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MRI of Tuberculous
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Albert de Roos1 Four patients with paravertebral extension of advanced tuberculous intervertebral
Els L. van Persijn van Meerten disk-space infection were studied by CT and MRI. In one patient gadolinium-DTPA (Gd-
Johan L. Bloem DTPA) was administered intravenously as a paramagnetic contrast agent MRI showed
the disk-space abnormalities and extension of the inflammatory process to best advan-
Rainer G. Bluemm
tage in the coronal plane. This plane demonstrated in one image the spinal localization
and the paravertebral extension of the inflammation. Gd-DiVA assisted in delineating
the communication of the vertebral and paravertebral components of inflammation. This
phenomenon introduces an additional diagnostic element into the evaluation of spon-
dylitis. Although the features of advanced tuberculous spondylitis are conspicuously
well shown with MRI, further experience is needed to evaluate the potential of MRI in
detecting early tuberculous spondylitis in relation to nontuberculous spondylitis.

Tuberculous spondylitis is initiated in most cases by hematogenous spread of

organisms, located first in the anterior aspect of the vertebral body near an
intervertebral disk. The developing inflammatory process may erode the cortical
bone, destroy the intervertebral disk, and involve the adjacent vertebral body.
Subligamentous spread and paraspinal extension of tuberculosis is a frequent
finding. Abscess formation is commonly bilateral, and small calcifications are
characteristic of tuberculosis. Healing in tuberculous spondylitis can lead to partial
or complete fusion of vertebral bodies. The lower thoracic and upper lumbar spine
are predilection sites for tuberculosis [1-3].
The typical plain radiographic appearance of tuberculous spondylitis is irregularity
of the vertebral end-plates, decreased height of the intervertebral disk, sclerosis of
the surrounding bone, and in a later phase a tendency to anterior wedging or fusion
[1 2].

Soft-tissue extension and involvement of the spinal canal are well demonstrated
by CT [4]. Furthermore, CT is well suited to show abscess formation as a mass
with a low-density center and a definable wall, which becomes clearer in enhanced
CT scans [5, 6].
To the best of our knowledge, the potential of MRI and the use of gadolinium
enhancement have not previously been reported in tuberculous spondylitis [4]. We
performed CT and MRI in four patients with tuberculous spondylitis and paraver-
tebral extension; one patient undergoing MRI was given gadolinium.
Received November 13, 1985; accepted after
revision February 19, 1986.
‘All authors: Department of Diagnostic Radiol- Methods
ogy of the University Hospital of Leiden, Leiden,
The Netherlands. Address reprint requests to A. de The CT scans were made with a Pfizer 450 or Philips 350 Tomoscan (Shelton, CT). MRI
Roos, Department of Diagnostic Radiology, Division studies were performed with a 0.5-T superconductive Philips Gyroscan. Various spin-echo
MRI/CT, University Hospital Leiden, Mail Area C2-
(SE) pulse sequences were used with repetition time (TA) = 250-1 650 msec and echo-delay
5, Rijnsburgerweg 10, 2333 AA Leiden, The Neth-
erlands. time (TE) = 30-1 50 msec. T2-weighted images were obtained by single-slice multiecho
technique and multislice dual-echo SE technique. SE technique with short repetition times
AJR 146: 79-82, July 1986
0361 -803x/86/1 466-0079 was used to obtain Ti-weighted images. After IV administration of 0.1 mmol/i kg body
C American Roentgen Ray Society weight gadolinium-DTPA (supplied by Schering AG, Berlin, FAG) SE sequences with TA of
80 DE ROOS ET AL. AJR:146, July 1986

Fig. 1 -Case 1 . A, Axial CT scan after administration of IV contrast material shows two large
collections in both psoas compartments. Peripheral rim enhancement indicates presence of
inflathmatory capsule. B, Ti -weighted coronal image (TE 30 msec, TA 250 msec) lacks contrast
differentiation to delineate inflammatory process. Kidneys are displaced laterally and superiorly.
C, T2-weighted coronal image (TE 100 msec, TA 1 000 msec) shows spondylitis as area of
increased signal intensity at level of disk; some extension in vertebral body is also demonstrated.
In same plane, psoas abscesses on both sides of spine are identified. No definite appreciation
of abscess membranes. Note lateral and superior displacement of kidneys.
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Fig. 2.-Case 2. A, Axial CT scan delineates bone destruction and fragmen- present. c, Sagittal MR plane (TE 30 msec, TA 250 msec) dearly depicts
tation as well as paravertebral extension. B, Coronal MR image (TE 50 msec, relation of spinal cord to level of spondylitis. Spinal cord is not compromised
TA 1500 msec) shows disk-space infection and paravertebral extension on by inflammatory process, which is represented by area of low signal intensity.
right side and to a lesser degree on left side. Right-sided pleural effusion is

