Diagnostic Imaging of Spinal Infection & Inflammation

Spine
Infection & Inflammation

Mohamed Zaitoun
Assistant Lecturer-Diagnostic Radiology
Department , Zagazig University Hospitals
Egypt
FINR (Fellowship of Interventional
Neuroradiology)-Switzerland
zaitoun82@gmail.com

Knowing as much as
possible about your enemy
precedes successful battle
and learning about the
disease process precedes
successful management

Infection & Inflammation
1-Spondylodiskitis
2-Spinal T.B. (Pott’s Disease)
3-Epidural Abscess
4-Arachnoiditis
5-Guillain-Barre Syndrome
6-Chronic Inflammatory Demyelinating Polyneuropathy
7-Sarcoidosis
8-Multiple Sclerosis
9-Neuromyelitis Optica
10-Acute Transverse Myelitis
11-Vitamin B12 Deficiency
12-Paget Disease

1-Spondylodiskitis :
a) Incidence
b) Etiology
c) Location
d) Radiographic Features

a) Incidence :
-Spine infections may progress from spondylitis → diskitis
→ epidural abscess → cord abscess
-In the pediatric age group infection often starts in the
intervertebral disc itself (direct blood supply still present)
whereas in adults infection is thought to begin at the
vertebral body endplate extending into the intervertebral
disc space and then into the adjacent vertebral body
endplate
-Infective spondylitis usually involves extradural
components of the spine such as posterior elements ,
disks (diskitis) , vertebral body (osteomyelitis) &
paraspinous soft tissues

b) Etiology :
1-Pyogenic : Staphylococcus aureus >
Enterococcus > E. coli , Salmonella
2-T.B.
3-Fungal
4-Parasitic

c) Location :
-Can occur anywhere in the vertebral
column but more commonly involves
lumbar spine

d) Radiographic Features :
1-Plain Radiography
2-CT
3-MRI
4-Nuclear Medicine

1-Plain Radiography :
-Insensitive to the early changes of
diskitis/osteomyelitis with normal appearances
being maintained for up to 2-4 weeks
-Thereafter disc space narrowing and irregularity
or ill-definition of the vertebral endplates can be
seen
-In untreated cases , bony sclerosis may begin to
appear in 10-12 weeks

Lateral x-ray of discitis , L1-L2 disc height loss , endplate sclerosis &
Indistinct endplates

2-CT :
-CT findings are similar to plain film but
more sensitive to earlier changes
-Additionally surrounding soft tissue swelling
, collections and even epidural
abscesses may be evident

3-MRI :
*T1 :
-Low signal in disc space (fluid)
-Low signal in adjacent endplates (bone marrow
edema)
*T2 (Fat sat or STIR especially useful) :
-High signal in disc space (fluid)
-High signal in adjacent endplates (bone marrow
edema)
-Loss of low signal cortex at endplates
-High signal in paravertebral soft tissues

*T1+C :
-Peripheral enhancement around fluid collection(s)
-Enhancement of vertebral endplates
-Enhancement of perivertebral soft tissues
-Enhancement around low density center indicates
abscess formation (hard to distinguish
inflammatory phlegmon from abscess without
contrast)
*Diffusion :
-Hyperintense in acute stage
-Hypointense in chronic stage

T1+C shows L1-L2 spondylodiskitis with epidural abscess

A: T2 sagittal showing high signal intensity of the intervertebral disc and vertebral body at the L4-L5
level , the prevertebral and epidural abscesses become hyperintense
B: T1 sagittal showing low signal intensity of the intervertebral disc and vertebral body
C: T1+C sagittal showing heterogenous enhancement was seen and epidural and prevertebral
abscesses are better delineated
D: T1+C axial showing the diffuse enhancement in the L4 body and paravertebral soft tissue ,
epidural abscess is also seen

4-Nuclear Medicine :
-A bone scan may be used to demonstrate
increased uptake at the site of infection and are
more sensitive than plain film and CT , however
lack specificity
-The classic appearance on multiphase bone
scans is increased blood flow and pool activity
and associated increased uptake on the
standard delayed static images

2-Spinal T.B. (Pott’s Disease) :
1-Incidence
2-Pathology
3-Radiographic Features
4-Differential Diagnosis

