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Dr. Schupeck,

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let's take a look at this 49-year-old man who comes in,

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evaluate for "benign neoplasm" of the vertebral column.

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See what we've got here.

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We've got a sagittal T2 spin echo o the left.

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A proton density fat suppression on the middle.

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And on the right, a T1 spin echo.

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So, let's start scrolling a little bit.

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There's a lot more disease on the proton density fat

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suppression image than one would have suspected

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on the T1 or on the T2.

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There's a pre-spinal mass on the T1,

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which is not all that bright

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on the T2-weighted image.

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It's kind of gray, got everything nicely labeled.

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And there's quite a bit of extension in the

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prevertebral space up and down.

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Here's the esophagus right there with some air in it.

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It's a little bit thickened on all walls.

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Both the posterior wall and the anterior wall.

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A little thickening.

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There's a little bit of thickening in the extra

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space in the posterior longitudinal ligament,

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and there's multiple levels of involvement in the thoracic spine.

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So, what do you think are some considerations here?

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Well, the first thing is

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you'll have a better handle than me.

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But things across the disc space,

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when you see something crossing the disc space,

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there is not a huge differential.

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I mean, there is a differential cordomas, stuff like that,

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but I tend to think of infection.

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But also with this paraspinal mass,

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there's thickening in the epidural space.

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You got edema expanding two whole bodies.

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You're losing end plate definition right

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there on the T1 anteriorly, right?

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And so we got a few criteria making us think of we don't know

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what this patient has, but I bet he's got severe pain.

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And I bet that was the presentation.

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And you think of a tumor, they might have gotten that off,

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maybe a plane film showing a soft tissue mass or something.

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Sure, but it's not expansile.

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And really, the disc space is pretty juicy there.

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But actually,

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the paraspinal component is maybe even a little more

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impressive than what's going on in the disc space.

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Let's take a look at the paraspinal component because there's

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quite a bit of it here in the axial projection.

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Look at that. Some of it's high signal,

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but most of it's intermediate in signal.

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It's a little higher signal in the back.

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And there's something in the lung to the right.

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So there's a lung mass for sure.

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And perhaps that's why somebody said rule out neoplasm,

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although they said benign neoplasm.

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Maybe somebody saw something on the X-ray posteriorly,

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weren't able to make it out.

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It's obviously a solid looking thing.

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I don't see any air bronchograms inside it,

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even though that's not really the strength of MRI,

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but that might have led to that.

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Sort of tumor-like

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introduction to the case by the clinician,

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but I'm sure you're right.

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The patient presented with intractable pain.

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Now, there are a couple of very interesting points.

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One is that we've got multiple levels of involvement.

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Two,

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you already pointed out that the vertebra demonstrate

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Holovertebral edema. Now. Now,

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even in Staphylococcus aureus pyogenic disease,

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you do get a lot of edema and you may get hallowed vertebral

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involvement, but often it's about 50% to 75% of the body.

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And in this case,

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hallowed vertebral involvement suggests either it's a whopper of

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acute inflammation or it's chronic and progressive and it's

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just worked its way into the entire vertebral body.

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And then you also have to say to yourself, wow,

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the two adjacent vertebrae are also edematous

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on the water-weighted image.

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So this thing has some real staying power and some length

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to it. And you would think if it was pyogenic,

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he would have come in a lot earlier.

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He wouldn't have lasted this long to get this

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bad unless it was a more indolent process.

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So that's kind of the way I think about the case.

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Another feature that points me towards an atypical

4:18

infection is the masses are pretty big.

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Now, admittedly, Staph aureus and other conditions,

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the masses are just gigantic sometimes,

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but classically in this entity,

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which I think TB is the best choice,

4:32

you get some pretty big masses and there's a lot of gray

4:35

tissue in these masses, so-called cold abscess formation,

4:40

granulomatous abscess formation, non-pyogenic types of masses.

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What does this tissue represent?

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Usually fluid. It may be a proteinaceous effusion,

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it may be a straight-out exudate, but most of the time not.

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And if you stick a needle in here,

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it's very uncommon that you're going to get

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anything that resembles pus out of here.

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In fact, even in discitis from staph. aureus,

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it's not common really to extract pus if you put a needle in

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these paraspinous masses, so you probably shouldn't do it.

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So we got thoracic location.

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It's a man, multiple levels of involvement,

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big paraspinous masses.

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A lot of the tissue is of intermediate character.

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And then you already pointed out this very nasty destructive

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erosion that is occurring along the anterior

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border of these two vertebrae,

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which is why these patients end up with these horrible Gibbos

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deformities. They get severe kyphosis and destruction.

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And we've also got a lung lesion.

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Granted, could be lung cancer,

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but if you want to give it one diagnosis,

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tuberculosis of the lung would be the one.

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Any other thoughts on this and how to treat it?

