Spinal tuberculosis in patients with human immunodeficiency virus infection: clinical presentation, therapy and outcome

Surgical management and clinical outcome of cervical, thoracic and thoracolumbar spinal tuberculosis in a middle-European adult population

Spinal tuberculosis is due to globalization no longer a disease limited to developing nations. It remains in Germany a rarity and still a difficult diagnosis. Here we analyzed patients with spinal tuberculosis treated at our neurosurgical department. According to the infected anatomic segment, patients were assigned in one of three groups. Surgery was performed when neurological deficit due to mechanical compression, deformity, instability, severe pain, necrotic bone or failure to respond to anti-tuberculous treatment were observed. We identified 34 patients with spinal tuberculosis who underwent surgical treatment. In the cervical spinal tuberculosis group, there were 15 cases (46.9%) In most cases treatment consisted of spinal instrumentation. In the thoracic group, 10 cases (29.4%) were observed. The treatment was performed by dorsolateral spinal instrumentation. For the thoracolumbar group, 9 cases (26.4%) were observed. In most cases dorsolateral spinal instrumentation was performed. One patient in the first group and one patient in the third group relapsed after operation. A second surgery was necessary. Patients with chronic back pain, immigration background and/or neurological deficit spinal TB should be considered as a differential diagnosis. Combined surgical intervention and medical treatment is associated with a favorable outcome.

Isolated Tuberculosis of the Ribs in an Immunocompetent Adult

Skeletal involvement is a frequent site of extrapulmonary tuberculosis, but an isolated disease of the ribs is rare. This case report studied an adult immunocompetent male patient who presented with constitutional symptoms, pain and point tenderness in two ribs. The diagnosis of rib tuberculosis was delayed due to earlier providers not recognizing the condition. Routine chest X-rays performed in the early stages of the disease did not reveal abnormalities, but computed tomography did. The patient had lytic rib lesions and a swelling of the chest wall soft tissue consistent with a cold abscess. Specifically, the scan was significant for the absence of involvement of the lung, pleura, spine and mediastinal lymph nodes. While routine smears and cultures were negative, a polymerase chain reaction test for Mycobacterium tuberculosis performed on a sample of aspirate from the swelling confirmed the diagnosis. The patient responded to anti-tuberculous drug therapy, made a complete recovery without complications or the need for surgery and has now been disease free for 16 years. The patient had no concomitant pulmonary disease and was not immunocompromised. The timely intervention could prevent complications. This case report reviews literature and recent research on rib tuberculosis. If these research findings are replicated in larger studies, it will pave the way for more effective management of this rare condition.

Review of the neurological aspects of HIV infection

There are almost 40 million people in the world who live with the human immunodeficiency virus (HIV). The neurological manifestations associated with HIV contribute to significant morbidity and mortality despite the advances made with anti-retroviral therapy (ART). This review presents an approach to classification of neurological disorders in HIV, differentiating diseases due to the virus itself and those due to opportunistic infection. The effects of antiretroviral therapy are also discussed. The emphasis is on the developing world where advanced complications of HIV itself and infections such as tuberculosis (TB), toxoplasmosis and cryptococcal meningitis remain prevalent.

Assessment of Clinical and Radiological Parameters in Spinal Tuberculosis: Comparison between Human Immunodeficiency Virus-Positive and Human Immunodeficiency Virus-Negative Patients

Study Design

Prospective comparative study.Purppse: A prospective comparative analysis of 30 patients with spinal tuberculosis (15 human immunodeficiency viruses [HIV] positive and 15 HIV negative). We compared the clinical and radiological parameters of the two groups.

Overview of Literature

With the increasing incidence of HIV and tuberculosis co-infection, spinal tuberculosis is increasing globally, especially in developing countries. The diagnosis of spinal tuberculosis presents a challenge due to nonspecific constitutional symptoms and late presentation.

Methods

A prospective study was conducted of 30 patients with spinal tuberculosis (15 HIV positive and 15 HIV negative) from August 2014–July 2016 for assessment of clinical and radiological parameters. Neurological assessment was done by classification of tuberculous paraplegia, and the amount of kyphosis was assessed by Cobb angle on a plain radiograph. Abscess size in anterior epidural space, the number of vertebral bodies involved and collapsed, and skip lesions were noted on magnetic resonance imaging.

Results

In the prospective analysis of 30 patients, HIV positive (n=15) and HIV negative (n=15), there was no significant difference in neurological grading between the two groups. The amount of vertebral body destruction and degree of kyphosis was significantly greater in HIV-negative patients as compared with HIV-positive patients. There was a significant difference in Cobb angle between the two groups. The amount of anterior epidural space abscess formation was greater in HIV-positive patients as compared with HIVnegative patients.

Conclusions

HIV-negative patients had greater vertebral body destruction and resultant kyphosis as compared with HIV-positive patients, who had greater anterior epidural abscess formation.

Spinal tuberculosis: a comprehensive review for the modern spine surgeon

Nearly one-third of the human population is infected with tuberculosis. Of those with active disease, approximately 10% are impacted by skeletal tuberculosis. Though, traditionally a disease of the developing world and susceptible populations, with the rise of immigration, patients may present in developed countries. The microbe responsible is the mycobacterium tuberculosis complex bacillus. The infection begins in the anterior vertebral bodies. The natural history and presentation are notable for cold abscesses causing mass effect, early or late neurological deficit, and kyphotic deformity of the spine caused by anterior vertebral body destruction. The disease can be diagnosed with laboratory studies and characteristic imaging findings, but tissue diagnosis with cultures, histology, and polymerase chain reaction is the gold standard. The cornerstone of medical management is multidrug chemotherapy to minimize relapse and drug resistance, and can be curative for spinal tuberculosis with minimal residual kyphosis. Surgical management is reserved for patients presenting with neurological deficits or severe kyphosis. The mainstays of surgical management are debridement, correction of spinal deformity and stable fusion. With appropriate and timely management, clinical outcomes of the treatment of spinal tuberculosis are overall excellent.

