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In patients who have a history of chronic posttraumatic osteomyelitis and suspected reactivation of bone infection, MRI has a sensitivity of 100%, a specificity of 60%, an accuracy of 79%, a positive predictive value of 69%, and a negative predictive value of 100% [127].

Vertebral osteomyelitis can be detected early by MRI (before evident changes appear in radiographic studies) as soft tissue swelling and bone destruction [88]. Involvement of two adjacent vertebrae may be demonstrated 1 to 3 weeks before radiographic or tomographic evidence of bone destruction. The endplates are ill defined; the vertebral disc and adjacent vertebral bodies are hypointense on T1-weighted SE noncontrast images and hyperin-tense on STIR and T2-weighted SE images (Fig. 20) [128]. Early extension of inflammatory edema outside the limits of the vertebral bodies and the annulus fibrosus into the paravertebral fat causes low signal intensity on T1-weighted SE noncontrast images and hyperintense postcontrast and on STIR images [88].

In tuberculosis arthritis bone erosions are revealed more frequently than in pyogenic arthritis. The pannus of granulation tissue erodes and destroys cartilage and eventually bone [129]; this process is not uniformly distributed, so that areas of cartilaginous destruction may be intermixed with relatively normal areas. In general, the progression of joint space loss is more prominent with pyogenic arthritis than with tuberculosis arthritis because bacterial proteolytic enzymes accelerate articular cartilage destruction [130]. On MRI mycobacterial arthritis displays intermediate to low signal intensity

Pyogenic Arthritis

Fig. 19. MRI of chronic osteomyelitis of the femur in a patient who has diabetes. (A) Transaxial T1-weighted (TR/TE 650/20) SE image demonstrates fluid collections around the femur with extensive soft tissue inflammatory changes, abscess formation, and gas collections. (B) Transaxial T1-weighted (TR/TE 540/80) SE images with gadolinium reveal intramedullary gas collections and subperiosteal abscess formation (arrows). (C) Transaxial T2-weighted (TR/TE 2000/80) image shows an intramedullary area of low signal intensity surrounded by alternating bands of high and low signal intensity reminiscent of target appearance.

Fig. 19. MRI of chronic osteomyelitis of the femur in a patient who has diabetes. (A) Transaxial T1-weighted (TR/TE 650/20) SE image demonstrates fluid collections around the femur with extensive soft tissue inflammatory changes, abscess formation, and gas collections. (B) Transaxial T1-weighted (TR/TE 540/80) SE images with gadolinium reveal intramedullary gas collections and subperiosteal abscess formation (arrows). (C) Transaxial T2-weighted (TR/TE 2000/80) image shows an intramedullary area of low signal intensity surrounded by alternating bands of high and low signal intensity reminiscent of target appearance.

on T1-weighted images and high signal intensity on T2-weighted images in joint and adjacent bone [93].

Tuberculous osteomyelitis is suggested by the presence of hypointense T2-weighted image (secondary to areas of caseation) associated with soft tissue abscess [131]. Spinal tuberculosis typically starts at the anteroinferior aspect of vertebral body and spreads to contiguous vertebrae along the anterior longitudinal ligament of the spine [88,132]. Although one report has indicated the presence of high signal intensity in diseased areas on T1-weighted spin-echo MR images [133], low signal intensity on such images and high signal intensity on T2-weighted images are characteristic [134]. Typical findings are erosions of the anterior surfaces of the vertebral bodies with relative preservation of the disks and posterior elements, at least early in the course of the disease [128]. Subligamentous spread and pronounced paravertebral and epidural abscesses with tendency for distant caudal extension are frequent [88]. As the disease progress, collapse of the anterior portion of the vertebrae can lead to a kyphotic wedging deformity of the spine,

Vertebrae Anterior Wedging

Fig. 20. Spinal infection. (A) Sagittal T1-weighted (TR/TE 600/25) and (B) proton density (TR/ TE 2500/80) weighted MR images reveal abnormalities consistent with L4-L5 infection. In (A), abnormal regions of low signal intensity within the vertebral bodies. In (B), the signal intensity in these intraosseous regions is greater than that of the adjacent bone marrow.

Fig. 20. Spinal infection. (A) Sagittal T1-weighted (TR/TE 600/25) and (B) proton density (TR/ TE 2500/80) weighted MR images reveal abnormalities consistent with L4-L5 infection. In (A), abnormal regions of low signal intensity within the vertebral bodies. In (B), the signal intensity in these intraosseous regions is greater than that of the adjacent bone marrow.

the gibbous of Pott's disease. It has been suggested that tuberculous spondylitis has a lesser extent of marrow edema than observed in pyogenic spondylitis [130]. In almost 70% of cases it presents as a fusiform cold paraspinal abscess, with or without calcifications [135,136]. Vertebral bodies adjacent to infected disks are hypointense on T1-weighted MRI and hyperintense on T2-weighted MRI, with contrast enhancement and delineation of the extent of epidural involvement [137].

In neuropathic arthritis patients, mainly in patients who have diabetes, osteomyelitis could be a difficult diagnosis. MRI can be useful to demonstrate the presence of associated osteomyelitis (15%) or septic arthritis. Pedal osteomyelitis results almost exclusively from contiguous infection coming from the soft tissue ulceration and occurs most frequently around the fifth and first metatarsophalangeal joints. The formation of adventitious bursa or subcutaneous callus is a precursor to the ulceration that can be seen in the diabetic foot. Recognition of these bursae before onset of tissue breakdown may prevent sinus tract formation and osteomyelitis [138]. One third of patients who have advanced infection of the foot show evidence of septic arthritis on MRI [139]. Osteomyelitis in neuropathic feet of leprosy patients has similar findings to those of patients who have diabetes [140].

