The course of spinal tuberculosis (Pott disease): results of the multinational, multicentre Backbone-2 study

Disparities in the Clinical Profile of Spinal Tuberculosis in Africa: A Scoping Review of Management and Outcome

BACKGROUND

Spinal tuberculosis (STB) is a significant contributor to nontraumatic myelopathy. There is a rising burden in Africa, in parallel with the high prevalence of human immunodeficiency virus. We conducted a scoping review to highlight the disparities in the management and outcomes of STB in Africa.

METHODS

This study was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for scoping review guidelines. AJOL, Embase, MEDLINE, Google Scholar, and Cochrane CENTRAL databases were searched to identify all relevant peer-reviewed articles published on the management of STB in African centers, excluding abstract-only articles, literature reviews, and meta-analyses.

RESULTS

Sixty studies were eligible for inclusion, comprising data from 3416 patients aged 8 months to 89 years (median, 32 years). Thoracic and lumbar segments were the most commonly affected vertebral regions (thoracic = 42.7%; lumbar = 35.9%). The most common clinical features were back pain and neurological deficits. Lack of essential laboratory and imaging diagnostic infrastructure was a common problem. Patients received antitubercular therapy (ATT) for varying durations, and only 18.3% underwent surgery. A favorable outcome was achieved in 51.6% of patients, 20.3% developed a permanent disability, and the mortality rate was 2.1%. Treatment outcome was adversely affected by a high rate of late presentation and treatment default.

CONCLUSIONS

ATT remains the mainstay of treatment; however, the duration of treatment varied widely among studies. Further research is required to explore the feasibility and efficacy of short-course ATT in treating STB in the African population.

Multi-level tuberculosis of the spine identified by 18 F-FDG-PET/CT and concomitant urogenital tuberculosis: a case report from the spinal TB X cohort

BACKGROUND

Tuberculosis (TB) is caused by Mycobacterium tuberculosis (Mtb) and typically infects the lungs. However, extrapulmonary forms of TB can be found in approximately 20% of cases. It is suggested, that up to 10% of extrapulmonary TB affects the musculoskeletal system, in which spinal elements (spinal tuberculosis, STB) are involved in approximately 50% of the cases. STB is a debilitating disease with nonspecific symptoms and diagnosis is often delayed for months to years. In our Spinal TB X Cohort, we aim to describe the clinical phenotype of STB using whole-body 18 F-fluorodeoxyglucose positron emission tomography computed tomography (PET/CT) and to identify a specific gene expression profile for the different stages of dissemination on PET/CT. Here we report on the first patient recruited into our cohort who underwent PET/CT before treatment initiation, at 6-months and at 12-months - time of TB treatment completion.

CASE PRESENTATION

A 27-year-old immunocompetent male presented with severe thoracolumbar back pain for 9 months with severe antalgic gait and night sweats. Magnetic resonance imaging (MRI) of the whole spine revealed multilevel spinal disease (T5/6, T11/12, L3/4) in keeping with STB. After informed consent and recruitment into the Spinal TB X Cohort, the patient underwent PET/CT as per protocol, which revealed isolated multilevel STB (T4-7, T11/12, L3/4) with no concomitant lung or urogenital lesion. However, sputum and urine were Xpert MTB/RIF Ultra positive and Mtb was cultured from the urine sample. CT-guided biopsy of the T11/12 lesion confirmed drug-sensitive Mtb on Xpert MTB/RIF Ultra and the patient was started on TB treatment according to local guidelines for 12 months. The 6-month follow-up PET/CT revealed new and existing spinal lesions with increased FDG-uptake despite significant improvement of clinical features and laboratory markers. After 9 months of treatment, the patient developed an acute urethral stricture, most likely due to urogenital TB, and a suprapubic catheter was inserted. The 12-month PET/CT showed significantly decreased PET/CT values of all lesions, however, significant persistent spinal inflammation was present at the end of TB treatment. Clinically, the patient was considered cured by the TB control program and currently awaits urethroplasty.

CONCLUSIONS

In our case, PET/CT emerged as a valuable imaging modality for the initial assessment, surpassing MRI by revealing more comprehensive extensive disease. Subsequent PET/CT scans at 6-month uncovered new lesions and increased inflammation in existing ones, while by the end of TB treatment, all lesions exhibited improvement. However, the interpretation of FDG avidity remains ambiguous, whether it correlates with active infection and viable Mtb. or fibro- and osteoblast activity indicative of the healing process. Additionally, the absence of extraspinal TB lesions on PET/CT despite positive microbiology from sputum and urine maybe explained by paucibacillary, subclinical infection of extraspinal organs. The Spinal TB X Cohort endeavours to shed light on whole-body imaging patterns at diagnosis, their evolution midway through TB treatment, and upon treatment completion. Ultimately, this study aims to advance our understanding of the biology of this complex disease.

Comparing gene expression profiles of adults with isolated spinal tuberculosis to disseminated spinal tuberculosis identified by 18FDG-PET/CT at time of diagnosis, 6- and 12-months follow-up: classifying clinical stages of spinal tuberculosis and monitoring treatment response (Spinal TB X cohort study)

BACKGROUND

Tuberculosis (TB) is one of the top ten causes of death worldwide, with approximately 10 million cases annually. Focus has been on pulmonary TB, while extrapulmonary TB (EPTB) has received little attention. Diagnosis of EPTB remains challenging due to the invasive procedures required for sample collection. Spinal TB (STB) accounts for 10% of EPTB and often leads to lifelong debilitating disease due to devastating spinal deformation and compression of neural structures. Little is known about the extent of disease, although both isolated STB and a disseminated form of STB have been described. In our Spinal TB X cohort study, we aim to describe the clinical phenotype of STB using whole-body 18FDG-PET/CT, identify a specific gene expression profile for different stages of dissemination and compare findings to previously described gene expression signatures for latent and active pulmonary TB.

METHODS

A single-centre, prospective cohort study will be established to describe the distributional pattern of STB detected by whole-body 18FDG-PET/CT and gene expression profile of patients with suspected STB on magnetic resonance imaging (MRI) at point of diagnosis, six months, and 12 months. Blood biobanking will be performed at these time points. Specimens for microbiology will be obtained from sputum/urine, from easily accessible sites of disease (e.g., lymph nodes, abscess) identified in the first 18FDG-PET/CT, from CT-guided biopsy and/or surgery. Clinical parameters and functional scores will be collected at every physical visit. Data will be entered into RedCap® database; data cleaning, validation and analysis will be performed by the study team. The University of Cape Town Ethics Committee approved the protocol (243/2022).

DISCUSSION

The Spinal TB X cohort study is the first prospective cohort study using whole-body 18FDG-PET/CT scans in patients with microbiologically confirmed spinal tuberculosis. Dual imaging techniques of the spine using 18FDG-PET/CT and magnetic resonance imaging as well as tissue diagnosis (microbiology and histopathology) will allow us to develop a virtual biopsy model. If successful, a distinct gene-expression profile will aid in blood-based diagnosis (point of care testing) as well as treatment monitoring and would lead to earlier diagnosis of this devastating disease.

TRIAL REGISTRATION

The study has been registered on ClinicalTrials.gov (NCT05610098).

Tuberculous Spondylodiscitis with Psoas Abscess Descending into the Anterior Femoral Compartment Identified Using 2-deoxy-2-[18F]fluoroglucose Positron Emission Tomography Computed Tomography

A 24-year-old immunocompetent woman underwent whole-body 18F-FDG PET/CT for the evaluation of MRI-suspicious tuberculous spinal lesions. The PET/CT results showed no pathological uptake in either lung, and there were no pathological changes on CT. There was increased uptake in the right psoas muscle, extending continuously down anterior to the right hip joint, posterior to and around the trochanteric region of the right femur, and into the right thigh, with an SUVmaxbw of 17.0. Subsequently, the patient underwent CT-guided biopsy as per protocol, which revealed drug-sensitive Mycobacterium tuberculosis, and the patient was started on standard tuberculosis treatment for 12 months.

