Differentiation between Tuberculous Spondylitis and Pyogenic Spondylitis on MR Imaging

박종한,신혜선,박종태,김태영,엄기성 대한척추신경외과학회 2011 Neurospine Vol.8 No.4

Objective: The objective of this study was to compare the magnetic resonance(MR) imaging of tuberculous spondylitis with pyogenic spondylitis. Methods: MR images of the spines of 41 patients with infectious spondylitis at our institution over 8-years of period were retrospectively reviewed. Eighteen patients with infective spondylitis were excluded because their results on the marrow biopsy and culture were negative. MR imaging findings in 6 patients with tuberculous spondylitis(3 male, 3 female) were compared with those of 17 patients(10 male, 7 female) with pyogenic spondylitis. Results: Two MR imaging findings were statiscally significant in differentiating the tuberculous spondylitis from pyogenic spondylitis: a well defined paraspinal abnormal signal and a thin and smooth abscess wall. There were no significant diffe- rences in the following MR imaging findings: paraspinal abscess or intraosseous abscess, subligamentous spread to three or more vertebra, involvement of multiple vertebra, hyperintense signal on T2-weighted images, heterogenous low signal on T1-weighted images, involvement of posterior element, epidural extension, involvement of intervertebral disk, disk space narrowing, rim enhancement of the abscess, skip lesion, and endplate destruction. Conclusion: MR imaging is an appropriate modality for differentiation of tuberculous spondylitis from pyogenic spondylitis. Objective: The objective of this study was to compare the magnetic resonance(MR) imaging of tuberculous spondylitis with pyogenic spondylitis. Methods: MR images of the spines of 41 patients with infectious spondylitis at our institution over 8-years of period were retrospectively reviewed. Eighteen patients with infective spondylitis were excluded because their results on the marrow biopsy and culture were negative. MR imaging findings in 6 patients with tuberculous spondylitis(3 male, 3 female) were compared with those of 17 patients(10 male, 7 female) with pyogenic spondylitis. Results: Two MR imaging findings were statiscally significant in differentiating the tuberculous spondylitis from pyogenic spondylitis: a well defined paraspinal abnormal signal and a thin and smooth abscess wall. There were no significant diffe- rences in the following MR imaging findings: paraspinal abscess or intraosseous abscess, subligamentous spread to three or more vertebra, involvement of multiple vertebra, hyperintense signal on T2-weighted images, heterogenous low signal on T1-weighted images, involvement of posterior element, epidural extension, involvement of intervertebral disk, disk space narrowing, rim enhancement of the abscess, skip lesion, and endplate destruction. Conclusion: MR imaging is an appropriate modality for differentiation of tuberculous spondylitis from pyogenic spondylitis.

