lower limbs ; totl body technetium bone scn ws lso negtive. The temperture of the child ws norml, though he hd slightly elevted CRP nd ESR. Eventully, creful exmintion of the bck reveled pressure tenderness in the lower lumbr region nd pinful stright leg rising ; there ws no neurologicl deficit. Rdiogrphs confirmed the suspicion of lumbr spondylodiscitis t L5-S1 with destruction of the vertebrl endpltes. This dignosis ws confirmed on CT ; MRI reveled n ssocited ventrl epidurl bscess (fig 3 nd d). The boy ws dmitted to the hospitl nd received intrvenous flucloxcillin, mg dy during period of 25 dys. After one week the pin disppered nd the child recovered slowly, regining his bility to wlk. CRP nd ESR decresed within few weeks. The ntibiotic tretment ws continued orlly for nother six weeks nd the child recovered without ny complictions. The epidurl bscess hd lmost totlly disppered nd the vertebre were heling on second MRI tken two months fter the first, thus confirming fvourble evolution (fig 3e nd f). c e Fig. 3. -d. Respectively MRI T1 TSE 512, T2 TSE 512, STIR Long TE nd T1 Gdolinium DOTA sgittl imges tken one month fter presenttion of the ptient, showing oedem nd slight collpse of the L5 nd S1 vertebre nd destruction of the L5-S1 vertebrl end-pltes. Subtotl destruction of the intervertebrl disk L5-S1 in combintion with ventrl epidurl bscess nd n nterovertebrl subligmentous bscess t the level of L5-S1 ; e-f. MRI STIR Long TE nd T1 Gdolinium DOTA sgittl imge tken 3 months fter presenttion of the ptient, showing oedem nd hyperemi of the L5-S1 vertebre nd slightly dvnced bony destruction ; limited mss effect of the residul fibrotic intervertebrl disc on the nterior nd posterior ligments ; no prvertebrl bscess formtion visible. d f
4 630 H. PLASSCHAERT, K. DE GEETER, G. FABRY Tble I. Differentil dignosis of spondylodiscitis (5) 1. Trum 2. Hip pthology hip dysplsi, trnsient synovitis 3. Spinl pthology spondylolysis, spondylolisthesis, disk hernition 4. Infections urinry, gstro intestinl, respirtory, rthritis, osteomyelitis, spondylodiscitis, tuberculous spondylodiscitis 5. Tumorl pthology Tble II. Comprison of sensitivity (2, 4, 8, 10) Sensitivity in cse Sensitivity in cse of of spondylodiscitis n ssocited bscess X-Ry 60-85% 25% CT 89-92% 69% Bone Scn 72-95% / MRI % 85% Rdiogrphs t 4 months fter dignosis showed heling of the vertebrl endpltes nd no evolution to spontneous fusion. DISCUSSION Juvenile spondylodiscitis is condition with vgue nd non-specific symptoms. The investigting physicin should lwys consider spinl pthology when child cries persistently during diper chnge or when it refuses to sit stright or stnd. Sometimes there is loclised tenderness in the ffected region, but very often clinicl investigtion only revels pin during mobilistion of the pelvis. The differentil dignosis should consider vriety of pthologies (tble I). The result of CRP nd ESR re mostly helpful in confirming the infectious origin of the disese, lthough their vlues cn occsionlly be norml. Sttistics show tht the dignosis of spondylodiscitis is usully mde 1 tot 28 dys fter the presenttion of the ptient. When MRI is not used in the process of dignosis, it tkes n verge of 16.6 dys before the pthology is discovered. On the other hnd, where MRI is used, it tkes only 7.6 dys to mke the dignosis (1). Unlike the bone scn, MRI cn provide sufficient evidence to dignose spondylodiscitis even when there is little or no bony destruction, but positive bone scn is helpful to focus the MRI imging nd thus