Diagnostic Delay of Spinal Tuberculosis Causing Medullary Compression

We present a case of a Philippine woman in her late twenties, diagnosed with spinal tuberculosis after surgical intervention due to medullary compression. The diagnosis was preceded by four months of unexplained back pain. Differential diagnoses included ulcer, liver-gallbladder disease, musculoskeletal causes, and cancer. This case highlights the importance of considering tuberculosis as a differential diagnosis in patients from high-endemic areas to avoid diagnostic delay and the risk of disease progression.

Plasma metabolomic analysis reveals the metabolic characteristics and potential diagnostic biomarkers of spinal tuberculosis

Objectives

This study aimed to conduct a non-targeted metabolomic analysis of plasma from patients with spinal tuberculosis (STB) to systematically elucidate the metabolomic alterations associated with STB, and explore potential diagnostic biomarkers for STB.

Methods

From January 2020 to January 2022, 30 patients with spinal tuberculosis (STBs) clinically diagnosed at the General Hospital of Ningxia Medical University and 30 age- and sex-matched healthy controls (HCs) were selected for this study. Using ultra-high performance liquid chromatography coupled with quadrupole time-of-flight mass spectrometry (UPLC-QTOF/MS) based metabolomics, we analyzed the metabolic profiles of 60 plasma samples. Statistical analyses, pathway enrichment, and receiver operating characteristic (ROC) analyses were performed to screen and evaluate potential diagnostic biomarkers.

Results

Metabolomic profiling revealed distinct alterations between the STBs and HCs cohorts. A total of 1635 differential metabolites were screened, functionally clustered, and annotated. The results showed that the differential metabolites were enriched in sphingolipid metabolism, tuberculosis, cutin, suberine and wax biosynthesis, beta-alanine metabolism, methane metabolism, and other pathways. Through the random forest algorithm, LysoPE (18:1(11Z)/0:0), 8-Demethyl-8-formylriboflavin 5'-phosphate, Glutaminyl-Gamma-glutamate, (2R)-O-Phospho-3-sulfolactate, and LysoPE (P-16:0/0:0) were determined to have high independent diagnostic value.

Conclusions

STBs exhibited significantly altered metabolite profiles compared with HCs. Here, we provide a global metabolomic profile and identify potential diagnostic biomarkers of STB. Five potential independent diagnostic biomarkers with high diagnostic value were screened. This study provides novel insights into the pathogenesis, diagnosis, and treatment strategies of STB.

A case report of coexisting breast cancer with peritoneal, cutaneous tuberculosis, and potential Pott's disease: therapeutic and diagnostic challenges

Introduction

Breast cancer affects one in eight women during their lifetime; it may coincide with other diseases due to its high prevalence. Different pathologies that occur simultaneously with breast cancer, or later during its course, lead to multiple interactions with cancer and have a significant impact on its management.

Presentation of case

A 58-year-old Syrian female was admitted to our hospital for compliant of abdominal distension. Following complete examination, obtained biopsies confirmed the diagnosis of peritoneal tuberculosis. At a subsequent time, she suffered back pain and the computed tomography showed vertebral lesion with breast mass that was diagnosed as invasive lobular carcinoma (ILC) of the left breast. Vertebral lesion that appeared on radiologic assessment was diagnosed as cancer metastasis. However, the interaction of this metastasis with the proposed management diverted the attention towards its non-cancerous entity. Five months after completing the chemotherapy, biopsies revealed the recurrence of triple-negative (ER-, PR-, HER2- neu-) ILC of the breast. Ultimately, the patient was followed up for an overall duration of 4 years.

Discussion

Latent tuberculosis infections may be activated by chemotherapy regimens that suppress immunity. Therefore, initial management of tuberculous infection is preferred when it coexists with cancer.

Conclusion

Breast cancer is common and may co-present with other diseases, which, in some cases, produce mimicking lesions that alter its diagnosis. Pott's disease, albeit a rare entity, has shown a resurgence in developed countries and should be considered in the differential diagnosis of vertebral lesions in patients with breast cancer.

Single Sequence Whole-Spine Screening Magnetic Resonance Imaging: Diagnostic and Therapeutic Role in Multiple-Level Spinal Tuberculosis

INTRODUCTION

Spinal tuberculosis (TB) is the most common form of skeletal tuberculosis. Paradiscal continuous vertebral involvement at a single level is the most prevalent pattern among all forms of spinal TB. There is a wide range of reported incidences of multiple-level non-contiguous spinal TB in the literature. We would like to discuss on the utility of single whole spine screening T2-weighted (T2W) mid-sagittal magnetic resonance imaging (MRI) film in diagnosing multiple-level spinal TB and therapeutic benefits it can provide.

METHODS

We have done a retrospective review of the collected data of patients in Vardhman Mahavir Medical College and Safdarjung Hospital from August 2017 to October 2021 to find the incidence of multiple-level spinal TB and possible factors attributed to this specific disease pattern. All the patients who had been diagnosed of spinal TB either microbiologically or histopathologically or by a good clinical response to anti-tubercular treatment (ATT) and had a whole spine screening MRI film, were included. Patients of spinal TB who did not have a whole spine screening MRI were excluded from the study. Multiple-level spinal TB was diagnosed when lesions were identified in vertebral levels other than a typical paradiscal lesion, and additional lesions were separated from the primary disease by at least one normal spinal segment.

RESULTS

Among the patients, 242 met the inclusion criteria, and 76 showed multiple-level non-contiguous spinal TB on MRI, incidence being 31.4%. The rest of the 166 patients showed typical single-segment contiguous lesions. By doing multivariate analysis to determine the independent risk factors for multiple-level spinal TB, extremes of age (<20 years and >50 years) have been found to be a significant factor with p value of 0.0001. Though drug resistance was not found to be a significant risk factor (p value 0.051), the proportion of patients having multiple-level TB was far more in the drug-resistant group (13/76).

CONCLUSIONS

Single sequence whole spine screening MRI film is an effective, economical, and time-saving tool to detect multiple-level spinal TB. Along with its diagnostic accuracy, it also provides therapeutic benefits like access to a more approachable site for biopsy.

Brucellar, Pyogenic, and Tuberculous Spondylodiscitis at Tertiary Hospitals in Saudi Arabia: A Comparative Retrospective Cohort Study

Introduction

Spondylodiscitis is rare yet the most common form of spinal infection. It is characterized by inflammation of the intervertebral disk space and adjacent vertebral body. In Western countries, the incidence of spondylodiscitis is increasing. Clinical outcomes most commonly reported in the literature are the 1-year mortality rate (range, 6%-12%) and neurologic deficits.

Methods

This multicenter retrospective cohort study assessed patients diagnosed with infectious spondylodiscitis who received treatment at King Abdulaziz Medical City in Riyadh and Jeddah, Saudi Arabia. All enrolled patients were ≥18 years old and were diagnosed per radiologic and microbiological findings and clinical manifestations between January 2017 and November 2021.

Results

This study enrolled 76 patients with infectious spondylodiscitis, with a median age of 61 years. All patients presented with back pain for a median 30 days. Patients were stratified into 3 groups based on the causative pathogen: brucellar spondylodiscitis (n = 52), tuberculous spondylodiscitis (n = 13), and pyogenic spondylodiscitis (n = 11). All laboratory data and biochemical markers were not significantly different. However, C-reactive protein, erythrocyte sedimentation rate, and white blood cells were significantly different in the pyogenic spondylodiscitis group, with medians of 121 mg/dL (P = .03), 82 mmol/h (P = .04), and 11.2 × 109/L (P = .014), respectively.

