TUBERCULOSIS OF THE SPINE: CT AND MR IMAGING FEATURES

A.I. De Backer1, K.J. Mortel2, I.J. Vanschoubroeck3, D. Deeren3, F.M. Vanhoenacker4,5, B.L. De Keulenaer6, P. Bomans3,
M.M. Kockx7

Tuberculosis (TB) remains endemic in most of the developing countries. However, a resurgence of tuberculosis has
also been reported in the past decades in developed countries, not only in the lungs, but also in extrapulmonary
sites, e.g. the vertebral column. Vertebral TB is most often found in the lower thoracic and upper lumbar regions.
Diagnosis is often difficult; clinical findings are usually non-specific and radiologic features may mimic those of other
bacterial, fungal, inflammatory and neoplastic diseases. However, recognition and understanding of the radiological
findings may help in diagnosis. Two distinct patterns of vertebral tuberculosis may be seen: the classic finding of
spondylodiscitis, characterized by destruction of two or more contiguous vertebrae and opposed end plates, disk
infection, and commonly a paraspinal mass or collection. The second pattern, increasing in frequency, is a atypical
form of spondylitis without disk involvement.The value of CT and MR imaging are discussed in the diagnostic work-
up of vertebral tuberculosis. A positive culture or histopathologic analysis of CT-guided needle aspiration or biopsy
specimens is required in the absence of pulmonary manifestations of tuberculosis for definitive diagnosis and ade-
quate treatment.

Key-words: Tuberculosis, musculoskeletal Spine, radiography Spine, CT Spine, MR.

Although TB was a frequent and remains endemic in most of the from countries with a high preva-
lethal disease prior to the develop- developing countries. Moreover, a lence and in patients with immun-
ment of antibiotics, since the 1950s resurgence of TB has been observed odeficiency (HIV and AIDS) or other
a steady decrease in its incidence since the mid-1980s in developed underlying chronic diseases (dia-
has been noted. However, TB countries, mainly in immigrants betes mellitus, chronic renal failure,
chronic obstructive pulmonary dis-
ease, liver cirrhosis, leukemia and
lymphoma). In addition, numerous
From: Departments of 1. Radiology, 3. Internal Medicine and 7. Pathology, Zieken- sociological factors contributed to
huisnetwerk Antwerpen, Antwerp, Belgium, Department of 2. Radiology, Division of
Abdominal Imaging and Intervention, Brigham and Womens Hospital, Harvard
the re-emergence of tuberculosis: a
Medical School, Boston, USA, Department of 4. Radiology, Campus Duffel, AZ St- growing elderly population, over-
Maarten, Duffel, Belgium, Department of 5. Radiology, Universitair Ziekenhuis crowded prisons, poor living facili-
Antwerpen, Edegem, Belgium, 6. Intensive Care Unit, Royal Darwin Hospital, ties, poor nutrition status, alcohol
Rocklands, Northern Territory, Australia. and drug abuse, and homelessness
Address for correspondence: Dr A.I. De Backer, M.D., Department of Radiology, (1, 2).
Stuivenberg, Ziekenhuisnetwerk Antwerpen, Lange Beeldekensstraat 267, B-2060 TB involves both pulmonary and
Antwerp, Belgium. extrapulmonary sites. Skeletal
 PROCEEDINGS OF THE SRBR-KBVR OSTEOARTICULAR SECTION MARCH MEETING 93

B
A
Fig. 1. 30-year-old Maroc born man with L1-L2 tuberculous spondylodiscitis pre-
senting with low back pain since several weeks, hemoptysis, night fever and weight
loss. A, Plain radiograph shows slight disk space narrowing. B, Axial and C, coronal
contrast-enhanced T1-weighted image show peripheral enhancement in the paraver-
tebral abscess and increased enhancement of bone marrow of the vertebral body L1
and L2. Destruction of adjacent cortical bone and vertebral endplates is seen.