결핵성 척추염과 화농성 척추염의 감별 진단

구기형,이혁진,염진섭,박건우,이춘기,장봉순 대한척추외과학회 2009 대한척추외과학회지 Vol.16 No.2

Study Design: This is a retrospective study Objectives: We wanted to make the early differential diagnosis between tuberculous spondylitis and pyogenic spondylitis according to the clinical and MRI findings. Summary of the Literature Review: Making an early differential diagnosis between tuberculous spondylitis and pyogenic spondylitis is essential to start prompt and proper treatment. However, the clinical symptoms and MRI findings of both these illnesses can vary considerably. Material and Method: Ninety-five patients (49 men and 46 women, mean age: 54.5) who were treated from January 2001 to February 2007 and whose diagnosis was confirmed by laboratory or pathological studies were retrospectively reviewed. 50 patients with tuberculous spondylitis and 45 patients with primary pyogenic spondylitis were included. The patients with combined infection or an uncertain diagnosis were excluded. We compared the medical records and MRI findings between the different groups of patients. Results: The patients with tuberculous spondylitis were younger (48.2 years vs. 61.5 years, respectively) and they had a longer symptom duration (4.3 months vs 1.8 months, respectively). The erythrocyte sedimentation rate (ESR) and the C-reactive protein (CRP) level were significantly higher in the patients with pyogenic spondylitis (71.3/49.6 mm/hr and5.74/2.98 mg/dl, respectively). A high fever above 38 degree was more frequent in the patients with pyogenic spondylitis. Intraosseous abscess, epidural abscess, a well-definded paraspinal abscess, focal enhancement and severe destruction of the vertebral body on MRI were more frequent in the patients with tuberculous spondylitis. Four parameters such as a symptom duration longer than 3 months, no fever higher than 38 degree, a well-defined paravertebral abscess and an intraosseous abscess were selected. 42 patients in the tuberculous group had 3 or more of these four parameters. The sensitivity and specificity of these combined 4 parameters were 84% and 97.8%, respectively, for making the differential diagnosis between these 2 maladies. Conclusion: These diagnostic criteria might be useful to discriminate between tuberculous spondylitis and pyogenic spondylitis even without definite laboratory or pathological results. 연구계획: 후향적 연구 연구목적: 결핵성 척추염과 화농성 척추염의 감별은 조기 진단 및 치료에 중요하나 임상 경과 및 방사선학적 소견이 다양하여 감별이 어려운 경우가 많다. 임상 소견 및 자기 공명 영상 소견을 비교 분석하여 이들을 감별하고자 하였다. 대상 및 방법: 2001년 1월부터 2007년 2월까지 감염성 척추염으로 수술적 치료를 시행하고 술 중 균배양 및 조직학 적 검사로 확진된 환자 95명을 대상으로 하였다. 남자가 49명, 여자가 46명이었고 평균 연령은 54.5(14~86)세이었다. 각 군에서 성별, 나이, 침범 추체수, 증상 발현 기간, 술전 임상 병리 검사 결과, 동통, 발열, 신경학적 증상 등의 임상 양상과 자기 공명 영상 소견을 비교하여 분석하였다. 결과: 결핵성 척추염이 50례, 화농성 척추염이 45례이었다. 결핵성 척추염에서 평균 연령이 48.2세로 화농성 척추염 의 61.5세에 비하여 조기에 발병하였으며, 평균 발병 기간은 4.3개월로 화농성 척추염의 1.8개월에 비하여 길었고, C 반응성 단백(CRP), 적혈구 침강 속도(ESR)는 화농성 척추염에서 5.74 mm/hr, 71.3 mg/이으로 결핵성 척추염의 2.98 mm/hr, 49.6 mg/이에 비하여 유의하게 높았고, 38도 이상의 고열도 화농성 척추염군에서 유의하게 많았다. 자기 공명 영상 소견에서 추체내 농양, 경막 주위 농양, 경계가 분명한 추체 주위 농양, 추체의 심한 파괴는 결핵성 척추염에서 유의하게 많았으며 조영 증강시 부분적이고 다양한 조영 증강 소견을 보이는 경우가 많았다. 3개월 이상의 이환 기 간, 38도 이상의 발열이 없는 경우의 임상 소견과 경계가 분명한 척추 주위 농양, 추체내 농양과 같은 방사선학적 소 견을 종합하여 이러한 4가지 항목 중 3가지 이상을 만족시키는 경우가 결핵성 척추염으로 진단된 50례 중 42례이었 고 진단의 민감도는 84%이었고, 특이도는 97.8%이었다. 결론: 이러한 진단 기준은 배양 검사나 조직학적 검사가 불확실한 상황에서의 감염성 척추염의 감별 진단에 유용하 게 이용될 수 있을 것으로 생각된다.

