Hi
I take it that T9-T11 staphylococcal spondylodiscitis is confirmed. In this context I would suspect the same infective process at L4/L5 unless proven otherwise. In the context of progression, I guess an imaging guided microbiology sample from L4/5 maybe in order.
Just my thoughts
Joy
Dr Joy Thomas
Consultant Radiologist
Wye Valley NHS Trust Hereford, United Kingdom
> On 30 Oct 2021, at 08:44, kulvinder singh <ksingh.rad@gmail.com> wrote:
>
>
More likely degenerative at L4/5, but it is slightly concerning.
It is not just the presence of the gas but also the shape of the gas
collection which parallels the endplate that makes this more likely DDD.
On the last timpoint, as well as the bright signal in the back of the disc
(which is concerning) we still clearly see the gas in the anterior disc
(which is reassuring!)
I would be reluctant to biopsy it, but if the patient is deteriorating
clinically you may be forced to.
Rob
On Sat, Oct 30, 2021 at 1:44 AM kulvinder singh <ksingh.rad@gmail.com>
wrote:
Hi-
Good case indeed!
Vacuum is obviously in favour of degenerative disk and I would not change my first hypothesis because of the presence of some T2 hypersignal :
pubs.rsna.org/doi/10.1148/radiology.187.2.8475295
Have a good weekend
Paolo Simoni
Envoyé de mon iPhone
If the gas is outside the osseous structures, it’s probably noninfectious. This has yet to be proven otherwise.
However, intraosseous gas suggests infection. Is there uptake with NM bone scan?
Dennis K. Bielecki, MD
Senior Lecturer in Imaging Sciences
King’s College, London, and
Senior MSK Specialty Radiologist
Department of Diagnostic Imaging
Kings College Hospital, London, SE5 9RS
+44 (0) 7771 98 99 81
Editor-in-Chief, Radiology Online Journal
Member, Royal College of Radiology
Member, European Skeletal Society
Member, British Society of Skeletal Radiology
________________________________
________________________________
Sent: Saturday, October 30, 2021 2:01 PM
Cc: ocad-msk@googlegroups.com <ocad-msk@googlegroups.com>
More likely degenerative at L4/5, but it is slightly concerning.
It is not just the presence of the gas but also the shape of the gas collection which parallels the endplate that makes this more likely DDD.
On the last timpoint, as well as the bright signal in the back of the disc (which is concerning) we still clearly see the gas in the anterior disc (which is reassuring!)
I would be reluctant to biopsy it, but if the patient is deteriorating clinically you may be forced to.
Rob
Hi All,
request for expert comments re this case.
Thanks in advance.
Kind regards,
KS
Hello,
Its only degenerative change.
Reason- deg- end plate cyst; no ghost sign, disc gas, common site of mechanical compression
Infection- ghost sign, end plate erosions, fluid, lig/perilig edema, no gas usually, and no cysts
I wouldn’t worry about it and left it alone.
Happy Sunday! from beautiful Tx- 73F
Best!
AC
Avneesh Chhabra, M.D. M.B.A.
Professor, Radiology & Orthopedic Surgery
Chief, Musculoskeletal Radiology
Department of Radiology
5323 Harry Hines Blvd., Dallas, Texas 75390-9316
Office: 214-648-2122
http://www.utsouthwestern.edu/radiology<http://www.utsouthwestern.edu/education/medical-school/departments/radiology/>
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If the gas is outside the osseous structures, it’s probably noninfectious. This has yet to be proven otherwise.
However, intraosseous gas suggests infection. Is there uptake with NM bone scan?
Dennis K. Bielecki, MD
Senior Lecturer in Imaging Sciences
King’s College, London, and
Senior MSK Specialty Radiologist
Department of Diagnostic Imaging
Kings College Hospital, London, SE5 9RS
+44 (0) 7771 98 99 81
Editor-in-Chief, Radiology Online Journal
Member, Royal College of Radiology
Member, European Skeletal Society
Member, British Society of Skeletal Radiology
________________________________
________________________________
Sent: Saturday, October 30, 2021 2:01 PM
Cc: ocad-msk@googlegroups.com <ocad-msk@googlegroups.com>
More likely degenerative at L4/5, but it is slightly concerning.
It is not just the presence of the gas but also the shape of the gas collection which parallels the endplate that makes this more likely DDD.
On the last timpoint, as well as the bright signal in the back of the disc (which is concerning) we still clearly see the gas in the anterior disc (which is reassuring!)
I would be reluctant to biopsy it, but if the patient is deteriorating clinically you may be forced to.
Rob
Hi All,
request for expert comments re this case.
Thanks in advance.
Kind regards,
KS
I would have gone for degenerative for the reasons stated above. But also I bet L5/S1 is transitional by the overall appearance making L4/5 (if that is the correct labeling) more prone to stress related changes (including modic type I) and therefore degeneration when combined with the other findings. We’ve all seen florid bone marrow edema and even disc fluid that turned out to be non infectious. Difficult conundrum in many cases.
11/6 – L4/5 end plates were clear on T1
30/6 – L4/5 end plates show new changes of infection on T1
16/8 – infection still fairly active in thoracic spine levels so likely
infection on going across at other levels as well.
11/10 – L4/5 changes have improved and with improved end plate outline and
resolving changes in L4/5 end plate on T1 but an intense foci of high
signal remains in posterior aspect of L4/5 disc. Imaging improvement can
lag behind blood marker and clinical improvement in infection.
Best wishes
Harun
On Sat, Oct 30, 2021 at 5:57 PM Phillip Tirman MD <ptirmanmd@gmail.com>
wrote:
Thank you all for sharing pearls of wisdom and experience.
Most of us are in favour of L4/L5 infection with some improvement in the
recent scan and with background progressive degenerative changes.
Since the patient is clinically better image-guided biopsy /
microbiological evaluation would not be done and follow up scan would be
the best in such a scenario.
Thanks again, I’ll update you all with the follow-up images.
Kind regards,
KS