Single Sequence Whole-Spine Screening Magnetic Resonance Imaging: Diagnostic and Therapeutic Role in Multiple-Level Spinal Tuberculosis

Abstract

Introduction: Spinal tuberculosis (TB) is the most common form of skeletal tuberculosis. Paradiscal continuous vertebral involvement at a single level is the most prevalent pattern among all forms of spinal TB. There is a wide range of reported incidences of multiple-level non-contiguous spinal TB in the literature. We would like to discuss on the utility of single whole spine screening T2-weighted (T2W) mid-sagittal magnetic resonance imaging (MRI) film in diagnosing multiple-level spinal TB and therapeutic benefits it can provide.

Methods: We have done a retrospective review of the collected data of patients in Vardhman Mahavir Medical College and Safdarjung Hospital from August 2017 to October 2021 to find the incidence of multiple-level spinal TB and possible factors attributed to this specific disease pattern. All the patients who had been diagnosed of spinal TB either microbiologically or histopathologically or by a good clinical response to anti-tubercular treatment (ATT) and had a whole spine screening MRI film, were included. Patients of spinal TB who did not have a whole spine screening MRI were excluded from the study. Multiple-level spinal TB was diagnosed when lesions were identified in vertebral levels other than a typical paradiscal lesion, and additional lesions were separated from the primary disease by at least one normal spinal segment.

Results: Among the patients, 242 met the inclusion criteria, and 76 showed multiple-level non-contiguous spinal TB on MRI, incidence being 31.4%. The rest of the 166 patients showed typical single-segment contiguous lesions. By doing multivariate analysis to determine the independent risk factors for multiple-level spinal TB, extremes of age (<20 years and >50 years) have been found to be a significant factor with p value of 0.0001. Though drug resistance was not found to be a significant risk factor (p value 0.051), the proportion of patients having multiple-level TB was far more in the drug-resistant group (13/76).

Conclusions: Single sequence whole spine screening MRI film is an effective, economical, and time-saving tool to detect multiple-level spinal TB. Along with its diagnostic accuracy, it also provides therapeutic benefits like access to a more approachable site for biopsy.

Keywords: drug resistant spinal tuberculosis; multiple level spinal tuberculosis; spinal tuberculosis:; spine biopsy; whole spine screening mri.

Figure 1. Whole spine T2W screening film showing multiple level TB at D1, D7-8, L1-2, L5-S1 (yellow arrows)

TB: tuberculosis; T2W: T2-weighted

Figure 2. Intraoperative clinical picture showing purulent material coming out from the lesion (yellow arrow)

Figure 3. Whole spine screening T2W MRI of a patient with disseminated TB showing extensive involvement of the spine at C7-D3 (yellow arrow) and D7-D12 (red arrow)

TB: tuberculosis; T2W: T2-weighted; MRI: magnetic resonance imaging

Figure 4. Whole spine screening T2W MRI of a patient who presented with axial neck pain as the chief complaint. MRI revealed multifocal lesions at C4, D7-8, and D10-12. Rather than taking a biopsy sample from C4 (yellow arrow), a transpedicular biopsy was done from the D12 vertebral body and D11-12 disc space (red arrow). This approach was more easy, convenient, and risk-free

TB: tuberculosis; MRI: magnetic resonance imaging