Risk factors of spinal infections

Advanced age > 50

MR Imaging of Intravenous drug abuse
Spinal Infections Immunosuppression or immune deficiency
Long--term steroid administration
Long
Diabetes mellitus
台大醫院 影像醫學部
Organ transplantation
台大醫學院 放射線科
Malnutrition
許昭禹醫師//施庭芳主任
許昭禹醫師 Malignancy
Urinary tract instrumentation
2009/02/14

Infectious pathways Vascular anatomy of spine

Hematogenous
– Arterial or venous
route
Direct inoculation
– Contiguous focus of
infection
– Direct open spinal
trauma Ross JS, Brant-Zawadzki M, et al.
– Postoperatively Diagnostic Imaging: Spine 2004; V-1-5
Greenspan A. Orthopedic Radiology:
A Practical Approach 1997; V-19-3

Yoshioka K, Niinuma H, et al.

Radiographics 2003; 23:1215-1225

Arterial route Microcirculation

Segmental artery
→ spinal artery → nutrient equatorial
artery
Segmental artery
→ metaphyseal artery
→ metaphyseal anastomosing artery
→ intermetaphyseal anastomosing artery Smith AS, Weinstein MA, et al.
AJNR 1989; 10:619-625
Ratcliffe JF. Acta Radiol [Diagn]
(Stockh) 1985; 26:137-143

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 Venous route Pathoanatomy of spinal infections
Retrograde seeding Vertebral endplates
of venous blood via
→ adjacent disk space
Batson plexus
Increased → adjacent vertebral body
intraabdominal → paravertebral tissues
pressure → epidural space
Genitourinary tract
infections Groen RJM, Toit DFd, et al.
Spine 2004; 29:1465-1471
Resnick D. Diagnosis of Bone and Joint
Disorders 1995; 155:745-749

MRI MRI of Spinal Infections

Coronal STIR Typical manifestations
Sagittal T1WI, – Pyogenic osteomyelitis
T2WI, STIR – Granulomatous osteomyelitis
Axial T2WI – Epidural abscess
– Paraspinal abscess
Gd--enhanced
Gd
T1WI with/without – Septic arthritis of facet joint
fat suppression Differential diagnosis
Stoller DW. Magnetic Resonance
Imaging in Orthopaeducs & Unusual manifestations
Sports Medicine 1997; 1071

Common MRI findings of

Pyogenic osteomyelitis
spinal infections
↓T1 signal with loss of disk margin & 2 adjacent vertebrae
endplate irregularity with intervening disk
Ill--defined marrow
Ill
↑T2 signal from intervertebral disk &
signal alternation
adjacent vertebral bodies
Loss of vertebral
Enhancement of vertebral bodies, endplate cortex
endplates & annulus (variable) Obliteration of
Epidural & paraspinal soft tissues intranuclear cleft
Ross JS, Brant-Zawadzki M, et al.
Diagnostic Imaging: Spine 2004; V-1-9

2
 M/69 persistent LBP x 4 months;
Pyogenic osteomyelitis colon cancer s/p op. 8 months ago

Disk space narrowing

Vertebral collapse
Lumbar > thoracic >
cervical spine L1-2
Paraspinal ± epidural
infiltrative soft tissues
± abscesses
Ross JS, Brant-Zawadzki M, et al.
Diagnostic Imaging: Spine 2004; V-1-9

T1WI

L1-2 L1-2

STIR T1WI C+ FS T2WI T1WI C+

Antibiotic treatment Aspiration: chronic inflammation;

4 months later Culture: (-
(-)

L1-2 L1-2

T1WI T1WI C+ T2WI T1WI C+

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 M/80 general weakness with LBP x 2.5 months;
Granulomatous osteomyelitis fever & chills x 2 days

Relatively intact
intervertebral disks
Gibbus vertebrae
(25%)
T-L spine T11-12
Large paraspinal
abscesses
Multiple
Ross JS, Brant-Zawadzki M, et al.
(non)contiguous Diagnostic Imaging: Spine 2004; III-1-10

T1WI

Culture:
Mycobacterium tuberculosis

T11-12 T11

STIR T1WI C+ FS T2WI T1WI C+

M/42 LBP with bil. sciatica x 2 months

L4-5 L4-5

T1WI STIR T1WI C+ FS

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 Surgical debridement:
caseating granulomatous inflammation (TB)

L5 S1

T2WI T1WI C+ T2WI T1WI C+

M/68 LBP with difficulty in walking x 2 wks

Epidural abscess
Epidural phlegmon
Posterior epidural >
anterior epidural >
circumferential
Lower T T-- & L
L--spine >
C- & upper T- T-spine L4-5

Multi--segmental
Multi
Ross JS, Brant-Zawadzki M, et al.
Diagnostic Imaging: Spine 2004; V-1-22

T1WI

Surgical debridement: osteomyelitis;

Culture: Staphylococcus aureus (MSSA)

L4-5 L5

T2WI T1WI C+ FS T2WI T1WI C+

5
M/48 Severe back pain with bil. paraplegia x 1 wk Surgical debridement: abscess;
Culture: Staphylococcus aureus
T2-9

T5

T1WI T2WI T1WI C+ FS T2WI T1WI C+

F/52 progressive LBP with bil. sciatica x 3 wks

Paraspinal abscess
Paravertebral
phlegmon
Obliterated soft tissue
fascial plane
Intra--abscess gas
Intra
L3-4
Calcified psoas
abscesses
Reactive LAP
Ross JS, Brant-Zawadzki M, et al.
Diagnostic Imaging: Spine 2004; V-1-30

T1WI

Surgical debridement: osteomyelitis;