Conclusions

Back pain is a common clinical feature associated with infectious spondylodiscitis. The immense value of microbiological investigations accompanied with histologic studies in determining the causative pathogen cannot be emphasized enough. Treatment with prolonged intravenous antimicrobial therapy with surgical intervention in some cases produced a cure rate exceeding 60%.

Intraspinal and Intracranial Neurotuberculosis, Clinical and Imaging Characteristics and Outcomes in Hospitalized Patients: A Cohort Study (2000-2022)

Neurotuberculosis (neuroTB) is a devastating disease, and is difficult to diagnose. The aim of this study was to analyze the clinical and imaging characteristics, and outcomes of a retrospective cohort (2000-2022) of hospitalized patients diagnosed with intraspinal and intracranial neuroTB. This work was designed through clinical, laboratory and imaging findings. Variables included: demographic data, history of tuberculosis, neurological complications, comorbidities and outcomes. Morbi-mortality risk factors were identified by univariate analysis. The cohort included: 103 patients with intraspinal and 82 with intracranial neuroTB. During the study period, in-hospital mortality of 3% for intraspinal and 29.6% for intracranial neuroTB was estimated. Motor deficit was found in all patients with intraspinal neuroTB. Risk factors for the unfavorable outcome of patients with intraspinal neuroTB were: age ≥ 40 years, diabetes mellitus (DM), diagnostic delay, kyphosis and spondylodiscitis ≥ 3 levels of involvement. Among the patients with intracranial neuroTB, 79/82 (96.3%) had meningitis and 22 patients had HIV infection (10 of them died). Risk factors for mortality from intracranial neuroTB were: HIV infection, hydrocephalus, stroke, lymphopenia and disseminated and gastrointestinal TB. Patients with intraspinal neuroTB had a significant number of destroyed vertebrae that determined their neurological deficit status. The mortality burden in intracranial neuroTB was conditioned by HIV infection and renal transplantation patients.

Multifocal Tuberculous Spondylitis and Extensive Extraspinal Tubercular Osteomyelitis without Immunocompromise: Case Report and Literature Review

Multifocal extensive spinal and extraspinal tuberculosis is very rare. So far, fewer than 10 cases have been reported. We hereby report two such cases to highlight their rarity, the diagnostic and therapeutic challenges they presented, and the overall prognosis of the condition. The two patients (a 19-year-old woman and another 20-year-old woman) had multifocal extensive tuberculosis involving spine and appendicular skeleton with neurological deficit. Both patients presented with back and neck pain and gradual neurological deficit. The insidious onset and malignancy-like spread pattern mimicked neoplasm. After thorough investigations with magnetic resonance imaging, positron emission tomography scan, and biopsy, antitubercular drug therapy was started, and debridement and fixation were done for significant thoracic and cervical vertebral lesions, respectively. Both patients showed excellent neurological recovery after the procedure. Early surgical treatment of the cases with large abscesses helped provide decompression and stabilization and prevented neurological deterioration and deformity. In patients with noncontiguous spinal tuberculosis, high percentage of surgical treatment may be required due to the aggressive behavior of the disease.

MMP9 and STAT1 are biomarkers of the change in immune infiltration after anti-tuberculosis therapy, and the immune status can identify patients with spinal tuberculosis

BACKGROUND

Due to a lack of studies on immune-related pathogenesis and a clinical diagnostic model, the diagnosis of Spinal Tuberculosis (STB) remains uncertain. Our study aimed to investigate the possible pathogenesis of STB and to develop a clinical diagnostic model for STB based on immune cell infiltration.

METHODS

Label-free quantification protein analysis of five pairs of specimens was used to determine the protein expression of the intervertebral disc in STB and non-STB. GO enrichment analysis, and KEGG pathway analysis were used to investigate the pathogenesis of STB. The Hub proteins were then eliminated. Four datasets were downloaded from the GEO database to analyze immune cell infiltration, and the results were validated using blood routine test data from 8535TB and 7337 non-TB patients. Following that, clinical data from 164 STB and 162 non-STB patients were collected. The Random-Forest algorithm was used to screen out clinical predictors of STB and build a diagnostic model. The differential expression of MMP9 and STAT1 in STB and controls was confirmed using immunohistochemistry.

RESULTS

MMP9 and STAT1 were STB Hub proteins that were linked to disc destruction in STB. MMP9 and STAT1 were found to be associated with Monocytes, Neutrophils, and Lymphocytes in immune cell infiltration studies. Data from 15,872 blood routine tests revealed that the Monocytes ratio and Neutrophils ratio was significantly higher in TB patients than in non-TB patients (p < 0.001), while the Lymphocytes ratio was significantly lower in TB patients than in non-TB patients (p < 0.001). MMP9 and STAT1 expression were downregulated following the anti-TB therapy. For STB, a clinical diagnostic model was built using six clinical predictors: MR, NR, LR, ESR, BMI, and PLT. The model was evaluated using a ROC curve, which yielded an AUC of 0.816.

CONCLUSIONS

MMP9 and STAT1, immune-related hub proteins, were correlated with immune cell infiltration in STB patients. MR, NR, LR ESR, BMI, and PLT were clinical predictors of STB. Thus, the immune cell Infiltration-related clinical diagnostic model can predict STB effectively.

The Relative Lymphocyte Count is Lower when the Etiological Agent in Pott Disease is Successfully Isolated

Objective  To describe the clinico-epidemiological, laboratory, and radiological characteristics of tuberculous spondylodiscitis in the Brazilian population, and to assess whether there are differences between patients in whom the etiological agent in Pott disease was isolated or not. Methods  Patients diagnosed with tuberculosis (TB) of the spine (Pott disease) underwent follow-up between 2009 and 2019 at a quaternary hospital and were divided into 2 groups: successful isolation (SI) of the etiological agent (through bacilloscopy, culture, or positive molecular rapid test) and unsuccessful isolation (UI) of the etiological agent. Results  From a total of 26 patients diagnosed with TB of the spine, 21 (80.7%) were male, with a mean age of 40 ± 22.5 years. The average lymphocyte counts were higher in the UI group (25.35 ± 13.08; p  = 0.025) compared to the SI group (14.18 ± 7.48). Moreover, the monocyte/lymphocyte ratio was lower in the UI group (0.39 ± 0.22; p  = 0.009) than in the SI group (0.89 ± 0.65). Relative lymphocyte counts higher than or equal to 16.7 had a sensitivity of 76.9% and specificity of 62.5% in the UI group. Values higher than or equal to 0.58 for the monocyte/lymphocyte ratio showed a sensitivity of 84.6% and specificity of 75.0% in the UI group. Conclusion  No differences were observed regarding the clinico-epidemiological and radiological characteristics of the two experimental groups. However, the UI group had higher lymphocyte counts and a lower monocyte/lymphocyte ratio.

Pathogenesis, Diagnostic Challenges, and Risk Factors of Pott's Disease

Tuberculosis (TB) prevalence is increasing in developed nations and continuing to cause significant mortality in low- and middle-income countries. As a result of the uptick in cases, there also exists an increased prevalence of extrapulmonary TB. TB is caused by Mycobacterium tuberculosis (M. tb). When M. tb disseminates to the vertebral column, it is called Pott's disease or spinal TB. The frequency, symptoms, and severity of the disease range by the location of the spine and the region of the affected vertebrae. While the current literature shows that timely diagnosis is crucial to reduce the morbidity and mortality from Pott's disease, there is a lack of specific clinical diagnostic criteria for Pott's disease, and the symptoms may be very non-specific. Studies have shown that novel molecular diagnostic methods are effective and timely choices. Research has implicated the risk factors for the susceptibility and severity of Pott's disease, such as HIV and immunosuppression, poverty, and malnutrition. Based on the current literature available, our group aims to summarize the pathogenesis, clinical features, diagnostic challenges, as well as the known risk factors for Pott's disease within this literature review.

