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

Advances in diagnosis and management of atypical spinal infections: A comprehensive review

Atypical spinal infections (ASIs) of the spine are a challenging pathology to management with potentially devastating morbidity and mortality. To identify patients with atypical spinal infections, it is important to recognize the often insidious clinical and radiographic presentations, in the setting of indolent and smoldering organism growth. Trending of inflammatory markers, and culturing of organisms, is essential. Once identified, the spinal infection should be treated with antibiotics and possibly various surgical interventions including decompression and possible fusion depending on spine structural integrity and stability. Early diagnosis of ASIs and immediate treatment of debilitating conditions, such as epidural abscess, correlate with fewer neurological deficits and a shorter duration of medical treatment. There have been great advances in surgical interventions and spinal fusion techniques for patients with spinal infection. Overall, ASIs remain a perplexing pathology that could be successfully treated with early diagnosis and immediate, appropriate medical, and surgical management.

Image-Guided Biopsy in Acute Diskitis-Osteomyelitis: A Systematic Review and Meta-Analysis

BACKGROUND. The reported sensitivity and yield of image-guided biopsies for diskitis-osteomyelitis vary widely. OBJECTIVE. The purpose of this study was to perform a systematic review of the literature and meta-analysis of pooled sensitivity data to elucidate strategies for optimal image-guided biopsies among patients suspected to have diskitis-osteomyelitis. EVIDENCE ACQUISITION. A comprehensive literature search was performed for studies of patient populations with proven or suspected diskitis-osteomyelitis that included percutaneous image-guided biopsy as part of the workup algorithm. Type of pathogens, imaging modality used for biopsy guidance, tissue targeted, antibiotic administration at the time of biopsy, true microbiology positives, true microbiology negatives, false microbiology positives, false microbiology negatives, disease (i.e., diskitis-osteomyelitis) positives as determined by reference standard, true infection positives (i.e., positive microbiology or pathology results), and total number of biopsies performed were extracted from the studies. Microbiology sensitivity, microbiology biopsy yield, and infection sensitivity were calculated from the pooled data. These terms and the data required to calculate them were also defined in detail. EVIDENCE SYNTHESIS. Thirty-six articles satisfied inclusion criteria and were used for analysis. The pooled microbiology sensitivity, infection sensitivity, and microbiology biopsy yields were 46.6%, 70.0%, and 26.7%, respectively. Mycobacterium tuberculosis-only microbiology sensitivity was significantly higher than both pyogenic bacteria and mixed-organism microbiology sensitivity (p < .001). Staphylococcus aureus was the most common causative organism (28.6%). Pooled microbiology sensitivity was not significantly different for CT guidance and fluoroscopy guidance (p = .16). There was a statistically significant difference between pooled microbiology sensitivity of bone/end plate (45.5%) and disk/paravertebral soft-tissue (64.8%) image-guided biopsies (p < .001). There was no statistically significant difference in pooled microbiology sensitivities for patients who received antibiotics before the procedure (46.2%) and those who did not (44.6%) (p = .70). CONCLUSION. Image guidance by CT or fluoroscopy does not affect microbiology yield, disk and paravertebral soft-tissue biopsies should be considered over bone and end plate biopsies, and preprocedural antibiotic administration does not appear to impact biopsy results. CLINICAL IMPACT. Understanding and correctly applying reported statistics contribute to appropriate interpretation of the abundant literature on this topic and optimization of care for patients with diskitis-osteomyelitis.

Importance of eosinophilic structures and its correlation with acid fast bacilli in fine needle aspiration smears of tubercular lymphadenitis

BACKGROUND

The hallmark of tuberculosis in cytological smears is the presence of epithelioid cell granulomas, necrosis and AFB. In cases, where AFB not detected, diagnosis of tuberculosis can be made by ancillary tests like PCR which requires infrastructure besides being expensive. In India, where majority of population is rural-based there is an imminent need of some morphological change in cytological smears which can point towards diagnosis of tuberculosis in absence of AFB. This study was done to assess the importance of eosinophilic structures (ES) and its correlation with presence of AFB.

