Diagnosis of infectious spinal pathology by imaging

Transcription

1 Diagnosis of infectious spinal pathology by imaging Poster No.: C-0425 Congress: ECR 2012 Type: Educational Exhibit Authors: F. Gonzalez, C. Laganâ, L. FERNANDEZ FRESNO ; MAdrid/ ES, Madrid/ES, MADRID/ES Keywords: Infection, Abscess, Imaging sequences, Diagnostic procedure, MR, Digital radiography, CT, Neuroradiology spine, Inflammation DOI: /ecr2012/C-0425 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 49

2 Learning objectives Reviewing spinal infectious inflammatory pathology and describing the imaging findings on MRI and CT allows us to establish an early diagnosis and to differentiate diagnosis from other pathologies. Spondylitis and discitis. Epidural and subdural infections. Meningitis, myelitis and medullary abscess. Paraspinal soft tissue. Background Pyogenic spondylodiscitis: Etiology: S. aureus: 60%, Enterobacter, E. Colli, Salmonella, P.aeruginosa and K. pneumoniae. Hematogenous spread (the most common cause bacteremia): arterial, venous (Batson's plexus) less likely. Contiguous dissemination: adjacent soft tissue infection. Direct contamination: open wounds, surgery, penetrating foreign bodies, sinus. Pathogenesis: Adults: st -1 Plates. Page 2 of 49

3 -2 nd Adjacent discs. rd -3 Vertebral body. th -4 Paravertebral soft tissue and epidural. Children: st -1 Disc space infection. -2 nd Vertebral body. rd -3 Soft tissue. Risk factors: Age > 50 years Immunodeficiency. AIDS. Chronic treatment with corticosteroids. Diabetes. Paraplegia. Urinary system instrumentation. Previous spinal fracture. Location and clinic: More frequently lumbar column followed by the dorsal. Pain and general discomfort. Febrile or not. Leucocytosis and GSV sedimentation velocity). (globular Page 3 of 49

4 Neurological deficits. Imaging findings: Simple x-ray: -Osteolysis in the plates followed by sclerosis. -Delayed findings (usually normal in 8-10 days). -Paraspinal soft tissue density. -Fusion through the disc spaces. CT: -Hypodense paraspinal sometimes gas. soft tissue, -Enhanced discs, bone marrow and paraspinal soft tissue. -Osteolysis/sclerosis eroded plates. -Bone sequestration. -Spinal deformity. MRI: most sensitive and specific. Alterations in earlier stages: -Edema-inflammatory bone marrow: hypointense on T1, hyperintense on T2. -T1: disc space narrowing and low signal on adjacent vertebral bodies. Soft tissue mass and cortical bone erosions. -T2: high signal in the disc space and vertebral bodies affected. "Nuclear cleft" wiped. -Post contrast sequences with fat saturation, enhancement disc and bone. Page 4 of 49

5 Granulomatous spondylodiscitis: Etiology: Granulomatous reaction: bacterial, viral, parasitic, fungal, autoimmune idiopathic. M.tuberculosis: more freq. Genus Brucella (B.melitensis). Fungi: infrequent. Increases in the debilitated and immunocompromised. Blastomicocis, aspergillosis (tuberculous spondylodiscitis indistinguishable) actinomycosis, cryptococcosis (destruction or patchy sclerosis of the body, generally affected disc). Parasite: very rare (Echinococcus). Incidence, age and sex: 6% extrapulmonary tuberculosis. A. North America and Europe, middleaged adults (40-45years). Developing countries through: children. Immunosuppression, alcoholism, drug addiction. Not predominantly male or female. Location and clinical: TB: lower thoracic and lumbar spine. 90% affects two bodies. 50% three or more. Injuries which "leapfrog" are frequent % paraspinal abscess. Insidious onset, duration of symptoms often months or years. Brucella spondylodiscitis: lumbar region. Vertebral height usually retained. Often preserved posterior elements, less hard and rarely involving epidural extension, paraspinal tissuesmeninges. Page 5 of 49

