Pott's Spine: Diagnostic Imaging Modalities and Technology Advancements

Magnetic resonance imaging of bacterial and tuberculous spondylodiscitis with associated complications and non-infectious spinal pathology mimicking infections: a pictorial review

Magnetic resonance (MR) imaging plays an important role in the evaluation of bacterial and tuberculous spondylodiscitis and associated complications. Owing to its high sensitivity and specificity, it is a powerful diagnostic tool in the early diagnosis of ongoing infections, and thus provides help in prompt initiation of appropriate, therapy which may be medical or surgical, by defining the extent of involvement and detection of complications such as epidural and paraspinal abscesses. More specifically, MR imaging helps in differentiating bacterial from tuberculous infections and enables follow up of progression or resolution after appropriate treatment. However, other non-infectious pathology can demonstrate similar MR imaging appearances and one should be aware of these potential mimickers when interpreting MR images. Radiologists and other clinicians need to be aware of these potential mimics, which include such pathologies as Modic type I degenerative changes, trauma, metastatic disease and amyloidosis. In this pictorial review, we will describe and illustrate imaging findings of bacterial and tuberculous spondylodiscitis, their complications and non-infectious pathologies that mimic these spinal infections.

Atypical spinal tuberculosis involved noncontiguous multiple segments: Case series report with literature review

In its typical form, spinal tuberculosis (TB) presents as destroyed contiguous vertebral bodies with involvement of intervertebral discs and paravertebral or psoas abscesses. Atypical forms are uncommonly reported. Here, we describe 8 patients with noncontiguous multisegmental spinal TB with no intervertebral disc involvement. From 2013 to 2014, we surgically treated 384 patients with spinal TB to relieve spinal cord compression, re-establish spinal stability, confirm the diagnosis, and debride the TB foci. Eight of these patients had noncontiguous multisegmental TB without intervertebral disc involvement. Seven of the 8 patients underwent short-segmental fixation and fusion at a single focus. Appropriate combinations of anti-TB medication were continued until final follow-up. They were followed at established intervals using plain radiography, 3-dimensional computed tomography, and magnetic resonance imaging of the surgical region to evaluate fusion and the condition of the foci. Mean follow-up was 26.6 months (range, 24-32 months), during which time all patients were prescribed the appropriate anti-TB medications. Satisfactory clinical and radiological results were obtained in all patients, without complications. Presentation of noncontiguous multisegmental spinal TB without the involvement of intervertebral disc resembles that of a neoplasm or other spinal infection. Differentiation requires the presence of a combination of general symptoms, laboratory test results, appropriate radiological results, and the physician's experience. For patients in whom surgery is indicated, the patient's general condition should be taken into consideration. Surgical intervention only focus on the responsible level is less invasive and can achieve satisfactory clinical and radiographic outcomes.

Diagnosis and Treatment Particularities in Osteoarticuar Tuberculosis

Osteoarticular tuberculosis (OATB) is a secondary chronic infection with paubacillary bacillus Koch (BK) that has bone and joint interest. Today in Romania, tuberculosis is a primary public health problem, according to World Health Organization (WHO) in 2015 alone, there have been 10.4 million new cases of tuberculosis (TB) in the world, of which 15.195 in Romania. Pulmonary and extrapulmonary tuberculosis, especially the osteoarticular form, with multiple outbreaks should of had a minimal impact, but because of the multiple characteristics such as: epidemiological, geographic, associated diseases, diagnosis capacity, therapeutic options, gene pool and racial evolutiv traits, the disease spreading and management in both developed and underdeveloped countries, the TB infection has seen an increase in the number of cases (e.g. Africa and Asia). Today there is a fecundity upsurge of BK infection, especially pronounced in low income populations, country side people being the most affected. There are multiple breakthroughs in the understanding of Mycobacterium tuberculosis physiopathology. This fact offers us a modern and genetically guided approach in the diagnosis, evolutive patterns and treatment involving the OATB.

