This document discusses spinal tuberculosis, including its presentation, imaging findings, and treatment. It describes the following key points: - Spinal tuberculosis most commonly affects the thoracolumbar junction and presents with back pain and deformity. Imaging shows destruction of vertebral bodies. - On MRI, paradiskal lesions narrow the intervertebral disk space while anterior lesions involve vertebral bodies under the anterior longitudinal ligament. - Complications include paraplegia from epidural abscesses or vertebral collapse compressing the spinal cord. - Treatment involves chemotherapy with antitubercular drugs. Surgery is indicated for neurological deficits, involvement of multiple vertebrae risking kyphosis, or if

1. Spinal Tuberculosis
Spinal tuberculosis
Alwan Hussein Dr

2. Case presentation 2
47 years old.
Destruction of D9 - D10
Presented with back pain and
deformity ( sharp angulations /
kyphos ).
Paraesthesia and weakness of the
legs.

5. Treatment
Anterior approach.
(Left lateral decubitus position)
Corpectomy (removal of all
destructed and dead tissue with
drainage of abscess) + screws &
rod fixation + bone graft (rib graft).

8. *tuberculosis of the spine accounts for more than 50%
of musculoskeletal tuberculosis.
*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
*In the developed countries, musculoskeletal
tuberculosis is uncommon, but its incidence is reported
to be greater in older individuals*

9. 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
*delayed hypersensitivity immune reaction
*The first stage is a pre-pus inflammatory reaction with Langerhans' giant
cells, epithelioid cells, and lymphocytes

10. 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

11. 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
areas are affected most often because of the generous arterial
and venous supply and the high O2 pressure requirement of the
tuberculosis bacilli

13. Site
The most frequent site of spinal tuberculosis is the
thoracolumbar junction . The incidence decreases above and
below this level. However, any segment of the spine can be
involved

14. 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).

15. 22-year-old woman with paradiskal lesion of thoracolumbar
junction, presenting with stiff back. Coronal T1-weighted MR
image shows left psoas abscess (arrows).

16. 20-year-old woman with cervical spinal tuberculosis, presenting
with fever and stiff neck, but no neurologic deficit. Sagittal 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

17. 18-year-old woman with sacral tuberculosis presenting with
lower backache. Sagittal T1-weighted MR image shows erosion
of second sacral segment (arrow) with pus filling sacral canal
and large presacral component

18. 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

19. Patterns of
Vertebral
Involvement

20. 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:
1-paradiskal,
2-anterior,
3-and central lesions

21. Paradiskal Lesions
A paradiskal lesion is adjacent to the intervertebral disk leading to a
narrowing of the disk space . The disk space narrowing is caused
either by
1-destruction of subchondral bone with subsequent herniation of the
disk into the vertebral body
2-or by direct involvement of the disk .
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

22. 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.

23. 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

24. Anterior Lesions
*The anterior type is a subperiosteal lesion under the anterior
longitudinal ligament .
*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 .
MR imaging shows the subligamentous abscess, preservation
of the disks, and abnormal signal involving multiple vertebral
segments representing vertebral tuberculous osteomyelitis.

25. 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).

26. 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.

27. 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

28. Central Lesions
The central lesion is centered on the vertebral body.
The disk is not involved .
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

29. 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.

30. 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

31. Posterior Element
Tuberculous involvement of the posterior elements is rare . MR
imaging shows evidence of bone erosion and the
associated abscess

32. 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
and C3 levels (arrows).

33. 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

34. 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

35. 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.

36. Complications of the Tuberculous Spine
*Paraplegia and sometimes quadriplegia are
serious complications of the tuberculous spine
seen in approximately 10% of patients .
1-Copious epidural pus and granulation tissue alone
2- or in combination with vertebral collapse,
subluxation, or dislocation ( produce cord
compression.
Rarely, the pus penetrates the dura resulting in
severe meningomyelitis

37. 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

38. 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.

39. 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.

40. 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

41. 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

42. 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.
Orthopedic principles
-----------------------------------
1-Typically, infectious spondylitis is characterized by involvement of
the intervertebral disk.
2-A history of chronicity and slow progression is suggestive of
tuberculosis.
3-Moreover, inflammatory collections tend to be larger in
tuberculosis than in pyogenic spondylitis.
4-In the central and posterior element forms of tuberculosis, only
biopsy can achieve a provide diagnosis

44. pyogenic infectious spondylitis(left)
TB spinal cord(right)

45. What about MR imaging role?
1-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.
3- MR imaging provides critical information about the
spinal cord and the extent of the epidural pus in
patients presenting with neurologic deficits..

46. 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

47. Treatment

48. begins with chemotherapy and general
measures to improve the patient’s
physiologic state.
Studies undertaken by the Medical
Research Council of Great Britain found
that outpatient chemotherapy is highly
effective for “uncomplicated” spinal
tuberculosis(90 %,)

49. 2RHZE/4RH

50. Prof.mohammed
Reza M.D chicago

51. Indication for
surgery
I/ The development of
neurological deficit is a
strong indication
for surgical treatment

52. II/ The indications for surgery in
the absence of neurological
symptoms

53. 1-Involvement of more than one vertebra
significantly increases the risk of kyphosis
and collapse.
Open biopsy for diagnosis, débridement, and
grafting with or without anterior instrumentation may
offer the most direct approach in these patients*

54. 2-Resistance to
chemotherapy and
recurrence of the disease
are other indications for
radical surgical
treatment

55. 3-ABSCESS DRAINAGE BY
ANATOMICAL LEVEL
Drainage of a
a/ Retropharyngeal Abscess

56. b/ Dorsal Spine

57. c/ Drainage of paravertebral
abscess.

58. D-Drainage of Psoas Abscess

59. OKU 2008(approach)