Semin Musculoskelet Radiol 2011; 15(5): 446-458
DOI: 10.1055/s-0031-1293491
© Thieme Medical Publishers

Tuberculous Osteomyelitis and Spondylodiscitis

Sumer N. Shikhare1 , Dinesh R. Singh1 , Trishna R. Shimpi1 , Wilfred C.G. Peh1
  • 1Department of Diagnostic Radiology, Khoo Teck Puat Hospital, Alexandra Health, Singapore, Republic of Singapore
Further Information

Publication History

Publication Date:
11 November 2011 (online)

ABSTRACT

Tuberculosis (TB) is no longer a disease limited to developing nations and is still a major cause of significant morbidity and mortality worldwide. The indolent clinical presentation, emergence of multidrug-resistant mycobacteria, and association with human immunodeficiency virus infection poses obstacles for early diagnosis and management. Compared with the other forms of TB, musculoskeletal involvement is relatively rare. Tuberculous spondylitis is the most common form of musculoskeletal TB and accounts for ~50% of cases. Extraspinal musculoskeletal TB shows a predilection for large weightbearing joints, long bones, and the skull. This article reviews the radiologic features of diverse forms of osseous TB and the diagnostic value of the different imaging techniques. It also reviews the imaging differential diagnoses, including other infections and malignancies/metastases. Conventional radiography is of key value in the diagnosis of musculoskeletal TB. Computed tomography, magnetic resonance imaging, and bone scintigraphy also play key roles in the early detection of disease and in demonstrating the extent of disease process and soft tissue involvement. Because delay in treatment significantly reduces the cure rate and increases the rate of complications and morbidity, early radiological diagnosis of TB is of paramount importance for appropriate management.