Fig. 3.-Case 3. A, Axial CT scan

shows paravertebral mass with some
small calcifications. B, Axial MR scan (FE
50 msec, TA 1 500 msec) failed to dern-
onstrate calciflcations shown in 3A. Par-
avertebral extension is seen as high-sig-.
nal-intensity area. C, Ti -weighted coronal
MR image (FE 30 msec, TA 250 msec)
shows paravertebral extension at level of
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spondylitis, as low-signal-intensity area.

vertebral origin of inflammation is not vis-
ible because of poor contrast resolution.
0, Coronal MA scan (FE 30 msec, TA
550 msec) after lv administration of ga-
dolinium shows communication of verte-
bral and paravertebral component of in-
flammation. Inflammatory process now
has high signal intensity because of short-
ened Ti relaxation time.

250-550 msec and TE of 30 msec were used in one patient. An at operation was positive for tuberculosis. The postoperative CT
informed consent was obtained before IV administration of Gd-DTPA. examination showed large collections in the psoas muscles on both
Slice thickness was i cm for the body coil and 0.5 cm for the surface sides, consistent with abscesses. These collections had high signal
coil. Sagittal, transverse, and coronal images were made with two to intensity on T2-weighted MA images (Fig. 1).
four measurements and two-dimensional Fourier reconstruction was
used. Case 2

A 30-year-old woman presented with fever of unknown origin.

Case Reports Cultures of bone marrow and sputum were positive for tuberculosis.
Spondylitis was diagnosed in the lumbar region on plain radiographs.
Case 1
CT and MRI were performed to study the extension of the inflam-
An 1 8-year-old man presented with low-back pain, followed by matory process. Bone destruction and fragmentation of the vertebral
paraparesis. This patient was operated on when a total extradural body were obvious at CT examination. The sagittal MR image showed
block was demonstrated on myelography, and an abscess compress- the relation of the spinal cord and the inflammatory process at the
ing the spinal cord posteriorly was found. Culture of material obtained level of spondylitis (Fig. 2).
82 DE ROOS ET AL. AJA:146, July1986

Case 3 Ti relaxation time [8]. Inflammatory tissue with a good blood

supply enhances after IV injection of Gd-DTPA and indicates
A 50-year-old man presented with fever and back pain in the
thoracic spine. Several years before, the patient had been treated for active disk-space infection. Furthermore, a connection be-
tuberculous spondylitis at the 8-9 level in the thoracic spine. Aadi- tween the disk-space infection and the paravertebral abscess
ographs of the dorsal spine showed old tuberculous spondylitis with was well shown on gadolinium-enhanced images. CT and
synostosis of two vertebral bodies and an adjacent fusiform soft- MRI were of complementary value in making a specific diag-
tissue mass. Clinical findings suggested reactivation ofthe spondylitis nosis. Further studies are needed to determine the relative
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with paravertebral extension. Bone scintigraphy was also consistent merits of Gd-DTPA-enhanced Ti -weighted images vs T2-
with this diagnosis. Because a paravertebral tumor could not be weighted multiecho SE techniques.
excluded by conventional radiography, CT and MRI examinations Increased signal intensity on the intervertebral disk can be
were performed. MAI scans were obtained before and after IV
helpful in diagnosing disk-space infection on MR scans. Modic
administration of gadolinium-DTPA. CT examination showed small
et al. [9] concluded that MRI was more sensitive in detecting
punctate calcifications in the paravertebral mass. These could not be
identified on MRI. Compared with CT, MRI demonstrated better the disk-space infection than either conventional radiography or
communication between the vertebral and paravertebral components CT. It was as sensitive as radionuclide studies and more
of the inflammatory process after gadolinium administration (Fig. 3). specific. Aguila et al. [1 0] showed that, in the absence of a
The paravertebral process had a homogeneous structure, probably normal intranuclear cleft, an increased signal intensity of the
due to the presence of viable inflammatory tissue. Histologic exami- disk is suggestive of disk-space infection [10].
nation of material obtained by puncture of the paravertebral mass One of the advantages of MRI is that it displays the infected
showed an inflammatory reaction. After initiation of antituberculous nucleus and the paravertebral extension in a single image.
therapy, signs and symptoms regressed. Furthermore, MRI does not involve the use of ionizing radia-
tion, making it well suited for repeated follow-up studies.
Case 4

