Increased Tracer Uptake In The C5 And C6 Vertebral Bodies

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Cystic Tuberculosis

Fig. 6.32A, B Classic osteolytic manifestation of long bone tuberculosis with abscess and unimpressive reactive bone change. A Dorsoventral radiograph of a 41-year-old female with cystic tuberculosis in the right distal radius shows a poorly defined ovoid radiolucency (open arrow) with reactive sclerosis in the ulnar side (solid arrow). B Dorsal pinhole scan shows intense tracer uptake with a photon defect due to the abscess (open arrow). Intense uptake is mainly in the ulnar side of the lesion (solid arrow)

Fig. 6.31A, B Tuberculous dactylitis with the spina ventosa (puffed spine) sign in an adult. A AP pinhole scan of the left first finger in a 33-year-old female patient with digital tuberculosis shows increased tracer uptake in the head of the proximal phalanx and the base of the distal phalanx with a photon defect in the interphalangeal joint (open arrow). B Lateral radiograph reveals swollen soft tissue with osteolysis and pathological fracture involving the proximal phalangeal head (arrow)

Fig. 6.32A, B Classic osteolytic manifestation of long bone tuberculosis with abscess and unimpressive reactive bone change. A Dorsoventral radiograph of a 41-year-old female with cystic tuberculosis in the right distal radius shows a poorly defined ovoid radiolucency (open arrow) with reactive sclerosis in the ulnar side (solid arrow). B Dorsal pinhole scan shows intense tracer uptake with a photon defect due to the abscess (open arrow). Intense uptake is mainly in the ulnar side of the lesion (solid arrow)

Radius Uptake

Fig. 6.33A, B Cyst-like manifestation of bone tuberculosis. A Anterior pinhole scan of the pubis in a 63-year-old female patient with tuberculosis shows multiple photon defects due to abscesses (open arrows) with prominent lesion uptake (arrowheads). B Transverse CT of the pubis reveals irregular lysis intermingled with residual bony fragments (arrows) and a large prepubic abscess formation (abscess)

Fig. 6.33A, B Cyst-like manifestation of bone tuberculosis. A Anterior pinhole scan of the pubis in a 63-year-old female patient with tuberculosis shows multiple photon defects due to abscesses (open arrows) with prominent lesion uptake (arrowheads). B Transverse CT of the pubis reveals irregular lysis intermingled with residual bony fragments (arrows) and a large prepubic abscess formation (abscess)

Characteristic radiographic features include bone destruction with minimal bone proliferation (Fig. 6.32). Unlike in pyogenic infection, sequestration or significant periosteal reaction is uncommon. In dactylitis, however, sequestrum may occasionally be formed (Fig. 6.31). Abscess formation is a prominent feature of bone tuberculosis (Fig. 6.33). When the spine is involved, bone destruction typically starts in the anterior subchondral region of the vertebral body, gradually extending to the remaining part and transdiskally to the adjacent ver-

Fig. 6.34A, B Tuberculous spondylitis with asymmetrical "sandwich" sign. A Posterior pinhole scintigraph of the midlumbar spine in a 50-year-old man shows very intense, band-like tracer uptake in the initially infected upper endplate of the L3 vertebra (arrow) and less intense uptake in the secondarily affected lower endplate of the L2 vertebra (arrowheads). The disk space is narrowed. B Lateral radiograph shows lysis in the upper anterior edge of the L3 vertebra (arrows) and a subtle, spread lesion in the apposing endplate across the disk space, which is slightly narrowed (arrowheads). Essentially, the alterations are the same as those of pyogenic spondylitis shown in Figs. 6.27 and 6.28

Fig. 6.34A, B Tuberculous spondylitis with asymmetrical "sandwich" sign. A Posterior pinhole scintigraph of the midlumbar spine in a 50-year-old man shows very intense, band-like tracer uptake in the initially infected upper endplate of the L3 vertebra (arrow) and less intense uptake in the secondarily affected lower endplate of the L2 vertebra (arrowheads). The disk space is narrowed. B Lateral radiograph shows lysis in the upper anterior edge of the L3 vertebra (arrows) and a subtle, spread lesion in the apposing endplate across the disk space, which is slightly narrowed (arrowheads). Essentially, the alterations are the same as those of pyogenic spondylitis shown in Figs. 6.27 and 6.28

