Risk factors of spinal infections

MR Imaging of Spinal Infections
台大醫院 影像醫學部 台大醫學院 放射線科 許昭禹醫師/ 許昭禹醫師/施庭芳主任
2009/02/14

Advanced age > 50 Intravenous drug abuse Immunosuppression or immune deficiency LongLong-term steroid administration Diabetes mellitus Organ transplantation Malnutrition Malignancy Urinary tract instrumentation

Infectious pathways
Hematogenous
– Arterial or venous route

Vascular anatomy of spine

Direct inoculation
– Contiguous focus of infection – Direct open spinal trauma – Postoperatively

Greenspan A. Orthopedic Radiology: A Practical Approach 1997; V-19-3 Yoshioka K, Niinuma H, et al. Radiographics 2003; 23:1215-1225

Ross JS, Brant-Zawadzki M, et al. Diagnostic Imaging: Spine 2004; V-1-5

Arterial route
Segmental artery → spinal artery → nutrient equatorial artery Segmental artery → metaphyseal artery → metaphyseal anastomosing artery → intermetaphyseal anastomosing artery

Microcirculation

Smith AS, Weinstein MA, et al. AJNR 1989; 10:619-625

Ratcliffe JF. Acta Radiol [Diagn] (Stockh) 1985; 26:137-143

1

T2WI. 155:745-749 MRI Coronal STIR Sagittal T1WI. et al. et al. 1071 Differential diagnosis Unusual manifestations Common MRI findings of spinal infections ↓T1 signal with loss of disk margin & endplate irregularity ↑T2 signal from intervertebral disk & adjacent vertebral bodies Enhancement of vertebral bodies. Magnetic Resonance Imaging in Orthopaeducs & Sports Medicine 1997. 29:1465-1471 Resnick D. Diagnostic Imaging: Spine 2004. Diagnosis of Bone and Joint Disorders 1995. V-1-9 2 .Venous route Retrograde seeding of venous blood via Batson plexus Increased intraabdominal pressure Genitourinary tract infections Pathoanatomy of spinal infections Vertebral endplates → adjacent disk space → adjacent vertebral body → paravertebral tissues → epidural space Groen RJM. Toit DFd. endplates & annulus (variable) Epidural & paraspinal soft tissues Pyogenic osteomyelitis 2 adjacent vertebrae with intervening disk IllIll-defined marrow signal alternation Loss of vertebral endplate cortex Obliteration of intranuclear cleft Ross JS. STIR Axial T2WI GdGd-enhanced T1WI with/without fat suppression MRI of Spinal Infections Typical manifestations – Pyogenic osteomyelitis – Granulomatous osteomyelitis – Epidural abscess – Paraspinal abscess – Septic arthritis of facet joint Stoller DW. Spine 2004. Brant-Zawadzki M.

Pyogenic osteomyelitis Disk space narrowing Vertebral collapse Lumbar > thoracic > cervical spine Paraspinal ± epidural infiltrative soft tissues ± abscesses Ross JS. Culture: (-) (- L1-2 L1-2 T1WI T1WI C+ T2WI T1WI C+ 3 . et al. Brant-Zawadzki M. Diagnostic Imaging: Spine 2004. 8 months ago L1-2 T1WI L1-2 L1-2 STIR T1WI C+ FS T2WI T1WI C+ Antibiotic treatment 4 months later Aspiration: chronic inflammation. V-1-9 M/69 persistent LBP x 4 months. colon cancer s/p op.

sciatica x 2 months L4-5 L4-5 T1WI STIR T1WI C+ FS 4 .5 months.Granulomatous osteomyelitis Relatively intact intervertebral disks Gibbus vertebrae (25%) T-L spine Large paraspinal abscesses Multiple (non)contiguous M/80 general weakness with LBP x 2. III-1-10 T1WI Culture: Mycobacterium tuberculosis T11-12 T11 STIR T1WI C+ FS T2WI T1WI C+ M/42 LBP with bil. Brant-Zawadzki M. Diagnostic Imaging: Spine 2004. fever & chills x 2 days T11-12 Ross JS. et al.

Surgical debridement: caseating granulomatous inflammation (TB) L5 S1 T2WI T1WI C+ T2WI T1WI C+ Epidural abscess Epidural phlegmon Posterior epidural > anterior epidural > circumferential Lower T.& L-spine > T.LC. Diagnostic Imaging: Spine 2004. Brant-Zawadzki M. Culture: Staphylococcus aureus (MSSA) L4-5 L5 T2WI T1WI C+ FS T2WI T1WI C+ 5 . V-1-22 M/68 LBP with difficulty in walking x 2 wks L4-5 T1WI Surgical debridement: osteomyelitis. et al.& upper T-spine TMultiMulti-segmental Ross JS.

