659

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Pictorial Essay

Tuberculosis of the Spine: Imaging Features

Dean J. Shanley1

Spinal tuberculosis, the most common form of skeletal Contiguous vertebral body involvement, destruction of the
involvement, is increasing in prevalence because of the resur- intervertebral disk (Fig. 2), and progressive vertebral body
gence of tuberculosis during the past decade in patients with collapse result in the characteristic gibbous deformity of the
AIDS, the spread of tuberculosis among the homeless, and the
spine commonly associated with tuberculosis [1]. Infection
expanding immigrant population. Spinal infection is usually the
limited to a single vertebral body, although less common,
result of hematogenous seeding of the vertebral body, and the
diagnosis often remains elusive because of the indolent nature also may lead to vertebral body collapse and development of
of tuberculous infection. As a result, the radiographic findings vertebra plana deformity (Fig. 3). Multiple vertebral levels
and the signs and symptoms are typically far advanced when the may be involved in a noncontiguous fashion, manifested on
diagnosis is finally established. Radiographic manifestations of plain radiognaphs as skip lesions of vertebral body destruc-
tuberculous spondylitis include intraosseous and paraspinal tion and collapse. The posterior elements of the spine are
abscess formation, subligamentous spread of infection, verte- usually secondarily involved by spread of infection from the
bral body destruction and collapse, and extension into the spinal vertebral body; infection isolated to this portion of the spine
epidural space. Significant instability and deformity of the spine is more common in nonwhite tuberculosis patients and may
can result, mandating prompt diagnosis and treatment to pie-
mimic a neoplasm [1]. Paraspinal abscess formation may be
vent permanent neurologic damage. The purpose of this essay is
detected on plain radiographs as areas of fusiform soft-tis-
to illustrate the broad spectrum of Imaging fIndings on plain
radiographs, bone scans, CT scans, myelograms, and MR sue swelling around the spine (Fig. 4).
images of patients with spinal tuberculosis. The value of MR
imaging in determining the extent of disease is demonstrated. Scintlgraphy
Evaluation of spinal tuberculosis with scintignaphy early in the
course of infection is limited by the indolent nature of skeletal
Plain Radiographs
tuberculosis. Bone scans and gallium studies may not show spi-
Spinal tuberculosis most commonly involves the thoracic nal tuberculosis initially, despite the presence of active disease
spine and the lumbar spine; involvement of the cervical clinically and radiographically [2]. As the infection progresses,
region and sacrum is less common. The infection usually extensive osseous changes and attempts at healing result in
begins in the anterior aspect of the vertebral body, either increased bony metabolism, manifested as areas of increased
inferiorly or superiorly, adjacent to the vertebral endplate. radionuclide uptake on bone scans. Bone scintignaphy is helpful
Focal areas of erosion and osseous destruction in the ante- in determining the number of sites of active disease, as multiple
nor corners of the vertebral body (Fig. 1) are typical plain film levels of involvement may be unsuspected initially. The addition
findings for tuberculous spondylitis. Involvement of the adja- of single-photon emission CT is helpful for evaluating the extent
cent intervertebral disk or vertebral body results from pene- of involvement of the posterior elements of the spine (Fig. 5).
tration through the disk itself or spread of infection beneath Gallium imaging is useful in the setting of chronic infection and
the anterior longitudinal or posterior longitudinal ligament. for monitoring the response to antituberculosis therapy.

Received August 1 5, 1994; accepted after revision October 3, 1994.

1Departrnent of Radiology, Tripler Army Medical Center, Honolulu, HI 96859. Address correspondence to D. J. Shanley.

AJR 1995;164:659-664 0361-803X/95/1643-659 )Amenican Roentgen Ray Society

 660 SHANLEY AJR:164, March 1995

Fig. 1 .-43-year-oId man with spinal tuber-

culosis.
A, Lateral radiograph of lumbar spine shows
focal erosion (arrow) in anterosuperior aspect
of L4 vertebral body. Subtle erosion of anteroin-
ferior L3 vertebral endplate also is present.
B, Plain radIograph obtained 3 months later
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shows further erosive changes In vertebral

bodies, sclerosis of vertebral endplates, loss
of adjacent disk space, faint soft-tissue mass
anteriorly (arrows), and early gibbus formation.

A B

Fig. 2.-42-year-old man with tuberculous spondylitls. Patient had had low back pain for 5 Fig. 3.-5-year-old boy with tuberculous infection
months. of thoracic spine. Lateral radiograph of thoracic
A and B, Anteroposterior (A) and lateral (B) radiographs of lumbar spine show destruction of spine shows nearly complete destruction of T6 verte-
Li and L2 vertebral bodies, with loss of Intervening disk space. Vertebral body destruction is bral body, resulting in vertebra plana deformity. Adja-
greatest in anterior portions of vertebral bodIes, resulting In characteristic gibbous deformity. cent disk spaces are not well visualized. Destruction
Reactive sclerosis, typical of indolent nature of tuberculous InfectIon, is present. of anterior and superior portions of 17 vertebral body
also is present, contributing to gibbous deformity.

ti’
I

;
.
.

