A new classification and guide for surgical treatment of spinal tuberculosis

Predictive Value of Vertebral Bone Destruction Classification Based on Computed Tomography in Diagnosing on Adult Spinal Tuberculosis

OBJECTIVE

Although magnetic resonance imaging (MRI) is well-established for evaluation of spinal tuberculosis (TB), the importance of computed tomography (CT) should not be overlooked. The purpose of this study was to determine the characteristics of spinal TB and the relationship between spinal TB and the bone lesion pattern seen on three-dimensional CT images.

METHODS

One hundred and sixty-one subjects were divided into a TB-positive group and a TB-negative group based on laboratory (X-pert mycobacterium tuberculosis/ rifampin) results and then subdivided further according to whether the bone lesion pattern seen on three-dimensional CT images was fragmentary, osteolytic, sclerotic, or had no evidence of bone destruction. The diagnostic value of the bone lesion pattern was compared between the TB-positive and TB-negative groups.

RESULTS

Ninety-nine of the 161 patients were TB-positive and 62 were TB-negative. Fifty-six (34.8%) of the 161 patients had fragmentary/osteolytic lesions, seventy-four (45.9%) had absolute osteolytic lesions, 13 (8.1%) had osteosclerotic lesions, and 18 (11.2%) had no evidence of bone destruction. The fragmentary/osteolytic lesion pattern was strongly predictive of spinal TB (odds ratio 3.33), and when combined with 3 MRI findings (thin abscess wall, more than one half of the vertebral body destroyed, and subligamentous spread) had an even stronger diagnostic value (odds ratio 15.58).

CONCLUSIONS

The absolute osteolytic pattern was the most common of the bone lesion patterns. The fragmentary/osteolytic pattern is highly suggestive of spinal TB, especially when combined with MRI findings of a thin abscess wall, destruction of more than one half of the vertebral body, and subligamentous spread.

Comprehensive Spinal Tuberculosis Score: A Clinical Guide for the Management of Thoracolumbar Spinal Tuberculosis

STUDY DESIGN

A newly proposed scoring tool was designed to assist in the clinical management of adult thoracolumbar spinal tuberculosis (TB).

PURPOSE

To formulate a comprehensive yet simple scoring tool to guide decision-making in the management of adult thoracolumbar spinal TB.

OVERVIEW OF LITERATURE

Spine surgeons have differing consensus in defining the threshold grade for clinico-radiological parameters when deciding between operative or conservative treatment for adult thoracolumbar spinal TB. Currently, the void in decision-making from the lack of well-defined guidelines is compensated by the surgeon's experience in treating these patients. To the best of our knowledge, no scoring system holistically integrates multiple facets of spinal TB to guide clinical decision-making.

METHODS

The RAND/University of California, Los Angeles appropriateness method was employed among an expert panel of 10 spine surgeons from four apex tertiary care centers. Vital characteristics that independently influenced treatment decisions in spinal TB were identified, and a scoring tool was formulated. Points were assigned for each component based on their severity. The cutoff scores to guide clinical management were determined from the receiver operating characteristic curve based on the retrospective records of 151 patients treated operatively or non-operatively with improved functional outcomes at the 1-year follow-up.

RESULTS

The components of the comprehensive spinal TB score (CSTS) are pain, kyphosis angle, vertebral destruction, and neurological status. A score classification of <5.5, 5.5-6.5, and >6.5 was established to guide the patient toward conservative, conservative/ operative, and operative management, respectively.

CONCLUSIONS

The CSTS was designed to reflect the essential indicators of mechanical stability, neurological stability, and disease process stabilization in spinal TB. The scoring tool is devised to be practical and serve as a common language in the spine community to facilitate discussions and decision-making in thoracolumbar spinal TB. The validity, reliability, and reproducibility of this tool must be assessed through multicenter long-term studies.

A Validated Score for Evaluating Spinal Instability to Assess Surgical Candidacy in Active Spinal Tuberculosis-An Evidence Based Approach and Multinational Expert Consensus Study

STUDY DESIGN

Modified Delphi Consensus and Observational Study.

OBJECTIVE

Instability in spinal tuberculosis (STB) leads to disabling spinal deformity and neurodeficit. Identifying and estimating instability remains subjective, mainly based on experience. This study aims to develop an objective scoring system to determine instability in STB.

MATERIALS AND METHODS

The study included 4 phases. (1) A panel of 10 experienced spine surgeons developed a questionnaire based on literature. (2) 68 spine surgeons from 12 countries opined on the importance of each factor in a survey. Five factors deemed important by >70% of participants were further analyzed (3) 60 representative cases of STB were analyzed for instability. A preliminary scoring system was developed, a threshold score for determining instability was derived, and (4) Results were validated.

RESULTS

All the 5 factors ("Spine at risk" signs, severity of vertebral body loss, Cervicothoracic/Thoracolumbar junction involvement, age ≤15, and kyphotic deformity ≥30°) considered important by >70% of participants were associated with instability and included in scoring: age ≤15 years (P-value, 0.05), cervicothoracic/thoracolumbar junction involvement (P-value, 0.028), sagittal deformity angle ratio (DAR) ≥ 15° (P-value, <.001), vertebral body loss-segmental ratio ≥.5 (P-value, <.001), and presence of spine at risk signs (P-value, <.001). A total score of ≥3/09 indicated definite instability with good sensitivity (77%) and excellent specificity (100%). Repeatability assessment showed a good agreement (.9625), and Cohen's kappa coefficient was strong (.809).

CONCLUSION

A simple objective scoring system for predicting instability in STB has been developed using 5 main factors; young age, junctional involvement, severity of the deformity, vertebral body loss, and presence of spine at risk signs.

Can We Extrapolate SINS Score to Evaluate Instability in Spinal Tuberculosis?

STUDY DESIGN

Prospective Observational Study.

OBJECTIVES

To assess the feasibility of utilizing SINS score, originally suggested for neoplastic conditions, to assess structural instability in spinal tuberculosis.

METHODS

Patients with an established diagnosis of spinal tuberculosis were included in the study. Based on SINS scoring, patients classified as those with "indeterminate stability" were managed with or without surgery based on other parameters including neurological status, severity of pain, medical comorbidities, etc.

RESULTS

Eighty [39 males, 41 females] patients prospectively evaluated with mean age 46.74 ± 17.3 years. Classification done into stable [n = 7], indeterminate [n = 45] and unstable [n = 28] groups based on SINS scoring. All the patients in unstable group were treated with surgical stabilization whereas none in the stable group required surgical stabilization. In the indeterminate group, 26 patients underwent surgical stabilization, while 19 treated non-operatively. Major determinants predisposing to surgical intervention in "indeterminate group" were pain [14 of 26 patients] and neurological status [11 of 26 patients]. Mean follow-up 38.5 ± 22.61 months with minimum follow-up being 24 months. Preoperative VAS score for pain improved from median of 9/10 to 1/10 following surgery [P < .0001]. In the non-operative group, the improvement was from median score of 6/10 to 1/10 [P < .0001]. Preoperative ODI improved in non-operative and operative group from median of 42% and 70%, respectively to 10% and 12%, respectively in the postoperative period [P < .0001 for both groups].

