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

Spine tuberculosis with an intercurrent active pulmonary location in a high incidence country: A rare case report

Spinal tuberculosis usually presents as destroyed contiguous vertebral bodies associated with intervertebral discs and paravertebral or psoas abscesses. Atypical forms are uncommonly reported. Vertebral involvement without disk destruction is a rare form that improves satisfactorily after appropriate medical management. We report the case of a 36-year-old male who had spine tuberculosis without disk involvement, associated with intercurrent active pulmonary location with good clinical improvement after treatment and follow-up imaging showing spectacular regression of bone lesions. By reporting this case, we also review the literature on this rare form of tuberculosis.

Accurate Differentiation of Spinal Tuberculosis and Spinal Metastases Using MR-Based Deep Learning Algorithms

Purpose

To explore the application of deep learning (DL) methods based on T2 sagittal MR images for discriminating between spinal tuberculosis (STB) and spinal metastases (SM).

Patients and Methods

A total of 121 patients with histologically confirmed STB and SM across four institutions were retrospectively analyzed. Data from two institutions were used for developing deep learning models and internal validation, while the remaining institutions' data were used for external testing. Utilizing MVITV2, EfficientNet-B3, ResNet101, and ResNet34 as backbone networks, we developed four distinct DL models and evaluated their diagnostic performance based on metrics such as accuracy (ACC), area under the receiver operating characteristic curve (AUC), F1 score, and confusion matrix. Furthermore, the external test images were blindly evaluated by two spine surgeons with different levels of experience. We also used Gradient-Class Activation Maps to visualize the high-dimensional features of different DL models.

Results

For the internal validation set, MVITV2 outperformed other models with an accuracy of 98.7%, F1 score of 98.6%, and AUC of 0.98. Other models followed in this order: EfficientNet-B3 (ACC: 96.1%, F1 score: 95.9%, AUC: 0.99), ResNet101 (ACC: 85.5%, F1 score: 84.8%, AUC: 0.90), and ResNet34 (ACC: 81.6%, F1 score: 80.7%, AUC: 0.85). For the external test set, MVITV2 again performed excellently with an accuracy of 91.9%, F1 score of 91.5%, and an AUC of 0.95. EfficientNet-B3 came second (ACC: 85.9, F1 score: 91.5%, AUC: 0.91), followed by ResNet101 (ACC:80.8, F1 score: 80.0%, AUC: 0.87) and ResNet34 (ACC: 78.8, F1 score: 77.9%, AUC: 0.86). Additionally, the diagnostic accuracy of the less experienced spine surgeon was 73.7%, while that of the more experienced surgeon was 88.9%.

Conclusion

Deep learning based on T2WI sagittal images can help discriminate between STB and SM, and can achieve a level of diagnostic performance comparable with that produced by experienced spine surgeons.

Diagnosis and Treatment of Skipped Multifocal Spinal Tuberculosis Lesions

Spinal tuberculosis, also known as Pott's disease or tuberculous spondylitis, is usually secondary to primary infection in the lungs or other systems, and in most instances, is thought to be transmitted via blood. Typical manifestations of infection include narrowing of the intervertebral disc by erosion and bone destruction of adjacent vertebrae. Atypical spinal tuberculosis is a specific type of spinal tuberculosis. It mainly consists of single vertebral lesions, single posterior structure lesions, multiple vertebral lesions, and intra-spinal lesions. Skipped multifocal spinal tuberculosis is one of these types and is characterized by two or more vertebral lesions without the involvement of the adjoining intervertebral discs, regardless of their location. To date, only a few cases have been reported. Upon clinical admission, it can be treated conservatively or surgically, depending on the patient's symptoms. In addition, gene or biological therapies are being investigated. However, because of the exceptional imaging findings and insidious symptoms, it is often misdiagnosed as a neoplastic lesion, osteoporotic fracture, or other infectious spondylitis, increasing the risk of neurological deficit and kyphotic deformity, and delaying the optimal treatment window. In this study, we review the diagnosis and treatment strategies for skipped multifocal spinal tuberculosis lesions and enumerate the common differential diagnoses, to provide reference and guidance for clinical treatment and diagnosis direction.

