Materials and methods
We retrospectively analyzed MR images of 40 patients of proven spinal tuberculosis who attended our hospital during 2011 to 2014.
The pattern,
extent,
soft tissue involvement and associated MRI features were studied.
Magnetic Resonance Imaging
MRI spine was taken using a 1.5Tesla Philips Achieva machine.
The sequences that were performed in our hospital for all cases of spine imaging are,
T1W,T2W ,STIR and contrast enhanced fat suppressed T1W images Gadodiamide at a dose of 0.1mmol per kilogram of body weight was used as an intravenous contrast agent.
- The following sequences were done.
- Sagittal T1W [repetition time(TR)/echo time (TE) 427/18msec]
- Sagittal STIR (short tau inversion recovery)- (3500/80 ms)
- Sagittal T2W (3276/116) fast spin echo (FSE) sequences
- Axial T2W (2845/120) FSE sequences
- Sagittal T1-weighted images (TR 300 to 500 milliseconds,
TE 20 to 30 milliseconds) and axial T1-weighed sequences provided the anatomic details for a survey of the spine.
Scan time was1-2 minutes.
The parameters of T2-weighted imaging includes a TR of 2000 to 3000 milliseconds and a TE of 60 to 120 milliseconds; the acquisition time is 2 to 3 times longer than that of T1-weighted imaging..
Slice thickness 4 mm,
and intersection gap 1 mm.
FOV-301 mm
Results
Majority (n-28) of the patients were males (70%) and 30% were females.
35% of patients were in 21 to 30 age group and 60% (n-24) were below 40 years.
We classified spinal involvement according to the site of involvement of the spine.
(figure 5)
- Cervical (10%),
- Thoracic (22.5),
- Lumbar (25%),
- Sacral (2.5%),
- Cervico-thoracic (5%),
- Thoraco-lumbar (5%),
- Lumbo-sacral (12.5),
- Sacro-iliac (2.5%),
- Whole spine (2.5%).
Further classified as typical and atypical presentations according to the site of lesion in the vertebral body and involvement of the intervetebral disk.(Table 1)
Most frequent presentation observed was involvement of the contiguous vertebrae (osteitis) with intervening disk (diskitis) (87.5%).
And among these the paradiskal involvement was most frequent 60 %(n-21),
followed by anterior 35.5%(n-10) and central 10%(n-4).(Table 1)
Atypical presentation observed was skip lesions (10%) and isolated posterior spinal involvement (2.5%).(Table 1)
Further the associated complications like fractures (5%),
compressive myelopathy (17.5%),
cord edema (5%),
gibbus deformity (12.5%) were identified.(Table 2)
Additionally the soft tissue involvement was demonstrated according to the involvement or collection in the pre and para vertebral,
epidural and psoas regions.(Table 3)
Radiological (MRI) findings:
On T1W sequence most of the lesions were hypointense with irregular vertebral endplates.
On T2W sequence the lesions were predominantly hyperintense,
few heterointense with adjacent soft tissue hyperintensity.
On STIR sequence the collections,
edema within and adjacent spine were more clear.
Post GAD fat suppressed T1W images showed peripherally enhancing collections,
early phases of the infections and multiple vertebral lesions.
And also cord edema was identified in one case (5%).
Presentation of Pathologically proven cases with typical radiological (MRI) Features
Typical lesions
Spondylodiskitis with involvement of the contiguous vertebra and intervetebral disk.
Case 1.
Pott's spine presentation as Cervical spondylodiskitis with abscess.
(Figure 5)
50 year old male patient presented with neck pain and weakness in the bilateral upper limbs.
MR images showed typical lesion involving the contiguous vertebral end plates of C4 and C5,
and intervening disk with disk space narrowing.
There is associated mild anterior prevertebral collection,
epidural collection cord compression.
No evidence of cord edema or infection.
Case 2.
Pott's spine presentation as Thoracic spondylodiskitis with abscess.
