spondylodiscitis10

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InfectiousSpondylodiscitis

Sebastián Bravo Grau(University los Andes - Faculty of Medicine 7th year)

Dr. Felipe AliagaDr. Gillian Lieberman

September 2009Beth Israel Deaconess Medical Center Harvard Medical SchoolAdvanced Radiology Clerkship


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Agenda

• Patient Presentation

• Normal Anatomy• General information

• Imaging of Spondylodiscitis• Plain films• CT• MRI• Bone scan

• Take Home PointsBackground image from: http://www.flickr.com/photos/deepblue66/369213890/


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Our Patient: PMH

• In Santiago, Chile.• Women - 67 years.• PMH:• Cirrhosis. Child-Turcotte-Pugh class B.• Secondary portal hypertension.

• Gastroesophageal varices.• Diabetes Mellitus Type 2• Hypertension. Hypertensive cardiopathy.


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Our Patient: PMH

• Admitted on June 2009 for UGB

• Gastric ulcer - Forrest IIC - treated.• During this period the patient referred:• 1 month history of upper back pain.• New onset band-like radiation of pain to

right side.

• Afebrile, normal WBC count.


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Our Patient: Thorax CT. Fracture of T4 vertebral

body with abnormal soft tissue surrounding

Cortical

breakthrough, bilaterally.

Abnormal softtissue

surrounding the

vertebral body.

Image From Hospital Militar de Santiago, Chile.

Thorax CT: axial view without contrast


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Our Patient Presentation

• To further assess intrathecal pathology,MRI was indicated by the medical team.

• In spite of this, the patient and her family,request discharge.

• At this point, the patient was afebrile,neurological exam was normal, as WBCcount.


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Our Patient Presentation

• … 6 days later


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Our Patient: HPI

• HPI:• History of 48 hours with progressive

paraparesia and sphincter relaxation.• Afebrile.

• Lab:• WBC: 27.400• ESR: 86• Blood cultures: Gram-positive cocciclusters.

• St. Aureus


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Our Patient: MRI. Spinal canal stenosis


T2-weighted image in sagittal plane

Posterior convex border.Retropulsion causing severe

spinal canal stenosis and cord

compression.


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Decreased signal intensity

of bone marrow in T4 andT5.

Our Patient: MRI. Severe Compression of T4.

Image From Hospital Militar de Santiago, Chile.T1-w sagittal plane

Severe compression of T4.


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T1-w sagittal plane contrast-enhanced

Our Patient MRI: Spondylodiscitis



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Severe compression of T4with abnormalenhancement


Our Patient MRI: Spondylodiscitis. Abnormal softtissue enhancement


Abnormal enhancementwithin the T5 vertebral

body. (*)

Soft tissueenhancement

*


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Our Patient: MRI. Spondylodiscitis withlarge paraspinal collection

Both Images From Hospital Militar de Santiago, Chile.

Coronal

Axial

MRI. T2-weighted.Axial and Coronal


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Agenda

• Patient Presentation

• Normal Anatomy• General information

• Imaging of Spondylodiscitis• Plain films• CT• MRI• Bone scan

• Take Home PointsBackground image from: http://www.flickr.com/photos/deepblue66/369213890/


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Thoracic Spine: Normal Anatomy onMRI

Image from PACS, BIDMC, Boston, MA.

Spinal cord

Sagittal T1-weighted MRI.

Ligamentum flavum

Vertebral body

Intervertebral disc Spinous process

Superior and inferior endplateAnterior cortical margin


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Diagrams of Normal Anatomy

Diagram from: http://www.spineuniverse.com/displayarticle.php/article1394.html

Diagram from: http://www.spineuniverse.com/displayarticle.php/article1267.html

http://www.spineuniverse.com/displayarticle.php/article1394.htmlhttp://www.spineuniverse.com/displayarticle.php/article1394.htmlhttp://www.spineuniverse.com/displayarticle.php/article1394.htmlhttp://www.spineuniverse.com/displayarticle.php/article1394.html


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Infectious Spondylodiscitis:

General Information• Infectious spondylitis accounts for 2%-4% of cases of

skeletal infection.• The most common infecting organism is Sthaphylococcus

aureus. (55%-90%)

• Other causes of pyogenic infections of the spine:• Streptococcus, Pneumococcus, Enterococcus, E. Coli, Salmonella,

Pseudomonas aeruginosa and Klebsiella.