Early diagnosis of spinal tuberculosis

Spinal tuberculosis (STB) is a common manifestation of extrapulmonary tuberculosis (TB). STB accounts for around 2% of all cases of TB and around 15% of extrapulmonary TB cases. The World Health Organization has proposed a global strategy and targets for TB prevention, care, and control after 2015. Under this strategy, patients will receive standard care according to the recommendations and guidelines after confirmation of STB diagnosis. However, current recommendations and guidelines focus on disease and medication therapy management, and recommendations for early detection or decision-making algorithms regarding STB are lacking. In this review, we identified five key components for early diagnosis: (1) risk factors for STB; (2) common symptoms/signs of STB; (3) significant neuroradiological findings of STB; (4) significant laboratory findings of STB, including positive interferon-γ release assays and nonpyogenic evidence in initial laboratory data; and (5) significant clinical findings of STB. Individualized consideration for each patient with STB is essential, and we hope that the algorithm established in this review will provide a valuable tool for physicians who encounter cases of STB.

Outcomes of radical debridement versus no debridement for the treatment of thoracic and lumbar spinal tuberculosis

PURPOSE

Whether radical debridement is necessary for the treatment of thoracic and lumbar tuberculosis is still questionable. The objective of this prospective randomized study was to compare the outcomes of radical debridement versus no debridement for the treatment of thoracic and lumbar tuberculosis.

METHODS

Seventy-four thoracic and lumbar tuberculosis patients with a neurological function of grade D and E underwent surgery and received the same chemotherapy regiment from January 2009 to October 2014. All patients were divided into group A and B by taking the drawing of lots. In group A, radical debridement, bone graft, and instrumentation were performed. Isolated posterior instrumentation without debridement were performed in group B. The operative time, blood loss, visual analogue score (VAS), erythrocyte sedimentation rate (ESR), kyphotic angle, Frankel grading, fusion rate, and complications were evaluated.

RESULTS

Group B had a better clinical outcome with regard to the operative time, blood loss, VAS score first week post-operatively, and the ESR value in the third and sixth month post-operatively than group A, and the differences between the two groups about those values all presented a significant difference (P < 0.05). However, no difference was observed between the two groups for the kyphotic angle (P = 0.088) and fusion rate (P = 0.164) at the final follow-up. Neurological function of all cases exhibited normal neurological function in the two groups at the final follow-up. Two cases of pulmonary infection and four cases of wound infection in group A. No serious complications were observed in group B.

CONCLUSIONS

Isolated posterior instrumentation without debridement is a suitable treatment for selected patients because of minor surgical trauma, fewer complications, and spontaneous fusion.

Atypical, multilevel and noncontiguous tuberculous spondylitis that affected the vertebrae of thoracic, lumbar and sacrum: a case report

AIM

Tuberculous spondylitis (TS, also called Spinal tuberculosis, Pott's spine or Pott's disease) is a common extrapulmonary manifestation of tuberculosis (TB), but multilevel, noncontiguous TS cases are rare.

METHODS

Physical examination, CT, MRI imaging, percutaneous biopsy and other lab tests were used to confirm the diagnosis.

RESULT

we report a rare case of atypical, multilevel and noncontiguous TS in a 50-year-old woman. We found four noncontiguous osteolytic lesions in her spine that affected the Intervertebral joints of T10/11, L1/2, L3/4 and L5/S1. Patient was then treated conservatively with anti-TB drugs and was followed-up for about 1 year. The treatment turned out to be successful.

CONCLUSION

The conservative anti-TB treatment was enough at least for this particular patient.