Culture: Staphylococcus aureus T5 T1WI T2WI T1WI C+ FS T2WI T1WI C+ Paraspinal abscess Paravertebral phlegmon Obliterated soft tissue fascial plane IntraIntra-abscess gas Calcified psoas abscesses Reactive LAP F/52 progressive LBP with bil. Brant-Zawadzki M. et al. Diagnostic Imaging: Spine 2004. sciatica x 3 wks L3-4 Ross JS. V-1-30 T1WI Surgical debridement: osteomyelitis.M/48 Severe back pain with bil. Culture: Staphylococcus aureus (MSSA) L3-4 L3-4 STIR T1WI C+ FS T2WI T1WI C+ 6 . paraplegia x 1 wk T2-9 Surgical debridement: abscess.

4 months ago L4-5 STIR T1WI C+ FS 7 . Brant-Zawadzki M.5 months. sciatica x 2. Diagnostic Imaging: Spine 2004. traffic accident before.F/43 LBP x 4 months. gastric cancer s/p op. V-1-18 M/73 LBP with bil. et al. Echo: retroperitoneal cystic mass T12 T11-L1 STIR T1WI C+ FS Culture: Mycobacterium tuberculosis T11-L1 T12 T1WI T2WI STIR T1WI C+ FS Septic arthritis of facet joint Lumbar spine (97%) Typically single level involvement Facet joint widening Eroded facet cortex Adjacent soft tissue edema & abscesses Ross JS.

or parasitic Tuberculosis. organisms – Limited paraspinal inflammatory tissue STIR L3-4 T1WI C+ FS M/42 Surgical debridement: caseating granulomatous inflammation (TB) Differential diagnosis of 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 . Culture: Staphylococcus aureus (MSSA) NonNon-pyogenic infection – Tuberculosis. Pseudomonas aureus. yeast. fungus. species – Remarkable paraspinal inflammatory tissue F/52 Surgical debridement: osteomyelitis.Blood culture: Enterococcus faecalis L4-5 T2WI T1WI C+ Differential diagnosis of spinal infections (1) Pyogenic infection – Staphylococcus aureus.

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 of disk with irregular new bone formation Erosive intervertebral osteochondrosis M/48 LBP with fever & chills x 1 wk Echo: r/o infectious endocarditis L2-3 L4-5 STIR T2WI T1WI STIR 9 .M/78 LBP x 2.

23:159-67 L4-5 T1WI C+ FS T1WI C+ T2WI F/70 Diabetes mellitus x 20 years Flank pain x 1 month L2 L2 T1WI T2WI T1WI T2WI Analgesics treatment 1 month later Biopsy: osteomyelitis Blood culture: Staphylococcus aureus (MSSA) L2-3 L2-3 T1WI T2WI T1WI C+ FS 1 month ago 10 .6%) Shih et al. Blood culture: Gram (+) cocci Unusual Manifestations of spinal infections (1) Single segment vertebral osteomyelitis – Anterior cortical disruption (100%) – Upward subligamentous spread (100%) – Upper disk involvement (66.Surgical debridement: osteomyelitis. Clin Imaging 1999.

Unusual Manifestations of spinal infections (2) Vertebral osteomyelitis mimicking metastases – Preserved intervertebral disks (100%) – Llimited paraspinal or epidural inflammatory tissue (86%) – Posterior element involvement (43%) Hsu et al. 29:1104-1110 F/46 Recurrent Salmonellosis x 9 months Fever x 2 days STIR T1WI STIR T1WI C+ FS Biopsy: chronic osteomyelitis Blood culture: Salmonella Antibiotics treatment 12 month later T11 T2WI T1WI C+ T1WI STIR T1WI C+ FS Diffusion Weighted Imaging of Bone Marrow Pathologies DWI – A powerful tool for evaluating bone marrow infiltration Metastasis ADC = 0. mimicking restricted diffusion Hypercellularity? Macromolecules? Herneth et al. EJR 2005. 55:74-83 11 .48 mm2/s DW-EPI b = 880 T1WI Vertebral osteomyelitis STIR DW-SSFP No signal aberration. AJNR 2008. EJR 2005. 55:74-83 Aggressive osteomyelitis ADC = 1.79 mm2/s Diffusion Weighted Imaging Apparent diffusion coefficient (ADC) – Highly specific and very sensitive to differentiate between malignant and benign skeletal processes Herneth et al.

granulomatous osteomyelitis – Epidural/paraspinal abscess Thank You for Your Attention 台大醫院 影像醫學部 台大醫學院 放射線科 許昭禹醫師/ 許昭禹醫師/施庭芳主任 2009/02/14 Differential Diagnosis – Type 1 degenerative endplate changes – Erosive intervertebral osteochondrosis Unusual Manifestations – Single segment vertebral osteomyelitis – Vertebral osteomyelitis mimicking metastases 12 . 5:191-96 STIR Osteomyelitis Fukuda et al. Magn Reson Med Sci 2006. 5:191-96 Conclusion Typical manifestations – Pyogenic vs. Magn Reson Med Sci 2006.SPIOSPIO-enhanced MRI 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 bone metastasis and osteomyelitis RE: relative enhancement (%) SPIOSPIO-enhanced MRI Metastasis Fukuda et al.

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