659

Pictorial

Essay

Tuberculosis
Dean J. Shanley1

of the Spine:

Imaging

Features

Spinal tuberculosis, the most common form of skeletal involvement, is increasing in prevalence because of the resurgence of tuberculosis during the past decade in patients with AIDS, the spread of tuberculosis among the homeless, and the expanding immigrant population. Spinal infection is usually the result of hematogenous seeding of the vertebral body, and the diagnosis often remains elusive because of the indolent nature of tuberculous infection. As a result, the radiographic findings and the signs and symptoms are typically far advanced when the diagnosis is finally established. Radiographic manifestations of tuberculous spondylitis include intraosseous and paraspinal abscess formation, subligamentous spread of infection, vertebral body destruction and collapse, and extension into the spinal epidural space. Significant instability and deformity of the spine can result, mandating prompt diagnosis and treatment to pievent permanent neurologic damage. The purpose of this essay is to illustrate the broad spectrum of Imaging fIndings on plain radiographs, bone scans, CT scans, myelograms, and MR images of patients with spinal tuberculosis. The value of MR imaging in determining the extent of disease is demonstrated.

Contiguous vertebral body involvement, destruction of the intervertebral disk (Fig. 2), and progressive vertebral body collapse result in the characteristic gibbous deformity of the spine commonly associated with tuberculosis [1]. Infection limited to a single vertebral body, although less common, also may lead to vertebral body collapse and development of vertebra plana deformity (Fig. 3). Multiple vertebral levels may be involved in a noncontiguous fashion, manifested on plain radiognaphs as skip lesions of vertebral body destruction and collapse. The posterior elements of the spine are usually secondarily involved by spread of infection from the vertebral body; infection isolated to this portion of the spine is more common in nonwhite tuberculosis patients and may mimic a neoplasm [1]. Paraspinal abscess formation may be detected on plain radiographs as areas of fusiform soft-tissue swelling around the spine (Fig. 4).
Scintlgraphy

Plain

Radiographs

Spinal tuberculosis most commonly involves the thoracic spine and the lumbar spine; involvement of the cervical region and sacrum is less common. The infection usually begins in the anterior aspect of the vertebral body, either inferiorly or superiorly, adjacent to the vertebral endplate. Focal areas of erosion and osseous destruction in the antenor corners of the vertebral body (Fig. 1) are typical plain film findings for tuberculous spondylitis. Involvement of the adjacent intervertebral disk or vertebral body results from penetration through the disk itself or spread of infection beneath the anterior longitudinal or posterior longitudinal ligament.

Evaluation of spinal tuberculosis with scintignaphy early in the course of infection is limited by the indolent nature of skeletal tuberculosis. Bone scans and gallium studies may not show spinal tuberculosis initially, despite the presence of active disease clinically and radiographically [2]. As the infection progresses, extensive osseous changes and attempts at healing result in increased bony metabolism, manifested as areas of increased radionuclide uptake on bone scans. Bone scintignaphy is helpful in determining the number of sites of active disease, as multiple levels of involvement may be unsuspected initially. The addition of single-photon emission CT is helpful for evaluating the extent of involvement of the posterior elements of the spine (Fig. 5). Gallium imaging is useful in the setting of chronic infection and 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. AJR

Address

correspondence

to D. J. Shanley.

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 tuberculosis. A, Lateral radiograph of lumbar spine shows focal erosion (arrow) in anterosuperior aspect of L4 vertebral body. Subtle erosion of anteroinferior L3 vertebral endplate also is present. B, Plain radIograph obtained 3 months later 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.

Fig. 2.-42-year-old man with tuberculous spondylitls. months. A and B, Anteroposterior (A) and lateral (B) radiographs Li and L2 vertebral bodies, with loss of Intervening disk greatest in anterior portions of vertebral bodIes, resulting Reactive sclerosis, typical of indolent nature of tuberculous

Patient

had

had

low back

pain

for 5

of lumbar spine show destruction of space. Vertebral body destruction is In characteristic gibbous deformity. InfectIon, is present.

Fig. 3.-5-year-old boy with tuberculous infection of thoracic spine. Lateral radiograph of thoracic spine shows nearly complete destruction of T6 vertebral body, resulting in vertebra plana deformity. Adjacent disk spaces are not well visualized. Destruction of anterior and superior portions of 17 vertebral body also is present, contributing to gibbous deformity.

ti
I

A
Fig. 4.-i 8-year-old man with tuberculous Fig. 5.45-year-old man with tuberculosis
parasplnal abscess. Chest radiograph shows fusiform soft-tissue swelling (arrows) In lower thoraclc region attributable to formation of tuberculous paraspinal abscess.