involvement has been reported to
occur in 1-5% of all TB patients (3). In
developing countries, skeletal TB
appears to be more common in chil-
dren, whereas in industrialized
nations adults are principally affect-
ed (4). No predilection for either sex
has been observed (5). The vertebral
column is the most common site of
osseous involvement, comprising in
most series about 50% of cases of
skeletal TB (6). The most common
location is the vertebral body of L1.
Pathogenesis and pathology
There is a general consent that
spread of TB to the spine results
from hematogeneous dissemination
of tubercle bacilli from a primary or
reactivated focus. Mycobacterium
tuberculosis may stay dormant in
the vertebra for an extended length
of time before clinical manifesta-
tions may develop. Rarely, vertebral
tuberculosis may result by exten-
sion from a paraspinal infection.
Lymphatic drainage from an adja-
cent affected area such as the pleura
or a kidney may alternatively cause
spread of tubercle bacilli (6-8).
Once in the vertebra, a granulo-
matous lesion develops containing
central caseating necrosis, multinu-
cleated giant cells, epithelioid cells
and peripheral lymphocytes. The
inflammatory reaction, with the for-
mation of granulation tissue, may
cause bone expansion with gradual-
ly trabecular destruction, progres-
sive demineralization, bone destruc-
tion and, in a later stage, eventually
cartilage destruction with subse-
quent involvement of the adjacent
disc space. The margins of the bony,
lytic lesions are distinct and usually
there is no bone regeneration or
periosteal reaction. Fibrosis, bone
sclerosis and a resulting ankylosis
occur when the disease has chroni-
cally faded out. Paraosseous
abscesses (so-called cold abscess-
es), erosion and sinus tract forma-
tion may also develop (9).
Clinical manifestations
The early diagnosis and prompt
treatment of vertebral TB are of fun-
damental importance in preventing
severe spinal deformity (gibbus)
resulting from an acute kyphotic
angulation. A delay between the ini-
tial symptoms and the etiological
diagnosis is possibly caused by the
low incidence of vertebral TB and
the slow development of the clinical
features. Time from symptom onset
to diagnosis may range from sever-
al days to up to three years, but
mostly spans several months (10).
Typically, multiple vertebral bod-
ies and disc spaces are involved. The
resulting presenting symptoms may
consist of local tenderness, limita-
tions of motion and, in the late phas-
es of the disease, severe spinal
deformity (gibbus) attributed to an
acute kyphotic angulation. Neuro-
logical symptoms and complica-
tions may occur in the acute and late
stages of the disease. Radicular
pain, severe cauda equina syn-
drome, and spinal cord compression
with paraplegia may result from
edema, vascular engorgement, ver-
tebral collapse, retropulsed debris,
meningomyelitis or subarachnoid
collections. Manifestations of sys-
temic TB may be present and include
low-grade fever with evening rise,
lethargy, malaise, night sweats,
anorexia and weight loss.
Diagnostic tests
The patient may have a normal
white blood cell count (WBC), and a
normal erythrocyte sedimentation
rate (ESR) in up to 10% of the cases
(11). Abnormal WBC, C-reactive pro-
tein level or complete blood count
does not contribute to the diagno-
sis. The finding of elevated ESR does
not advance the diagnosis, but may
be useful to follow during treat-
ment. Tuberculin skin testing when
positive is not of much help either
especially in endemic areas or with
recipients of the bacille Calmette-
Gurin vaccine (12). Furthermore,
the Mantoux and purified protein
skin tests may be negative in as
many as 14% of the patients with
vertebral TB (11). A negative skin test
may be caused by anergy, particu-
larly with immunosuppressed and
older patients (6). Finally, the chest
radiographs and exposure history
may not be positive.
Microbiological and/or histologi-
cal confirmation is required for the
final diagnosis of vertebral TB and
fine-needle aspirate, imaging-guid-
ed percutaneous biopsy, or open
biopsy may be essential. CT-guided
fine needle aspiration, by using
standard 22-gauge technique, has
been reported as a reasonably accu-
94 JBRBTR, 2005, 88 (2)

