Clinical features and outcomes of spinal tuberculosis in southern Taiwan

Development of the novel gene chip and restriction fragment length polymorphism (RFLP) methods for rapid detection of Mycobacterium tuberculosis complex in broth culture

BACKGROUND

Tuberculosis (TB) is a major global public health issue. Prompt and accurate TB diagnosis is crucial for starting appropriate treatments and preventing the disease's spread. Current diagnostic techniques are either slow or expensive. This study aimed to create and evaluate a new, fast, highly reliable, and cost-effective TB detection method using a gene chip and Restriction Fragment Length Polymorphism (RFLP) analysis on Mycobacteria Growth Indicator Tubes (MGIT) specimens.

METHODS

We assessed the effectiveness of a novel gene chip and RFLP methods targeting the 16S rRNA gene of Mycobacterium tuberculosis in 2000 MGIT culture-positive specimens. RFLP analysis identified the AfeI restriction site within the M. tuberculosis complex (MTBC) genome. Discrepancies were investigated through extensive sequencing and Cobas TaqMan PCR analysis, along with reviewing patient profiles.

RESULTS

Both methods showed high efficacy in detecting MTBC in broth cultures, with the gene chip method achieving a sensitivity of 99.27 %, specificity of 98.35 %, and the RFLP method showing a sensitivity of 98.18 %, specificity of 99.31 %. False negatives in two isolates were due to a mutation in the AfeI site. Additionally, five cases showed MTBC presence when nontuberculous Mycobacterium species grew in cultures.

CONCLUSION

Our novel gene chip and RFLP methods are effective for rapid highly-reliable and cost-effective M. tuberculosis detection in MGIT specimens. Both gene chip and RFLP methods are suitable for resource-limited settings, offering an economical advantage. These methods have significant potential to improve clinical TB diagnosis.

Exploring Thoracolumbar Pott's Disease in the Immunocompetent; Institutional Experience Over a Decade and Comprehensive Literature Review

Background

The presentation of Pott's has a wide variation and an insidious onset, which makes timely accurate diagnosis quite challenging.

Objective

To review Pott's cases to enhance the disease management and fill the literature gap regarding the approach to Pott's disease.

Methods

A descriptive observational retrospective hospital-based study conducted from 2007 to 2022 at KFHU. 346 patients who were diagnosed with TB were reviewed thoroughly. Only 13 cases were labeled as Pott's disease based on imaging or microbiology testing and hence were included in this study, and other TB pulmonary and extrapulmonary cases were excluded.

Results

In our analysis of 13 cases of Pott's disease, we observed a significant male predominance (69.23%) and diverse symptoms, with back pain (69.2%) being most prevalent among our patients. Lumbar involvement was the most frequently observed site (38.4%), and diagnoses were made through microbiology (69.2%) or clinical/radiological means (30.8%). Acid-fast bacilli (AFB) culture testing exhibited a positivity rate of 61.5%, while TB-PCR showed positive results in 57.1%. Imaging studies revealed vertebral lesions (90.9% CT, 81.8% MRI), abscesses (54.5% CT, 81.8% MRI), and spondylodiscitis (18.2% CT, 54.5% MRI). Treatment, administered in 92.3% of cases, involved the use of Isoniazid, Rifampicin, and Ethambutol. Surgical interventions, though less frequent, encompassed various procedures. Outcomes demonstrated a notable high cure rate of 84.9%, with a 15.4% incidence of cases experiencing loss of follow-up.

Conclusion

The high cure rate of 84.9% accentuates the effectiveness of early diagnosis and comprehensive treatment strategies that combine medical and surgical interventions when necessary.

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.

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

STUDY DESIGN

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

PURPOSE

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

OVERVIEW OF LITERATURE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Active tuberculosis of spine: Current updates

Background

Spinal tuberculosis (TB) is the most common extrapulmonary form of tuberculosis. In both developing and developed countries, TB has been on the rising trend due to factors such as increasing HIV coinfection, multidrug resistance of the organism, and global migration. Spinal TB, which most often affects the lower thoracic and thoracolumbar area, accounts for 50% of all musculoskeletal tuberculosis.

