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Advanced cervical DOM with extension beyond the discovertebral complex. Sagittal T2 (A), sagittal (B), and axial (C) T1 post contrast MR images coned in to the mid cervical spine show characteristic MR features of C5-C6 DOM with advanced disc and endplate destruction. In addition, there is prominent ventral epidural extension of phlegmonous infection (arrow in A-C) contributing to spinal canal stenosis and spinal cord compression. C) Axial T1-post contrast image best demonstrates the right more than left ventral and lateral paraspinous extension of infection without drainable fluid collection.
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Citations
... There is moderate T2 hyperintensity, but the hallmark is extensive diffuse contrast enhancement secondary to enhancing fibroconnective granulation tissue changes and phlegmonous changes. This type of enhancement is seen in approximately 70% of cases with SEA [17]. The phlegmonous accumulation within the SES can result in a significant mass effect on the dural sac and can completely encase the dural sac. ...
Purpose of Review
The goal of this review is to summarize the importance of identifying and treating a spinal epidural abscess. This review also delves into the intricacies of imaging modalities and the controversies regarding management options.
Recent Findings
Although magnetic resonance imaging (MRI) is a valuable diagnostic tool for evaluating SEA, focused attention to T2 imaging to the exclusion of other sequences can result in diagnostic errors and overlooking critical epidural abscesses.
Summary
Spinal epidural abscess is a rare disease; however, it has high morbidity and mortality if left untreated. Although rare, there is a slow progressive increase in the incidence of SEA. Imaging should be considered for any patient with red flags in their history or physical examination. MRI is the imaging test of choice to assure early diagnosis and treatment. Reliance on T2 imaging can result in an underappreciation of SEA. The characteristic space-occupying process, the essential comparison of T1 and T2 imaging, and the use of contrast characteristics are key ingredients for an accurate diagnosis.
... Computed tomography (CT) scan may be performed in addition to MRI. CT scans can provide superior evaluation of bony abnormalities such as end plate and vertebral body erosion, as well as assessment of overall bone quality [27] . Additionally, when a causative organism cannot be obtained from blood cultures, CT-guided biopsy may be necessary to guide antimicrobial treatment. ...
Imaging plays an important role in the diagnosis of spinal infections. Early diagnosis is paramount in the treatment of spinal infections and leads to improved outcomes. This article reviews the imaging and relevant clinical details of infections of the spine: pyogenic spondylodiscitis, tuberculous spondylodiscitis, septic facet arthritis, epidural abscess, and subdural abscess. Though radiographs can reveal subtle changes with infections, advanced imaging modalities have increased sensitivity to aid in early diagnosis. Magnetic resonance imaging (MRI) is emphasized given it is generally the most sensitive and specific advanced imaging modality. However, nuclear medicine imaging and computer tomography (CT) play a role diagnosis in cases where MRI is not available or contra-indicated. Additionally, CT is also important for image-guided biopsy to guide antimicrobial treatment.
... Spinal infections, discitis-osteomyelitis (DOM) and septic facet joints may affect the paraspinal region in many ways: reactive inflammation, pyomyositis and abscesses can occur in the epaxial muscles around the affected joint (Fig. 11) [111]. DOM is often associated with paraspinal soft tissue abnormalities, especially in hypaxial muscles, Muscle contusion of the right erector spinae muscle in a 27-year-old male after bicycle accident (c). ...
The paraspinal region encompasses all tissues around the spine. The regional anatomy is complex and includes the paraspinal muscles, spinal nerves, sympathetic chains, Batson's venous plexus and a rich arterial network. A wide variety of pathologies can occur in the paraspinal region, originating either from paraspinal soft tissues or the vertebral column. The most common paraspinal benign neoplasms include lipomas, fibroblastic tumours and benign peripheral nerve sheath tumours. Tumour-like masses such as haematomas, extramedullary haematopoiesis or abscesses should be considered in patients with suggestive medical histories. Malignant neoplasms are less frequent than benign processes and include liposarcomas and undifferentiated sarcomas. Secondary and primary spinal tumours may present as midline expansile soft tissue masses invading the adjacent paraspinal region. Knowledge of the anatomy of the paraspinal region is of major importance since it allows understanding of the complex locoregional tumour spread that can occur via many adipose corridors, haematogenous pathways and direct contact. Paraspinal tumours can extend into other anatomical regions, such as the retroperitoneum, pleura, posterior mediastinum, intercostal space or extradural neural axis compartment. Imaging plays a crucial role in formulating a hypothesis regarding the aetiology of the mass and tumour staging, which informs preoperative planning. Understanding the complex relationship between the different elements and the imaging features of common paraspinal masses is fundamental to achieving a correct diagnosis and adequate patient management. This review gives an overview of the anatomy of the paraspinal region and describes imaging features of the main tumours and tumour-like lesions that occur in the region.
... Associated medical co-morbidities and risk factors found in patients with spondylodiscitis were concurrent infection in 35% of cases, cardiovascular disease in 24% of cases, diabetes in 20% of cases, intravenous drug use in 15% of cases, and immunosuppression in 11% of cases [4]. Alcohol abuse was a contributing comorbidity in 19.2% of cases [1] as well as concurrent malignancy as a common medical comorbidity in 11% of cases [2]. The average age of presentation was found to be 63.3 and 66.6 in two population studies, while it was 58.3 in a meta-analysis [1,2,4]. ...
