Presentation
Chest pain and fever.
Patient Data
T4/5 level show sub-endplate erosive changes associated with irregular endplates with still preservation of the inter-vertebral disc space. Pre-vertebral and left para-vertebral soft tissue lesion showing air foci. Suspected related epidural extension.
Left posterior partial pleural thickening associated with mild left pleural effusion.
Minimal right partial pleural thickening.
Bilateral posterior basal consolidation atelectasis, confluent at the left side.
Marked alteration of the marrow signals involving bodies of T4 and T5 vertebral bodies showing predominantly T1 low and T2 high signals with erosion of the opposing end plates. T4/5 disc showed marked increased T2 signals.
A small intra-spinal anterior epidural collection is noted indenting the ventral aspect of the spinal cord with a linear high T2 signal at the spinal cord opposite T3/4 level reflecting myelomalacia changes.
There is also an extension to pre- and paravertebral regions with bilateral paraspinal collections, more on the left side mounting to left paraspinal abscess formation.
Case Discussion
Imaging features are representative of T4/5 spondylodiscitis with an associated intraspinal epidural and bilateral paravertebral components. MRI is the modality of choice for reliable diagnosis and for differentiation from similar diseases. Important diagnostic signs include a T2 hyperintense signal at the intervertebral disc, end plates erosions, epidural and paraspinal abscesses and enhancement of the disc, end plates as well as the involved perivertebral soft tissues. Typically pyogenic spondylodiscitis is centered at the intervertebral disc, as in this case, and tuberculous spondylodiscitis is centered on the vertebral body.