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Tuberculous Spondylitis

Salim Samuel, MD
Liangge Hsu, MD

April 22, 1997

Presentation

A 59-year-old woman presented with a 3-month history of progressive low back pain and a 2-week history of increasing bilateral leg pain and weakness.

Imaging Findings

Plain AP radiograph of the lower lumbar spine
Sagittal T1-weighted MR image of the lumbar spine
Gadolinium-enhanced T1 MR image at L4
Bone window CT image at L4

An anteroposterior (AP) plain film of the lower lumbar spine demonstrates severe compression of the L4 vertebral body (arrow).

A sagittal T1-weighted magnetic resonance (MR) image of the lumbar spine again shows severe compression of L4 (short arrow) with retropulsion into the spinal canal. There is also involvement of the inferior/posterior L3 vertebral body (long arrow). The disk spaces appear to be maintained.

A gadolinium-enhanced axial T1-weighted MR image at L4 demonstrates paraspinal extension with bilateral enhancing psoas abscesses (arrows). An axial bone window image from a computed tomography (CT) study at the same level shows calcification within the psoas collections. Both images show severe central spinal stenosis with sparing of the posterior elements (arrow).

Differential Diagnosis

Possible causes of the above findings include infectious, neoplastic, and traumatic etiologies. Staphylococcus aureus is the most common pyogenic infection of the spine, usually presenting acutely and often demonstrating early disc space involvement. Mycobacterium tuberculosis has a more indolent course and is commonly associated with paraspinous extension. Tuberculous and fungal spondylitis occur most often in immunocompromised and debilitated patients.

Metastatic disease and multiple myeloma usually involve the posterior elements while sparing the disc spaces.

This patient had no history of trauma to the area.

Diagnosis

Tuberculous spondylitis involving L3 and L4

Discussion

Tuberculous spondylitis, or Pott's disease, results from the hematogenous spread of M. tuberculosis. Bony destruction usually results in some degree of vertebral collapse, while anterior wedging causes the typical gibbous deformity of focal kiphosis. Usually there is involvement of multiple vertebral bodies, relative sparing of the intervertebral discs and posterior elements, and limited periosteal reaction. Rare cases of isolated posterior vertebral body involvement have been reported. Paraspinal extension is very common, with calcification in a psoas abscess being nearly pathognomonic for tuberculous infection.

Symptoms of tuberculous infection are distinct from those of pyogenic infection in that patients may be afebrile with a normal white blood cell count and erythrocyte sedimentation rate. The tubercle bacillus is notably difficult to isolate, with only 50% of biopsies yielding positive cultures.

The disease often has an insidious course and is most common in immunosuppressed patients, such as those with AIDS. There is often a history of pulmonary tuberculosis or a positive purified protein derivative of tuberculin (PPD) test.

Treatment remains controversial, but surgical decompression is indicated for patients with neurologic impairment.

References

1. Resnick D. Diagnosis of bone and joint disorders. Philadelphia: Saunders, 1995;2463-2474.

2. St Amour TE, Hodges SC, et al. MRI of the spine. New York: Raven, 1994:635-643.

3. Sharif HS, Morgan JL, et al. Role of CT and MR imaging in the management of tuberculous spondylitis. Radiologic Clinics of North America 1995;33:787-803.

4. Osborn AG. Diagnostic neuroradiology. St Louis: Mosby, 1994:820-824.

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