 Hi, I'm Dr. Steven Pomerance, neuroradiologist. This is my partner in crime, Dr. Malcolm Schupeck, a neurosurgeon and a neuroimager. And this is our new edition of the ProScan Mentor Case Review Series focusing on core board review and recredentialing cases for you complementary from our team. Let's tackle our first case, shall we? Our first case is a 50-year-old man who has chronic back pain for several months. And you are shown a sagittal T2 fat suppression image, a sagittal T1 spin echo image, and an axial T1 weighted image at a strategic location. One of your main challenges is to decide whether you are looking at a crushed, collapsed vertebral body, as in vertebral plana, or are you looking at a destroyed and inflamed disk space with destruction of bone above and below. So let's scroll a little bit to assist you with that decision and any other findings that you think you might pick out. And here is your axial T1 weighted image and now the first question. The abnormality on the MR study most likely represents a, pyogenic diskitis, b, cordoma, c, metastasis, or d, atypical diskitis. Let's evaluate each of these choices. First, pyogenic diskitis, usually not isolated in the thoracic region and usually not associated with a collection in the lung or a lung lesion. Cordoma, very rare in the thoracic region, usually seen at C2, or the sacrum, or the clivus. So the location is poor. Metastasis, these are not centered in the disk space. And you should have chosen disk space and end plate destruction rather than vertebral body compression for several reasons. One, there is paravertebral soft tissue swelling and mass effect. And two, there's involvement of the left lung and pleura. So metastatic disease doesn't fit for that reason, although you can get metastases to disk spaces. It is extremely rare. And metastases are usually multifocal. They tend to expand and destroy rather than collapse. So the correct answer, Dr. Schupak, is d, atypical diskitis. And which of the atypical organisms is most likely? Well, tuberculosis, much less frequently, brucellosis could give a very similar picture. I think the other thing I would point out is the history of months of back pain. Pyogenic diskitis, usually within weeks, progressive within weeks, this type of patient generally when I have seen them, has been brought in after being kicked out of every ER in the county for six months or more, and then eventually is carried in by the family. So the history of a month's progression is also very supportive of an atypical diskitis as opposed to pyogenic, which is also associated with surgery, sepsis. So those are things that may probably would be in the history if the answer was going to be pyogenic. And sometimes with pyogenic, you may get it from prostatitis in men, spontaneously. Is there some other evidence, reason to have a bacteremia? So that would be in the history of that question if pyogenic was the proper answer. There are the differential of things that cross the disk space is pretty short, isn't it? It's extremely short. It's pretty much limited to diskitis. Diskitis, cordoma, but as Dr. Pomeran said, doesn't fit with that. That is something that can cross the disk space because it's a notochordal problem, but doesn't fit any of these other things. The progressive back pain, the location. So there's going to be several clues in the question that should tip you off to look out for. And some of them are historic, and some of them are anatomic. So let's move on to question number two. Factors that support this diagnosis could include a, perivertable mass involvement, b, preferential thoracic and anterior thoracic location, c, demographic features, including country of origin, d, pulmonary involvement, or e, all of the above. And you could pause if you want, but I'll give you the answer. The answer is e. All of the above support the diagnosis of a tuberculous diskitis. So this is another situation where the question, meaning far in travel, that's the demographic, meaning the patient, they're going to say something about either where the patient has been or some demographic factor that's going to tip you off if that's going to be their diagnosis. The perivertable involvement is very characteristic. I think Dr. Pomerance already mentioned that, that the diskitis of pyogenic is really a disk process that can kind of go out. But these atypicals, TB and brucellosis, I would say, have a major paraspinal component, as this one does. And then, of course, you have an image on the left showing a lung lesion. So that is also very helpful. And it looks like that lung lesion is plural-based. Let's move on to question number three. I'll read the question, and then you can comment on whether it's true or false. Which is true regarding skeletal tuberculosis? A, concurrent active pulmonary tuberculosis is present less than 20% of the time. Yes, that is false. Skeletal involvement is actually in about 1% to 3% of patients. And intracurrent inter thoracic disease is present in less than 50%. B, polyarticular involvement is characteristic. TB is characteristically monoarticular, knee and hip most frequent. So that is false. C, spina ventosa, a synonym for wind-filled sal, in other words, expansion of a digit, is a radiographic sign seen with spondylitis. That is false. That's a radiographic sign that's seen as tuberculosis dectilitis of the tubular bones of the hands and feet with soft tissue swelling. Let's go with D. Tuberculosis osteomyelitis typically involves the metaphysis of the axial skeleton. That is true. Femur and tibia and the small bones of the hands and feet are most commonly involved. Typically, the metaphysis is affected. And diaphysial disease has a very narrow differential diagnosis, which we'll discuss in the orthopedic case section. So in summary, the diagnosis is a typical dyscytus of tuberculosis origin, which likes to start in the anterior aspect of the thoracic spine, as previously stated. The perispinous masses with this disease are often large. They frequently don't contain much fluid. They're more akin to solid gray tissue, or what we call cold abscesses. And usually, if you stick a needle in them, you won't get fluid back. Tuberculosis often involves multiple levels. Tip-offs that we reviewed include the patient traveling from another part of the world, lung disease, renal disease. And it's imperative that you drop down, perhaps, with CT and ultrasound, and make sure there's no evidence of renal tuberculosis. Thanks, and have a great day.