radiology

1. TUBERCULOSIS OF
BONES AND JOINTS

2. Historical aspects
 Oldest recognized disease of mankind
 Percival Pott presented the classic
description of spinal tuberculosis in 1779
 Robert Koch discovered Mycobacterium
tuberculosis in 1882

3. Predisposing factors
• Malnutrition's
• Poor sanitation
• Living in crowded areas
• Close contact with TB patients
• Immunodeficiency states

4. Lesions of individual bones
• Spine
• Greater trochanter
• Phalanx
• Skull
Joint lesions

5. infection by mycobacterium tuberculosis of one or
more extradural components of spine namely the
vertebra, intervertebral discs, paraspinal soft tissues
and epidural space
Tuberculosis of spine

6. Pathophysiology
• Usually by hematogenous route
• Midthoracic spine and the region below it is
more frequently involved
• Usually two continuous vertebrae are involved
but several vertebrae may be effected
• Skip lesions or solitary vertebral involvement
may occur

7. Clinical features
Constitutional
symptoms
 Malaise
 Loss of
appetite/weight loss
 Night sweats
Specific features
 Stiffness
 Enlarged lymph
nodes
 Neurodeficit

8. Imaging modalities
• Conventional radiographs
• CT
• MRI
• Ultrasonography

9. 1.Conventional Radiographs
• Reduced disc space
• Blurred paradiscal margins
• Destructions of bodies
• Loss of trabecular pattern
• Increased prevertebral soft tissue shadow
• Subluxation/dislocation
• Decreased lordosis/kyphosis

13. Central type of lesion:
• Spread through batson’s venous plexus/
branches
of posterior vertebral artery
• Minimal disc space reduction
• At the end concentric collapse

14. Anterior type lesion
 Starts beneath the
anterior longitudnal
ligament & periosteum
 Collapse & disc
reduction usually
minimal & occurs late
 Erosion is primarily
mechanical
Appendicular type
 Rare
 Isolated infection of
pedicles/lamina/transver
se process/spinous
process
 Erosions
 Paravertebral shadows
 Intact disc space

15. Lateral shift & scoliosis:
• More destruction of vertebral body on one
side
• Posterior articulation involvement in addition
to usual paradiscal lesions

16. Skipped lesions:
• More than one TB lesion present in vertebral
column with one or more healthy vertebrae in
b/w the 2 lesions
• 7% on routine x-rays
• More frequently detected on CT/MRI

17. Healing is indicated by
• decreased soft tissue shadow
• Disappearance of erosions
• Return of normal density(mineralization)
• Bony ankylosis

18. CT & MRI
• the extent of involvement
• presence of epidural component
• cord compression
• Irregularity of both end plate and anterior
aspect of vertebral bodies
• Bone marrow edema
• Enhancement on MRI

21. T2 Weighted sagital image of lumbar spine shows altered
Marrow signals involving anterosuperior margin.

22. Ultrasonography
To diagnose the presence of tubercular
abscesses in dorsolumber vertebral disease

23. Ultrasound
Joint effusion may be the
only finding but is
nonspecific.

24. Difference
TB spondylitis
 a pattern of mainly bone
destruction
• relative disc
preservation(destruction is late
sign)
• focal and heterogeneous
contrast enhancement of the
vertebral body
• well-defined paraspinal area of
abnormal signal intensity
Pyogenic spodylitis
 a pattern of mainly discitis
 mild to moderate peridiscal
bone destruction
 relative diffuse and
homogeneous contrast
enhancement of the vertebral
body

25. Difference
TB spondylitis
 vertebral intraosseous rim
enhancement on sagittal
views.
 Calcification when present
indictes TB.
Pyogenic spodylitis
• ill-defined paraspinal area of
abnormal signal intensity
• peridiscal rim enhancement

26. Tuberculous
dactylitis

27. spina = short bone
ventosa = expanded with air
• Plain Radiography is the modality of choice
• Tends to affect the bones distal to tarsus and wrist
• upper limb being more commonly involved
• involved bone shows a diaphyseal expansile lesion
• a periosteal reaction is uncommon
• healing is by sclerosis and is usually gradual

28. Poorly defined lytic change with medullary expansion, cortical erosion
and mild periosteal reaction in the mid and distal aspect of the right
middle finger in a patient with TB dactylitis.

29. Calvarial tuberculosis

30. • Rare entity
• May be localized and well defined
• Or may be more diffuse
• Associated with cold abscess

31. 1)Lateral radiograph shows large circumscribed lytic lesion in frontal bone.
2) AP radiograph demonstrates a large frontoparietal lytic lesion suggestive
of diffuse spreading type.
3) Frontal radiograph shows a lytic lesion with a sclerotic margin.

33. Joint Lesions
• One of the common cause of infectious arthritis in
developing countries
 Never a primary lesion it is always a sequelae of
pulmonary or lymph node tuberculosis
 It can occur at any age.

34. Radiographic features
Plain film
 early stages (stage of synovitis and
arthritis)
• periarticular demineralisation
• joint space widening (due to joint effusion)
• mild subchondral erosion

35. late stages (stage of erosion and destruction)
• gradual narrowing of joint space (there is involvement of
articular cartilage)
• severe subchondral erosion and destruction
• pathological subluxation and dislocation
• fibrous ankylosis
• atrophic changes in bones may occur and lead to
atrophic arthropathy (seen in shoulder joint as carries
sicca)

36. CT
 degree of bone destruction or rarely sequestrum
 Extension of infection in surroundings or any sinus tract
formation can also be demonstrated on post contrast
scan.

37. Caries sicca : there is erosion and destruction of humoral head and
glenoid cavity with soft tissue swelling, along with fibrotic opacites in the
right upper and middle lobe.

39. Osteolytic lesion in distal shaft of radius with osteopenia

40. There is a lucent lesion in the medial tibial metaphysis with thinning of
the cortex, subtle periosteal reaction and faint calcification in the
adjacent soft tissue.

41. Many Thanks