Decrease in osteoarticular tuberculosis in Spain between 1997 and 2018

BACKGROUND AND OBJECTIVE

osteoarticular tuberculosis represents 2%-5% of the manifestations of tuberculosis. The objective was to calculate the incidence and describe the epidemiological characteristics of patients with osteoarticular tuberculosis who received hospital care in Spain between 1997-2018.

METHODS

A retrospective study was conducted of patients treated with osteoarticular tuberculosis in Spanish hospitals between 1997 and 2018, using the data from the Minimum Basic Data Set at hospital discharge, using the ICD-9-CM and ICD-10 codes.

RESULTS

5710 patients with osteoarticular tuberculosis were detected over the 22 years in Spain. The mean annual incidence for the period was 6 cases per million inhabitants (95% CI 5.58-6.30). There was a significant difference between the mean annual incidence per million inhabitants of the first period (1997-2007) of 6.95 and that of the second (2008-2018) of 5.35 (p<.001).

CONCLUSIONS

The incidence of osteoarticular tuberculosis in Spain is low, has reduced over 22 years and predominates in men.

Mechanism of COVID-19-Related Proteins in Spinal Tuberculosis: Immune Dysregulation

Purpose

The purpose of this article was to investigate the mechanism of immune dysregulation of COVID-19-related proteins in spinal tuberculosis (STB).

Methods

Clinical data were collected to construct a nomogram model. C-index, calibration curve, ROC curve, and DCA curve were used to assess the predictive ability and accuracy of the model. Additionally, 10 intervertebral disc samples were collected for protein identification. Bioinformatics was used to analyze differentially expressed proteins (DEPs), including immune cells analysis, Gene Ontology (GO) and KEGG pathway enrichment analysis, and protein-protein interaction networks (PPI).

Results

The nomogram predicted risk of STB ranging from 0.01 to 0.994. The C-index and AUC in the training set were 0.872 and 0.862, respectively. The results in the external validation set were consistent with the training set. Immune cells scores indicated that B cells naive in STB tissues were significantly lower than non-TB spinal tissues. Hub proteins were calculated by Degree, Closeness, and MCC methods. The main KEGG pathway included Coronavirus disease-COVID-19. There were 9 key proteins in the intersection of COVID-19-related proteins and hub proteins. There was a negative correlation between B cells naive and RPL19. COVID-19-related proteins were associated with immune genes.

Conclusion

Lymphocytes were predictive factors for the diagnosis of STB. Immune cells showed low expression in STB. Nine COVID-19-related proteins were involved in STB mechanisms. These nine key proteins may suppress the immune mechanism of STB by regulating the expression of immune genes.

Does computed tomography-guided percutaneous catheter drainage is effective for spinal tuberculous abscess: a midterm results

STUDY DESIGN

Retrospective cohort study.

PURPOSE

To evaluate an effectiveness and report a midterm clinical outcome in pain and neurological status in spinal tuberculous abscess after treated by CT-guided percutaneous catheter drainage.

OVERVIEW OF LITERATURE

Spinal tuberculosis is one of the destructive forms of tuberculosis infection, which can cause undesirable consequences. The gold standard of surgical treatment of spinal tuberculosis with tuberculous abscess is radical debridement, abscess drainage, and bone grafting of the defect via anterior approach. However, this treatment may lead to several serious complications. CT-guided percutaneous catheter drainage is an alternative procedure for this condition and may reduce the serious complications from standard surgical treatment.

MATERIALS AND METHODS

The medical record of the patients with spinal tuberculosis with tuberculous abscess who underwent CT-guided percutaneous catheter drainage (CT-guided PCD) from 2015 to 2021. The visual analog pain scale (VAS), Frankel grading scale, duration of drainage, amount of spinal tuberculous abscess, and complications were evaluated.

RESULTS

Twenty-nine patients (mean age 44 years old) were included in the study. All patients were followed up for 24 to 72 months with an average of 36 months. Level involvements were mostly found in L1-L2 followed by L2-L3 and T12-L1 levels. A 14-Fr catheter was the mostly use followed by 16-Fr catheter. Amount of abscess drainage ranged from 110 to 2,490 ml (mean 599 ml). The drainage duration ranged from 6 to 42 days (mean 17 days). Additional surgery was performed in three patients due to subsequent mechanical instability developed despite successful drainage of abscess. At the last follow-up, VAS, Frankel grading scale were improved significantly in all patients without complications.

CONCLUSIONS

CT-guided percutaneous catheter drainage is a safe and effective alternative procedure in the treatment of spinal tuberculous abscess patients with high success rate, less complications, and satisfied midterm outcomes.

Candidate Biomarkers to Distinguish Spinal Tuberculosis From Mechanical Back Pain in a Tuberculosis Endemic Setting

Background

Spinal tuberculosis (TB) may have a variable, non-specific presentation including back pain with- or without- constitutional symptoms. Further tools are needed to aid early diagnosis of this potentially severe form of TB and immunological biomarkers may show potential in this regard. The aim of this study was to investigate the utility of host serum biomarkers to distinguish spinal TB from mechanical back pain.

Methods

Patients with suspected spinal TB or suspected mechanical back pain were recruited from a tertiary hospital in the Western Cape, South Africa, and provided a blood sample for biomarker analysis. Diagnosis was subsequently confirmed using bacteriological testing, advanced imaging and/or clinical evaluation, as appropriate. The concentrations of 19 host biomarkers were evaluated in serum samples using the Luminex platform. Receiver Operating Characteristic (ROC) curves and General Discriminant Analysis were used to identify biomarkers with the potential to distinguish spinal TB from mechanical back pain.

Results

Twenty-six patients with spinal TB and 17 with mechanical back pain were recruited. Seven out of 19 biomarkers were significantly different between groups, of which Fibrinogen, CRP, IFN-γ and NCAM were the individual markers with the highest discrimination utility (Area Under Curve ROC plot 0.88-0.99). A five-marker biosignature (CRP, NCAM, Ferritin, CXCL8 and GDF-15) correctly classified all study participants after leave-one-out cross-validation.

Conclusion

This study identified host serum biomarkers with the potential to diagnose spinal TB, including a five-marker biosignature. These preliminary findings require validation in larger studies.

Lumbar infection caused by Mycobacterium paragordonae: A case report

BACKGROUND

Mycobacterium paragordonae (M. paragordonae), a slow-growing, acid-resistant mycobacterial species, was first isolated from the sputum of a lung infection patient in South Korea in 2014. Infections caused by M. paragordonae are rare.

CASE SUMMARY

Herein, we report the case of a 53-year-old patient who presented with fever and low back pain. Lumbar nuclear magnetic resonance imaging revealed the destruction of the lumbar vertebra with peripheral abscess formation. After anti-infective and diagnostic anti-tuberculosis treatment, the patient had no further fever, but the back pain was not relieved. Postoperatively, the necrotic material was sent for pathological examination, and all tests related to tuberculosis were negative, but pus culture suggested nontuberculous mycobacteria. The necrotic tissue specimens were subjected to metagenomic next-generation sequencing, which indicated the presence of M. paragordonae. Finally, the infecting pathogen was identified, and the treatment plan was adjusted. The patient was in good condition during the follow-up period.

