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Pictorial Essay
Spectrum of MR Imaging Findings in Spinal Tuberculosis
Srikanth Moorthy 1 and Nirmal K. Prabhu

uberculosis, caused by Mycobacterium tuberculosis, remains a major

public health hazard, especially in
developing countries in which poverty, malnutrition, and the presence of drug-resistant strains
have combined to aid the spread of the disease.
Infection with HIV increases the risk of reactiva-

tion of dormant tuberculosis and the risk of acquiring the primary infection. In those coinfected,
a high frequency of extrapulmonary disease has
been observed [1, 2]. tuberculosis of the spine
accounts for more than 50% of musculoskeletal
tuberculosis [3]. 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 [4]. In the developed countries,
musculoskeletal tuberculosis is uncommon, but
its incidence is reported to be greater in older
individuals [2]. The relative rarity and varied

Fig. 1.22-year-old woman with paradiskal lesion of thoracolumbar junction, presenting with stiff back.
A, Sagittal gradient-recalled echo T2-weighted MR image shows hyperintense paradiskal lesion (arrow) in T12 inferior endplate. Hyperintense signal in adjacent T12L1 vertebral bodies indicates marrow edema. Note small prevertebral fluid collection (arrowhead).
B, Coronal spin-echo T1-weighted MR image shows left psoas abscess (arrows).

Fig. 2.20-year-old woman with cervical spinal

tuberculosis, presenting with fever and stiff neck,
but no neurologic deficit. Sagittal spin-echo T1weighted 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.

Received January 28, 2002; accepted after revision March 29, 2002.
1

Both authors: Department of Radiology, Amrita Institute of Medical Sciences, Amrita La., Elamakkara P. O., Cochin-682026, Kerala, India. Address correspondence to S. Moorthy.

AJR 2002;179:979983 0361803X/02/1794979 American Roentgen Ray Society

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Moorthy and Prabhu

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Fig. 3.18-year-old woman with sacral tuberculosis

presenting with lower backache.
A, Sagittal spin-echo T1-weighted MR image shows
erosion of second sacral segment (arrow) with pus
filling sacral canal and large presacral component.
B, 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.

Fig. 4.22-year-old woman undergoing treatment for pulmonary tuberculosis who presented with back pain and progressive paraparesis.
A, 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.
B, Axial gradient-recalled echo T2-weighted MR image shows large bilateral paraspinal and prevertebral pus. Anterior epidural collection
(arrow) is seen compressing cord.

Fig. 5.54-year-old woman with anterior lesion and progressive paraparesis.

A, 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).
B, Sagittal gradient-recalled echo T2weighted MR image clearly shows
erosion of anterior aspects of multiple
vertebral bodies (black arrows). Note
anterior epidural pus (white arrow)
compressing cord.
C, Axial gradient-recalled echo T2weighted MR image shows large
homogenous, hyperintense pus and
elevated anterior longitudinal ligament (arrows).

A
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C
AJR:179, October 2002

Spectrum of MR Imaging Findings in Spinal Tuberculosis

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Fig. 6.25-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. CTguided biopsy revealed tuberculosis.

Fig. 7.56-year-old man with central lesion and paraparesis after 6 months of
treatment with antituberculous chemotherapy. Sagittal spin-echo T1weighted MR image shows collapse of T6 vertebral body (arrowhead) with preservation of adjacent disksvertebra plana appearance.

Fig. 8.22-year-old woman with tuberculosis of posterior element who presented with low-grade fever and pain in nape
of neck.
A, Sagittal gradient-recalled echo T2-weighted MR image
shows bright signal pus under ligamentum nuchae at C2 and
C3 levels (arrows).
B, 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.

Fig. 9.18-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.
A, Axial gradient-recalled echo T2-weighted MR image shows hyperintense lymph node abscess (asterisk) in right side of neck.
B, 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.
C, Axial gradient-recalled echo T2-weighted MR image shows homogenous hyperintense left paraspinal pus (arrow) extending into T12 neural foramen.

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Moorthy and Prabhu

Fig. 10.22-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.

Fig. 11.47-year-old man with increasing spinal deformity and paraparesis.

A, 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. Note similarity to Figure 10.
B, 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.

presentations of spinal tuberculosis pose diagnostic difficulty, warranting its inclusion in the
differential diagnosis of any spinal disorder [4].
However, immigration, an aging population, and
the association of spinal tuberculosis with HIV
infection can be expected to increase its prevalence. MR imaging is usually performed to

evaluate suspected spinal abnormalities, and

the disease may first be detected when symptomatic patients undergo this examination. The
purpose of our pictorial essay is to review the
various typical and atypical findings of spinal
tuberculosis on MR imaging. All patients included were HIV negative.

