ECR 2018 / C-1897
The many faces of Spinal Tuberculosis - A Pictorial review
Congress: ECR 2018
Poster No.: C-1897
Type: Educational Exhibit
Keywords: CNS, Neuroradiology spine, MR, Diagnostic procedure, Infection
Authors: S. Patwari1, H. C. Chadaga2; 1Bangalore/IN, 2BANGALORE, KA/IN
DOI:10.1594/ecr2018/C-1897

Findings and procedure details

A pictorial review of various imaging patterns and sites of Spinal tuberculosis is made:

 

                       VERTEBRAL TUBERCULOSIS - POTT'S SPINE

 

Fig. 3: Patterns of vertebral involvement. VR CT image use for depicting various sites of vertebral involvement. Blue and green lines indicated PARADISKAL, Star indicates CENTRAL, Yellow line indicates ANTERIOR, Orange oval indictes posterior elements involvement.
References: Columbia Asia Referral Hospital - Bangalore/IN

 

Fig. 2: Types and spread of vertebral TB
References: Columbia Asia Referral Hospital - Bangalore/IN

 

PARADISKAL: 

  • A paradiskal lesion is adjacent to the intervertebral disc leading to a narrowing of the disc space (Fig. 4). The disc 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 (2).
  • 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 disc and large paraspinal and sometimes epidural abscesses

 

 

Fig. 4: Paradiskal tuberulosis. Axial and Sagittal T2 (A,B) and Post contrast axial and sagittal T1 (C,D) images show dorsal vertebral end plate erosion with involvement of intervening disc, pre/paravertebral collection and granulation tissue. Significant anterior epidural granulation tissue seen causing cord compression.
References: Columbia Asia Referral Hospital - Bangalore/IN

 

ANTERIOR MARGINAL:

  • The anterior type is a subperiosteal lesion under the anterior longitudinal ligament (Figs. 5). 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(2).  
  • MR imaging shows the subligamentous abscess, preservation of the disks, and abnormal signal involving multiple vertebral segments representing vertebral tuberculous osteomyelitis.

 

Fig. 5: Anterior marginal lesion. Sagittal STIR image shows Anterior subligamentous granulation tissue with involvement of anterior aspects of vertebral bodies and sparing of intervertebral discs.
References: Columbia Asia Referral Hospital - Bangalore/IN

 

 

CENTRAL LESION:

  • The central lesion is centered on the vertebral body. The disc is not involved (Fig. 6). Vertebral collapse can occur, producing a vertebra plana appearance.
  • 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. The presence of prevertebral/ epidural collections can be a clue to suggest central type of vertebral tuberculosis.
Fig. 6: Central lesion. Sagittal T2w (A), T1w (B) and Post contrast sagittal T1w (C,D) images shows abnormal marrow signal intensity in dorsal vertebral with heterogeneous post contrast enhancement with sparing of adjacent discs and vertebral bodies. Associated peripherally enhancing anterior epidural abscess seen causing cord compression.
References: Columbia Asia Referral Hospital - Bangalore/IN

 

 

POSTERIOR LESION:

 

Tuberculous involvement of the posterior elements is rare. MR imaging shows evidence of bone erosion and associated abscess (Figs. 7 and 11).

 

Fig. 7: Posterior lesion. Sagittal T2 (A), T1 (B), axial T2 (C) and post contrast axial T1 (D) images shows destruction of lamina of L5 vertebra with associated peripherally enhancing collection seen causing spinal canal stenosis.
References: Columbia Asia Referral Hospital - Bangalore/IN

 

 

Fig. 11: Epidural and paraspinal abscess. Sagittal STIR (A), Post contrast T1 (B,C) images show abnormal enhancement in facet joints in lower dorsal spine with posterior epidural abscess seen causing cord compression. Associated paraspinal abscess can also be noted.
References: Columbia Asia Referral Hospital - Bangalore/IN

 

 

SKIPPED LESIONS:

 