CONCLUSION

M. paragordonae, a rare nontuberculous mycobacterium, can also cause spinal infections. In the clinic, it is necessary to identify nontuberculous mycobacteria for spinal infections similar to Mycobacterium tuberculosis.

Postoperative clinicoradiological outcome of pott's spine

Introduction:

Tuberculosis (TB) is one of the main diseases impacting humanity. Fifty percent of all the cases of skeletal TB belong to spinal TB (STB), and it is also the most common form of TB. In India, patients usually present late after the onset of neurological symptoms, for which surgical management is essential for recovery. In our study, we have evaluated the outcome of forty patients of STB who underwent posterior decompression and instrumentation.

Methods:

Forty patients with STB who underwent posterior decompression and instrumentation were reviewed. All cases were followed up for 18 months. The groups were compared by parameters such as improvement in pain, improvement in kyphosis, and neurological recovery. Visual Analog Scale (VAS) score and american spinal cord injury assosciation (ASIA) score are used for the assessment.

Results:

VAS score was significantly decreased postoperatively (mean: 1.28) as compared to preoperative values (mean: 7.25). Erythrocyte sedimentation rate (ESR) was significantly decreased postoperatively (mean: 30.95) as compared to preoperative values (76.15). Cobb's angle was significantly decreased immediate postoperatively (mean: 7.8) as compared to preoperative values (mean: 24.8). There was no deterioration of neurological symptoms in any of the patients.

Conclusion:

Surgical intervention in Pott's spine with posterior decompression and stabilization, whenever indicated, gives good improvement in pain, decreases kyphotic deformity, and in most cases, also improves neurology.

Pott Disease: A Tale of Two Cases

Tuberculosis is considered one of the great masqueraders alongside syphilis and vasculitis. Pott disease is recognized as a classic manifestation of tuberculosis, yet it stands as a rare infectious syndrome in regions with low tuberculosis disease burden. To illustrate the challenges of diagnosing Pott disease in these settings, we report two cases and offer a brief overview of management recommendations for vertebral osteomyelitis caused by Mycobacterium tuberculosis. Case one concerns an 81-year-old man with a remote history of incarceration who presented with altered mental status and new pleural effusions. Case two is a 49-year-old man with well-controlled HIV who was transferred to our institution after being found to have extensive destruction of L3-L5 vertebrae and bilateral iliopsoas abscesses on outpatient imaging. These stand as illustrative examples of low and high suspicion for tuberculosis, respectively, and both cases required complex diagnostic and management decisions.

Tuberculosis related disability: a systematic review and meta-analysis

BACKGROUND

The sustainable development goals aim to improve health for all by 2030. They incorporate ambitious goals regarding tuberculosis (TB), which may be a significant cause of disability, yet to be quantified. Therefore, we aimed to quantify the prevalence and types of TB-related disabilities.

METHODS

We performed a systematic review of TB-related disabilities. The pooled prevalence of disabilities was calculated using the inverse variance heterogeneity model. The maps of the proportions of common types of disabilities by country income level were created.

RESULTS

We included a total of 131 studies (217,475 patients) that were conducted in 49 countries. The most common type of disabilities were mental health disorders (23.1%), respiratory impairment (20.7%), musculoskeletal impairment (17.1%), hearing impairment (14.5%), visual impairment (9.8%), renal impairment (5.7%), and neurological impairment (1.6%). The prevalence of respiratory impairment (61.2%) and mental health disorders (42.0%) was highest in low-income countries while neurological impairment was highest in lower middle-income countries (25.6%). Drug-resistant TB was associated with respiratory (58.7%), neurological (37.2%), and hearing impairments (25.0%) and mental health disorders (26.0%), respectively.

CONCLUSIONS

TB-related disabilities were frequently reported. More uniform reporting tools for TB-related disability and further research to better quantify and mitigate it are urgently needed.

PROSPERO REGISTRATION NUMBER

CRD42019147488.

A case of not just Pott's disease

Spinal tuberculosis (TB) is a rare cause of vertebral osteomyelitis in the developed world. Co-infections with other microorganisms are seldom reported in the literature. Here we report a case of Mycobacterium tuberculosis and Streptococcus anginosus causing acute on chronic vertebral osteomyelitis with an epidural abscess.

THE PROFILE OF POTT’S DISEASE IN A SOUTH AMERICAN REFERENCE SERVICE

ABSTRACT Objective: Tuberculosis (TB) represents one of the top ten causes of death in the world. Its insidious onset and nonspecific symptoms usually result in delayed diagnosis. The objective is to evaluate the characteristics of patients with tuberculous spondylodiscitis in follow-up at a South American reference hospital. Method: Retrospective evaluation of the medical records of patients of both sexes and between 0 and 80 years of age diagnosed with tuberculosis of the spine between 2009 and 2018. The variables were analyzed based on groups: epidemiological, clinical, laboratorial, microbiological, imaging tests and treatment. Results: Total of 26 cases, about 80.8% male, mean age 41.6 ± 22.46 years. Axial pain was the most prevalent symptom (84.6%), the VAS score was 6.85 ± 2.87. The mean time between symptom onset and diagnosis was 23.8 ± 24.1 weeks (4-96). The most affected region was the thoracic spine (50% of the cases). Most participants (61.4%) had no change in neurological function (Frankel D and E) at the beginning of treatment and after 6 months, and 84.5% improved. During treatment 34.6% required surgery and the main indication was isolated neurological deficit (55.5%). The most frequently performed procedure was decompression and arthrodesis (55.5%). The average time to cure was 12.0 ± 8.8 months (8-48). Conclusion: Disease with insidious onset, nonspecific symptoms, high frequency of negative microbiological tests in cases with the disease. A small number of the cases required surgical treatment and most of them achieved good neurological recovery. Level of evidence IV; Case series.

An unusual case of childhood osteoarticular tuberculosis from the Árpádian Age cemetery of Győrszentiván-Révhegyi tag (Győr-Moson-Sopron county, Hungary)

Ancient human remains exhibiting bony changes consistent with osteoarticular tuberculosis (OATB) indicate that the disease has afflicted mankind for millennia. Nonetheless, not many pediatric OATB cases have been published in the paleopathological literature–from Hungary, only three cases have been described up to now. In our paper, we demonstrate a child (S0603) from the Árpádian Age cemetery of Győrszentiván-Révhegyi tag (northwestern Hungary), who represents a unique case of OATB regarding both the pattern and severity of the observed bony changes. During the macromorphological and radiological investigations, the most serious alterations were discovered in the upper thoracic spine–the development of osteolytic lesions led to severe bone loss and consequent collapse and fusion of several adjacent vertebrae. The pathological process terminated in a sharp, rigid angular kyphosis. Disruption of the normal spine curvature resulted in consequent deformation of the whole thoracic wall–it became “rugby-ball-shaped”. The overall nature and pattern of the detected alterations, as well as their resemblance to those of described in previously published archaeological and modern cases from the pre-antibiotic era indicate that they are most consistent with OATB. Based on the severity and extent of the lesions, as well as on the evidence of secondary healing, S0603 suffered from TB for a long time prior to death. Besides body deformation, OATB resulted in consequent disability in daily activities, which would have required regular and significant care from others to survive. It implies that in the Árpádian Age community of Győrszentiván-Révhegyi tag, there was a willingness to care for people in need. Detailed archaeological case studies can give us a unique insight into the natural history and different presentations of OATB. Furthermore, they can provide paleopathologists with a stronger basis for diagnosing TB and consequently, with a more sensitive means of assessing TB frequency in past populations.