Methods

Using the Cochrane Database of Systematic Reviews, EMBASE, and PubMed, a systematic computerized literature search was performed. Analyses of studies published within the past 10 years were conducted. The searches were performed using Medical Subject Headings terms, with "spinal tuberculosis," "diagnosis," "epidemiology," and "etiology","management," "surgery," and "therapy" as subheadings.

Results

Progressive collapse, kyphosis, and neurological deficiency are hallmarks of the disease because of its destructive effect on the intervertebral disc and adjacent vertebral bodies. The condition may be identified using laboratory testing and distinctive imaging features, but the gold standard for diagnosis is tissue diagnosis using cultures, histology, and polymerase chain reaction. Uncomplicated spinal TB is today a medical condition that can be adequately treated by multidrug ambulatory chemotherapy. Surgery is reserved for individuals who have instability, neurological impairment, and deformity correction. Debridement, deformity correction, and stable fusion are the cornerstones of surgical treatment.

Conclusions

Clinical results for the treatment of spinal TB are generally satisfactory when the disease is identified and treated early. However, the major health issue and the biggest obstacle in achieving the goals of the "End TB strategy" is the recent rise in the emergence of drug resistance. Hence strict vigilance and patient perseverance in the completion of the treatment is the main need of the hour.

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.

Clinical Features and Outcomes of Spinal Tuberculosis in Central China

Purpose

The appropriate management of spinal tuberculosis (TB) is challenging for clinicians and the key to treat spinal TB. Surgery and long course anti-TB chemotherapy may not be necessary to all situations. This study aimed to characterize the clinical features and factors affecting treatment outcomes.

Patients and Methods

A retrospective study of patients with spinal TB over a 5-year period at a teaching hospital in central China was conducted. Features of patients with spinal TB who received different treatment modalities and factors associated with patient outcomes at the end of chemotherapy were analyzed.

Results

Forty-five patients (21 men and 24 women) with spinal TB were available for analysis. The mean age was 55.39 ± 14.94 years. The most common vertebral area involved was the lumbar (42.2%). The mean number of vertebrae involved was 2.20 ± 0.59. 27 patients (60.0%) received surgical treatment, of which 21 (77.8%) received radical surgical treatment. Thirty-five patients (77.8%) had achieved a favorable status. Statistically, there was no significant correlation between favorable status and surgery, but among 27 surgical patients with spinal tuberculosis, patients receiving radical surgery tended to achieve good prognosis (P = 0.010; odds ratio = 0.053; 95% confidence interval 0.006–0.493). Moreover, there was no significant difference between long course and short course of anti-TB chemotherapy in prognosis in different treatment modalities.

Conclusion

Although the patients with spinal TB who needed surgical treatment often got a better prognosis when they had radical surgery, surgery was not actually a factor for the favorable outcomes of patients with spinal TB. In different treatment modalities, there was no additional benefit in longer anti-TB chemotherapy periods.

One-stage surgical treatment of upper thoracic spinal tuberculosis by posterolateral costotransversectomy using an extrapleural approach

BACKGROUND

Due to the complexity of the anatomical structure and the difficulty of exposing the surgical area, the surgery for spinal tuberculosis in the upper thoracic vertebra (above T6-T7) is complicated and the prognosis is not good. This study aimed to investigate the clinical effects of posterolateral costotransversectomy using an extrapleural approach in patients with upper thoracic spinal tuberculosis.

