MR imaging features of facet joint septic arthritis and

correlation with evidence of systemic and synchronous

spinal infection

Poster No.: P-0070

Congress: ESSR 2016
Type: Scientific Poster
Authors: T. Peachey, S. Kulkarni, N. Kotnis; Sheffield/UK
Keywords: Infection, Abscess, Biopsy, MR, Musculoskeletal system,
Musculoskeletal spine
DOI: 10.1594/essr2016/P-0070

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Page 1 of 18
Purpose

Facet joint septic arthritis is an uncommon manifestation of spinal infection. Failure to

recognise the diagnosis can lead to prolonged back pain and potentially progressive
spinal sepsis.

Small case series, mainly describing lumbar facet joint infection, have been published
previously with little focus on radiological findings.

Our aim was to evaluate for specific MR imaging features of facet joint septic arthritis and
correlate these with other diagnostic evidence of infection. We also wanted to assess for
the prevalence of synchronous spinal infection and determine the typical distribution of
spinal involvement.

To the best of our knowledge, this the largest single case series of facet joint septic
arthritis. We present example cases, describe pertinent imaging findings which point
towards a diagnosis of facet joint septic arthritis, and highlight the most common
complications. These findings are placed within the wider context of the published
literature.

Page 2 of 18
Methods and Materials

Retrospective analysis of MRI reports from our Radiology information database was
performed to identify cases where a diagnosis of facet joint septic arthritis was made
on imaging between March 2010 and November 2015. Further information about the
identified cases was found through interrogation of the radiology request cards, hospital
pathology reports, discharge summaries and the written clinical notes.

The presence of one of the following criteria was required to confirm the diagnosis of
facet joint septic arthritis: positive blood culture, positive biopsy sample, or MR features
of synchronous spinal infection.

The MR imaging from each case was retrospectively assessed for the presence of bone
marrow oedema, joint effusion, peri-articular soft tissue inflammation and peri-articular
abscess formation. Imaging assessment was performed independently by a fellowship
trained musculoskeletal radiology consultant (NK) and a musculoskeletal imaging fellow
(SK).Where there was discrepancy in opinion, a concensus opinion was reached.

The spinal level involved was recorded for each case and where multiple levels were
affected, this was also documented.

Page 3 of 18
Results

19 cases with a radiological diagnosis of facet joint septic arthritis were identified. 11%
(2/19) had negative blood cultures and no evidence of synchronous spinal infection.
These two were excluded.

In the seventeen cases that were included, 9 cases (53%) were male, 8 cases (47%)
were female. Age range was 26 - 88 years, with a mean age of 60 years 7 months and
a median age of 61 years.

70% (12/17) had positive blood cultures. 41% (7/17) had both positive blood cultures and
synchronous spinal infection. 47% (8/17) grew staphylococcus aureus on blood cultures.
One case (6%) had staphylococcus aureus identified from urine culture. One further case
(6%) had documetation of staphylococcus aureus sepsis in the clinical notes but the
culture source could not be ascertained.

8% (3/17) cases were streptococcal infections. The bacterial pathogen in 66% of these
cases (2/3) was identified through blood cultures. In 33% (1/3) of streptococcal infections
the diagnosis was made through both blood cultures and culture of a wrist aspirate. This
patient had evidence of septic arthritis of the left wrist in addition to facet joint septic
arthritis.

82% (14/17) cases involved the lumbar spine, 12% (2/17) the cervical spine and 6%
(1/17) the thoracic spine. The case with thoracic spine facet joint septic arthritis had
synchronous C4/C5 discitis with endplate destruction and kyphosis.

In 12% (2/17) two consecutive lumbar facet joint levels were involved. Bilateral lumbar
facet joint infection was noted in one case (6%). 12% (2/17) of cases had synchronous
discitis. One case had right L5/S1 facet joint septic arthritis with synchronous discitis at
T5/6, T8/9 and L5/S1. The second case had right T4/T5 facet joint septic arthritis with
synchronous C4/C5 discitis with endplate destruction and kyphosis.

On MR evaluation, 100% (17/17) cases had peri-articular soft tissue inflammatory

change, 88% (15/17) had joint effusions, 88% (15/17) had bone marrow oedema
surrounding the facet joint, 82% (14/17) had a peri-articular collection, 41% (7/17)
cases had an epidural collection. Four cases underwent post-contrast imaging. Of these
four, 75% (3/4) had periarticular enhancement whilst 25% (1/4) had no periarticular
enhancement. All three cases which underwent post-contrast imaging also had joint

Page 4 of 18
effusions and bone marrow oedema. 75% (3/4) did not have a peri-articular collection,
whilst 25% (1/4) demonstrated peri-articular collection.

Two cases (12%) had no pathogen identified on blood cultures and underwent image
guided tissue biopsy. One of these cases had histological evidence of granulomatous
disease from biopsy in a case of suspected tuberculosis. In the second case, where there
was evidence of synchronous spinal infection of C4/C5 discitis, no pathogen was grown
on either blood cultures or tissue biopsy.

