Spinal disorders mimicking infection

Spinal infections are very commonly encountered by radiologists in their routine clinical practice. In case of typical MRI features, the diagnosis is relatively easy to interpret, all the more so if the clinical and laboratory findings are in agreement with the radiological findings. In many cases, the radiologist is able to make the right diagnosis, thereby avoiding a disco-vertebral biopsy, which is technically challenging and associated with a risk of negative results. However, several diseases mimic similar patterns, such as degenerative changes (Modic) and crystal-induced discopathy. Differentiation between these diagnoses relies on imaging changes in endplate contours as well as in disc signal. This review sought to illustrate the imaging pattern of spinal diseases mimicking an infection and to define characteristic MRI and CT patterns allowing to distinguish between these different disco-vertebral disorders. The contribution of advanced techniques, such as DWI and dual-energy CT (DECT) is also discussed.

Percutaneous CT Guided Vertebral Biopsy: Anatomy and Technical Considerations

In this review article, the authors discuss the anatomy and technical aspects of CT-guided biopsy of vertebral lesions. CT guidance is highly useful for vertebral biopsies, as the anatomy of the spine is complex and varies widely across the levels. Prebiopsy imaging should be reviewed and later correlated with the final histopathological diagnosis. The majority of the spine biopsies are performed under local anesthesia, except those in critical locations and pediatric age groups. The biopsy sample is sent for histopathological analysis and/or microbiological analysis depending on the indications. It is preferable to use a coaxial system for biopsies, so multiple cores can be obtained with a single needle puncture, thus minimizing the negative yield and complications. Complications after image-guided percutaneous biopsy are rare and can be managed easily.

Rokitansky diverticulum with esophageo-spinal fistula leading to infective spondylodisciitis – A case report and review of literature

Background- Infective thoracic spondylodiscitis secondary to spontaneous perforation of the esophageal diverticulum is a rare condition. Case Report- A 56-year-old lady with cystic lung disease and pulmonary arterial hypertension of nine years duration and progressive dysphagia for two years was diagnosed with mid-esophageal diverticulum five months prior to presentation. The lady presented with infrascapular chest wall pain of one month’s duration and dyspnoea and wheezing of 15 days duration. Imaging showed a mid-esophageal diverticulum at T4-T5 level with a sinus tract extending to the T2-T3 disc, reduced T2-T3 disc height with endplate irregularities, and contrast enhancement of T2-T5 vertebral bodies suggestive of spondylodiscitis. Although a percutaneous vertebral biopsy was inconclusive, the blood culture grew Streptococcus Pseudoporcinus. The esophageal diverticulum was managed with an endoluminal stent and the infective spondylodisciitis was managed with an extended course of antibiotics led to the healing of both lesions. Conclusions- A Rokitansky mid-esophageal diverticulum with esophageo-spinal fistula causing infective spondylodisciitis is a rare condition. A combined management of the leaking esophageal diverticulum using an esophageal endoluminal metallic stent and an extended course of antibiotics to treat the infective spondylodisciitis led to a good outcome.

Rokitansky diverticulum with esophageo-spinal fistula leading to infective spondylodisciitis – A case report and review of literature

Background- Infective thoracic spondylodiscitis secondary to spontaneous perforation of the esophageal diverticulum is a rare condition. Case Report- A 56-year-old lady with cystic lung disease and pulmonary arterial hypertension of nine years duration and progressive dysphagia for two years was diagnosed with mid-esophageal diverticulum five months prior to presentation. The lady presented with infrascapular chest wall pain of one month’s duration and dyspnoea and wheezing of 15 days duration. Imaging showed a mid-esophageal diverticulum at T4-T5 level with a sinus tract extending to the T2-T3 disc, reduced T2-T3 disc height with endplate irregularities, and contrast enhancement of T2-T5 vertebral bodies suggestive of spondylodiscitis. Although a percutaneous vertebral biopsy was inconclusive, the blood culture grew Streptococcus Pseudoporcinus. The esophageal diverticulum was managed with an endoluminal stent and the infective spondylodisciitis was managed with an extended course of antibiotics led to the healing of both lesions. Conclusions- A Rokitansky mid-esophageal diverticulum with esophageo-spinal fistula causing infective spondylodisciitis is a rare condition. A combined management of the leaking esophageal diverticulum using an esophageal endoluminal metallic stent and an extended course of antibiotics to treat the infective spondylodisciitis led to a good outcome.

Computed Tomography-Guided Vertebral Biopsy in Suspected Tuberculous Spondylodiscitis: Comparing a New Navigational Tram-Track Technique versus Conventional Method

Introduction Computed tomography (CT)-guided vertebral biopsy is always recommended for histopathological and microbiological confirmation in cases of tuberculous spondylodiscitis and for antimycobacterial drug sensitivity testing. Aim To compare the conventional technique and a novel axis-defined tram-track technique of CT-guided vertebral biopsy in suspected tuberculous spondylodiscitis. Materials and Methods Sixty-seven patients of clinico-radiologically suspected tuberculous spondylodiscitis referred for CT-guided vertebral biopsy were categorized into two groups: “Group A” patients (n = 32) underwent biopsy by conventional technique, and “Group B” patients (n = 35) by axis-defined tram-track technique. The time taken for procedure, radiation exposure, and any procedural complications were recorded for both the groups. Results A statistically significant difference in procedure time and mean radiation dose was observed between the two groups: a longer procedural time was required in “Group A” (52.5 ± 3.5 minutes) as compared to “Group B” (37.3 ± 3.6 minutes) (p < 0.0001); and mean radiation dose (CTDIvol) in “Group A” and “Group B” was 8.64 ± 1.06 mGy and 5.73 ± 0.71 mGy, respectively (p < 0.0001). However, the difference in complication rate and tissue yield for successful diagnosis of the biopsies in the two groups was found to be statistically insignificant. Conclusion Axis-defined tram-track technique was found to have a significantly shorter procedural time as well as lower radiation exposure compared to the conventional technique of vertebral biopsy in our study.

