anatomy pyogenic spondylodiscitis...6/2/2017 1 spinal infection pramot tanutit, m.d. department of...
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6/2/2017
1
Spinal infection Pramot Tanutit, M.D.
Department of Radiology, Songklanagarind Hospital
Faculty of Medicine, Prince of Songkla University
Outline
• 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, 2005Radiographics 2009; 29:599-612
• Location: Lumbar(48%)>Thoracic(35%)>Cervical(6.5%)
– Usually one segment
• Onset: acute to subacute period
• Clinical: back pain, fever, focal neurological manifestation(late)
Ross, Diagnostic imaging spine, 2015
Pyogenic spondylodiscitis
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Stage of infection Characteristic
• Location: Lumbar
• Disc and end plate: Destroyed
• Marrrow: Extensive edema
• Paraspinal involvement: Small abscess with thick, irregular rim enhancement
• Epidural involvement: Positive
Ross, Diagnostic imaging spine, 2015Radiol Clin N Am 50(2012) 777-789
• Location: Lumbar
• Disc and end plate: Destroyed
• Epidural involvement
• Paraspinal involvement:Small abscess with thick, irregular rim enhancement
• Marrow: extensive edema
T2W T1W-Gd
Tuberculous spondylitis
• Onset: subacute to chronic
• Route of spreading: mainly hematogenous route
• Clinical: lack of symptom in early phase
Ross, Diagnostic imaging spine, 2015Resnick, Bone and joint imaging, 2005
• Location: Mid-thoracic or thoracolumbar> lumbar, cervical
• Possible isolated posterior element involvement
• Lamina> pedicle> spinous process> transverse process
Ross, Diagnostic imaging spine, 2015
Tuberculous spondylitis
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Characteristic• Disc and end plate: Early spared
Tuberculous spondylitis
Characteristic
• 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
Ross, Diagnostic imaging spine, 2015Radiol Clin N Am 50(2012) 777-789
Imaging
Subligamentous spreadingLarge right psoas abscess Characteristic
• Paraspinal involvement: Large abscess(+/- calcify), thin smooth rim enhancement
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Calcified nodes
Pyogenic Tuberculous
Location Lumbar Mid-thoracic/ thoracolumbar
Disc & endplate Destroyed Early spared
Bony part Body involvement Anterior body, isolated posterior element
Paraspinalinvolvement
Small abscess with thick, irregular rim enhancement
large abscess(+/- calcify), thinsmooth rim enhancement
Epidural + +
Other Leukocytosis Gibbus(advanced),subligamentous spreading, multiple involvement
Ross, Diagnostic imaging spine, 2015Radiol Clin N Am 50(2012) 777-789
Our study, 2011
• The Combination of Magnetic Resonance Findings in Differentiation between Pyogenic Spondylitis and Tuberculousspondylitis
• Population: 150 patients(2003-2010)
Table: MRI findings of TB and pyogenic spondylitis
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 / /
Probability of pyogenic spondylitis
Intraosseousabscess
para/ perispinalabnormal
signal
Subligamentouosspreading > 2
levels
Sacral spine involvement
Probability(%)
+ 66
+ 70
+ + + 72
+ + 92
Enhancing lung nodule with central necrosis at left apical lung
Left paravertebral abscess
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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
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Spondyloarthropathies
Romanus lesionAndersson lesion
Degenerative disc disease
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, intraosseousabscess, subligamentous spreading(>3 levels), large abscess, calcification, calcified nodes
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