6 Abscess formation is rare. Imaging findings: X-ray simple: - Bone destruction and associated soft tissue mass. - Early sclerosis by 50%. - 75% disc height loss. - Final vertebral body fusion. CT: - Extensive bone destruction. - Large abscesses disproportionate destruction. Frequent and dissemination subligamentosa epidural extension. MRI: - Sample loss of cortical definition of vertebrae. - In T1 often further spread of infection affecting spinal ligaments and adjacent bodies. - Relatively affected discs to the extent of bone destruction. - Posterior elements frequently affected. Epidural abscess: Etiology S. aureus the most common. Direct hematogenous seeding. Two stages: state "phlegmonous" and frank abscess. Incidence, age and sex: It is infrequent. Page 6 of 49

7 1 / tertiary hospitals. Average age years. Predominantly in males. Location and clinical: Affects all areas. Sometimes extensive.1 / 3 affects more than six segments. 80% concomitant discitis and osteomyelitis. Fever and localized tenderness. Sometimes nonspecific. Diabetes, intravenous drug addicts, medical illnesses, injuries. Imaging findings: MRI: -Extradural-intraspinal mass. -Isointense or hypointense compared with the spinal cord on T1. -Hyperintense on T2. MRI after contrast administration: -70% or slightly heterogeneous homogeneous enhancement. Phlegmonous stadium. -Thick or thin flange surrounding enhancement pus collection of low signal. In 40%, representing necrotic abscess frank. -In some cases a combination of both. Meningitis: Germs bacterial (pyogenic granuloma), fungal, parasitic or viral. Page 7 of 49

8 Most frequently pyogenic leptomeningitis. Meningitis granulomatous pyogenic and aseptic tissue are displayed as showing contrast enhancement and surrounding bone and root. Imaging findings: MRI: -Enhancement delicate, smooth and linear drawing pial surface of the bone, nerve roots or dura. -Well-defined nodular foci on the surface of these structures. -Diffusely thickened and soft tissue that appears as intradural filling defect. Myelitis Viruses normally affecting gray matter: HIV, Coxsackie, herpes, polio. Epidural abscess, chronic meningeal infections (tuberculosis), fungal meningitis. Nonspecific imaging findings. Increased focal or diffuse intramedullary signal on T2-weighted MRI, with or without mass effect. Sometimes enhancement after contrast administration. Imaging findings OR Procedure details We retrospectively evaluated adult patients with spinal infectious inflammatory disease who came to our department in the last 3 years, analyzing the most representative images of each space spinal pathology: pyogenic and granulomatous spondylodiscitis, epidural abscess, paraspinal soft tissue abscesses and psoas muscle, meningitis, radiculitis, myelitis, and intramedullary abscesses. Page 8 of 49

9 We introduce the different anatomical spinal spaces: extradural, intradural extramedullary, and intramedullary. We describe the imaging findings, especially in MR and CT in some cases, in each of the spaces with special emphasis on spinal radiographic signs most useful for early diagnosis and distinct from other diseases (degenerative, tumor, demyelinating disease, ischemic and traumatic). In our hospital we perform examinations with 1.5 Tesla MRI and CT of 32 crowns. Cases: Pyogenic spondylodiscitis: 63 year old man with dysphagia to solids and liquids for two days. Endoscopy: posterior bulging of the hypopharynx. 22,000 leucocytes. (Fig.1,2,3,4,5,6 and 7). Pyogenic spondylodiscitis: 76 year old woman, back pain for three months and unable to walk in the last few days. (Fig.8,9,10,11,12 and 13). Tuberculous spondylodiscitis: 52 year old man, back pain for three months, resistant to analgesics, without neurological deficit. Mantoux +. (Fig.14,15,16,17,18 and 19). Epidural abscess: 87 year old woman coming from another center with a diagnosis of psoas abscess. (Fig.20,21,22 and 23). Meningitis and radiculitis: 32 year old woman with rapidly progressive paraparesis and sphincter incontinence. HIV +, HCV +. (Fig.24,25 and 26). Radiculitis: 55 year old woman underwent surgery for lumbar stenosis, urinary incontinence from the surgery. (Fig.27,28,29,30,31 and 32). Myelitis: 31 year old woman, impaired sensation in back four with tetraparesis, urinary incontinence, abnormal sensitivity to temperature and pain. (Fig.33,34,35,36 and 37). Images for this section: Page 9 of 49