Pyogenic Spondylitis

Fig. 6.35A, B Pathological fracture of tuberculous vertebra with apparent widening of subjacent disk space. A AP radiograph of the midthoracic spine of a 46-year-old female with tuberculous spondylitis shows moderate compression of the T9 vertebra (arrow). The disk space is narrowed with the central portion being seemingly preserved. Focal osteolysis is noted in the right edge of the T10 upper endplate, denoting transdiskal spread of tuberculosis (arrowhead). B Posterior pinhole scan shows diffuse tracer uptake in the collapsed T9 vertebra with segmental transdiskal spread to the T10 upper endplate (arrowheads). Note apparent disk space widening (open arrow), and side mismatch due to the different radiographic and scintigraphic projections

Fig. 6.35A, B Pathological fracture of tuberculous vertebra with apparent widening of subjacent disk space. A AP radiograph of the midthoracic spine of a 46-year-old female with tuberculous spondylitis shows moderate compression of the T9 vertebra (arrow). The disk space is narrowed with the central portion being seemingly preserved. Focal osteolysis is noted in the right edge of the T10 upper endplate, denoting transdiskal spread of tuberculosis (arrowhead). B Posterior pinhole scan shows diffuse tracer uptake in the collapsed T9 vertebra with segmental transdiskal spread to the T10 upper endplate (arrowheads). Note apparent disk space widening (open arrow), and side mismatch due to the different radiographic and scintigraphic projections tebra (Fig. 6.34). Disk-space narrowing is the hallmark of diskitis, and tuberculous spondylitis is usually multivertebral. Pathological fracture is not uncommon, and, if it occurs the disk space may appear spuriously preserved (Fig. 6.35).

Characteristic pinhole scintigraphic features of long-bone tuberculosis include increased tracer uptake in the metaphysis (Figs. 6.32 and 6.36), an important feature of hematogenous infection in the long bones, as discussed in osteomyelitis (Fig. 6.2). In the same context the bone scan features of flat bone tuberculosis are not dissimilar to those of nontuberculous infection of the flat bones: a protean mixture of irregular increased and decreased tracer uptake. Sufficiently large tuberculous abscess or lytic focus is portrayed as a photopenic area surrounded by markedly increased tracer uptake in the perifocal sclerosis (Figs. 6.32 and 6.37). As in other infective spondylitides, the scintigraphic findings of tuberculous spondylitis vary according to the disease stage. In the early stage, the dominant tracer uptake occurs in the initial focus in one vertebral endplate (not in the two apposing endplates of the two neighboring vertebrae as seen in the later stage; Fig. 6.34). Even in this early stage the reduction of intervertebral distance may be evident. Nearly all cases reveal the involvement of the apposing endplate at this stage, although the change is mild. Importantly, sooner or later the unchecked initial lesion in the end-zone spreads to the center of the vertebra, manifesting as diffused uptake in a large area (Fig. 6.38). It is unusual to observe such a central spread in infective spondylitis, in which acute or suba-cute changes with intense uptake are still in the

Fig. 6.36 Tuberculosis in long bone. Posterior pinhole scan of both hips in a 4-year-old boy shows increased tracer uptake in the proximal metaphysis of the right femur, denoting tuberculous osteomyelitis (arrow). Compare with the normal left hip (L). The finding is very similar to that of acute osteomyelitis, but the uptake is less intense

Fig. 6.38 Centripetal and transdiskal spread of initial endplate tuberculosis. Anterior pinhole scintigraph of L5 and S1 vertebrae in a 68-year-old man shows intense tracer uptake in nearly the entire L5 vertebral body and fairly extensive alteration in the S1 vertebra, indicating trans-diskal spread from L5. The disk space is markedly narrowed (arrow)

Fig. 6.38 Centripetal and transdiskal spread of initial endplate tuberculosis. Anterior pinhole scintigraph of L5 and S1 vertebrae in a 68-year-old man shows intense tracer uptake in nearly the entire L5 vertebral body and fairly extensive alteration in the S1 vertebra, indicating trans-diskal spread from L5. The disk space is markedly narrowed (arrow)