Page 5 of 18
Images for this section:

Fig. 1: 55 year old male. Selected T2 axial slice at the level of L5/S1 demonstrating
periarticular collection (white arrow), a small joint effusion and bone marrow oedema (red
arrow). A diagnosis of staphylococcus aureus was made on blood cultures.

© - Sheffield/UK

Page 6 of 18
Fig. 2: 71 year old female with right T4/T5 facet joint septic arthritis. Selected image from
CT guided biopsy. An 11 gauge bone biopsy needle was advanced via a costovertebral
approach into the right T5 superior articular pillar/pedicle as close to the joint as possible.
A good sized bone core was yielded and the sample sent for microscopy, culture and
sensitivity (MC&S), alcohol and acid fast bacilli (AAFB) culture and mycobacterial culture.
Blood cultures and analysis of the CT guided biopsy yielded no pathogen. The patient
received empirical antibiotic therapy.

© - Sheffield/UK

Page 7 of 18
Fig. 3: 26 year old male. Axial T2 fat suppressed image demonstrating right L3/L4 facet
joint septic arthritis with periarticular collection (solid arrow) and bone marrow oedema
(dotted arrow) at the L3 lamina. A diagnosis of tuberculosis was made following CT guided
biopsy.

© - Sheffield/UK

Page 8 of 18
Fig. 4: 61 year old male. Axial T2 spoiled gradient echo image at the level of C3/C4 facet
joint. There is the presence of a small joint effusion at the left facet joint (white arrow) and
periarticular collection (dotted white arrow). Blood cultures confirmed Staphylococcus
aureus sepsis.

© - Sheffield/UK

Page 9 of 18
Fig. 5: 58 year old female. Selected axial T2 image. Right L4/5 facet joint septic arthritis.
Image demonstrates joint effusion (dotted arrow), periarticular collection (solid white
arrow), and right paraspinal collection (red arrow). Blood cultures grew streptococcus
pneumoniae.

© - Sheffield/UK

Page 10 of 18
Fig. 7: 42 year old female. Sagittal T1 fat saturated post contrast image. Selected image
shows synovial enhancement (solid white arrow) and bone marrow enhancement (dotted
white arrow). Blood cultures grew gram positive cocci.

© - Sheffield/UK

Page 11 of 18
Fig. 6: 43 year old female. Axial T1 fat saturated post gadolinium image demonstrating
bilateral L4/5 facet joint septic arthritis. Imaging appearances are worse on the right with
synovial enhancement (dotted white arrow), bone marrow enhancement (green arrow),
periarticular inflammation (solid white arrow) and epidural collection (red arrow). Blood
cultures grew staphylococcus aureus. Ultrasound guided aspiration of the paraspinal
collection was unsuccessful.

© - Sheffield/UK

Page 12 of 18
Fig. 8: 79 year old male. Sagittal T2 fat saturated image demonstrating a right L4/5
facet joint septic arthritis with an epidural collection (white arrow) extending throughout
the visualised spinal canal. On whole spine imaging the collection was demonstrated to
extend the length of the spine. Blood cultures grew staphylococcus aureus.

© - Sheffield/UK

Page 13 of 18
Fig. 9: 79 year old male. Sagittal T2 fat saturated image demonstrating a right L4/5 facet
joint septic arthritis with a joint effusion (white arrow), peri-articular oedema (red arrow),
and epidural collection (dotted white arrow) extending throughout the visualised spinal
canal. On whole spine imaging the epidural collection was demonstrated to extend the
length of the spine. Blood cultures grew staphylococcus aureus.

© - Sheffield/UK

Page 14 of 18
Conclusion

(1, 2, 3, 4, 5)
There have been several publications of single case studies or small series
(6, 7, 8, 9, 10, 11, 12)
containing two or more cases of facet joint septic arhritis . To our
knowledge this is the largest single case series reported to date, previously the largest
12
published case series comprised 11 patients . Our findings suggest MR imaging
features of facet joint septic arthritis are consistent and reliable, correlating well with other
diagnostic evidence of infection.

The lumbar region is most commonly affected. In our study 82% cases (14/17) involved
the lumbar spine. This is comparable to other published data, where single case reports
10
describe facet joint septic arthritis in the lumbar region. In a series containing 6 cases all
infections were located in the lumbar spine, whilst larger case series have found between
(11, 12)
80% to 90% of facet joint septic arthritis to be located in the lumbar spine . Our
results confirm earlier published findings and provide further evidence that the lumbar
region is preferentially, but not exclusively, involved.

The cervical and thoracic are uncommonly affected. In our series of seventeen cases,
two cases (12%) affected the cervical spine and only in one case (6%) was the thoracic
spine involved.

