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Dai G, Li S, Yin C, Sun Y, Hou J, Luan L, Liu C, Wang Z, Cao Z, Wang T. Culture-negative versus culture-positive in pyogenic spondylitis and analysis of risk factors for relapse. Br J Neurosurg 2024; 38:527-531. [PMID: 33683182 DOI: 10.1080/02688697.2021.1896677] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 02/23/2021] [Accepted: 02/24/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVES This study aims to compare and analyze the clinical features, diagnosis, treatment and prognosis of culture-negative and culture-positive primary pyogenic spondylitis. METHODS In a retrospective analysis, 202 cases of adult primary pyogenic spondylitis with complete clinical data in our hospital from January 2013 to January 2020 were divided into two groups according to bacterial culture results: culture negative (n = 126) and culture positive (n = 76). We compare the clinical characteristics, diagnosis, treatment and prognosis of patients with different culture results. RESULTS The culture positive rate was 37.62% (76/202). There were no significant differences in age, gender, affected segment, spinal abscess, diabetes mellitus, course of disease, surgery, recurrence, and follow-up time between the two groups (p>.05). There were statistically significant differences in hospital admission erythrocyte sedimentation rate (ESR), admission C-reactive protein (CRP), admission white blood cell (WBC) count, discharge ESR, discharge CRP, ESR decline rate, CRP (p<.05). There were statistically significant differences in the rate of decline, hospitalization days, and body temperature ≥38 °C (p<.05). Higher CRP levels on admission, antibiotic treatment time <6 weeks, and body temperature ≥ 38 °C are independent risk factors for infection recurrence. CONCLUSIONS The culture-negative group's admission WBC, admission ESR, admission CRP, discharge ESR, discharge CRP, ESR decline rate, CRP decline rate, and hospital stay were lower than the culture positive group, the difference was statistically significant (p<.05). The independent risk factors for infection recurrence are higher CRP levels in hospital admission, antibiotic treatment time <6 weeks, and body temperature ≥ 38 °C.
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Affiliation(s)
- Guohua Dai
- Spine Surgery, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Shuzhong Li
- Spine Surgery, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Chuqiang Yin
- Spine Surgery, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yuanliang Sun
- Spine Surgery, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Jianwen Hou
- Spine Surgery, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Liangrui Luan
- Spine Surgery, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Chenjing Liu
- Spine Surgery, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Zhichao Wang
- Spine Surgery, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Zhenlu Cao
- Spine Surgery, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Ting Wang
- Spine Surgery, Affiliated Hospital of Qingdao University, Qingdao, China
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Rezvani M, Ahmadvand A, Yazdanian T, Azimi P, Askariardehjani N. Value of Spinal Infection Treatment Evaluation Score, Pola Classification, and Brighton Spondylodiscitis Score from Decision to Surgery in Patients with Spondylodiscitis: A Receiver-Operating Characteristic Curve Analysis. Asian Spine J 2024; 18:218-226. [PMID: 38650093 PMCID: PMC11065507 DOI: 10.31616/asj.2023.0317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 12/10/2023] [Accepted: 01/01/2024] [Indexed: 04/25/2024] Open
Abstract
STUDY DESIGN This was a retrospective study. PURPOSE This study aimed to assess the value of the Spinal Infection Treatment Evaluation (SITE) score, Brighton Spondylodiscitis Score (BSDS), and Pola classification to predict the need for surgical intervention in patients with spondylodiscitis. OVERVIEW OF LITERATURE Spondylodiscitis is a rare disease, and the prediction of its outcome is crucial in the decision-making process. METHODS All case records were assessed to extract information on the American Spinal Injury Association (ASIA), Visual Analog Scale (VAS), and Japanese Orthopedic Association Back Pain Evaluation Questionnaire (JOABPEQ) scores before and after surgery. The SITE score, Pola classification, and BSDS were recorded. The receiver-operating characteristic (ROC) curve analysis and the area under the curve (AUC) were applied to estimate the predictive ability of the scoring systems. Patients' satisfaction with surgery outcomes was evaluated using the VAS, ASIA, JOABPEQ, and Likert scale for quality-of-life evaluation. RESULTS In all 148 patients, case records were reviewed. The mean±standard deviation age of the patients was 54.6±14.7 years. Of these, 112 patients underwent surgery. The AUC scores were 0.86, 0.81, and 0.73 for the SITE score, BSDS, and Pola classification, respectively. In the comparison of the AUC of ROC curves, SITE score vs. BSDS showed a significantly greater AUC, 0.13 (Z =2.1, p =0.037); SITE score vs. Pola classification, 0.05 (Z =0.82, p =0.412); and Pola classification vs. BSDS, 0.08 (Z =1.22, p =0.219). The optimal cutoff score was 8.5 (sensitivity, 80.6%; specificity, 81.2%) for the SITE score and 9.5 (sensitivity, 52.8%; specificity, 83.0%) for the BSDS in the decision to surgery. VAS back pain and JOABPEQ subscales showed a significant difference when compared with preoperative scores. According to ASIA grading, none of the patients experienced neurological deterioration. Overall, patients' satisfaction was observed. CONCLUSIONS The findings suggest that the SITE score is a useful measure and helps clinicians make clinically sound decisions in patients with spondylodiscitis.