1-Incidence :
-Also known as tuberculous spondylitis
-Refers to vertebral body and intervertebral
disc involvement with tuberculosis
-N.B. :
Brucellosis can present as granulomatous
osteomyelitis of the spine that can be
difficult to distinguish from TB

2-Pathology :
-There is usually a slow collapse of one or usually
more vertebral bodies which spreads
underneath the longitudinal ligaments , this
results in an acute kyphotic or gibbus deformity
-This angulation , coupled with epidural granulation
tissue and bony fragments can lead to cord
compression , unlike pyogenic infections , the
discs can be preserved
-In late-stage spinal TB , large paraspinal
abscesses without severe pain or frank pus are
common leading to the expression cold abscess

Gibbus deformity (short-segment structural thoracolumbar
kyphosis resulting in sharp angulation)

(A) T1 , (B) T2 show severe destruction of T11/T12 resulting in a significant
kyphosis

*N.B. Differential Diagnosis of Gibbus deformity :
a) Congenital :
1-Achondroplasia
2-Cretinism (hypothyroidism)
3-Apert syndrome
4-Coffin-Lowry syndrome
5-Mucopolysaccharidoses :
Hurler syndrome
Hunter syndrome
Maroteaux-Lamy syndrome

b) Acquired :
1-Compression fracture/vertebra plana :
Osteoporosis
Langerhans cell histiocytosis
Vertebral metastases
2-Osteomyelitis/discitis :
Pyogenic spinal osteomyelitis
Tuberculosis (Pott’s disease)
3-Scheuermann disease

3-Radiographic Features :
a) Plain Radiography
b) CT & MRI

a) Plain Radiography :
1-Bone destruction is prominent , more prolonged onset
than with pyogenic bone destruction
2-Loss of disk height , 80% (affects intervertebral discs ,
but mets no)
3-Gibbus deformity : anterior involvement with normal
posterior vertebral bodies (Kyphosis)
4-Vertebra plana or pancake vertebra (vertebral body has
lost almost its entire height anteriorly and posteriorly)
5-Involvement of several adjacent vertebral bodies with
disk destruction
6-Large paraspinous abscess
7-Extension into psoas muscles (psoas abscess)

Destructive processes involving T11 associated with kyphosis

Cervical Pott’s disease presenting as a retropharyngeal abscess

AP (A) and lateral (B) X-ray of the lumbar spine showing spondylitis of
the second lumbar vertebral body (L2) and lateral X-ray of the
thoracic spine (C) of another patient showing a severe kyphosis as
a consequence of T5-T6 spondylitis

b) CT & MRI :
-Cross-sectional imaging is required to better
assess the extent of involvement and particularly
for the presence of an epidural component and
cord compression , MRI is the modality of choice
for this, with CT with contrast being a distant
second
-Features include irregularity of both the endplate
and anterior aspect of the vertebral bodies with
bone marrow edema and enhancement seen on
MRI
-The collections are typically well circumscribed
with fluid centers and well defined enhancing
margins

(A) T1 shows destruction of the intervertebral disc space and endplates
of the adjacent vertebral bodies is marked , vertebral body
alignment is normal , (B) T2 shows diskitis and destruction of the
endplates of the adjacent vertebral bodies

(A,C) T2 , (B,D) T1+C show destruction of L3 vertebral body (A , white arrow)
with gibbus formation and retropulsion of bony fragments with compromise
of the central canal at that level (A, black arrow) , there is fluid signal within
the disc space that communicates with bilateral psoas abscesses (B, C, D,
white asterisks) and pathologic enhancement is noted following contrast
administration (B, D)

(A) T2 , (B) T1 show destruction of T8/T9 with some preservation of the disc

T1+C show destruction of L2 and L3 vertebral bodies with intraosseous and
epidural abscess resulting in spinal canal stenosis

T1+C shows heterogeneous enhancement (arrows) of T8-
T9 vertebral bodies , intraosseous abscess (asterisk)

Edema of the bone marrow of L2 and L3 with intra-discal
(blue star) and epidural abscess (red arrows)

