Imaging of musculoskeletal tuberculosis

Abstract

Extra-pulmonary tuberculosis (TB) of the musculoskeletal system usually manifests with non-specific clinical features, mimicking a variety of diseases. Diagnosis and treatment of spinal and extra-spinal musculoskeletal TB are often challenging. Imaging has an important role in detecting this disease, aiding diagnosis, identifying complications, and monitoring disease progression. Radiographs and magnetic resonance imaging are the key imaging modalities utilized. Radiologists should aim to be familiar with the spectrum of imaging features of TB affecting spinal and extra-spinal locations in the musculoskeletal system.

Keywords: bone tuberculosis; extra-pulmonary tuberculosis; joint tuberculosis; musculoskeletal tuberculosis; skeletal tuberculosis; spinal tuberculosis; tuberculosis; tuberculous bursitis; tuberculous osteomyelitis; tuberculous tenosynovitis.

Figure 1.

Early tuberculous spondylodiscitis. Lateral lumbar spine radiograph shows subchondral bone resorption of inferior L4 and superior L5 vertebral body corners (white arrows), with L4-L5 disc narrowing.

Figure 2.

Severe tuberculous spondylodiscitis. Lateral lumbar spine radiograph shows destruction of the L2-L3 intervertebral disc and adjacent vertebral bodies (thick white arrow), with adjacent bone sclerosis (thin white arrows).

Figure 3.

Tuberculous spondylodiscitis with vertebra plana. (A) Frontal and (B) lateral radiographs show destruction, sclerosis and compression of T11 vertebral body (thick white arrows), with severe narrowing of the adjacent T10-11 and T11-12 intervertebral discs. Sagittal (C) T2-W and (D) contrast-enhanced T1-W MR images show T2-hyperintense signal and rim enhancement surrounding the remnant flattened T11 vertebral body (thin white arrow) which is T1- and T2-hypointense. The lesion extends to a small epidural phlegmon (black arrowheads) and T9-12 anterior paravertebral abscess (open arrows). The inferior T10 and superior T12 vertebral bodies show abnormal T2-hyperintense signal. (E) Coronal CT image better shows the remnant sclerotic T11 vertebral body (thin white arrow) and calcifications (small white arrowheads) within the paravertebral abscess (open arrows). Inferior T10 vertebral body destruction and sequestra, as well as superior T12 vertebral body sclerosis are also noted.

Figure 4.

Tuberculous spondylodiscitis. (A) Frontal chest radiograph shows a large mediastinal opacity with convex contours, which bulges more prominently to the left (arrows). (B) Frontal thoracic spine radiograph shows the opacity to be due to a large paraspinal mass (arrows) that is related to multilevel destructive lesions of the underlying thoracic vertebral bodies and intervertebral discs (black arrowheads). (C) Coronal STIR MR image shows multiple levels of vertebral osteomyelitis, disco-vertebral destruction (white arrowheads) and heterogeneous T2-hyperintense paravertebral abscesses (arrows).

Figure 5.

Tuberculous paravertebral muscle abscess of the thoracic spine. (A) Longitudinal US image of the paravertebral muscle shows a fluid collection containing echogenic debris and small calcifications (black arrow). (B) Axial and (C) sagittal T2-W MR images show a well-circumscribed T2-hyperintense fluid collection within the right erector spinae muscle (white arrows). The adjacent vertebrae are normal.

Figure 6.

Tuberculous spondylodiscitis with vertebral body intra-osseous abscess. (A) Coronal T2-W, (B) axial T2-W and (C) axial contrast-enhanced T1-W MR images show a large vertebral body intra-osseous abscess (thick white arrows) which extends superiorly into the intervertebral disc (small white arrow) and adjacent vertebral body. There are extensive paravertebral abscesses (white arrowheads). The abscesses all show T2-hyperintensity with irregular rim enhancement. Corresponding (D) coronal and (E) axial CT images show a large osteolytic lesion (thick white arrows) with a small sequestrum (small white arrow) within the vertebral body. There is destruction and sclerosis of the adjacent vertebral body (open arrows) and narrowing of the intervening disc.

Figure 7.

Tuberculous spondylodiscitis with bilobed epidural abscess. Axial T2-W MR image shows a bilobed epidural abscess (white arrows) as well as a large anterior paravertebral abscess (white arrowheads).

Figure 8.

Tuberculous spondylitis (solitary vertebral involvement). Sagittal CT image shows a mostly sclerotic L3 vertebral body with some patchy osteolytic areas within. The adjacent intervertebral discs are normal.

Figure 9.

Tuberculous arthritis of the hip joint. Radiograph shows irregular destruction of the femoral head with marked joint narrowing (black arrows). There are adjacent soft tissue calcifications (white arrowheads) and associated ill-defined irregularity of the greater trochanter due to osteomyelitis.

Figure 10.

Ischial tuberculous osteomyelitis. Radiograph shows a multiloculated osteolytic lesion with surrounding sclerosis, containing sequestra (white arrows).

Figure 11.

Tuberculous arthritis of the right sacro-iliac joint. Axial CT image shows irregular destruction of the joint margins with small calcifications within the joint space (white arrows).

Figure 12.

Tuberculous arthritis of the ankle. (A) Frontal and (B) lateral radiographs show an osteolytic lesion at the postero-superior medial aspect of the talus containing a sequestrum. There is surrounding soft tissue swelling. (C) Sagittal CT image better shows bone destruction of the talus and multiple calcifications (white arrows). Sagittal (D) T1-W and (E) fat-suppressed contrast-enhanced T1-W MR images show prominent synovial thickening and enhancement (white arrowheads), with bone and cartilage destruction.

Figure 13.

Tuberculous tenosynovitis of the peroneus longus and brevis tendons in a 25-year-old man. Coronal (A) T1-W, (B) T2-W and (C) fat-suppressed contrast-enhanced T1-W, and axial (D) T1-W, (E) T2-W and (F) fat-suppressed contrast-enhanced T1-W MR images show prominent enhancement of thickened synovium of the peroneal tendon sheaths (arrowheads). There is very little synovial fluid as most of the areas with T2-hyperintense signal enhances.

Figure 14.

Tuberculous subdeltoid bursitis in a 22-year-old man presenting with a painless fluctuant swelling (“cold abscess”) over the deltoid region for 1 month. (A) Radiograph shows soft tissue swelling over the deltoid region (white arrowheads). Coronal (B) fat-suppressed T2-W and (C) fat-suppressed contrast enhanced T1-W and axial (D) T1-W, (E) fat-suppressed T2-W, and (F) fat-suppressed contrast enhanced T1-W MR images show a huge multiloculated fluid collection within the grossly distended subdeltoid bursa (white arrows). The bursa walls are mildly T1-hypertinese (penumbra sign), T2-isotense and show intense enhancement. There is a relative lack of surrounding oedema and the underlying bone is unaffected.

Figure 15.

Same patient as in Figure 14 with tuberculous subdeltoid bursitis. (A) Initial US image shows a large fluid collection with echogenic contents (white arrowheads). A total of 300 ml of pus was aspirated from various multiloculated fluid collections. (B) Repeat US-guided aspiration performed 6 days later yielded another 100 ml. (C) Post-aspiration US image shows residual bursal wall thickening (white arrows).