• Non-pyogenic (granulomatous) infections originate from:• Mycobacterium tuberculosis, Brucella, fungi and parasites.


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General Information

• Note:• This presentation is mainly related to

pyogenic infectious spondylodiscitis.


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Infectious Spondylodiscitis

Epidemiology

• Incidence has steadily risen in recent years because of:• Increases in spine surgery• Increases in nosocomial bacteremia• Aging of population• Intravenous drug addiction


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Clinical Manifestations

• Patients with a spinal infection most often present withaxial back pain.• Other constitutional symptoms may be present.• Neurologic compromise not usually part of the early

manifestations.

• Laboratory results are often, but not always, abnormal.• Leukocytosis often present, but not always.• ESR and CRP are usually, but nor always, elevated.


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Pathophysiology of Spinal Bacterial Infection

• Direct inoculation

•Penetrating trauma

• Spinal procedures (percutaneous or open)

•Contiguous spread from an adjacent infection

• Local spread following intra-abdominal or retro-peritoneal infections.

•Hematogenous

• From distant septic foci. Skin and soft tissue infections, infected vascularaccess sites, UTI.

Tay B, Deckey J, Hu S. SPINAL INFECTIONS. J Am Acad Orthop Surg 2002;10:188-97.


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Pathophysiology:

Hematogenous Dissemination

•Venous Theory• Batson demonstrated retrograde flow from the pelvic venous

plexus to the perivertebral venous plexus via valvelessmeningorrhachidian veins.

• Arteriolar Theory

• Wiley and Trueta: bacteria can become lodged in the end-arteriolar network near the vertebral plate.



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Pathophysiology:

Contiguous Spread

• Infection established adjacent to the end plate ofone vertebral body.• Can rupture through it into the adjoining diskand infect the next vertebral body.

• The disk material is relatively avascular and israpidly destroyed by the bacterial enzymes.

• Cervical spine: if infection penetrates the prevertebral fascia, it can extend into themediastinum.



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Pathophysiology:

Contiguous Spread

• Lumbar spine: abscess formation may track along the psoasmuscle and into piriformis fossa, perianal region and the groin.• Extension into the spinal canal, may result in: epidural abscess

or even bacterial meningitis.• Destruction of the vertebral body and intervertebral disk can potentially lead to instability and collapse. (as in our patient)

• Infected bone or granulation tissue may be retropulsed intothe spinal canal, causing neural compression or vascularocclusion.



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Classification of Spinal Infections:

Duration of Symptoms


Acute Subacute Chronic

3 months


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• Spinal infections can be devastating andcan result in significant pain, deformity,

and neurologic deterioration (as in our patient).

• The accurate diagnosis and appropriatetreatment of spinal infections is important.


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Menu of Tests Used to DiagnoseInfectious Spondylodiscitis

• Plain Film• CT• Radionuclide Bone Scan• MRI


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Plain Radiographs

• Should be taken on all patients with orsuspected of having a spinal infection.

• Changes appear at least 3 to 4 weeks afteronset of the disease.

• Sensitivity: poor in early acute osteomyelitis.


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Plain Radiographs

• Findings:

• Soft tissue swelling around the area ofinfection.

• Loss of disc height.• Endplate sclerosis, from reactive boneformation.

• Cortical resorption: osteopenia, scallopingof endplates, subperiosteal defects.


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Companion Patient 1: Lateral C-Spine

• Spinal infection.

• Early radiographic abnormalities.• Lateral radiograph of the cervical

spine.

• Destructive lesion within theanterior subchondral region of C5

and C4.• Initial narrowing of C4-C5 disc.

Image From: Jevtic V. VERTEBRAL INFECTION. Eur Radiol 2004;14:E43-E52.

C i P ti t 2 L t l L


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Companion Patient 2: Lateral L-

Spine• Vertebral infection.• Advanced radiographic

changes.

• Lateral radiograph of thelumbar spine.• Destruction of vertebral bodies

with narrowing of the L3-L4disc space.

Image From: Jevtic V. VERTEBRAL INFECTION. Eur Radiol 2004;14:E43-E52.


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Spiral CT with IV contrast

• Excellent detail of bony anatomy, including any sequestra orinvolucra.

• Identify the presence of adjacent soft tissue masses orabscesses.