Epidural abscess with cord displacement and compression (red
arrows) and paraspinal phlegmon within the left psoas muscle
(yellow arrows)

T2 shows collapse of L1 vertebral body with irregularity of superior end plate of
L2 along with bilateral psoas abscesses

T1+C shows bilateral psoas abscesses

T1+C with fat sat shows peripheral enhancement of psoas collections
consistent with the "cold" abscesses of spinal TB

3-Differential Diagnosis :
-From non-specific infections :
a) Site :
-Lumbar vertebrae are more affected in non-specific
infections
-T.B. : Dorsal & cervical then lumbar
b) Course :
-Acute with non-specific and prolonged in T.B.
c) Soft tissue mass , collapsed vertebrae :
-More with T.B.
d) Sclerosis :
-More with non-specific infections

e) MRI :
1-T1+C : Rim enhancement of abscess on MRI is
suggestive of tuberculous spondylitis , however ,
rim enhancement can be observed in both
tuberculous and pyogenic spondylitis :
-TB Spondylitis :
Thin and smooth enhancement of the abscess wall
and well-defined paraspinal abnormal signal
-Pyogenic Infections :
Thick and irregular enhancement of abscess wall
and ill-defined paraspinal abnormal signal

(A) T1+C in TB shows smooth enhancement of intraosseous abscess (asterisk) , (B)
T1+C in pyogenic abscess shows irregular enhancement of abscess (asterisk)
presents in L4-5 disk space extending to L5 vertebral body

2-Hyperintense signal on T2 is more
common in tuberculous spondylitis
3-Subligamentous spread to three or more
vertebral levels was frequent in
tuberculous spondylitis
4-Involvement of the posterior element has
been reported in tuberculous spondylitis
and very uncommonly in pyogenic
spondylitis

(A) T2 in TB shows T8 and T9 vertebral bodies are heterogeneously hyperintense (arrows) , (B) T2 in
pyogenic infection shows L4 and L5 vertebral bodies are isointense (arrows) to adjacent normal
vertebrae

T.B. spondylitis, T1 shows heterogeneously hypointense signal
(arrows) in T8-T9 vertebral bodies with epidural mass and
subligamentous spread (arrowheads) from T7 to T10

Normal spinal posterior elements

(A) T1 , (B) T1+C show the extension of the abnormal signal intensity and
enhancement of the vertebral body to both pedicle , anterior paraspinal and
epidural soft tissues abnormal signal intensity and enhancement

(A) T1 , (B) T1+C shows the extension of the abnormal signal intensity and
enhancement of the vertebral body to the right pedicle , right transverse
process and adjacent right rib with marginal enhancing right paraspinal
abscess

3-Epidural Abscess :
a) Etiology
b) Radiographic Features

a) Etiology :
-Rare but important emergency
-Peak incidence in the fifth to seventh
decades of life with a male predominance
-Usually secondary to disc or vertebral
sepsis

b) Radiographic Features :
-Gadolinium-enhanced MRI is the imaging choice
for diagnosis of SEA, there are two basic
patterns :
1-Phlegmonous stage of infection results in
homogeneous enhancement of the abnormal
area which correlate to granulomatous-thickened
tissue with embedded micro-abscess without a
significant pus collection
2-Liquid abscess surrounded by inflammatory
tissue which shows varying degree of peripheral
enhancement with gadolinium (long segment
extradural mass with marginal enhancement)

T2 (A) , T1 fat-saturated image after intravenous gadolinium (B)
showing spondylodiscitis (arrow) complicated by an SEA at the C6-7
level (arrowheads)

T1+C fat-saturated revealing a posterior SEA from the
vertebral level C5 to T5 (arrowheads)

4-Arachnoiditis :
a) Definition
b) Etiology
c) Radiographic Features

a) Definition :
-inflammation of the meninges and
subarachnoid space

b) Etiology :
1-Infectious :
-Meningitis
2-Inflammatory :
-Surgery
-Intrathecal hemorrhage
-Intrathecal compounds : myelographic contrast media ,
anesthetics
3-Neoplastic :
-Hematogenous spread of systemic tumors
-Direct seeding of the CSF from primary central nervous
system tumors (GMB , medulloblastoma , ependymoma
& choroid plexus carcinoma)

c) Radiographic Features :
-The nerve roots are irregularly thickened and
clumped together (asymmetric distribution of
nerve roots) , often stuck to the dura resulting in
an empty thecal sac sign (is when the thecal sac
appears empty on MRI of the lumbar spine , best
seen on T2 , if the empty thecal sac sign is
present , a diagnosis of adhesive arachnoiditis
can be made)
-Intradural scarring / loculation (limited
enhancement)
-Intradural cysts (may be bright on T1)
-Irregular margins of thecal sac