결핵성 척추염과 화농성 척추염의 감별진단: 판별력 있는 MR 소견을 중심으로

김소영,홍석주,이창윤,정규병,박철민 대한영상의학회 2007 대한영상의학회지 Vol.56 No.2

Purpose: The purpose of this study is to analyze the most discriminative MR findings for making the differential diagnosis of tuberculous and pyogenic spondylitis. Materials and Methods: Sixty MR scans of 18 pyogenic spondylitis patients and 42 tuberculous spondylitis patients were retrospectively reviewed. The statistical analysis was performed using stepwise discriminant analysis and Student’s T-test. Results: The patients with tuberculous spondylitis had a significantly higher incidence of MRI findings as follows (p <0.05): smooth margin of a paraspinal mass/abscess in 67% [28/42] of the tuberculous spondylitis patients vs 6% [1/18] in the pyogenic spondylitis patients, mild endplate erosion in 52% [22/42] vs 38% [7/18], respectively, the presence of paraspinal mass/abscess in 100% [42/42] vs 6% [1/18], respectively, central dark signal intensity of the abscess in 86% [36/42] vs 39% [7/18]), respectively, subligamentous spread in 81% [34/42] vs 50% [9/18]), respectively, severe vertebral collapse in 20% [8/42] vs 11% [2/18]), respectively, and posterior extension in 62% [26/42] vs 33% [6/18]), respectively. Among of them, the significant discriminative MR findings were the margin of a paraspinal mass, the grade of endplate erosion and the presence or absence of a paraspinal mass in that order. Conclusion: In the differentiation of tuberculous and pyogenic spondylitis, the margin of the paraspinal mass, the grade of endplate erosion and the presence or absence of a paraspinal mass are the most three discriminating MR findings in that order. 목적: 결핵성 척추염과 화농성 척추염의 감별진단에 가장 판별력 있는 MR 소견을 분석하고자 하였다. 대상과 방법: 18명의 화농성 척추염 환자와 42명의 결핵성척추염 환자로 구성된 총 60명의 척추 MR영상을 후향적으로 분석하였다. 단계적 판별분석(stepwise discriminant analysis)과 Student T-test를 시행하여 통계 분석하였다. 결과: 매끈한 경계의 척추주위 종괴/농양(결핵성 척추염 67%[28/42] 대 화농성 척추염 6%[1/18]), 경한 종판 미란(52%[22/42] 대 38%[7/18]), 척추주위 종괴/농양의 존재(100%[42/42 대 6%[1/18]), 농양 중심의 어두운 신호(86%[36/42] 대 39%[7/18]), 인대하 확장(81%[34/42] 대 50%[9/18]), 심한 척추체 허탈(20%[8/42] 대 11%[2/18]), 척추후궁 침범(62%[26/42] 대 33%[6/18])이 결핵성 척추염 환자에서 통계학적으로 유의하게(p< 0.05) 높은 빈도를 보이는 MR 소견들이었다. 이 중 결핵성 척추염과 화농성 척추염의 감별진단에 판별력 있는 MR 소견은 척추주위 종괴/농양의 경계, 종판미란의 등급, 척추주위 종괴/농양의 존재 여부 순이었다. 결론: 결핵성 척추염과 화농성 척추염을 감별 진단에서 척추 주위 종괴/농양의 경계, 종판 미란의 정도, 척추 주위 종양/농양의 존재 여부가 가장 판별력 있는 MR 소견이다.

강직성 척추염에 동반된 IgA 신증 1 예

유대현(Dae Hyun Yoo),변정원(Jeong Won Byeon),이오영(Oh Young Lee),김태화(Tae Hwa Kim),김성윤(Seong Yoon Kim),강종명(Chong Myung Kang),김목현(Mok Hyun Kim),박문향(Moon Hyang Park) 대한내과학회 1989 대한내과학회지 Vol.37 No.4

N/A The renal lesions in ankylosing spondylitis are known as renal injury due to nonsteroidal anti-inflamatory drugs, renal amyloidosis and golomrelonephritis, but the accurate incidence of renal lesions in ankylosing spondylitis has not been determined. After the first report of IgA nephropathy associated with ankylosing spondylitis by Sisson et al., several investigators have reported a few cases of IgA nephropathy associated with ankylosing spondylitis and related spondyloarthritides. Elevated serum IgA and IgA circulating immune complexes are noted in ankylosing spondylitis and play a major role in the pathcogenesis of ankylosing spondylitis. lgA nephropathy is characterized by predominant deposition of IgA at the mesangium and renal injury is caused by circulating immune complexes in IgA nephropathy. Because of the similarity of the suggested pathogenesis between ankylosing spondylitis and IgA nephropathy, a few investigators have proposed that ankylosing spondylitis and IgA nephropathy are related. We experienced a case of IgA nephropathy associated with ankylosing spondylitis in a 34-year-old male patient and report this with a review of the literature.