Non-contiguous multilevel spinal tuberculosis: A case report of unusual spinal tuberculosis resembling spinal metastasis

Spinal tuberculosis (TB) is diagnostically challenging, particularly in atypical forms. Non-contiguous multilevel spinal TB (NMLST) is a rare presentation of spinal TB, mimicking spinal malignancies. We reported an unusual NMLST case with a paraspinal and epidural abscess in a young patient with misleading clinical and imaging presentations.

Vacuum Sealing Drainage for Primary Thoracolumbar Spondylodiscitis: A Technical Note

Primary spinal infection is a challenge for neurosurgeons. Here, for the first time, we introduced the vacuum sealing drainage (VSD) sponge into the intervertebral space for the primary thoracolumbar infection treatment. This study included 6 bedridden patients with thoracolumbar spondylodiscitis without deformity formation. All 6 patients were treated with the VSD in our hospital from June 30, 2018, to August 31, 2019. All 6 cases of thoracolumbar infection achieved clinical cure at 3-month follow-up, and no surgical-related mortalities occurred in our series. One patient died of acute cerebral infarction 5 months after surgery, and the remaining 5 patients completed a 12-month follow-up without recurrence. The JOA score of all 6 cases improved significantly after VSD treatment. VSD is feasible for safe and effective treatment for primary thoracolumbar infection. The short-term follow-up effect is definite.

A Scoring System for Outpatient Orthopedist to Preliminarily Distinguish Spinal Metastasis from Spinal Tuberculosis: A Retrospective Analysis of 141 Patients

Objective

Spinal tuberculosis (TB) misdiagnosed of spinal metastasis was not rarely reported, especially in outpatients department. This study was aimed to establish an outpatient scoring system to preliminarily distinguish spinal metastasis from spinal TB.

Methods

We retrospectively reviewed consecutive 141 patients with a pathological diagnosis of spinal metastasis (82 cases) or spinal TB (59 cases) in our hospital from January 2017 to June 2018. The following clinical characteristics which can be obtained by outpatient orthopedist were recorded and analyzed: age, gender, malignant tumor history, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and imaging features including distribution characteristics of vertebral lesions, subligamentous spread, paravertebral or psoas abscess, involved vertebral element, intervertebral disc, and sequestra formation. The prevalence of clinical characteristics in spinal metastasis was evaluated, and the scoring system was established using logistic regression analysis. The performance of the scoring system was also prospectively validated.

Results

The outpatient scoring system was based on five clinical characteristics confirmed as significant predictors of spinal metastasis, namely, malignant tumor history, subligamentous spread, posterior element lesions, preserved discs, and no sequestra formation. Spinal metastasis showed a significant higher score than spinal TB (8.17 points vs. 1.97 points, t = 18.621, P < 0.001), and the optimal cut-off value for the scoring system was 5 points. The sensitivity and specificity of the scoring system for predicting spinal metastasis were 97.85% and 88.33%, respectively, in the validation set.

Conclusion

Spinal lesions with the score of 5 to 10 would be considered a diagnosis of spinal metastasis, while the score of 0 to 4 may be spinal TB. Because the scoring system is mainly based on the clinical characteristics that can be obtained by an outpatient orthopedist, it is suitable to be used as a diagnostic tool in the outpatient department.

Unusual Presentation of Koch's Spine Involving Posterior Elements of Vertebra- A Case Report

Introduction:

Spinal Koch involving posterior elements of the neural arch is one of the atypical presentations which are often missed.

Case presentation:

A 40-year-old female presented with radiculopathy and bilateral lower limb claudication for 5 months. Radiological investigations showed compressive lesion resembling flavum hypertrophy and a degenerative etiology was thus suspected. However, histopathology report pointed toward tuberculosis (TB) of the posterior elements (atypical form). Management with surgical decompression and anti-Koch treatment gave a successful outcome.