The majority of our cases had only one facet joint involved, so that the infection was
unilateral and limited to one level. However in two cases, 2 consecutive lumbar facet joint
levels were involved. Bilateral lumbar facet joint infection was noted in one case. One
(6)
case report has reported bilateral facet joint infection , but the majority of cases in the
published literature are also unilateral.

All cases had peri-articular soft tissue inflammatory change in our series. Joint effusions,
bone marrow oedema surrounding the facet joint, and peri-articular collections were
seen in the vast majority of cases. Included in the results section is example images
demonstrating these radiological findings.

Four cases underwent post-contrast imaging. Post contrast MR imaging is not routinely
carried out in our centre for MSK spine imaging. The study was carried out retrospectively,
with the acquisition of post-contrast imaging being justified on clinical grounds. Post
contrast imaging was not required to make the diagnosis in these cases though it is
possible that more cases could be detected with routine use of contrast.

Page 15 of 18
In our series, 70% cases had positive blood cultures. In 59% cases the pathogen was
identified as staphylococcus aureus, the most common pathogen implicated in most
(1, 8, 9, 10, 11)
of the published literature on facet joint septic arthritis . Although a series
of eleven cases found staphylococcus aureus in only 4 (36%), with a variety of other
(12)
pathogens identified including tuberculosis and streptococcus . Several case series
(5, 6)
have reported not being able to isolate any pathogen .

In our series one case had histological evidence of granulomatous disease from biopsy
in a case of suspected tuberculosis. Tuberculosis has only previously been identified in
(12)
one other published case series .

We have presented the largest published single centre case series of facet joint septic
arthritis. Facet joint septic arthritis is an uncommon but important condition. It should be
actively considered and specifically evaluated for when reporting MR spine imaging in the
clinical context of sepsis. The majority of cases affect the lumbar spine and are unilateral.
In our case series every case had peri-articular soft tissue inflammatory change. Other
important common imaging findings were joint effusions, bone marrow oedema and peri-
articular collections. The most common pathogen is staphylococcus aureus with the
other causative organisms being streptococcus and tuberculosis. Blood cultures proved
the most common method of identifying the pathogen, with CT-guided biopsy providing
additional useful information in one case.

Page 16 of 18
References

1. Unilateral septic arthritis of a lumbar facet joint secondary to acupuncture

treatment - a case report. Daivajna, Jones, Malleh and Mehdian. Acupuncture
in Medicine 2004;22(3):152-5
2. Isolated septic facet joint arthritis as a rare cause of acute and chronic low back
pain - a case report and literature review. Klekot, Zimny, Czapiga, Sasiadek.
Pol J Radiol, 2012; 77(4):72-6
3. Paraspinal abscess communicated with epidural abscess after extra-articular
facet joint injection. Park, Moon, Hahn and Lee. Yonsei Medical Journal.
2007;48(4):711-4
4. Lumbar facet joint infection associated with epidural and paraspinal abscess.
A case report with review of the literature. Okada, Takayama, Doita et al. J
Spinal Disord Tech. 2005;18(5):458 - 61
5. Septic arthritis of bilateral lumbar facet joints. Report of a case with MRI
findings in the early stage. Doita, Nishida, Miyamoto et al. Spine. 2003;
28(10):198-202
6. Septic arthritis of lumbar facet joints without predisposing infection. Doita,
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report of two cases and review of the literature. Muffolerro, Nader, Westmark
et al. J Neurosurg. 2001 Jul;95(1 Suppl): 135-8
8. Septic arthritis of lumbar facet joints. A review of six cases. Ergan, Macro,
Benhamou et al. Rev Rhum Engl Ed. 1997 Jun;64(6):386-95.
9. Septic arthritis of the spine facet joint: early positive diagnosis on magnetic
resonance imaging. Review of two cases. Pilleul and Garcia. Joint Bone Spine.
2000;67(3):234-7.
10. Hematogenous pyogenic facet joint infection. Muffoletto, Ketonen, Mader et
al. Spine. 2001. 26(14):1570-6
11. Spontaneous pyogenic facet joint infection. Narvaez, Nolla, Narvaez et al.
Semin Arthritis Rheum. 2006;35:272-283
12. Septic arthritis of the facet joint. Andre, Pot-Vaucel, Cozic et al. Medicine et
maladies infectieuses. 2015;45:215-21

Page 17 of 18
Personal Information

T. Peachey, BA(Oxon), MBChB(Hons), Northern General Hospital, Sheffield Teaching

Hospitals NHS Foundation Trust. thomas.peachey@sth.nhs.uk

S. Kulkarni, MBBS, MRCGP, FRCR. Northern General Hospital, Sheffield Teaching

Hospitals NHS Foundation Trust. shubhang.kulkarni@sth.nhs.uk

N. Kotnis, MBChB, FRCR. Northern General Hospital, Sheffield Teaching Hospitals NHS
Foundation Trust. nikhil.kotnis@sth.nhs.uk

Page 18 of 18