AJR 2002; 179:979-983
© American Roentgen Ray Society
Spectrum of MR Imaging Findings in Spinal Tuberculosis
Srikanth Moorthy1 and
Nirmal K. Prabhu
1 Both authors: Department of Radiology, Amrita Institute of Medical Sciences,
Amrita La., Elamakkara P. O., Cochin-682026, Kerala, India.
Received January 28, 2002;
accepted after revision March 29, 2002.
Address correspondence to S. Moorthy.
Introduction
Tuberculosis, caused by Mycobacterium tuberculosis, remains a
major public health hazard, especially in developing countries in which
poverty, malnutrition, and the presence of drug-resistant strains have
combined to aid the spread of the disease. Infection with HIV increases the
risk of reactivation of dormant tuberculosis and the risk of acquiring the
primary infection. In those coinfected, a high frequency of extrapulmonary
disease has been observed [1,
2]. tuberculosis of the spine
accounts for more than 50% of musculoskeletal tuberculosis
[3]. In the developing
countries, the disease commonly afflicts children and young adults and tends
to be more aggressive in extent and abscess formation. Consequently,
neurologic complications and spinal deformities are seen frequently
[4]. In the developed
countries, musculoskeletal tuberculosis is uncommon, but its incidence is
reported to be greater in older individuals
[2]. The relative rarity and
varied presentations of spinal tuberculosis pose diagnostic difficulty,
warranting its inclusion in the differential diagnosis of any spinal disorder
[4]. However, immigration, an
aging population, and the association of spinal tuberculosis with HIV
infection can be expected to increase its prevalence. MR imaging is usually
performed to evaluate suspected spinal abnormalities, and the disease may
first be detected when symptomatic patients undergo this examination. The
purpose of our pictorial essay is to review the various typical and atypical
findings of spinal tuberculosis on MR imaging. All patients included were HIV
negative.
Pathology
Spinal tuberculosis is usually a secondary infection from a primary site in
the lung or genitourinary system. Spread to the spine is thought to be
hematogenous in most instances. Tuberculosis infection is characterized by a
delayed hypersensitivity immune reaction. The first stage is a pre-pus
inflammatory reaction with Langerhans' giant cells, epithelioid cells, and
lymphocytes. The granulation tissue proliferates, producing thrombosis of
vessels. Tissue necrosis and breakdown of inflammatory cells result in a
paraspinal abscess. The pus may be localized, or it may track along tissue
planes. Progressive necrosis of bone leads to a kyphotic deformity. Typically,
the infection begins in the anterior aspect of the vertebral body adjacent to
the disk. The infection then spreads to the adjacent vertebral bodies under
the longitudinal ligaments. Noncontiguous (skip) lesions are also occasionally
seen [4,
5].
Site
The most frequent site of spinal tuberculosis is the thoracolumbar junction
(Fig.
1A,1B).
The incidence decreases above and below this level. However, any segment of
the spine can be involved [4]
(Figs. 2 and
3A,3B).
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Fig. 1A. —22-year-old woman with paradiskal lesion of thoracolumbar
junction, presenting with stiff back. Sagittal gradient-recalled echo
T2-weighted MR image shows hyperintense paradiskal lesion (arrow) in
T12 inferior end-plate. Hyperintense signal in adjacent T12-L1 vertebral
bodies indicates marrow edema. Note small prevertebral fluid collection
(arrowhead).
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Fig. 2. —20-year-old woman with cervical spinal tuberculosis,
presenting with fever and stiff neck, but no neurologic deficit. Sagittal
spin-echo T1-weighted MR image shows destruction of lower endplate of C2 with
preservation of C2-3 disk (black arrowhead). Small anterior epidural
collection is seen indenting cord (white arrowhead). Note
retropharyngeal soft-tissue widening (arrow). Patient recovered after
being treated with antituberculous chemotherapy alone.
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Fig. 3A. —18-year-old woman with sacral tuberculosis presenting with
lower backache. Sagittal spin-echo T1-weighted MR image shows erosion of
second sacral segment (arrow) with pus filling sacral canal and large
presacral component.
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Fig. 3B. —18-year-old woman with sacral tuberculosis presenting with
lower backache. Coronal spin-echo T1-weighted MR image shows large pus
collection (arrows) extending into bilateral gluteal regions through
greater sciatic foramina. At surgery, 1500 mL of pus was drained.
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Patterns of Vertebral Involvement
The primary focus of infection in the spine can be either in the vertebral
body or in the posterior elements. Three patterns of vertebral body
involvement are recognized: paradiskal, anterior, and central lesions
[4].