Conclusion:

TB affecting posterior elements of spine is a rare entity and needs a high degree of suspicion for accurate diagnosis. Newer radiological interventions such as computed tomography and magnetic resonance imaging along with histopathological evidence will help to clinch the diagnosis of Koch’s spine early before neurological problems or deformity sets in. Keeping a high index of suspicion will help to avoid missing the atypical forms of the disease.

Could an increase in vigilance for spinal tuberculosis at primary health care level, enable earlier diagnosis at district level in a tuberculosis endemic country?

BACKGROUND

Expert clinicians and researchers in the field of spinal tuberculosis (STB) advocate for early identification and diagnosis as a key to reducing disability, severity of disease, expensive surgery and death, especially in tuberculosis (TB) endemic countries like South Africa. South Africa has the highest incidence per capita of tuberculosis in the world, and a conservative estimate of the incidence of STB in South Africa is 8-16:100 000. People living with STB may initially present to primary health care (PHC) centres, where the opportunity exists for early identification. Spinal pain is the most common presentation of STB, but even this symptom may not be present. Occasionally the only symptoms are neurological injury, dysphagia or referred pain. Computerised tomography-guided biopsy remains the diagnostic gold standard for STB.

AIM

A narrative review was undertaken to investigate the evidence available that could assist with the early diagnosis of STB.

METHOD

Articles were searched for and retrieved from three databases and assessed for quality and relevance to primary settings in a TB endemic country.

RESULTS

The following evidence-based, affordable and available tools could facilitate early diagnosis of STB at PHC and district hospital levels: (1) back pain screening questions, undressed spinal physical examination, HIV and antiretroviral therapy history, (2) erythrocyte sedimentation rate, C-reactive protein, platelets, haemoglobin, white cell count (WCC), sputum for GeneXpert and accurate weight measurement, (3) physiotherapy and/or medical and/or speech therapy assessment, (4) full spinal radiograph, chest radiograph, abdominal ultrasound, urine lipoarabinomannan (LAM) if CD4 < 200 and ultrasound-guided biopsy of superficial abscesses, (5) clear referral guidelines at all levels, (6) a positive response to treatment to confirm the diagnosis.

CONCLUSION

These affordable and simple actions at PHC and district levels could facilitate earlier diagnosis of STB.

Unlocking the mystery of persistent skin ulcers in a young man and successful treatment with a simple regimen

Despite the high prevalence of pulmonary tuberculosis worldwide, extrapulmonary tuberculosis especially cutaneous and osteoarticular tuberculosis occurs rarely, both of which are often difficult to be recognized since their symptoms mimic those of many other cutaneous and osteoarticular diseases. Here, we present a rare case of cutaneous tuberculosis potentially accompanied by osteroarticular tuberculosis in a 36-year-old Chinese man who presented with multiple persistent skin ulcers for one year and were nonresponsive to multiple therapeutic approaches. A single anti-tuberculous regimen with rifampicin resulted in healing of all skin lesions and excellent recovery of the general condition.

Skipped multifocal extensive spinal tuberculosis involving the whole spine: A case report and literature review

RATIONALE

Skipped multifocal extensive spinal tuberculosis (TB) involving the whole spine is very rare. So far, only 3 cases have been reported.

PATIENT CONCERNS

We report a rare case of skipped multifocal extensive TB involving the whole spine of a 33-year-old Chinese male. The patient had been asymptomatic until his symptom was significantly aggravated, which caused him to have difficulty in walking and sleeping. The whole spinal computed tomography (CT) scan showed multifocal worm-eaten and osteolytic bony destruction spread over noncontiguous multilevel vertebral involvement in cervical, thoracic, lumbar, and sacral. In addition, the patient presented with low back pain, progressive fever, night sweats, and weight loss. An open biopsy was undergone indicating granulomatous inflammation after thorough radiographic examinations and laboratory investigations, which to our knowledge have been rarely reported by the published medical reference literature.