... Magnetic resonance imaging (MRI) has a specificity of 94%, sensitivity of 96%, and accuracy of 92% and is thought to be the imaging modality of choice for diagnosing infections of the spine [14,16,17]. Expected imaging changes are decreased T1 intensity from involved areas, increased T2-weighted intensity, and gadolinium enhancement of the infected disc, vertebrae, and surrounding soft tissues [13,14,16,17] Although MRI is the choice of imaging for diagnosis of spinal infections, computed tomography (CT) can be performed to better elucidate bone anatomy; which can assist in determining if surgical intervention is indicated [14,18,19]. CT scans are also often used for guidance for needle biopsies, if indicated [14]. ...
Infections of the spine are an ever-increasing health concern requiring an often complex and prolonged treatment that can lead to significant morbidity. Of particular interest is the cervical spine where there is an increase rate of post-infectious deformity, secondary neurological deficits and substantially higher rates of associated morbidity and mortality than the thoracic or lumbar spine. In this review, we explore the diagnosis and treatment of spondylodiscitis with particular focus on the cervical spine.
... MRI contrast study is the gold standard for spinal infections.MR imaging is very much useful in early stages of infection when other modalities are either normal or nonspecific [5] . MRI contrast study is especially helpful for anatomical localization and early diagnosis of spinal infections [18] . ...
... 1,2,3,5 The challenge of detecting this uncommon signal from a great deal of background noise can result in diagnostic delay, which can lead to the progression of unrecognized sepsis, permanent neurologic deficit for the patient, and increasing medicolegal risk for the physician. [5][6][7][8][9][10] Although magnetic resonance imaging (MRI) with gadolinium contrast is 96% sensitive and 93% specific for PSI, it is not an easily administered test. It requires 4-8 hours for test results, 11 is uncomfortable in some patients, contributes to ED crowding, and is not available at all facilities where back pain is evaluated. ...
... It requires 4-8 hours for test results, 11 is uncomfortable in some patients, contributes to ED crowding, and is not available at all facilities where back pain is evaluated. 6,10,12,13 Currently there are no clinical prediction tools to estimate PSI risk, [14][15][16][17] no agreement on C-reactive protein (CRP) cut-off levels to indicate imaging, 18 and no uniform recommendations regarding MRI use. 13,19 Recent publications recommend imaging spine pain patients who have any of the following PSI risk features: historical risk factors; fever; history of fever or progressive neurological deficit, 2,6,7,17,20,21 and to consider an alternate diagnosis if none of these are present. ...
... Eighty-three percent (25/30) of PSI patients with neurological deficits had no fever to prompt consideration of infection among the 89 spinal infections, highlighting a key circumstance where infection could be overlooked. The algorithm in Figure 3 considers this by using current published recommendations of contrast-enhanced MRI in patients suspected of infection, 3,9,10,12,13,21 as indicated by SIRCH score ≥3. For those with a neurological deficit, who are at low risk for infection (SIRCH score of <3), current recommendations indicate that MRI (without contrast) is the appropriate imaging modality. ...
Introduction: Patients with pyogenic spinal Infection (PSI) are often not diagnosed at their initial presentation, and diagnostic delay is associated with increased morbidity and medical-legal risk. We derived a decision tool to estimate the risk of spinal infection and inform magnetic resonance imaging (MRI) decisions. Methods: We conducted a two-part prospective observational cohort study that collected variables from spine pain patients over a six-year derivation phase. We fit a multivariable regression model with logistic coefficients rounded to the nearest integer and used them for variable weighting in the final risk score. This score, SIRCH (spine infection risk calculation heuristic), uses four clinical variables to predict PSI. We calculated the statistical performance, MRI utilization, and model fit in the derivation phase. In the second phase we used the same protocol but enrolled only confirmed cases of spinal infection to assess the sensitivity of our prediction tool. Results: In the derivation phase, we evaluated 134 non-PSI and 40 PSI patients; median age in years was 55.5 (interquartile range [IQR] 38–70 and 51.5 (42–59), respectively. We identified four predictors for our risk score: historical risk factors; fever; progressive neurological deficit; and C-reactive protein (CRP) ≥ 50 milligrams per liter (mg/L). At a threshold SIRCH score of ≥ 3, the predictive model’s sensitivity, specificity, and positive predictive value were, respectively, as follows: 100% (95% confidence interval [CI], 100–100%); 56% (95% CI, 48–64%), and 40% (95% CI, 36–46%). The area under the receiver operator curve was 0.877 (95% CI, 0.829–0.925). The SIRCH score at a threshold of ≥ 3 would prompt significantly fewer MRIs compared to using an elevated CRP (only 99/174 MRIs compared to 144/174 MRIs, P
... Its sensitivity is 96%, and specificity is 93% for an accuracy of 94%. An infection will show as a region of low T1 and high T2 signal intensity, with post-contrast enhancement on fat-suppressed T1-weighted images ( Figure 2) [20,21]. There is increased FDG uptake in the bone and soft tissues immediately adjacent to the hardware from T12 to L4 (arrows). ...