B
Involving thoracic spine.

A, Posterior view from whole-body bone scan shows increased radionuclide uptake in middle and lower thoracic spine. B, Axial sIngle-photon emission CT scans show involvement of vertebral bodies and extension into posterior elements (arrows) not apparent on plain films.

AJR:164,

March

1995

TUBERCULOSIS

OF THE

SPINE

661

culosis. Contrast-enhanced

man with spinal tuberCT scan of abdomen shows lytic destruction of anterior portion of Li vertebral body (black arrows) and adjacent paraspinal and right psoas abscess formation (white arrows).

Fig. 6.-43-year-old

Fig. 7.-42-year-oid man wIth tuberculous spondylitis. Unenhanced CT scan of spine shows destruction and fragmentation of Li vartebral 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

of spinal tuberculosis that can be seen on CT scans anterior vertebral body destruction (Fig. 6), vertebral body collapse, disk space narrowing, and large paraspinal softtissue masses representing abscess formation [3, 4] (Fig. 7). During the course ofthe infection, a cloaca (Fig. 8A) may be visualized 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 formation 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 enhancing wall on contrast-enhanced CT scans. CT readily shows the extent of abscess formation and can provide guidance
include

Features

Fig. 9.-42-year-eid man with tuberculous Infection of sacrum. Unenhanced CT scan of pelvis shows destruction of anterior portion of sacrum and large presacrai tubercuious abscess (white arrows). Large sequestrum Is identified (black arrow).

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1995

for diagnostic and therapeutic procedures. In the early stages of infection, areas of erosion or osseous destruction may be subtle and can be better demonstrated with reformatted sagittal and coronal CT images. In the more chronic stages of infection, CT typically shows extensive osseous destruction, sequestrum formation (Fig. 9), and marked heterotopic bone formation.

body destruction and collapse and to epidural extension of paraspinal abscesses. Plain film myelographic findings associated with tuberculous spondylitis include displacement (Figs. 1OA and lOB) or thinning of the column of contrast material because of a mass effect (Figs. hA and 11 B) and partial or complete obstruction of the flow of myelographic

contrast
Myelography

material.

CT myelography

is helpful

for determining

Cord compression and spinal canal block complications of spinal tuberculosis that can with plain film myelography or CT myelography. ment on the spinal canal may be attributable

are potential be evaluated Encroachto vertebral

the extent of the epidural process (Fig. 1 OC) and for differentiating between an epidural abscess and bony encroachment on the spinal canal [2, 5]. CT myelography also provides additional anatomic information and may reveal unsuspected paraspinal (Fig. 11C) or regional complications associated with spinal tuberculosis.

:.

13

1.

14

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 thinnlng 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 contrast 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 epidural abscess (black arrow) encroaching on thecal sac.

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1995

TUBERCULOSIS

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663

MR

Imaging

The believed 7]. The improves

MR imaging features of spinal tuberculosis are to be diagnostic in the appropriate clinical setting [6, multiplanar imaging capability of MR imaging greatly the detection of vertebral intraosseous abscesses

(Fig. 12), skip lesions (Fig. 13), subligamentous spread of infection, and epidural extension commonly associated with tubenculous spondylitis. Ti-weighted images ofthe spine (Fig. i4A) typically show decreased signal within the affected yentebral bodies, loss of disk height, and panaspinal soft-tissue

FIg. i2.-41-year-oid man with spinal tuberculosis. A, Enhanced Ti-weIghted (750/il) sagittal MR Image shows diffusely Increased signal within T8 vertebral body attributable to tuberculous infection. intraosseous abscess within T9 vertebral body shows thick rim of enhancement. Marked enhancement of epidural abscess is present, and cephalic and caudal extent of spread is clearly defined with use of contrast material. B, Enhanced Ti-weighted (600/il) coronal MR Image of thoracic spine shows thick rIm of enhancement around Intraosseous abscess. Small parasplnai abscesses are seen bilaterally (arrows).