REFERENCES

  • 1 World Health Organization .Stop TB Annual Report 2001. Geneva, Switzerland: WHO; 2002
  • 2 World Health Organization .Global Tuberculosis Control 2009. Geneva, Switzerland, WHO. Available at: http://www.who.int/tb/publications/global_report/2009/update/tbu_9.pdf Accessed October 14, 2011
  • 3 Kochi A. The global tuberculosis situation and the new control strategy of the World Health Organization.  Tubercle. 1991;  72 (1) 1-6
  • 4 World Health Organization .Tuberculosis factsheet. Geneva, Switzerland, WHO; November 2010
  • 5 Muraldi D, Gold W L, Vellend H, Becker E. Multifocal osteoarticular tuberculosis: report of four cases and review of management.  Clin Infect Dis. 1993;  17 (2) 204-209
  • 6 Martini M, Ouahes M. Bone and joint tuberculosis: a review of 652 cases.  Orthopedics. 1988;  11 (6) 861-866
  • 7 Watts H G, Lifeso R M. Tuberculosis of bones and joints.  J Bone Joint Surg Am. 1996;  78 (2) 288-298
  • 8 Office for National Statistics. Census 2001. 2001. Available at: http://www.ons.gov.uk/ons/guide-method/census/census-2001/index.html Accessed October 14, 2011
  • 9 Foster P AL, Bismil Q, Venkateswaran B, Shanker J. Delayed presentation of tuberculosis of the talo-navicular joint: a case report.  Foot Ankle Surg. 2003;  9 237-239
  • 10 Davidson P T, Horowitz I. Skeletal tuberculosis. A review with patient presentations and discussion.  Am J Med. 1970;  48 (1) 77-84
  • 11 Yao D C, Sartoris D J. Musculoskeletal tuberculosis.  Radiol Clin North Am. 1995;  33 (4) 679-705
  • 12 Engin G, Acunaş B, Acunaş G, Tunaci M. Imaging of extrapulmonary tuberculosis.  Radiographics. 2000;  20 (2) 471-488 quiz 529-530 532
  • 13 De Backer A I, Vanhoenacker F M, Sanghvi D A. Imaging features of extraaxial musculoskeletal tuberculosis.  Indian J Radiol Imaging. 2009;  19 (3) 176-186
  • 14 De Vuyst D, Vanhoenacker F, Gielen J, Bernaerts A, De Schepper A M. Imaging features of musculoskeletal tuberculosis.  Eur Radiol. 2003;  13 (8) 1809-1819
  • 15 Murray R O, Jacobson H G. Skeletal tuberculosis. In: Radiology of Skeletal Diseases. Exercises in Diagnosis. 2nd ed. Edinburgh, UK: Churchill Livingstone; 1997: 414-426
  • 16 Bandhu S. Tuberculosis of bones and joints. In: Berry M, Choudhary V, Mukopadhyay Suri S, eds. Diagnostic Radiology: Musculoskeletal and Breast Imaging. 2nd ed. New Delhi, India: Jaypee Brothers; 2005: 70-95
  • 17 Bhan S, Nag H L. Skeletal tuberculosis. In: Sharma S K, ed. Tuberculosis. New Delhi, India: Jaypee Brothers; 1997: 237-260
  • 18 Teo H EL, Peh W CG. Skeletal tuberculosis in children.  Pediatr Radiol. 2004;  34 (11) 853-860
  • 19 Hagga J R, Lanzieri C F, Gilkeson R C. MR imaging of infections of spine. In: CT and MR imaging of Whole Body. 4th ed. St. Louis. MO: Mosby; 2003: 805-812
  • 20 Bhatia R G, Sklar E ML, Ruiz A, Falcone S. Spinal infections: vertebral and paravertebral abnormalities. In: Clinical Magnetic Resonance Imaging. 3rd ed. Philadelphia, PA: Elsevier; 2010: 2338-2357
  • 21 Moore S L, Rafii M. Imaging of musculoskeletal and spinal tuberculosis.  Radiol Clin North Am. 2001;  39 (2) 329-342
  • 22 Smith A S, Weinstein M A, Mizushima A et al.. MR imaging characteristics of tuberculous spondylitis vs vertebral osteomyelitis.  AJR Am J Roentgenol. 1989;  153 (2) 399-405
  • 23 Spiegel D A, Singh G K, Banskota A K. Tuberculosis of the musculoskeletal system.  Tech Orthop. 2005;  20 167-178
  • 24 Aggarwal A N, Dhammi I K, Jain A K. Multifocal skeletal tuberculosis.  Trop Doct. 2001;  31 (4) 219-220
  • 25 Campbell J AB, Hoffman E B. Tuberculosis of the hip in children.  J Bone Joint Surg Br. 1995;  77 (2) 319-326
  • 26 Goodman P C. Tuberculosis and AIDS.  Radiol Clin North Am. 1995;  33 (4) 707-717
  • 27 Desai S S. Early diagnosis of spinal tuberculosis by MRI.  J Bone Joint Surg Br. 1994;  76 (6) 863-869
  • 28 Nocera R M, Sayle B, Rogers C, Wilkey D. Tc-99m MDP and indium-111 chloride scintigraphy in skeletal tuberculosis.  Clin Nucl Med. 1983;  8 (9) 418-420
  • 29 Dhillon M S, Rao S S, Sandhu M S, Vasisht R K, Nagi O N. Tuberculosis of the patella.  Skeletal Radiol. 1998;  27 (1) 40-42
  • 30 Dhillon M S, Sharma S, Gill S S, Nagi O N. Tuberculosis of bones and joints of the foot: an analysis of 22 cases.  Foot Ankle. 1993;  14 (9) 505-513
  • 31 Renton P. Periosteal reaction, bone and joint infections. In: Sutton D, ed. Textbook of Radiology and Imaging. 7th ed. Philadelphia, PA: Elsevier; 2003: 1153-1177
  • 32 Peh W CG, Cheung K M. Progressive shoulder arthropathy.  Ann Rheum Dis. 1995;  54 (3) 168-173
  • 33 Andronikou S, Smith B. “Spina ventosa”—tuberculous dactylitis.  Arch Dis Child. 2002;  86 (3) 206
  • 34 Sunderamoorthy D, Gupta V, Bleetman A. TB or not TB: an unusual sore finger.  Emerg Med J. 2001;  18 (6) 490-491
  • 35 Hassen-Zrour S, Younes M, Haj Salah-Othman M et al.. Multifocal tuberculous dactylitis: a case report [in French].  Chir Main. 2008;  27 (2–3) 122-125
  • 36 Trikha V, Varshney M K, Rastogi S. Isolated tuberculosis of the vastus lateralis muscle: a case report.  Scand J Infect Dis. 2006;  38 (4) 304-306