In children, diagnosis of a very early stage of osteomyelitis can be made with high sensitivity using the turbo inversion recovery magnitude (TIRM) with standard T1-weighted and T2-weigted MRI, with the advantage of no sedation being needed. A recognized limitation of TIRM sequences is the high signal in hematopoietic marrow of children under 3 years of age and the different degrees of marrow fat that are heterogeneous in the pediatric population [141]. MRI is especially useful for children who have pelvic [87] or vertebral osteomyelitis [2]; in the latter MRI has been found to have a sensitivity of 96% and a specificity of 93% [142].

The presence of osteomyelitis and bone infarction may coexist. Medullary infarcts might function as sequestra, predisposing to osteomyelitis and soft tissue infection [143]. The hallmark of avascular necrosis is hypointense peripheral band signal on all sequences, similar to rim sign; however, identification of a double-line sign on T2-weighted images is considered pathognomonic for osteonecrosis [144]. Gadolinium can also help to distinguish between infarction and osteomyelitis. The former shows thin, linear rim or long serpiginous central medullary enhancement, whereas osteomyelitis displays a thick, irregular peripheral enhancement around a nonenhancing center.

Patients who have rheumatoid arthritis have an increased risk for joint infection, so that in presence of a single disproportionately inflamed joint with inadequate therapy response and fever or in presence of immunosuppres-sive therapy, infection should be strongly considered. Osteoarticular rheumatic abnormalities in these patients might be difficult to distinguish from anatomic changes secondary to infection, however. MRI is an accurate method to evaluate the extent of the infective process; additionally, fat-suppressed gadolinium-enhanced sequences help to delineate marrow extension [145].

MRI is not useful for whole-body examinations (unlike radionuclide studies); metal implants in the region of interest may produce focal artifacts, mainly with high field systems [94].

Development of squamous cell carcinoma of the sinus tract is an uncommon, well-known complication of longstanding chronic osteomyelitis, which occurs in 0.23% to 1.6% of these patients [146,147]. MRI can identify this complication as an abnormal soft tissue mass [147-149].

Positron emission tomography and single photon emission computed tomography

The Positron Emission Tomography (PET) systems are relatively novel techniques that are being applied in several medical fields. Unfortunately there is limited availability of PET systems.

A nonspecific indicator of increased intracellular glucose metabolism, 18 fluorodeoxyglucose (18FDG) accumulates in infection and inflammation sites (leukocytes, granulocytes, and macrophages) [150,151]. Guhlmann and colleagues [152] were the first authors to evaluate the role of fluorodeox-yglucose PET (FDG-PET) in chronic osteomyelitis, reporting a high diagnostic accuracy of this method, especially in the axial skeleton. Further studies have deepened the diagnosis of acute and chronic osteomyelitis [153-155]. It has been demonstrated that FDG-PET has the highest diagnostic accuracy for confirming or excluding the diagnosis of chronic osteomyelitis in comparison with bone scintigraphy, MRI, or leukocyte scintigraphy; FDG-PET also is superior to leukocyte scintigraphy for detecting chronic osteomyelitis in the axial skeleton [44,156,157]. A limitation of this technique is that early bone healing involves a short inflammatory phase with highly activated metabolism and glucose consumption, which might be confused with osteomyelitis; however, this period of false positive images is smaller than with nuclear medicine modalities [158]. It is proposed, therefore, that in postsurgical and traumatic bone healing 18FDG-PET should be avoided in the first 3 to 6 months to minimize the risk for false positive findings [151]. This technique also may have limited usefulness in patients who have failed joint prosthesis or a tumor [66]. FDG-PET might play a role in the future in the diagnosis of osteomyelitis, but its value currently is not well defined.

Gallium-67 (67Ga) has been used successfully as an infection-detecting tracer in scintigraphy. PET imaging confirmed that the uptake of 68Ga was lower than that of 18FDG during normal bone healing; this fact has been proposed to play a significant role in lowering the possibility of false positive findings of osteomyelitis in postsurgical and posttraumatic bone healing. Further studies are needed to verify the value of 68Ga PET for clinical purposes, however [151]. Single positron emission computed tomography (SPECT)/CT combines the functional evaluation provided by SPECT with the spatial definition of CT [159]. It can accurately identify the location of osteomyelitis foci in the appendicular and axial skeleton and differentiate between cortical, corticomedullary, and subperiosteal foci [160]. In addition, it may allow the discrimination between osteomyelitis, septic arthritis, and soft tissue infection [159]. Furthermore, this method had been suggested to be accurate for the evaluation of chronic posttraumatic osteomyelitis [159]. This claim is supported by the fact that acute fractures and postsurgical intervention of bone can increase 18FDG uptake, but this phenomenon lasts a maximum of 3 months; therefore, any abnormal increased 18FDG bone uptake after this period must be suspected to be secondary to infection or malignancy [161]. It has been suggested that SPECT/CT in addition to 67Ga or 111In WBC scintigraphy can accurately help in the precise localization and definition of the extension of infections, highlighting the potential role of combined imaging techniques [160].

Summary

Osteomyelitis frequently requires more than one imaging technique for an accurate diagnosis. Conventional radiography still remains the first imaging modality. MRI and nuclear medicine are the most sensitive and specific methods for the detection of osteomyelitis. MRI provides more accurate information regarding the extent of the infectious process. Ultrasound represents a noninvasive method to evaluate the involved soft tissues and cortical bone and may provide guidance for diagnostic or therapeutic aspiration, drainage, or tissue biopsy. CT scan can be a useful method to detect early osseous erosion and to document the presence of sequestra. PET and SPECT are highly accurate techniques for the evaluation of chronic osteomyelitis, allowing differentiation from soft tissue infection.

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