METHODS

This was a retrospective analysis of 132 patients (including 78 males and 54 females) with upper thoracic spinal tuberculosis who underwent one-stage internal fixation and debridement followed by combined interbody and posterior fusion via posterolateral costotransversectomy using an extrapleural approach. The age ranged from 23 to 82 years (54.5 ± 13.2 years). Lesion segments were distributed from T2 to T7. According to Frankel's spinal cord function evaluation, there were 2 cases of grade A, 6 of grade B, 6 of grade C, 12 of grade D, and 106 of grade E. The preoperative Cobb angle was 16-40° (29.1° ± 6.5°). Operation time, bleeding volume, incision healing, bone graft fusion, deformity correction, and improvement of nerve function were analyzed.

RESULTS

The operation time ranged from 2.8 to 4.1 h (3.4 ± 0.3 h), and blood loss ranged from 350 to 550 mL (460 ± 47 mL). All incisions healed in the first stage. The bone graft fusion time was 3-6 months (median of 4 months). There was no loosening or broken of the internal fixation. The C-reactive protein and erythrocyte sedimentation rate were significantly improved at the end of follow-up in comparison with before surgery. The Cobb angle of the fusion segment was corrected and ranged from 5° to 17° (average of 10.7° ± 3.3°) at the end of follow-up. The nerve function of all patients improved at different degrees by the time of the last follow-up. In the last follow-up, the Frankel grade distribution was 1 case in B grade, 2 cases in grade C, 6 cases in grade D, and 123 cases in grade E.

CONCLUSION

Posterolateral costotransversectomy using an extrapleural approach is a safe and effective surgical method that can expose the upper thoracic spine lesions and reduce trauma.

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.

Surgical management of complex post-tuberculous kyphosis among African patients: clinical and radiographic outcomes for a consecutive series treated at a single institution in West Africa

STUDY DESIGN

Retrospective review of consecutive series.

OBJECTIVE

To assess the clinical and radiographic outcomes after surgical management of post-tuberculous kyphosis. Post-tuberculous (TB) kyphosis can lead to progressive pulmonary and neurological deterioration. Surgery is indicated to decompress neural elements and correct the spine deformity. Although posterior vertebral column resection (PVCR) has been established as the treatment of choice for severe TB kyphosis, there is paucity of studies on the clinical outcomes among patients treated in West Africa.

METHODS

Clinical and radiographic data of 57 patients (pts) who underwent surgical correction of post-TB kyphosis at a single site in West Africa between 2013 and 2018 (≥ 2-year follow-up in 36 pts, ≥ 1-year FU in 21 pts). Pre- and post-op SRS scores and radiographic outcomes were compared using Paired t test.

RESULTS

57 patients, 36M:21F. Mean age 19 (11-57 years). 22/57 pts (39.3%) underwent pre-op halo gravity traction (HGT) for an average duration of 86 days (8-144 days). HGT pts had a higher baseline regional kyphosis (125.1 ± 20.9) compared to non-HGT pts (64.6 ± 31.8, p < 0.001). Post-HGT regional kyphosis corrected to 101.2 ± 23 (24° correction). 53 pts (92.9%) underwent posterior-only surgery and 4 (7.0%) combined anterior-posterior surgery. 39 (68.4%) had PVCR, 11 (19.3%) PSO, and 16 (28.1%) thoracoplasty. Intraoperative neuromonitoring (IOM) signal changes occurred in 23/57 pts (≈ 40%), dural tear in 5 pts (8.8%), pleural tear in 3 pts (5.3%), ureteric injury in 1 pt (1.7%), and vascular injury in 1 pt (1.7%). Post-op complications included four (7.0%) infection, three (5.3%) implant related, two (3.5%) radiographic (one PJK and one DJK), one (1.7%) neurologic, one (1.7%) wound problem, and two (3.5%) sacral ulcers. IOM changes were similar in the VCR (48.7%) and non-VCR (23.5%) pts, p > 0.05. Complication rates were similar among HGT and non-HGT groups. Significant improvements from baseline were seen in the average SRS Total and domains scores and radiographic measurements for patients who attained 2-year follow-up.

CONCLUSION

PVCR ± HGT can provide safe and optimal correction in cases of severe post-TB kyphosis with good clinical and radiographic outcomes in underserved regions.