Paradiskal Lesions
A paradiskal lesion is adjacent to the intervertebral disk leading to a
narrowing of the disk space (Fig.
1A,1B).
The disk space narrowing is caused either by destruction of subchondral bone
with subsequent herniation of the disk into the vertebral body or by direct
involvement of the disk [6].
This is the most common pattern of spinal tuberculosis. MR imaging shows low
signal on T1-weighted images and high signal on T2-weighted images in the
endplate, narrowing of the disk, and large paraspinal and sometimes epidural
abscesses (Figs.
1A,1B
and
4A,4B).
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Fig. 4A. —22-year-old woman undergoing treatment for pulmonary
tuberculosis who presented with back pain and progressive paraparesis.
Sagittal spin-echo T1-weighted MR image shows loss of T9-10 disk space
(arrow) with hypointense signal involving multiple contiguous
vertebral bodies. Skip involvement of T3 and L1 vertebral bodies
(arrowheads) can be seen.
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Fig. 4B. —22-year-old woman undergoing treatment for pulmonary
tuberculosis who presented with back pain and progressive paraparesis. Axial
gradient-recalled echo T2-weighted MR image shows large bilateral paraspinal
and prevertebral pus. Anterior epidural collection (arrow) is seen
compressing cord.
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Anterior Lesions
The anterior type is a subperiosteal lesion under the anterior longitudinal
ligament (Figs.
4A,4B
and
5A,5B,5C).
Pus spreads over multiple vertebral segments, stripping the periosteum and
anterior longitudinal ligament from the anterior surface of the vertebral
bodies. The periosteal stripping renders the vertebrae avascular and
susceptible to infection. Both pressure and ischemia combine to produce
anterior scalloping [4] (Fig.
5A,5B,5C).
MR imaging shows the subligamentous abscess, preservation of the disks, and
abnormal signal involving multiple vertebral segments representing vertebral
tuberculous osteomyelitis.
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Fig. 5A. —54-year-old woman with anterior lesion and progressive
paraparesis. Sagittal spin-echo T1-weighted MR image shows collapse of T3
vertebral body (black arrow) and large anterior subligamentous pus
collection extending from lower cervical region to T7. Note displaced anterior
longitudinal ligament (white arrow).
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Fig. 5B. —54-year-old woman with anterior lesion and progressive
paraparesis. Sagittal gradient-recalled echo T2-weighted MR image clearly
shows erosion of anterior aspects of multiple vertebral bodies (black
arrows). Note anterior epidural pus (white arrow) compressing
cord.
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Fig. 5C. —54-year-old woman with anterior lesion and progressive
paraparesis. Axial gradient-recalled echo T2-weighted MR image shows large
homogenous, hyperintense pus and elevated anterior longitudinal ligament
(arrows).
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Central Lesions
The central lesion is centered on the vertebral body. The disk is not
involved (Fig. 6). Vertebral
collapse can occur, producing a vertebra plana appearance
(Fig. 7). MR imaging shows a
signal abnormality of the vertebral body with preservation of the disk. The
appearance is indistinguishable from that of lymphoma or metastasis.
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Fig. 6. —25-year-old man with central lesion who presented with vague
back pain. Sagittal spin-echo T1-weighted MR image shows abnormal hypointense
signal involving T4 and T9 vertebral bodies (arrows). Disks are
spared. CT-guided biopsy revealed tuberculosis.
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Fig. 7. —56-year-old man with central lesion and paraparesis after 6
months of treatment with antituberculous chemotherapy. Sagittal spin-echo
T1-weighted MR image shows collapse of T6 vertebral body (arrowhead)
with preservation of adjacent disks—vertebra plana appearance.
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Posterior Element
Tuberculous involvement of the posterior elements is rare
[4]. MR imaging shows evidence
of bone erosion and the associated abscess (Figs.
8A,8B
and
9A,9B,9C).
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Fig. 8A. —22-year-old woman with tuberculosis of posterior element who
presented with low-grade fever and pain in nape of neck. Sagittal
gradient-recalled echo T2-weighted MR image shows bright signal pus under
ligamentum nuchae at C2 and C3 levels (arrows).
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Fig. 8B. —22-year-old woman with tuberculosis of posterior element who
presented with low-grade fever and pain in nape of neck. Axial
gradient-recalled echo T2-weighted MR image shows abnormal bright signal and
erosion of C2 spinous process (arrow). Biopsy from spinous process
confirmed tuberculosis.