MATERIAL & METHODS

This was a retrospective study over a period of one year. Lymph node aspirates reported as granulomatous lymphadenitis, tubercular lesion or suppurative lesion were included. All smears for each case, stained with May Grunwald Giemsa (MGG), Hematoxylin and Eosin (H&E) and ZN stain were retrieved and rescreened for the presence of eosinophilic structure, necrosis, granulomas and AFB.

RESULTS

Our study included 256 cases. Most common age group was 21-30 years with female predominance. Cervical lymph nodes were most commonly involved. In relation to ES and AFB four cytological pictures were seen i.e ES + AFB+ (44.54%) ES + AFB- (5.46%) ES- AFB+ (14.45%) ES - AFB- (35.55%). Chi square test showed a high significant statistical association between ES and AFB(p = 0.00001).

CONCLUSION

In developing countries with very high TB prevalence like India, where new diagnostic modalities are unaffordable by rural population, presence of ES should be included as a morphological parameter in routine cytology reporting of tubercular lesions.

[Tuberculous Spondylitis - Diagnosis and Management]

Tuberculous Spondylitis - Diagnosis and Management Abstract. Despite a decreasing incidence of tuberculosis (TB) over the last decades in Switzerland, the frequency of newly diagnosed tuberculous spondylitis has remained stable. It occurs most frequently in old, immunocompromised persons and/or persons who have moved to Switzerland from TB endemic areas. It is a chronic manifestation of TB, which is characterized by 'cold abscesses', neurological deficits and kyphotic spinal deformity. Tuberculous spondylitis is often diagnosed with a delay, which can lead to higher morbidity and treatment complexity. Antibiotic therapy is essential in tuberculous spondylitis. Surgical interventions aim to obtain samples, decompress nervous structures, obtain pain control and, if necessary, deformity correction/stabilization. This paper provides an overview of the modern diagnostic and therapeutic management of tuberculous spondylitis in Switzerland.

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.

Non traumatic vertebral lesions: incremental utility of PET-CT over MRI and FNAC in a suggested diagnostic algorithm

OBJECTIVE

To prospectively compare positron emission tomography-computed tomography (PET-CT) with conventional magnetic resonance imaging (MRI) and FNAC for diagnosis of non- traumatic vertebral lesions fracture in countries like India where tuberculosis is endemic.

METHODS

Fifty four patients with non-traumatic spontaneous vertebral lesions were prospectively studied. All patients underwent CEMRI focusing on the spinal lesions, whole-body PET-CT and FNAC.Results were then analysed and compared with final diagnosis obtained either by FNAC or clinical follow up.

RESULTS

Out of total 54 patients, FNAC from the spinal lesion could establish diagnosis in 36 patients (26 TB, 1 Fungal and 9 tumors). Of the remaining 18 patients, diagnosis could be established in 7 utilizing FNAC from other sites as dictated by PET-CT. In the remanining11 patients, the diagnosis and management was decided on the concordance of MRI and PET-CT.

CONCLUSION

All three investigations have their own advantages and pitfalls and they complement each other in reaching the final diagnosis. MRI has a better pick up rate (than PET-CT) for inflammatory lesions. PET-CT on the other hand has better sensitivity for malignant vertebral disease. Diagnosis was established if FNAC was conclusive. In cases where FNAC was inconclusive, an additional 38.9% patients' diagnosis could be established by FNAC from other sites of involvement as dictated by PET-CT. This was an incremental utility of PET-CT. When even this fails, there were two possible scenarios-MRI and PET-CT in concordance with each other. In such a scenario, the combined report of MRI and PET-CT was relied upon. The last sub group (where MRI and PET-CT were discordant and FNAC was inconclusive) still remains achilles' heel. Wide bore biopsy may help in establishing diagnosis in such group.