C D
Fig. 2. 37-year-old male immigrant with spinal pain caused by T8 tuberculous
spondylitis complicated by vertebral collapse. A, Plain radiograph shows height loss
A of vertebral body and relative sparing of the intervertebral disc spaces. B, CT of the
chest clearly demonstrates paravertebral mass showing peripheral enhancement. C,
STIR MR image confirms vertebral collapse, relative sparing of the intervertebral disc,
and shows convex posterior cortex. The vertebral body is hyperintense on STIR MR
images. D, Coronal contrast-enhanced T1-weighted image shows marked height loss
of the vertebral body, sparing of the intervertebral disc and enhancing paravertebral
inflammatory mass.

eases, such as sarcoidosis, brucel- narrowing secondary to herniation

losis, fungi or atypical mycobacte-
ria, and gout.
B Radiological features
Vertebral TB is most often found
in the lower thoracic and upper lum-
bar regions. Cervical and sacral
rate means of obtaining material for involvement is uncommon. Two dis-
histologic evaluation and culture tinct patterns of vertebral osteo-
(13). Percutaneous aspirates have myelitis may be seen. The classic
been reported to yield more positive finding of spondylodiscitis is charac-
smears for acid-fast bacilli than sur- terized by destruction of two or
gical or percutaneous needle biop- more contiguous vertebrae and
sies, while surgical and percuta- opposed end plates, disk infection,
neous biopsies show no differences and commonly a paraspinal mass or
in bacteriologic and histologic find- collection; the increasingly more
ings (10). common atypical form of spondyli-
Histopathological diagnosis is tis without disk involvement is the
suggested by the presence of second pattern (10). The infection
caseating granulomas and con- typically commences at the superior
firmed by showing acid-fast bacilli or inferior anterior vertebral body
on Ziehl-Nielsen staining; by corner adjacent to the discoverte-
demonstration of mycobacterial bral junction, and spreads by sub-
DNA on a highly specific poly- ligamentous extension and penetra-
merase chain reaction-based (PCR) tion of the subchondral plate. With
assay or by showing growth of acid- further disease progression, the lat-
fast bacilli on culture (4, 6). If bacte- eral and anterior cortices of the ver-
riology is negative and only non- tebral body may become destroyed,
caseating granulomas are found on leading to collapse, kyphosis and
histological examination additional vertebral instability. Because the
tests may be required to differenti- disk is avascular, disk infection is
ate it from other granulomatous dis- seen late, and results in disk interval
of the disk into the undermined, col-
lapsed vertebral body. When two
contiguous vertebral bodies are
involved, the nutrition of the disk is
affected. Collapse and wedging of
multiple vertebral bodies because of
intraosseus cavitation result in the
characteristic gibbus deformity. Less
often, posterior elements of the
spine may be involved. The latter
finding has been reported to occur
characteristically in TB, and is not
found in pyogenic infections of the
spine (14, 15). Involvement of the
neural arch may occur either alone
or in combination with vertebral
body lesions (10). Other atypical pat-
terns of tuberculous involvement of
the spine consist of infection of a
single vertebra or multiple nonadja-
cent vertebrae (skip lesions) (6,10).
Paravertebral and/or epidural soft
tissue infection with subsequent
abscess formation may track for
considerable distances beneath the
anterior or posterior longitudinal
ligament, and may discharge by
sinus tracts in unusual locations,
such as groin, buttock, or chest.
Advanced disease may demonstrate
abscesses tracking along fascial
planes. Paraspinal infection may
involve the iliopsoas muscle, result-
 PROCEEDINGS OF THE SRBR-KBVR OSTEOARTICULAR SECTION MARCH MEETING 95