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Affiliation(s)
- Majid Rezvani
- Department of Neurosurgery, Neuroscience Research Center, Al-Zahra Hospital, School of Medicine, Isfahan University of Medical Sciences, Isfahan,
Iran
| | - Ali Ahmadvand
- Department of Neurosurgery, Isfahan University of Medical Sciences, Isfahan,
Iran
| | | | - Parisa Azimi
- Neuroscience Research Center, Shahid Beheshti University of Medical Sciences, Tehran,
Iran
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George AJ, Santhanagopal S, Mohan MM, Lal JV, Basappa M, Thomas JC, Jeevo J. Spondylodiscitis: A Diagnostic and Management Dilemma. Cureus 2024; 16:e58284. [PMID: 38752024 PMCID: PMC11094521 DOI: 10.7759/cureus.58284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2024] [Indexed: 05/18/2024] Open
Abstract
Aims Spondylodiscitis (SpD), a debilitating infective condition of the spine, mandates early diagnosis and institution of appropriate therapy, for which accurate microbiology and histological evaluation of the affected tissue is vital. The objectives of the study were to assess the correlation between clinical and magnetic resonance imaging (MRI) findings with histopathology (HPE) and microbiology (MB) in clinically diagnosed spondylodiscitis. Settings and design This was a prospective study of 34 consecutive patients reporting at the outpatient department of a tertiary hospital with clinical and imaging features of SpD, who underwent image-guided/surgical biopsy of lesions. Methods and material The provisional diagnosis of SpD in all patients was made on the combined basis of clinical profile and MRI Spine findings. Tissue samples in all patients, obtained by either open surgery or CT-guided biopsy, were subjected to HPE and MB analysis. Results SpD has a bimodal age distribution with the majority of patients being males in the fourth to fifth decades. Only raised erythrocyte sedimentation rate (ESR) was consistently seen amongst laboratory parameters, with leucocytosis being added pointer towards pyogenic etiology. MRI remained the imaging modality of choice for SpD but was not dependable for etiologic differentiation. On HPE and MB evaluations, 24 patients (71%) had findings consistent with infective SpD, while combined results augmented etiologic confirmation for 28 patients (82.4%). HPE was more sensitive than traditional MB methods to determine etiology in SpD, but the addition of the GeneXpert (Cepheid, Sunnyvale, California, United States) technique improved the MB positivity rate, especially in patients with tubercular SpD. Six patients (17.6%) with both negative HPE and MB results were categorized as 'Non-specific' SpD. Conclusions SpD poses a challenge to determine the etiology for the administration of specific antimicrobial therapy. A stratified standard institutional approach needs adoption to systematically evaluate SpD patients by having a high index of clinical suspicion, early imaging, followed by tissue biopsy for HPE and MB. Despite efforts to reach a diagnosis, a subset of patients without conclusive etiologic agent identification would remain as 'Non-specific', needing empiric antibiotic treatment based on clinico-radiologic profile.