This 27-year-old man was treated for tuberculous spondylitis and ACKNOWLEDGMENTS
a left psoas abscess. Culture of material obtained by puncture of the
abscess confirmed tuberculosis. Follow-up examination revealed a We thank Schering AG Berlin (FAG), in particular W. Clauss, for
psoas abscess on the right side. Furthermore, a left subcutaneous supplying gadolinium (Gd-DTPA) meglumine, and we thank Fokje
collection was visualized. The MA image with a long TE (iOO msec) Noorderijk for secretarial assistance. The photographic work was
helped to differentiate fat and inflammation (Fig. 4). done by M. G. Popkes and G. Kracht.

A paravertebral soft-tissue mass with destruction of a
1 . Weaver P, Lifeso AM. The radiological diagnosis of tuberculosis
vertebral body and disk occurs in a variety of conditions,
of the adult spine. Skeletal Radiol 1984;i 2: 178-i 86
including pyogenic infection, tuberculosis, and neoplasm. Al-
2. Aesnick D, Niwayama G. Osteomyelitis, septic arthritis, and soft
though advanced pyogenic or tuberculous spondylitis is easily tissue infection: the organisms. In: Aesnick D, Niwayama G, eds.
recognized on plain radiographs or CT, a specific diagnosis Diagnosis of bone and joint disorders. Philadelphia: Saunders,
is not always obvious. The ability of MRI to provide good 1981 :21 67-21 70
contrast resolution in any plane makes it valuable for defining 3. Wiley AM, Trueta J. The vascular anatomy of the spine and its
the features of spondylitis, specifically disk-space disease, relationship to pyogenic vertebral osteomyelitis. J Bone Joint
paravertebral extension, and involvement of the spinal canal. Surg 1959;4i :796-809
Inflammatory tissue, especially abscesses, causes rela- 4. Maritz NGJ, De Villiers JFK, Van Castricum 005. Computed
tively low signal intensity on Ti -weighted images and rela- tomography in tuberculosis of the spine. Comp Radiol 1982;6: 1-
tively high signal intensity on T2-weighted images [71. This is 5
5, Price AC, Allen JH, Eggers FM, Schaff Ml, Everette JA. Interver-
due to increased water content and prolonged Ti and T2.
tebral disk-space infection: CT changes. Radiology 1983;
Extension of abscesses are visualized on T2-weighted im- 149:725-729
ages. In tuberculosis the abscesses are often bilateral and 6. Jeffrey RB. Computed tomography of the peritoneal cavity and
located caudal to the level of spondylitis, and they involve mesentery. In: Moss AA, Gamsu G, Genant HK, eds. Computed
mainly the psoas muscle. Identification of the abscesses on tomography of the body. Philadelphia: Saunders, 1983:955-986
MRI adds specificity and allows a specific diagnosis of ad- 7, Wall SD, Fisher MA, Amparo EG, Hricak H, Higgins CB. Magnetic
vanced tuberculosis to be made in one coronal image. How- resonance imaging in the evaluation of abscesses. AJR

ever, small calcifications, demonstrated on CT examination 1985;i 44: i 21 7-i 221

(case 3), cannot be identified on MR imaging. These calcifi- 8. Strich G, Hagan PL, Gerber KH, Slutsky AA. Tissue distribution
and magnetic resonance spin lattice relaxation effects of gadoli-
cations are important because they are rarely present in
nium-DTPA. Radiology 1985;i 54:723-726
nontuberculous abscesses [2J.
9. Modic TM, Pavlicek W, Weinstein MA, et al. Magnetic resonance
In case 3, a change in the configuration of signal enhance-
imaging of intervertebral disk disease: clinical and pulse so-
ment on MRI after administration of gadolinium was noted in quence considerations. Radiology 1984;1 52: i 03-111
a presumedly healed spondylitis. The IV administration of Gd- 10. Aguila LA, Piraino DW, Modic TM, Dudley AW, Duchesneau PM,
DTPA resulted in an increased signal intensity of viable inflam- Weinstein MA. The intranuclear cleft of the intervertebral disk:
matory tissue on Ti -weighted images due to shortening of magnetic resonance imaging. Radiology 1985;i 55:155-158