Preoperative Gadolinium-enhanced Magnetic Resonance Images on Infectious Spondylitis

Kim, Seok-Won,Lee, Seung-Myoung,Shin, Ho The Korean Neurosurgical Society 2005 Journal of Korean neurosurgical society Vol.38 No.5

Objective : The purpose of this study is to analyze the patterns of intervertebral disc enhancement seen in infectious spondylitis, differentiate between two groups[tuberculous vs pyogenic spondylitis]. Methods : Between January 1994 and December 2002, 83patients underwent operative procedure with confirmed to histopathologic evaluation. Magnetic resonance[MR] images were obtained in all patients and were analyzed retrospectively. 57patients had tuberculosis and 26patients were infected by pyogens. The patterns of gadolinium enhancement of disc were classified into 4 types[post's classification] : Type I, non-enhancing; Type II, enhancement of the peripheral rim; Type III, Type II with central area and partial endplate; Type IV, general enhancement. Results : The enhancement patterns observed were as follows : Common pattern of tuberculous spondylitis was Type II, and pyogenic spondylitis was Type III. [p < 0.01] This difference may result from pathophysiologic varieties of organisms. Conclusion : Careful preoperative MR analysis of the patterns of disc enhancement occuring in infectious spondylitis can be useful for differentiating between the tuberculous and pyogenic spondylitis.

강직성 척추염 환자의 수술적 치료 시 컴퓨터를 이용한 가상교정의 임상적 의의

이재원,김훈철,박예수 대한척추외과학회 2015 대한척추외과학회지 Vol.22 No.2

Study Design: Retrospective study. Objectives: To evaluate the clinical value of preoperative planning via computer simulation by comparing preoperative and postoperative measurements of a patient with ankylosing spondylitis. Summary of Literature Review: Ankylosing spondylitis is a disorder that results in a spinal deformity because chronic inflammation at the ligament attachment sites triggers ossification; it causes round fixed kyphosis. This causes limitations in not only everyday life but also social interaction because it is impossible for patients to face forward. Therefore, surgical correction is necessary. Materials and Methods: We analyzed 38 patients (41 instances) who underwent correctional osteotomy between June 2007 and March 2014 to treat kyphosis caused by ankylosing spondylitis. We chose the appropriate operation site on the basis of preoperative simulations of osteotomy and the site for pre- and postoperative radiological evaluations conducted from the lateral view in a standing position. For the clinical evaluation, Bath Ankylosing Spondylitis Function Index (BASFI), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Hospital Anxiety and Depression Survey (HADS), and Health Locus of Control Form C Questionnaire (HLC-C) were used. Results: The mean sagittal vertical axis (SVA) was improved from 123.4 mm to 66.1 mm, the mean thoracic kyphosis angle (TKA) changed from 42.2° to 40.1°, and the mean lumbar lordosis angle (LLA) improved from 16.0° to 28.5°. The correlation coefficients between the preoperative predictive value and the postoperative radiographic measurement were 0.43, 0.93, and 0.87, which were all statistically significant. Conclusions: By comparing the preoperative measurement with the postoperative radiologic score, we found that the two were correlated and that the clinical assessment improved on the basis of the visualization. Therefore, preoperative simulation of patients with ankylosing spondylitis along with a kyphotic deformity is thought to be clinically effective. 연구계획: 후향적 연구. 목적: 척추 후만이 동반된 강직성 척추염 환자에서 교정 절골술을 시행하기 전 가상교정을 통한 술 전 계획과 술 후 상태를 비교하여 가상교정의임상적 가치를 평가하고자 하였다. 선행문헌의 요약: 강직성 척추염은 인대의 골 부착부에 발생하는 만성적인 염증에 의한 골화 현상에 따라 척추의 변형이 오는 질환으로, 원형의고정된 후만증을 가져오게 된다. 이로 인하여 전방주시가 불가능할 뿐만 아니라 반듯이 눕지도 못하게 되어 환자의 일상 생활뿐만 아니라 사회생활의 제약 등을 초래하여 수술적 교정이 필요하다. 대상 및 방법: 2007년 6월부터 2014년 3월까지 강직성 척추염으로 인한 후만증에 대하여 척추경 제거 절골술(PSO: pedicle subtraction osteotomy)을 단독 혹은 Smith-Peterson 절골 술식(SPO: Smith-Peterson Osteotomy)을 병행한 환자 38명, 41예를 대상으로 후향적으로 분석하였다. 모든 수술은 술 전 가상교정을 시행하여 절골 부위를 결정하였고, 수술 전 후 방사선학적 평가는 기립 자세에서 촬영한 척추전장 측면 사진(long-cassette standing lateral spinal radiographs)을 촬영하였다. 임상적 평가는 Bath Ankylosing Spondylitis Function Index (BASFI), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Hospital Anxiety and Depression Questionnaire (HADS) 및 Health Locus of Control- Form C Questionnaire(HLC-C)를 이용하였다. 결과: 방사선학적으로는 평균 시상 수직축이 123.4 mm에서 66.1 mm으로 호전되었으며, 평균 흉추 후만각은 42.2°에서 40.1°으로 변하였고, 평균 요추 전만각은 16.0°에서 28.5°로 호전되었다. 술 전후 방사선학적 지표의 상관관계를 분석하였을 때, 시상 수직축은 예측 값과 연관계수는0.43, 흉추 후만각 및 요추 전만각은 각각 0.93, 0.87로 통계학적으로 유의한 상관관계를 보여주었다. 결론: 가상교정을 통한 방사선학적 지표와 수술 후 방사선학적 지표를 비교를 하여 두 지표가 통계학적으로 일치함을 확인하였으며, 임상적 지표가 향상되었다. 이를 통해 후만 변형이 동반된 강직성 척추염 환자에서 가상교정을 이용한 술 전 계획이 임상적으로 유의한 의미를 갖는 방법으로 판단되었다.

