Ross JS, Brant-Zawadzki M, et al. Diagnostic Imaging: Spine 2004; V-1-5. Greenspan A. Orthopedic Radiology: A Practical Approach 1997; V-19-3
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1 MR Imaging of Spinal Infections 台大醫院 台大醫學院 影像醫學部 放射線科 許昭禹醫師 / 施庭芳主任 2009/02/14 Risk factors of spinal infections Advanced age > 50 Intravenous drug abuse Immunosuppression or immune deficiency Long-term steroid administration Diabetes mellitus Organ transplantation Malnutrition Malignancy Urinary tract instrumentation Infectious pathways Vascular anatomy of spine Hematogenous Arterial or venous route Direct inoculation Contiguous focus of infection Direct open spinal trauma Postoperatively Greenspan A. Orthopedic Radiology: A Practical Approach 1997; V-19-3 Diagnostic Imaging: Spine 2004; V-1-5 Yoshioka K, Niinuma H, et al. Radiographics 2003; 23: Arterial route Microcirculation Segmental artery spinal artery nutrient equatorial artery Segmental artery metaphyseal artery metaphyseal anastomosing artery intermetaphyseal anastomosing artery Smith AS, Weinstein MA, et al. AJNR 1989; 10: Ratcliffe JF. Acta Radiol [Diagn] (Stockh) 1985; 26:
2 Venous route Pathoanatomy of spinal infections Retrograde seeding of venous blood via Batson plexus Increased intraabdominal pressure Genitourinary tract infections Groen RJM, Toit DFd, et al. Spine 2004; 29: Vertebral endplates adjacent disk space adjacent vertebral body paravertebral tissues epidural space Resnick D. Diagnosis of Bone and Joint Disorders 1995; 155: MRI MRI of Spinal Infections Coronal Sagittal,, Axial Gd-enhanced with/without fat suppression Stoller DW. Magnetic Resonance Imaging in Orthopaeducs & Sports Medicine 1997; 1071 Typical manifestations Pyogenic osteomyelitis Granulomatous osteomyelitis Epidural abscess Paraspinal abscess Septic arthritis of facet joint Differential diagnosis Unusual manifestations Common MRI findings of spinal infections T1 signal with loss of disk margin & endplate irregularity T2 signal from intervertebral disk & adjacent vertebral bodies Enhancement of vertebral bodies, endplates & annulus (variable) Epidural & paraspinal soft tissues Pyogenic osteomyelitis 2 adjacent vertebrae with intervening disk Ill-defined marrow signal alternation Loss of vertebral endplate cortex Obliteration of intranuclear cleft Diagnostic Imaging: Spine 2004; V-1-9 2
3 Pyogenic osteomyelitis Disk space narrowing Vertebral collapse Lumbar > thoracic > cervical spine Paraspinal ± epidural infiltrative soft tissues ± abscesses M/69 persistent LBP x 4 months; colon cancer s/p op. 8 months ago L1-2 Diagnostic Imaging: Spine 2004; V-1-9 L1-2 L1-2 C+ Antibiotic treatment 4 months later Aspiration: chronic inflammation; Culture: (-) L1-2 L1-2 C+ C+ 3
4 Granulomatous osteomyelitis M/80 general weakness with LBP x 2.5 months; fever & chills x 2 days Relatively intact intervertebral disks Gibbus vertebrae (25%) T-L spine Large paraspinal abscesses Multiple (non)contiguous Diagnostic Imaging: Spine 2004; III-1-10 T11-12 Culture: Mycobacterium tuberculosis T11-12 T11 C+ M/42 LBP with bil. sciatica x 2 months 4
5 Surgical debridement: caseating granulomatous inflammation (TB) L5 S1 C+ C+ Epidural abscess Epidural phlegmon Posterior epidural > anterior epidural > circumferential Lower T- & L-spine > C- & upper T-spine Multi-segmental M/68 LBP with difficulty in walking x 2 wks Diagnostic Imaging: Spine 2004; V-1-22 Surgical debridement: osteomyelitis; Culture: Staphylococcus aureus (MSSA) L5 C+ 5
6 M/48 Severe back pain with bil. paraplegia x 1 wk Surgical debridement: abscess; Culture: Staphylococcus aureus T2-9 T5 C+ Paraspinal abscess F/52 progressive LBP with bil. sciatica x 3 wks Paravertebral phlegmon Obliterated soft tissue fascial plane Intra-abscess abscess gas Calcified psoas abscesses Reactive LAP Diagnostic Imaging: Spine 2004; V-1-30 L3-4 Surgical debridement: osteomyelitis; Culture: Staphylococcus aureus (MSSA) L3-4 L3-4 C+ 6