B C

E
Fig. 3. 26-year-old Senegal born man
presenting with chronic low back pain,
paresthesia and paraparesis of the lower
limbs caused by tuberculous T11-T12
spondylodiscitis, epidural abscess and
associated radiculomyelitis. A, CT shows
D bone destruction centrally and posterior
located in the vertebral body and destruc-
tion of posterior border T12. B, Sagittal T1-weighted, C, Sagittal T2-weighted D, Sagittal
STIR MR image shows vertebral lesion characterized by increased signal intensity on
T1-weighted image and high signal intensity on T2-weighted and STIR image. These
findings are consistent with intraosseous abscess. Destruction of the upper endplate
T12 is noted with T11-T12 disk involvement. Sparing of the lower endplate T12 and nor-
mal intervertebral disk T12-L1 is noted. A large subligamentous abscess is present and
epidural involvement noted. E, Axial and F, Sagittal contrast-enhanced T1-weighted MR
image shows peripheral enhancement of intraossous and paravertebral abscess.
Enhancement of vertebral disk T11-T12 representing discitis is seen. Marked enhance-
F
ment of epidural-leptomeningeal complex encasing spinal cord is noted. The nonen-
hancing extradural area represents epidural abscess.

ing in psoas abscess and may
extend into the groin and thigh. The
paravertebral collection in a high
cervical infection may be seen as a
retropharyngeal collection. Calcifi-
cation within the abscess is virtually
pathognomonic of tuberculosis and
is best seen on CT scan (16).
Plain radiography
Plain radiography of tuberculous
spondylodiscitis may demonstrate
loss of vertebral height, disk space
narrowing, erosions, indistinction of
the end plates, paravertebral mass-
es, and soft tissue calcifications (6).
However, plain radiography is
insensitive for the early detection of
vertebral TB (Fig. 1). Disk space nar-
rowing may be quite subtle and ver-
tebral involvement is not detected
until at least 50% of the trabecular
bone is lost. A paravertebral abscess
may hardly be recognized in the tho-
96 JBRBTR, 2005, 88 (2)

Computed tomography

CT is of great importance in
demonstrating small, early foci of
bone infection and the extension of
the bone and soft tissue involve-
ment. CT may also be used in the
follow-up of patients under treat-
ment with antituberculous chemo-
therapy. End plate destruction, frag-
mentation of the vertebrae, and par-
A avertebral calcifications are ade-
quately demonstrated (Fig. 2-5).
After administration of intravenous
iodinated contrast paravertebral
and/or epidural abscesses may
show thick, nodular wall-enhance-
ment and a sinus tract may ade-
quately be delineated (7). However,
beam hardening may impair detec-
tion of more subtle epidural involve-
ment. CT-guided fine needle aspira-
tion has become widely accepted
for both culture and histological
diagnosis.