• Disk space narrowing or decreased attenuation in the disk.• With contrast: abnormal disk space, vertebral marrow or

paravertebral soft tissues may enhance.• Destruction of vertebral body and fragmentation of vertebral

endplates.


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Spiral CT with IV contrast

• Inferior to MRI in evaluating disc spaces and the neuralelements.• The size of the infected granulation tissues or abscesses can

be monitored but the inflammatory reaction in the bonemarrow is not well depicted.

• CT myelograms is not the preferred imaging technique in pyogenic infections.• Potential for intradural spread of the infection.


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Companion Patient 3: Infectious

Spondylodiscitis on CT

Images From: http://www.statdx.com Case Contributor: Jud W. Gurney, MD, FACR

CT. Coronal reconstruction

Disc space narrowing witherosion of the adjacent

vertebral body endplates.

http://www.statdx.com/http://www.statdx.com/


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Companion Patient 3: Infectious

Spondylodiscitis on CT

Images From: http://www.statdx.com Case Contributor: Jud W. Gurney, MD, FACR

CT. Axialview

Paraspinal widening.



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•Lets remember our patient ...


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Our Patient: Thorax CT. Fracture of T4 vertebral body with abnormal soft tissue surrounding

Cortical

breakthrough, bilaterally.

Abnormal softtissue

surrounding the

vertebral body.


Thorax CT: axial view without contrast


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Radionuclide Bone Scan

• Can be much more sensitive than radiographsin detecting early disease.

• Menu of Bone Scan:

• Three-phase technetium-99m bone scan• Gallium-67 citrate scan

• Combination of technetium and gallium• Indium 111-labeled leukocyte scintigraphy

R di lid B S


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Radionuclide Bone Scan:

Technetium 99m Three-phase BoneScintigraphy

• Technetium 99m Three-phase BoneScintigraphy:• Flow phase.• Blood pooling phase.• Delayed phase.

• Osteomyelitis causes focally increased uptake inall three phases.


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Three-phase technetium-99m bone scan

• Sensitive (90%) but nonspecific (78%) for spinal infections.• Particularly in older patients with some degree of spondylosisand degenerative disc disease.

• Provide little anatomic detail.• Can be positive in the setting of osteoporotic fractures and

neoplasms.

An H, Seldomridge J. SPINAL INFECTIONS DIAGNOSTIC TESTS AND IMAGING STUDIES.Clinical Orthopaedics and Related Research 2006;444:27-3


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Gallium-67 citrate scan

• Gallium-67 citrate scans have similar sensitivity (89%)and specificity (85%) and accuracy (86%) as technetiumscans in evaluating pyogenic spinal infections.

• Combination of these studies (gallium and technetiumscans) can be more helpful in making diagnosis.

•Accuracy of 94%.



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Indium 111-labeled leukocyte

scintigraphy

• Specificity is improved.• Sensitivity is very low (17%).

• May be helpful only in selected patients.• Should not be used routinely. (because highrate of false-negative results)


Whalen JL, Brown ML, McLeod R, Fitzgerald RH Jr. LIMITATIONS OF INDIUMLEUKOCYTE IMAGING FOR THE DIAGNOSIS OF SPINE INFECTIONS. Spine 1991;16:193-7

C i P ti t 4 B S


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Companion Patient 4. Bone Scan:

Labeled white cells. Osteomyelitis.• Posterior labeledleukocyte

scintigraphy shows photopenia inknown spinal

osteomyelitis.• Labeled leukocyte

scan is oftenfalsely negative inspinalosteomyelitis.

Image From: http://www.statdx.com



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Companion Patient 5. Bone Scan:

three-phase technetium-99m. Discitis.

• Posterior bone scanshows increasedactivity in endplates of

two adjacent vertebral bodies.

• Characteristic of discitisor discogenic sclerosis.

Image From: http://www.statdx.com



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MRI

• Magnetic resonance imaging is a powerfuldiagnostic tool that can be used to help evaluate

spinal infection and to help distinguish betweenan infection and other clinical conditions.

• Gold standard for imaging of spinal infections.• Especially useful in the early stages when other

imaging modalities are still normal or

nonspecific.• Sensitivity (96%) and specificity (92%).