Spinal Tuberculosis: Clinicoradiological Findings in 274 Patients

Background

Mycobacterium tuberculosis is a major cause of myelopathy and radiculopathy in settings with a high prevalence of tuberculosis/human immunodeficiency virus (HIV) coinfection. However, a paucity of publications exists on the spectrum of neurological and magnetic resonance (MR) imaging findings of spinal tuberculosis in these populations.

Methods

We conducted a retrospective study of adults with spinal tuberculosis at a referral center in South Africa for patients with spinal disease without bony involvement seen at plain film radiography. We report the clinical, laboratory and spinal MR imaging findings, compare HIV-infected and HIV-uninfected patients, and correlate clinical and cerebrospinal fluid findings with those of MR imaging.

Results

Of 274 patients, 209 (76%) were HIV infected and 49 (18%) were HIV uninfected. Radiculomyelitis occurred in 77% (n = 210), and spondylitis in 39% (n = 106). Subdural abscess (n = 42) and intramedullary tuberculoma (n = 33) were common. In 24% of HIV-infected and 14% of HIV-uninfected patients, spinal disease manifested as a paradoxical tuberculosis reaction, frequently following tuberculous meningitis. The triad of neurological deficit, fever, and back pain was similar in patients with spondylitis (24%), epi/subdural abscess without bony disease (14%), meningoradiculitis (17%), and isolated myelitis (17%) .

Conclusions

Radiculomyelitis is a common manifestation of spinal tuberculosis in settings with high tuberculosis/HIV prevalence, often presenting as a paradoxical reaction. We describe a high frequency of rarely reported spinal tuberculosis manifestations, suggesting that these are more common than implied by the literature.

Musculoskeletal Tuberculosis

Musculoskeletal tuberculosis (TB) accounts for approximately 10% of all extrapulmonary TB cases in the United States and is the third most common site of extrapulmonary TB after pleural and lymphatic disease. Vertebral involvement (tuberculous spondylitis, or Pott's disease) is the most common type of skeletal TB, accounting for about half of all cases of musculoskeletal TB. The presentation of musculoskeletal TB may be insidious over a long period and the diagnosis may be elusive and delayed, as TB may not be the initial consideration in the differential diagnosis. Concomitant pulmonary involvement may not be present, thus confusing the diagnosis even further. Early diagnosis of bone and joint disease is important to minimize the risk of deformity and enhance outcome. The introduction of newer imaging modalities, including MRI (imaging procedure of choice) and CT, has enhanced the diagnostic evaluation of patients with musculoskeletal TB and for directed biopsies of affected areas of the musculoskeletal system. Obtaining appropriate specimens for culture and other diagnostic tests is essential to establish a definitive diagnosis and recover M. tuberculosis for susceptibility testing. A total of 6 to 9 months of a rifampin-based regimen, like treatment of pulmonary TB, is recommended for the treatment of drug susceptible musculoskeletal disease. Randomized trials of tuberculous spondylitis have demonstrated that such regimens are efficacious. These data and those from the treatment of pulmonary TB have been extrapolated to form the basis of treatment regimen recommendations for other forms of musculoskeletal TB.

The epidemiology of spinal tuberculosis in the United States: an analysis of 2002–2011 data

OBJECTIVE

The aim of this study was to investigate the incidence of spinal tuberculosis (TB) in the US between 2002 and 2011.

METHODS

The Nationwide Inpatient Sample database from 2002 to 2011 was used to identify patients with a discharge diagnosis of TB and spinal TB. Demographic and hospital data were obtained for all admissions, and included age, sex, race, comorbid conditions, insurance status, hospital location, hospital teaching status, and hospital region. The incidence rate of spinal TB adjusted for population growth was calculated after application of discharge weights.

RESULTS

A total of 75,858 patients with a diagnosis of TB were identified, of whom 2789 had a diagnosis of spinal TB (3.7%); this represents an average of 278.9 cases per year between 2002 and 2011. The incidence of spinal TB decreased significantly—from 0.07 cases per 100,000 persons in 2002 to 0.05 cases per 100,000 in 2011 (p < 0.001), corresponding to 1 case per 2 million persons in the latter year. The median age for patients with spinal TB was 51 years, and 61% were male; 11.6% were patients with diabetes, 11.4% reported recent weight loss, and 8.1% presented with paralysis. There were 619 patients who underwent spinal surgery for TB, with the most common location being the thoracolumbar spine (61.9% of cases); 50% of patients had instrumentation of 3 or more spinal segments.

CONCLUSIONS

During the examined 10-year period, the incidence of spinal TB was found to significantly decrease over time in the US, reaching a rate of 1 case per 2 million persons in 2011. However, the absolute reduction was relatively small, suggesting that although it is uncommon, spinal TB remains a public health concern and most commonly affects male patients approximately 50 years of age. Approximately 20% of patients with spinal TB underwent surgery, most commonly in the thoracolumbar spine.

Spinal tuberculosis, natural history of disease, classifications and principles of management with historical perspective

PURPOSE

To describe the natural history spinal tuberculosis, classifications and principles of management based upon the grading of the neurological deficit.

METHODS

Review of literature was conducted with the aim to provide the clinico-radiological correlation of the natural history of spinal tuberculosis in different stages. Management strategy is developed based upon the severity of the neurological deficit.

RESULTS

A five stage natural history of spinal tuberculosis is described. Stage of neurological involvement is further divided into 4 grades, predominantly on the basis of progressively increasing motor deficits as negligible, mild, moderate and severe with sensory and autonomic dysfunctions. Suitable principles of management with role of rest, braces, chemotherapy and surgery are discussed. Neurological deficit grading based management is developed. Grade 1 and 2, conservative treatment, grade 3, gray zone and grade 4, operative treatment is emphasized.

CONCLUSION

The five stages of natural history of tuberculosis of spine have been developed from the clinician's point of view. Management of tuberculosis of spine, in general, it is no different than management of soft tissue tuberculosis, in HIV negative or positive patients. Role of surgery is very limited. Management of tubercular paraplegia, based upon the grading of paraplegia is simple, logical, efficient and easy to understand and remember by any orthopedic surgeon.