CONCLUSIONS

SINS scoring can be a helpful tool in surgical decision-making even in spinal tuberculosis. Further refinement of the score can be done with a larger, multicenter study.

Diagnosis, Management, and Prognosis of Spinal Tuberculosis: A Case Report

Spinal tuberculosis (TB) is a condition that affects numerous people around the world. The incidence of TB prior to the pandemic was decreasing by about 1.8% per year; however, COVID-19 has complicated this incidence rate leading to an increase of 4.5% in 2020 and 2021. Spinal TB is a rare event in all TB patients. The management could be multifactorial including location, severity, and symptom, and this case demonstrates an example of issues to consider in the diagnosis and management of patients. This is a case of a patient presenting with back pain which was subsequently diagnosed as spinal TB. We will review this patient's presentation and consideration for multifactorial opinions in the literature. This literature review demonstrates that there is no one treatment option available. Providers need to tailor treatment to each individual case. This is an example of a case that illustrates that diagnosis of spinal TB is not straightforward and clinicians may have to make a judgment call and treat prophylactically to prevent a poor prognosis.

Comparative study of the effect of two different doses of remifentanil on bleeding control in lumbar fusion surgery: A randomized clinical trial

Objectives

Spinal fusion surgery completely prevents movement or friction between the two vertebrae. Remifentanil, a selective drug agonist, suppresses and decreases the vasomotor system upon release of histamine. In this study, the efficacy of remifentanil infusion at doses of 0.1 and 0.3 μg/kg/min in the control of low blood pressure was compared.

Methods

In this randomized clinical trial, 110 candidates for selective spinal fusion surgery were entered and randomized into 2 groups. The first group received 0.1 μg/kg/min and in the second group 0.3 μg/kg/min remifentanil. The systolic and diastolic blood pressure, pulse rate, SPO2, and surgeon's satisfaction were measured and compared between groups.

Results

the systolic blood pressure was significantly lower in patients receiving 0.3 μg of remifentanil by the time 30, 45, 60, and 90 min during the surgeries (P < 0.05). No significant difference was observed in terms of PR (P = 0.19) and SPO2 (P = 0.41) between the two groups. We also observed significantly higher duration of surgeries (P = 0.002), duration of anesthesia (P = 0.009), significantly higher bleeding volume (P < 0.001), higher fluid intake (P = 0.01) and higher transfused blood (P = 0.01) in patients that received 0.1 μg remifentanil compared to other patients.

Conclusion

Here we showed that administration of 0.3 μg/kg/min remifentanil was associated with significantly lower systolic blood pressure during the surgeries. On the other hand, patients that received 0.1 μg/kg/min remifentanil had significantly higher duration of surgeries, duration of anesthesia, significantly higher bleeding volume, higher fluid intake, and also higher transfused blood.

•

Spinal fusion surgery completely prevents movement or friction between the two vertebrae.

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Remifentanil, a selective drug agonist, suppresses and decreases the vasomotor system.

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0.3 μg/kg/min remifentanil was associated with significantly lower systolic blood pressure.

•

Patients that received 0.1 μg/kg/min remifentanil had significantly higher duration of surgeries.

Comparative efficacy of traditional conservative treatment and CT-guided local chemotherapy for mild spinal tuberculosis

Background

There are considerable differences in the treatment strategy for spinal tuberculosis, including conservative or surgical procedures. Conservative treatment is always suitable for most patients. This study aimed to compare the clinical efficacy of traditional conservative treatment with CT-guided local chemotherapy strategy of mild spinal tuberculosis.

Methods

This research retrospectively analysed 120 patients with spinal tuberculosis between January 2005 and January 2016 according to the diagnostic criteria of mild spinal tuberculosis. In total, 89 patients underwent traditional conservative treatment, 31 underwent CT-guided local chemotherapy. Clinical outcome, laboratory indexes, and radiological results were analysed to provide a clinical basis for the choice of mild spinal tuberculosis treatment.

Results

All cases achieved a clinical cure with 24 to 50 months followed up. Cobb angle of the two groups spinal tuberculosis segments was 6.25 ± 3.1100B0, 5.69 ± 2.5800B0 before treatment and 12.36 ± 6.3100B0, 14.87 ± 7.2600B0 after treatment, respectively. The VAS scores were significantly decreased post-treatment. At the 1 month follow-up, the VAS scores and erythrocyte sedimentation rate (ESR) were significantly differences between the two groups. The efficacy in the CT-guided local chemotherapy (Group B) was better than the traditional conservative treatment (Group A). But from the 3 months follow-up to the last follow-up, the VAS scores and ESR was no significant differences between the two groups and the average ESR decreased to normal. There was no evident kyphosis, symptoms or neurological deficits at the final follow-up. The paravertebral abscesses had disappeared, with no significant progression of local kyphosis, significant absorption and clear lesion edges, pain relief and normal ESR in the two groups.

Conclusions

For mild spinal tuberculosis, traditional conservative treatment can achieve satisfactory results. The strategy combined with CT-guided local chemotherapy treatment is minimally invasive, beneficial for the drainage of paravertebral abscesses and pain relief.

Temporary standalone percutaneous fixation with pedicle screws for the treatment of subacute tuberculous osteomyelitis with kyphotic deformity in the lumbar spine

Background:

Tuberculous (TB) osteomyelitis is a rare, but challenging infection, that mandates antituberculosis antibiotics, and potentially surgical intervention. Per the Gulhane Askeri Tip Akademisi (GATA) classification system, corrective reconstruction is indicated in severe cases, where the kyphotic deformity is >20° (GATA Class III). Here, we describe a case of BCG vaccine-induced lumbar TB osteomyelitis at the L1-2 level in a patient presenting with mechanical pain and a focal, nonfixed kyphotic deformity of 36.1°. Surgery consisted of percutaneous fixation with pedicle screws without debridement, fusion arthrodesis, or anterior reconstruction.

Case Description:

A 77-year-old male presented with L1-2 TB osteomyelitis secondary to intravesical BCG application. A 36.1° focal nonfixed kyphotic deformity was evident on standing X-rays that reduced in the supine position. He underwent posterior percutaneous screw fixation with rods extending from the T12 to L3 levels, with resolution of his mechanical pain. Nine months later, the CT demonstrated reconstitution of the vertebral bodies (i.e., volume increase of 6.99 cm³ (21%) and 7.49 cm³ (27%) at L1 and L2, respectively). Standing X-rays after hardware removal demonstrated 32.7° of lumbar lordosis and a reduction of focal kyphosis to 12.9°.

Conclusion:

Here, we present an exceedingly rare case of BCG vaccine-induced L1-2 spinal tuberculosis with extensive vertebral body destruction and deformity. This was effectively treated with standalone temporary pedicle fixation instead of corpectomy and reconstruction.

Osteotomized debridement versus curetted debridement in posterior approach in treating thoracolumbar tuberculosis: a comparative study

PURPOSE

This study aimed to compare osteotomized debridement (OD) with traditional curetted debridement (CD) in treating thoracolumbar tuberculosis (TB).