Swiss Cheese Loin: A Rare Initial Presentation of Pott's Spine

Spinal tuberculosis (TB) is the most common form of skeletal TB with an exceedingly diverse set of clinical presentations. Most often, there is a slow onset of the disease with patients presenting only with back pain. Although some patients can present later with neurological deficits or with compressive symptoms of an accompanying cold abscess, an initial presentation of a spontaneous cutaneous fistulization of a paraspinal abscess is rare. We present the case of a young boy with such a primary presentation, with no other common symptoms of spinal TB. He was treated with ultrasound-guided percutaneous drainage of the paraspinal abscess and a multidrug anti-tubercular chemotherapy regimen.

What pulmonologists need to know about extrapulmonary tuberculosis

Extrapulmonary tuberculosis (EPT) can affect all organs. Its diagnosis is often challenging, especially when the lung is not involved. Some EPT locations, such as when the central nervous system is involved, are a medical emergency, and some have implications for treatment options and length. This review describes clinical features of EPT, diagnostic tests and treatment regimens.

Extrapulmonary tuberculosis can affect any organ, can be potentially life threatening or disabling, poses diagnostic difficulties and may change the type and length of treatment. Looking for concomitant pulmonary tuberculosis is essential.https://bit.ly/2YEaRVb

Early surgical intervention for active thoracic spinal tuberculosis patients with paraparesis and paraplegia

Background

To explore the therapeutic effect of early surgical intervention for active thoracic spinal tuberculosis (TB) patients with paraparesis and paraplegia.

Methods

Data on 118 active thoracic spinal TB patients with paraparesis and paraplegia who had undergone surgery at an early stage (within three weeks of paraparesis and paraplegia) from January 2008 to December 2014 were retrospectively analyzed. The operation duration, blood loss, perioperative complication rate, VAS score, ASIA grade and NASCIS score of neurological status rating, Erythrocyte Sedimentation Rate (ESR), C-reactive protein (CRP), kyphotic Cobb’s angle, and duration of bone graft fusion were analyzed to evaluate the therapeutic effects of surgery.

Results

The mean operating time was 194.2 minutes, and the mean blood loss was 871.2 ml. The perioperative complication rate was 5.9 %. The mean preoperative VAS score was 5.3, which significantly decreased to 3.2 after the operation and continued decreasing to 1.1 at follow up (P<0.05). All cases achieved an increase of at least one ASIA grade after operation. The rate of full neurological recovery for paraplegia (ASIA grade A and B) was 18.0 % and was significantly lower than the rate (100 %) for paraparesis (ASIA grade C and D) (P<0.05). On the NASCIS scale, the difference in the neurological improvement rate between paraplegia (22.2 % ± 14.1 % in sensation and 52.2 % ± 25.8 % in movement) and paraparesis (26.7 % ± 7.5 % in sensation and 59.4 % ± 7.3 % in movement) was remarkable (P<0.05). Mean preoperative ESR and CRP were 73.1 mm /h and 82.4 mg/L, respectively, which showed a significant increase after operation (P>0.05), then gradually decreased to 11.5 ± 1.8 mm/h and 2.6 ± 0.82 mg/L, respectively, at final follow up (P<0.05). The mean preoperative kyphotic Cobb’s angle was 21.9º, which significantly decreased to 6.5º after operation (P<0.05) while kyphotic correction was not lost during follow up (P>0.05). The mean duration of bone graft fusion was 8.6 ± 1.3 months.

Conclusions

Early surgical intervention may be beneficial for active thoracic spinal TB patients with paraparesis and paraplegia, with surgical intervention being more beneficial for recovery from paraparesis than paraplegia.

Proteomic analysis reveals critical molecular mechanisms involved in the macrophage anti-spinal tuberculosis process

Tuberculosis infection activates the autoimmune system. However, the role of host-pathogen interactions involved in Mycobacterium tuberculosis infection is unclear. In this study, we analyzed 6 spinal tuberculosis tissues and 6 herniated disc tissues by using liquid chromatography-tandem mass spectrometry coupled with tandem mass spectrometry, and immunohistochemical staining was performed for validating the results. We identified 42 differential immune-related proteins and 3 hub genes that are primarily localised in the tertiary granule and involved in biological processes such as cellular response to the presence of cadmium ions, regulation of ion transmembrane transport, transmembrane transport, and inflammatory responses. Genes encoding cytochrome B-245 beta chain (CYBB), matrix metallopeptidase 9 (MMP9), and C-X-C motif chemokine ligand 10 (CXCL10) were identified as the hub genes that exhibited anti-tuberculosis activity and were responsible for macrophage resistance against M. tuberculosis. In conclusion, CYBB, MMP9, and CXCL10 resist M. tuberculosis infection through chemotaxis and macrophage activation. Our results indicate that CYBB, MMP9, and CXCL10 could be considered as molecular targets for spinal tuberculosis treatment, which may significantly improve patients' quality of life and prognosis.

Concordance and Discordance of Orthopedicians with Revised National Tuberculosis Control Program with Reference to Musculoskeletal Tuberculosis: A Qualitative Inquiry

BACKGROUND

Musculoskeletal tuberculosis (TB) continues to share the major burden of extrapulmonary TB. This burden up to some extent may be attributed to the implementation gap which is reasonably broadest at the level of the immediate point of care. As an orthopedic physician is an important stakeholder at this juncture, it is imperative to recognize their experiences, perceptions, and anticipations to fill this gap. This qualitative inquiry tries to explore these attributes in the context of the recent development at the policy level in Revised National Tuberculosis Control Program.

METHODOLOGY

Type of Study Qualitative inquiry with framework approach.

SETTINGS

Orthopedic surgeons working in different work settings.

SAMPLING METHOD

Purposive sampling. An iterative topic guide for an in-depth interview was prepared by reviewing the literature and expert opinions. The questions were contextual, diagnostic, evaluative, and strategic. This study adopted a framework approach as the issue was near to evaluative and strategic policy research. The recorded interviews were transcribed and coded into axial and serial codes. A framework matrix was created and thematic mapping was done to understand the phenomena and to offer the solution framework.

RESULTS

The investigators detected an element of unawareness of the current context coupled with the perceived previous stringency of the program. This is in conjunction with already multifaceted diagnostic and prognostic complexity. This leads to mutual dissociation and skepticism.

CONCLUSION

This qualitative inquiry explored an element of dissociation between programmatic objectives and individualistic concerns of the caregivers. An integrated ecosystem which may take care of synergistic reciprocation among the two is imperative for successful implementation.

Minimally invasive surgery for paravertebral or psoas abscess with spinal tuberculosis - a long-term retrospective study of 106 cases

Background

Minimally invasive surgery (MIS) is a common treatment option for paravertebral or psoas abscesses (PAs) in patients with spinal tuberculosis (ST). However, its efficacy remains controversial. The aim of the study was to evaluate the efficacy of MIS for PA with ST combined with anti-tuberculous chemotherapy.

Methods

A total of 106 consecutive patients who underwent MIS for ST with PA from January 2002 to Oct 2012 were reviewed. The MIS involved computed tomography (CT)-guided percutaneous catheter drainage and percutaneous catheter infusion chemotherapy. Clinical outcomes were evaluated based on the changes observed on preoperative and postoperative physical examination, inflammatory marker testing, and magnetic resonance imaging (MRI).

Results

The mean follow-up period was 7.21 ± 3.15 years. All surgeries were successfully completed under CT-guidance without intraoperative complications and all patients experienced immediate relief of their symptoms, which included fever and back pain. The preoperatively elevated erythrocyte sedimentation rate and C-reactive protein values returned to normal at a mean period of 3 months postoperatively. Solid bony union was observed in 106 patients and no abscesses were found on MRI examination.