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Affiliation(s)
- Akhshay J George
- Orthopaedics, St. Johns Medical College Hospital, Bangalore, IND
| | | | - Madan M Mohan
- Orthopaedics, St. Johns Medical College Hospital, Bangalore, IND
| | - Jaya V Lal
- Orthopaedics, St. Johns Medical College Hospital, Bangalore, IND
| | | | - Johann C Thomas
- Orthopaedics, St. Johns Medical College Hospital, Bangalore, IND
| | - Jerin Jeevo
- Orthopaedics, St. Johns Medical College Hospital, Bangalore, IND
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Rezvani M, Veisi S, Sourani A, Ahmadian H, Foroughi M, Mahdavi SB, Nik Khah R. Spondylodiscitis instrumented fusion, a prospective case series on a standardized neurosurgical protocol with long term follow up. Injury 2024; 55:111164. [PMID: 37923678 DOI: 10.1016/j.injury.2023.111164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 10/10/2023] [Accepted: 10/23/2023] [Indexed: 11/07/2023]
Abstract
PURPOSE To investigate the fusion construct properties, construct length, intervertebral prosthesis (IVP) selection, bone grafting methods, complications management, and follow-up outcomes of spondylodiscitis fusion. METHOD This case series was conducted in Al-Zahra University referral hospital from March 2016 to November 2021. All the surgery-eligible patients were enrolled. Those who did not participate or failed the neurosurgical intervention were excluded. A unified neurosurgical protocol was defined. After operation and follow-up, all variables were documented. IBM SPSS v.26 was used for data analysis. P-value ≤ 0.05 was considered significant. RESULT Ninety-two patients were reviewed in the final analysis with 65.2 % males. The mean age was 55.07 ± 14.22 years old. The most frequent level of pathology and surgery was the lumbar spine (48.9 %). Short and long constructs were almost equally used (57.6 and 42.4 %, respectively). Bone graft mixture was the dominant IVP (75 %). The most frequent persistent postoperative symptom was back pain (55.4 %), while the neurological deficits resolution rate was 76.7 %. The fusion rate was 92.3 %. Proximal junctional kyphosis incidence was 16.3 % and had a significant association with on-admission neurological symptoms, thoracic and thoracolumbar junction involvements (p < 0.05). Follow-up Oswestry disability index scores showed 44.6 % of the patients had mild or no functional disabilities. Advanced age, On-admission deficits, comorbidities, titanium cages, and poor fusion status were associated with poor functional outcomes and higher mortality rates (P < 0.05). CONCLUSION The introduced neurosurgical protocol could effectively achieve acceptable SD treatment, spine stabilization, and fusion with low long-term surgical complications. Autologous bone graft mixture in comparison to titanium cages showed a higher fusion rate with a lower mortality rate. Patients with older age, neurological symptoms, and comorbidities are expected to experience less favorable clinical outcomes.
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Affiliation(s)
- Majid Rezvani
- Department of Neurosurgery, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Shaahin Veisi
- Hypertension Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran.
| | - Arman Sourani
- Department of Neurosurgery, Isfahan University of Medical Sciences, Isfahan, Iran; Environment Research Center, Research Institute for Primordial Prevention of Non-Communicable Disease, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Hamed Ahmadian
- Department of Neurosurgery, Babol University of Medical Sciences, Mazandaran, Iran
| | - Mina Foroughi
- Isfahan Medical Students' Research Committee (IMSRC), Isfahan University of Medical Sciences, Isfahan, Iran
| | - Sadegh Baradaran Mahdavi
- Department of Physical Medicine and Rehabilitation, School of Medicine, Student Research Committee, Child Growth and Development Research Center, Research Institute for Primordial Prevention of Non-Communicable Disease, Isfahan, Iran
| | - Roham Nik Khah
- Isfahan Medical Students' Research Committee (IMSRC), Isfahan University of Medical Sciences, Isfahan, Iran
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Rezvani M, Zohrevand A, Azimi P, Fallahpour S, Saghaei S, Yazdanian T, Pashnehtalaee M. Autograft and allograft bone chips interbody fusion for spondylodiscitis: Surgery outcomes. CASPIAN JOURNAL OF INTERNAL MEDICINE 2023; 14:133-137. [PMID: 36741477 PMCID: PMC9878893 DOI: 10.22088/cjim.14.1.133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 03/26/2022] [Accepted: 04/03/2022] [Indexed: 02/07/2023]
Abstract
Background Spondylodiscitis is a rare illness and serious complication of the vertebral column. The suitable type of surgery is debatable for these patients. This study describes a series of cases that are treated with modified interbody fusion for the treatment of spondylodiscitis by combining allograft and autograft bone chips with posterior segmental fusion. Methods This was a retrospective study. The clinical deficit was evaluated with ASIA, VAS, and JOABPEQ scores before and after surgery. Radiological parameters were assessed with local kyphosis angle (degree), segmental height correction, and loss of correction. Post-operative bone union was evaluated as suggested by Tan et al. Results The mean age of patients (n=34) was 52.3(SD=13.6) years and 67.6% were males. The mean follow-up duration was 25.8 (2.3) months. In the last follow-up, VAS back pain 4.9(0.77), VAS leg pain 4.6(0.78), JOABPEQ low back pain 68.1 (9.3), JOABPEQ lumbar function 81.3 (8.9), and JOABPEQ walking ability 72.8 (8.3) shows a significant difference when compared with preoperative scores. According to ASIA grading, none of the patients deteriorated neurologically (all p<0.0001). The average segmental height correction and loss of correction were observed 7.5(3.7) % and -1.8(3.6) %, respectively, indicating improvements in the patients. A high union fusion rate (82.4%) was observed in the last follow-up. Conclusion This modified method can be a safe and effective technique for surgical intervention in patients with spondylodiscitis.