METHODS

A total of 188 patients were diagnosed with active thoracolumbar TB and underwent one-stage posterior surgery at our institution. Of the 188 patients, 85 patients were treated with OD, and 103 patients were treated with traditional CD. The patient information, laboratory results, imaging findings, and clinical effectiveness were, respectively, compared between the two groups.

RESULTS

Group OD consumed less operation time and blood loss than group CD (P < 0.05 for both values). No significant difference in hospitalization time was found between the two groups (P > 0.05). The values of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) in both groups returned to the normal range within one month postoperatively. All patients had significant improvement in visual analog scale (VAS) and oswestry disability index (ODI) postoperatively. The mean fusion time in group OD was shorter than that in group CD (P < 0.05). There was no statistically significant difference in preoperative kyphotic angle between the two groups (P > 0.05), but group OD showed less correction loss than group CD at the final follow-up (P < 0.05). The rate of recurrence and surgery-related complications in group OD was lower than group CD.

CONCLUSIONS

Posterior OD, reconstruction with titanium mesh cages (TMCs), and instrumentation is feasible and effective in treating thoracolumbar TB. Compared with the traditional CD, OD can achieve radical lesion removal, more effective kyphosis correction, lower recurrence rate, and fewer complications.

Surgical Approaches in Management of Spinal Tuberculosis

Although the management of spinal tuberculosis (TB) is mainly medical, there are select surgical interventions for the same, especially in the event of complications. However, with multiple choices with regard to approaches and surgical techniques, one is often left with too many options. We, therefore, performed a literature review on the subject with respect to the surgical approaches to control spinal TB. Our aim is to enable the reader to understand the rationale behind various surgical approaches and techniques involved in managing spinal TB.

It's Never Too Late: Neurological Outcome of Delayed Decompression in Tuberculosis of Spine

STUDY DESIGN

Retrospective observational study.

OBJECTIVE

To study the neurological recovery in patients with progressive neurological deficit undergoing delayed decompression and fixation in tuberculosis of spine.

METHODS

Retrospective analysis of 50 cases with thoracolumbar tuberculosis of spine, undergoing posterior decompression and instrumentation was done. Parameters like time interval between appearance of neurological deficit to decompression surgery, maximal spinal cord compression, neurology on admission, presence of drug resistance, and number of vertebrae involved were evaluated. The subjects were divided into 2 groups depending on neurological improvement measured with LEMS (Lower Extremity Motor Score) at the end of 1-year follow-up.

RESULTS

The mean LEMS score on admission was 27.72 (SD 12.88), which improved to 40.80 (SD 10.46) at the end of 1 year (P < .001). A total of 26 (52%) subjects were categorized into "Satisfactory" outcome (LEMS >10) group and remaining 24 subjects formed the "nonsatisfactory" outcome group. The median time interval between the appearance of neurological deficit and decompression surgery was 23.50 days in the satisfactory group and 29.50 days (P = .110) in the nonsatisfactory group. Maximal spinal cord compression was 0.370 in satisfactory group and 0.357 in nonsatisfactory group (P = .754). The mean preoperative LEMS score was 34.62 in the satisfactory outcome group while that in the nonsatisfactory outcome group was 20.25 (P < .001).

CONCLUSION

There is significant scope for neurological improvement even after delayed decompression and fixation in cases of tuberculosis of spine with progressive neurological deficits. Preoperative neurological status was found to be the most significant determinant of postoperative neurological outcome.

Unilateral Limited Laminectomy for Debridement to Treat Localized Short-Segment Lumbosacral Spinal Tuberculosis: A Retrospective Case Series

Objective

This study aimed to investigate the clinical effects of surgically treating lumbosacral tuberculosis with a modified posterior unilateral limited laminectomy method for debridement.

Methods

This retrospective study enrolled a total of 26 patients who were administered in our institution from January 2010 to December 2016, diagnosed with lumbosacral tuberculosis at the L5/S1 level, and underwent one‐stage posterior unilateral limited laminectomy as surgical treatment for debridement, allograft of cortical bone grafting, and fixation. The erythrocyte sedimentation rate (ESR), C‐reactive protein (CRP) level, visual analog scale (VAS) score, Oswestry Disability Index (ODI), and lumbosacral angle (LA, Cobb's method) were statistically compared, and the American Spinal Injury Association Impairment (ASIA) Scale was compared between the preoperative and postoperative time points to evaluate the clinical outcomes.

Results

All 26 patients were observed during the follow‐up period, and the mean follow‐up time was 1.3 ± 0.42 years. The mean age was 56 ± 7.4 years old. The average operation time was 118.1 ± 17.5 min, and the mean bleeding volume was 513.0 ± 79.6 mL. There were no intraoperative complications or tuberculous sinus, and two cases experienced hypostatic pneumonia during hospitalization, which resolved with responsive antibiotics and symptomatic supportive treatment. At the final follow‐up, there was no recurrence of tuberculosis, and the ESR (11.8 ± 1.8 mm/h) and CRP (3.0 ± 1.0 mg/L) levels in all patients had returned to normal. The patients with neurologic deficits had improved, and the mean ODI was 79.9 ± 10.6 (87–62) preoperatively and significantly decreased to 20.5 ± 5.7 (11–29) at the final follow‐up (P < 0.01). ASIA scale scores were improved by 1~2 grades at the last follow‐up. The patients' pain levels were significantly alleviated; the mean VAS score declined to 1.2 ± 0.4 (0–2.5) at the final follow‐up compared to 7.5 ± 1.6 (6.5–8.5) preoperatively (P < 0.01). All patients achieved bony graft fusion at an average time of 6.8 ± 1.2 months. Physiological lumbar lordosis was significantly improved, and the mean LA before operation was 17.6° ± 2.1°, which was significantly different from the postoperative LA (29.3° ± 7.4°, P < 0.01) at the final follow up. The LA (27.1° ± 5.5°, P = 0.15) slightly rebounded but without significance compared to the postoperative level.

Conclusion

Only posterior approach by unilateral limited laminectomy for debridement could be served as an effective and safe method to treat short‐segment lumbosacral tuberculosis without extensive anterior sacral and gravitation abscesses.

One-stage combined anterior-posterior surgery for thoracic and lumbar spinal tuberculosis

Context: Surgical intervention is imperative when spinal tuberculosis (TB) is accompanied by severe spinal damage or kyphotic deformity. As one-stage anterior-only or posterior-only surgery for thoracic and lumbar spinal TB has many disadvantages, combined anterior-posterior surgery was proposed to be a more effective strategy.Objective: To examine the clinical outcomes of one-stage combined anterior-posterior surgery for patients with spinal TB.Design: Retrospective investigation design.Setting: All patients were enrolled at the Hangzhou Red Cross Hospital between August 2002 and October 2014.Participants: Sixty-seven patients with thoracic and lumbar spinal TB were studied.Interventions: All patients were treated with one-stage surgery using a combined anterior-posterior approach.Outcome measures: The patients were evaluated preoperatively and postoperatively by measuring their neurological function using the visual analogue scale (VAS) and the Frankel grades, and spinal deformity using the Cobb angle and radiological examinations. All patients were followed up for at least 11 months and up to 96 months.Results: There was a significant postoperative improvement in neurological outcomes, according to VAS scores and Frankel grades. Kyphotic angles were corrected significantly and were maintained during the final follow-up. Bone fusion was achieved within 4-7 months.Conclusion: One-stage surgical treatment via a combined anterior-posterior approach is an effective and feasible method for treating spinal TB.