DIGNOSES

It was initially diagnosed as lymphoma, multiple myeloma, or a metastatic disease by the radiologist. Final pathology confirmed it as an atypical form of spinal TB, which is extremely rare.

INTERVENTIONS

The patient with no progressive severe neurological symptoms, spinal deformity, or a huge abscess was put on a combination of anti-TB treatment and discharged in an improved state to continue medication for a total of 12 months.

OUTCOMES

This article is a case report, no outcomes.

LESSONS

Multifocal extensive spinal TB involving the whole spine is rarely reported in the literature, which presents with atypical presentations and imaging features. It is noticeable that the possibility of TB is considered for any skip lesions involving the spine cautiously. Meanwhile, careful physical examination, trials of anti-TB treatment, and using the whole spine MRI routinely also play an important role in the diagnosis and treatment of this disease.

Atlantoaxial Langerhans cell histiocytosis radiographic characteristics and corresponding prognosis analysis

BACKGROUND

Langerhans cell histiocytosis (LCH) may affect atlas and axis, and there were very few published cases describing a characteristic of LCH of atlantoaxial.

OBJECTIVE

The objective of the study is to investigate the image manifestations of atlantoaxial LCH to improve the in-depth comprehension on it.

MATERIALS AND METHODS

A retrospective study was done of computed tomography (CT) and magnetic resonance imaging in atlas and axis and prognosis was analyzed.

RESULTS

The study included 41 patients (average age 12.9 years and median age 8 years) diagnosed with LCH, with 75.6% under 15 years old. Eighty-four lesions of LCH were identified including 47 in the atlas and 37 in the axis. The osteolytic bone destructions in the atlas and axis were characterized, 22% accompanied by sclerotic margins. Thirteen patients had a compression fracture, 11 in the lateral mass of the atlas and 2 in the C2 vertebral body. Sixteen and three patients had atlantoaxial malalignment and dislocation, respectively. On T2-weighted images, 68.9% showed iso- or low-signal intensity, 27.6% showed hyperintensity signal, and 3.4% showed heterogeneous signal. On postcontrast images, 81.9% showed significant enhancement, 12.5% showed moderate enhancement, and 6.3% showed mild enhancement. CT reexamination of 14 patients indicated atlantoaxial bone destruction relatively repaired in 12 patients. Thirty-three patients were a follow-up, 81.8% had no significant symptoms and 18.2% with remaining symptoms.

CONCLUSIONS

The atlas and axis were affected by LCH, mainly in children. The lateral mass was easily affected and compressed, destruction of the atlas and axis could lead to atlantoaxial joint instability. The prognosis was good in most of the patients.

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.

The Evaluation of the Clinical, Laboratory, and Radiological Findings of 16 Cases of Brucellar Spondylitis

Objective. To evaluate the clinical, laboratory, and radiological presentation of 16 cases of brucellar spondylitis. Methods. The clinical manifestations, laboratory tests, and imaging findings of 16 patients (aged from 24 to 66 years) with brucellar spondylitis treated between September 2012 and September 2014 at the Second Affiliated Hospital of Xi'an Jiaotong University (Xi'an, China) were retrospectively analyzed. Results. Clinical manifestations included high fever, severe pain, sweating, and fatigue. One patient had epididymitis, and two showed clear signs of spinal nerve damage. Laboratory tests showed elevated erythrocyte sedimentation rate (ESR) and C-reactive protein content. Serum brucella agglutination tests were positive, and 11 brucella blood cultures were positive. Imaging manifestations mainly consisted of abnormal signals in the intervertebral space or abnormal signals in the adjacent vertebral bodies (16/16, 100%) in magnetic resonance imaging (MRI), disc space narrowing (14/16, 88%) in X-ray and MRI, or bone destruction and sclerosis around the damaged zone (13/16, 81%) in computed tomography, with rare cases of psoas abscess (2/16, 13%) and sequestrum (1/16, 6%). Conclusion. Since brucellar spondylitis exhibited characteristic clinical and imaging manifestations, it could be diagnosed with specific laboratory tests. Early MRI examination of suspected cases could improve rapid diagnosis.

