spine infections

8/6/2019 Spine Infections

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MR Imaging ofMR Imaging ofSpinal InfectionsSpinal Infections

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2009/02/142009/02/14

Risk factors of spinal infectionsRisk factors of spinal infections

AdvancedAdvanced ageage > 50> 50IntravenousIntravenous drugdrug abuseabuse

ImmunosuppressionImmunosuppression or immune deficiencyor immune deficiency

LongLong--termterm steroidsteroid administrationadministration

DiabetesDiabetes mellitusmellitus

OrganOrgan transplantationtransplantation

MalnutritionMalnutrition

MalignancyMalignancy

Urinary tractUrinary tract instrumentationinstrumentation

Infectious pathwaysInfectious pathways

HematogenousHematogenous

Arterial or venousArterial or venous

routeroute

Direct inoculationDirect inoculation

Contiguous focus ofContiguous focus of

infectioninfection

Direct open spinalDirect open spinaltraumatrauma

PostoperativelyPostoperatively Greenspan A. Orthopedic Radiology:A Practical Approach1997; V-19-3

Vascular anatomy of spineVascular anatomy of spine

Ross JS, Brant-Zawadzki M, et al.Diagnostic Imaging: Spine2004; V-1-5

Yoshioka K, Niinuma H, et al.Radiographics2003; 23:1215-1225

Arterial routeArterial routeSegmental arterySegmental artery

spinal artery spinal artery nutrient equatorialnutrient equatorial

arteryartery

Segmental arterySegmental artery

metaphyseal arterymetaphyseal artery

metaphyseal anastomosing artery metaphyseal anastomosing artery

intermetaphyseal anastomosing artery intermetaphyseal anastomosing artery

MicrocirculationMicrocirculation

Smith AS, Weinstein MA, et al.AJNR1989; 10:619-625

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


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Venous routeVenous route

Retrograde seedingRetrograde seedingof venous blood viaof venous blood via

Batson plexusBatson plexus

IncreasedIncreased

intraabdominalintraabdominal

pressurepressure

Genitourinary tractGenitourinary tract

infectionsinfectionsGroen RJM, Toit DFd, et al.Spine2004; 29:1465-1471

Pathoanatomy of spinal infectionsPathoanatomy of spinal infections

VertebralVertebral endplatesendplates adjacent adjacent disk spacedisk space

adjacent adjacent vertebral bodyvertebral body

paravertebralparavertebral tissuestissues

epiduralepidural spacespace

Resnick D. Diagnosis of Bone and JointDisorders1995; 155:745-749

MRIMRI

CoronalCoronal STIRSTIR

SagittalSagittal T1WI,T1WI,

T2WI, STIRT2WI, STIR

AxialAxial T2WIT2WI

GdGd--enhancedenhanced

T1WI with/withoutT1WI with/without

fat suppressionfat suppressionStoller DW. Magnetic ResonanceImaging in Orthopaeducs &Sports Medicine1997; 1071

MRI of Spinal InfectionsMRI of Spinal Infections

Typical manifestationsTypical manifestations

Pyogenic osteomyelitisPyogenic osteomyelitis

Granulomatous osteomyelitisGranulomatous osteomyelitis

Epidural abscessEpidural abscess

Paraspinal abscessParaspinal abscess

Septic arthritis of facet jointSeptic arthritis of facet joint

Differential diagnosisDifferential diagnosis

Unusual manifestationsUnusual manifestations

Common MRI findings ofCommon MRI findings of

spinal infectionsspinal infections

T1 signalT1 signal with loss of disk margin &with loss of disk margin &

endplate irregularityendplate irregularity

T2 signalT2 signal from intervertebral disk &from intervertebral disk &

adjacent vertebral bodiesadjacent vertebral bodies

EnhancementEnhancement of vertebral bodies,of vertebral bodies,

endplates & annulus (variable)endplates & annulus (variable)

