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Koo, Lee, Chang, Yeom, Park, and Lee: Differential Diagnosis between Tuberculous Spondylitis and Pyogenic Spondylitis
Original Article

Journal of Korean Spine Surg 2009;16(2):112-121.

Published online: 21 February 2009

DOI: https://doi.org/10.4184/jkss.2009.16.2.112

Differential Diagnosis between Tuberculous Spondylitis and Pyogenic Spondylitis

Ki-Hyoung Koo, M.D., Hyeok-Jin Lee, M.D., Bong-Soon Chang, M.D., Jin-Sup Yeom, M.D., Kun-Woo Park, Choon-Ki Lee, M.D.#

Department of Orthopaedic Surgery, Seoul National University, College of Medicine, Seoul, Korea

#Department of Orthopaedic Surgery, Dongguk University International Hospital, Goyang, Korea

Address reprint requests to Bong-Soon Chang, M.D. Department of Orthopaedic Surgery, Seoul National University Hospital 101 Daehangno, Jongno-gu, Seoul 110-744, Korea Tel: 82-2-2072-3864, Fax: 82-2-764-2718, E-mail: bschang@snu.ac.kr

Copyright © 2009 Korean Society of Spine Surgery

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

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.

Keywords: Infectious spondylitis, Tuberculous spondylitis, Pyogenic spondylitis, Differential diagnosis, MRI

REFERENCES

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Figures and Tables%

Fig. 1.
A 32-year-old man with tuberculous spondylitis. He had the symptom duration of 1 month. ESR was 71 mm/hr. Fever higher than 38 degree and neurologic deficit were not observed. (A). T1 weight image shows loss of cortical definition, anterior wedging less than 50% of body. T2 weight image shows inhomogenous hyperintensity and relative disc preservation. Enhanced sagittal image shows inhomogenous focal enhancement. intraosseous abscess with rim enhancement and epidural abscess. (B) Enhanced axial image shows epidural abscess, well-defined rim-enhanced paraspinal abscess and intraosseous abscess.
jkss-16-112f1.tif
Table 1.
Clinical features of patients.
Tuberculous spondylitis Pyogenic spondylitis p-value
Number. of patients 50 45
Sex male 23 26 0.25
female 27 19
Mean age (yr) 48.2 (±17.56) 61.5 (±14.71) 0.00
Symptom duration (mo) 4.3 (±3.69) 1.8 (±1.17) 0.00
Number. of infected vertebra 2.26 (±0.69) 2.22 (±0.64) 0.78
Skip lesion 2 4 0.42
Fever (>38 deg) Yes 7 21 0.00
No 43 24
Capable of walking Yes 42 36 0.61
No 8 9
Neurologic deficit Yes 11 12 0.59
No 39 33
WBC count 7652.2 (±2492.1) 8616.2 (±3821.0) 0.15
ESR (mm/hr) 49.6 (±35.2) 71.3 (±29.0) 0.00
CRP (mg/dl) 2.98 (±3.20) 5.74 (±4.63) 0.00
Table 2.
Radiologic findings of patients.
Tuberculous spondylitis Pyogenic spondylitis p-value
1 13 31
Body destruction 2 22 11 0.00
3 11 03
4 04 00
1 23 11
Disc destruction 2 21 16 0.00
3 03 00
4 03 18
W/D* 44 09
Paraspinal abscess I/D† 05 32 0.00
No 01 04
Disc abscess Yes 02 18 0.00
No 48 27
Osseous abscess Yes 45 02 0.00
No 05 43
Epidural abscess Yes 34 16 0.00
No 16 29
Epidural extension Yes 38 22 0.01
No 12 23
ALL spread Yes 35 15 0.56
No 15 16
Body enhancement Focal 47 08 0.00
Diffuse 03 37

∗ W/D: well-defined paraspinal abscess (well-defined signal abnormality)

† I/D: ill-defined paraspinal abscess (ill-defined signal abnormality)

Table 3.
Intraobserver and interobserver reliablity
Intraobserver reliabilty (κ) Interobserver reliability (κ)
Body destruction more than half 0.752 0.770
W/D paraspinal abscess 0.959 0.939
Intraosseous abscess 0.785 0.678
Epidural abscess 0.743 0.634
Focal enhanced vertebrae 0.891 0.824
Table 4.
Sensitivity and specificity of features for tuberculous spondylitis.
Sensitivity (%) Specificity (%)
Age more than 45 yrs 50 86.2
Sx. duration more than 3 mos 60 75
ESR less than 50 mm/hr 52 70.3
No fever higher than 38 deg. 86 64.2
Body destruction more than half 30 83.3
W/D paraspinal abscess 88 83
Intraosseous abscess 90 95.7
Epidural abscess 68 68
Focal enhanced vertebrae 94 85.5
Table 5.
Trends of diagnostic criteria for tuberculous spondylitis.
Dx. Criteria 0 1 2 3 4 Sum
Tuberculous spondylitis 0 1 7 21 21 50
Pyogenic spondyliltis 11 24 9 1 0 45
Sum. 11 25 16 22 21 95
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