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.

Prognostic factors for unfavourable outcomes of patients with spinal tuberculosis in a country with an intermediate tuberculosis burden

Aims

Spinal tuberculosis (TB) remains an important concern. Although spinal TB often has sequelae such as myelopathy after treatment, the predictive factors affecting such unfavourable outcomes are not yet established. We investigated the clinical manifestations and predictors of unfavourable treatment outcomes in patients with spinal TB.

Patients and Methods

We performed a multicentre retrospective cohort study of patients with spinal TB. Unfavourable outcome was defined according to previous studies. The prognostic factors for unfavourable outcomes as the primary outcome were determined using multivariable logistic regression analysis and a linear mixed model was used to compare time course of inflammatory markers during treatment. A total of 185 patients were included, of whom 59 patients had unfavourable outcomes.

Results

In multivariate regression analysis, the factors associated with unfavourable outcome were old age (odds ratio (OR) 2.51; 95% confidence interval (CI) 1.07 to 5.86; p = 0.034), acid-fast bacilli (AFB) smear positivity in specimens obtained through biopsy (OR 3.05; 95% CI 1.06 to 8.80; p = 0.039), and elevated erythrocyte sedimentation rate (ESR) at the end of treatment (OR 3.85; 95% CI 1.62 to 9.13; p = 0.002). Patients with unfavourable outcomes had a significant trend toward higher ESR during treatment compared with patients with favourable outcome (p = 0.009). Duration of anti-TB and surgical treatment did not affect prognosis.

Conclusion

Elevated ESR at the end of treatment could be used as a marker to identify spinal TB patients with a poor prognosis. Patients whose ESR is not normalized during treatment, as well as those with old age and AFB smear positivity, should be aware of unfavourable outcomes. Cite this article: Bone Joint J 2019;101-B:1542–1549

Vertebral column resection for post tuberculosis severe kyphotic deformity: Results of 5 year follow-up

Background

Spinal TB is endemic in our study region and many patients present with severe kyphotic deformities and neurological deficit. We corrected such deformities with all posterior single stage surgeries. This study was undertaken to evaluate the results, efficacy and safety of this technique.

Methods

Deformity correction of 16 patients was done during January 2012 to December 2014. All patients underwent posterior only approach for vertebral column resection at peri-apical region, posterior instrumentation with pedicular screws and anterior reconstruction using mesh cage. Postoperative X-ray films were evaluated. All patients were followed up at six weeks, 12 weeks, 18 weeks, six months and yearly thereafter. At follow-up patients were evaluated neurologically and radio-graphically.

Results

Mean age of the patients was 19.43 years. (Range 3-37) An average 1.62 vertebrae were excised and 5.93 vertebral levels were instrumented. Mean blood loss was 1013 ml and the mean duration of surgery was 6.78 h. The decrease in mean kyphotic deformity from preoperative 90.08⁰ to postoperative 38.06⁰ was statistically significant. (P < 0.000) Mean percentage correction was 57.59%. No pseudoarthrosis was found on X-rays. The decrease in Oswestry's Disability Index was from 55.43 to 10.06 was statistically significant. (P < 0.000) Two patients had neurological complications and one patient had wound complication.

Conclusion

The safety and efficacy of Posterior VCR technique for post tuberculosis severe kyphotic deformity is favorable with no severe late stage complications. Excision of ribs, careful handling of cord and gradual correction of deformity with good hemostasis is important.

Joint EANM/ESNR and ESCMID-endorsed consensus document for the diagnosis of spine infection (spondylodiscitis) in adults

PURPOSE

Diagnosis of spondylodiscitis (SD) may be challenging due to the nonspecific clinical and laboratory findings and the need to perform various diagnostic tests including serologic, imaging, and microbiological examinations. Homogeneous management of SD diagnosis through international, multidisciplinary guidance would improve the sensitivity of diagnosis and lead to better patient outcome.