Epidural & paraspinal soft tissuesEpidural & paraspinal soft tissues

Pyogenic osteomyelitisPyogenic osteomyelitis2 adjacent vertebrae2 adjacent vertebrae

withwith intervening diskintervening disk

IllIll--defineddefined marrowmarrow

signal alternationsignal alternation

Loss of vertebralLoss of vertebral

endplate cortexendplate cortex

Obliteration ofObliteration of

intranuclear cleftintranuclear cleftRoss JS, Brant-Zawadzki M, et al.Diagnostic Imaging: Spine2004; V-1-9


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Pyogenic osteomyelitisPyogenic osteomyelitis

Disk spaceDisk space narrowingnarrowingVertebralVertebral collapsecollapse

LumbarLumbar > thoracic >> thoracic >

cervical spinecervical spine

ParaspinalParaspinal epiduralepidural

infiltrative soft tissuesinfiltrative soft tissues

abscessesabscesses


M/69M/69 persistent LBP x 4 months;persistent LBP x 4 months;

colon cancer s/p op. 8 months agocolon cancer s/p op. 8 months ago

T1WI

L1-2

T1WI C+ FSSTIR

L1-2

T2WI T1WI C+

L1-2

T1WI T1WI C+

Antibiotic treatmentAntibiotic treatment

4 months later4 months later

L1-2

T2WI T1WI C+

L1-2

Aspiration: chronic inflammation;Aspiration: chronic inflammation;

Culture: (Culture: (--))


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Granulomatous osteomyelitisGranulomatous osteomyelitis

Relatively intactRelatively intactintervertebral disksintervertebral disks

GibbusGibbus vertebraevertebrae

(25%)(25%)

TT--LL spinespine

LargeLarge paraspinalparaspinal

abscessesabscesses

MultipleMultiple

(non)contiguous(non)contiguousRoss JS, Brant-Zawadzki M, et al.Diagnostic Imaging: Spine2004; III-1-10

M/80M/80 general weakness with LBP x 2.5 months;general weakness with LBP x 2.5 months;

fever & chills x 2 daysfever & chills x 2 days

T1WI

T11-12

STIR T1WI C+ FS

T11-12

Culture:Culture:

Mycobacterium tuberculosisMycobacterium tuberculosis

T2WI T1WI C+

T11

M/42M/42 LBP with bil. sciatica x 2 monthsLBP with bil. sciatica x 2 months

T1WI

L4-5

STIR T1WI C+ FS

L4-5


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T1WI C+T2WI

L5

Surgical debridement:Surgical debridement:

caseating granulomatous inflammation (TB)caseating granulomatous inflammation (TB)

T2WI T1WI C+

S1

Epidural abscessEpidural abscess

EpiduralEpidural phlegmonphlegmon

PosteriorPosterior epidural >epidural >

anterior epidural >anterior epidural >

circumferentialcircumferential

Lower TLower T-- & L& L--spine >spine >

CC-- & upper T& upper T--spinespine

MultiMulti--segmentalsegmental


M/68M/68 LBP with difficulty in walking x 2 wksLBP with difficulty in walking x 2 wks

T1WI

L4-5

T2WI T1WI C+ FS

L4-5

Surgical debridement: osteomyelitis;Surgical debridement: osteomyelitis;

Culture: Staphylococcus aureus (MSSA)Culture: Staphylococcus aureus (MSSA)

T2WI T1WI C+

L5


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T1WI T2WI T1WI C+ FS

T2-9

M/48M/48 Severe back pain with bil. paraplegia x 1 wkSevere back pain with bil. paraplegia x 1 wk

T5

Surgical debridement: abscess;Surgical debridement: abscess;

Culture: Staphylococcus aureusCulture: Staphylococcus aureus

T2WI T1WI C+

Paraspinal abscessParaspinal abscess

ParavertebralParavertebral

phlegmonphlegmon

Obliterated soft tissueObliterated soft tissue

fascial planefascial plane

IntraIntra--abscessabscess gasgas

CalcifiedCalcified psoaspsoasabscessesabscesses

ReactiveReactive LAPLAPRoss JS, Brant-Zawadzki M, et al.Diagnostic Imaging: Spine2004; V-1-30

F/52F/52 progressive LBP with bil. sciatica x 3 wksprogressive LBP with bil. sciatica x 3 wks