Hwan Hong S, Choi JY, Woo Lee J, Kim N, Choi JA, Kang H. MR IMAGING ASSESMENTOF THE SPINE: INFECTION OR AN IMITATION? Radiographics 2009;29:599-612


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MRI

• Usual findings:• Vertebral endplate destruction

• Bone marrow and disk signal abnormalities• Paravertebral or epidural abscesses.

•Typical signal pattern of acute spinal infection:

• Increase in fluid signal because of marrowedema

• Signal decrease in T1-weighted sequences• Signal increase in T2-weighted sequences.



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MRI

• Not always easy:• Classic MRI features are absent

• Unusual patterns of infectiousspondylitis• Noninfectious inflammatory diseases and

degenerative disease may simulate spinalinfection.


Companion Patient 6 MRI:


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Companion Patient 6. MRI:diskitis/osteomyelitis

Image From: E-Medicine:http://emedicine.medscape.com/article/340211-media

• Destruction of L3-4 disk space with theadjacent endplate and vertebral body.

•

L3 and L4 vertebral bodies showincreased T2 signal.

• Retropulsion of debris, with secondary

compression.

MRI. T2-w of lumbar spine. Sagittal view.

O P ti t MRI S d l di iti



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Severe compression of T4with abnormalenhancement


Our Patient MRI: Spondylodiscitis


Abnormal enhancementwithin the T5 vertebral

body

Soft tissueenhancement *


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BIDMC PACS. 84 yo man. MRI. T1 seq.Sag. Acute moderate T6 compression fracture.

Some

DifferentialDiagnosis

This is NOT aninfectious

spondylodiscitis


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Osteomyelitis vs Tumor

Osteomyelitis Tumor

Contiguity Yes No

Paraspinal soft tissue mass Yes (abscess) Less common

Disk space Isocenter Not involved

Primer of Diagnostic Imaging. Weisldder. Third Edition.


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Take Home Points

• Changes on plain radiographs occur at latedisease.

• MRI is the gold standard for imaging ofspinal infection.• Soft tissue helps to narrow the differential diagnosis.

• This is a patient where the imaging findingssuperseed the clinical findings.

R f (1 f 2)


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References (1 of 2)

• Pintado-García V. ESPONDILITIS INFECCIOSA. Enferm InfeccMicrobiol Clin 2008;26(8):510-7.

• Fica A, Bozán F, Aristegui M, Bustos P. ESPONDILODISCITIS.ANÁLISIS DE UNA SERIE DE 25 CASOS. Rev Med Chile2003;131:473-82.

• Jevtic V. VERTEBRAL INFECTION. Eur Radiol 2004;14:E43-E52.• An H, Seldomridge J. SPINAL INFECTIONS DIAGNOSTIC TESTS

AND IMAGING STUDIES. Clinical Orthopaedics and Related Research2006;444:27-33.

• Tay B, Deckey J, Hu S. SPINAL INFECTIONS. J Am Acad Orthop Surg2002;10:188-97.• Grados F, Lescure F, Senneville E, Flipo R, Schmit JL, Fardellone P.SUGGESTIONS FOR MANAGING PYOGENIC (NON-TUBERCULOUS) DISCITIS IN ADULTS. Joint Bone Spine

2007;74:133-9.

References (2 of 2)


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References (2 of 2)

• Sharif H. ROLE OF MR IMAGING IN THE MANAGEMENT OFSPINAL INFECTIONS. AJR 1992;158:1333-45.

• Hwan Hong S, Choi JY, Woo Lee J, Kim N, Choi JA, Kang H. MRIMAGING ASSESMENT OF THE SPINE: INFECTION OR ANIMITATION? Radiographics 2009;29:599-612.

• Whalen JL, Brown ML, McLeod R, Fitzgerald RH Jr. LIMITATIONSOF INDIUM LEUKOCYTE IMAGING FOR THE DIAGNOSIS OFSPINE INFECTIONS. Spine 1991;16:193-7.

• Primer of Diagnostic Imaging. Weisldder. Third Edition.

• StatDx – http://www.statdx.com• Emedicine – http://emedicine.medscape.com

http://www.statdx.com/http://emedicine.medscape.com/http://emedicine.medscape.com/http://www.statdx.com/


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Acknowledgements

•Dr. Rivka Colen

• Dr. Dan Anghelescu

• Nicolás Ahumada

Background image from: http://www.flickr.com/photos/m750/50103339/


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