10 Fig. 1: CT with intravenous contrast. Axial: Prevertebral collection with air bubbles inside the walls and enhancement in connection with prevertebral abscess (large arrow). Collection spinal canal epidural abscess related to epidural contiguity (small arrow). Page 10 of 49

11 Fig. 2: CT with intravenous contrast. Sagittal: Prevertebral abscess (C2 to C6) (large arrow) and epidural abscess by contiguity (small arrow). Page 11 of 49

12 Fig. 3: CT bone window. Sagittal: Involvement of C4 and C5 vertebrae in relation to osteomyelitis (arrow). Page 12 of 49

13 Fig. 4: SE T1 MRI. Sagittal: Prevertebral collection drainage catheter inside, showing a predominantly hypointense signal, extends from the level of C2 to C6 (large arrow) C4 and C5 vertebrae show a hypointense signal. C4-C5 interbody disc shows altered signal, isointense (small arrow). Page 13 of 49

14 Fig. 5: SE T1 MRI with gadolinium. Sagittal: Prevertebral collection showing gadolinium enhancement (large arrow). C4 and C5 vertebrae and interbody disc, show enhancement (small arrow). Collection in the spinal canal (epidural above) at the level of C3, C4 and C5 which has enhancement (thin arrow). Page 14 of 49

15 Fig. 6: SE T1 MRI with gadolinium. Axial: Prevertebral collection showing enhancement (large arrow). Collection anterior epidural enhancement (small arrow). Page 15 of 49

16 Fig. 7: FSE T2 MRI. Sagittal: Prevertebral collection showing a hyperintense signal in relation to abscess (large arrow). C4 and C5 vertebrae show a hyperintense signal. C4C5 interbody disc with hyperintense signal. Spondylodiscitis findings regarding (small arrow). Hyperintense collection in relation to epidural abscess (thin arrow). Page 16 of 49

17 Fig. 8: SE T1 MRI. Axial: Paraspinal soft tissue mass, surrounding the anterior and lateral surface of the vertebral bodies (large arrow). Within the spinal canal in the posterior surface of the spinal cord and thecal sac, an image is displayed hyperintense (small arrow). Page 17 of 49

18 Fig. 9: FSE T2 MRI. Axial: Paraspinal soft tissue mass, surrounding the anterior and lateral surface of the vertebral bodies (large arrow). Within the spinal canal in the posterior surface of the spinal cord and thecal sac, an image is displayed hyperintense (small arrow). Page 18 of 49

19 Fig. 10: SE T1 MRI with gadolinium. Axial: In vertebral bodies and pedicles, displays an alteration appearing hypointense signal and irregular enhancement after gadolinium administration. Page 19 of 49

20 Fig. 11: SE T1 MRI. Sagittal: In vertebral bodies and pedicles D5 and D6, it displays an alteration appearing hypointense signal (large arrow). Within the spinal canal in the posterior surface of the spinal cord and thecal sac, displays a wide picture from D1 to D10 hyperintense, this injury causes a mass effect, both compressing and displacing the thecal sac above the spinal cord. In this region, the subarachnoid space surrounding the spinal cord (thin arrow) disappears. Page 20 of 49

21 Fig. 12: FSE T2 MRI. Sagittal: In vertebral bodies and pedicles D5 and D6, it displays an alteration appearing isointense signal (large arrow). Within the spinal canal in the posterior surface of the spinal cord and thecal sac, displays a wide picture hyperintense from D1 to D10 of this lesion produces a mass effect, compressing and displacing the thecal sac as above and the spinal cord. In this region, disappears the subarachnoid space surrounding the spinal cord (thin arrow). Page 21 of 49

