safo radiologi

8/13/2019 Safo RADIOLOGI

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P O T T S D I S E A S E: A Radiological Review of

Tuberculous

Spondylitis

Stella SafoGillian Lieberman, MD

April 2009

Harvard Medical School

Beth Israel Deaconess Medical Center
http://focus.hms.harvard.edu/2009/011009/index.html


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Agenda1 . Explain the evaluation, diagnosis and

treatment

of

spinal tuberculosis.

2. Review features of spinal tuberculosis on radiographs, CT and MRI.

3. Focus on the diagnosis of spinal TB using radiographs , as

this is the primary modality available in many resource limited settings where spinal TB is endemic.


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Our Patient: Initial Presentation

A 40 year old healthy Kenyan woman, Ms B.G, presented to her PCP

with a 1 yr history of low back pain (LBP)

that began after a fall.

Sharp, unremitting pain exacerbated by movement, without radiculopathy

Physical exam was unremarkable

Minimal relief with NSAIDS and physical therapy

She became pregnant

three months later.

LBP continued and worsened throughout pregnancy

Postpartum

Developed bilateral anterior thigh paresthesias

exacerbated by sitting

Due to failure to respond to conservative therapy, she was sent for radiological evaluation.

Further exploration of this topic requires a review of the anatomyof the spine and of a differential diagnosis of low back pain


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Spine Anatomy

http://www.columbiaspine.org

http://www.fla-ortho.com

http://www.sofamordanek.com

C E R V I C L

T H O R C I C

L U M R

T r a n s v e r s ep r o c e s s

S p i n o u s

p r o c e s s

Ve r t e b r a l

b o d y

I n t e r v e r t e b r a ld i s c

P e d i c l e


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Differential Diagnosis Low Back Pain MECHANICAL

Degenerative disk disease, compression fracture, musculoskeletal

sprain or strain

NEUROGENIC Disk herniation, sciatica, spinal stenosis, infection, malignancy,

connective tissue disorder (ie. ankylosing

spondylitis)

Others: VISCEROGENIC

UTI, pyelonephritis, retroperitoneal tumor or bleed VASCULAR

Abdominal aortic aneurysm PSYCHOGENIC

With this differential in mind for patient BG,further imaging revealed infection of the spine.


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Introducing Pott Disease Known by many names : spinal tuberculosis, tuberculous

spondylitis, Pott disease or Potts disease

First described in 1782 by Percival Pott , a British orthopedic surgeon.

Differential diagnosis of Pott disease Pyogenic or fungal osteomyelitis

Eosinophilic granuloma

Multiple myeloma Multiple compression fractures Note : Brucellosis of the spine and Pott disease are radiologically

indistinct.


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Our Patient: Imaging

Ms. BGs diagnosis was made based on her imaging

Imaging

Plain film of the spine demonstrated compression fracture L12 with anterior kyphosis

MRI spine revealed

T12 L3 vertebral osteomyelitis

L12 compression fractures with forward angulation

Cauda

equina

impingement

Left psoas abscess


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Our Patient: Radiograph

PACS, BIDMC

Lateral radiograph

Anterior collapse of L1,L2 vertebrae with loss of disk

space. ( *).

Central lucencies

within the L1vertebrae ( *).


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Our Patient: CT Torso

PACS, BIDMC

Noncontrast

axial CT

Large left psoas

abscess withhypoattenuated core region.


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Our Patient: MRI

Spine

PACS, BIDMC

Sagittal

T2W

Destruction of L1-L2 disk space and collapse of adjacent vertebral bodies ( *) withretropulsion into the spinal canal( *). In image, edema in T12 to L3 vertebral bodies ( *),suggestive of spinal osteomyelitis.

1 2


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Our Patient: Clinical Outcome Diagnosis : Pott

disease was diagnosed based on

Radiologic

findings

1) psoas

abscess

2)

continuous

anterior

vertebral

body

destruction

3) cord compression

Emigration from an area with endemic tuberculosis Indolent nature of symptoms

Treatment : Patient was placed on bed rest and fitted for a thoracolumbosacral

orthosis(TLSO)

Underwent debridement

and spinal stabilization Mycobacterium tuberculosis was isolated from surgical specimens and

sputum Placed on a long course of Rifampin, Isoniazid, Pyrazinamide, & Ethambutol


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Pott Disease: Epidemiology

Pott

disease is uncommon in the United States U.S. versus Kenya (homeland of case patient)

4/100,000/yr : 384/100,000/yr Spinal tuberculosis loosely reported as 100 200 cases yearly

Skeletal tuberculosis Accounts for 10% of all cases of extrapulmonary

TB

Targets the hips, knees, spine Spinal tuberculosis is most common, accounts for 50% all skeletal TB cases

Clinical presentation varies by geographic location High TB prevalence

Pott

disease is commonly seen in children Targets thoracic vertebrae

United States Seen in immigrants from endemic countries, immunocompromised,

men > women Targets lumbar vertebrae


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Pott Disease: Pathophysiology

