By

: Nurul Sakinah binti Rosli Noor Tilawatu binti Kamaruddin Nurul Hidayati binti Zainal Abidin Nurhamidah binti Jamaludin

Clinical History

Identification Data
Mr. M, 47 years old, Malay gentleman Ex-IVDU and heroin chaser past 10 year(5 months) Chronic smoker for past 30 years

Clinical Presentation
Presented with alleged MVA 2 weeks prior to

admission. However, post trauma, he did not sustain any injuries except abrasion wound over right forearm. But since then, he experiencing on and off numbness over lower limb, associated with pain over lower back and progressive weakness of lower limb.

 2 days prior to admission, he started having difficulty

in ambulation due to weakness-need aid of walking frame. The numbness and weakness was associated with fecal incontinence, difficulty in urination and sensation of incomplete voiding. Also claimed, having on and off numbness since 2 years ago but resolves spontaneously-frequently associated with blurry vision. On admission, he complaint of lower back pain and weakness of lower limb and inability to ambulate.

Physical Finding
Patient was alert and concious, GCS:15/15 Tenderness over lower cervical and lumbar spine Neurology

Upper Limb Right

Tone Power (C5T1) Reflexes Sensation Normal 5/5 ++

Left
Normal 5/5 ++

Lower Limb
Tone Power: L2 Power: L3-S1 Reflexes

Right
Normal 3/5 5/5 ++

Left
Normal 3/5 5/5 ++

Reduced from T10 downwards bilaterally

What is spondylodiscitis?
Spondylodiscitis is an inflammation of the base and upper plates of the vertebra as well as the adjoining intervertebral disc and is frequently accompanied by spondylitis (inflammation of the vertebral body). Infectious spondylodiscitis is caused by bacteria, viruses, fungi or parasites and can result in deformed vertebral segments and neurological complications.

BASE PLATE INTERVERTEBRAL DISC UPPER PLATE VERTEBRAL BODY SPINALNERVE

SPINALCORD SPINAL NERVE FIBROUS RING GELATINOUS CORE INTERVERTEBR AL DISC

Classification of Spondylodiscitis?
Bacterial caused Non Bacterial caused Specific Non Specific S.aureus S.epidermidis S.viridans E.coli P.aeruginosa Pneumococci Clostridium perfringens Proteus mirabilis Immunocompromised patients, viruses fungi Candida albicans Aspergillus parasitic infection tapeworms (Echinococcus)

Mycobacterium tuberculosis Mycobacterium leprae Brucella bacteria Salmonella typhosa

Hematogenous Spread

Lymphogenic Spread

Continuous spread

Iatrogenic

Mode of Transmission

Pounding, pulsing back pains Severe neurological complications with sensorimotor defects (paraplegia, paralyses)

Back pains that result from movement and pressure

Diagnosis
Elevated laboratory inflammation parameters (CRP, BSR, leukocytes)

change in posture to relieve the pain

Fever

Diagnostic Procedures
MEDICAL HISTORY
PHYSICAL & NEURO EXAMINATION

LABORATORY DIAGNOSTICS

DETECTION OF PATHOGEN

IMAGING METHODS

recent bacterial infection recent surgery /therapeutic procedures o tuberculosis or salmonellosis any autoimmune diseases or diabetes mellitus

location of pain Any radicular or pseudoradicular neurological symptoms

BSR CRP WBC (leukocytes) PMN elastase Lymphocyte Tine test positive (tB diagnosis)

histological (cellular) or microbiologic al detection of the pathogen. fine needle aspiration or punch biopsies

Conventiona l x-rays (AP and lateral views) Skeletal scintigraphy CT Scan MRI

Differential Diagnosis
1. Trauma 2. Hip Pathology Hip dysplasia,Transient synovitis

3. Spinal pathology

Spondylolysis,Spondylolisthesis, Disk herniation Urinary, Gastro intestinal, respiratory,Arthritis, Osteomyelitis, tuberculous spondylodiscitis

4.Infections

5.Tumoral Pathology

Last unfused vertebra is taken as L5 There is loss of normal signal seen at the vertebral bodies and bilateral pedicles of T9 and T10 vertebra which are hypointense on T1W images and mixed hyperintense-hypointense on T2W/STIR images. Post contrast, there is enhancement seen. The end plates of T9/T10 disc space ( inferior end plate of T9 vertebral body and superior end-plate of T10 vertebral body) are irregular. This finding is best appreciated on sagittal T1W images ( pre and post contrast). There is hyperintense signal seen at the T9/T10 disc space on STIR.