Normal nerve roots , (A) T2 shows normal lumbar roots are individually
visible and because they float freely in the spinal fluid they follow the
rules of gravity by positioning more towards the back , (B) T1 ,
hardly shows the nerve roots situated posteriorly in the spinal canal

Normal appearance of nerve roots in
thecal sac on a T2 axial , note the
slender caliber of the well-spaced
nerve roots
Patient with mild arachnoiditis , suggested
by thickened nerve roots (arrows) on
T2 axial , which do not appear as
spatially separated in the sac as is
typical

T2 shows normal nerve roots T2 shows clumping of roots on
the right side

Normal "fanning" of nerve roots within the thecal
sac (arrows) is apparent on this T2 sagittal
view of the lumbar region
In a patient with mild arachnoiditis, a T2 fails to
demonstrate the usually fanning of nerve
roots (arrow) on off-center sagittal views

T2 axial image reveals moderately thickened nerve roots with abnormal
distribution in the thecal sac (arrows) , compatible with clumping

Post-operative , T2 axial image reveals moderately thickened nerve
roots with abnormal distribution in the thecal sac (arrows) ,
compatible with clumping

The empty sac sign is present due to peripheral adherence
of nerve roots (arrows) to the arachnoid

T2 shows the (empty sac) with clumping of the nerve roots
to both sides

T2 sagittal reveals central clumping of nerve roots and
pseudotethering (arrows)

T1+C shows no significant enhancement in association
with the thickened nerve roots (arrows)

T2 sagittal image reveals thickened nerve roots (arrows) , intradural
cysts (arrowheads) and pseudotethering

5-Guillain-Barre Syndrome :
a) Incidence
c) Differential Diagnosis

a) Incidence :
-Defined as heterogeneous group of autoimmune
polyradiculopathy involving sensory , motor and
autonomic nerves and is the most common
cause of rapidly progressive flaccid paralysis
-Most cases preceded by upper respiratory tract
infections or diarrhea 1-3 weeks before its onset
-Classical presentation of GBS includes
symmetrical ascending muscle paresis or palsy ,
areflexia or hyporeflexia along with variable
degree of sensory or autonomic involvement

-Diagnosed by combination of clinical
presentation , CSF study and
electrophysiological criteria
-Radiologic studies are ordered to exclude other
causes and in cases where nerve conduction
studies and CSF examination are equivocal
-MRI of the spine is most useful helps excluding
other etiologies such as transverse myelitis and
compressive causes of polyradiculopathy

-It is essential that contrast be administered if the
diagnosis is suspected as non-contrast
sequences are essentially normal
-Typical findings are :
1-Nerve root thickening
2-Enhancement surrounding the conus and
extending along the cauda equina , resulting
from break down in the blood brain barrier which
usually prevents enhancement
3-The most common site of enhancement is
considered to be anterior nerve roots , although
enhancement of the posterior nerve roots is also
seen
-In the brain, the facial nerve is the most
commonly affected

(A) T1 shows no abnormality , (B,C) T1+C show marked enhancement
of the cauda equina (white arrows) & dorsal and ventral nerve roots
(black arrows)

T1+C shows abnormal enhancement along nerve roots of
cauda equina

T1+C show that the area of enhancement grew smaller during the clinical
course

c) Differential Diagnosis :
-The differential is essentially that of nerve root / cauda
equina enhancement :
1-AIDS-related polyradiculopathy
2-Arachnoiditis from any cause (e.g. post operative or post
intrathecal injection)
3-Neurosarcoidosis
4-Leptomeningeal carcinomatosis and lymphoma
5-Chronic Inflammatory Demyelinating Polyneuropathy
(CIPD) :
-Acute presentation of CIPD can be similar to GBS
-Difficult to differentiate in the first 6 weeks
-After 6-8 weeks GBS should be improving whereas CIDP
will demonstrate chronic inflammation