Tuberculosis infiltrates the spine via Hematogenous

spread through the dense vasculature of cancellous

bone of the anterior vertebral bodies

Lymphatic spread from para aortic lymph nodes possible but rare

Up to 75% of infected individuals develop a soft tissue infection Commonly occurs in the psoas

muscle cold abscess Known as cold abscess because forms slowly and does not normally

present with heat, inflammation or pain

Paraspinal

fistula which may form a communication with the chest

wall or pelvic floor

Left untreated, degeneration and inflammation of the vertebrae causes Herniation

into the cord space cord compression and cauda equina

Kyphosis gibbous (severe kyphosis) Paraplegia


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Pott

Disease: Complications

Pappou et al.- http://ovidsp.tx.ovid.com.ezp-prod1.hul.harvard.edu/spb/ovidweb.cgi?WebLinkFrameset

Oguz et al.- http://www.springerlink.com.ezp-prod1.hul.harvard.edu/content/h482j21x5548q078/fulltext.pdf

Gibbous

Lateral radiographs andT2W MRI

Young male with gibbus

deformtity

(A) atthoracolumbar

junction

seen on radiograph (B) andT2W MRI (C).

Cord Compression

Radiograph (1), sagittalCT reconsturction

(2) and MRI (3) of a 70 year oldman with Pott

disease.

Note continuousvertebral bodydestruction ofthoracolumbar

spine,

causing severekyphosis.

Patient developedcompression of theconus

medullaris,resulting in inability toambulate.

2 3

1


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Pott

Disease: Diagnosis Physical Diagnosis:

Usually presents with 4 month to 3 year history of low back pain

with or without associated neurological deficits.

Signs of nearby cold abscess or fistula may be present

Only 20% present with concomitant TB lung infection

Routine lab tests and the Mantoux

skin test are of little diagnostic aid

KEY POINT: Must maintain high clinical suspicion in order to makethe diagnosis of tuberculous spondylit is in a timely fashion.


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Pott

Disease: Imaging Menu of tests

May start with plain film

to visualize gross deformities i.e. kyphosis, fracture. CT is good for visualizing disco vertebral lesions and paravertebral

abscess, particularly for abscess calcification.

MRI

provides the best visualization of the extent of spinal canal and soft tissue involvement. Allows for early detection.

Examples of types ofimaging modalities

>

Lateral Radiograph-

shows signs of early diskdestruction ( *)

> Coronal T2W MRI-

diskdestruction and bonemarrow edema ( *)

> Transaxial

CT-

large leftparavertebral

abscess ( *)

R A D I O G R A P H C TM R IOguz et al.- http://www.springerlink.com.ezp-prod1.hul.harvard.edu/content/h482j21x5548q078/fulltext.pdf


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Pott Disease: Additional Imaging

Lesser used imaging modalities include:

Bone scintigraphy

Ultrasound

useful in visualizing

paraspinal

abscesses

Nigg et al.- http://www.springerlink.com.ezp-prod1.hul.harvard.edu/content/74l418224t055432/fulltext.pdf

46 year old male withspinal TB on bonescintigraphy

Increased radionuclideuptake in thoracic and

lumbar spine ( *)secondary to increasedbony metabolism frominfection.


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Radiographs: General Features Features of Potts

on radiograph include Signs of infection with lytic

lucencies

in anterior portion of vertebrae Disk space narrowing

Erosions of the endplate Sclerosis resulting from chronic infection Compression fracture Continuous vertebral body collapse

Kyphosis; gibbous (severe kyphosis)

Atypical features

Soft tissue swelling from paraspinal

abscesses, +/

calcification Involvement of only one vertebral body

Involvement of several vertebral bodies without

intervertebral

discitis

Bowing of rib cage secondary to collapse of multiple vertebral bodies

Destruction of lateral or posterior aspects of vertebral bodies


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Radiographs: Erosions Lucent area in lateral aspect of adjacent vertebral bodies erosions (*)

Loss of intervertebral

disk space (*) Central lucency

(*) with surrounding sclerosis suggesting chronic infection (*)

Pertuiset et al.- http://ovidsp.tx.ovid.com.ezp-prod1.hul.harvard.edu/spb/ovidweb.cgi?QS2
http://ovidsp.tx.ovid.com.ezp-prod1.hul.harvard.edu/spb/ovidweb.cgi?View+Image=00005792-199909000-00003%7CFF1&S=AFDGFPDLBDDDFBIPNCGLDHJJLKMNAA00&WebLinkReturn=Full+Text=L%7CS.sh.15.16%7C0%7C00005792-199909000-00003http://ovidsp.tx.ovid.com.ezp-prod1.hul.harvard.edu/spb/ovidweb.cgi?View+Image=00005792-199909000-00003%7CFF3&S=AFDGFPDLBDDDFBIPNCGLDHJJLKMNAA00&WebLinkReturn=Full+Text=L%7CS.sh.15.16%7C0%7C00005792-199909000-00003http://ovidsp.tx.ovid.com.ezp-prod1.hul.harvard.edu/spb/ovidweb.cgi?View+Image=00005792-199909000-00003%7CFF1&S=AFDGFPDLBDDDFBIPNCGLDHJJLKMNAA00&WebLinkReturn=Full+Text=L%7CS.sh.15.16%7C0%7C00005792-199909000-00003


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Radiographs: Endplate Destruction

Private Collectionof Ferris Hall MD


Image 1Lateral radiograph ofspinal TB in a 23 yo

man

showing endplateerosion, loss of diskspace (*) , and anteriorcompression fracture ofthe lumbar spine.