(figure 7)
A 41 year old male presented with low grade fever and upper back pain.
MRI revealed T5 and T6 vertebrae with end plate destruction,
loss of disk space.
There is anterior subligamentous extension of the collection with scalloping of anterior margin of the vertebral bodies.
Epidural space collection together with posterior angulation of the vertebrae compressing the cord with cord edema and compression.
Extension of the infection to the multiple contiguous thoracic vertebral is observed.
Case 3.
Pott's spine presentation as Lumbar spondylodiskitis with abscess.(figure 8)
A 75 year old male patient presented with history of paraplegia,
bladder incontinence and low back pain.
MR images revealed L4 and L5 vertebrae end plate destruction,
diskitis,
mild prevertebral and epidural collection.
Case 4.
Pott's spine presentation as Sacral spondylodiskitis.
(figure 9)
A 22 year old male patient presented with history of pain in the left lower back with pain during walking.
MR images showed lesions in the sacral vertebrae with minimal prevertebral collection.
Case 5.
Pott's spine presentation as Cervico thoracic spondylodiskitis.(figure 10)
MR images showed multiple cervical vertebral lesions (C3 to T1) with collapsed vertebrae (C3 and C4) compressing the thecal sac.
There is associated cord compression.
Case 6.
Pott's spine presentation as Thoracolumbar spondylodiskitis.
(figure 11)
MR images showed T10 to L1 peripherally enhancing collections in the vertebrae,
loss of T12-L1 disk space,
nonenhancing prevertebral collection.
Case 7.
Pott's spine presentation as Lumbosacral spondylodiskitis.(figure 12)
MR images showed L5 and S1 end plated destruction,
narrow disk space,
prevertebral collection and epidural collection.
Case 8.
Pott's spine presentation as Sacroiliac tuberculosis.
(figure 13)
MR images at different planes showed left sacral and iliac lesions with collection in the left SI joint.
The right SI joint,
right sacrum and Ilium are normal.
Pattern of lesions within the vertebrae.
Case 9.
Paradiskal lesions.(figure 14)
MR images reveal Paradiskal lesions in L3 and L4.
Case 10.
Anterior lesions.(figure 15)
MR image reveals anteroinferior lesion with lesions in the adjacent disk.
Case 11.
Central lesions.(figure 16)
MR images reveal central lesion of L5 vertebral body with collapse.
This patient had presented with neurogenic bladder.
There is chronic sinus tract formation extending posteriorly into the subcutaneous plane.
Atypical lesions
Case 12.
Skip lesions.
Multiple non-contiguous vertebral Involvement.(figure 17)
MR images showed multiple enhancing lesions in the thoracic and lumbar vertebra and in the L1 posterior spinal elements.
The CT guided biopsy from the spinous process lesion confirmed tuberculosis.
Case 13.
Isolated posterior spinal elements tuberculosis.
(figure 18)
MR images reveal lesions in the laminae and spinous process of thoracic vertebrae involving two contiguous vertebrae.
There is no involvement of the vertebral bodies.
There is narrowing of the bony spinal canal.
Associated collections and complications
Case 14.
Pre and epidural abscess.(figure 19,21)
MR images showed thoracic and lumbosacral vertebral lesions with anterior prevertebral subligamentous collection,
epidural thickening and collection.
There is stenosis of the spinal canal with cord compression.
Case 15.
Psoas abscess (figure,
20)
MR images showed thoracolumbar typical vertebral peripherally enhancing lesions and right psoas collection.
Case 16.
Cord edema and cord compression.
(figure 21)
MR images showed typical spondylodiskitis lesion,
prevertebral,
epidural collection with spinal canal stenosis,
cord compression and signal intensity changes in the cord at the same level.
Case 17.
Vertebral body fracture with Gibbus deformity (figure 22)
MR image revealed destruction and anterior erosion of the T12 and L1 vertebral bodies with posterior angulation and deformity.