ORIGINAL RESEARCH PAPER

PREVALENCE OF DIFFERENT TYPE OF LESIONS IN MRI OF POTT'S SPINE CASES IN JHARKHAND

Dr. Anima Ranjni Xalxo

Assistant Professor, Department Of Radio-diagnosis, Rajendra Institute Of Medical Sciences, Ranchi, Jharkhand-834009.

Dr. Suresh Kumar Toppo

Professor & Head Of The Department, Radio-diagnosis, Rajendra Institute Of Medical Sciences, Ranchi, Jharkhand. 834009.

Dr. Punam Bara Consultant Radiologist, Gupta Diagnostic Clinic, Burla, Sambalpur, Odisha. 768016.

Dr. Leo Minkan Khoya*

Consultant Physician, Department Of Medicine, Seventh Day Adventist Mission Hospital Ranchi, Jharkhand. 834009. *Corresponding Author

INTRODUCTIONThe pott's spine is the tuberculosis of spine caused by Mycobacterium Tuberculosis infection. It remains a major public health hazard mostly among low socio economic group in Jharkhand; where poverty, malnutrition, alcoholism and drug resistance are responsible for the spread of disease.

The thoracic and the thoraco-lumbar spine are the most common area involved, comprising 48% to 67% respectively and the lumbar spine about 27%. Most of the cases are seen during the rst four decades of life. Pott's spine is one of the oldest diseases known to mankind and has

[1]been found in Egyptian mummies dating back to 3400 BC . The Pott's spine name traces back its origin from the description of tuberculous

[2].infection of the spine by Sir Percival Pott in his monograph in 1779

Approximately 10% skeletal involvement in case of extrapulmonary tuberculosis has been noted. Most commonly spines followed by the hip and knee are affected. 50% cases of skeletal tuberculosis are spinal

[3]tuberculosis . Thoracic spine (42%), thoracolumbar spine 67% and lumbar spine (26%) regions are most affected with other regions less

[4]than 12% each . Spinal tuberculosis is secondary to hematogenous spread from a primary infection most commonly the lungs. Since paradiscal vessels supplies the subchondral bone on either side of the disc space; therefore paradiscal vertebral involvement is most common. The other patterns are central (with predominant vertebral body involvement), posterior (involving the posterior structures primarily) and non-osseous involvement (presenting with the abscess) [5, 6]. Progressive vertebral destruction leads to spinal kyphotic deformity and instability.

Clinical PresentationIn this study; most of the patients were presented with weakness of lower limbs, back pain, weight loss, bladder dysfunction, tingling & numbness and fever.

PathologyThe spinal involvement is due to hematogenous spread via the venous

[7]plexus of Batson . There is usually a slow collapse of one or usually more vertebral bodies, which spreads underneath the longitudinal ligaments and results in an acute kyphotic or "gibbus" deformity. This

angulation, along with epidural granulation tissue and bony fragments, can lead to cord compression. The disc are usually spared in early stage but get involved in later stage. In late-stage large paraspinal abscesses without severe pain or frank pus are common, leading to the expression "cold abscess".

Methodology:The study is a part of a major study entitled “MRI Evaluation of Compressive Myelopathy of Dorsolumbar Spine in Adults” was conducted in Rajendra institute of Medical sciences, Ranchi, in the department of Radio-Diagnosis. The target of present study was those patients of Jharkhand hailing from rural as well as urban background. Cases were referred from Medicine, Neurosurgery and Orthopedics departments with the complains of acute or chronic backache, restricted movements, paraesthesia, sensory or/and motor weakness and sphincter disturbances.

Procedure:Total 36 patient of pott's spine of both sexes and of different age groups (18 to 70 years) were taken from different department with symptoms suggestive of Compressive Myelopathy and selected for MRI. Presenting complains with detail history taken. Clinical examination with basic laboratory test was done along with X-Ray Chest PA view, Dorsolumbar spine AP and lateral view. All the patients underwent plain and contrast enhanced MRI. Pre and post contrast T1 weighted spin-echo (T1W SE), T2 weighted spin-echo (T2W SE) sequences in axial, sagittal and if required coronal plain were obtained. IV Gadolinium Dimeglumine at the dose of 0.1 mmol/kg of body weight of the patient was used for contrast.