Analysis of changing paradigms of management in 179 patients with spinal tuberculosis over a 12-year period and proposal of a new management algorithm

OBJECTIVE

To describe management and outcome in a large cohort of patients with spinal tuberculosis (TB).

METHODS

Of 212 patients with spinal TB treated between January 1999 and June 2011, 179 patients were included in the study (≥6 months follow-up; mean age, 34.8 years; age range, 10-75 years). The cohort was divided into two groups (n = 89 and n = 90); group I was treated from 1999-2003, and group II was treated from 2004-2011.

RESULTS

The study cohort comprised 93 male patients. Mean age was 34.8 years ± 7.2 (range, 10-75 years). Mean duration of symptoms was 2.4 months. Sensorimotor deficits were present in 167 patients (93.5%; 74 patients were paraplegic), pain was present in 156 patients (87%), bladder involvement was present in 127 patients (71.7%), and extraspinal TB was present in 36 patients (22.3%). Of patients, 92% were receiving prior chemotherapy; one fifth of these patients were on second-line chemotherapy. Thoracic spine involvement was most common (n = 86; 57%), followed by cervical spine (n = 50; 29%), craniovertebral junction (n = 22; 15%), and lumbosacral spine (n = 20; 10.5%). Surgery was performed in 146 patients (68% instrumented fusions and 16% circumferential fusions). Mean follow-up was 20.2 months (range, 6-60 months). Sensorimotor deficits improved in 89% of patients, pain improved in 71%, bladder symptoms improved in 88%, and paraplegia improved in 77%. Patients in group II had a higher incidence of cord compression (P < 0.01), severe vertebral body collapse (P < 0.001), and paraplegia (P < 0.001). Group II patients underwent more instrumented surgeries (P < 0.01), especially circumferential fusions (P < 0.001). The improvement in paraplegia was better after 2004 (group II). Bladder symptoms correlated with the timing of surgery (P < 0.1).

CONCLUSIONS

Medical treatment of spinal TB is the mainstay; however, radical, instrumented surgeries should be offered when indicated. The presence of paraplegia should not preclude surgery. A practical management paradigm is also suggested.

Bone and joint tuberculosis

INTRODUCTION

Bone and joint tuberculosis has increased in the past two decades in relation with AIDS epidemics.

MATERIAL AND METHODS

A literature review of bone and joint tuberculosis, focusing on Pott's disease.

RESULTS

Bone and joint TB comprises a group of serious infectious diseases whose incidence has increased in the past two decades, especially in underdeveloped countries, in part due to the AIDS epidemic. Tuberculous spinal infections should be suspected in patients with an insidious, progressive history of back pain and in individuals from an endemic area, especially when the thoracic vertebrae are affected and a pattern of bone destruction with relative disc preservation and paravertebral and epidural soft tissue masses are observed. Atypical tuberculous osteoarticular manifestations involving the extraspinal skeleton, a prosthetic joint, or the trochanteric area, and nontuberculous mycobacterial infections should be considered in favorable epidemiological contexts. Surgery combined with prolonged specific antituberculous chemotherapy is mainly indicated in patients with neurological manifestations or deformities, and provides satisfactory results in most cases.

CONCLUSIONS

Spinal tuberculosis is still a relative common extra spinal manifestation of spinal tuberculosis that requires a high degree of suspicion in order to avoid neurological complications and need of surgery.

Tuberculosis of the spine. A systematic review of case series

PURPOSE

The objective of this systematic review was to characterise the methodological issues, as well as clinical, diagnosis, microbiological and treatment characteristics of patients with spinal tuberculosis.

METHODS

We conducted a systematic review including prospective or retrospective case series written in English, Spanish, French, German and Italian published in the period from January 1980 to March 2011.

RESULTS

Thirty-seven articles were included with a total of 1,997 patients; the median of the percentage of men was 53% (interquartile range [IQR] 48-64) and the median of the patients mean age was 43.4 (IQR 37-55). The most common symptom reported was back pain, and thoracic spine was the most frequent segment involved. Spinal plain radiography was done in 35 studies (94.6%), magnetic resonance imaging (MRI) in 26 (70.2%), computed tomography scan (CT-scan) in 13 (35%) and microbiological diagnosis in 29 (78.3%). Surgical treatment was reported in 28 articles 75.7%; finally, 24 articles reported follow-up, and in 15 of them at least 80% of patients improved.

CONCLUSIONS

Spinal TB is still an important public health issue, it must be suspected in the presence of back pain or characteristic images and should be confirmed with microbiological procedures. Chemotherapy treatment is often used; in contrast, there is heterogeneity in the percentage of patients treated by surgery.

Spinal tuberculosis: a review

Spinal tuberculosis is a destructive form of tuberculosis. It accounts for approximately half of all cases of musculoskeletal tuberculosis. Spinal tuberculosis is more common in children and young adults. The incidence of spinal tuberculosis is increasing in developed nations. Genetic susceptibility to spinal tuberculosis has recently been demonstrated. Characteristically, there is destruction of the intervertebral disk space and the adjacent vertebral bodies, collapse of the spinal elements, and anterior wedging leading to kyphosis and gibbus formation. The thoracic region of vertebral column is most frequently affected. Formation of a 'cold' abscess around the lesion is another characteristic feature. The incidence of multi-level noncontiguous vertebral tuberculosis occurs more frequently than previously recognized. Common clinical manifestations include constitutional symptoms, back pain, spinal tenderness, paraplegia, and spinal deformities. For the diagnosis of spinal tuberculosis magnetic resonance imaging is more sensitive imaging technique than x-ray and more specific than computed tomography. Magnetic resonance imaging frequently demonstrates involvement of the vertebral bodies on either side of the disk, disk destruction, cold abscess, vertebral collapse, and presence of vertebral column deformities. Neuroimaging-guided needle biopsy from the affected site in the center of the vertebral body is the gold standard technique for early histopathological diagnosis. Antituberculous treatment remains the cornerstone of treatment. Surgery may be required in selected cases, e.g. large abscess formation, severe kyphosis, an evolving neurological deficit, or lack of response to medical treatment. With early diagnosis and early treatment, prognosis is generally good.