  • 37 Morris B S, Varma R, Garg A, Awasthi M, Maheshwari M. Multifocal musculoskeletal tuberculosis in children: appearances on computed tomography.  Skeletal Radiol. 2002;  31 (1) 1-8
  • 38 Quinn S F, Murray W, Prochaska J, Cochran C, Clark R. MRI appearance of disseminated osseous tuberculosis.  Magn Reson Imaging. 1987;  5 (6) 493-497
  • 39 Turpin S, Lambert R. Role of scintigraphy in musculoskeletal and spinal infections.  Radiol Clin North Am. 2001;  39 (2) 169-189
  • 40 Maurer A H, Chen D C, Camargo E E, Wong D F, Wagner Jr H N, Alderson P O. Utility of three-phase skeletal scintigraphy in suspected osteomyelitis: concise communication.  J Nucl Med. 1981;  22 (11) 941-949
  • 41 Al-Sheikh W, Sfakianakis G N, Mnaymneh W et al.. Subacute and chronic bone infections: diagnosis using In-111, Ga-67 and Tc-99m MDP bone scintigraphy, and radiography.  Radiology. 1985;  155 (2) 501-506
  • 42 Dureja S, Sen I. Role of FDG PET CT in detection of occult multifocal tubercular disease in skeletal tuberculosis.  J Nucl Med. 2010;  51 97
  • 43 Burrill J, Williams C J, Bain G, Conder G, Hine A L, Misra R R. Tuberculosis: a radiologic review.  Radiographics. 2007;  27 (5) 1255-1273
  • 44 Weaver P, Lifeso R M. The radiological diagnosis of tuberculosis of the adult spine.  Skeletal Radiol. 1984;  12 (3) 178-186
  • 45 Harisinghani M G, McLoud T C, Shepard J A, Ko J P, Shroff M M, Mueller P R. Tuberculosis from head to toe.  Radiographics. 2000;  20 (2) 449-470 quiz 528-529, 532
  • 46 Boxer D I, Pratt C, Hine A L, McNicol M. Radiological features during and following treatment of spinal tuberculosis.  Br J Radiol. 1992;  65 (774) 476-479
  • 47 Resnick D, Niwayama G. Osteomyelitis, septic arthritis, and soft tissue infection: the axial skeleton. In: Diagnosis of Bone and Joint Disorders. 2nd ed. Philadelphia, PA: WB Saunders; 1988: 1619-1754
  • 48 Chapman M, Murray R O, Stoker D J. Tuberculosis of the bones and joints.  Semin Roentgenol. 1979;  14 (4) 266-282
  • 49 Hong S H, Choi J Y, Lee J W, Kim N R, Choi J A, Kang H S. MR imaging assessment of the spine: infection or an imitation?.  Radiographics. 2009;  29 (2) 599-612
  • 50 Ehara S, Shimamura T, Wada T. Single vertebral compression and involvement of the posterior elements in tuberculous spondylitis: observation on MR imaging.  Radiat Med. 1997;  15 (3) 143-147
  • 51 Arizono T, Oga M, Shiota E, Honda K, Sugioka Y. Differentiation of vertebral osteomyelitis and tuberculous spondylitis by magnetic resonance imaging.  Int Orthop. 1995;  19 (5) 319-322
  • 52 Modic M T, Feiglin D H, Piraino D W et al.. Vertebral osteomyelitis: assessment using MR.  Radiology. 1985;  157 (1) 157-166
  • 53 Lifeso R M, Weaver P, Harder E H. Tuberculous spondylitis in adults.  J Bone Joint Surg Am. 1985;  67 (9) 1405-1413
  • 54 Gordin F, Stamler C, Mills J. Pyogenic psoas abscesses: noninvasive diagnostic techniques and review of the literature.  Rev Infect Dis. 1983;  5 (6) 1003-1011
  • 55 Shanley D J. Tuberculosis of the spine: imaging features.  AJR Am J Roentgenol. 1995;  164 (3) 659-664
  • 56 Shivaram U, Wollschlager C, Khan F, Khan A. Spinal tuberculosis revisited.  South Med J. 1985;  78 (6) 681-684
  • 57 Whelan M A, Naidich D P, Post J D, Chase N E. Computed tomography of spinal tuberculosis.  J Comput Assist Tomogr. 1983;  7 (1) 25-30
  • 58 Hoffman E B, Crosier J H, Cremin B J. Imaging in children with spinal tuberculosis. A comparison of radiography, computed tomography and magnetic resonance imaging.  J Bone Joint Surg Br. 1993;  75 (2) 233-239
  • 59 Modic M T, Feiglin D H, Piraino D W et al.. Vertebral osteomyelitis: assessment using MR.  Radiology. 1985;  157 (1) 157-166
  • 60 Park Y H, Taylor J A, Szollar S M, Resnick D. Imaging findings in spinal neuroarthropathy.  Spine. 1994;  19 (13) 1499-1504
  • 61 Reda M I, Bakr I I. Tuberculous spondylitis and the role of magnetic resonance imaging in Pott's disease of the spine.  Int J Neuroradiol. 1997;  3 470
  • 62 Jung N Y, Jee W H, Ha K Y, Park C K, Byun J Y. Discrimination of tuberculous spondylitis from pyogenic spondylitis on MRI.  AJR Am J Roentgenol. 2004;  182 (6) 1405-1410
  • 63 Moorthy S, Prabhu N K. Spectrum of MR imaging findings in spinal tuberculosis.  AJR Am J Roentgenol. 2002;  179 (4) 979-983
  • 64 Sharif H S. Role of MR imaging in the management of spinal infections.  AJR Am J Roentgenol. 1992;  158 (6) 1333-1345
  • 65 Sharif H S, Clark D C, Aabed M Y et al.. Granulomatous spinal infections: MR imaging.  Radiology. 1990;  177 (1) 101-107
  • 66 Blumberg H M, Leonard Jr M K, Jasmer R M. Update on the treatment of tuberculosis and latent tuberculosis infection.  JAMA. 2005;  293 (22) 2776-2784
  • 67 Mitnick C D, Shin S S, Seung K J et al.. Comprehensive treatment of extensively drug-resistant tuberculosis.  N Engl J Med. 2008;  359 (6) 563-574

Wilfred C.G. Peh, M.D. 

Department of Diagnostic Radiology, Khoo Teck Puat Hospital

Alexandra Health, 90 Yishun Central, Singapore 768828, Republic of Singapore

Email: [email protected]