6-Chronic Inflammatory Demyelinating
Polyneuropathy (CIPD) :
a) Incidence

a) Incidence :
-An acquired demyelinating disease involving
peripheral nerves and is generally considered
the chronic counterpart to Guillain-Barre
syndrome (GBS)
-Uncommon demyelinating disease
-Patients typically present with a gradual and
protracted (> 2month) weakness of both
proximal and distal musculature associated with
areflexia and sensory change

-Thickening and enhancement of peripheral
nerves , brachial and lumbosacral plexus
and nerve roots
-In many cases the nerves become so
thickened that they resemble onion bulbs
(The nerve roots appear bulbous tapering
as they extend along the nerve)

T2 shows extensive hyperintense nodular masses along the cervical
ventral rami (white arrows) and brachial plexus bilaterally (black
arrows)

(A) T1 , (B) T2 , (C) T1+C show thickening of nerve roots of
cauda equina

T2 of the right C7 and C8 nerve roots (arrowheads) and brachial plexus
(arrow) demonstrated marked swelling and hyperintensity

(A,B,C) T1+C show massive hypertrophy of cervical nerve roots
causing cervical spinal cord compression (A,B) dotted arrow : spinal
cord , white arrows : nerve roots) and major hypertrophy of brachial
plexi (C, white arrows)

(A) T1 , (B) T2 show root hypertrophy

T2 shows enlargement of spinal roots in the lower spinal canal , the
lumbar and sacral ventral rami are massively enlarged (arrows)

T1+C shows enlarged enhancing roots of the brachial plexus passing
between the scalene muscles (arrows)

7-Sarcoidosis :
a) Incidence

a) Incidence :
-Noncaseating granulomatous disease of
unknown etiology treated with
corticosteroids

-Fusiform cord enlargement with abnormal
high signal intensity on T2
-Patchy enhancement

(A) T2 , (B) T1 , (C) T1+C show high T2 signal within the spinal cord
(arrowheads) , a portion of the lesion show intense enhancement
(arrowhead) , the cord is mildly expanded

Sagittal T2 of the thoracic cord of a 45-year-old woman with sarcoidosis who
presented with a subacute myelopathy

8-Multiple Sclerosis :
a) Incidence

a) Incidence :
-Presentation is usually between adolescence and
the sixth decade with a peak at approximately 35
years of age
-More in females
-The spinal cord is known to be frequently involved
in MS or in combination with lesions in the brain
-As many as 25% of cases have been found to
involve only the spinal cord
-Most spinal cord lesions occur in the cervical cord

-T2 hyperintense
-Typical spinal cord lesions in MS are relatively
small , peripherally located and multiple
-They are most often found in the cervical cord and
are usually less than 2 vertebral segments in
length
-A spinal cord lesion together with a lesion in the
cerebellum or brainstem is very suggestive of
MS
-Active lesions show enhancement
-Active plaques may demonstrate restricted
diffusion

(A,B) T2 , (C) T1+C show multiple hyperintense lesions are visible
in (A) & (B) which suggest multifocal disease , in (C) one of these
lesions (arrow) is contrast enhancing

(A) T2 , (B) T1+C show a large lesion posteriorly within the
cord, best seen on the T2 (on which it is hyperintense)
with subtle abnormal contrast enhancement

9-Neuromyelitis Optica :
a) Incidence

a) Incidence :
-Known as Devic disease
-Typically found in patients that are somewhat
older than those with MS and there is an even
stronger female predilection
-Characterized by :
Optic neuritis (unilateral or bilateral) & myelitis with
lesions in both the optic nerve & the spinal cord
with blindness and paraplegia
-Although NMO was initially thought of as a
monophasic illness it is now evident that , like
many patients with multiple sclerosis , it is
usually a relapsing disease with symptomatic
events separated by many years