increse its ccurcy. In both cses the pthology ws first discovered on plin rdiogrphs, lthough they re the dignostic tool with the lowest sensitivity (tble II) nd lthough the ltent phse is known to be extended. It my tke up to 8 weeks before the rdiogrphs show ny signs of the pthology (3, 5, 9) nd usully the sgittl imges present the best view (4, 9). MRI seems to hve the highest sensitivity (tble II) nd specificity (83 to 97%) in cse of spondylodiscitis (1, 2, 4, 10), especilly when medullry compression or bscess formtion re present, s in 37% of the cses (4). The gdolinium contrst imges increse the ccurcy of the investigtion even more nd re crucil in the exclusion of tumorl pthology nd the evlution of soft tissue dmge (1, 5). CT is most useful in the evlution of the extent of bone destruction t the primry investigtion (4), nd in the course of the further follow-up of the ptient. Wirtz et l (10) proved tht CT imges cn show signs of osseous consolidtion nd regression of inflmmtion s soon s 5 to 6 weeks fter inititing the ntibiotic tretment. The lterntion of the Tble III. Chnge in signl intensity on MRI during the inflmmtory process (10) NMR T1 NMR T2 Progressive inflmmtion Hypo-intense signl Hyper-intense signl Regressive inflmmtion Hyper-intense signl Hypo-intense signl Heling phse Normlistion of signl intensity
5 JUVENILE SPONDYLODISCITIS 631 signl intensity on T1 nd T2 MRI imges lso llows us to differentite between progression, regression nd heling of spondylodiscitis (tble III), but the signs of regression seem to pper lter on MRI, fter n verge of 12 weeks (10). According to these findings, the evolution of CT imges corresponds better with the decrese of CRP, which is the most relible prmeter for the severity of the inflmmtion. ESR nd clinicl symptoms re the essentil prmeters during the heling phse of spondylodiscitis. In most cses, the pthology will dispper without sequels, but fusion of the involved vertebre is seen in 0 to 44% of the cses (1, 6). Scoliosis nd kyphosis or decresed lumbr lordosis lso previl but functionl restrictions re rre (1, 4, 9). To summrize, we could sy tht MRI plys very importnt role not only in the process of dignosis nd differentil dignosis of juvenile spondylodiscitis, but lso in the initil evlution of soft tissue dmge. CT nd rdiogrphs re sufficient nd less expensive to evlute the bony deformtions during the heling phse. REFERENCES 1. Brown R, Hussin M, McHugh K et l. Discitis in young children. J Bone Joint Surg 2001 ; 83-B : Crwford AH, Kuchrzyk DW, Rud R, Smithermn HC. Diskitis in children. Clin Orthop 1991 ; 266 : Cushing AH. Diskitis in children. Clin Infect Dis 1993 ; 17 : Grron E, Viehweger E, Luny F et l. Nontuberculous spondylodiscitis in children. J Peditr Orthop 2002 ; 22 : Mliner LI, Johnson DL. Intervertebrl disc spce inflmmtion in children. Child s Nerv Syst 1997 ; 13 : Ryöppy S, Jääskeläinen J, Rpol J, Alberty A. Nonspecific diskitis in children. Clin Orthop 1993 ; 297 : Mhboubi S, Morris MC. Imging of spinl infections in children. Rdiol Clin North Am 2001 ; 39 :2, Te Ps AB, Feith SWW, Wit JM. Osteomyelitis bij kinderen : soms moeilijk te herkennen. Ned Tijdschr Geneeskd 2002 ; 146 : VndenBerghe L, Moens P. Andoeningen vn de Wervelkolom, in : G. Fbry (red) : Leerboek Kinderorthopedie ; 2 e herziene druk 2002 ; Grnt, pp Wirtz DC, Genius I, Wildberger JE et l. Dignostic nd therpeutic mngement of lumbr nd thorcic spondylodiscitis. Arch Orthop Trum Surg 2000 ; 120 :
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