There is a large peripherally enhancing epidural lesion seen extending from upper border of T9 vertebral body to lower border of T10 vertebral body , likely to be epidural collection/abscess. This epidural collection occupies the anterior and lateral aspects ( left>right) of the spinal canal. The spinal cord is compressed and is displaced posteriorly and to the right, with the narrowest diameter seen at T9/T10 level measuring about 0.7cm (AP) x 0.7cm (W). There is hyperintense signal (on T2W and STIR) seen at the spinal cord at this level but no obvious enhancement seen post contrast

The epidural collection is also seen extending through bilateral exit neural foramina of T9/T10 level (left>right) and left exit neural foramen of T10/T11 level. The exiting nerve roots (mainly left exiting T9 nerve root) appear compressed. There is small paravertebral collection seen at T9/T10 level (noted on coronal T2W images),larger on the right measuring about 1.0cm (AP) x 0.8cm (W) x 1.9cm(CC).

At the lumbosacral spine, there is loss of normal intervertebral disc signal noted at L3/L4 level. The L3/L4 disc space is slightly narrowed. There are small posterior disc bulges noted at L2/L3, L3/L4 and L4/L5 levels.

At L2/L3 level, small posterior disc bulge is abutting theca sac with anteroposterior diameter of spinal canal measures 1.3 cm. No significant exit neural foramina narrowing. No evidence of exiting nerve roots compression seen.

At L3/L4 level, diffuse posterior sac bulge is abutting theca sac with anteroposterior diameter of spinal canal measures 1.2 cm. Bilateral exit neural foramina appeared narrowed. No evidence of exiting nerve roots compression seen.

At L4/L5 level,the posterior disc bulge is abutting theca sec with anteroposterior diameter of spinal canal measures 1.2 cm. Bilateral exit neural formina appeared narrowed. No evidence of exiting nerve roots compression seen.

At cervical spine, there is loss of normal signal of the intervertebral discs. The C3/C4 disc space appears narrowed. Posterior disc-osteophyte complexes noted, moat prominently seen at C3/C4 and C6/C7 levels.

At C3/C4 level, posterior discosteophyte complex is compressing theca sac with anteroposterior diameter of spinal canal measures 1.0cm. bilateral exit neural foramina are narrowed (left>right) with possible impingement on bilateral exiting C4 nerve roots.

At C6/C7 level, posterior discosteophyte complex is compressing theca sac with anteroposterior diameter of spinal canal measures 0.9cm. Bilateral exit neural foramina are narrowed with possible impingement on bilateral exiting C7 nerve roots.

Spinal cord ends at L1/L2 level. Normal cervico-medullary junction. No Chiari malformation. No other focal lesion seen at visualized spinal cord. The vertebral body heights are preserved No other focal lesion seen at visualized vertebral bodies

IMPRESSION
1.

The MRI findings at T9-T10 levels are suggestive of spondylodiscitis ( due to TB? Pyogenic) with large epidural abscess collection compressing on the spinal cord. The hyperintense signal seen at the spinal cord at this level could be due to oedema. Small paravertebral collection is also noted.

2. Degenerative disc disease noted at lumbosacral spine at L2/L3, L3/L4 and L4/L5 level. There is no spinal canal stenosis and no evidence of exiting nerve compression seen at these levels. 3. Cervical spondylosis, most prominently at C3/C4 and C6/C7 levels with possible impingement on bilateral exiting C4 and C7 nerve roots.