Conclusion

MIS carries advantages in terms of less invasiveness, precise drainage, and enhanced local drug concentration. While the technique has not been fully characterized and clinically prove, its use in addition to conservative chemotherapy and open debridement and instrumental fixation may be recommended for patients with ST and PA.

MRI of the axial skeleton in spondyloarthritis: the many faces of new bone formation

Spondyloarthritis has two hallmark features: active inflammation and structural lesions with new bone formation. MRI is well suited to assess active inflammation, but there is increasing interest in the role of structural lesions at MRI. Recent MRI studies have examined the established features of new bone formation and demonstrated some novel features which show diagnostic value and might even have potential as possible markers of disease progression. Although MRI is not the first imaging modality that comes into mind for assessment of bony changes, these features of new bone formation can be detected on MRI—if one knows how to recognize them. This review illustrates the MRI features of new bone formation and addresses possible pitfalls.

Severe Pott's Kyphosis in a 19-Month-Old Child: Case Report and Review of Literature

BACKGROUND

Spinal osseous tuberculosis, or Pott's spine, although very common in endemic countries, has a lower incidence in very young children. However, the infection has the propensity to cause greater vertebral destruction in this age group, leading to severe structural kyphotic deformity and associated neurologic deficits. We report the case of a 19-month-old child with severe tubercular kyphotic deformity of the upper thoracic spine managed with posterior vertebral column resection (VCR) and nonfusion posterior pedicle screw instrumentation.

CASE DESCRIPTION

This 19-month-old boy presented with 1-month history of spontaneous-onset, progressive, painful rigid kyphotic deformity of the upper back associated with spastic paraparesis with bowel and bladder incontinence. Magnetic resonance imaging showed severe destruction of bodies of D4-D7 vertebrae with cord edema and draping of the spinal cord over the internal gibbus at D4-D7. Surgery was performed with a restricted anterior fusion via single-stage posterior VCR at D4-D7 with nonfusion pedicle screw instrumentation from D1 to D9, with subsequent extension of instrumentation to D10 after 4 months.

CONCLUSIONS

Multilevel posterior VCR with a restricted fusion and nonfusion pedicle screw instrumentation beyond the resection site can be safely done in young children (age <3 years) requiring rigid tubercular kyphotic deformity correction. However, these patients require regular follow-up and may need multiple surgeries.

Delayed Diagnosis of Spinal Tuberculosis in a 44-year-old Male with Acute on Chronic Low Back Pain

Spinal tuberculosis (STB), also known as tuberculous spondylitis, tuberculous vertebral osteomyelitis, or Pott’s disease is a rare subset of extrapulmonary tuberculosis. Although rare in developed countries, STB is an important diagnosis for the emergency physician to consider. We report a case of a 44-year-old African-American male with STB presenting as an acute exacerbation of chronic low back pain complicated by urinary retention and difficulty ambulating. Our patient had no known predisposing risk factors for tuberculosis. This patient’s STB was mistakenly diagnosed as nontuberculous vertebral osteomyelitis. This is not uncommon, as it is often difficult to distinguish the two clinically. This patient experienced advanced neurologic features at the time of initial presentation, which improved with surgical decompression. Ultimately, he re-presented to the emergency department 10 days after hospital discharge with recurrence of symptoms due to inaccurate antimicrobial selection. The diagnosis may hinge on the astute physician recognizing the characteristic, albeit subtle, imaging findings of STB.

Back pain following instillations of BCG for superficial bladder cancer is not a reactive complication: review of 30 Mycobacterium bovis BCG vertebral osteomyelitis cases

Mycobacterium bovis Bacillus Calmette-Guérin (BCG) instillations are used in bladder cancer treatment. Adverse effects can occur. Osteoarticular complications are mainly reactive arthritis, but true infections have been described, such as vertebral osteomyelitis. We made a review of M. bovis BCG vertebral osteomyelitis after instillations for bladder cancer using PubMed search. We added three new French cases. Twenty-seven cases of BCG vertebral osteomyelitis had been reported on PubMed. Of the 30 cases, all were male, averaging 73.4 ± 8.7 years old. Median time between diagnosis and first and last instillation was 22.5 and 14 months respectively. Half of vertebral osteomyelitis was thoracic and lumbar in the other half. Sensitivo-motor deficit was present at diagnosis in 42% of cases. Other infectious locations were common, mainly infectious abdominal aortic aneurysms (20%). Rifampicin, ethambutol and isoniazid were the usual therapy. Poor outcomes were reported with 50% of one or more spine surgery. M. bovis BCG vertebral osteomyelitis following bladder instillation for bladder cancer is a rare complication. However, the late onset of back pain after instillations differentiates them from reactive arthritis. Concomitant septic location such as infectious abdominal aortic aneurysms must be known.

Presentation and Outcomes After Medical and Surgical Treatment Versus Medical Treatment Alone of Spontaneous Infectious Spondylodiscitis: A Systematic Literature Review and Meta-Analysis

STUDY DESIGN

Systematic literature review.

OBJECTIVES

The aims of this study were to (1) describe the clinical features, disabilities, and incidence of neurologic deficits of pyogenic spondylodiscitis prior to treatment and (2) compare the functional outcomes between patients who underwent medical treatment alone or in combination with surgery for pyogenic spondylodiscitis.

METHODS

A systematic literature review was performed using PubMed according to PRISMA guidelines. No year restriction was put in place. Statistical analysis of pooled data, when documented in the original report (ie, number of patients with desired variable and number of patients evaluated), was conducted to determine the most common presenting symptoms, incidence of pre- and postoperative neurologic deficits, associated comorbidities, infectious pathogens, approach for surgery when performed, and duration of hospitalization. Outcomes data, including return to work status, resolution of back pain, and functional recovery were also pooled among all studies and surgery-specific studies alone. Meta-analysis of studies with subgroup analysis of pain-free outcome in surgical and medical patients was performed.

RESULTS

Fifty of 1286 studies were included, comprising 4173 patients undergoing either medical treatment alone or in combination with surgery. Back pain was the most common presenting symptom, reported in 91% of patients. Neurologic deficit was noted in 31% of patients. Staphylococcus aureus was the most commonly reported pathogen, seen in 35% of reported cases. Decompression and fusion was the most commonly reported surgical procedure, performed in 80% of the surgically treated patients. Combined anterior-posterior procedures and staged surgeries were performed in 33% and 26% of surgeries, respectively. The meta-analysis comparing visual analog scale score at follow-up was superior among patients receiving surgery over medical treatment alone (mean difference -0.61, CI -0.90 to -0.25), while meta-analysis comparing freedom from pain in patients receiving medical treatment alone versus combined medical and surgical treatment demonstrated superior pain-free outcomes among surgical series (odds ratio 5.35, CI 2.27-12.60, P < .001), but was subject to heterogeneity among studies (I ² = 56%, P = .13). Among all patients, freedom from pain was achieved in 79% of patients, and an excellent outcome was achieved in 73% of patients.

CONCLUSION

Medical management remains first-line treatment of infectious pyogenic spondylodiscitis. Surgery may be indicated for progressive pain, persistent infection on imaging, deformity or neurologic deficits. If surgery is required, reported literature shows potential for significant pain reduction, improved neurologic function and a high number of patients returning to a normal functional/work status.

Analysis of infectious spondylodiscitis: 7-years data

Objective:

Infectious spondylodiscitis (SD) is an infectious disease that is rare and difficult to diagnose due to its non-specific clinical features. In this study, we aimed to describe the clinical and diagnostic features of infectious spondylodiscitis.