... 4. CT-guided biopsy: Spinal biopsy for cultures is not routinely done, and therapy is usually guided by clinical and radiological findings, but in chronic cases, atypical cases, and cases not clinically responding to IV antibiotic, a CT-guided biopsy can yield an organism if blood cultures were negative, which can determine the activity of the disease and guide treatment [18]. The success rate of CT-guided biopsy in finding an organism is between 36% and 91% [1], compared to a yield of 76% for open surgical biopsy [21]. ...
... On MRI, the presence of multiple vertebral levels involvement with intervening normal levels (skip lesions) is suggestive of tuberculosis over pyogenic spondylodiscitis ( Figure 5) [21]. ...
... Its sensitivity is 96%, and specificity is 93% for an accuracy of 94%. An infection will show as a region of low T1 and high T2 signal intensity, with post-contrast enhancement on fat-suppressed T1-weighted images ( Figure 2) [20,21]. There is increased FDG uptake in the bone and soft tissues immediately adjacent to the hardware from T12 to L4 (arrows). ...
... 4. CT-guided biopsy: Spinal biopsy for cultures is not routinely done, and therapy is usually guided by clinical and radiological findings, but in chronic cases, atypical cases, and cases not clinically responding to IV antibiotic, a CT-guided biopsy can yield an organism if blood cultures were negative, which can determine the activity of the disease and guide treatment [18]. The success rate of CT-guided biopsy in finding an organism is between 36% and 91% [1], compared to a yield of 76% for open surgical biopsy [21]. ...
... On MRI, the presence of multiple vertebral levels involvement with intervening normal levels (skip lesions) is suggestive of tuberculosis over pyogenic spondylodiscitis ( Figure 5) [21]. ...
The management of pediatric spine infections requires a multidisciplinary approach that includes orthopedic surgeons, infectious disease specialists, interventional radiologists, and others.
The prevalence of the disease has increased in frequency, virulence, and degree of soft tissue involvement over the past several years; there has also been a resurgence of some types of infections, such as tuberculosis, fungal, and viral pathogens.
The diagnosis can often be reached with a detailed history, physical examination, laboratory tests, and imaging studies. Pathologies mimicking infection require a more invasive approach for diagnosis, including core or open biopsy.
The treatment of discitis, spondylodiscitis, vertebral osteomyelitis, spinal epidural, and intramedullary abscesses in children is at times complex, and although many infections can be treated non-surgically with antibiotic therapy, some more extensive infections require surgical management.
A timely diagnosis is important as it allows the initiation of the appropriate antimicrobial therapy and would decrease the complexity of the subsequent surgical intervention.
... The challenge of detecting this uncommon signal from a great deal of background noise can 42 result in diagnostic delay, which can lead to the progression of unrecognized sepsis, permanent 43 neurologic deficit for patients, and increasing medical-legal risk for physicians. [5][6][7][8][9][10] Although 44 magnetic resonance imaging (MRI) with gadolinium contrast is 96% sensitive and 93% specific progressive neurological deficit, 2,6,7,17,20,21 and to consider an alternate diagnosis if none of these 53 are present. 2,6,20,21 54 55 Goals of this Investigation 56 We aimed to develop an intuitive risk prediction score using history, physical examination, 57 and CRP measurement that provides a sensitive assessment of the risk of PSI and appropriately 58 recommends MRI. ...
The paper describes a derived prediction model that estimates the probability of pyogenic spinal infection in ED patients with back or neck pain.
... The pathological features of suppurative spondylitis are primarily the coexistence of bone destruction with bone hyperplasia and sclerosis [10]. Clinically, it can be divided into acute phase, subacute phase, chronic phase and healing phase [3]. ...
Background
This study investigated the diagnostic and therapeutic experience, including conservative, endoscopic and surgical methods, of chronic suppurative spondylitis.
Methods
A total of 39 patients were included in the imageological, laboratory, and pathological examinations. The patients underwent conservative treatment or operation according to their respective conditions. We used erythrocyte sedimentation rate (ESR) and c-reactive proteins (CRP) to evaluate the state of the illness, visual analogue scales (VAS) to assess lower back and lower limb pain, and the oswestry dysfunction index (ODI) to assess the degree of functional disability. All patients were followed up for 12–36 months.
Results
Two patients were treated conservatively with antibiotics for 6–8 weeks, while 34 patients underwent different open surgeries, including two cases who underwent second stage surgery. Endoscopic surgery was operated on 3 patients under acute inflammatory stage. All patients' body temperature, VAS score, ESR, and CRP decreased significantly (P < 0.05). Imaging showed that lesions were stationary and that bone fusion occurred 8–14 months after surgery, with an average of 10.00 ± 0.92 months.
Conclusions
Clinicians should acquire a detailed medical history and evaluate the laboratory and imaging results comprehensively to select an appropriate treatment plan. Treatment, including the choosing of an adequate surgical method, should be based on the purpose of the operation and the patient's general condition.