Clinical features and outcomes of spinal tuberculosis in southern Taiwan

BACKGROUND/PURPOSE

The early diagnosis and appropriate management of spinal tuberculosis (TB) is challenging for clinicians. This study aimed to characterize the clinical features and factors affecting treatment outcomes.

METHODS

A retrospective study of patients with spinal TB over a 7-year period at a medical center in southern Taiwan was conducted. Clinical features, underlying diseases, laboratory results, imaging findings, therapy, treatment duration and outcomes were analyzed.

RESULTS

Forty-eight patients (24 men and 24 women) were diagnosed with spinal TB. Their mean age was 64.3 years. The most common presenting symptoms were backache, neurological deficits, and fever. The most common vertebral area involved was lumbar spine (41.7%). The mean number of vertebra involved was 2.46. Surgery was carried out on 30 patients (62.5%). Patients who had a longer duration of symptoms prior to diagnosis were more likely to have surgery (p = 0.03), and patients who received surgery had a more favorable outcome (p = 0.063). The mean treatment course was 11.4 +/- 3.7 months. A long course treatment did not contribute to favorable outcomes. Twenty-six patients had a favorable outcome and 11 had an unfavorable outcome. Factors associated with an unfavorable outcome included older age, limb weakness, incontinence, spinal kyphotic deformity, and spinal cord compression.

CONCLUSION

For elderly patients with chronic back pain in Taiwan, the differential diagnosis of spinal TB should be considered. Image studies and computed tomography-guided aspiration are helpful for early detection. Combined surgical intervention tended to have a more favorable outcome and longer treatment periods had no additional benefit.

Treatment of spondylodiscitis in human immunodeficiency virus-infected patients: a comparison of conservative and operative therapy

STUDY DESIGN

Multicenter retrospective case series.

OBJECTIVE

To determine relevant clinical presentation and outcome of human immunodeficiency virus (HIV)-positive patients with spondylodiscitis as a function of the treatment.

SUMMARY OF BACKGROUND DATA

This is the first study comparing the clinical outcome of HIV-positive patients with spondylodiscitis as a function of the treatment.

METHODS

We performed a national multicenter retrospective case series comparing operatively versus conservatively treated HIV-positive patients with spondylodiscitis presenting between 1991 and 2007.

RESULTS

Twenty patients were included in the study. The average age of the patients at the time of admission was 43.0 years. The sex ratio m:w resulted in 2.3:1. On admission, 50% of the patients were in CDC stage C3. The CD4 T-cell count was determined as being 237.5/microL on average. At the occurrence of spondylodiscitis HIV had been known for a mean 8.5 years. In altogether 75% of the cases a pathogen was found. In 3 cases, mixed infections were present. Half of the patients received surgery. In none of these patients a wound infection or a delay of wound healing could be observed. One patient died during in-patient stay. Eleven of the 19 patients could be followed up a mean 13 months after discharge. In the follow-up period further 3 patients died on an average of 45 months after discharge.

CONCLUSION

The occurrence of spondylodiscitis in HIV-positive patients is associated with a low CD4 T-cell count. The probability of mixed infections rises with a CD4 T-cell count <100/microL. The occurrence of spondylodiscitis in HIV-positive patients is accompanied by high mortality. Operative therapy of spondylodiscitis in HIV-positive patients is not associated with an increased surgical complication rate. HIV infection or AIDS should not have an influence on decision-making regarding conservative or operative therapy of spondylodiscitis.

Spinal hydatidosis accompanied by a secondary infection. Case report

Spinal hydatid disease is rarely encountered in nonendemic regions. It is a progressive disease that is associated with risks of serious morbidity. The authors report a case of an isolated primary hydatid cyst of the spine in a 34-year-old woman who presented with back pain, which had lasted for 3 months, as well as lower-extremity pain and fatigue, which had persisted for 2 months. A neurological examination yielded findings indicative of upper motor neuron involvement with complete sensory loss below the level of T-11. Magnetic resonance imaging of the spine showed multiple extradural cystic lesions with an abscess formation at T-11 and involvement of the paraspinal muscles. The patient underwent spinal decompression in which stabilization and total excision of the multiple epidural and psoas abscesses and paraspinal multiloculated cysts were performed. The diagnosis of hydatid disease associated with another infection was confirmed by histopathological evaluation. Albendazole was administered during the postoperative period. Previous reports of secondary infections accompanying this disease in extraspinal locations have been published. However, to the best of the authors' knowledge, there have been no publications about a secondary infection associated with hydatidosis in the spinal cord. One should bear in mind that spinal hydatidosis may be accompanied by other infections in endemic regions. Antihelminthic treatment should be administered for a long period following early decompressive surgery and adequate stabilization.

Medical management of Pott disease in the thoracic and lumbar spine: a prospective clinical study

OBJECT

The aim of this study was to evaluate conservative medical management of 44 patients with Pott disease. The prognostic significance of various clinical, radiological, and long-term follow-up findings in these patients was also evaluated.

METHODS

Between January 1990 and January 2005 data were collected prospectively at the authors' clinic in 44 patients with Pott disease in the thoracic or lumbar spine. These patients had no major neurological deficits or severe spinal deformities. The study population consisted of 21 male (48%) and 23 female (52%) patients, with a mean age of 42.1 years (range 10-70 years). The most common region of Pott disease was the thoracolumbar junction (18 cases; 41%), followed by the thoracic (16 cases; 36%) and lumbar (10 cases; 23%) regions. All patients presented with abscesses. With the exception of two cases, all had kyphotic angles smaller than 30 degrees. At presentation, 20 patients had neurological signs of spinal cord compression during clinical examination. Both clinical and biopsy findings were used in all cases for diagnosis. A diagnosis was confirmed by a positive biopsy specimen culture in 19 (43.2%) of 44 cases, and histopathological findings were compatible with the results of these cultures in all cases. All patients were treated with antituberculous chemotherapy, and the diseases in only two (4.5%) was resistant to the regimen. An independent observer assessed the clinical and imaging findings after a mean follow-up duration of 40 months. Forty-two (95.4%) of the 44 patients were successfully treated with conservative medical management and attained acceptable spinal deformity angles, and none of these patients had any residual instability, radiculopathy, or neurological compromise. Only 4.5% of the patients experienced residual spine deformity (as much as a 30 degrees kyphotic angle), which was clinically obvious but biomechanically stable.