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Affiliation(s)
- Majid Rezvani
- Department of Neurosurgery, School of Medicine, Neuroscience Research Center, Al-Zahara Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Amirhosein Zohrevand
- Department of Neurosurgery, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Parisa Azimi
- Department of Neurosurgery, Isfahan University of Medical Sciences, Isfahan, Iran,Correspondence: Parisa Azimi, Neuroscience Research Center, Shahid Beheshti University of Medical Sciences, Arabi Ave, Daneshjoo Blvd, Velenjak, Tehran 19839- 63113, Iran. E-mail: , Tel: +98 2122439770
| | - Soheil Fallahpour
- Department of Neurosurgery, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Saeid Saghaei
- Department of Neurosurgery, Isfahan University of Medical Sciences, Isfahan, Iran
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Hosameldin A, Hussein M, Abdelhalim E, Shehab M, Osman A. Surgical management of spontaneous thoracic and lumbar spondylodiscitis by fixation and debridement. Surg Neurol Int 2022; 13:44. [PMID: 35242410 PMCID: PMC8888297 DOI: 10.25259/sni_1236_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 01/18/2022] [Indexed: 11/06/2022] Open
Abstract
Background: Spondylodiscitis could be considered one of the most disturbing challenges that face neurosurgeons due to variety of management strategies. The lumbar region was highly affected then dorsal region with higher percentage for lesion in L4/5 (25%) followed by T11/12 and L5/S1 (15%). In our study, we discuss the efficacy of debridement and fixation in cases of spontaneous thoracic and lumbar spondylodiscitis. Methods: This retrospective study included 40 patients with spontaneous thoracic or lumbar spondylodiscitis indicated for surgical intervention in the period from March 2019 to February 2021. All patients were subjected to thorough history taking, neurological examination, and investigations. The patients were operated on through posterior approach by debridement and posterior transpedicular screws fixation and fusion. Results: Clinical assessment early postoperative revealed 75% of cases showed full motor power and 20% showed improvement in motor power, for sensory assessment, 85% showed improvement, the mean visual analog scale (VAS) score was of 3.65 ± 0.87. After 3 months postoperatively, 95% of cases were full motor power with sensory and autonomic (sphincteric) improvement. The mean VAS score was 2.5 ± 0.68. After 6 months postoperative, the clinical assessment revealed that 95% of cases were full motor power with sensory manifestation improvement, and 95% of them were continent. The mean VAS score was 1±0.85. Culture results showed that 65% of samples were negative culture, 15% had methicillin-resistant Staphylococcus aureus, and 10% had Escherichia coli with a single case of Pseudomonas and another one of fungal (Candida albicans). Postoperative 90% of cases showed improvement in erythrocyte sedimentation rate results and 95% of cases showed improvement in C-reactive protein results. Conclusion: Management of spontaneous thoracic and lumbar spondylodiscitis by surgical debridement and posterolateral open transpedicular fixation seems to be effective and safe method despite the presence of infection. We found that the clinical condition of our patients showed significant improvement with this addressed approach.
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Affiliation(s)
- Ahmed Hosameldin
- Department of Neurosurgery, Fayoum University Hospitals, Fayoum University, Fayoum, Egypt
| | - Mohammed Hussein
- Department of Neurosurgery, Fayoum University Hospitals, Fayoum University, Fayoum, Egypt
| | - Ehab Abdelhalim
- Department of Neurosurgery, Cairo University, Cairo, Cairo, Egypt
| | - Mohammed Shehab
- Department of Neurosurgery, Cairo University, Cairo, Cairo, Egypt
| | - Ashraf Osman
- Department of Neurosurgery, Fayoum University Hospitals, Fayoum University, Fayoum, Egypt
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Single-stage debridement via autogenous iliac bone graft through the OLIF corridor and lateral fixation in treating spontaneous single-level lumbar pyogenic spondylodiscitis. BMC Musculoskelet Disord 2021; 22:947. [PMID: 34781926 PMCID: PMC8591950 DOI: 10.1186/s12891-021-04815-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 10/25/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The aim of the present study was to investigate the efficacy and safety of mini-open oblique debridement and lumbar interbody fusion combined with lateral screw fixation for treating single-level pyogenic spondylodiscitis. METHODS Twelve patients with single-level lumbar pyogenic spondylodiscitis underwent OLIF combined with lateral screw fixation were analyzed. Patients underwent follow-up for 12 