Fig. 6.37 Tuberculous bone abscess. Anterior pinhole scintigraph of the left sacroiliac joint shows diffusely increased tracer uptake in the lower aspect of the left sacroiliac joint. Irregular "cold" areas represent bone destruction (open arrows). Unlike in pyogenic infection, reactive bone formation is inconspicuous

Fig. 6.37 Tuberculous bone abscess. Anterior pinhole scintigraph of the left sacroiliac joint shows diffusely increased tracer uptake in the lower aspect of the left sacroiliac joint. Irregular "cold" areas represent bone destruction (open arrows). Unlike in pyogenic infection, reactive bone formation is inconspicuous

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Fig. 6.39 Tuberculosis in the lower cervical spine. Posterior pinhole scintigraph of the lower cervical spine shows intense tracer uptake in C5 and C6 vertebrae with narrowing of the disk space (arrow). Note intense tracer uptake in the adjacent normal spinous processes, confusing the situation. However, disk space narrowing is the hallmark of infective spondylitis

Fig. 6.39 Tuberculosis in the lower cervical spine. Posterior pinhole scintigraph of the lower cervical spine shows intense tracer uptake in C5 and C6 vertebrae with narrowing of the disk space (arrow). Note intense tracer uptake in the adjacent normal spinous processes, confusing the situation. However, disk space narrowing is the hallmark of infective spondylitis

Fig. 6.40A-C Sensitivity of pinhole scan in the diagnosis of a pathological fracture of a tuberculous spine. A AP radiograph of the T5 and T6 vertebrae in a 75-year-old male with tuberculous spondylitis shows a barely discernible fracture in the anterior lower edge of T5 (arrow). The fracture was noticed after observing the pinhole scan. Note disk space narrowing due to tuberculous diskitis. B Posterior pinhole scan reveals prominent uptake in the fracture (arrow). Underlying tuberculous changes are indicated by increased uptake that frames the affected vertebrae (arrowheads). C T2-weighted MRI confirms the diagnosis (arrowhead)

Fig. 6.40A-C Sensitivity of pinhole scan in the diagnosis of a pathological fracture of a tuberculous spine. A AP radiograph of the T5 and T6 vertebrae in a 75-year-old male with tuberculous spondylitis shows a barely discernible fracture in the anterior lower edge of T5 (arrow). The fracture was noticed after observing the pinhole scan. Note disk space narrowing due to tuberculous diskitis. B Posterior pinhole scan reveals prominent uptake in the fracture (arrow). Underlying tuberculous changes are indicated by increased uptake that frames the affected vertebrae (arrowheads). C T2-weighted MRI confirms the diagnosis (arrowhead)

end-zone (Figs. 6.27 and 6.28). Eventually, with protracted transdiskal spread of the infection, the neighboring vertebra becomes extensively involved, making the difference between the original and following lesions nearly unrecognizable (Fig. 6.38). Frequently, the affected vertebrae are collapsed at this stage. Tuberculous spondylitis in the lower cervical spine may impose a diagnostic problem because the normally intense tracer uptake in the vertebral bodies and spinous processes often simulates pathology. Nevertheless, the disk space narrowing in infective spondylitis is a highly reliable sign (Fig. 6.39). In advanced cases the disk space is completely obliterated, and two or more neighboring vertebrae may become fused to form a "block vertebra".

The vertebrae replaced with tuberculous necrosis and granulomatous tissues are fragile and prone to pathological fracture (Fig. 6.34), and small fractures defy radiographic detec-

tion, especially in the thoracic spine that is difficult to visualize radiographically without anatomical overlapping (Fig. 6.40A). However, pinhole scintigraphy can sensitively detect it (Fig. 6.40B). It is to be remembered that the necrosis, granulomas, and sequestrated bones of tuberculosis are not imaged positively because they do not accumulate tracer. Rib tuberculosis or caries manifests as mottled or homogeneous uptake with occasional fracture (Fig. 6.41).

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Responses

  • mirabella
    What does multiphaic increased tracer uptake mean?
    6 months ago
  • ermes
    WHAT DOES TRACER UPTAKE IN THE LOWER CERVICAL SPINE MEAN?
    12 days ago

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