On the basis of MRI picture in pott's spine we found following appearances: On T1Wi: Hypointense (Image- 1); on T2Wi: Hyperintense (Image-2) and on Contrast Enhanced MRI (Image- 3): Rim Enhancement. Lesions usually appear lobulated with adjacent inammatory involvement and maintained anatomical boundaries in early stages which however lost in advance stages.

Multiplanar MRI helps in lesion localization and extension i.e. Thoracic, Thoracolumbar or Lumbar/ Single or Multiple/ Pre and paravertebral soft tissue extension/ Epidural extension with spinal

INTERNATIONAL JOURNAL OF SCIENTIFIC RESEARCH

Radiodiagnosis

Volume-9 | Issue-5 | May-2020 | PRINT ISSN No. 2277 - 8179 | DOI : 10.36106/ijsr

ABSTRACTAIMS: Cross sectional observational comparative study in a tertiary care hospital on “Prevalence of different type of lesions in MRI of Pott's Spine cases in Jharkhand”.MATERIAL AND METHODS: 36 subjects 52.78% male (n=19) and 47.22% female (n=17) were selected for the study, who had presented with acute or chronic backache, restricted movements, paraesthesia, sensory or/and motor weakness and sphincter disturbances.RESULTS: In MRI study which helps in the proper site location and severity of lesion i.e. epidural extension with cord compression was 97.22% (n=35), pre & paravertebral soft tissue lesion was 91.67% (n=33), posterior elements involvement & Intraosseous abscess was 88.89% (n=32) in each and vertebral collapse was 77.78% (n=28). The Single vertebral involvement was found in 16.67% (n=6); whereas 83.33% (n=30) had multiple vertebral involvement. Common site of lesion was thoracic 61.1% (n=22) and lumbar involvement was 38.8% (n=14). Males were more commonly affected than female. CONCLUSION: according to MRI study of the group selected of pott's spine; 97.22% had epidural extension with cord compression, 83.33% had multiple vertebral involvements with common site of lesion was thoracic 61.1%, most commonly affects the age group of 41-50 years and males are more commonly affected. The MRI is the best imaging for the diagnosis of pott's spine. It is more sensitive and specic.

KEYWORDSMRI nding, Pott's spine.

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cord and nerve root compression/ Evidence of vertebral collapse (complete or partial) and kyphotic de formities were identied.

Image -1: Sagittal T1WI image of a pott's spine showing hypointense signal involving multiple vertebrae, prevertebral soft tissue with partial collapse and epidural extension.

Image -2: Sagittal T2WI image of a Pott's spine showing hyperintense signal in prevertebral and anterior epidural space causing cord compression consecutive vertebra showing hypersignal intensity; however intervening IV disc is spared. One of the vertebra is showing reduced in height (Collapsed).

Image- 3:Post contrast T1WI image of a Pott's spine showing enhancement, prevertebral subligamentous spread of pus with epidural extension causing cord compression.

DISCUSSIONThe disease often involves two contiguous vertebral bodies with the intervening disc, but multilevel extension (three or more vertebrae) is characteristic of the disease. Single or multiple vertebral involvement

[8–14].preserved disc has been recognized It is very difcult to say that whether the multivertebral disease is a consequence of hematogenous dissemination or it's a direct subligamentous, paraspinal or

[15],subarachnoid spread disease although subligamentous spread [12].seems most likely

The earliest ndings are radiolucencies and the loss of denition of the [9, 11, 16-19].disc plate margins Most commonly it appears as vertebral body

destruction (predominantly anterior), loss of disc height, erosion of end plates, vertebral geodes, bone sequestration, sclerosis and

[10, 13, 16, 18, 20- 22]paravertebral masses . The calcication in paraspinal [12, 16, 18].masses is highly suggestive of tuberculous infection

MRI is the method of choice in spinal infection as it combines high [11, 16, 20, 23- 25].sensitivity and specicity too When no other imaging

modality shows lesions; MRI shows signal changes early in the development of the disease.