-High T2 signal extend over long distances (over
three or more vertebral segments , often much
more) , this is known as a longitudinally
extensive spinal cord lesion (LESCL)
-Also helpful in distinguishing it from multiple
sclerosis demyelination is the involvement of the
central part of the cord (MS lesions tend to
involve individual peripheral white matter tracts)
- May displace abnormal contrast enhancement

NMO , (A) T1+C shows extensive multiple levels of cervical spinal cord
involvement with edema and blood-brain barrier breakdown , (B) T2
indicates the extent of signal abnormality

10-Acute Transverse Myelitis :
a) Incidence
c) Differential Diagnosis

a) Incidence :
-Affects individuals of all ages with peaks between
ages 10-19 years and 30-39 years
-Acute transverse myelitis may occur as :
1-An isolated idiopathic entity (with possible viral
or autoimmune etiology)
2-Or in association with systemic diseases (lupus
or sarcoidosis)
-The clinical presentation :
Acute or subacute motor , sensory & autonomic
dysfunction related to a focal cord lesion

Sagittal T2 in a 43-year-old man who developed herpes zoster in the
upper limbs and simultaneously a longitudinally extensive cervical
myelitis

-Up to 40% of cases have no findings on MRI
-Centrally located abnormal cord high signal
intensity on T2 (involving the majority of the cord
in cross-section)
-Extending over multiple segments (3-4 spinal
segments)
-Fusiform enlargement of the cord
-More commonly found within the thoracic cord
-Variable enhancement patterns (none , diffuse ,
patchy & peripheral)

(A) Sagittal & axial T2 , (B) Sagittal & axial T1+C show the T2 signal abnormality extends
to 3 or more cord segments and the lesion is centrally located (A) , also note the
patchy enhancement (B)

(A) T2 sagittal , (B) T2 axial show an ill-defined area of hyperintensity within the
thoracic spinal cord at the T-10 vertebral level , there is mild cord swelling at
this level , the corresponding axial T2 shows an area of increased signal
within the thoracic spinal cord

Axial T2 of cervical spine shows normal cord signal (A , circle) and increased
T2 signal in the central cord (B , circle)

c) Differential Diagnosis :
1-Multiple Sclerosis
2-ADEM
3-Neuromyelitis Optica
4-Spinal Cord Infarction
5-Spinal AVFs
6-Intramedullary Spinal Tumors
7-Radiation Associated Myelopathy

1-Multiple Sclerosis :
-With multiplicity of cord lesions combined
with characteristic brain lesions consistent
with M.S.
-Plaques are generally shorter than two
vertebral body segments in length and
involve less than half the cross-sectional
area of the cord
-Plaques are characteristically peripherally
located in the dorsal and lateral columns

M.S. , (A) Sagittal T2 shows discrete lesions without cord swelling , (B) Axial T2
shows that the lesion is peripherally located within the cord

2-ADEM :
-Monophasic disorder that affects the brain
and occasionally the spinal cord
-Typically following a recent (1-2 weeks
prior) viral infection or vaccination
-Similar appearance to spinal MS plaques ,
more often associated with thalamic
lesions

3-Neuromyelitis Optica :
-Lesions are centrally located
-The lesions in the cord are typically long (>
3 vertebral segments)
-A history of severe optic neuritis should
raise suspicion of NMO

NMO , T2 show longitudinally extensive T2 signal abnormality in >3 vertebral segments
(A) , the lesion is centrally located within the cord (B) with cord swelling (A)

4-Spinal Cord Infarction :
-Arterial occlusions are rare and develop
acutely over minutes
-Acute vascular occlusion can lead to spinal
cord infarction mimicking myelitis

Spinal cord infarction , sagittal T2 , arrow points to the linear lesion in
the anterior cord-presumed anterior spinal artery occlusion

5-Spinal AVFs :
-Arteriovenous fistulas (AVFs) usually
progress slowly due to gradual ischemia
resulting from venous congestion
-Sudden decompensation of myelopathy
caused by AVFs or bleeding into vascular
malformations may also mimic myelitis

AVF , (A) T1 shows no definite abnormality , (B) T2 shows
hyperintense longitudinally extensive lesion , (C) T1+C reveals
dilated blood vessels on the surface of the cord