to 24 months. The clinical characteristics, etiological examinations, operative time, intraoperative blood loss, Oswestry Disability Index (ODI), visual analog scale score (VAS), postoperative complications, and the bony fusion rate were recorded. RESULTS The mean follow-up period of time was 14.8 months. The average operative time and intra-operative blood loss were 129.0 ± 19.76 min and 309.2 ± 92.96 mL, respectively. No severe intra-operative complications were observed during surgery, except in 1 case that develops abdominal pain and distension after surgery, 2 cases that develop left-sided transient thigh pain/numbness and 8 cases that complains of donor site (iliac crest) pain. All of these symptoms disappeared 8 weeks after surgery. Tissue sample cultures were obtained from all patients intraoperatively and four (33.3%) were positive, including 2 with Staphylococcus aureus, 1 with Staphylococcus epidermidis, and 1 with Escherichia coli. During an average of 22.5 ± 2.1 days (range, 14-29 days) after surgery, WBC, CPR, and ESR levels in all patients had returned to normal. All patients were pain free with no recurring infection. Solid bony fusions were observed in all cases within 6 months, including 10 with I grade fusion, 2 with II grade fusion according to the classification suggested by Burkus et al. No fixation failure was observed during follow up and solid bony fusions were observed in all 12 patients at finally follow-up. A significant postoperative increase was also observed in the mean segmental height and lordosis (P < 0.05), followed by a slight decrease of segmental height and lordosis at final follow-up. At the final follow up, the mean VAS (1.5 ± 0.6) and ODI (18.9 ± 7.6) were significantly lower than VAS (8.4 ± 2.7) and ODI (71.2 ± 16.5) before surgery (P < 0.01). CONCLUSION Single-stage debridement with autogenous iliac bone graft through the OLIF corridor and lateral fixation was a feasible surgical approach in our consecutive 12 cases of pyogenic spondylitis.
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Mittal S, Yadav G, Ahuja K, Ifthekar S, Sarkar B, Kandwal P. Predicting neurological deficit in patients with spinal tuberculosis - A single-center retrospective case-control study. SICOT J 2021; 7:7. [PMID: 33666548 PMCID: PMC7934611 DOI: 10.1051/sicotj/2021002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 01/26/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Identifying the risk factors for the neurological deficit in spine tuberculosis would help surgeons in deciding on early surgery, thus reducing the morbidity related to neurological deficit. The main objective of our study was to predict the risk of neurological deficit in patients with spinal tuberculosis (TB). METHODS The demographic, clinical, radiological (X-ray and MRI) data of 105 patients with active spine TB were retrospectively analyzed. Patients were divided into two groups - with a neurological deficit (n = 52) as Group A and those without deficit (n = 53) as Group B. Univariate and multivariate logistic regression analysis was used to predict the risk factors for the neurological deficit. RESULTS The mean age of the patients was 38.1 years. The most common location of disease was dorsal region (35.2%). Paradiscal (77%) was the most common type of involvement. A statistically significant difference (p < 0.05) was noted in the location of disease, presence of cord compression, kyphosis, cord oedema, loss of CSF anterior to the cord, and degree of canal compromise or canal encroachment between two groups. Multivariate analysis revealed kyphosis > 30° (OR - 3.92, CI - 1.21-12.7, p - 0.023), canal encroachment > 50% (OR - 7.34, CI - 2.32-23.17, p - 0.001), and cord oedema (OR - 11.93, CI - 1.24-114.05, p - 0.03) as independent risk factors for predicting the risk of neurological deficit. CONCLUSION Kyphosis > 30°, cord oedema, and canal encroachment (>50%) significantly predicted neurological deficit in patients with spine TB. Early surgery should be considered with all these risk factors to prevent a neurological deficit.
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Affiliation(s)
- Samarth Mittal
- Senior Resident, AIIMS Rishikesh, 249203 Rishikesh, Uttarakhand, India
| | - Gagandeep Yadav
- Department of Orthopaedics, AIIMS Rishikesh, 249203 Rishikesh, Uttarakhand, India
| | - Kaustubh Ahuja
- Senior Resident, AIIMS Rishikesh, 249203 Rishikesh, Uttarakhand, India
| | - Syed Ifthekar
- Senior Resident, AIIMS Rishikesh, 249203 Rishikesh, Uttarakhand, India
| | - Bhaskar Sarkar
- Assistant Professor, AIIMS Rishikesh, 249203 Rishikesh, Uttarakhand, India
| | - Pankaj Kandwal
- Additional Professor, Consultant Spine Surgeon, AIIMS Rishikesh, 249203 Rishikesh, Uttarakhand, India
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