22 Fig. 13: SE T1 MRI with gadolinium. Sagittal: In vertebral bodies and pedicles D5 and D6, with enhancement after gadolinium administration (large arrow), leaving areas of the disc and adjacent to it without enhancement (small arrow) findings regarding spondylodiscitis. Within the spinal canal in the posterior surface of the spinal cord and thecal sac, displays a wide picture with loss of fat suppression signal from D1 to D10 of this lesion produces a mass effect, compressing and displacing both the above thecal sac and the spinal cord jacket. In this region, disappears the subarachnoid space surrounding the spinal cord (thin arrow). Findings in relation to intraspinal lipoma superinfection. Page 22 of 49

23 Fig. 14: SE T1 MRI. Axial: Isointense lesion with geographic pattern in the vertebral body (large arrow). Paravertebral soft tissue mass (small arrow). Page 23 of 49

24 Fig. 15: SE T1 MRI with gadolinium. Axial: Lesion with geographical pattern in vertebral body with enhacement (large arrow). Paravertebral soft tissue mass with enhancement (small arrow). Page 24 of 49

25 Fig. 16: FSE T2 MRI. Axial: Hyperintense lesion with a geographic pattern in the vertebral body (large arrow). Signal alteration in relation to the vertebral body edema (thin arrow). Paravertebral soft tissue mass (small arrow). Page 25 of 49

26 Fig. 17: SET1 MRI. Sagittal: Isointense lesion in the vertebral bodies of D10 and D11. Page 26 of 49

27 Fig. 18: SE T1 MRI with gadolinium. Sagittal: Injury D10 and D11 vertebral bodies with annular contrast enhancement. Hyperintense signal alteration in the bodies of these vertebrae. Page 27 of 49

28 Fig. 19: FSE T2 MRI. Sagittal: Hyperintense lesion in the vertebral bodies of D10 and D11 in relation to abscess. Alteration of the vertebral bodies signal D10 and D11 in relation to edema. Page 28 of 49

29 Fig. 20: CT with intravenous contrast. Axial: Air interbody space in relation to herniated disc (thin arrow). Left psoas collection with peripheral contrast uptake in relation to abscess (large arrow). Page 29 of 49

30 Fig. 21: CT with intravenous contrast. axial: Collection in the spinal space with contrast enhancement in relation to epidural abscess. Page 30 of 49

31 Fig. 22: CT with intravenous contrast. Sagittal: L1-L2 space, which shows changes in the density of the vertebral bodies adjacent vertebral endplates appear, irregular, ragged, with disruption of cortical line, findings that could correspond to an epidural abscess causing spondylodiscitis. Page 31 of 49

32 Fig. 23: CT with intravenous contrast. Coronal: Left psoas abscess by contiguity. Page 32 of 49

33 Fig. 24: SE T1 MRI. Sagittal: Isointense epidural collection in relation to abscess (large arrow). L5-S1 spondylodiscitis (thin arrow). Page 33 of 49

34 Fig. 25: FSE T2 MRI. Sagittal: Hyperintense collection in relation to epidural abscess (large arrow). L5-S1 spondylodiscitis (thin arrow). Page 34 of 49

35 Fig. 26: SE T1 MRI with gadolinium. Sagittal: L5-S1 space there is a loss of disc space with irregularity of dishes and peripheral uptake, findings that suggest changes of spondylodiscitis (large arrow). Collection in relation to epidural abscess (small arrow). Enhancement was seen duraly sac walls in relation to root uptake meningitis and radiculitis (thin arrow). Page 35 of 49

36 Fig. 27: FSE T2 MRI. Sagittal: Postsurgical changes with subsequent arc laminectomy L3 and L4 vertebrae. Behind them observe a wide area, heterogeneous signal, predominantly hyperintense, ferromagnetic artifacts are observed in connection with any other surgery, this area would consist mainly of fibrotic scar tissue. Page 36 of 49