Multiplex PCR as a novel method in the diagnosis of spinal tuberculosis-a pilot study

BACKGROUND

Establishment of a reliable and rapid diagnosis is of paramount importance in spinal tuberculosis. The available gadgetry of investigations, such as AFB smear, culture of Mycobacterium tuberculosis, and Uniplex PCR, suffers from a lack of adequate sensitivity and/or a lack of rapidity. Therefore, many times a diagnosis is made either very late in the disease process or sometimes empirical therapy has to be started because a definite diagnosis could not be made. All of these are not ideal situations for a clinician. The present study was done with the aim to establish a rapid and reliable diagnosis of M. tuberculosis infection. This was established by identifying M. tuberculosis genes.

METHODS

The study was done on nine consecutive patients who presented with non-traumatic spontaneous vertebral compression collapse. CT-guided aspirate from the involved vertebra was subjected to Multiplex PCR (MPCR) using three primers: IS6110, protein b, and MPB 64. The aspirate was also subjected to smear and culture. The results of MPCR were compared with the final diagnosis.

RESULTS

Seven out of nine patients had a final diagnosis of tuberculosis. MPCR was positive in six of these seven patients, thus showing sensitivity of 85.7% and specificity of 100%. Results of MPCR were obtained within 24 h.

CONCLUSIONS

MPCR using IS6110, protein b, and MPB64 primers has a high sensitivity and specificity in rapid diagnosis of spinal tuberculosis. To the best of our knowledge, this has not been attempted before in spinal tuberculosis. This is particularly useful for paucibacillary infections like spinal tuberculosis. However, further studies using large sample sizes are needed to confirm the practical applicability of this technique.

Role of Percutaneous Image Guided Biopsy in Spinal Lesions: Adequacy and Correlation with MRI Findings

INTRODUCTION

Although, MRI has increased our understanding of spinal pathologies, accurate diagnosis of spinal lesions need biopsy, so that early treatment can be initiated.

AIM

To evaluate the accuracy of biopsy, safety and yield of percutaneously done image guided spinal biopsy using a large bore needle and correlate between MRI findings and biopsy as well as the importance of various MRI findings in establishing the diagnosis.

MATERIALS AND METHODS

All spinal lesions after clinical and MRI evaluation were subjected to Jamshidi Needle biopsy using 11 gauge needles. Biopsy material was sent for culture/sensitivity, AFB smear and histopathological examination. The outcome assessment included percentage of patients in whom diagnosis was changed after biopsy, yield in biopsy and complications of biopsy. MRI findings, biopsy findings and final diagnosis were correlated to know the sensitivity and specificity of MRI and biopsy diagnosis. Logistic regression analysis was used to study the importance of each of MRI findings in making a diagnosis.

RESULTS

Forty five patients with spinal lesions underwent biopsy using an 11 gauge Jamshidi needle. Initial biopsy was inconclusive in 4 patients giving a positive yield in about 91.2% of cases and a repeat biopsy ensured conclusive report in all cases. Following biopsy there was a change in diagnosis in 8% cases. MRI showed sensitivity of 85.71% and specificity of 93.54% for the diagnosis of malignancy and sensitivity of 85.71% and specificity of 86.48% for the diagnosis of tuberculosis. In contrast, initial biopsy had sensitivity of 92.85% and specificity of 100% for the diagnosis of malignancy and sensitivity of 71.42% and specificity of 100 % for the diagnosis of infection. Logistic regression analysis showed good correlation between malignancy and posterior bugle in the vertebral body in the absence of a fracture (p = 0.007), involvement of pedicles and posterior elements (p = 0.001) and soft tissue extension (p = 0.002); there was good correlation between infection and epidural abscess (p<0.001) as well as paradiscal involvement (p<0.001).

CONCLUSION

Image guided biopsy done with good technique helps in accuracy of diagnosis thus ensuring the correct treatment at the earliest and has minimal complications. This study also shows that presence of epidural abscess and paradiscal involvement in MRI are highly suggestive of infection, while pedicle involvement and posterior bulge of vertebral body before the onset of pathological fracture are suggestive of malignancy, but all spinal lesions should be biopsied to confirm the diagnosis.