CONCLUSIONS

Patients with Pott disease in the lumbar or thoracic region, without neurological deficits or kyphosis, can be treated conservatively in the vast majority of cases. Indications for surgery need to be redefined given these new data.

The Incidence of Multiple Level Noncontiguous Vertebral Tuberculosis Detected Using Whole Spine MRI

The commonest site of osseous tuberculosis is the spine. Most vertebral lesions are contiguous. Current research indicates the incidence of multiple level noncontiguous vertebral tuberculosis is 1.1% to 16%. The aim of this study was to identify the incidence of multiple level noncontiguous vertebral tuberculosis using whole spine magnetic resonance imaging (MRI). A retrospective review was undertaken of case notes and whole spine MRI studies of all acute spinal infection cases that presented to a regional Spinal Unit over 3 years. Patients were included if spinal infection was identified by whole spine MRI and confirmed as tuberculosis by a combination of histology and microbiology. The incidence of multiple level noncontiguous vertebral tuberculosis was 71.4%. This is higher than previously quoted when MRI is not undertaken. Tuberculosis may affect the spine at multiple noncontiguous sites more frequently than thought previously. A large proportion of the affected noncontiguous sites may also be asymptomatic. We currently perform whole spine MRI on all patients with suspected spinal infection to aid detection of multiple level noncontiguous tuberculosis.

Rheumatic manifestations of human immunodeficiency virus infection

Rheumatic complaints are common in patients with HIV, and HIV positivity confers an increased susceptibility in populations with similar risk factors for HIV infection. With the advent of the modern combined antiretroviral treatment, HAART has had a profound beneficial effect on survival in HIV-infected patients, with lifelong control of HIV infection and normalization of life expectancy; but it has also contributed to both an altered frequency and a different nature of rheumatic complications now being observed in this population, with new rheumatic complications, such as osteoporosis, osteonecrosis, gout, mycobacterial, mycotic osteoarticular infections, and neoplasia perhaps more prevalent. Rheumatologists, internists, and general physicians need to be aware of these changes to provide optimal diagnosis and how to disclose the results to their patients. They also need to be familiar with the management of HIV infection and to direct careful attention to the prevention of HIV transmission in health care facilities.

Current difficulties in the diagnosis and management of spinal tuberculosis

BACKGROUND

The diagnosis of spinal tuberculosis (ST) is difficult and it commonly presents at an advanced stage. The management and follow up is complicated by a lack of guidance on the appropriate use and interpretation of spinal magnetic resonance studies (MR).

AIMS

A retrospective study was performed at a UK centre to identify the demographic and presenting features of a spinal TB population, their response to treatment, and the value of follow up MR studies.

PATIENTS AND RESULTS

Twenty one patients were identified with mean symptom duration of 11 (1.5-36) months having been assessed by a health practitioner on 3.2 (0-10) occasions before referral for investigation for ST. Twenty were born outside the UK. Their mean duration of residence in the UK was 6.67 (0.75-20) years, and six (32%) were resident for more than 10 years. Most (85.7%) did not have a medical history and one was HIV positive. Back pain, neurological, and constitutional symptoms were found in 100%, 29%, and 38% respectively. Musculoskeletal and neurological signs were found in 29% and 19% respectively. Spinal MR performed between 6 and 12 months suggests that six months of chemotherapy (for a fully sensitive organism) may not be sufficient to achieve disease resolution.

CONCLUSIONS

Awareness of the demographic, clinical, and laboratory features of an ST population may facilitate earlier diagnosis. Guidance is required on the appropriate use and interpretation of MRI in the follow up of these patients.

Extraspinal tuberculous arthritis in HIV era

A worldwide reemergence of tuberculosis is appreciable. Extrapulmonary tuberculosis has been observed to increase disproportionately from past incidence. One of the main attributing factors is the human immunodeficiency virus (HIV) infection. The objective of this study was to study clinical features, laboratory findings, and association with HIV infection in patients with peripheral tuberculous arthritis. The retrospective study was performed by reviewing the medical records of 27 patients with extraspinal tuberculous arthritis treated from January 1994 to December 2002. The diagnosis was made either by compatible clinical presentation and positive culture for Mycobacterium tuberculosis or histological finding of caseating granuloma in biopsy tissue or both. The average age of the patients' population was 49.3 years (range 27-74 years), made up of a 52% or 14 patients of male subjects. The mean duration of disease before seeking medical treatment was 10.2+11 weeks and from onset to diagnosis was 25 weeks. The most frequently affected joints were knees (36.6%) followed by wrists, ankles, shoulders, hips, sacroiliacs, and elbows, respectively. Monoarthritis was the main feature of this group, except for two patients who had two and three joints involvement, respectively. Dactylitis (tenosynovitis) was also found in two out of the 27 patients. Six patients (24%) had active pulmonary infiltration on chest X-ray. Of 11 patients with synovial polymerase chain reaction (PCR) testing for tuberculosis, seven patients had positive result. Only one patient with extraspinal tuberculous arthritis tested positive for HIV. Therefore, extraspinal tuberculous arthritis is observed to be usually present with chronic monoarthritis. The diagnosis is delayed in most occasions. PCR from synovial fluid may facilitate rapid diagnosis of tuberculous arthritis. Human immunodeficiency virus may not be a main contributing factor for extraspinal tuberculous arthritis.

Tuberculous myelopathy: current aspects of neurologic sequels in the southeast of Iran

OBJECTIVE

The spinal cord may be affected in different ways in the course of tuberculous infection. The objective of this study was to determine the epidemiologic features, clinical manifestations, pathophysiologic mechanisms, neurologic sequels, and treatment outcomes of tuberculous myelopathy in the southeast of Iran in which the disease is endemic.