Spinal Tuberculosis Treatment: An Enduring Bone of Contention

Spinal tuberculosis is the most common form of extrapulmonary tuberculosis. It is of great importance to neurologists because of the potentially devastating complication of paraplegia, which may set in during active disease or the healed phase. Due to the deep-seated nature of the disease, definitive diagnosis is often challenging. There is no clear consensus on the appropriate duration of therapy for spinal tuberculosis, with various guidelines recommending treatment from as short as 6 months to up to 18 months. In this article, we present a critical appraisal of the evidence on the same. In our opinion, the duration of antitubercular therapy needs to be individualized and the decision to terminate therapy should be multifactorial (clinical, radiological, pathological/microbiological where possible) rather than being enmeshed within any particular guideline.

A multicenter retrospective research of anterior debridement, decompression, bone grafting, and instrumentation for cervical tuberculosis

Objective: To observe the clinical effect of anterior debridement, decompression, bone grafting, and instrumentation for cervical spinal tuberculosis in four hospitals. Materials and Methods: This research retrospectively analyzed 146 patients with cervical spinal tuberculosis who were treated by anterior debridement, decompression, bone grafting, and instrumentation in four institutions between January 2000 and January 2015. There were 68 males and 78 females with an average age of 31.32 ± 11.69 years. All patients received chemotherapy for 18 months after surgery, and fixed by brace for 3 months. Clinical outcome, laboratory indexes and radiological results were analyzed to evaluate the efficacy of anterior approach surgery in the treatment of cervical spinal tuberculosis. Results: All cases were followed up about 18 to 52 months later (average 24 months). At the last follow-up, all patients obtained bone fusion, pain relief and neurological recovery. There was no recurrence in any of the patients, and no complications related to internal fixation. There were statistically significant differences before and after treatment in terms of Visual analog scale (VAS), Neck disability index (NDI) and Japanese Orthopedic Association (JOA)(P < 0.05). During the last follow-up examination, in 83 patients with neurological deficit, 78 patients improved. The kyphosis was significantly improved postoperatively (P < 0.05). At the last follow-up, the Cobb angle had some degree of correction loss, but the difference was not statistically significant. Conclusion: Our study suggests that one-stage anterior debridement, decompression, bone grafting, and instrumentation are safe and effective methods in the surgical management of cervical spinal tuberculosis. Abbreviation: VAS: Visual Analog Scale; JOA: Japanese Orthopaedic Association; NDI: Neck Disability Index; ESR: Erythrocyte Sedimentation Rate; ASIA: American Spinal Injury Association; TB: Tuberculosis.

Clinical Efficacy of Three Surgical Approaches for the Treatment of Cervicothoracic Tuberculosis: A Multicenter Retrospective Study

Objective

To evaluate the efficacy of three surgical approaches for the treatment of cervicothoracic tuberculosis.

Methods

This is a multicenter retrospective study. We analyzed 74 patients with cervicothoracic tuberculosis who were treated in six institutions between January 2000 and January 2015. There were 37 male and 37 female patients, with an average age of 24 years (range, 5–62 years). The operative method was selected according to the indications. A total of 33 patients underwent one‐stage anterior surgery (group A); 16 underwent a combined anterior and posterior surgery (group B) and 25 underwent one‐stage posterior surgery (group C). Clinical outcomes, laboratory indexes, and radiological results were analyzed.

Results

All cases were followed up for approximately 36–96 months post‐surgery (average, 39 months). At the last follow‐up, patients in all three groups had achieved bone fusion, with pain relief and neurological recovery. No major vessel and nerve injuries were found during the operation. There were significant differences before and after treatment for visual analogue scale (VAS), neck disability index (NDI), and Japanese Orthopedic Association (JOA) score (P < 0.001). Three surgical strategies significantly improved kyphosis (P < 0.001).

Conclusion

The choice of operation for cervicothoracic tuberculosis should be selected based on the pathological changes, scope, and general physical condition of the patient. The indication for a posterior approach is narrow and it should be used selectively. The combined anterior and posterior approach involved a longer operating time, larger blood loss, and greater trauma, and also required a higher level of surgical skill. Therefore, the indications for this approach should be strictly controlled. Anterior approach surgery for the treatment of cervicothoracic tuberculosis showed excellent efficacy and fewer complications.

Comparison of anterior, posterior, and anterior combined with posterior surgical treatment of thoracic and lumbar spinal tuberculosis: a systematic review

Background

This study was performed to compare different surgical approaches in the treatment of spinal tuberculosis.

Methods

We conducted a literature search to identify and analyze papers published from January 1966 to April 2018 relevant to comparison of the anterior, posterior, and anterior combined with posterior approaches in the treatment of spinal tuberculosis of the thoracic and lumbar regions.

Results

Twenty-five studies involving 2295 patients were identified in this systematic review. The operative time was significantly longer in the anterior combined with posterior approach than in the other two approaches. Blood loss was significantly greater in the anterior combined with posterior approach (1125.0 ± 275.5 mL) than in the posterior approach (710.4 ± 192.4 mL). The difference in correction of the kyphosis angle among the three procedures was not significant. The overall surgical and transthoracic complications were significantly lower in the posterior approach. The clinical outcome of all patients improved, but there was no significant difference among the three procedures.

Conclusions

Blood loss, overall surgical and transthoracic complications, and the operative time are different among the three approaches. Therefore, different factors must be carefully assessed in deciding among the three procedures.

Single-stage posterior debridement, decompression and transpedicular screw fixation for the treatment of thoracolumbar junction (T12-L1) tuberculosis with associated neurological deficit: a multicentre retrospective study

BACKGROUND

A multicentre retrospective study was conducted to evaluate the safety and efficacy of single-stage posterior debridement, decompression and transpedicular screw fixation for the treatment of thoracolumbar junction (T12-L1) tuberculosis in patients with associated neurological deficit.

METHODS

Thoracolumbar junction (T12-L1) tuberculosis patients (n = 69) with neurological deficit who underwent single-stage posterior debridement, decompression and transpedicular screw fixation from January 2005 to January 2015 were included in the study. Antituberculosis therapy was performed both before and after surgery. The surgery duration and patient blood loss were evaluated, in addition to the change in pain visual analogue score (pVAS), kyphotic angle, Oswestry disability index (ODI) score and American Spinal Injury Association (ASIA) grade assessed preoperatively, immediate postoperatively and at the final follow-up visit.