Multiple Bony Metastatic Lesions and Evaluation of Primary: Case Records of a Cancer Research Centre

During 2012-13, we diagnosed 4 patients with extensive skeletal tuberculosis (TB) who were referred to us as cases of bony metastasis with unknown primary. Radiological investigations done outside favoured a diagnosis of disseminated malignancy. Positron emission tomography/computed tomography (PET/CT) scan performed in our institute for localization of primary lesion also suggested metastatic disease. There was no evidence of malignancy on histo-pathological examination (HPE) of the involved sites. The diagnosis of TB was established on characteristics HPE. This article highlights the diagnostic dilemma of PET/CT in cases of TB versus malignancy and the importance of HPE for reaching an accurate diagnosis.

Computed Tomography-Guided Biopsy for Potts Disease: An Institutional Experience from an Endemic Developing Country

Study Design

A retrospective chart review.

Purpose

In endemic resource poor countries like Pakistan, most patients are diagnosed and treated for Potts disease on clinical and radiological grounds without a routine biopsy. The purpose of this study was to evaluate the use and effect of computed tomography (CT)-guided biopsy in the management of Potts disease since the technique is becoming increasingly available.

Overview of Literature

CT-guided biopsy of spinal lesions is routinely performed. Literature on the utility of the technique in endemic resource poor countries is little.

Methods

This study was conducted at the Neurosurgery section of Aga Khan University Hospital Karachi. All the patients with suspected Potts disease who underwent CT-guided biopsy during the 7 year period from 2007 to 2013 were included in this study. Details of the procedure, histopathology and microbiology were recorded.

Results

One hundred and seventy-eight patients were treated for suspected Potts disease during the study period. CT-guided biopsies of the spinal lesions were performed in 91 patients (51.12%). Of the 91 procedures, 22 (24.2%) were inconclusive because of inadequate sample (10), normal tissue (6) or reactive tissue (6). Sixty-nine biopsies were positive (75.8%). Granulomatous inflammation was seen in 58 patients (84.05%), positive acid-fast bacillus (AFB) smear in 4 (5.7%) and positive AFB culture in 12 patients (17.3%). All 91 cases in which CT-guided biopsy was performed responded positively to antituberculosis therapy (ATT).

Conclusions

75.8% of the specimens yielded positive diagnoses. Granulomatous inflammation on histopathology was the commonest diagnostic feature. In this series, the rates of positive AFB smear and culture were low compared to previous literature.

Correlation of eosinophilic structures with detection of acid-fast bacilli in fine needle aspiration smears from tuberculous lymph nodes: Is eosinophilic structure the missing link in spectrum of tuberculous lesion?

Background:

Acid-fast bacilli (AFB) is not seen in all necrotic tuberculous lesions. If the subset of tuberculous lesions which yield positive result for AFB can be identified, it would save on time and manpower besides optimizing use of resources. A prospective study was undertaken to assess if presence of eosinophilic structures (ESs) in necrotic tuberculous lesions correlated with the presence of AFB.

Materials and Methods:

Patients referred for fine needle aspiration cytology for evaluation of lymphadenopathy between July 2012 and June 2013 were analyzed. The hematoxylin and eosin and May-Grünwald-Giemsa stained slides were screened for epithelioid cell granuloma, ES and necrosis and Ziehl Neelsen stained smears for AFB.

Result:

One hundred and eight tuberculous lymph nodes yielded necrotic material on aspiration. Four cytologic pictures were seen: (a) ES⁺ AFB⁺ in 58.33%, (b) ES⁺ AFB⁻ in 20.37%, (c) ES⁻ AFB⁺ in 9.26% (d) ES⁻ AFB⁻ in 12.04% cases. Overall AFB was found in 67.59% cases, out of which 58.33% correlated with the presence of ES while 9.26% were seen in smears without ES.

Conclusion:

Presence of ESs should be included in the morphological description of tuberculous lesions. In the absence of granulomas, they indicate tuberculous nature of the lesion. Presence of ES mandates a search for AFB as probability of finding AFB is high in such lesions. Significance of ES lies in their presence and not in their absence. Eosinophilic structures appear to be the missing link in the spectrum of tuberculous lesion.