A B
Fig. 4.-i 8-year-old man with tuberculous Fig. 5.- 45-year-old man with tuberculosis Involving thoracic spine.
parasplnal abscess. Chest radiograph shows A, Posterior view from whole-body bone scan shows increased radionuclide uptake in middle
fusiform soft-tissue swelling (arrows) In lower and lower thoracic spine.
thoraclc region attributable to formation of B, Axial sIngle-photon emission CT scans show involvement of vertebral bodies and extension
tuberculous paraspinal abscess. into posterior elements (arrows) not apparent on plain films.
 AJR:164, March 1995 TUBERCULOSIS OF THE SPINE 661

Fig. 6.-43-year-old man with spinal tuber-

culosis. Contrast-enhanced CT scan of abdo-
men shows lytic destruction of anterior
portion of Li vertebral body (black arrows)
and adjacent paraspinal and right psoas
abscess formation (white arrows).
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Fig. 7.-42-year-oid man wIth tuberculous

spondylitis. Unenhanced CT scan of spine
shows destruction and fragmentation of Li var-
tebral body. Posterior extension of intraosseous
abscess (arrow) is present, resulting In mild
encroachment on thecal sac.

Fig. 8.-33-year-old man with spinal tuberculosis.

A, Contrast-enhanced CT scan of abdomen photographed with bone window technique shows closes (arrow) in anterolateral aspect of Ti 2 vertebral body.
B, CT scan several centimeters caudal to that shown in A shows large abscess In left psoas muscle attributable to spontaneous decompression of
Ti 2 intraosseous abscess.
C, CT scan through lower part of chest shows large left pleural effusion and left lower lobe atelectasis. Eftusion is attributable to cephallc extensIon
of paraspinal abscess and rupture Into left pleural cavity.

CT

Features of spinal tuberculosis that can be seen on CT scans

include anterior vertebral body destruction (Fig. 6), vertebral
body collapse, disk space narrowing, and large paraspinal soft-
tissue masses representing abscess formation [3, 4] (Fig. 7).
During the course ofthe infection, a cloaca (Fig. 8A) may be visu-
alized and may result from spontaneous decompression and
drainage of the vertebral body abscess. Paraspinal abscesses
form as a result of this drainage, which can then travel through
fascial planes and lead to the development of mediastinal
abscesses, pleural effusions, or psoas and flank abscesses,
depending on the level and direction of spread (Figs. 8B and 8C).
Posterior extension of paraspinal abscesses may lead to the for-
mation of an epidural abscess, encroachment on the spinal
canal, and compression of the spinal cord. Paraspinal and
intraosseous abscesses typically show a thick and irregular Fig. 9.-42-year-eid man with tuberculous Infection of sacrum. Unen-
hanced CT scan of pelvis shows destruction of anterior portion of
enhancing wall on contrast-enhanced CT scans. CT readily sacrum and large presacrai tubercuious abscess (white arrows). Large
shows the extent of abscess formation and can provide guidance sequestrum Is identified (black arrow).
 662 SHANLEY AJA:164, March 1995

for diagnostic and therapeutic procedures. In the early stages of body destruction and collapse and to epidural extension of
infection, areas of erosion or osseous destruction may be subtle paraspinal abscesses. Plain film myelographic findings asso-
and can be better demonstrated with reformatted sagittal and ciated with tuberculous spondylitis include displacement
coronal CT images. In the more chronic stages of infection, CT (Figs. 1OA and lOB) or thinning of the column of contrast
typically shows extensive osseous destruction, sequestrum for- material because of a mass effect (Figs. hA and 11 B) and
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mation (Fig. 9), and marked heterotopic bone formation. partial or complete obstruction of the flow of myelographic
contrast material. CT myelography is helpful for determining
the extent of the epidural process (Fig. 1 OC) and for differen-
Myelography
tiating between an epidural abscess and bony encroachment
Cord compression and spinal canal block are potential on the spinal canal [2, 5]. CT myelography also provides
complications of spinal tuberculosis that can be evaluated additional anatomic information and may reveal unsuspected
with plain film myelography or CT myelography. Encroach- paraspinal (Fig. 11C) or regional complications associated
ment on the spinal canal may be attributable to vertebral with spinal tuberculosis.

:. 13

1. 14

. S

C
Fig. 1O.-43-year-oid man with tuberculous spondyiltls Involving lumbar spine.
A and B, Anteroposterior (A) and lateral (B) radiographs obtained during lumber myelography show extradural defect at L3-L4 level resulting in thin-
nlng of column of contrast material anteriorly and toward left. Erosion of anterior and superior portions of L4 and anterior and Inferior portions of L3 is
present, with narrowing of intervertebral disk space. Tuberculous epidural abscess extending superiorly from L3-L4 disk space was found at surgery.
C, Selected Image from CT myelogram at L3-L4 disk level shows epldural abscess (arrow) encroachIng on thecal sac.

