Keywords:
Musculoskeletal system
Authors:
N. S. Saini, G. Gujral, M. Popli, P. Kumar, S. Kapoor, R. P. Tripathi; Delhi/IN
DOI:
10.1594/ecr2010/C-2444
Results
Five clinical syndromes of osteoarticular tuberculosis have been described. Spondylitis (50%) the most common clinical manifestation followed by peripheral arthritis (30%), osteomyelitis (19%), tenosynovitis, bursitis and Poncet disease (1%)[2].
Unusual manifestations of Tuberculous spondylitis
Spinal TB is an uncommon condition in developed nations and its symptoms are not so unique as to indicate the proper diagnosis.
Spine is the most common site of musculoskeletal tuberculous infection and thoracolumbar region is the most commonly affected region
Majority of patients have two or more adjacent vertebrae affected at the time of presentation.
Atypical presentations include isolated involvement of the posterior elements with sparing of the vertebral bodies, infection confined to one vertebra and ivory vertebra
Isolated vertebral involvement (Case A)
The classic radiologic picture of two vertebral involvement with destruction of the intervening intervertebral disc is easily diagnosed and treated but its atypical forms are often misdiagnosed and mistreated.
Discontiguous vertebral involvement (Case B)
- Tubercular spondylitis commonly involves the thoracic and lumbar spine.
- The most common presentation of tubercular spondylitis involves destruction adjacent to the endplates of two (or more) vertebral bodies (paradiscal type)
- Skip lesions involving many vertebrae at different levels occurs rarely [4] .
- Multiple non contiguous vertebral involvement can be easily mistaken for metastatic malignancy.
- Factors that distinguish TB from neoplastic disease include the presence of paravertebral abscesses and subligamnetous spread.
Posterior element involvement (Case C)
- The neural arch or posterior elements include spinous processes, laminae, transverse processes, articular processes, and pedicles.
- Classical Spinal TB with vertebral body involvement commonly presents as clinical kyphosis. Contrary to it, in isolated posterior element TB, kyphosis is rare unless there destruction of the corresponding facet joints. This is because the main stabilising anterior and middle column is intact in posterior arch TB .
- Conventional radiographs are not very useful in posterior element TB because lesions < 1.5 cm are missed as a result of overlapping shadows. Very good quality radiographs with cone down penetrating views are essential to detect small early involvement . Even then studies have quoted positive radiographs only in 10% cases [5].
- Distinguishing features of posterior element TB on CT includes bony destruction localized to the vertebral arch
- MRI is the best imaging modality to demonstrate the abnormal soft tissue involvement . Spread of the abscess can be well demonstrated by MRI.
- The smooth margin of a cold abscess due to its subligamental spread contrasts with the irregular margin of a pyogenic abscess, which can destroy the paraspinal ligament.
Tubercular osteomyelitis with bone sclerosis (Case D)
- Tubercular osteomyelitis constitues 2 to 3 % of all osteoarticular tuberculosis [6].
- Classic features of osteoarticular tuberculosis are metaphyseal or epiphyseal destruction that lacks sclerosis.
- The lesion may penetrate the physis to involve joints.
- Radiographs reveal irregular cavities and areas of bone destruction with little surrounding sclerosis unless secondary infection through a sinus supervenes [6].
Tubercular osteomyelitis mimicking neoplasia (Case E)
- Radiographic features of tuberculosis include osteopenia, osteolytic foci with poorly defined edges. These findings are non specific and can be found in a host of pathologies including neoplasia
- There are a few radiographic findings which favour tuberculosis over neoplasia. These include presence of small juxtacortical abscesses, rings of inflammatory tissue due to cortical destruction and spread of infection to the extra osseous tissues [7].
Tuberculous dactylitis is an unusual form of osseous tuberculosis (Case F)
- Spina ventosa: This is an unusual form of tuberculosis rarely seen.
- There is spindle shaped expansion of the short tubular bones with multiple layers of subperiosteal new bone. This appearance is termed spina ventosa (“wind filled sail”) [8].
Tuberculous osteitis of the Skull (case G)
- Tuberculosis of the skull base is rare.
- Though infection with immunodeficiency virus has once again caused a rise in the prevalence of tuberculosis in general, tuberculous osteitis does not seem to be on the rise [9] .
- The skull base is involved in contiguity either from the mastoid air cells, middle ear, paranasal sinuses or from the convexity.
Tuberculous tenosynovitis (Case H)
- This is a relatively uncommon presentation of mycobacterial tuberulosis [10].
- Tendons of the hands and wrist are the more common presentations.
- Involvement of the foot and ankle is much less commonly reported.