Multicentric spinal tuberculosis with sternoclavicular joint involvement: a rare presentation

Background. Tuberculosis is a chronic disease which may have varied presentations. Though pulmonary tuberculosis is the commonest, extrapulmonary tuberculosis involving skeletal system is often seen. Individuals with poor nourishment and immunological status are especially susceptible for disseminated and multicentric tuberculosis. Case Report. We here present a case of tuberculosis involving multiple anatomical locations in an immune-competent patient which was diagnosed with radiological studies and confirmed with histological examination. Patient was put on multidrug antitubercular therapy and responded well to the treatment with improvement in clinical and radiological picture. Clinical Relevance. This report of a rare case makes us aware of the varied presentations which tuberculosis can present with. It should be kept as a differential diagnosis in patients with cough and fever but not responding to conventional treatment. This is even more important in countries with poor socioeconomic conditions.

Conservative management of spinal tuberculosis: initial series from pakistan

Study Design

A prospective study on spinal tuberculosis (TB) at a tertiary care hospital in an endemic region.

Purpose

The aim of the study is to reiterate the importance of conservative management of spinal TB.

Overview of Literature

Spinal tuberculosis can present with wide spectrum of symptoms, with back pain being the most common symptom. It is the leading cause of non-traumatic paraplegia in developing countries. There is an emerging trend to operate on patients early with spinal TB.

Methods

Forty-seven (M=14, F=33) patients were enrolled in the study during the four year study period. Initially, all the patients were subjected to computed tomography guided percutaneous needle aspiration (PCNA) followed by antituberculous therapy (ATT) for 12 months. Indications for surgery included patients with moderate to severe symptoms in which PCNA either failed, was impossible to carry out, or produced minimal improvement within 48 hours.

Results

Presenting complaints included pain (95.7%), weakness (85.1%) and sphincter involvement (12.8%). On the magnetic resonance imaging, a paravertebral abscess was seen in 37 (78.7%), disc and body destruction in 29 (61.7%), and an epidural abscess in 12 (25.9%) patients. Of the 47 patients, 9 (19.1%) required surgery, 4 of whom had failed PCNA attempts and 5 demonstrated indications despite successful PCNA.

Conclusions

The results of conservative treatment consisting of PCNA and ATT for at least 12 months in compliant patients are excellent. A combined approach using clinical staging, PCNA, and ATT can minimize surgical intervention in most patients. However, ATT remains to be the cornerstone of management of spinal TB.

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.

Spinal tuberculosis among human immunodeficiency virus-negative patients in a Kenyan tertiary hospital: a 5-year synopsis

BACKGROUND CONTEXT

Spinal tuberculosis (TB) accounts for more than half of all cases of skeletal TB. Although Kenya has one of the highest burdens of TB, data on spinal TB in this country remain scarce.

PURPOSE

To highlight the clinical presentation and management of this condition in our setup.

STUDY DESIGN

Retrospective study.

SETTING

Kenyatta National Hospital in Kenya.

PATIENT SAMPLE

One hundred twenty-nine patients.

OUTCOME MEASURES

Patients' condition after intervention and duration of hospital stay.

METHODS

This study involved review of patients admitted to our hospital between 2004 and 2009 with a diagnosis of spinal TB.

RESULTS

The most common presenting complaints were back pain in 100 patients (77.5%) and limb weakness in 94 patients (72.9%), whereas the most frequent physical examination finding was gibbus deformity in 85 patients (65.8%). Most (79 patients, 61.2%) had severe motor and sensory impairment graded as either American Spinal Injury Association (ASIA) A or ASIA B. Imaging revealed multiple vertebrae disease in 90 patients (79.6%). Of these, the most common was two vertebrae disease in 77 patients (68.1%). All patients were managed using anti-TB drugs and analgesics; however, 33 (25.6%) required adjunctive operative management. Mean hospital stay was 53.3 days. Marked clinical improvement was seen in 91 patients (70.0%) within 6 months of treatment.

CONCLUSION

Patients with spinal TB in our setting tended to present late and with advanced disease. Therefore, a high index of suspicion should be maintained and appropriate chemotherapy started as early as possible.