Magnetic resonance imaging

Multiplanar capability and superi-

or tissue contrast make MR imaging
the modality of first choice in the
evaluation and follow-up of spondy-
lodiscitis. A major advantage of MR
C imaging, compared with CT scan
and plain radiography, is the higher
sensitivity for detection of early
inflammatory bone marrow changes
and infiltrative end plate changes in
the vertebra (Fig. 1). MR imaging is
mostly useful in delineating par-
avertebral, epidural, and intra-
osseous abscesses and in evaluat-
ing the extent of cord compression
and the presence of intramedullary
lesions (Fig. 1-5).
MR imaging findings in tubercu-
lous osteomyelitis may be non-spe-
B D cific and consist of low signal inten-
sity (SI) on T1-weighted images and
Fig. 4. 41-year-old Kosovo born woman with thoracic pain of several months a heterogeneous increased SI on T2-
duration caused by spondylodiscitis T7-T8. A, CT shows osteolytic lesion located weighted images. With intraosseous
anterolaterally in the vertebral body T8 and paravertebral abscess. Heterotopic calcifi- abscess, low SI on T1-weighted
cations are seen within the abscess. B, Sagittal T1-weighted C, Sagittal T2-weighted images and very high SI on T2-
shows decreased signal intensity on T1-weighted MR image of both vertebral bodies weighted images may be seen locat-
and disc space T7-T8 with destruction of the opposed end plates. T2-weighted MR ed centrally in the vertebral body (6,
image shows increased signal intensity in the vertebral disc and areas of markedly 7) (Fig. 3). However, characteristic
decreased signal intensity in the vertebral bodies T7 and T8. Anterior subligamentous findings of MRI in vertebral TB
abscess, epidural involvement and extension of inflammation in T6 with preservation
include decreased signal intensity
of the lower endplate is noted. D, Axial contrast-enhanced T1-weighted image shows
peripheral enhancement of paravertebral abscess and marked enhancement of on T1-weighted images of both ver-
epidural involvement. Epidural involvement results in displacement of spinal cord. tebral bodies and disc spaces, but a
signal intensity that is increased in
the vertebral disc and markedly
racic spine even with adequately thoracic spine. Finally, no specific or decreased in the vertebral bodies on
penetrated views (Fig. 2), or only pathognomonic plain radiographic T2-weighted images (17) (Fig. 4).
may result in a barely visible asym- findings distinguish tuberculous With late chronic vertebral tubercu-
metry or bulging of the psoas shad- from pyogenic spinal infection, and losis, signal intensity is variable
ow. Furthermore, plain radiography correlation with the clinical findings (15).
is of limited value in evaluation of and duration of symptoms is essen- The intravenous administration
the posterior arch, particularly in the tial. of gadolinium chelates allows better
 PROCEEDINGS OF THE SRBR-KBVR OSTEOARTICULAR SECTION MARCH MEETING
A in adults. Retrospective study of
Fig. 5. 36-year-old woman with long
history of drug abuse presenting with
acute onset of paraplegia. A, CT shows
fragmentation of vertebral body and par-
avertebral soft tissue mass and paraver-
tebral calcifications. B, Sagittal STIR MR
image shows extensive spondylodiscitis
of T8-T10 characterized by destruction of
vertebral bodies and disc spaces. Large
paravertebral and epidural abscesses are
noted, which are of high signal intensity
on T2-weighted (not shown) and STIR
images.
delineation of epidural abscesses
and masses, and cord and nerve
root compromise. Peripheral
enhancement is seen in abscesses
and represents granulomatous
infectious tissue while central low SI
on T1-weighted contrast-enhanced
images represents central necrosis
(Fig. 1, 3). With tuberculous spondy-
lodiscitis, the disk shows signal
characteristics seen with pyogenic
discitis in at least 75% of cases;
bright signal on T2-weighted
images, decreased signal on T1-
weighted images, and enhancement
after contrast administration (6)
(Fig. 4). Disk space preservation
(Fig. 3), normal signal intensity, and
lack of enhancement may also been
seen.
Differential diagnosis of vertebral
tuberculosis
Many infectious processes may
have imaging findings similar to
those of vertebral spondylodiscitis.
These include low-grade pyogenic
infections, such as brucellosis, and
other bacterial and fungal infec-
tions. Granulomatous diseases (sar-
coidosis), traumatic and osteoporot-
ic fractures, and primary and
metastatic neoplasms may have
features comparable to that of verte-
bral tuberculosis. However, the
diagnosis of tuberculosis is favored
if a large, calcified paravertebral
B surgical management, and outcome.
mass and absence of sclerosis or
new bone formation are noted.
Conversely, a reduced height of an
intervertebral disc is only rarely
seen in neoplastic forms, and a
rapid loss of height in the disc with
destruction, along with extensive
sclerosis, the absence of gibbus
deformities and the absence of cal-
cified paravertebral masses are in
favor of a pyogenic spondylodisci-
tis. Characteristic features of brucel-
lar spondylitis include gas within
the disk, a minimal associated
paraspinal mass, absence of kypho-
sis and a predilection for the lower
lumbar spine (9, 16). CT-guided fine
needle biopsy may be necessary
and allows prompt diagnosis and
proper treatment.
Conclusion
TB is still a serious health care
problem affecting mainly immi-
grants and immunocompromised
patients. Vertebral TB occurs very
rare. If untreated, vertebral TB car-
ries the risk of serious complications
as consequence of vertebral col-
lapse and spinal cord compression.
Diagnosis is often difficult because
many diseases may have similar
imaging findings. However, to diag-
nose vertebral TB one must consider
the possibility. MR imaging and to a
lesser extend CT are cornerstone
imaging modalities for evaluation
vertebral TB. CT-guided fine needle
aspiration is a reasonable accurate
means of obtaining material for
histopathologic evaluation and cul-
ture.
97
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