6-Intramedullary Spinal Tumors :
-Present over weeks
-This is not a difficult diagnosis when there
is an enhancing heterogenous lesion on
MRI
-Hemorrhage or infarction of tumors
resulting in acute swelling can mimic
myelitis
-Commonly associated with cysts and
syringohydromyelia

(A) T2 shows intramedullary tumor formation at C6-7 accompanying
moderate syrinx , (B) T1+C shows the enhanced tumor within the
spinal cord

7-Radiation Associated Myelopathy :
-Usually slowly progressive but may occur
up to 15 years after the end of radiation
treatment which may obscure the role of
radiation therapy in causing the
myelopathy
-Early in the course , cord swelling or
enhancement may be seen but later
atrophy may be the only finding

Sagittal T2 in a 34-year-old man with Hodgkin’s lymphoma who received radiotherapy
and presented 2 years later with subacute myelopathy and thoracic sensory level.
Long arrow points to the longitudinally extensive T2 hyperintense intramedullary
lesion , the short arrow points to the vertebral changes in the field of radiation , the
vertebra immediately below seems normal

11-Vitamin B12 Deficiency :
a) Incidence
b) Etiology
c) Radiographic Features
d) Differential Diagnosis

a) Incidence :
-known as Subacute Combined
Degeneration
-Most common in patients older than 40 and
especially older than 60
-The vitamin deficiency leads to
accumulation of methylmalonic acid which
is myelinotoxic

b) Etiology :
1-Malabsorption (most common) , e.g.
Crohn’s disease & other causes of
terminal ileitis
2-Inadequate vitamin B12 intake (rare)
3-Nitrous oxide toxicity (inactivates B12)
-Treatment by intramuscular injection of B12
, the potential for reversal of clinical
symptoms is inversely proportional to their
duration & severity

c) Radiographic Features :
-Most commonly there is symmetric bilateral
high signal within the dorsal columns ,
occasionally lateral columns extending
over several vertebral body segments
-This appearance has been described as
the (inverted V sign)
-Predominately in the lower cervical and
upper thoracic region
-May enhance
-Often there is cerebral white matter change
also

T2 shows hyperintensity (arrows) in the dorsal aspect of the cord spinal
extending from the level of C2 to the level of C5

Axial T2 obtained through the cervical spinal cord at three separate
levels from C3 to C4 show bilateral symmetric signal intensity
abnormality within the dorsal columns (arrows)

d) Differential Diagnosis :
1-Demyelination :
-M.S. : also affects dorsal columns but usually over a
shorter length
-T.M. : although longer length , usually not restricted to
dorsal columns
2-Infectious causes :
-HIV vacuolar myelopathy : may appear very similar
-Herpes viruses myelitis
-Syphilis (tabes dorsalis)
3-Inflammatory :
-Sarcoidosis
4-Ischemia
5-Neoplasm :
-Astrocytoma : not particularly of dorsal columns , usually
more cord expansion , often enhance
-Ependymoma : not particularly of dorsal columns , usually
more cord expansion , often enhance

12-Paget Disease :
-Picture frame vertebral body : enlarged
square vertebral body with peripheral thick
trabeculae and inner lucency (increased
opacity of the cortex on all sides of the
vertebral body whereas the characteristic
sclerosis of the rugger jersey spine is seen
only at the superior and inferior endplates)
-Ivory vertebra

Picture-frame and the increase in size compared to the
vertebras above and below (arrow)

(A) Lateral radiograph shows uniformly increased opacity of entire T7
vertebra (arrow) , (B) CT shows increased opacity involving nearly
the entire vertebral body

(A) T2 , (B) T1 shows mild increase in the AP diameter of L3 vertebral
body with thick coarses trabeculations , irregular T1hypointensity
noted in the posterior body and posterior elements of L3

Irregular thickening of the cortex in the body with preservation of marrow and
spinal canal , few thick coarse trabeculae are seen with osteolysis of the
rest , diffuse sclerosis with few lytic areas seen in the posterior elements

Mild expansion of the L3 vertebral body in the transverse and AP
directions with few thickened trabeculae and lysis of the rest , mild
expansion with sclerosis of the spinous process

Diagnostic Imaging of Spinal Infection & Inflammation

Diagnostic Imaging of Spinal Infection & Inflammation

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