5:58

Yeah, I think that

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the points you made to me when I've seen disasters with

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Discitis, you think, well, Discitis, once a diagnosis is made,

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you're cool, right.

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Because you can treat it with antibiotics and people do well.

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Where you can get into trouble is getting off

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on the wrong track in terms of an organism.

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Okay, so Dr. Pomeranz was just saying a lot of

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these biopsies are negative.

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This is one and he is really good at saying he's good enough

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to say, okay, this looks like it could be TB or Brucellosis,

6:33

let's say, would be another thing that would look the same,

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right. One of those things and the atypical things.

6:38

Okay.

6:39

But you got to be sure that you're not getting off on the

6:42

wrong track because what will happen is you start on a track,

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the patient does get a little bit better,

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but now none of your cultures are going to

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grow because they're partially treated.

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And where I've seen problems is somebody say, oh,

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we're treating this thing and then they got a little bit

6:57

better and then started dipping down and now

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you can't even figure out what's going on.

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And the few times I've actually had to go in and debride

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something has been that situation not getting better,

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not getting better. This down antibiotic,

7:08

that antibiotic and it's turned out to be something strange.

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So you got to have a good grip on it.

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Now, a lot of these are going to be pyogenic,

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they're going to be staph, and you can treat them clinically,

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but you got to getting on the right track in terms of an

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organism is key because it could be treated non-surgically.

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You could also get staph EPI out of this as a contaminant.

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And then you go down that road,

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unless you tell them to stain for AFB,

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they're not going to find.

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And also, I mean,

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I've had that experience of discitis and so I did everything.

7:41

Okay. And then six weeks later,

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the state lab sends back AFB and you're like, wow.

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And these people typically complain of back pain right.

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Showing up in every ER in the county until eventually

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the family carries them into your office.

7:57

Okay.

7:57

So one other move that we would make in a case like this,

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we've already established there's lung disease.

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This patient needs a CT of the lung,

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but they also need a CT of the abdomen to look at

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the adrenal glands and especially the kidneys.

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The kidneys and the lung are two of the main organs that we

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want to attack and make sure that they're okay in somebody

8:15

with tuberculosis multilevel discover TBR osteomyelitis.

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And it's actually more of an infectious spondylitis than it is

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a Discover TBR osteomyelitis because the

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infection starts here near the limbus,

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right where the attachment of the ligaments are.

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So let's move on to another one, unless you have any.

8:36

Yeah, let me just make one other sure.

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A real common request for the radiologist is the clinician

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will send you a thing and said, okay, this guy had a Discitis.

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We've treated him. Is he cured?

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Okay. Is it gone? Okay.

8:51

And the problem is, if you look at the image,

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this thing has huge lag time.

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Meaning the patient could be doing great.

8:58

The thing still looks terrible.

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Terrible, it may always look terrible.

9:02

So you got to kind of educate and work with your clinicians

9:05

because you say, yeah, you know, no evidence,

9:07

so the clinical is much more important.

9:09

Absolutely. And also,

9:10

you'll know very rapidly whether you're on the right track,

9:13

meaning if you have a pyogenic one,

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at least TB is a little slower.

9:17

You should know within 48 to 72 hours whether you're on the

9:19

right antibiotics. Patient will have a dramatic improvement.

9:22

They are miserable, they can't move, they cough,

9:26

they go crazy,

9:27

but they will definitely be a lot better if you're

9:31

on the right track. And if they just say, yeah,

9:33

I'm a little bit better,

9:34

you got to rethink it because you could be, as they say,

9:37

partially treating is kind of the worst thing because it just

9:40

kind of starts this sort of indolent smoldering thing.

9:44

And I've been looking for that ever since.

9:46

It's been many years since you told me that,

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and it is spot on.

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When you've got a pyogenic one and they go on antibiotics,

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you know, within 72 hours if they're getting better.

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You're so right.

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The MR imaging findings lag way behind patient improvement.

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The one thing that you have to look for is progression.

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If you've been on antibiotics for two

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or three weeks and it looks worse,

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that's a problem.

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But if they're on antibiotics and it looks the same and they

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feel better and it's three months later, it's fine.

10:19

That's the expected course or progression.

10:22

They're probably going to fuse too.

10:24

I mean,

10:24

there's nothing that's going to get your osteoblast going,

10:27

like Staph aureus or something.

10:29

So usually they'll fuse like a rock.

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So stabilizing isn't usually an issue,

10:34

although TB is a little bit different because they

10:36

do get those kind of Gibbous deformities.

10:39

But at this point point, at least,

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you'd treat this guy medically great and follow it.

10:43

So tuberculosis. Discover t well, tuberculosis.

10:46

Infectious spondylitis in the thoracic

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region is the diagnosis.

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There's lung involvement and we would want to do

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a CT of the abdomen.

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Let's move on, shall we?