Tuberculous Spondylitis: What every Radiologist should

know

Poster No.: C-1917

Congress: ECR 2011
Type: Educational Exhibit
Authors: J. Kavanagh, R. Dunne, J. Keane, A. M. Mc Laughlin; Dublin/IE
Keywords: MR, Bones, Spine, Musculoskeletal bone, Musculoskeletal spine,
CT, Infection
DOI: 10.1594/ecr2011/C-1917

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Page 1 of 15
Learning objectives

To outline the Radiological features of Tuberculous (TB) Spondylitis using

cases from a National TB Referral centre.

To review the imaging modalities involved in assessment of disease and

compare and contrast them using varied examples.

To illustrate the classic radiological features of TB Spondylitis and the

differential diagnoses.

Background

TB Spondylitis is one of the oldest diseases of mankind having been found in Egyptian
Mummies dated as far back as 4000BC. Bone and Joint infection account for 10-35%
of extrapulmonary TB but only 2% of overall TB worldwide.This ancient disease has
experienced a recent resurgence most notably in the immunocompromised host and the
development of multidrug resistant strains. Prevalence is highest in Africa and lowest in
The Americas but due to better transport links and increasing population TB is a global
problem.

Page 2 of 15
Fig.
References: The antiquity of tuberculosis in Hungary: the skeletal evidence Antnia
MarcsikI,1; Erika MolnrI; Lszl SzathmryII

The vertebral bodies are vunerable to seeding from Primary TB bacillemia due to the
consistent vascular supply throughout adulthood. The Lower Thoracic and upper lumbar
vertebrae are affected most commonly (80-90%), cervical spine involvement being both
rarer (10%) and causing more morbidity.Infection starts anteroinferiorly and spreads
down behind the anterior or posterior ligaments to involve the adjacent vertebral body
causing local bone destruction and abscess formation.

Page 3 of 15
Fig.: Mycobacterium Tuberculosis
References: J. Kavanagh; Department of Respiratory Medicine, St James Hospital,
Dublin, IRELAND

Back Pain, fever and weight loss are the most common presenting symptoms but due
to the indolent nature of the disease and low index of suspicion in developed countries,
diagnosis is often delayed. Intrathoracic disease can be absent in up to 50% of TB
Spondylitis as well as false negative tuberculin skin test rates of up to 14%. Because
of this,Radiologists often make the diagnosis leading to prompt anti microbial therapy to
prevent serious neurological consequences. Once the diagnosis is made Radiologists are
once again key in obtaining microbial evidence of TB infection using CT or Fluoroscopic
guided procedures.

Page 4 of 15
Imaging findings OR Procedure details

Plain Film, CT and MRI all have roles in diagnostic imaging of TB Spondylitis.

Plain Film

Non specific plain film abnormalities such as osteopenia and soft tissue swelling can point
the Radiologist towards the right diagnosis in the appropriate clinical setting. Examples
below Demonstrate bony abnormalities from the cervical spine down to the lumbar spine
in our patient cohort. In all cases plain film was the first investigation performed.

Page 5 of 15
Fig.: Increase in Atlanto- Fig.: Gibbous Deformity
Axial distance and with Collapse
Paravertebral soft tissue References: J. Kavanagh;
swelling Department of Respiratory
References: J. Kavanagh; Medicine, St James
Department of Respiratory Hospital, Dublin, IRELAND
Medicine, St James
Hospital, Dublin,
IRELAND

Page 6 of 15
Fig.: Loss of Right Pedicle
of T5
References: J. Kavanagh;
Department of Respiratory
Medicine, St James
Hospital, Dublin, IRELAND

CT vs MRI

CT is superior to MRI in the evaluation of the degree of bony destruction, deformity and
calcification. The degree of destruction of the vertebra is seen much more clearly in the

Page 7 of 15
second example below on CT compared to MRI. CT can be very useful in a paraspinal
"cold abscess". Calcification within this can virtually diagnose TB infection as well as
indentify a small area of lytic bone disease.