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.

Tuberculosis of the spine: a fresh look at an old disease

The dismal outcome of tuberculosis of the spine in the pre-antibiotic era has improved significantly because of the use of potent antitubercular drugs, modern diagnostic aids and advances in surgical management. MRI allows the diagnosis of a tuberculous lesion, with a sensitivity of 100% and specificity of 88%, well before deformity develops. Neurological deficit and deformity are the worst complications of spinal tuberculosis. Patients treated conservatively show an increase in deformity of about 15 degrees . In children, a kyphosis continues to increase with growth even after the lesion has healed. Tuberculosis of the spine is a medical disease which is not primarily treated surgically, but operation is required to prevent and treat the complications. Panvertebral lesions, therapeutically refractory disease, severe kyphosis, a developing neurological deficit, lack of improvement or deterioration are indications for surgery. Patients who present with a kyphosis of 60 degrees or more, or one which is likely to progress, require anterior decompression, posterior shortening, posterior instrumented stabilisation and anterior and posterior bone grafting in the active stage of the disease. Late-onset paraplegia is best prevented rather than treated. The awareness and suspicion of an atypical presentation of spinal tuberculosis should be high in order to obtain a good outcome. Therapeutically refractory cases of tuberculosis of the spine are increasing in association with the presence of HIV and multidrug-resistant tuberculosis.

Role of fine-needle aspiration cytology in tuberculosis of bone

This study was designed to evaluate the role of fine-needle aspiration cytology (FNAC) in diagnosis of skeletal tuberculosis (TB). In this retrospective study, 20 cases were retrieved over a 10-year period in which a cytologic diagnosis of osseous TB was rendered. The aspirations were performed with a 22-gauge needle attached on a 20-ml syringe after taking into consideration the radiological findings. The cytologic findings were subdivided into the following categories--epithelioid cell granulomas with necrosis, epithelioid cell granulomas without necrosis, and necrosis only. These cases were either with or without AFB positivity. The smears showed epithelioid cell granulomas in 23 cases (85.2%), multinucleate and Langhans' giant cells in 15 cases (55.6%), and inflammatory cells were noted in the background in 15 cases (55.6%). AFB was positive in six cases (22.7%). FNA provides a simple and safe outpatient procedure for the diagnosis of osseous TB and obviates the need of an open biopsy.

Posterior spinal cord compression: outcome and results

STUDY DESIGN

Prospective, comparative study of neurologic outcome in patients with posterior extradural cord compression.

OBJECTIVE

To compare the results of surgical decompression in patients presenting with neurologic deficit due to posterior element tuberculosis with those due to other causes.

SUMMARY OF BACKGROUND DATA

Posterior cord compression is a relatively uncommon entity with not much literature published on it.

METHODS

Over a period of 5 years, 14 patients with extradural posterior cord compression with neurologic deficit were divided into two etiologic groups: 9 patients had Koch's and 5 had other pathologies. All these cases were surgically decompressed posteriorly and the results compared.

RESULTS

While results of surgery in patients with Koch's were good, with 7 of the 9 patients showing full recovery, outcome in patients with compression due to other causes (tumor/pyogenic infection) was not very satisfactory even after adequate mechanical decompression, with 3 of the 5 cases remaining paraplegic even after surgery.

CONCLUSION

Posterior cord compression due to nontuberculous causes frequently mimics the picture of Koch's both clinically and radiologically. Prognosis of surgical decompression is good in tuberculous compression but not in other cases.

Osteoarticular tuberculosis in a developed country

OBJECTIVES

To evaluate the clinical and diagnostic features of osteoarticular tuberculosis (OT) from a series of cases seen over 30 years in a large university hospital in Naples, Italy.

METHODS

We reviewed the files of all patients admitted to our department from 1975 to 2004 with a diagnosis of osteoarticular tuberculosis.