Tuberculosis of symphysis pubis: A case report

Symphysis pubis is an uncommon site of tuberculosis and only few cases have been reported in the literature. It is important to distinguish it from the more common entities like Osteitis pubis and Osteomyelitis of pubis symphysis to prevent delay in diagnosis and minimize morbidity and prevent complications. We report a rare case of tuberculosis of symphysis pubis in a 50-year-old Indian female from low socioeconomic status. Diagnosis is not difficult if one is aware of the condition. A high index of suspicion along with radiograph and fine needle aspiration led to the diagnosis. The patient had an excellent outcome following a complete course of anti-tuberculous chemotherapy for tuberculosis.

Spinal tuberculosis in western mexico, 2008-2013

Objective: To identify the prevalence, clinical features and postoperative outcome of patients with spinal tuberculosis at the Instituto Mexicano del Seguro Social, in Jalisco, Mexico from 2008 to 2013. Methods: Prevalence study of patients undergoing spine surgery due to tuberculosis. Clinical, surgical pre- and postoperative parameters were evaluated by analysis of 41 medical records. Results: Seventeen (41.4%) were women and 24 (58.6%) were men with a mean age of 47.7 years. The main diagnoses were tuberculous spondylitis in 14 (34.1%) patients; discitis in 13 (31.7%); infectious spondylitis in 9 (21.9%); chronic spondylitis in four (9.7%); abscess in one patient (2.4%). Only 22% of patients were positive for epidemiological study of tuberculosis contacts. The most affected region was the lumbar spine followed by the thoracic spine and the most affected vertebrae were L3-L4. The most used surgical instrumentation was by posterior approach with drainage on 29 occasions, anterior approach with drainage in nine, and the mixed approach in three. Twenty-nine patients were independent to perform daily activities after discharge. Conclusion: The discitis or infectious spondylodiscitis should be considered in any patient with localized pain at any level of the spine. Once solved the problem of infection and stability, patients respond favorably to the surgical procedure.

Atypical imaging features of tuberculous spondylitis: case report with literature review

Spinal tuberculosis in its typical form that shows destruction of two adjacent vertebral bodies and opposing end plates, destruction of the intervening intervertebral disc and a paravertebral or psoas abscess, is easily recognized and readily treated. Atypical tuberculous spondylitis without the above mentioned imaging features, although seen infrequently, has been well documented. We present, in this report, a case of atypical tuberculous spondylitis showing involvement of contiguous lower dorsal vertebral bodies and posterior elements with paravertebral and epidural abscess but with preserved intervertebral discs. The patient presented in advanced stage with progressive severe neurological symptoms due to spinal cord compression. Non-enhanced magnetic resonance imaging led to misdiagnosis of the lesion as a neoplastic process. It was followed by contrast enhanced computed tomography of the chest and abdomen that raised the possibility of an infectious process and, post-operatively, histopathological examination of the operative specimen confirmed tuberculosis. This case indicates the difficulty in differentiating atypical spinal tuberculosis from other diseases causing spinal cord compression. The different forms of atypical tuberculous spondylitis reported in the literature are reviewed. The role of the radiologist in tuberculous spondylitis is not only to recognize the imaging characteristics of the disease by best imaging modality, which is contrast enhanced magnetic resonance imaging, but also to be alert to the more atypical presentations to ensure early diagnosis and prompt treatment to prevent complications. However, when neither clinical examination nor magnetic resonance imaging findings are reliable in differentiating spinal infection from one another and from neoplasm, adequate biopsy, either imaging guided or surgical biopsy is essential for early diagnosis.

SPECTRUM OF SPINAL ABNORMALITIES ON MAGNETIC RESONANCE IMAGING OF PATIENTS WITH CLINICAL SUSPICION OF SPINAL LESIONS IN KANO, NIGERIA

BACKGROUND

Magnetic resonance imaging (MRI) of the spine is a powerful tool for evaluation, assessment of severity, and follow up of diseases of the spine. It is one of the most sensitive diagnostic tests for detecting anatomic abnormalities of the spine and the adjacent structures.

AIM

To determine the pattern of spinal abnormalities on MRI in Kano, Nigeria.