Usually, two or more contiguous vertebrae are involved in spinal tuberculosis owing to hematogenous spread through one intervertebral artery feeding two adjacent vertebrae(3). Non-contiguous multifocal tuberculous spondylitis is rare and results from spread of infection from valveless Batsons venous plexus. (Fig. 8)

 

Fig. 8: Multifocal skipped lesions. Sagittal STIR(A), T1(B) images show multifocal skipped involvement of upper dorsal, dorsolumbar vertebra with multiple vertebral destruction, prevertebral and anterior epidural collection and granulation tissue seen with compression of spinal cord and cauda equina. Coronal STIR (C) image show large bilateral psoas abscess and concommitant pulmonary tuberculosis can be seen in right upper lobe.
References: Columbia Asia Referral Hospital - Bangalore/IN

 

 

CV JUNCTION TUBERCULOSIS:

 

Tuberculosis of the craniovertebral junction is a life-threatening condition. This can lead to abscess or granuloma formation with or without instability at the CVJ (Fig. 9). Both of these conditions can cause compression of the upper cervical spinal cord and brain stem, leading to tetraparesis and bulbar symptoms(4).

 

Fig. 9: CV junction tuberculosis. Sagittal T1w (A) and T2w (B) images show erosion odontoid process with abnormal marrow signal in clivus and anterior arch with associated collection in interdental space with atlantoaxial subluxation.
References: Columbia Asia Referral Hospital - Bangalore/IN

 

 

                                      EPIDURAL SPACE

 

Epidural space infection (Fig. 10&11) are uncommon manifestation of spinal tuberculosis and may represent a manifestation of hematogenous dissemination during primary infection with localization at the epidural space, probably after mild trauma as a predisposing factor. Most patients with epidural tubercular infection may not have evidence of TB infection elsewhere in the body(5)

 

Fig. 10: Epidural abscess. Sagittal post contrast T1w (A) and T2w images show peripherally enhancing posterior epidural abscess with thick pachymeningeal enhancement in cervical spine causing cord compression and long segment cord edema. Note the absence of bone / disc involvement in spine. Associated cerebellar tuberculoma and posterior fossa leptomeningeal enhancement can also be seen.
References: Columbia Asia Referral Hospital - Bangalore/IN

 

Fig. 11: Epidural and paraspinal abscess. Sagittal STIR (A), Post contrast T1 (B,C) images show abnormal enhancement in facet joints in lower dorsal spine with posterior epidural abscess seen causing cord compression. Associated paraspinal abscess can also be noted.
References: Columbia Asia Referral Hospital - Bangalore/IN

 

 

                      SPINAL MENINGEAL TUBERCULOSIS

 

TUBERCULAR LEPTOMENINGITIS WITH ARACHNOIDITIS:

 

Three possible pathogeneses for the occurrence of spinal TB arachnoiditis are the following:

 

1. TB lesion primarily arising in the spinal meninges

 

2. Extension of TB spondylitis

 

3. Downward extension of intracranial TBM (Most common)

 

On imaging, diffuse spinal leptomeningeal (Fig. 12) and cauda equina thickening and enhacement seen. Thick enhancing exudates can be seen in lumbar spinal canal causing clumping of the cauda equina (Fig. 13). Frequently, comcommitant cranial tubercular meningitis with basal exudates and granulomata can be seen (Fig. 13). 

 

 

Fig. 12: Leptomeningitis. Sagittal post contrast T1w images show smooth enhancement of spinal leptomeninges with small ring enhancing granuloma along posterior surface of dorsal cord. Abnormal leptomeningeal enhancement can also be seen in posterior fossa.
References: Columbia Asia Referral Hospital - Bangalore/IN

 

 

Fig. 13: Arachnoiditis. Sagittal (A) and axial (B) post contrast images show abnormal leptomeningeal and cauda equina enchancement with enhancing exudates seen in lumbar subarachnoid space. Post contrast cervical spine (C) images of the same patient show significant exudates and granulomas in posterior fossa and in cervical spine.
References: Columbia Asia Referral Hospital - Bangalore/IN

 

 

HYPERTROPHIC PACHYMENINGITIS AND ARACHNOIDITIS OSSIFICANS:

 

  • Hypertrophic pachymeningitis is a unique entity characterized by fibrosis and thickening of dura mater resulting in neurological dysfunction.
  • It could be idiopathic or due to variety of inflammatory and infectious conditions.
  • Tubercular pachymeningitis is uncommon manifestation of spinal tuberculosis. On MRI, thickened dura appears isointense or hypointense on T1WI and hypointense on T2WI sequence with thick post contrast enhancement (Fig. 14).
  • Arachnoiditis ossificans is a rare cause of chronic, progressive myelopathy. In contrast to the more common benign causes of meningeal calcification, arachnoiditis ossificans results in replacement of portions of the spinal arachnoid by bone as an end-stage complication of adhesive arachnoiditis. The findings of intraspinal ossification on computed tomography are characteristics and diagnostic (Fig. 15). 

 

Fig. 14: Pachymeningitis. Sagittal post contrast T1w image show thick pachymeningeal enhancement with mild posterior epidural abscess causing cord compression.
References: Columbia Asia Referral Hospital - Bangalore/IN

 

Fig. 15: Spinal arachnoiditis ossificans. Follow up case of craniospinal tuberculosis show long segment T2 hypointense pachymeninges (A-C) with areas of dural calcification (D,E) and long segment syrinx. Few calcific peripancreatic lymph nodes can also be seen on axial CT(D).
References: Columbia Asia Referral Hospital - Bangalore/IN

 

 

                                    SPINAL CORD TUBERCULOSIS

 

  • Spinal intramedullary tuberculoma and abscess present as spinal tumour syndrome and are very rare. They mimic intramedullary tumour in symptomatology with a rapidly advancing course. If such patient has a TB lesion elsewhere in the body at present or in the past, one can keep this condition in differential diagnosis with non- TB, tumorous and nontumourous lesion(5).
  • On imaging, they have similar characteristics as intracranial tuberculomas with solid caseating granulomas showing T2 hypointensity and ring enhancement (Fig. 16&17). They can be a manifestation of military tuberculosis (Fig. 18).

 

Fig. 16: Conus medullaris tuberculoma. Sagittal, Axial T2w (A-B) and Post contrast images (C-F) shows intramedullary T2 hypointense lesion in conus medullaris with thick rim enhancement and significant perifocal cord edema suggesting Tuberculoma with solid caseation. Associated pulmonary tuberculosis changes can be seen on coronal post contrast images (E-F)
References: Columbia Asia Referral Hospital - Bangalore/IN
Fig. 17: Multiple intramedullary tuberculomas. Sagittal T2 (A-C) and Post contrast T1 (D) shows multiple small T2 hypointense intramedullary ring and nodular enhancing tuberculomas.
References: Columbia Asia Referral Hospital - Bangalore/IN

 

Fig. 18: Spectrum of craniospinal miliary tuberculosis
References: Columbia Asia Referral Hospital - Bangalore/IN

 

  • Tuberculous myelitis is usually associated with tuberculous intracranial involvement of the meninges or brain parenchyma or with tuberculous arachnoiditis of the spine. It can manifest as acute transverse myelitis and longitudinal extensive transverse myelitis.  In majority of patients, tuberculous myelitis affects more than one spinal segment, most commonly affected areas being the thoracic and cervical region. Occasionally, imaging changes of myelitis may affect the entire length of the spinal cord. An abnormal immune reaction against mycobacterial antigen is thought to be the main pathogenic mechanism(6).
  • On imaging , Tuberculous myelitis shows long segment cord swelling with T2 hyperintensity and T1 iso to hypointensity and patchy segmental enhancement on post-contrast images. Chronic Myelitis can shows long segment myelomalacic changes or syringohydromyelia (Fig. 19). 

 

Fig. 19: Sequel of Tubercular myelitis with calcific and enhancing active tubercular granulomas and long segment syrinx. Also noted are areas of pachymeningeal thickening and T2 hypointense calcifications
References: Columbia Asia Referral Hospital - Bangalore/IN

 

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