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.
Tuberculosis infection is characterized by a
delayed hypersensitivity immune reaction.
The first stage is a pre-pus inflammatory reaction with Langerhans giant cells, epithelioid
cells, and lymphocytes. 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. 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. Noncontiguous (skip) lesions are also
occasionally seen [4, 5].
Site

Fig. 12.56-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.
A, 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.
B, Enhanced sagittal spin-echo T1-weighted MR image shows bizarre irregular enhancement in lumbar subarachnoid space and conus.

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The most frequent site of spinal tuberculosis is the thoracolumbar junction (Fig. 1). The
incidence decreases above and below this
level. However, any segment of the spine can
be involved [4] (Figs. 2 and 3).
Patterns of Vertebral Involvement

The primary focus of infection in the

spine can be either in the vertebral body or in

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Spectrum of MR Imaging Findings in Spinal Tuberculosis

the posterior elements. Three patterns of vertebral body involvement are recognized:
paradiskal, anterior, and central lesions [4].

body with preservation of the disk. The appearance is indistinguishable from that of lymphoma or metastasis.

Paradiskal Lesions

Posterior Element

A paradiskal lesion is adjacent to the intervertebral disk leading to a narrowing of the disk
space (Fig. 1). The disk space narrowing is
caused either by destruction of subchondral
bone with subsequent herniation of the disk into
the vertebral body or by direct involvement of
the disk [6]. 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 (Figs. 1 and 4).

Tuberculous involvement of the posterior

elements is rare [4]. MR imaging shows evidence of bone erosion and the associated
abscess (Figs. 8 and 9).

Anterior Lesions

The anterior type is a subperiosteal lesion under the anterior longitudinal ligament (Figs. 4
and 5). 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 [4] (Fig. 5).
MR imaging shows the subligamentous abscess,
preservation of the disks, and abnormal signal
involving multiple vertebral segments representing vertebral tuberculous osteomyelitis.
Central Lesions

The central lesion is centered on the vertebral body. The disk is not involved (Fig. 6).
Vertebral collapse can occur, producing a vertebra plana appearance (Fig. 7). MR imaging
shows a signal abnormality of the vertebral

AJR:179, October 2002

Complications of the Tuberculous Spine

Paraplegia and sometimes quadriplegia are

serious complications of the tuberculous spine
seen in approximately 10% of patients [7]. Copious epidural pus and granulation tissue alone
or in combination with vertebral collapse, subluxation, or dislocation (Figs. 10 and 11) produce cord compression. Rarely, the pus
penetrates the dura resulting in severe meningomyelitis [8] (Fig. 12).
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. Typically, infectious spondylitis is
characterized by involvement of the intervertebral disk. A history of chronicity and slow progression is suggestive of tuberculosis.
Moreover, inflammatory collections tend to be
larger in tuberculosis than in pyogenic
spondylitis. In the central and posterior element forms of tuberculosis, only biopsy can
achieve a provide diagnosis [2, 6].
MR imaging is sensitive for detecting vertebral osteomyelitis and is therefore the imag-

ing 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. MR
imaging provides critical information about
the spinal cord and the extent of the epidural
pus in patients presenting with neurologic
deficits. 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.

References
1. Bureau NJ, Cardinal E. Imaging of musculoskeletal and spinal infections in AIDS. Radiol Clin
North Am 2001;39:343355
2. Moore SL, Rafii M. Imaging of musculoskeletal
and spinal tuberculosis. Radiol Clin North Am
2001;39:329342
3. Hodgson AR, Skinsnes OK, Leong CY. The
pathogenesis of Potts paraplegia. J Bone Joint
Surg Am 1967;49:11471156
4. Ho EKW, Leong JCY. The pediatric spine: principles and practice. In: Weinstein SL, ed. Tuberculosis of the spine, 3rd ed. New York: Raven, 1994:
837849
5. Cotran SR, Kumar V, Tucker C. Robbins pathologic basis of disease, 6th ed. Philadelphia: Saunders, 1999:349352
6. Smith AS, Weinstein MA, Mizushima A, et al. MR
imaging characteristics of tuberculous spondylitis vs
vertebral osteomyelitis. AJNR 1989;10:619625
7. Ahmadi J, Bajaj A, Destian S, Segall HD, Zee
CS. Spinal tuberculosis: atypical observations at
MR imaging. Radiology 1993;189:489493
8. Sharma A, Goyal M, Mishra NK, Gupta V, Gaikwad SB. MR imaging of tubercular spinal arachnoiditis. AJR 1997;168:807812

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