METHODS

An expert specialist team, comprising nuclear medicine physicians appointed by the European Association of Nuclear Medicine (EANM), neuroradiologists appointed by the European Society of Neuroradiology (ESNR), and infectious diseases specialists appointed by the European Society of Clinical Microbiology and Infectious Diseases (ESCMID), reviewed the literature from January 2006 to December 2015 and proposed 20 consensus statements in answer to clinical questions regarding SD diagnosis. The statements were graded by level of evidence level according to the 2011 Oxford Centre for Evidence-based Medicine criteria and included in this consensus document for the diagnosis of SD in adults. The consensus statements are the result of literature review according to PICO (P:population/patients, I:intervention/indicator, C:comparator/control, O:outcome) criteria. Evidence-based recommendations on the management of adult patients with SD, with particular attention to radiologic and nuclear medicine diagnosis, were proposed after a systematic review of the literature in the areas of nuclear medicine, radiology, infectious diseases, and microbiology.

RESULTS

A diagnostic flow chart was developed based on the 20 consensus statements, scored by level of evidence according to the Oxford Centre for Evidence-based Medicine criteria.

CONCLUSIONS

This consensus document was developed with a final diagnostic flow chart for SD diagnosis as an aid for professionals in many fields, especially nuclear medicine physicians, radiologists, and orthopaedic and infectious diseases specialists.

Clinical-Morphological Aspects in Spinal Tuberculosis

Osteoarticular tuberculosis (OATB) Aim: The authors made a clinical morphological assessment of tissue samples from patients admitted in Surgical Departments of the Emergency County Hospital of Craiova, Romania, between 1990 and 2015, proved as presenting tuberculous lesions of the spine in the Department of Pathology of the same Hospital. Materials and Methods: The studied material consisted of bone, joint and sometimes muscle tissue fragments resulted from biopsies or surgical excisions from 7 cases coming out of 54 patients investigated in the above-mentioned period of time, where the established histological diagnosis was tuberculosis (TB). For diagnostic confirmation, Ziehl-Neelsen staining has been used as a rule but, in some cases, immunohistochemistry was also used. Results: TB lesions have prevailed in men and around the age of 50 years. Thoracic segment of the spine was the most involved. Epithelioid and giant Langhans cells dominated the inflammatory cellular population. Necrosis was always present, usually in its classical acidophilic form. Fibrosis was almost always absent. On the whole, the granulomatous reaction was in almost half of the cases hyporeactive and disorganized. Conclusions: The clinical morphological profile of our series is fitting with data described in the literature. Because of its life threatening potential, spinal TB should be investigated thoroughly especially in its morphological features in order to obtain as quickly as possible an etiological diagnosis.

Extrapulmonary tuberculosis: a debilitating and often neglected public health problem

We report a case of a 33-year-old woman from Nepal who presented to a hospital with paraplegia. She was found to have pulmonary tuberculosis (TB) with lumbar spine involvement, and bilateral psoas abscesses. She had no initial symptoms attributable to pulmonary involvement. Her delayed presentation to the hospital led to complication of TB spine, which compromised the life of this woman working as a labourer. Early diagnosis and treatment of extrapulmonary TB is essential. Awareness regarding symptoms of different forms of extrapulmonary TB and making diagnostic modalities such as CT scan, MRI or biopsy readily available through insurance schemes are some important measures to minimise the problem so that complications like paraplegia as in our patient with spinal TB can potentially be avoided.

Spinal Tuberculosis: Current Concepts

STUDY DESIGN

Review article.

OBJECTIVES

A review of literature on the epidemiology, diagnosis, and management of spinal tuberculosis (TB).

METHODS

A systematic computerized literature search was performed using Cochrane Database of Systematic Reviews, EMBASE, and PubMed. Studies published over the past 10 years were analyzed. The searches were performed using Medical Subject Headings terms, and the subheadings used were "spinal tuberculosis," "diagnosis," "epidemiology," "etiology," "management," "surgery," and "therapy."