RESULTS

The average blood loss was 354 ± 291 mL. The average kyphosis angle was corrected from 21 ± 9° preoperatively to 9 ± 4° postoperatively, with a mean decrease in pVAS and ODI scores of 3.4 and 16, respectively. The postoperative ASIA grading was grade A for five patients, grade C for 15 and grade D for 49 patients, which had improved to grade C for four patients, grade D for three patients and grade E for 62 patients at the final follow-up. The neurological deficit did not worsen in any of the patients.

CONCLUSIONS

Single-stage posterior debridement, decompression and transpedicular screw fixation is an effective treatment method in thoracolumbar junction (T12-L1) tuberculosis patients with neurological deficit, with good neurological recovery and no progression of kyphosis.

Arthroscopic management for early-stage tuberculosis of the ankle

Background

Due to atypical clinical presentation, wide use of antibiotics, and lack of specificity in diagnosis, diagnosis of tubercular (TB) infection in joints is increasingly difficult, and misdiagnosis is common. The use of arthroscopy for the diagnosis and treatment of early-stage ankle TB has rarely been reported. This case series intended to present the clinical outcomes of arthroscopic management for early-stage ankle TB.

Methods

Fifteen patients with chronic synovitis of the ankle and suspicious cause of early-stage ankle TB underwent arthroscopic treatment from April 1, 2010, to March 31, 2016. These cases all failed to confirm diagnosis of TB by ankle arthrocentesis. They included seven males and eight females with an average age of 37.5 (8 to 70) in the study. Among them, five cases had history of pulmonary tuberculosis, and six had history of trauma. The procedure included synovial membrane biopsy and debridement. The diagnosis was confirmed by pathologic examination and culture. The treatment was combined with systemic anti-tuberculous drugs. Follow-up measurements included VAS score, AOFAS score, ESR, CRP, and MRI.

Results

After arthroscopic management, 13 cases confirmed TB by pathologic examination and culture, and two cases still remained clinically suspected TB; the rate of confirmed case was 87%. The incision healed well in all cases, and no serious complications were observed. There were significant differences in VAS scores, AOFAS scores, ESR, and CRP between before and after treatment (P < 0.01). Joint swelling disappeared or was relieved after 2 months in most patients. Ankle swelling and pain in one patient was improved after changing anti-tuberculous drugs. MRI suggested that all patients had effusion in the articular cavity, accompanied by bone edema of the distal tibia and talus before the treatment. After the surgery, the effusion was significantly reduced, and the signal of bone edema almost disappeared. No recurrent TB was found during the follow-ups.

Conclusion

Arthroscopic management for early-stage ankle TB is minimally invasive, safe, and reliable. It can easily obtain samples from specific area of TB for further confirmation of the diagnosis, while the debridement can also assist in local disease control. For cases of highly suspicious joint TB, arthroscopic biopsy and debridement after transient anti-TB treatment is recommended.

Level of evidence

Level IV, therapeutic case series

Electronic supplementary material

The online version of this article (10.1186/s13018-018-1048-y) contains supplementary material, which is available to authorized users.

Challenges in the Diagnosis and Management of Spinal Tuberculosis: Case Series

Though uncommon in developed countries, spinal tuberculosis must still be considered in patients with a suspicious clinical history, to avoid delays in treatment. This case series highlights the special considerations that need to be taken into account while tackling the diagnostic and therapeutic challenges associated with this disease.

We present two interesting cases of spinal tuberculosis. The first case was a 26-year-old female who presented with chronic back pain and an initial misdiagnosis of ankylosing spondylitis. The second case was a 26-year-old male with new lower extremity weakness, numbness, and urinary retention.

Both cases had clear indications for surgery, however, the first case was treated with medical management upon patient request. The patient was managed non-surgically and improved clinically though she may need surgery in the future. The second case was treated with emergency surgery and the patient regained full neurologic function at follow-up.

These cases demonstrate the importance of considering spinal tuberculosis in the differential diagnosis of high-risk patients as well as individualizing treatment strategies for each patient.

A comparative study to evaluate the feasibility of preoperative percutaneous catheter drainage for the treatment of lumbar spinal tuberculosis with psoas abscess

Background

Spinal tuberculosis is a frequent cause of psoas abscess (PA), and PA largely negates the efficacy of antituberculosis therapy. This study aimed to investigate the clinical outcome of preoperative percutaneous catheter drainage (PCD) in patients with lumbar spinal tuberculosis and PA.

Methods

Between January 2015 and January 2017, 72 patients with lumbar spinal tuberculosis with PA were assigned to group A (preoperative PCD) and group B (n = 36 per group). All patients received posterior pedicle screw fixation and anterior focal debridement and fusion. Data on intraoperative blood loss, the duration of the surgery, and the length of the anterior incision were recorded, as well as the postoperative anal exhaust time, visual analogue scale (VAS), Cobb angle, lumbar vertebra function, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) level, and sinus tract formation.

Results

Sixty-eight patients were followed up for an average time of 13 months (range 6–21 months). Until the final follow-up, no mixed infections, recurrence of tuberculosis, pedicle screw loosening, or screw pullout had occurred. There were significant between-group differences in blood loss, surgery duration, anterior incisional length, postoperative anal exhaust time, and sinus tract formation. As compared with group B, the ESR and CRP levels of the patients in group A were markedly improved following 3 weeks of antituberculosis therapy and 1 week postsurgery.

Conclusion

Preoperative PCD helps to increase the efficacy of antituberculosis therapy prior to surgery, reduce surgical trauma, and avoid postoperative complications, making it a safe and feasible treatment option for lumbar spinal tuberculosis with PA.

Could an increase in vigilance for spinal tuberculosis at primary health care level, enable earlier diagnosis at district level in a tuberculosis endemic country?

BACKGROUND

Expert clinicians and researchers in the field of spinal tuberculosis (STB) advocate for early identification and diagnosis as a key to reducing disability, severity of disease, expensive surgery and death, especially in tuberculosis (TB) endemic countries like South Africa. South Africa has the highest incidence per capita of tuberculosis in the world, and a conservative estimate of the incidence of STB in South Africa is 8-16:100 000. People living with STB may initially present to primary health care (PHC) centres, where the opportunity exists for early identification. Spinal pain is the most common presentation of STB, but even this symptom may not be present. Occasionally the only symptoms are neurological injury, dysphagia or referred pain. Computerised tomography-guided biopsy remains the diagnostic gold standard for STB.

AIM

A narrative review was undertaken to investigate the evidence available that could assist with the early diagnosis of STB.

METHOD

Articles were searched for and retrieved from three databases and assessed for quality and relevance to primary settings in a TB endemic country.

RESULTS

The following evidence-based, affordable and available tools could facilitate early diagnosis of STB at PHC and district hospital levels: (1) back pain screening questions, undressed spinal physical examination, HIV and antiretroviral therapy history, (2) erythrocyte sedimentation rate, C-reactive protein, platelets, haemoglobin, white cell count (WCC), sputum for GeneXpert and accurate weight measurement, (3) physiotherapy and/or medical and/or speech therapy assessment, (4) full spinal radiograph, chest radiograph, abdominal ultrasound, urine lipoarabinomannan (LAM) if CD4 < 200 and ultrasound-guided biopsy of superficial abscesses, (5) clear referral guidelines at all levels, (6) a positive response to treatment to confirm the diagnosis.