Methods:

All patients who were diagnosed with SD at our hospital during a 7-year period from January 1, 2011 through December 31, 2017 were included in the study. Spondylodiscitis is divided into the following three types: pyogenic, tuberculous, and brucellar. Clinical and laboratory data were collected retrospectively from the medical records of the patients.

Results:

Of the 118 patients, 66 (55.9%) were female, 81 (68.6%) had pyogenic SD (PSD), 21 (17.8%) had tuberculous SD (TSD), and 16 (13.6%) had brucellar SD (BSD). The mean age was 59.3 ± 14.6 years. Leucocytosis was significantly higher in patients with PSD (p=0.01) than in patients with other types of SD. Thoracic involvement (47.6%) was significantly higher in patients with TSD (p=0.005) than in other patients. Sacral involvement (12.5%) was significantly higher in patients with BSD (p=0.01) than in other patients. Paravertebral abscess formation (42.8%) occurred most frequently in patients with TSD. Microbiologic agents were defined in 50% (18/36) of the surgical specimens and in 12.5% of the fine needle aspiration biopsy (FNAB) specimens. Staphylococcus aureus was the most common microbiological agent in patients with PSD. Spinal surgery was defined as a risk factor for PSD (p = 0.0001). Binary logistic regression analysis revealed that female gender, thoracic involvement and night sweats were the predictive markers for TSD (OR 4.5 [95% CI 1.3-15.3] and OR 5 [95% CI 1.7-14.6]).

Conclusion:

PSD is the most frequent form of SD. Leucocytosis is most common in patients with PSD. Thoracic involvement and paraspinal abscess were prominent in patients with TSD. Sacral involvement was most common in patients with BSD. Thoracic involvement, female gender and night sweats were the predictive markers for TSD. The microbiological culture positivity rate was higher in surgical specimens compared to FNAB specimens. The need for surgical treatment was most common in patients with TSD.

Analysis of Treatment and Prognosis of 863 Patients with Spinal Tuberculosis in Guizhou Province

The objective of this study was to investigate the treatment and prognosis of patients with spinal tuberculosis in Guizhou province. A total of 863 patients with spinal tuberculosis admitted to our hospital from 2006 to 2017 were included in this study. All patients underwent standardized quadruple antituberculosis treatment. Eighty patients were lost to follow-up due to a change of their contact information or noncompliance. A total of 783 patients completed the follow-up. The average follow-up period was 20.33 ± 8.77 months (range: 6 to 38 months). Among these patients, 145 patients underwent conservative treatment, while 638 patients underwent surgical treatment. All patients in the surgery group were treated with lesion removal, bone graft fusion, and internal fixation. Preoperative and postoperative standard quadruple antituberculosis treatment was administered. The clinical efficacy was evaluated according to erythrocyte sedimentation rate (ESR), c-reactive protein (CRP), visual analogue scale (VAS), Cobb angle correction, neurological functional recovery, and interbody fusion with bone graft and tuberculosis outcome. A total of 608 patients achieved clinical cure. The symptoms, physical signs, blood tests and imaging findings were improved in 143 patients. Twenty patients showed refractory clinical symptoms, and 12 patients had local tuberculosis recurrence. Conservative and surgical treatments are the mainstream treatments for spinal tuberculosis. According to the patients' individual conditions, individualized treatments should be used to achieve good efficacy. Standardized antituberculosis treatment should be applied over the course of spinal tuberculosis.

Child and adult spinal tuberculosis at tertiary hospitals in the Western Cape, South Africa: 4-year burden and trend

The aim of this retrospective review was to assess the overall burden and trend in spinal tuberculosis (TB) at tertiary hospitals in the Western Cape Province of South Africa. All spinal TB cases seen at the province's three tertiary hospitals between 2012 and 2015 were identified and clinical records of each case assessed. Cases were subsequently classified as bacteriologically confirmed or clinically diagnosed and reported with accompanying clinical and demographic information. Odds ratios (OR) for severe spinal disease and corrective surgery in child vs. adult cases were calculated. A total of 393 cases were identified (319 adults, 74 children), of which 283 (72%) were bacteriologically confirmed. Adult cases decreased year-on-year (P = 0.04), however there was no clear trend in child cases. Kyphosis was present in 60/74 (81%) children and 243/315 (77%) adults with available imaging. Corrective spinal surgery was performed in 35/74 (47%) children and 80/319 (25%) adults (OR 2.7, 95% confidence interval 1.6-4.5, P = 0.0003). These findings suggest that Western Cape tertiary hospitals have experienced a substantial burden of spinal TB cases in recent years with a high proportion of severe presentation, particularly among children. Spinal TB remains a public health concern with increased vigilance required for earlier diagnosis, especially of child cases.

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.

Skipped multifocal extensive spinal tuberculosis involving the whole spine: A case report and literature review

RATIONALE

Skipped multifocal extensive spinal tuberculosis (TB) involving the whole spine is very rare. So far, only 3 cases have been reported.

PATIENT CONCERNS

We report a rare case of skipped multifocal extensive TB involving the whole spine of a 33-year-old Chinese male. The patient had been asymptomatic until his symptom was significantly aggravated, which caused him to have difficulty in walking and sleeping. The whole spinal computed tomography (CT) scan showed multifocal worm-eaten and osteolytic bony destruction spread over noncontiguous multilevel vertebral involvement in cervical, thoracic, lumbar, and sacral. In addition, the patient presented with low back pain, progressive fever, night sweats, and weight loss. An open biopsy was undergone indicating granulomatous inflammation after thorough radiographic examinations and laboratory investigations, which to our knowledge have been rarely reported by the published medical reference literature.

DIGNOSES

It was initially diagnosed as lymphoma, multiple myeloma, or a metastatic disease by the radiologist. Final pathology confirmed it as an atypical form of spinal TB, which is extremely rare.

INTERVENTIONS

The patient with no progressive severe neurological symptoms, spinal deformity, or a huge abscess was put on a combination of anti-TB treatment and discharged in an improved state to continue medication for a total of 12 months.

OUTCOMES

This article is a case report, no outcomes.

LESSONS

Multifocal extensive spinal TB involving the whole spine is rarely reported in the literature, which presents with atypical presentations and imaging features. It is noticeable that the possibility of TB is considered for any skip lesions involving the spine cautiously. Meanwhile, careful physical examination, trials of anti-TB treatment, and using the whole spine MRI routinely also play an important role in the diagnosis and treatment of this disease.

Prognostic Factors for Recovery of Patients After Surgery for Thoracic Spinal Tuberculosis

BACKGROUND

Thoracic spinal tuberculosis (TST) is a dangerous disease. Besides antituberculosis chemotherapy, surgery is also necessary for treating TST. To date, no study has focused on the prognostic factors for recovery of patients after surgery for TST.

METHODS

From 2001-2016, 237 patients who underwent surgery for TST in our department were included in this study. Japanese Orthopedic Association score was used to assess recovery after surgery. Kaplan-Meier method and Cox regression analysis were employed to identify the significant prognostic factors.

RESULTS

Univariate analysis demonstrated that diabetes, paralysis, kyphosis, duration of symptoms (≥3/<3 months), and number of involved vertebrae (>2/≤2) were identified as potential prognostic factors responsible for recovery after surgery for TST. Multivariate analysis suggested that paralysis, duration of symptoms (≥3/<3 months), and number of involved vertebrae (>2/≤2) were identified as the significant prognostic factors responsible for recovery after surgery for TST.

CONCLUSIONS

This study supports the previously published evidence that nonparalysis, shorter duration of symptoms, and fewer involved vertebrae are favorable prognostic factors for recovery after surgery for TST. For a better recovery effect, the key points for treating TST were timely diagnosis and treatment. It is urgent for government to arouse attention and popularize the knowledge of spinal tuberculosis.