RESULTS

Tissue diagnosis remains the only foolproof investigation to confirm diagnosis. Magnetic resonance imaging and Gene Xpert help in early detection and treatment of spinal TB. Uncomplicated spinal TB has good response to appropriately dosed multimodal ambulant chemotherapy. Surgery is warranted only in cases of neurological complications, incapacitating deformity, and instability.

CONCLUSIONS

The incidence of atypical clinicoradiological presentations of spinal TB is on the rise. Improper dosing, inadequate duration of treatment, and inappropriate selection of candidates for chemotherapy has not only resulted in the resurgence of TB but also led to the most dreadful consequence of multidrug resistant strains. In addition, global migration phenomenon has resulted in worldwide spread of spinal TB. The current consensus is to diagnose and treat spinal TB early, prevent complications, promote early mobilization, and restore the patient to his or her earlier functional status.

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.

Demographics of tuberculosis of spine and factors affecting neurological improvement in patients suffering from tuberculosis of spine: a retrospective analysis of 312 cases

OBJECTIVES

The purpose of the study was to study demographics of tuberculosis of spine and analyze factors that might affect neurological improvement in such patients.

METHODS

Of the 638 suspected cases of spinal tuberculosis, 312 cases with confirmed diagnosis with at least 1-year follow-up were selected for retrospective analysis. Two hundred cases who presented with neurological deficit were further divided into three groups-completely improved, partially improved and no improvement according to American Spinal Injury Association impairment scale (AIS) grading. All continuous variables and categorical variables were compared across groups.

RESULTS

A total of 209 (66.99%) patients had typical clinical presentation. A total of 264 (84.62%) had typical magnetic resonance imaging (MRI) presentation. Among 356 involved vertebrae, thoracic levels (T1-10) were most commonly affected in 163 (45.78%) followed by thoracolumbar (T11-L2) vertebrae in 98 (27.52%). In 250 patients (80.12%), disease was restricted to one or two adjoining vertebrae. At presentation, 112 (35.89%) patients were neurologically intact, whereas 97 (31%) were AIS D, 65 (20.83%) were AIS C, 8 (2.5%) were AIS B and 30 (9.61%) were AIS A. On statistical analysis, although three groups of patients with complete improvement, partial improvement and no improvement were similar in age, sex, radiological presentation, and co-morbidities and the presence of pulmonary tuberculosis, they were significantly different with regard to the levels of vertebral involvement, AIS grade at presentation, bladder and bowel involvement and its duration.

CONCLUSIONS

In management of patients suffering from tuberculosis of spine, levels of vertebral involvement, AIS grade at presentation, bladder and bowel involvement and its duration significantly affect the final neurological improvement.

Evaluation of prognostic factors in medically treated patients of spinal tuberculosis

This study was aimed to determine the prognostic factors in medically treated patients of spinal tuberculosis. In this longitudinal observational study, from July 2010 to December 2011, 70 consecutive patients (40 males and 30 females) spinal tuberculosis were enrolled. Diagnosis of spinal tuberculosis was based on characteristic clinical and neuroimaging features. Diagnosis was histopathologically and/or bacteriologically verified. Patients received antituberculous treatment as per World Health Organization guidelines and were followed for 6 months. Disability was evaluated with modified Barthel index (MBI). Outcome was defined as good (MBI > 12) and poor (MBI ≤ 12). Various clinical and neuroimaging parameters, likely to affect the outcome, were analyzed using univariate and multivariate analysis. After 6 months, 45 patients had a good outcome, while 25 patients had a poor outcome. On univariate analysis, duration of illness >6 months (OR 0.062, CI 0.018-0.212), bladder involvement (OR 0.102, CI 0.033-0.317), spinal deformity (OR 0.050, CI 0.013-0.196), spastic paraparesis (OR 0.572, CI 0.190-1.723), and flexor spasms (OR 0.077, CI 0.021-0.280) were found as important clinical predictors of poor outcome. Involvement of more than 2 vertebrae (OR 0.095, CI 0.028-0.328), complete collapse (OR 0.072, CI 0.022-0.241), cord compression (OR 0.025, CI 0.003-0.204), spinal extension of the abscess (OR 0.044, CI 0.005-0.350), and thick/septate abscess wall (OR 0.062, CI 0.016-0.240) were the neuroimaging parameters associated with poor prognosis. However, on multivariate analysis, duration of illness >6 months (Exp-b 0.086, CI 0.019-0.378), cord compression (Exp-b 0.035, CI 0.003-0348), and spinal extension of the abscess (Exp-b 0.109, CI 0.017-0.91) were significant. Medical management results in clinical improvement in a majority of the patients of spinal tuberculosis. Duration of illness >6 months, cord compression, and spinal extension of abscess are associated with poor outcome.