FRI0431 PROFILE OF INFECTIOUS SPONDYLODISCITIS ACCORDING TO THE SITE: UNIFOCAL VERSUS MULTIFOCAL

Background:Infectious spondylodiscitis is a therapeutic emergency and is a current problem. It can affect the different levels of the spine. Multifocal forms, touching several floors, however remain rare.Objectives:To compare the clinical, biological, radiological and therapeutic aspects of unifocal versus multifocal spondylodiscitis.Methods:This is a retrospective study of 113 patients admitted to our service over a period of 20 years [1998-2018]. The diagnosis of spondylodiscitis was made on the basis of clinical, biological, radiological and bacteriological data. We have divided our population into two groups: unifocal and multifocal spondylodiscitis.Results:Spondylodiscitis was more frequently unifocal (75.2%) than multifocal (24.8%). The average age of the patients was 55.8 years. There were 62 men and 51 women. There was no difference in age and sex between the two groups (p=0.5 and p=0.8, respectively).Diabetes was more frequent in the group of multifocal spondylodiscitis but with no statistically significant difference (p=0.4). No statistically significant difference between the two groups regarding the start mode (p=0.7), the schedule (p=0.3), the presence of neurological signs (p=0.7), fever (p = 0.2), impaired general condition (p=0.6) and biological inflammatory syndrome (p=0.6).Cervical and dorsal spine involvement was more common in multifocal spondylodiscitis (p = 0.02 and p = 0.01; respectively). There were 11 spondylodiscitis involving 2 floors (cervical and dorsal: 2 cases, cervical and lumbar: 3 cases, dorsal and lumbar: 6 cases) and 3 spondylodiscitis involving 3 floors.Radiologically, the presence of vertebral fracture and involvement of the posterior arch was more frequent during the multifocal form (p=0.03 and p=0.001; respectively). The frequency of para-vertebral abscesses, epiduritis and the presence of spinal cord compression were similar in the two groups (p=0.6; p=0.7 and p=0.2, respectively).Tuberculosis was more frequent during the multifocal form (p = 0.05) and brucellosis during the unifocal form (p = 0.03). Disco-vertebral biopsy was performed in 79 cases. It was more often contributory during multifocal spondylodiscitis (p = 0.03).The occurrence of immediate complications was more frequent in multifocal spondylodiscitis but with no statistically significant difference (p=0.2).Conclusion:Multifocal sppondylodiscitis is seen mainly in immunocompromised subjects. Our study found that diabetes is the most common factor in immunosuppression. Note also the predominance of involvement of the posterior elements, tuberculous origin and immediate complications.Disclosure of Interests:None declared

AB0942 INFECTIOUS SPONDYLODISCITIS: TUBERCULOSIS VERSUS BRUCELLOSIS

Background:Infectious spondylodiscitis is a serious impairment that can compromise the functional and vital prognosis. The determination of the germ responsible is the key of the treatment.Objectives:The objective of our work is to describe the epidemiological, clinical and evolutionary profile according to the germ responsible by comparing tuberculous and brucellar spondylodiscitis.Methods:This is a retrospective study including 32 cases of spondylodiscitis with specific germs (Mycobacterium tuberculosis and Brucella) collected in an internal medicine department over a period of 18 years (2000-2018).Results:These were 20 men and 12 women with an M / F ratio of 1.66. The average age of our patients was 50.63 [16-84]. The germ implicated was Koch’s Bacillus in 11 patients (34.38%) and Brucella in 21 patients (65.63%). The mean age for tuberculosis (TB) was 45.18 years versus 53.48 years for brucellosis. Spinal pain was the major symptom in the 02 groups. The deterioration in general condition was present in 80.95% for the brucellosis group versus 81.82% for the tuberculosis group.Biological inflammatory syndrome was observed in 94.24% of the brucellosis group and 63.63% of the TBC group. The lumbar location was the most frequent in the 02 groups (71.88%).It was a multifocal localization in 27.27% (TB) and 61.90% (Brucellosis) respectively. The imaging allowed the detection of para abscesses -vertebral in 54.55% for the TB group versus 23.81% for the brucellar group. An epiduritis was objectified in 36.36% of the TB group against 33.33% for that of brucellar. CT-guided biopsy was performed in 54.55% of tuberculosis patients compared to 47.62% in the other group. It was only positive in one case of brucellosis, whereas it allowed diagnosis in 36.36% of cases of TB.The evolution after initiation of adequate antibiotic treatment was interspersed with neurological complications in the tuberculosis group in 18.18% of cases against 14.29% in the brucellosis group. Draining abscess was necessary in the tuberculosis group in 18.18% and in 9.52% of the brucellosis cases.Conclusion:Our results show a higher frequency of neurological complications in tuberculosis forms. Vertebral biopsy is of no interest in Brucellar spondylodiscitis unlike tuberculosis forms where it allows the diagnosis.References:[1]Bousson,et al (2014). Infection rachidienne: du germe lent au staphylocoque doré. Revue Du Rhumatisme Monographies, 81(1), 27–35.[2]Bierry, G., & Dietemann, J.-L. (2012). Imagerie des spondylodiscites infectieuses. EMC - Radiologie et Imagerie Médicale - Musculosquelettique - Neurologique - Maxillofaciale, 7(4), 1–16.Disclosure of Interests:None declared