Fig.: Collapse of T11/T12 with Fig.: T2 Weighted MRI showing T11/T12

retropulstion of bone fragments
posteriorly
References: J. Kavanagh; Department of
Respiratory Medicine, St James Hospital,
Dublin, IRELAND
involvement and spinal cord compression
References: J. Kavanagh; Department of
Respiratory Medicine, St James Hospital,
Dublin, IRELAND

Page 8 of 15
Fig.: Axial Bone windows demonstrating
degree of bony destruction C1
References: J. Kavanagh; Department of
Respiratory Medicine, St James Hospital,
Dublin, IRELAND
MRI
Fig.: Axial T2 weighted image
showing extension through foramen
transversarium and paraspinal abscess
References: J. Kavanagh; Department of
Respiratory Medicine, St James Hospital,
Dublin, IRELAND
Page 9 of 15
MRI is the Gold standard of imaging in TB Spondylitis due to its superior soft tissue
resolution and multiplanar capability. The Classic pattern of spread starting anteriorly
and moving to involve opposing vertebrae via subligamentous spread is clearly seen on
MRI. The most common findings on MRI are decreased signal intensity on T1 weighted
images and increased signal intensity on T2. Paraspinal abscesses and disk herniation
threatening the spinal cord can diagnosed accurately and quickly treated.

In contrast to pyogenic infections such as S. Aureus, TB generally spares the

intravertebral disc due to the absence of proteolytic enzymes. In rare cases when the
disc is involved there will be increased signal intensity on T2 weighted imaging. There is
minimal periosteal reaction and sclerosis with TB and the anterior vertebral elements are
preferentially involved, which can be useful in differentiating it from metastatic disease.
In general, however, TB Spondylitis has many mimics such as fungal infection and
sarcoidosis, the clinical picture and obtaining tissue samples being vital in accurate
diagnosis.

Page 10 of 15
Fig.: T1 Sagittal Pre Contrast Image Fig.: T1 Para-Sagittal Pre Contrast
References: J. Kavanagh; Department of References: J. Kavanagh; Department of
Respiratory Medicine, St James Hospital, Respiratory Medicine, St James Hospital,
Dublin, IRELAND Dublin, IRELAND

Page 11 of 15
Fig.: T1 Post Contrast image with
enhancing soft tissue mass extending
through the posterior endplate into the
intrathecal space displacing the spinal
cord
References: J. Kavanagh; Department of
Respiratory Medicine, St James Hospital,
Dublin, IRELAND
Fig.: T1 post contrast para-saggital
image showing TB extending laterally into
right paraspinal space
References: J. Kavanagh; Department of
Respiratory Medicine, St James Hospital,
Dublin, IRELAND
Page 12 of 15
Fig.: Saggital T2 weighted image
References: J. Kavanagh; Department of
Respiratory Medicine, St James Hospital,
Dublin, IRELAND
MRI
Conclusion
Fig.: Parasaggital T2 showing paraspinal
abscess
References: J. Kavanagh; Department of
Respiratory Medicine, St James Hospital,
Dublin, IRELAND
Page 13 of 15
The total number of cases of TB is rising globally due to rising population in developed
countries. Although a post primary manifestation, over half the cases of TB Spondyltis
present with no active pulmonary disease. For a clinician in an area of low incidence it
can be difficult to diagnose due to its insidious nature and low index of suspicion.

Radiologists play a vital role in disease assessment and diagnosis. Subtle plain film
findings on routine exams in the right clinical scenario can make the diagnosis. CT and
MRI have a synergistic role in TB Spondylitis in evaluation of the bony and soft tissue
spread respectively. This can lead to prompt medical or surgical intervention to prevent
potentially serious neurological sequelae.

Personal Information

J Kavanagh, R Dunne, J Keane, A Mc Laughlin

Department of Respiratory, Department of Radiologyl,

University of Dublin Teaching Hospital, St James Hospital,

James Street, Dublin 8, www.stjames.ie

Mail: jokavana@tcd.ie

References

Daniel, TM, Bates, JH, Downes, KA. History of tuberculosis. In: Tuberculosis:
Pathogenesis, Protection, and Control, Bloom, BR (Ed), American Society for
Microbiology,Washington, 1994, p. 13.

Martini M, Ouahes M. Bone and joint tuberculosis:a review of 652 cases. Orthopedics
1988;11(6):861-866.Martini M, Ouahes M. Bone and joint tuberculosis:a review of 652
cases. Orthopedics 1988;11(6):861-866.

Jain R, Sawhney S, Berry M. Computed tomography of vertebral tuberculosis: patterns

of bone destruction.Clin Radiol 1993;47(3):196-199.48.

Weaver P, Lifeso R. The radiological diagnosis of tuberculosis of the adult spine. Skeletal
Radiol 1984;12(3):178-186.

Floyd K, Lienhardt C WHO - The global plan to stop TB 2011-2015: transforming the
#ght towards elimination of tuberculosis

Page 14 of 15
Resnick D. Tuberculous infection. In: Resnick D,ed. Diagnosis of bone and joint
disorders. 3rd ed. London, United Kingdom: Saunders, 2002;2524-2545.

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