METHOD

A retrospective study was scheduled. All cases of tuberculous myelopathy treated in our hospital over the last 7 years were reviewed. Only those with histologic or microbiologic confirmation or those who responded to antituberculous therapy were included.

RESULTS

During a 7-year period, 43 cases of tuberculous myelopathy were found. The most frequent clinical manifestations were backache (86%) and fever (67%). Twenty patients were paraparetic or paraplegic and 40% had kyphosis. Imaging studies revealed thoracic and/or lumbar spine involvement in 92% of patients with tuberculous spondylitis. Fifteen, five and two patients had sensorimotor spinal cord syndrome, radiculomyelitis and intramedullary syringomyelic syndrome, respectively. Forty-seven percent required surgical intervention. There was improvement in 81% of the cases.

CONCLUSION

Different pathophysiologic mechanisms acted on the clinical manifestations of spinal neurotuberculosis. A good outcome is expected if the diagnosis is made in the early stages before the appearance of spinal deformity and neurologic deficits.

Spinal infections in patients with compromised immune systems

Spinal infections are relatively uncommon but have potentially devastating consequences if not diagnosed and treated correctly. Compromised immunologic responsiveness, either transient or permanent, predisposes patients to more frequent and more severe infections. Through a Medline review of the English-language literature from 1990 to 2005, we examined the current understanding of the etiology of common immunocompromising conditions, how these diagnoses impact the relative spine infection rates including diagnosis and therapeutic monitoring, and practice trends regarding surgical intervention.

LEVEL OF EVIDENCE

Level V (expert opinion). Please see Guidelines for Authors for a complete description of the levels of evidence.

Spectrum of spine infections in patients with HIV: a case report and review of the literature

Because of the increase in patients with human immunodeficiency virus, practitioners are likely to see a concordant increase of infections. Spontaneous spinal infections can result from a variety of organisms. A common pathogen is Staphylococcus aureus, which is the most frequent cause of pyogenic spinal infection in patients who test positive for the human immunodeficiency virus. Human immunodeficiency virus has caused a resurgence of spinal tuberculosis and other infections. The pandemic of human immunodeficiency virus has caused a rise in extremely rare spinal infections caused by fungus, virus, and atypical bacteria that usually are nonpathogenic. As the number of elective and emergent spinal surgeries become more frequent, spinal practitioners also must become more familiar with the particularities of preoperative and perioperative decision making. Patients' CD4 cell counts are a useful preoperative parameter to stratify the risk for postoperative wound infection because counts less than 200/mm3 seem to be a critical threshold. A case of a patient with the human immunodeficiency virus is presented. The patient had a chronic, postoperative infection and posttraumatic post-laminectomy kyphosis; he was successfully treated with staged procedures including debridement, deformity correction, stabilization, and appropriate antibiotic therapy.

LEVEL OF EVIDENCE

Level V (expert opinion). Please see the Guidelines for Authors for a complete description of levels of evidence.

Pott disease in the thoracolumbar spine with marked kyphosis and progressive paraplegia necessitating posterior vertebral column resection and anterior reconstruction with a cage

STUDY DESIGN

Case report.

OBJECTIVES

To report on a patient with Pott disease, progressive neurologic deficit, and severe kyphotic deformity, who had medical treatment fail and required posterior/anterior decompression with instrumented fusion. Treatment options will be discussed.

SUMMARY OF BACKGROUND DATA

Tuberculous spondylitis is an increasingly common disease worldwide, with an estimated prevalence of 800,000 cases.

METHODS

Surgical treatment consisting of extensive posterior decompression/instrumented fusion and 3-level posterior vertebral column resection, followed by anterior debridement/fusion with cage reconstruction.

RESULTS

Neurologic improvement at 6-month follow-up (Frankel B to Frankel D), with evidence of radiographic fusion.

CONCLUSIONS

A 70-year-old patient with progressive Pott paraplegia and severe kyphotic deformity, for whom medical treatment failed is presented. A posterior vertebral column resection, multiple level posterior decompression, and instrumented fusion, followed by an anterior interbody fusion with cage was used to decompress the spinal cord, restore sagittal alignment, and debride the infection. At 6-month follow-up, the patient obtained excellent pain relief, correction of deformity, elimination of the tuberculous foci, and significant recovery of neurologic function.

Routine surgery in addition to chemotherapy for treating spinal tuberculosis

BACKGROUND

Tuberculosis is generally curable with chemotherapy, but there is controversy in the literature about the need for surgical intervention in the one to two per cent of people with tuberculosis of the spine.

OBJECTIVES

To compare chemotherapy plus surgery with chemotherapy alone for treating people diagnosed with active tuberculosis of the spine.

SEARCH STRATEGY

We searched the Cochrane Infectious Diseases Group Specialized Register (October 2005), CENTRAL (The Cochrane Library 2005, Issue 4), MEDLINE (1966 to October 2005), EMBASE (1974 to October 2005), LILACS (1982 to October 2005), conference proceedings, and reference lists.

SELECTION CRITERIA

Randomized controlled trials with at least one year follow up that compared chemotherapy plus surgery with chemotherapy alone for treating active tuberculosis of the thoracic and/or lumbar spine.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial eligibility, methodological quality, and extracted data. We analysed data using odds ratio with 95% confidence intervals.

MAIN RESULTS

Two randomized controlled trials (331 participants) met the inclusion criteria. They were conducted in the 1970s and 1980s with follow-up reports available after 18 months, three years, and five years; one trial also reported 10 years follow up. Completeness of follow up varied at the different time points, with less than 80% of participants available for analysis at several time points. There was no statistically significant difference for any of the outcome measures: kyphosis angle, neurological deficit (none went on to develop this), bony fusion, absence of spinal tuberculosis, death from any cause, activity level regained, change of allocated treatment, or bone loss. Neither trial reported on pain. Of the 130 participants allocated to chemotherapy only, 12 had a neurological deficit and five needed a decompression operation. One trial suggested that an initial kyphosis angle greater than 30 degrees is likely to deteriorate, especially in children.