CONCLUSION

These affordable and simple actions at PHC and district levels could facilitate earlier diagnosis of STB.

Posterior intervertebral space debridement, annular bone grafting and instrumentation for treatment of lumbosacral tuberculosis

Background

The choice of surgical methods for lumbosacral tuberculosis is controversial due to the complex anterior anatomy and peculiar biomechanics of the lumbosacral junction. The objective of this study was to explore the clinical effect of posterior intervertebral space debridement with annular bone graft fusion and fixation for the treatment of lumbosacral tuberculosis.

Methods

We retrospectively analysed data from 23 patients with lumbosacral tuberculosis who had undergone posterior intervertebral space debridement with annular bone fusion and fixation between January 2008 and September 2014. The mean age of the patients was 49.0 years (range, 27–71), and the mean duration of disease until treatment was 10.2 months (range, 6–20). The lumbosacral angle, visual analogue scale (VAS) score, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) level, American Spinal Injury Association (ASIA) grade and Social Functioning-36 (SF-36) score were determined to ascertain the clinical effects of the treatment.

Results

All patients underwent follow-up observation. The mean follow-up time was 34.2 months (range, 18–45), the mean operation time was 167.0 min (range, 130–210) and the mean blood loss was 767.4 ml (range, 500–1150). The lumbosacral angle was 21.0° ± 2.1° before operation, rising to 28.8° ± 1.7° after operation (p < 0.05) and being maintained thereafter. The mean VAS score before operation was 8.1 ± 0.6, decreasing to 1.2 ± 0.5 (p < 0.05) at the final follow-up. The mean ESR and CRP values were 49.1 ± 5.6 mm and 64.9 ± 11.9 mg/L, respectively, before operation, decreasing to normal at the final follow-up. The preoperative ASIA grade was C in 6 patients, D in 12 and E in 5. At the final follow-up, all patients had an ASIA grade of E except for one patient with a grade of D. For all patients, the SF-36 score at the final follow-up was higher than the preoperative and postoperative scores.

Conclusions

Posterior intervertebral space debridement with annular bone graft fusion and fixation is an effective treatment for lumbosacral spine tuberculosis.

RETRACTED: The in vitro and in vivo effects of microRNA-133a on intervertebral disc destruction by targeting MMP9 in spinal tuberculosis

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). This article has been retracted at the request of the Editor-in-Chief. Concern was raised about the reliability of the Western blot results in Figure 4 A+C, which appear to have a similar phenotype as seen in many other publications, as detailed here: https://pubpeer.com/publications/0D0667F09124C7911264C51064AF20; and here: https://docs.google.com/spreadsheets/d/1r0MyIYpagBc58BRF9c3luWNlCX8VUvUuPyYYXzxWvgY/edit#gid=262337249. The journal requested that the corresponding author comment on these concerns and provide the raw data. The authors did not respond to this request and therefore the Editor-in-Chief decided to retract the article.

Results of Single-Staged Posterior Decompression and Circumferential Fusion Using a Transpedicular Approach to Correct a Kyphotic Deformity due to Thoracolumbar Spinal Tuberculosis

STUDY DESIGN

This is a prospective study.

PURPOSE

The aim of this study was to investigate the results of single-staged posterior decompression and circumferential fusion using a transpedicular approach to correct a kyphotic deformity due to thoracolumbar spinal tuberculosis.

OVERVIEW OF LITERATURE

Surgical management is frequently an imperative choice to achieve spinal decompression and deformity correction due to tuberculosis to relieve pain, improve neurology, and reconstruct the spine stability. Since the time anterior radical debridement and noninstrumented fusion was described, it has become apparent that even anterior debridement and bone grafting was often unsatisfactory in correcting or preventing the progression of kyphosis deformity. With the advent of modern segmental spinal instrumentation systems, isolated posterior instrumentation; combined anterior and posterior fusion; and single-staged posterior decompression and circumferential fusion have been described by many authors for correcting angular deformity and stabilizing the spine; however, there is a lack of consensus regarding the most effective means of correcting the deformity due to thoracolumbar spinal tuberculosis.

METHODS

This is a prospective study of 20 patients with thoracolumbar spinal tuberculosis who underwent surgery at our institute.

RESULTS

Twenty patients who were started on antituberculosis treatment underwent surgery using a single-staged posterior approach involving fixation, decompression, and kyphosis correction. Preoperatively, all patients had varying degrees of neurological deficit and a 27.45° average kyphotic angle, which improved. At the 1-year follow-up, correction was maintained at 6.9°, and 55% of patients showed neurological improvement. None of the patients experienced neurological deterioration. Two patients with lumbar spine tuberculosis underwent revision surgery because of nonunion.

CONCLUSIONS

The procedure of posterior decompression, fixation, and circumferential fusion using a transpedicular approach performed for thoracolumbar spinal tuberculosis is effective, safe, and excellent in correcting and maintaining kyphosis.

Spinal Tuberculosis and Cold Abscess without Known Primary Disease: Case Report and Review of the Literature

Extrapulmonary tuberculosis (TB) is uncommon but not rare. Bone and joint involvement constitute about 10% of extrapulmonary TB cases, with the spine being the most frequently affected site. Spinal TB patients typically present with back pain but other constitutional or pulmonary symptoms may be absent, rendering the diagnosis difficult. This case explores challenges in the diagnosis of spinal TB. We report a case of a 39-year-old woman presenting with vague back swelling for many years. Imaging revealed osteomyelitis of the spine but initial studies and cultures were negative for Mycobacterium tuberculosis. The diagnosis was confirmed weeks later when cultures demonstrated Mycobacterium tuberculosis. Considering the severe complications of untreated spinal TB including paraplegia and need for surgical intervention, high suspicion is critical in early diagnosis.

Tuberculosis of spine: An experience of 30 cases over two years

OBJECTIVE

Tuberculosis of spine is still a very common condition in India. Here, the results of 30 cases of tuberculosis of spine treated in SSG Hospital, Vadodara, Gujarat, in the last two years, are reviewed.

MATERIALS AND METHODS

A total of 30 patients with tuberculosis of spine were treated in SSG Hospital in the last two years. They were classified into three groups, based on the GATA, GATA = Gulhane Askeri Tip Akademisi (Gulhane Military Medical Academy) classification for spinal tuberculosis, with few modifications. Their neurologic status was evaluated by the Frankel's grading. All the patients were started on four drug anti-tuberculosis medication given every alternate day as per the DOTS and RNTCP program of the Government of India for 6 months. Patients in group 1 were treated by bed rest, analgesics, and antituberculous drugs after confirmation of the diagnosis by CT-guided biopsy. Patients in group 2 were treated by surgical of USG-guided aspiration of abscesses followed by full course of antituberculous drugs. Twenty-one patients in group 3 underwent surgery. A single-stage anterior decompression and anterior fixation was done in all the cases.