RESULTS

We identified 136 patients with 140 osteoarticular tuberculosis lesions. Fifty-three cases were diagnosed from 1975 to 1984, 36 cases from 1985 to 1994, and 47 cases from 1995 to 2004. Eleven patients (8%) were from high-incidence areas outside of Italy. The mean delay until diagnosis was 216.6 days. Pain, low-grade fever, and loss of weight were the most common presenting symptoms. Neurological involvement was present in 11 cases out of 79 spinal lesions (13.9%). Serological methods were used to study antimycobacterial antibodies using enzyme-linked immunosorbent assays (ELISA-TB test) in 59 patients (42.1%). Positive results on this test were obtained in 43 patients (72.9%). ELISA-TB test was the only diagnostic test associated with a shorter diagnostic delay in a model of multivariate regression analysis (p=0.001). Tc-99m MDP bone scans were obtained from 83 patients with 84 lesions and increased uptake in the affected area was noted in 72 lesions (85.7%). Histological and microbiological examinations were positive in 97 (69.3%) and 57 (40.7%) lesions, respectively. In 43 (30.7%) lesions, we could not definitively confirm the diagnosis. In these cases chemotherapy was nevertheless initiated.

CONCLUSIONS

Thorough and even invasive diagnostic work-up is mandatory for the proper and timely management of patients with OT. Tc-99m MDP bone scanning and ELISA-TB test are useful diagnostic tools. We always used microbiological testing and histological examination to confirm the diagnosis of OT, but empirical antituberculosis treatment was nevertheless initiated in the patients with high clinical suspicion in order to limit the potentially permanent destruction of affected skeletal segments.

Imaging of infectious spinal disorders in children and adults

The aim of this review article is to outline the imaging of infectious disorders of the spine in adults and children. The clinical presentation, potential routes of infection and the pathogens commonly identified are discussed. The value of different imaging modalities in the diagnosis of spinal infection is presented including radiographic, CT, MR imaging and Nuclear Medicine including PET. The use of image guided techniques for diagnosis and subsequent treatment is briefly covered. The major differential diagnoses of infectious disorders of the spine are identified and contrasted with the typical findings in infection. The use of follow up imaging is evaluated.

Diagnosis of tuberculous vertebral osteomyelitis (TVO) in a developed country and literature review

STUDY DESIGN

Review of medical and radiological records and literature to study the diagnosis of tuberculous vertebral osteomyelitis (TVO) and the differential diagnosis between TVO and pyogenic vertebral osteomyelitis (PVO).

OBJECTIVE

To identify the correct criteria for the diagnosis.

SETTING

National Spinal Injuries Centre, UK.

METHODS

(1) Medical and radiological records of 10 patients diagnosed as vertebral osteomyelitis and treated elsewhere but later admitted to the NSIC were reviewed retrospectively. (2) Medical literature on vertebral osteomyelitis were reviewed.

RESULTS

(1) Case review: Before the study, four of the 10 patients TVO had been diagnosed based on positive bacteriology. Of the other six, the diagnosis of PVO had been made in one based on positive blood culture of staphylococcus while in another without any positive result of bacteriology. The diagnosis had been uncertain in four because of negative results of both bacteriology and histology on both tuberculous and pyogenic infection. The author made the diagnosis of TVO in all 10 cases based on clinical manifestations and plain radiographs. Highly raised ESR with moderate rise of or normal WBC in eight cases supported TVO. Computer tomography and magnetic resonance imaging did not contribute to the differential diagnosis. Laminectomy in five patients led to some clinical improvement. The five patients without surgery deteriorated. Two of them died. (2) LITERATURE REVIEW: A total of 188 articles were reviewed. The crucial role of plain radiographs in the diagnosis of TVO and the high incidence of false-negative of tuberculosis in both bacteriological and histological tests were neglected in most articles. Polymerase chain reaction (PCR) was more reliable in diagnosing tuberculosis.

CONCLUSION

Clinical manifestations, discrepancy between ESR and WBC, plain radiographs and PCR are keys to a correct diagnosis of TVO.

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.