AUTHORS' CONCLUSIONS

The two included trials had too few participants to be able to say whether routine surgery might help. Although current medication and operative techniques are now far more advanced, these results indicate that routine surgery cannot be recommended unless within the context of a large, well-conducted randomized controlled trial. Clinicians may judge that surgery may be clinically indicated in some groups of patients. Future studies need to address these topics as well as the patient's view of their disease and treatment.

Spinal tuberculosis: CT and MRI feature

BACKGROUND

Spinal tuberculosis (TB) is perhaps the most clinically important extrapulmonary form of the disease. Early recognition is therefore necessary to minimize residual spinal deformity and/or permanent neurological deficit. We defined the CT and MRI image morphology of spinal TB and correlated the imaging features of these two modalities.

METHODS

CT (29 patients) and MRI (11 patients) images were retrospectively analyzed in 30 patients with proved spinal TB. CT and MRI findings were compared in cases with both imaging tests (10 cases). The parameters assessed were the type and extent of bone and soft tissue involvement.

RESULTS

The majority of the 30 patients were males (n=18) in the 30-49 year age group (43%). The most common clinical presentation was backache (73.3%) followed by fever (63.3%) and malaise (36.6%). The lumbar spine was the commonest site of the disease (43.3%) followed by the thoracic region (36.6%). A fragmentary type of bone destruction was the most frequent CT feature of the disease (48.2%) followed by the lytic type (24.1%). Intervertebral disc destruction (72%) and paravertebral mass/abscess (65.5%) were other features. Of the 11 patients who had an MRI, contiguous vertebral disease with disc destruction was seen in 10 cases. In 4 patients, there was distant vertebral disease in addition to the disease at the symptomatic site.

CONCLUSIONS

MRI offers excellent visualization of the bone and soft tissue components of spinal tuberculosis and helps to identify disease at distant asymptomatic sites. CT is useful in assessing bone destruction, but is less accurate in defining the epidural extension of the disease and therefore its effect on neural structures. MR imaging clearly demonstrated the extent of soft tissue disease and its effect on the theca/cord and foramen in cases with doubtful CT findings.

A surgical revisitation of Pott distemper of the spine

BACKGROUND CONTEXT

Pott disease and tuberculosis have been with humans for countless millennia. Before the mid-twentieth century, the treatment of tuberculous spondylitis was primarily supportive and typically resulted in dismal neurological, functional and cosmetic outcomes. The contemporary development of effective antituberculous medications, imaging modalities, anesthesia, operative techniques and spinal instrumentation resulted in quantum improvements in the diagnosis, management and outcome of spinal tuberculosis. With the successful treatment of tuberculosis worldwide, interest in Pott disease has faded from the surgical forefront over the last 20 years. With the recent unchecked global pandemic of human immunodeficiency virus, the number of tuberculosis and secondary spondylitis cases is again increasing at an alarming rate. A surgical revisitation of Pott disease is thus essential to prepare spinal surgeons for this impending resurgence of tuberculosis.

PURPOSE

To revisit the numerous treatment modalities for Pott disease and their outcomes. From this information, a critical reappraisal of surgical nuances with regard to decision making, timing, operative approach, graft types and the use of instrumentation were conducted.

STUDY DESIGN

A concise review of the diagnosis, management and surgical treatment of Pott disease.

METHODS

A broad review of the literature was conducted with a particular focus on the different surgical treatment modalities for Pott disease and their outcomes regarding neurological deficit, kyphosis and spinal stability.

RESULTS

Whereas a variety of management schemes have been used for the debridement and reconstruction of tuberculous spondylitis, there has also been a spectrum of outcomes regarding neurological function and deformity. Medical treatment alone remains the cornerstone of therapy for the majority of Pott disease cases. Surgical intervention should be limited primarily to cases of severe or progressive deformity and/or neurological deficit. Based on the available evidence, radical ventral debridement and grafting appears to provide reproducibly good long-term neurological outcomes. Furthermore, recurrence of infection is lowest with such techniques. Posterior operative techniques are most effective in the reduction and prevention of spinal deformity.

CONCLUSIONS

Unlike historical times, effective medical and surgical management of tuberculous spondyitis is now possible. Proper selection of drug therapy and operative modalities, however, is needed to optimize functional outcomes for each individual case of Pott disease.

Rheumatic manifestations of human immunodeficiency virus infection

Rheumatic complaints are common in patients with human immunodeficiency virus (HIV) infection. With the advent of the modern combined antiretroviral treatment, life-long control of HIV infection and normalization of life expectancy in HIV-positive patients have become realistic perspectives, but new rheumatic complications, such as osteoporosis, osteonecrosis, gout, and mycobacterial and mycotic osteoarticular infections may be more prevalent. Rheumatologists, internists, and general physicians need to be familiar with the presentation and treatment of these conditions in HIV-positive patients.

Tuberculosis of the spine (Pott's disease) presenting as 'compression fractures'

STUDY DESIGN

Case reports and survey of literature.

OBJECTIVE

Case reports of two women with tuberculosis (TB) of the spine (Pott's disease) presenting with severe back pain and diagnosed as compression fracture are described. Physicians should include Pott's disease in the differential diagnosis when patients present with severe back pain and evidence of vertebral collapse.

SETTING

Ohio, USA METHODS: A review of the literature on the pathogenesis, pathophysiology, clinical presentation, diagnostic methods, treatment and prognosis of spinal TB was conducted.

RESULTS

After initial delay, proper diagnosis of spinal TB was made in our patients. Microbiologic diagnosis confirmed M. tuberculosis, and appropriate medical treatment was initiated.