Evaluation of Apparent Diffusion Coefficient Values in Spinal Tuberculosis by MRI

INTRODUCTION

Spinal tuberculosis presents a radiological challenge in many cases when it presents with atypical pattern of involvement and has to be distinguished from various differentials, which include metastases. In such cases Diffusion Weighted Imaging (DWI) with Apparent Diffusion Co-efficient (ADC) value may play a role in reaching towards a conclusion, thereby preventing unnecessary biopsy in such patients.

AIM

Measurement of mean ADC values in tubercular vertebrae and associated collection.

MATERIALS AND METHODS

The study was comprised of 55 patients and was conducted on 3.0 TESLA Siemens machine Magnetom Verio. Patients either known to have tuberculosis or those with classic tuberculous findings were included in the study. All these patients were followed up for post-treatment confirmation and ADC value. All the patients underwent routine MRI along with DW-MRI sequence, ADC values and FNAC/ Biopsy if required. The ADC values were calculated from the involved vertebral bodies and surrounding soft tissue and also from normal vertebrae preferably from one above and below the affected vertebrae to establish ADC of normal vertebrae, which was helpful in treatment response in patients with antitubercular therapy. At least six ADC value was taken from affected vertebrae and soft tissue.

RESULTS

The mean ADC value of tubercular vertebrae was found out to be 1.47 ± 0.25 x 10(-3) mm(2)/sec, of adjacent soft tissue collection (abscess) was 1.94 ± 0.30 x 10(-3) mm(2)/sec and normal vertebrae was 0.48 ± 0.16 x 10(-3) mm(2)/sec. ADC value of post treated vertebrae decreased and complete resolution showed ADC near normal vertebrae.

CONCLUSION

Normal range of the ADC values in spinal tuberculosis and associated paravertebral collection may be helpful in the differentiation of spinal tuberculosis from lesions with spinal involvement which are not proven to be tuberculosis and who did not have the classical appearance of either tuberculosis or metastasis. But there exists a zone of overlap of ADC values in metastatic and tubercular vertebrae, which can lead to false negative results. Therefore, in overlap cases there should be correlation with clinical history, other related investigations or biopsy.

Spinal Tuberculosis Resembling Neoplastic Lesions on MRI

BACKGROUND

Tuberculous spondylitis is one of the commonest forms of skeletal tuberculosis in developing countries like India causing significant morbidity due to compression of spinal cord and adjacent nerve roots. Diagnosis and intervention at early stage can prevent permanent damage such as spinal deformity and neurological deficits.

AIM

The purpose of this study was to demonstrate atypical MRI features in cases of tubercular spondylitis resembling neoplastic lesions and to stress that tuberculous spondylitis should be one of the differential diagnoses in any spinal pathology especially in developing countries.

MATERIALS AND METHODS

This was a prospective study done in the patients diagnosed as tuberculous spondylitis on 0.2 T Siemens MRI between June 2011 and December 2014 in a tertiary care hospital in India. Total 529 cases of tubercular spinal lesions were diagnosed. Out of which only 59 patients showed atypical features on MR imaging which resembled neoplastic lesions were included in the study. The diagnosis was confirmed by cytology, histopathology, serology and corroborative findings.

RESULTS

Lumbo-sacral region involvement (30.5%) is the commonest in our study followed by dorsal and cervical region. Multiple level lesions are seen in 14 cases (23.7%). All the 59 (100%) cases show no involvement of intervetebral disc. Posterior appendage involvement seen in 32 cases (54.2%). Soft tissue component seen in Intraspinal (37.2%) and paraspinal (45.7%) compartments. Cord compression seen in 19 cases (32.2%), out which only 7 cases (11.8%) shows cord oedema.

CONCLUSION

On MRI, tubercular spondylitis may have variable pictures on imaging. For any spinal and paraspinal lesions, we should also consider the possibility of tubercular aetiology along with other. Since early diagnosis avoids unnecessary delay in the treatment thereby reducing morbidity and possible complications.