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Fig. 9A. —18-year-old woman admitted for drainage of large tuberculous
abscess of cervical lymph node. MR imaging was performed to evaluate upper
dorsal pain. Patient was presumed to have tuberculosis of costovertebral joint
and improved after treatment with chemotherapy. Axial gradient-recalled echo
T2-weighted MR image shows hyperintense lymph node abscess (asterisk)
in right side of neck.
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Fig. 9B. —18-year-old woman admitted for drainage of large tuberculous
abscess of cervical lymph node. MR imaging was performed to evaluate upper
dorsal pain. Patient was presumed to have tuberculosis of costovertebral joint
and improved after treatment with chemotherapy. Axial spin-echo T1-weighted MR
image shows destructive lesion (arrow) eroding head of first rib on
left side and cortical margin of adjacent T1 vertebral body.
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Fig. 9C. —18-year-old woman admitted for drainage of large tuberculous
abscess of cervical lymph node. MR imaging was performed to evaluate upper
dorsal pain. Patient was presumed to have tuberculosis of costovertebral joint
and improved after treatment with chemotherapy. Axial gradient-recalled echo
T2-weighted MR image shows homogenous hyperintense left paraspinal pus
(arrow) extending into T1-2 neural foramen.
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Complications of the Tuberculous Spine
Paraplegia and sometimes quadriplegia are serious complications of the
tuberculous spine seen in approximately 10% of patients
[7]. Copious epidural pus and
granulation tissue alone or in combination with vertebral collapse,
subluxation, or dislocation (Figs.
10 and
11A,11B)
produce cord compression. Rarely, the pus penetrates the dura resulting in
severe meningomyelitis [8]
(Fig.
12A,12B).
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Fig. 10. —22-year-old woman presenting with quadriplegia in ninth month
of pregnancy. Sagittal spin-echo T1-weighted MR image shows destruction of C5
vertebral body (arrow) with posterior subluxation. C5-6 disk is
obliterated. Spinal decompression was performed after induction of labor.
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Fig. 11A. —47-year-old man with increasing spinal deformity and
paraparesis. Sagittal spin-echo T1-weighted MR image shows complete
destruction of L2 vertebral body, L1-2 disk, and lower half of L1 vertebral
body. Marked ureterolithiasis of L1 has produced bayonet deformity. Conus and
upper cauda equina are compressed. Note similarity to
Figure 10.
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Fig. 11B. —47-year-old man with increasing spinal deformity and
paraparesis. Coronal spin-echo T1-weighted MR image shows symmetric paraspinal
psoas abscesses (arrows), which, at spinal stabilization surgery,
were found to be organized and partly calcified.
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Fig. 12A. —56-year-old man with tuberculous meningomyelitis who
presented with spasticity of lower limbs and bladder incontinence 2 years
after laminectomy for presumed disk prolapse, which turned out to be epidural
tuberculous abscess. Unenhanced sagittal spin-echo T1-weighted MR image shows
narrowed L3-4 disk space (arrow) and extensive lumbar laminectomy.
Lumbar subarachnoid space has isointense featureless appearance. Conus is not
identified.
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Fig. 12B. —56-year-old man with tuberculous meningomyelitis who
presented with spasticity of lower limbs and bladder incontinence 2 years
after laminectomy for presumed disk prolapse, which turned out to be epidural
tuberculous abscess. Enhanced sagittal spin-echo T1-weighted MR image shows
bizarre irregular enhancement in lumbar subarachnoid space and conus.
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Conclusion
The differential diagnosis of the tuberculous spine includes pyogenic and
fungal infections, sarcoidosis, metastasis, and lymphoma. No pathognomonic
imaging signs allow tuberculosis to be readily distinguished from other
conditions. Typically, infectious spondylitis is characterized by involvement
of the intervertebral disk. A history of chronicity and slow progression is
suggestive of tuberculosis. Moreover, inflammatory collections tend to be
larger in tuberculosis than in pyogenic spondylitis. In the central and
posterior element forms of tuberculosis, only biopsy can achieve a provide
diagnosis [2,
6].
MR imaging is sensitive for detecting vertebral osteomyelitis and is
therefore the imaging technique of choice in spinal infections
[2]. In spinal tuberculosis,
the superior contrast resolution of MR imaging is useful for showing
contiguous vertebral involvement, skip lesions, and paraspinal collections. MR
imaging provides critical information about the spinal cord and the extent of
the epidural pus in patients presenting with neurologic deficits. Familiarity
with the spectrum of MR findings in tuberculosis spondylitis, especially in a
high-risk patient population, can prevent a delay in diagnosis and may limit
the morbidity that can be caused by this aggressive but curable infectious
disease.
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