RESULTS

All the nine patients in group I and 2 responded well to medical management and were cured of the disease. Out of the 21 operated patients, 19 had significant improvement in neurological status and return to their normal activities. The first operated patient died. The neurological status of one patient did not improve till 1 month after surgery and was lost to follow-up. Thus, 100% of group 1 and 2 patients were cured of the disease and 90% of group 3 patients had good neurological recovery.

CONCLUSIONS

If treated timely and adequately, the outcome for tuberculosis of spine is relatively good. Anterolateral approach to the spine with decompression and fixation gives good result with respect to neurological function.

A Rare Case of Pott's Disease (Spinal Tuberculosis) Mimicking Metastatic Disease in the Southern Region of Denmark

Patient: Female, 78

Final Diagnosis: Pott’s disease

Symptoms: Back pain • nausea • vomiting • weight loss

Medication: —

Clinical Procedure: MRI

Specialty: Infectious Diseases

The outcomes of chemotherapy only treatment on mild spinal tuberculosis

Background

The treatments for spinal tuberculosis (TB) patients without absolute surgical indications have been controversial. Some people believed that most spinal TB patients were indicated for surgery, while other people believed in chemotherapy only. To help clarify the treatment over spinal TB patients without absolute surgical indications, we characterized a subtype spinal TB and then analyzed the treatment outcomes of standard chemotherapy alone.

Methods

In this retrospective study, 740 adult patients of spinal TB from January 2005 to January 2013 in our institution were reviewed. Patients who fit into the characterizations of mild spinal TB were started by standard chemotherapy for 18 months and followed up for at least 2 years upon the completion of treatment. The overall outcome, neurological function, local kyphosis, and level of pain at different time points were assessed.

Results

After starting the conservative treatment, 89 out of 740 patients were chosen for chemotherapy alone, and all patients were followed up for at least 2 years (ranging from 24 to 50 months) upon the completion of the treatment. Of 89 patients, 95.4 % of patients showed a definite and clinical response within 1 month after starting the treatment, 69 % of patients had excellent to good results, with no complications of the disease, and 77.5 % had asymptomatic local kyphosis with intact neurological function; solid bony fusion of adjacent segment was achieved in 88.8 % of patients.

Conclusions

We believe that the mild spinal TB respond well to the standard chemotherapy, and the detailed description of mild TB would provide crucial guidance in determination of conservative treatment.

Treatment of lumbosacral spinal tuberculosis by one-stage anterior debridement and fusion combined with dual screw-rod anterior instrumentation underneath the iliac vessel

BACKGROUND

There has been no consensus regarding what is the optimal means of treating lumbosacral segment tuberculosis. The aim of this study was to evaluate the clinical outcomes of our newly developed one-stage anterior debridement and fusion combined with dual screw-rod construct anterior instrument underneath the iliac vessels for lumbosacral spinal tuberculosis.

METHODS

We retrospectively reviewed 22 patients with lumbosacral spinal tuberculosis who underwent one-stage anterior debridement and fusion combined with dual screw-rod anterior instrument underneath the iliac vessels between January 2004 and June 2013. We assessed the visual analogue scale (VAS), erythrocyte sedimentation rates (ESR), neurological performance, kyphotic angles, fusion rates, and computed tomographic angiography (CTA) before and after surgery.

RESULTS

All patients were followed-up for a mean of 46.59 months. There were no instances of spinal tuberculosis recurrence. The mean VAS scores and ESR decreased significantly from the preoperative levels both postoperatively and at the final follow-up (all P <0.001). The mean kyphotic angle significantly increased from the mean preoperative angle both postoperatively and at the final follow-up (both P <0.001). All patients had bone fusion at a mean of five months after surgery. No postoperative vascular complications were observed.

CONCLUSIONS

Our findings suggest that anterior radical debridement, fusion combined with dual screw-rod anterior instrument underneath the iliac vessels can be an effective and safe treatment option for lumbosacral segment tuberculosis.

Anterior Cervical Retropharyngeal Debridement Combined With Occipital Cervical Fusion to Upper Cervical Tuberculosis

STUDY DESIGN

A retrospective analysis of 11 cases.

OBJECTIVE

The aim of the study was to evaluate the effectiveness of anterior cervical and retropharyngeal debridement combined with posterior occipital-cervical fusion in treatment of upper cervical spinal tuberculosis.

SUMMARY OF BACKGROUND DATA

The anterior approach simply could not provide strong fixation whereas the posterior treatment could not clear up the lesions completely. The method combining anterior and posterior approaches to treat the upper cervical tuberculosis is advisable.

METHODS

The clinical data of 11 patients with upper cervical tuberculosis who underwent an upper cervical operation in our hospital were retrospectively analyzed. All 11 patients underwent the surgery of anterior cervical and retropharyngeal approaches to debridement, and then, according to the different degrees of patient pedicle destruction and deformity, different occipitocervical approaches were used (either through pedicle screw or laminar screw fixation). After surgery, antituberculosis drugs were administered for 18 months. During the follow-up, neurological function, clinical symptoms, fusion, reducible degree, and complications were all evaluated and documented.

RESULTS

Surgeries for 11 patients were performed successfully; anatomical reduction was achieved in nine cases, bony fusion was achieved in all 11 patients, and all cases with tuberculosis were clinically cured in the 18 months after the operation. The Japanese Orthopaedic Association score increased from 8.4 ± 1.3 preoperative to 15.0 ± 1.3 in the last follow-up (P < 0.05). The occipitocervical visual analog scale decreased from 6.7 ± 0.6 preoperative to 0.6 ± 0.6 at the last follow-up (P < 0.05). No serious complications were documented during follow-up.

CONCLUSION

The approach of anterior cervical and retropharyngeal debridement combined with posterior occipitocervical fusion has been proved to be an effective treatment of upper cervical tuberculosis, which plays an important role in removing the lesions, restoring stability, and anatomical reduction.

LEVEL OF EVIDENCE

4.

Comparison between the antero-posterior and posterior only approaches for treating thoracolumbar tuberculosis (T10-L2) with kyphosis in children: a minimum 3-year follow-up

PURPOSE

There are few papers in the literature comparing outcomes between antero-posterior and posterior-only approaches for treating thoracolumbar tuberculosis (T10–L2) in children.

METHODS

We performed a retrospective review of 47 children who were diagnosed and treated as thoracolumbar tuberculosis (T10–L2) in our department from January 2005 to June 2009. Forty-seven cases of thoracolumbar tuberculosis were treated by two different surgical approaches. All the cases were divided into two groups: 25 cases in group A underwent one-stage posterior debridement, transforaminal fusion, and instrumentation, and 22 cases in group B underwent anterior debridement, bone graft, and posterior instrumentation in a single- or two-stage procedure. Two approaches were compared in terms of average operative time, blood loss, hospitalizations, bony fusion, intraoperative and postoperative complications, the Oswestry disability index score, neurological status, and the angle of kyphosis.