T1WI

L3-4

STIR T1WI C+ FS

L3-4



T2WI T1WI C+

L3-4


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F/43F/43 LBP x 4 months; traffic accident before;LBP x 4 months; traffic accident before;

Echo: retroperitoneal cystic massEcho: retroperitoneal cystic mass

T12

STIR T1WI C+ FS

T11-L1

T1WI T2WI

T11-L1

Culture:Culture:

Mycobacterium tuberculosisMycobacterium tuberculosis

STIR T1WI C+ FS

T12

Septic arthritis of facet jointSeptic arthritis of facet jointLumbarLumbar spine (97%)spine (97%)

TypicallyTypically single levelsingle level

involvementinvolvement

Facet jointFacet joint wideningwidening

Eroded facetEroded facet cortexcortex

AdjacentAdjacent soft tissuesoft tissue

edema & abscessesedema & abscesses


M/73M/73 LBP with bil. sciatica x 2.5 months;LBP with bil. sciatica x 2.5 months;

gastric cancer s/p op. 4 months agogastric cancer s/p op. 4 months ago

STIR T1WI C+ FS

L4-5


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Blood culture:Blood culture:

Enterococcus faecalisEnterococcus faecalis

T2WI T1WI C+

L4-5

Differential diagnosis ofDifferential diagnosis of

spinal infections (1)spinal infections (1)

Pyogenic infectionPyogenic infection

Staphylococcus aureusStaphylococcus aureus, Pseudomonas, Pseudomonas

speciesspecies

RemarkableRemarkable paraspinal inflammatory tissueparaspinal inflammatory tissue

NonNon--pyogenic infectionpyogenic infection

TuberculosisTuberculosis, fungus, yeast, or parasitic, fungus, yeast, or parasiticorganismsorganisms

LimitedLimited paraspinal inflammatory tissueparaspinal inflammatory tissue

STIR T1WI C+ FS

L3-4

F/52F/52 Surgical debridement: osteomyelitis;Surgical debridement: osteomyelitis;


T1WI C+ FSSTIR

L4-5

M/42M/42 Surgical debridement: caseatingSurgical debridement: caseating

granulomatous inflammation (TB)granulomatous inflammation (TB)

Differential diagnosis ofDifferential diagnosis of


Degenerative endplate changesDegenerative endplate changes

Modic type 1: vascularized fibrous tissueModic type 1: vascularized fibrous tissue

Erosive intervertebral osteochondrosisErosive intervertebral osteochondrosis

UnremarkableUnremarkable paraspinal inflammatory tissueparaspinal inflammatory tissue


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STIRT1WI

L4-5

M/78M/78 LBP x 2.5 monthsLBP x 2.5 months

T1WI C+

Type 1Type 1

degenerative endplate changesdegenerative endplate changes

T1WI C+ FS

L4-5

L2-3

2 months later

M/55M/55 Nasopharyngeal cancer s/p CCRTNasopharyngeal cancer s/p CCRT

LBP with low grade fever x monthsLBP with low grade fever x months

T1WI T2WI

L2-3

L2-3

T2WISTIR

Laminectomy: myxomatous degenerationLaminectomy: myxomatous degeneration

of disk with irregular new bone formationof disk with irregular new bone formationErosive intervertebral osteochondrosisErosive intervertebral osteochondrosis

T1WI STIR

L4-5

M/48M/48 LBP with fever & chills x 1 wkLBP with fever & chills x 1 wk

Echo: r/o infectious endocarditisEcho: r/o infectious endocarditis


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L4-5

T1WI C+T1WI C+ FS


Blood culture: Gram (+) cocciBlood culture: Gram (+) cocci

Unusual Manifestations ofUnusual Manifestations of


Single segmentSingle segmentvertebral osteomyelitisvertebral osteomyelitis

Anterior corticalAnterior cortical

disruption (100%)disruption (100%)

Upward subligamentousUpward subligamentous

spread (100%)spread (100%)

Upper disk involvementUpper disk involvement

(66.6%)(66.6%)