MATERIALS AND METHOD

Patients aged between 2 and 95 years who had spinal MRI with AIRIS II TOSHIBA (0.5T) Tesla machine from January to December 2013 were reviewed. Information concerning age, gender, region and findings were recorded.

RESULTS

Two hundred and sixty one patients made up of187 males and 74 females were reviewed. Their ages ranged from 2 to 95 years with the mean of 46.43 ± 15.7 years. Lumbo-sacral MRI was the most commonly performed (46.4 %) followed by cervical (44.1%), thoraco-lumbar spine (4.2%), thoracic spine (3.8%) and cervical and lumbar (1.5%). The most common indication of MRI was low back pain in 211 (80.8% ) patients followed by trauma in 36 (17.8% ) patients. About 19.6% of the MRI examinations were normal while spondylosis and moderate disc prolapse was seen in 31.5% and compressive fracture comprised 7.3% of cases.

CONCLUSION

Lumbo-sacral MRI was the commonest MRI in this study and the commonest indications for MRI were low back pain and trauma while the commonest findings were spondylosis, disc prolapse, compressive fracture and spinal metastases.

Clinical, radiological and molecular diagnosis correlation in serum samples from patients with osteoarticular tuberculosis

OBJECTIVE

To assess the role of polymerase chain reaction (PCR) in serum samples, in the diagnosis of osteoarticular tuberculosis (OTB) in a setting where only clinical and imaging diagnoses determine the treatment.

METHODS

A total of 44 consecutive serum specimens were collected from clinically suspected OTB patients, based on clinical and radiological [X-ray or magnetic resonance imaging/computed tomography] features. They were screened by in-house nested PCR. In addition, a few specimens were examined by Gram stain, acid-fast bacilli stain, histopathology and routine bacterial culture. A total of 39 specimens were collected from patients suffering from other bone diseases of nontuberculous origin and included as negative controls.

RESULTS

Of the 44 clinically suspected OTB patients, in-house nested PCR was positive in 40 (91%) cases; PCR was negative in 38 (97%) negative controls. Sensitivity and specificity of our in-house nested PCR was 90.9% and 97.4%, respectively. The PCR report was available within 48 h. It was possible to standardize serum PCR technique and in positive cases, a good correlation was observed in terms of an adequate treatment response.

CONCLUSIONS

Nested PCR in serum samples is a rapid, highly sensitive and specific modality for OTB detection. PCR should be performed in addition to clinical evaluation, imaging studies, acid-fast bacilli staining, culture and histopathology diagnosis, if possible.

Magnetic Resonance Image findings of Spinal Tuberclosis at first presentation

Background

Spinal tuberculosis presents in various pathological patterns. The clinical presentation and often the management depend on exact pathological findings. Objective of study was to evaluate the Pathology of spinal tuberculosis as depicted by MRI findings in 119 consecutive cases of spinal TB.

Methodology

It was a cross sectional and observational study conducted at Civil Hospital, Karachi from July 2010 to December 2012.Total numbers of participants were 119. Diagnosis was based on positive histopathology results along with the supportive evidence in MRI. A pre-structured questionnaire was constructed to record the data. Study was ethically approved by Institutional Review Board of Dow University of Health Sciences. Sample size was calculated by using Open-EPI software. All the data was entered and analyzed through SPSS 19.

Result

There were 119 patients who participated in this study out of which 52 were males and 67 were females. Most common level was Dorso-lumbar (33.6%) and 87.5% of them had spondylodiscitis while 90% had cord compression. All 6 (100%) patients who had their upper- dorsal region affected had gibbus formation while all those patients having lumbosacral region involved had thecal compression 4 (100%). Most common mode of treatment used in patients having Spinal TB at Lumbar region was conservative (86.2%).

Conclusion

MRI findings were mostly shadowed with features such as disc destruction and thecal or cord compression. MRI scan could be used for early detection of spinal TB which can reduce disability and deaths in patients. Major clinical findings in spinal TB were fever, Para paresis and back pain.