Intervertebral focal surgery for the treatment of non-contiguous multifocal spinal tuberculosis

PURPOSE

The purpose of this study was to assess the clinical efficacy of intervertebral focal surgery by complete debridement, deformity correction, graft fusion, and internal fixation for patients with non-contiguous multifocal spinal tuberculosis.

METHODS

A total of 29 cases with non-contiguous multifocal spinal tuberculosis admitted to the hospital from January 2000 to January 2007 were treated by intervertebral focal surgery. There were 63 foci in 29 cases, averaging 2.2 foci per case, and 146 affected vertebral bodies, averaging 2.3 vertebral bodies per focus. Three cases had one normal intervertebral disc between two foci, and the other 26 cases had two or more normal intervertebral discs between two foci.

RESULTS

All cases were followed-up for an average of five years. The kyphosis showed a mean correction rate of 67.7% after surgery. A mean loss rate of correction of 8.2% was observed at the final follow-up. The levels of erythrocyte sedimentation rate and C-reactive protein returned to normal in 27 cases on average at 5.8 months and bone union could be observed at five months after surgery. Eleven cases with nerve damage recovered to E grade at the final follow-up.

CONCLUSIONS

Intervertebral focal surgery by complete debridement, deformity correction, graft fusion, and internal fixation for patients with non-contiguous multifocal spinal tuberculosis was feasible and effective.

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.

Effect of delayed diagnosis on severity of Pott's disease

PURPOSE

We analysed delay in diagnosis (DID) and disease severity in patients with vertebral tuberculosis (TB) in India.

METHODS

We interviewed 228 patients with vertebral TB and reviewed their diagnostic magnetic resonance images (MRIs). We examined patient characteristics at the time of presentation and associations between socioeconomic background, access to care, DID and radiographic disease severity at the time of diagnosis.

RESULTS

The most common presenting symptom was localised back pain (84%), followed by fever (40%) and pain elsewhere (28%). The median DID was five months [interquartile range (IQR) 3-9]. In multivariate logistic regression, Muslim and older patients had a higher risk of extreme (more than ten months) DID [adjusted odds ratio (aOR) 2.91; 95% confidence interval (CI) 1.20-7.08 and 2.33; 95% CI 1.23-4.94, respectively]. One hundred and two patients (64%) had vertebral abscesses. Median local kyphotic deformity was 11.7° (IQR 0-18.5°). Fifty-four (34%) patients had radiologically severe disease at the time of diagnosis. Older patients and those with higher education were less likely to have severe disease at the time of diagnosis (aOR 0.32; 95% CI 0.13-0.76 and 0.20 95% CI 0.06-0.62, respectively). Patients who experienced extreme DID were more likely to have severe disease (aOR 2.67; 95% CI 1.05-6.99).

CONCLUSIONS

Most patients in this cohort experienced long delays in diagnosis, and such delay was significantly associated with the presence of severe disease. Clinicians in TB-endemic areas must consider vertebral TB early and obtain imaging in patients who complain of persistent back pain. Improved diagnostic criteria are needed to identify patients at higher risk of disease.