T2WI

Shih et al. Clin Imaging

1999; 23:159-67

L2

T2WIT1WI

F/70F/70 Diabetes mellitus x 20 yearsDiabetes mellitus x 20 years

Flank pain x 1 monthFlank pain x 1 month

T2WIT1WI

L2

L2-3

Analgesics treatmentAnalgesics treatment

1 month later1 month later

T1WI T2WI T1WI C+ FS

L2-3

1 month ago

Biopsy: osteomyelitisBiopsy: osteomyelitis

Blood culture: StaphylococcusBlood culture: Staphylococcusaureus (MSSA)aureus (MSSA)


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Unusual Manifestations ofUnusual Manifestations of


Vertebral osteomyelitisVertebral osteomyelitismimicking metastasesmimicking metastases

Preserved intervertebralPreserved intervertebral

disks (100%)disks (100%)

Llimited paraspinal orLlimited paraspinal or

epidural inflammatoryepidural inflammatory

tissue (86%)tissue (86%)

Posterior elementPosterior element

involvement (43%)involvement (43%)

Hsu et al. AJNR

2008; 29:1104-1110

STIR T1WI T1WI C+ FSSTIR

F/46F/46 Recurrent Salmonellosis x 9 monthsRecurrent Salmonellosis x 9 months

Fever x 2 daysFever x 2 days

T11

T2WI T1WI C+

Biopsy: chronic osteomyelitisBiopsy: chronic osteomyelitis

Blood culture: SalmonellaBlood culture: Salmonella

T1WI STIR T1WI C+ FS

Antibiotics treatmentAntibiotics treatment

12 month later12 month later

DWIDWI

A powerful tool for evaluatingA powerful tool for evaluating

bone marrow infiltrationbone marrow infiltration

Apparent diffusionApparent diffusion

coefficient (ADC)coefficient (ADC)

Highly specific and veryHighly specific and very

sensitive to differentiatesensitive to differentiate

betweenbetween malignantmalignant andand

benignbenign skeletal processesskeletal processes

Diffusion Weighted ImagingDiffusion Weighted Imaging

of Bone Marrow Pathologiesof Bone Marrow Pathologies

DW-EPIb= 880

Metastasis

ADC= 0.79 mm2/s

Aggressive

osteomyelitis

ADC= 1.48 mm2/s

Herneth et al. EJR2005; 55:74-83

T1WI STIR DW-SSFP

Vertebral

osteomyelitis

No signal aberration, mimickingrestricted diffusion

Hypercellularity? Macromolecules?

Diffusion Weighted ImagingDiffusion Weighted Imaging

Herneth et al. EJR2005; 55:74-83


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SuperparamagneticSuperparamagneticiron oxide (SPIO)iron oxide (SPIO)

Comparison of SI usingComparison of SI using

STIRSTIR images beforeimages before

and 3hrs afterand 3hrs after

ferucarbotran (< 20 nm)ferucarbotran (< 20 nm)

injectioninjection

Useful in differentiatingUseful in differentiating

bonebone metastasismetastasis andand

osteomyelitisosteomyelitis

SPIOSPIO--enhanced MRIenhanced MRI

for Bone Marrow Imagingfor Bone Marrow Imaging

RE: relative enhancement (%)

Fukuda et al. Magn Reson Med Sci2006; 5:191-96

SPIOSPIO--enhanced MRIenhanced MRI

Metastasis Osteomyelitis

Fukuda et al. Magn Reson Med Sci

2006; 5:191-96

STIR

Typical manifestationsTypical manifestations

Pyogenic vs. granulomatous osteomyelitisPyogenic vs. granulomatous osteomyelitis

Epidural/paraspinal abscessEpidural/paraspinal abscess

Differential DiagnosisDifferential Diagnosis

Type 1 degenerative endplate changesType 1 degenerative endplate changes

Erosive intervertebral osteochondrosisErosive intervertebral osteochondrosis

Unusual ManifestationsUnusual Manifestations

Single segment vertebral osteomyelitisSingle segment vertebral osteomyelitis

Vertebral osteomyelitis mimicking metastasesVertebral osteomyelitis mimicking metastases

ConclusionConclusion

Thank YouThank Youfor Your Attentionfor Your Attention

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2009/02/142009/02/14

spine infections

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