Differentiation between Tuberculous and Pyogenic Spondylodiscitis: The Role of the Anterior Meningovertebral Ligament in Patients with Anterior Epidural Abscess

Abstract

BACKGROUND AND PURPOSE: Differentiation between tuberculous and pyogenic spondylodiscitis is a diagnostic challenge because imaging often does not reliably distinguish the 2 entities and percutaneous biopsies are often culture-negative. The purpose of this study was to determine whether violation of the anterior meningovertebral ligament in the setting of anterior epidural abscess discriminates between these entities. MATERIALS AND METHODS:This was a retrospective cohort study of all patients with acid-fast bacillus testing and anterior epidural abscess diagnosed on spinal MR imaging between May 2014 and September 2019, with a final diagnosis of tuberculous or pyogenic spondylodiscitis. Six cases of tuberculous spondylodiscitis (mean age, 45.5 years; 80% male) and 35 cases of pyogenic spondylodiscitis were evaluated (mean age, 56.6 years; 49% male). Demographic characteristics were recorded. Cases were assessed for anterior meningovertebral ligament destruction on MR imaging, as demonstrated by the shape of the epidural collection. Segmental location of the infection was also assessed. Independent 2-sample t tests and x 2 tests of independence were performed to evaluate the significance of the difference between the groups.RESULTS: Five of 6 (83.3%) cases of tuberculous epidural abscess had an intact anterior meningovertebral ligament, and 0/35 cases of pyogenic epidural abscess demonstrated an intact ligament (P , .001). The presence of an intact anterior meningovertebral ligament had 83.3% sensitivity and 100% specificity for tuberculous spondylodiscitis, a 100% positive predictive value, and a 97.2% negative predictive value. CONCLUSIONS:The presence of an intact anterior meningovertebral ligament has high sensitivity and specificity for tuberculous spondylodiscitis-associated epidural abscess, though these results should be validated in a larger sample.

Bone and Joint Infections: The Role of Imaging in Tailoring Diagnosis to Improve Patients’ Care

“…MRI can help in differentiating tubercular from pyogenic spondylodiscitis. The detection of an intact anterior meningo-vertebral ligament in presence of an epidural abscess is associated with tuberculous spondylodiscitis rather than pyogenic ones [119]. The presence of an almost undamaged vertebra with a homogeneous high signal on T2WI is an important MRI feature to distinguish Brucella SD from tubercular ones [120].…”

A case of not just Pott’s disease

“…This finding was sensitive and specific for TB spondylodiscitis in a retrospective cohort study comparing six cases of TB epidural abscess with 35 cases of pyogenic epidural abscess. 5 The growth of S. anginosus on multiple surgical tissue cultures also complicated the clinical picture of the case. The presence of tissue granulomas is not pathognomonic of mycobacterial disease; Brucella, Salmonella, and fungi are other possible etiologies for granulomatous spinal infections.…”

“…This finding was sensitive and specific for TB spondylodiscitis in a retrospective cohort study comparing six cases of TB epidural abscess with 35 cases of pyogenic epidural abscess. 5 …”

“…There is preservation of the anterior meningovertebral ligament; a finding suggestive of tuberculosis spondylodiscitis. 5 …”

“…Magnetic resonance image with gadolinium, T2 axial view. Bone marrow edema and abnormal enhancement at the T3-T4 level with large epidural abscess and severe spinal cord compression.There is preservation of the anterior meningovertebral ligament; a finding suggestive of tuberculosis spondylodiscitis 5.…”