7 F/43 LBP x 4 months; traffic accident before; Echo: retroperitoneal cystic mass T12 T11-L1 Culture: Mycobacterium tuberculosis T11-L1 T12 Septic arthritis of facet joint Lumbar spine (97%) Typically single level involvement Facet joint widening Eroded facet cortex Adjacent soft tissue edema & abscesses M/73 LBP with bil. sciatica x 2.5 months; gastric cancer s/p op. 4 months ago Diagnostic Imaging: Spine 2004; V
8 Blood culture: Enterococcus faecalis C+ Differential diagnosis of spinal infections (1) Pyogenic infection Staphylococcus aureus, Pseudomonas species Remarkable paraspinal inflammatory tissue Non-pyogenic infection Tuberculosis, fungus, yeast, or parasitic organisms Limited paraspinal inflammatory tissue F/52 Surgical debridement: osteomyelitis; Culture: Staphylococcus aureus (MSSA) L3-4 M/42 Surgical debridement: caseating granulomatous inflammation (TB) Differential diagnosis of spinal infections (2) Degenerative endplate changes Modic type 1: vascularized fibrous tissue Erosive intervertebral osteochondrosis Unremarkable paraspinal inflammatory tissue 8
9 M/78 LBP x 2.5 months Type 1 degenerative endplate changes C+ M/55 Nasopharyngeal cancer s/p CCRT LBP with low grade fever x months L2-3 L2-3 2 months later Laminectomy: myxomatous degeneration of disk with irregular new bone formation Erosive intervertebral osteochondrosis M/48 LBP with fever & chills x 1 wk Echo: r/o infectious endocarditis L2-3 9
10 Surgical debridement: osteomyelitis; Blood culture: Gram (+) cocci Unusual Manifestations of spinal infections (1) Single segment vertebral osteomyelitis Anterior cortical disruption (100%) Upward subligamentous spread (100%) Upper disk involvement (66.6%) C+ Shih et al. Clin Imaging 1999; 23: F/70 Diabetes mellitus x 20 years Flank pain x 1 month L2 L2 Analgesics treatment 1 month later Biopsy: osteomyelitis Blood culture: Staphylococcus aureus (MSSA) L2-3 L2-3 1 month ago 10
11 Unusual Manifestations of spinal infections (2) Vertebral osteomyelitis mimicking metastases Preserved intervertebral disks (100%) Llimited paraspinal or epidural inflammatory tissue (86%) Posterior element involvement (43%) F/46 Recurrent Salmonellosis x 9 months Fever x 2 days Hsu et al. AJNR 2008; 29: Biopsy: chronic osteomyelitis Blood culture: Salmonella Antibiotics treatment 12 month later T11 C+ Diffusion Weighted Imaging of Bone Marrow Pathologies Diffusion Weighted Imaging DWI A powerful tool for evaluating bone marrow infiltration Apparent diffusion coefficient (ADC) Highly specific and very sensitive to differentiate between malignant and benign skeletal processes Herneth et al. EJR 2005; 55:74-83 DW-EPI b = 880 Metastasis ADC = 0.79 mm 2 /s Aggressive osteomyelitis ADC = 1.48 mm 2 /s DW-SSFP Vertebral osteomyelitis Herneth et al. EJR 2005; 55:74-83 No signal aberration, mimicking restricted diffusion Hypercellularity? Macromolecules? 11
12 SPIO-enhanced MRI for Bone Marrow Imaging SPIO-enhanced MRI Superparamagnetic iron oxide (SPIO) Comparison of SI using images before and 3hrs after ferucarbotran (< 20 nm) injection Useful in differentiating bone metastasis and osteomyelitis RE: relative enhancement (%) Fukuda et al. Magn Reson Med Sci 2006; 5: Metastasis Osteomyelitis Fukuda et al. Magn Reson Med Sci 2006; 5: Conclusion Typical manifestations Pyogenic vs. granulomatous osteomyelitis Epidural/paraspinal abscess Differential Diagnosis Type 1 degenerative endplate changes Erosive intervertebral osteochondrosis Unusual Manifestations Single segment vertebral osteomyelitis Vertebral osteomyelitis mimicking metastases Thank You for Your Attention 台大醫院 台大醫學院 影像醫學部 放射線科 許昭禹醫師 / 施庭芳主任 2009/02/14 12
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