Diagnostic yield of computed tomography-guided bone biopsy and clinical outcomes of tuberculous and pyogenic spondylitis

( Eun Jeong Joo ),( Joon Sup Yeom ),( Young Eun Ha ),( So Yeon Park ),( Chong Suh Lee ),( Eun Sang Kim ),( Cheol In Kang ),( Doo Ryeon Chung ),( Jae Hoon Song ),( Kyong Ran Peck ) 대한내과학회 2016 The Korean Journal of Internal Medicine Vol.31 No.4

Background/Aims: This study aimed to evaluate the effi cacy of computed tomography (CT)-guided bone biopsy for the diagnosis of spinal infection and compared the clinical outcomes between tuberculous and pyogenic spinal infections. Methods: The retrospective cohort study included patients who received CT-guided bone biopsy at a tertiary hospital over the 13 years. Results: Among 100 patients, 67 had pyogenic spondylitis and 33 had tuberculous spondylitis. Pathogens were isolated from bone specimens obtained by CT-guided biopsy in 42 cases, with diagnostic yields of 61% (20/33) for tuberculous spondylitis and 33% (22/67) for pyogenic spondylitis. For 36 culture-proven pyogenic cases, Staphylococcus aureus was the most commonly isolated organism. Patients with pyogenic spondylitis more frequently presented with fever accompanied by an increase in inflammatory markers than did those with tuberculosis. Among all patients who underwent surgery, the incidence of late surgery performed one month after diagnosis was higher in patients with tuberculous infection (56.3%) than in those with pyogenic disease (23.3%, p = 0.026). Conclusions: Results obtained by CT-guided bone biopsy contributed to prompt diagnoses of spinal infections, especially those caused by tuberculosis. Despite administration of anti-tuberculous agents, patients with tuberculous spondylitis showed an increased tendency to undergo late surgery.

강직성 척추염과 비분류성 척추관절증 환자의 심장이상에 대한 연구

이영호 ( Young Ho Lee ),지종대 ( Jong Dai Ji ),진동규 ( Dong Kyu Jin ),박창규 ( Chang Gyu Park ),서홍석 ( Hong Seong Seo ),오동주 ( Dong Joo Oh ),송관규 ( Gwan Gyu Song ) 대한류마티스학회 1997 대한류마티스학회지 Vol.4 No.1