Culture: Staphylococcus aureus (MSSA)

L3-4 L3-4

STIR T1WI C+ FS T2WI T1WI C+

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F/43 LBP x 4 months; traffic accident before;
Echo: retroperitoneal cystic mass

T12 T11-L1

STIR T1WI C+ FS

Culture:
Mycobacterium tuberculosis

T11-L1 T12

T1WI T2WI STIR T1WI C+ FS

M/73 LBP with bil. sciatica x 2.5 months;

Septic arthritis of facet joint gastric cancer s/p op. 4 months ago

Lumbar spine (97%)

Typically single level
involvement
Facet joint widening
Eroded facet cortex
L4-5
Adjacent soft tissue
edema & abscesses
Ross JS, Brant-Zawadzki M, et al.
Diagnostic Imaging: Spine 2004; V-1-18

STIR T1WI C+ FS

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 Blood culture:
Enterococcus faecalis

L4-5

T2WI T1WI C+

Differential diagnosis of F/52 Surgical debridement: osteomyelitis;

spinal infections (1) Culture: Staphylococcus aureus (MSSA)

Pyogenic infection
– Staphylococcus aureus,
aureus, Pseudomonas
species
– Remarkable paraspinal inflammatory tissue
Non--pyogenic infection
Non L3-4
– Tuberculosis
Tuberculosis,, fungus, yeast, or parasitic
organisms
– Limited paraspinal inflammatory tissue

STIR T1WI C+ FS

M/42 Surgical debridement: caseating Differential diagnosis of

granulomatous inflammation (TB) spinal infections (2)
Degenerative endplate changes
– Modic type 1: vascularized fibrous tissue
– Erosive intervertebral osteochondrosis
– Unremarkable paraspinal inflammatory tissue
L4-5

STIR T1WI C+ FS

8
M/78 LBP x 2.5 months Type 1
degenerative endplate changes

L4-5 L4-5

T1WI STIR T1WI C+ FS T1WI C+

M/55 Nasopharyngeal cancer s/p CCRT

LBP with low grade fever x months

L2-3 L2-3

2 months later T1WI T2WI

Laminectomy: myxomatous degeneration

M/48 LBP with fever & chills x 1 wk
of disk with irregular new bone formation
Echo: r/o infectious endocarditis
Erosive intervertebral osteochondrosis

L2-3 L4-5

STIR T2WI T1WI STIR

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 Surgical debridement: osteomyelitis; Unusual Manifestations of
Blood culture: Gram (+) cocci spinal infections (1)
Single segment
vertebral osteomyelitis
– Anterior cortical
disruption (100%)
– Upward subligamentous
L4-5 spread (100%)
– Upper disk involvement
(66.6%)

Shih et al. Clin Imaging

1999; 23:159-67
T1WI C+ FS T1WI C+ T2WI

F/70 Diabetes mellitus x 20 years

Flank pain x 1 month

L2 L2

T1WI T2WI T1WI T2WI

Biopsy: osteomyelitis
Analgesics treatment
Blood culture: Staphylococcus
1 month later
aureus (MSSA)

L2-3 L2-3

T1WI T2WI T1WI C+ FS 1 month ago

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 Unusual Manifestations of F/46 Recurrent Salmonellosis x 9 months
spinal infections (2) Fever x 2 days

Vertebral osteomyelitis
mimicking metastases
– Preserved intervertebral
disks (100%)
– Llimited paraspinal or
epidural inflammatory
tissue (86%)
– Posterior element
involvement (43%)

Hsu et al. AJNR

2008; 29:1104-1110
STIR T1WI STIR T1WI C+ FS

Biopsy: chronic osteomyelitis Antibiotics treatment

Blood culture: Salmonella 12 month later

T11

T2WI T1WI C+ T1WI STIR T1WI C+ FS

Diffusion Weighted Imaging

Diffusion Weighted Imaging
of Bone Marrow Pathologies

DWI Metastasis
– A powerful tool for evaluating
bone marrow infiltration ADC
= 0.79 mm2/s
Apparent diffusion
coefficient (ADC)
– Highly specific and very Aggressive
sensitive to differentiate osteomyelitis
between malignant and T1WI STIR DW-SSFP
ADC
benign skeletal processes = 1.48 mm2/s Vertebral No signal aberration, mimicking
osteomyelitis restricted diffusion
DW-EPI Hypercellularity? Macromolecules?
Herneth et al. EJR 2005; 55:74-83 b = 880 Herneth et al. EJR 2005; 55:74-83

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 SPIO--enhanced MRI
SPIO
SPIO--enhanced MRI
SPIO
for Bone Marrow Imaging

Superparamagnetic
iron oxide (SPIO)
Comparison of SI using
STIR images before
and 3hrs after
ferucarbotran (< 20 nm)
injection
– Useful in differentiating
RE: relative enhancement (%)
bone metastasis and
osteomyelitis Metastasis STIR Osteomyelitis
Fukuda et al. Magn Reson Med Sci Fukuda et al. Magn Reson Med Sci
2006; 5:191-96 2006; 5:191-96

Conclusion
Typical manifestations Thank You
– Pyogenic vs. granulomatous osteomyelitis
– Epidural/paraspinal abscess for Your Attention
Differential Diagnosis
– Type 1 degenerative endplate changes 台大醫院 影像醫學部
– Erosive intervertebral osteochondrosis 台大醫學院 放射線科
Unusual Manifestations 許昭禹醫師//施庭芳主任
許昭禹醫師
– Single segment vertebral osteomyelitis
– Vertebral osteomyelitis mimicking metastases 2009/02/14

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