Fig. i3.-5-year-old boy wIth spinal tuberculosis. Contiguous T2-welghted (180W85) sagfttal MR images show two levels of tUbeTCUIOUS Infection. Gibbous deformity is present in upper thoracic region because of nearly complete destruction and collapse of T6 vartebral body. 17 vertebral body Is partially destroyed and angled, and Intervertebral disk space is poorly 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. A, Sagittal Ti-weighted (600/18) MR Image shows decreased signal wIthIn multiple lower theracic vertebral bodies (T8-T1 1). vertebral endplate destruction and disk space involvement also are present at multiple levels. Paraspinal abscess formation Is seen extending anteriorly and posteriorly Into epidural space and encroaching on thecal sac. B and C, Proton density-weighted (A) and T2-welghted (B) (2000/80) sagittal MR Images of thoracic spine show Increased signal intensity within affected vertebral bodIes and disk spaces. Extent of paraspinal abscess formation anteriorly Is better vIsualized on proton densItyweighted 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.

Fig. i5.-45-year-oid man with spinal tuberculosis. Enhanced Ti-weighted (75Gfi2) axial MR Image through T9 vertebral body shows thick rim of enhancement around intraosseous abscess, typical of spinal tuberculosis. Rim of enhancement also Is present around multiple paraspinal abscesses (arrows). EnhancIng epidural abscess (arrowhead) is seen compressing thecal sac.

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FIg. 16.-3-year-oId monary tuberculosis. (700/17) coronal MR

girl with spinal and pulEnhanced Ti-weighted image of spine shows

Fig. i7.-42-year-old

man

with

spinal

tubercu-

losis. Contiguous 12-weighted fast spin-echo (2500185/echo train, 8) saglttal MR images show
Increased signal within utable to tubercuious Li vertebral body attrlbInfection. Disruption of

extensive
ligamentous

paraspinai
spread

abscess

formation.

Sub-

of Infection and large intraosseous abscess are well visualized on thIs coronal Image. Tuberculous Infiltrate in left upper lobe also is identified.

anterosuperior

margin

of vertebral

body

is

present, resulting in paraspinal abscess formation and subilgamentous spread anteriorly. Decreased signal Intensity and narrowing of Ti2Li disk space are attributable to penetration of Infection through dIsk. Intraosseous abscess formation also is present wIthIn L4 vertebral body.

Fig. i8.-45-year-old man wIth history of spinal tuberculosis. Contiguous Ti-weighted (65Wi8) sagthai MR images of thoracic spine obtained postoperatively show autologous fibular graft in place. Multiple tuberculous intraosseous abscesses were drained and debrided during surgery before graft placement and spinal stabilization. Spinal canal is well visualized and uncompromlsed.

masses.

T2-weighted

images

(Figs.

i4B

and

i4C)

often

show

nonspecific

increased

signal

within the areas

of osseous

and

postoperative assessment ofthe spine (Fig. 1 8) and follow-up studies for monitoring the response to therapy.

soft-tissue changes. Contrast-enhanced sequences are helpful in distinguishing between tuberculous spondylitis and other granulomatous spinal infections; the presence of a thick rim of enhancement around paraspinal and intraosseous abscesses (Fig. 15) is reported to be diagnostic of tubencubus spondylitis [8]. Involvement of the paraspinal soft tissues and subligamentous spread of infection often are best evaluated with coronal contrast-enhanced images (Fig. 1 6). The recent development of fast spin-echo techniques (Fig. 17) also provides a myelographic effect without significantly lengthening the examination time. Because of its multiplanar capability and sensitivity in detecting osseous and soft-tissue changes associated with osteomyelitis, MR imaging should be considered the method of choice for imaging spinal tuberculosis [6, 8]. The lack of ionizing radiation and the multiplanan capability of MR imaging make it advantageous for

REFERENCES
1 . Chapman M, Murray RO, Stoker DJ. Tuberculosis of the bones and joints. Semin Roentgenol 1979:14:266-282 2. Weaver P, Lifeso AM. The radiological diagnosis of tuberculosis of the adult spine. Skeletal Radiol i984;12:1 78-186 3. 5hivaram U, Wollschlager C, Khan F, Khan A. Spinal tuberculosis revisited. South Med J 1985;78:681 -684 4. Whelan MA, Naidich DP, Post JD, Chase NE. Computed tomography of spinal tuberculosis. J ComputAssist Tomogr i983;7:25-30 5. LaBerge JM, Brant-Zawadzki M. Evaluation of Potts disease with cornputed tomography. Neuroradiology 1 984;26:429-434 6. Sharif HS, Clark DC, Aabed MY, et al. Granulornatous spinal infections: MA imaging. Radiology i990;177:101-107 7. deRoos A, van Persijn van Meerten EL, Bloom JL, Bluemm AG. MRI of tuberculous spondylitis. AJR 1 986; 147:79-82 8. Sharif HS. Role of MA imaging in the management of spinal infections. AJR i992;158:1333-1 345