Objective: To investigate the frequency, type and severity of cardiac abnormalities in the patients with ankylosing spondylitis and undifferentiated spondyloarthopathy. Methods: A history, clinical examination, standard 12 lead electrocardiography, two dimensional, M mode, and Doppler echocardiographies were performed on 19 patients with ankylosing spondylitis, 15 patients with undifferentiated spondyloarthropathy and 21 normal controls. Results: 1) Cardiac abnormalities were detected in 8 patients(42.1%) with ankylosing spondylitis. 2) Cardiac abnormalities were detected in 8 patients (53.3%) with undifferentiated spondyloarthropathy including 2 patients with aortic valve abnormalities (mild aortic insufficiency, aortic valve thickening). 3) Cardiac abnormalities were detected in one (4.8%) among normal controls (mild tricuspid regurgitation). 4) There were sinus bradycardias on electrocardiography in 2 patients among patients witn ankylosing spond litis and in 1 patient among undifferentiated spondyloarthropathy. But there was no conduction disturbance in both groups. 5) The frequency of cardiac abnormality was higher in patients with ankylosing spondylitis and undifferentiated spondyloarthropathy than in normal controls. 6) The mean age, mean disease duration, presence of uveitis, peripheral arthritis, HLA-B27, enthesopathy, Schober test and chest expansion in the patients with ankylosing spondylitis and undifferentiated spondyloarthropathy with cardiac abnormalities were not different from those in the patients without cardiac abnormalities. Conclusion: The frequency of cardiac abnormality was higher in patients with ankylosing spondylitis and undifferentiated spondyloarthropathy than in normal controls. The frequency, type and severity of cardiac involvement in patients with ankylosing spondylitis were not different from those in patients with undifferentiated spondyloarthropathy.

Is Titanium Mesh Cage Safe in Surgical Management of Pyogenic Spondylitis?

Heo, Won,Kang, Dong-Ho,Park, Kyung-Bum,Hwang, Soo-Hyun,Park, In-Sung,Han, Jong-Woo The Korean Neurosurgical Society 2011 Journal of Korean neurosurgical society Vol.50 No.4

Objective : To report our experience with pyogenic spondylitis treated with anterior radical debridement and insertion of a titanium mesh cage and to demonstrate the effectiveness and safety of the use of a titanium mesh cage in the surgical management of pyogenic spondylitis. Methods : We retrospectively analyzed the clinical characteristics of 19 patients who underwent surgical treatment in our department between January 2004 and December 2008. The average follow-up period was 11.16 months (range, 6-64 months). We evaluated risk factors, cultured organisms, lab data, clinical outcomes, and radiographic results. Surgical techniques for patients with pyogenic spondylitis were anterior radical debridement and reconstruction with titanium mesh cage insertion and screw fixation. All patients received intravenous antibiotics for at least 6 weeks postoperatively, and some patients received oral antibiotics. Results : The infections resolved in all of the patients as noted by normalization of their erythrocyte sedimentation rates and C-reactive protein levels. The mean pain score on a Visual Analog Scale was 7.8 (range, 4-10) before surgery and 2.4 (range, 1-5) after surgery. The Frankel grade was improved by one grade in seven patients. After surgery, the average difference of the angle was improved about $6.96^{\circ}$ in all patients. At the last follow-up, the mean loss of correction was $4.86^{\circ}$. Conclusion : Anterior radical debridement followed by the placement of instrumentation with a titanium mesh cage may be a safe and effective treatment for selected patients with pyogenic spondylitis. This surgical therapy does not lead to recurrent pyogenic spondylitis.

MRI Findings of Brucellar Spondylitis: A Case Report

김진우,김명순,김영주 대한영상의학회 2013 대한영상의학회지 Vol.68 No.3

Brucellosis is a systemic infectious disease, and musculoskeletal involvement is a frequent complication. Particularly, spondylitis is a common involvement. However, early diagnosis of brucellar spondylitis is often difficult due to non-specific clinical symptoms and long latent period. Especially in Korea, where tuberculosis is an endemic disease, differentiation between tuberculous and brucellar spondylitis is clinically and radiologically more challenging. A 59-year-old male cattle farmer, who presented with non-specific back pain, had spondylitis on magnetic resonance imaging (MRI), and serologic test finally confirmed brucellar spondylitis. Therefore, we report a case of a rather rare disease in Korea, brucellar spondylitis with a review of MRI findings.