CASE 23
By: Dr. Sattam Lingawi and Dr. Alaa Al-Turkustani
HISTORY: 68-year-old man with sever low back pain and inability to walk.
What are your findings?
What is the differential diagnosis?
What are the causes?
FINDINGS:
Fig 1: Sagittal reconstructed non-enhanced CT scan of the lumbar spine demonstrating L2/3 intervertebral disc space narrowing, with gas bubble in the anterior intervertebral disc space (peripheral vacuum phenomena). Irregularity and sclerosis of the corresponding superior and inferior end-plates noted.
Fig 2: Sagittal STIR of the lumbar spine demonstrating corresponding L2/3 intervertebral disc bright signal intensity.
Fig 3: Sagittal STIR of the lumbar spine demonstrating interval progression of intervertebral disc bright signal intensity with development of bone marrow oedema in the L2 & L3 vertebral bodies and an anterior epidural collection reaching down to the L4-5 level.
Fig 4 and Fig 5: Sagittal and Axial post enhanced T1 WI of the lumbar spine demonstrating enhancement of the L2/3 vertebral bodies and intervertebral disc with anterior intra-spinal/epidural & para-vertebral abscess formation demonstrating peripheral enhancement.
DIFFERENTIAL DIAGNOSIS:
Spondylodiscitis weather spinal brucellosis, TB or pyogenic spondylodiscitis.
DIAGNOSIS:
Spinal brucellosis.
PEARLS AND DISCUSSION:
Brucellosis is endemic to some regions. It is transmitted mainly by unpasteurized milk and milk products. It is important to differentiate tuberculous spondylodiskitis from brucellar spondylodiskitis because proper treatment for each of these diseases can prevent complications. The radiologic findings for these two forms of spondylodiskitis are similar, so serologic testing for brucellosis is necessary in such cases.
A well-defined paraspinal region with abnormal signal intensity; a thin, smooth abscess wall; subligamentous spread to three or more vertebral levels; and multiple vertebral or entire-body involvement are findings more suggestive of tuberculous spondylitis than of pyogenic spondylitis. The presence of skip lesions and of a large paraspinal cold abscess also is suggestive of tuberculous spondylitis.
Pyogenic spondylodiscitis most commonly caused by Staphylococcus aureus and occur in IV drug abuser and immunocompromised individuals.
Characteristic MR imaging features of brucellar spondylodiscitis include a predilection for the lower lumbar spine, intact vertebral architecture despite evidence of diffuse vertebral osteomyelitis, a marked increase in signal intensity in the intervertebral disk on T2-weighted image sequence, facet joints involvement and characteristic peripheral vacuum phenomena secondary to disc degeneration.
FURTHER READING:
Aysin Pourbagher, Mir Ali Pourbagher, Epidemiologic, Clinical, and Imaging Findings in Brucellosis Patients withOsteoarticular Involvement. AJR 2006; 187:873–880
Nizar A. Al-Nakshabandi, the Spectrum of Imaging Findings of Brucellosis: A Pictorial Essay, Canadian Association of Radiologists Journal 63 (2012) 5e11
Sung Hwan Hong, MD • Ja-Young Choi, MD •MR Imaging Assessmentof the Spine: Infection or an Imitation. RadioGraphics 2009; 29:599–612