Fig. ii .-i 8-year-old man with spinal tuberculosis involving thoracic region.
A and B, Anteroposterler (A) and lateral (B) radiographs of spine obtained during thoracic myelography show marked thinning of column of con-
trast material attributable to tuberculous epidural abscess. Destruction and collapse of Ti 0 vertebral body are evident. Paraspinal abscess formatIon
accounts for soft-tissue swelling around spine.
C, Selected Image from CT myelogram shows formation of large tuberculous parasplnal abscess (white arrows), vertebral body destructIon, and epi-
dural abscess (black arrow) encroaching on thecal sac.
 AJR:164, March 1995 TUBERCULOSIS OF THE SPINE 663

MR Imaging (Fig. 12), skip lesions (Fig. 13), subligamentous spread of

The MR imaging features of spinal tuberculosis are infection, and epidural extension commonly associated with
believed to be diagnostic in the appropriate clinical setting [6, tubenculous spondylitis. Ti-weighted images ofthe spine (Fig.
7]. The multiplanar imaging capability of MR imaging greatly i4A) typically show decreased signal within the affected yen-
improves the detection of vertebral intraosseous abscesses tebral bodies, loss of disk height, and panaspinal soft-tissue
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FIg. i2.-41-year-oid man with spinal tuberculosis. Fig. i3.-5-year-old boy wIth spinal tuberculosis.
A, Enhanced Ti-weIghted (750/il) sagittal MR Image shows diffusely Increased signal within Contiguous T2-welghted (180W85) sagfttal MR images
T8 vertebral body attributable to tuberculous infection. intraosseous abscess within T9 vertebral show two levels of tUbeTCUIOUS Infection. Gibbous
body shows thick rim of enhancement. Marked enhancement of epidural abscess is present, deformity is present in upper thoracic region because
and cephalic and caudal extent of spread is clearly defined with use of contrast material. of nearly complete destruction and collapse of T6 var-
B, Enhanced Ti-weighted (600/il) coronal MR Image of thoracic spine shows thick rIm tebral body. 17 vertebral body Is partially destroyed
of enhancement around Intraosseous abscess. Small parasplnai abscesses are seen bilat- and angled, and Intervertebral disk space is poorly
erally (arrows). vIsualized. Collapse and angling of anterior half of L4
vertebral body also are present, with narrowing of
adjacent disk spaces. L5 vertebral body shows
increased signal attilbUtabIe to tuberculous Infection.
s_ canal is minimallyencroached on at both levels.

Fig. 1 4.-45-year-old man with thoracic spinal tuberculosis. Fig. i5.-45-year-oid man with spinal tuberculo-
A, Sagittal Ti-weighted (600/18) MR Image shows decreased signal wIthIn multiple lower the- sis. Enhanced Ti-weighted (75Gfi2) axial MR Image
racic vertebral bodies (T8-T1 1). vertebral endplate destruction and disk space involvement also through T9 vertebral body shows thick rim of
are present at multiple levels. Paraspinal abscess formation Is seen extending anteriorly and enhancement around intraosseous abscess, typical
posteriorly Into epidural space and encroaching on thecal sac. of spinal tuberculosis. Rim of enhancement also Is
B and C, Proton density-weighted (A) and T2-welghted (B) (2000/80) sagittal MR Images of present around multiple paraspinal abscesses
thoracic spine show Increased signal intensity within affected vertebral bodIes and disk spaces. (arrows). EnhancIng epidural abscess (arrowhead)
Extent of paraspinal abscess formation anteriorly Is better vIsualized on proton densIty- is seen compressing thecal sac.
weighted and T2-weighted images than on Ti -weighted image. Epidural abscess formation Is not
as well depicted on T2-weighted image because of high signal intensity of CSF.
 664 SHANLEY AJA:164, March 1995
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FIg. 16.-3-year-oId girl with spinal and pul- Fig. i7.-42-year-old man with spinal tubercu- Fig. i8.-45-year-old man wIth history of spinal
monary tuberculosis. Enhanced Ti-weighted losis. Contiguous 12-weighted fast spin-echo tuberculosis. Contiguous Ti-weighted (65Wi8) sag-
(700/17) coronal MR image of spine shows (2500185/echo train, 8) saglttal MR images show thai MR images of thoracic spine obtained postop-
extensive paraspinai abscess formation. Sub- Increased signal within Li vertebral body attrlb- eratively show autologous fibular graft in place.
ligamentous spread of Infection and large utable to tubercuious Infection. Disruption of Multiple tuberculous intraosseous abscesses were
intraosseous abscess are well visualized on anterosuperior margin of vertebral body is drained and debrided during surgery before graft
thIs coronal Image. Tuberculous Infiltrate in left present, resulting in paraspinal abscess forma- placement and spinal stabilization. Spinal canal is
upper lobe also is identified. tion and subilgamentous spread anteriorly. well visualized and uncompromlsed.
Decreased signal Intensity and narrowing of Ti2-
Li disk space are attributable to penetration of
Infection through dIsk. Intraosseous abscess for-
mation also is present wIthIn L4 vertebral body.

masses. T2-weighted images (Figs. i4B and i4C) often show postoperative assessment ofthe spine (Fig. 1 8) and follow-up
nonspecific increased signal within the areas of osseous and studies for monitoring the response to therapy.
soft-tissue changes. Contrast-enhanced sequences are help-
ful in distinguishing between tuberculous spondylitis and
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