RESULTS

All 47 patients (24 M/23F), averaged 9.1 ± 2.6 years old (range 5 to 14 years), who were followed up for mean of 49.3 ± 8.6 months (range 36 to 65 months). Spinal tuberculosis (TB) was completely cured, and the grafted bones were fused in 9 months in all cases. It was obviously that the average operative time, blood loss, hospitalization, and complication rate of group A was less than those of group B. Good clinical outcomes were achieved in both groups.

CONCLUSIONS

Both the antero-posterior and posterior approaches can effectively heal T10–L2 vertebral tuberculosis, but the average surgical time, blood loss, complications, and hospital stay following the posterior approach are prominently less than those following the antero-posterior approach. It might be a better surgical treatment for thoracic spinal tuberculosis in children with poor health status, especially for cases in early phase of bone destruction and/or mild and moderate kyphosis.

Spinal Tuberculosis

Spinal tuberculosis (TB) is a significant form of TB, causing spinal deformity and paralysis. Early diagnosis and treatment are crucial for avoiding multivertebral destruction and are critical for improving outcomes in spinal TB. We believe that appropriate treatment method should be implemented at the early stage of this disease and that the Gulhane Askeri Tıp Akademisi classification system can be considered a practical guide for spinal TB treatment planning in all countries.

Application of digital tomosynthesis in diagnosing spinal tuberculosis

OBJECTIVE

To study the value of digital tomosynthesis (DTS) applied in diagnosing spinal tuberculosis.

METHODS

Images of digital radiology (DR) and DTS were retrospectively analyzed in patients with spinal tuberculosis, and image quality and ratio of detection of lesions were compared.

RESULTS

Excellent ratio was higher for DTS images than DR images; ratios of detection of bone destruction, sequestration, and paraspinal abscess were higher for DTS than DR.

CONCLUSIONS

DTS had better image quality and ratios of detection of lesions and could be applied in diagnosing and following spinal tuberculosis and other spinal conditions such as infections or suspected tumors.

Spinal tuberculosis: Our experience and a review of imaging methods

We share our experience of 2000 spinal tuberculosis (TB) cases, including both typical and atypical presentations. The aim of the study is to estimate the incidence and types of spinal TB referred to our department for diagnosis. 2000 patients were selected by convenience sampling from January 2006 to September 2010. Study design was descriptive and among 2000 mostly unknown cases without evidence of symptoms of systemic TB (1080 males and 920 females). MRI without and with IV contrast, CECT with MPR, and in some cases not fit for MRI, CT myelography, were performed. Out of 2000 cases of tuberculous spine, 1080 (54%) were male and 920 (46%) were female. Their age ranged from 8-60 years. About 90% of patients were below the age of 40 years. Peak age among the males and females was 20-29 years and 14-35 years, respectively. The most common site of involvement was dorsal spine (45%) followed by lumbo-sacral spine (33%), cervical spine (10%) and at multiple levels (12%). Biopsies were done in 240 (12%) cases. Spinal TB should always be suspected when radiographs demonstrate a destructive spinal process. Awareness and prompt management of TB spine will help in reducing the continuing morbidity of this disease.

Treatment effect, postoperative complications, and their reasons in juvenile thoracic and lumbar spinal tuberculosis surgery

OBJECTIVE

Fifty-four juvenile cases under 18 years of age with thoracic and lumbar spinal tuberculosis underwent focus debridement, deformity correction, bone graft fusion, and internal fixation. The treatment effects, complications, and reasons were analyzed retrospectively.

MATERIAL AND METHOD

There were 54 juvenile cases under 18 years of age with thoracolumbar spinal tuberculosis. The average age was 9.2 years old, and the sample comprised 38 males and 16 females. The disease types included 28 thoracic cases, 17 thoracolumbar cases, and 9 lumbar cases. Nerve function was evaluated with the Frankel classification. Thirty-six cases were performed with focus debridement and deformity correction and were supported with allograft or autograft in mesh and fixed with pedicle screws from a posterior approach. Eight cases underwent a combined anterior and posterior surgical approach. Nine cases underwent osteotomy and deformity correction, and one case received focus debridement. The treatment effects, complications, and bone fusions were tracked for an average of 52 months.

RESULTS

According to the Frankel classification, paralysis was improved from 3 cases of B, 8 cases of C, 18 cases of D, and 25 cases of E preoperatively. This improvement was found in 3 cases of C, 6 cases of D, and 45 cases of E at a final follow-up postoperatively. No nerve dysfunction was aggravated. VAS was improved from 7.8 ± 1.7 preoperatively to 3.2 ± 2.1 at final follow-up postoperatively. ODI was improved from 77.5 ± 17.3 preoperatively to 28.4 ± 15.9 at final follow-up postoperatively. Kyphosis Cobb angle improved from 62.2° ± 3.7° preoperatively to 37° ± 2.4° at final follow-up postoperatively. Both of these are significant improvements, and all bone grafts were fused. Complications related to the operation occurred in 31.5% (17/54) of cases. Six cases suffered postoperative aggravated kyphosis deformity, eight cases suffered proximal kyphosis deformity, one case suffered pedicle penetration, one case suffered failure of internal devices, and one case suffered recurrence of tuberculosis.

CONCLUSION

As long as the treatment plan is fully prepared, the surgical option can achieve a satisfactory curative effect in treating juvenile spinal tuberculosis despite some complications.

Surgical treatment for spinal tuberculosis with bilateral paraspinal abscess or bilateral psoas abscess: one-stage surgery

STUDY DESIGN

This was a prospective study on the clinical outcomes of single-stage surgery for thoracic and lumbar spine tuberculosis patients with bilateral paraspinal or bilateral psoas abscesses.

OBJECTIVE

The aim of this study was to investigate the feasibility of, indications for, and clinical effects of single-stage posterior surgery for the treatment of thoracic and lumbar spinal tuberculosis with bilateral paraspinal or bilateral psoas abscesses.

SUMMARY OF BACKGROUND DATA

An increasing number of articles have been published on the use of single-stage surgery for spinal tuberculosis; however, none of these articles have discussed the use of such surgery in patients with bilateral abscesses.

METHODS

Between January 2003 and January 2011, 41 patients with thoracic and lumbar spinal tuberculosis and bilateral paraspinal or bilateral psoas abscesses were treated with single-stage posterior surgery. All of the patients were treated preoperatively with 1-2 weeks of antituberculosis drugs. All patients were managed postoperatively with standard courses of chemotherapy with triple or quadruple antituberculosis drugs. The clinical symptoms, complications, and laboratory and image indicators were recorded.

RESULTS

There were no local recurrences except in one L3-L4 tuberculosis patient. Two patients presented with extraspinal tuberculosis in the third year. There were no incision complications. Bone fusion was observed 6 months after the operation. The erythrocyte sedimentation rate was normal at 3 weeks-3 months postoperatively. There were no internal fixation failures. The internal fixations in 6 young patients were removed after the spinal tuberculosis was cured.

CONCLUSIONS

Single-stage posterior surgery with instrumentation results in less operative trauma and can be a suitable alternative for treating thoracic and lumbar tuberculosis with bilateral paraspinal or bilateral psoas abscesses.