CONCLUSIONS

Although uncommon, spinal TB still occurs in patients from developed countries, such as the US and Europe. Back pain is an important symptom. Vertebral collapse from TB may be misinterpreted as 'compression fractures' especially in elderly women. Magnetic resonance imaging scan (MRI) is an excellent procedure for the diagnosis of TB spine. However, microbiologic diagnosis is essential. Mycobacterium tuberculosis may be cultured from other sites. Otherwise, biopsy of the spine lesion should be done for pathologic diagnosis, culture and stain for M. tuberculosis. Clinicians should consider Pott's disease in the differential diagnosis of patients with back pain and destructive vertebral lesions. Proper diagnosis and anti-tuberculosis treatment with or without surgery will result in cure.

Human immunodeficiency virus and osteoarticular tuberculosis

The human immunodeficiency virus pandemic has contributed to a marked increase in patients infected with tuberculosis. In parts of SubSaharan Africa, osteoarticular tuberculosis has increased fourfold in the past decade and approximately 60% of the patients are infected with the human immunodeficiency virus. The human immunodeficiency virus has complicated the diagnostic process and treatment. Tuberculosis will respond to chemotherapy in patients who are positive for the human immunodeficiency virus but adverse drug reactions are common. Careful assessment is necessary if surgery is contemplated because of the high risk of infection and poor wound healing in patients with advanced human immunodeficiency virus disease. In patients with osteoarticular tuberculosis who are positive for human immunodeficiency virus, the prognosis will depend on the stage that the human immunodeficiency virus infection has reached by the time of presentation.

Detection of tubercular antibody and antigen in sera of bone and joint tuberculosis

Trichloroacetic acid (TCA) solubilized and DEAE fractionatedMycobacterium tuberculosis H(37)Ra excretory-secretory (ES) antigen viz., Mtb EST DE1 and affinity purified goat antibodies to the TCA solubilized ES antigen (Mtb EST) were explored in detecting tubercular antibody and antigen respectively in sera of bone and joint tuberculosis by indirect and sandwich ELISA. Out of total 36 bone & joint tuberculosis cases, tubercular antibody was detected by indirect ELISA in 30 patients (sensitivity 83%), while circulating tubercular antigen was detected by sandwich ELISA in 27 patients (sensitivity 75%). Out of 34 non tubercular disease control cases, 10 patients showed positive reaction for antibody while only 4 patients showed positive reaction for antigen. In another group of 34 healthy subjects who were screened, 4 individuals showed positive reaction for tubercular antibody and 2 cases for antigen. This study shows that antigen detection assay using affinity purified anti Mtb EST antigen antibody is superior with overall specificity of 91% as compared to antibody detection assay with 75% specificity in bone & joint tuberculosis.

Value of radiologically guided fine needle aspiration cytology (FNAC) in the diagnosis of spinal tuberculosis: a study of 29 cases

FNAC is a simple diagnostic tool for the initial evaluation of various deep seated pathological lesions. This study describes the applicability and practical aspects of the technique in establishing the diagnosis of spinal tuberculosis (TB) with the aid of radiographic guidance. The study was conducted in a major teaching hospital in Kuwait between the years 1985 and 1994. Twenty-nine patients (M:F = 18:11 and age range 8-72 years) with clinically and/or radiologically suspected spinal TB were seen in the Department of Cytology, Mubarak Al Kabeer Hospital. The patients were re-examined by either computed tomography (CT) scanning (n = 19) or fluoroscopy (n = 10) to localize the lesion for FNAC. FNAC smears were routinely stained with Papanicolaou and Diff Quik stains and one smear of each case was stained with Ziehl-Neelsen (Z-N) stain for acid-fast bacilli (AFB). Aspirated purulent material or syringe washings of dry aspirates were also submitted for microbiological cultures including AFB. Radiological and cytological findings were recorded in each case. Radiological findings included: bony rarefaction and destruction (93.1%), narrowed disc space (89.7%), soft tissue calcification (65.5%) and para-vertebral abscess formation (51.7%). Cytological findings included: epithelioid cell granulomas (89.7%), granular necrotic background (82.8%) and lymphocytic infiltration (75.9%). Smears were positive for AFB in 51.7% of cases. A positive AFB culture was obtained in 82.8% of cases, including all cases with positive AFB on smear by Z-N stain. Radiologically guided FNAC with AFB culture is a simple, reliable and practical approach to diagnosing spinal TB lesions. With a high diagnostic yield, it allows immediate initiation of specific treatment, helps to avoid invasive diagnostic procedures, and decreases hospitalization time.

Spinal tuberculosis in adults. A study of 103 cases in a developed country, 1980-1994

Spinal tuberculosis (TB) accounts for about 2% of all cases of TB. New methods of diagnosis such as magnetic resonance imaging (MRI) or percutaneous needle biopsy have emerged. Two distinct patterns of spinal TB can be identified, the classic form, called spondylodiscitis (SPD) in this article, and an increasingly common atypical form characterized by spondylitis without disk involvement (SPwD). We conducted a retrospective study of patients with spinal TB managed in the area of Paris, France, between 1980 and 1994 with the goal of defining the characteristics of spinal TB and comparing SPD to SPwD. The 103 consecutive patients included in our study had TB confirmed by bacteriologic and/or histologic studies of specimens from spinal or paraspinal lesions (93 patients) or from extraspinal skeletal lesions (10 patients). Sixty-eight percent of patients were foreign-born subjects from developing countries. None of our patients was HIV-positive. SPD accounted for 48% of cases and SPwD for 52%. Patients with SPwD were younger and more likely to be foreign-born and to have multiple skeletal TB lesions. Neurologic manifestations were observed in 50% of patients, with no differences between the SPD and SPwD groups. Of the 44 patients investigated by MRI, 6 had normal plain radiographs; MRI was consistently positive and demonstrated epidural involvement in 77% of cases. Bacteriologic and histologic yields were similar for surgical biopsy (n = 16) and for percutaneous needle aspiration and/or biopsy (n = 77). Cultures for Mycobacterium tuberculosis were positive in 83% of patients, and no strains were resistant to rifampin. Median duration of antituberculous chemotherapy was 14 months. Surgical treatment was performed in 24% of patients. There were 2 TB-related deaths. Our data suggest that SPwD may now be the most common pattern of spinal TB in foreign-born subjects in industrialized countries. The reasons for this remain to be elucidated.