Four different MRI patterns of disease were found in pott's spine: paradiscal, anterior, central and posterior lesions. The majority

[15, 26].research suggests that the onset of the spinal infection is paradiscal

The signal increases in both T2-weighted imaging and STIR sequence whereas signal intensity decreased in the vertebral bodies on T1-weighted sequence. This shows the replacement of bone marrow by

[22].inammatory exudates, cells and hyperemia

[27]Na-Young et al. has also found that MRI showed a sensitivity of 100 %, a specicity of 80 % and an accuracy of 90 % in diagnosing pott's spine when compared to pyogenic infection. The most indicative signs of pott's spine in MRI were: well-dened paraspinal abnormal signal, thin and smooth abscess wall, combination of both, presence of soft tissue or intraosseous abscess, subligamentous spread to three or more vertebra, involvement of multiple vertebral bodies, thoracic spine localization and hyperintense signal on T2-weighted images. There was no signicant differences were found in involvement of intervertebral disc, disc space narrowing, epidural extension and contrast enhancement pattern.

MRI gives more accurate anatomic localization of vertebral and paravertebral abscesses in multiple planes which was not previously available with conventional diagnostic tools in the patients of

[28-31].suspected pott's spine MRI has clearly demonstrated the extent of soft tissue disease and its effect on the theca, cord, and foramen in cases

[32, 33].with doubtful CT ndings

CONCLUSION: The Prevalence of different type of lesions in MRI of Pott's Spine cases in Jharkhand was 97.22% Epidural extension with cord compression (n=35) while 91.67% was Pre & paravertebral soft tissue lesion (n=33), 88.89% of each Intraosseous abscess & posterior elements involvement (n=32) and 77.78% of Vertebral collapse were found (Table- 1).

There was multiple vertebral involvement 83.33% (n=30); whereas 16.67% (n=6) had single vertebral involvement (Table- 2). Common site of involvement was thoracic 61.1% (n=22) followed by lumbar 38.8% (n=14) (Table- 3).

According to age wise distribution; more common in the age group of 41-50years 44.44% (n=16) followed by 31-40, 51-60, 18-30 and 61-70 i.e.: 25% (n=9), 16.66% (n=6) 8.33% (n=3) and 5.55% (n=2) respectively (Table-4). Males are more commonly affected than female may be due to their more outdoor activity, more social and occupational exposure.

This study shows that pott's spine is the major cause of morbidity and mortality; as most of the time presentation is too late where more than one vertebra is involved and neurological symptoms develops. Because of poverty, illiteracy, malnutrition, alcoholism and poorly available health care facilities patients' early diagnosis and treatment compromised which result s in development of such co-morbidity and mortality.

So, including the Health Workers; Governmental as well as Non-Governmental organization have the major health challenges towards the health awareness, health education, proper nutrition, early diagnosis and proper treatment will minimize the burden of mortality and co-morbidity due to pott's spine.

Table -1: Associated lesions not e d in MRI in Pott's Spine cases

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Lesions No. of cases (total no. of cases – 36)

Percentage

Pre & paravertebral soft tissue lesion

33 91.67%

Intraosseous abscess 32 88.89%Posterior elements involvement 32 88.89%Epidural extension with cord compression

35 97.22%

Vertebral collapse 28 77.78%

Table – 2: involvement of vertebra in pott's spine cases.

Table- 3: Site of lesion in Pott's Spine

Table-4: Age wise distribution of pott's spine

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Vertebral involvement

No. of cases (total no. of cases- 36) percentage

Single vertebra 6 16.67%Multiple vertebra 30 83.33%

Location No. of cases (total no. of cases – 36) Percentage

Thoracic 22 61.1%

Lumbar 14 38.8%

Age Group in years No. of Patients Percentage18-30 3 8.33%31-40 9 25%41-50 16 44.44%51-60 6 16.66%61-70 2 5.55%