Atypical spinal tuberculosis

Typical spinal tuberculosis is readily diagnosed and treated. Certain atypical clinical and radiologic presentations of spinal tuberculosis are described. Failure to recognize these presentations may lead to delay in diagnosis and initiation of treatment. In some atypical forms of the disease, this may have disastrous consequences. The current authors present a new classification for atypical spinal tuberculosis and describe the various presentations. The role of advanced imaging studies such as computed tomography scanning and magnetic resonance imaging and imaging-guided aspiration cytology is discussed.

Comparative cytological study of lymph node tuberculosis in HIV-infected individuals and in patients with diabetes in a developing country

Tuberculosis (TB) is a common infection affecting patients with human immunodeficiency virus (HIV) and diabetes mellitus (DM). With the increasing incidence of HIV infection and DM in a developing country like India, TB is definitely on the rise. In a given population, one expects to see these three diseases in varying combinations, such as HIV and TB, DM and TB, HIV and DM with TB. In such combinations TB may lack the characteristic clinical and histological picture due to the associated depressed cell-mediated immunity seen in both diseases and TB may have an unusual clinical presentation and cytology picture. In this retrospective study of 36 months, from January 1997 to December 1999, 109 cases diagnosed cytologically as tuberculous lymphadenitis and tested for HIV infection and investigated as well for DM were selected. Forty-six (42%) were nondiabetic HIV patients, 13 (12%) were non-HIV DM patients, and 50 (46%) had TB without HIV infection or DM. The coexistence of both HIV and DM was not noted. The cytomorphological characteristics supplemented by culture studies of each of these three groups were compared in detail and based on these four cytological patterns, Pattern 1, Pattern 2, Pattern 3, and Pattern 4 emerged and were characterized. This study highlights the usefulness of cytomorphology of the lymph nodes to characterize the cytopathological profile of TB in both HIV and DM, which have many clinical and immunological similarities, and indirectly postulate the extent of immune suppression and evolve effective strategies in the management of coexisting diseases. Such a comparative study has not been carried out in the past.

Tuberculous spondylitis: analysis of 69 cases from Saudi Arabia

DESIGN

Retrospective chart and radiographic review of all cases admitted to the authors' hospital and diagnosed to have tuberculous spondylitis.

OBJECTIVE

To identify the frequency, presenting features, utility of diagnostic tests, and treatment outcome of spinal tuberculosis in a tertiary care center.

METHODS

All cases of spinal tuberculosis treated in the authors' hospital over 14 years were reviewed. Only those with histologic or microbiologic confirmation or those who responded to antituberculous spondylitis therapy were included. Outcome was assessed according to predefined criteria.

RESULTS

Between 1985 and 1998, 69 cases of tuberculous spondylitis were found, i.e., 5% of all tuberculous spondylitis cases diagnosed. The mean age was 52.8 years (range, 15-80 years), and 37 (53.6%) were male. Only five patients had a history of tuberculosis. The most frequent symptoms were backache (84%) and fever (32%), and the most frequent sign was spinal tenderness (45%). Nineteen (28%) patients had paraparesis and 12 (17%) had kyphosis. Except for elevated sedimentation rate (94.5%), the laboratory workup was not helpful. Both computed tomography and magnetic resonance imaging were found to be helpful in diagnosis, often with complementary information. Thirty-eight patients (55%) had thoracic spine involvement and 55 patients (80%) had paraspinal abscesses. Tissue aspirates had a yield of 70%, 35%, and 57% for granulomas, acid-fast bacilli smear, and culture, respectively. Medical therapy alone was given in 37 cases (54%), whereas 32 patients (46%) required additional surgical intervention, mainly those with spinal cord compression, spinal deformity, or risk of spinal instability. There was definite improvement in 63 cases (91%). The best outcome was in those patients presenting early before the occurrence of spinal deformity or neurologic symptoms.

CONCLUSION

Tuberculous spondylitis is prevalent in the authors' hospital. Both computed tomography and magnetic resonance imaging are extremely helpful for diagnosis, and tissue aspirate is a good confirmatory method. A good outcome is expected if the diagnosis is made in early stages before the appearance of spinal deformity and neurologic symptoms. Surgical intervention can be avoided in these cases regardless of the presence or absence of paraspinal abscesses.