Image 2Lateral radiograph of 56yo

man with Pott

diseasewith additional features

of sclerosis at vertebralendplates that haveundergone severecompression anderosion (*).

21


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Radiographs: Osteosclerosis

Private Collection o fFerris Hall MD

Private Collection o fFerris Hall MD

1 2

Image 1Frontal radiograph 45yo

female. Note

compression fracturewith loss ofintervertbral

diskspace (*).

Image 2Lateral radiograph of56 yo

male. Similarly,note compressionfracture and secondaryosteosclerosis

(*).

R di h


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Radiographs: Atypical Features

72 yo

M with

long history of long history of spinal TB.

Note collapse of multiple thoracicvertebrae ( *) with resultingbowing in of ribs ( *).

Paraspinal

abscess seen with circularcalcified mass ( *).

Private Collectionof Ferri s Hall MD


72 yo

M with longhistory of long history of spinal TB.

Collapse of mulitplethoracic vertebrae ( *)resulting in severekyphosis

(*).


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CT: Features

Features on CT

Soft tissue findings

Abscess with calcification is diagnostic of spinal TB; CT is excellent modality to visualize soft tissue calcifications

Pattern and severity of bony destruction

Pattern of vertebral body destruction

framentary, osteolytic,

localized and sclerotic, and subperiosteal

Used to guide needle in percutaneous

needle biopsy of

paraspinal

abscess


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CT: Calcification

PACS, BIDMC

Noncontrast

axial CT

Large psoas

abscess ( *) with central calcification ( *); these features are highly diagnostic ofspinal TB.


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CT: Bony Destruction

Noncontrast

axial CT

Extensive vertebral body destruction causing bony fragments ( *). Destruction of cancellous

bone

indicated by hypoattenuation

of central vertebral body ( *).

PACS, BIDMC


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MRI: Features

Highly sensitive and specific for spinal TB

Provides early

detection

Best to distinguish exact extent of spinal cord and soft tissue involvement

Features Edema of vertebrae and disk space

Signs of spinal compromise i.e. cord compression Note : Poorly visualizes calcification in abscesses


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MRI: Spinal Cord Involvement

PACS, BIDMC

Sagittal

T2W (Images 1-3)and axial T1W (Image 4)

High intensity activity in T12 to L3 vertebrae indicative of infection ( *) (*). Complete destruction ofvertebral bodies with osseous retropulsion

into the spinal canal, causing cauda

equina

(*). On axialview, note destruction of vertebral body with loss of circular shape( *).

1 2 3

4


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Pott Disease: Treatment

Various imaging modalities are useful in determining extent of disease. Treatment options then depend on the degree of spinal destruction.

Most practicing clinicians simply define Potts

as

EARLY

or LATE

disease.

GATA ClassificationOguz et al.- http://www.springerlink.com.ezp-prod1.hul.harvard.edu/content/h482j21x5548q078/fulltext.pdf


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Conservative Treatment

Early Disease:

Treat with a four drug regimen for six to twelve months

Common antibiotics

are

Rifampin,

Isoniazid,

Pyrazinamide, Ethambutol

Most individuals experience full resolution of symptoms with appropriate anti tuberculosis treatment


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Surgical Interventions Late Disease:

Loosely defined by neurologic deficits, spinal kyphosis

>40%, or failure of medical therapy

Surgical debridement, abscess drainage, and/or vertebral fusion in addition to antibiotics

PACS, BIDMC

Ms. BG post surgery

Young man with gibbous deformity ( *) status postinstrumentation surgery.Note stabilization of spine and resolution of gibbous ( *).

Lateral radiograph

Our index patient,Ms. BG afterspinaldebridement andvertebral fusion.

Oguz et al.- http://www.springerlink.com.ezp-prod1.hul.harvard.edu/content/h482j21x5548q078/fulltext.pdf


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Summary Imaging modalities

are plain film, CT and MRI; MRI is gold standard for

imaging spinal TB.

Spinal tuberculosis is not common in U.S., therefore must maintain high clinical suspicion so as not to overlook diagnosis, especially among immigrant populations.

Diagnosis and treatment of spinal TB in endemic areas is difficult given resource limitations; rely on radiographs and clinical signs to facilitate early diagnosis.

Conservative versus surgical treatment of Pott

disease depends on degree of spinal destruction,

making early diagnosis essential for a

positive outcome.


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