37 Fig. 28: SE T1 MRI. Sagittal: Wide area, heterogeneous signal, predominantly hypointense, there are ferromagnetic artifacts related to any other surgery, this area would consist mainly of fibrotic scar tissue. Page 37 of 49

38 Fig. 29: SE T1 MRI with gadolinium. Sagittal: Within the fibrotic scar tissue, there is a cavity of irregular shape, shows peripheral enhancement after gadolinium administration, which merges with the rest of the scar tissue enhancement. This collection corresponds to an abscess (large arrow) Meningeal enhancements are observed (possible meningitis) (thin arrow). Page 38 of 49

39 Fig. 30: FSE T2 MRI. Axial: In thecal sac is displayed thickening of nerve roots. Page 39 of 49

40 Fig. 31: SE T1 MRI. Axial: In thecal sac is displayed thickening of nerve roots. Page 40 of 49

41 Fig. 32: SE T1 MRI with gadolinium. Axial: In thecal sac is displayed thickening of nerve roots, which also shows enhancement after gadolinium administration, forming a mass of roots that enhances especially the left half of the spinal canal, findings regarding radiculitis. Page 41 of 49

42 Fig. 33: GE MRI. Axial: Widening of the cervical spinal cord with marked intramedullary signal changes. There perimedullar reduction subarachnoid spaces. Page 42 of 49

43 Fig. 34: SE T1 MRI with gadolinium. Axial: Widening of the cervical spine with contrast enhancement. Page 43 of 49

44 Fig. 35: SE T1 MRI. Sagittal: Widening of the cervical spine from the base of the vertebral body of C2 to C6-C7 interspace. Page 44 of 49

45 Fig. 36: SE T1 MRI with gadolinium. Sagittal: Widening of the cervical spine from the base of the vertebral body of C2 to C6-C7 interspace with contrast enhancement. Page 45 of 49

46 Fig. 37: FSE T2 MRI. Sagittal: Widening of the cervical spine from the base of the vertebral body of C2 to C6-C7 interspace with marked intramedullary signal changes. Findings related to myelitis. Page 46 of 49

47 Conclusion The studying of images, and in particular MR imaging represents an essential pillar in the diagnosis of these patients. It allows us to confine the damage according to the dural space in which they are found, so that we can specify a differential diagnosis and give an early diagnosis, with a view to avoiding delays in treatment which could lead to higher risk of after-effects and mortality. Typically presents as hypointense disc space on T1 images and hyperintensity on T2, with enhancement after contrast administration of the disc, the vertebral bodies and, when present, soft tissue mass and paravertebral epidural. When infectious spondylodiscitis is more advanced, irregular vertebral endplates and reactive bone formation are progressive. Since the clinic is often non-specific and the diagnosis may be delayed several months, in daily practice we face other diagnostic possibilities such as degenerative disease and other simulators of this entity. Knowledge of the MRI findings of these entities will allow us better diagnostic approach and in many cases to prevent the implementation of additional procedures such as biopsy, while in other cases it will be necessary to confirm the diagnosis or the isolation of the germ involved. Personal Information References Khan IA, Vaccaro AR, Zlotow DA.Management of vertebral discitis and osteomyelitis. Orthopedics 1999 ; 22: Varma R, Lander P, assaf A.Imaging of pyogenic infectious spondylodiscitis. Radiol Clin North Am 2001 ; 39 : Moore SL, Raffi M. Imaging of musculoskeletal and spinal tuberculosis.radiol Clin North Am 2001 ; 39 : Page 47 of 49

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49 Steven C. Wagner, MD Mark E. Schweitzer, MD Willian B. Morrrison, MD Gregory J. Przybylski, MD Laurence Parker, PhD. Can imaging findings help differenciate spinal neuropathic arthrophaty from disks space infection? Initial experience. Radiology (2000) 214: Page 49 of 49