Treatment of tuberculosis of the cervical spine: operative versus nonoperative

Post-tuberculosis sequelae in children and adolescents: a systematic review

In 2020, an estimated total of 155 million people had survived tuberculosis. Among this number, a sizable proportion have considerable post-tuberculosis morbidity, as shown for the adult population. This systematic review aims to identify the spectrum and prevalence of post-tuberculosis sequelae in children and adolescents. Four databases were systematically searched from database inception to Feb 7, 2022, for literature on post-treatment outcomes of tuberculosis acquired during childhood. Of the 4613 identified publications, 71 studies were included in this systematic review. Studies on cohorts with comparably rare (most of which were extrapulmonary) tuberculosis presentations, such as spinal tuberculosis and tuberculous meningitis were over-represented; however, no study assessed long-term sequelae in a cohort with an average childhood tuberculosis spectrum. The descriptive analysis includes long-term outcomes of 3529 paediatric patients 1 month to 36 years after confirmed (47%) or clinical (53%) tuberculosis. In a considerable proportion of children, a broad spectrum of post-tuberculosis sequelae were identified, ranging from radiological residua after pulmonary tuberculosis, to disabling deformities after musculoskeletal and cutaneous tuberculosis, to somatic and psychosocial impairment after tuberculous meningitis. A better understanding and comprehensive assessment of post-tuberculosis sequelae in children are needed to improve tuberculosis care beyond antituberculous treatment.

Anterior debridement, bone grafting and fixation for cervical spine tuberculosis: an iliac bone graft versus a structural manubrium graft

Background

Anterior debridement, decompression, bone grafting, and instrumentation are safe and effective techniques for patients with lower cervical spine tuberculosis. However, there is no consensus regarding the methods for using autogenous bone grafts. The purpose of this retrospective study was to compare the clinical outcomes of anterior surgical management for cervical spine tuberculosis by using an iliac bone graft versus a structural manubrium graft.

Methods

From January 2009 to September 2018, 23 patients with cervical spine tuberculosis were treated with anterior debridement, autogenous structural bone grafting and fixation at our spinal department. The patients were divided into 2 groups according to the different graft materials, namely, iliac crest bone grafts (Group A) and structural manubrium grafts (Group B). The clinical and radiographic results of the 2 groups were analyzed and compared.

Results

The mean duration of follow-up was 24 months. Bony fusion was achieved in all patients without failure of internal fixation. There were no significant differences between the two groups with respect to the operation time, blood loss, fusion time, neurological outcomes, or postoperative local Cobb angle (P > .05). However, the donor site complication rate in Group A was greater than that in Group B. The postoperative ambulation time in Group A was later than that in Group B. The mean visual analog scale (VAS) score for donor site pain in Group A was higher than that in Group B at 1 week after surgery (P < 0.05). However, there was no significant difference between the 2 groups at the last visit (P > .05).

Conclusion

Both iliac bone grafts and sternal manubrium grafts can effectively reconstruct anterior column defects in anterior surgery. However, structural sternal manubrium autografts cause fewer complications associated with donor site morbidities than iliac bone grafts.

Treatment for tuberculosis of the subaxial cervical spine: a systematic review

PURPOSE

To systematically review the clinical manifestations and treatment outcomes of patients with subaxial cervical spinal tuberculosis (SCS-TB) and evaluate the current evidence for surgical or nonsurgical treatment.

METHOD

A systematic review was performed using the PubMed, ScienceDirect, Scopus and Cochrane Central Register of Controlled Trials (CENTRAL) databases. Studies published in English from January 2000 to December 2018 were included in the search. A reference lists search of relevant articles was also conducted for other potential references. The risk of bias was assessed with the 13-item criteria recommended by the Cochrane Back and Neck Group and the Methodological Index for Non-Randomized Studies.

RESULTS

Fifteen articles were included with a total of 456 patients, of which only 1 study was randomized and fourteen were nonrandomized. The most common symptom reported was neck pain and stiffness, and the most common segment involved was C5. Of the 456 patients, 329 (72.1%) were treated surgically. Most experienced neurologic recovery after surgery. Instrumentation resulted in maintenance of the correction of alignment throughout the follow-up period. The use of radical debridement is still in debate.

CONCLUSIONS

Anti-TB therapy is necessary for all SCS-TB patients, including those underwent surgical management. For patients with neurological dysfunction, the surgical method with decompression and instrumentation could provide better cervical spinal alignment and stability. For adult, the radical debridement remains in debate, while for children, radical debridement may cause the development of progressive kyphosis during growth. Larger randomized comparative studies with longer follow-up times are needed.

A multicenter retrospective research of anterior debridement, decompression, bone grafting, and instrumentation for cervical tuberculosis

Objective: To observe the clinical effect of anterior debridement, decompression, bone grafting, and instrumentation for cervical spinal tuberculosis in four hospitals. Materials and Methods: This research retrospectively analyzed 146 patients with cervical spinal tuberculosis who were treated by anterior debridement, decompression, bone grafting, and instrumentation in four institutions between January 2000 and January 2015. There were 68 males and 78 females with an average age of 31.32 ± 11.69 years. All patients received chemotherapy for 18 months after surgery, and fixed by brace for 3 months. Clinical outcome, laboratory indexes and radiological results were analyzed to evaluate the efficacy of anterior approach surgery in the treatment of cervical spinal tuberculosis. Results: All cases were followed up about 18 to 52 months later (average 24 months). At the last follow-up, all patients obtained bone fusion, pain relief and neurological recovery. There was no recurrence in any of the patients, and no complications related to internal fixation. There were statistically significant differences before and after treatment in terms of Visual analog scale (VAS), Neck disability index (NDI) and Japanese Orthopedic Association (JOA)(P < 0.05). During the last follow-up examination, in 83 patients with neurological deficit, 78 patients improved. The kyphosis was significantly improved postoperatively (P < 0.05). At the last follow-up, the Cobb angle had some degree of correction loss, but the difference was not statistically significant. Conclusion: Our study suggests that one-stage anterior debridement, decompression, bone grafting, and instrumentation are safe and effective methods in the surgical management of cervical spinal tuberculosis. Abbreviation: VAS: Visual Analog Scale; JOA: Japanese Orthopaedic Association; NDI: Neck Disability Index; ESR: Erythrocyte Sedimentation Rate; ASIA: American Spinal Injury Association; TB: Tuberculosis.

Most Reliable Time in Predicting Residual Kyphosis and Stability: Pediatric Spinal Tuberculosis

Study Design

A case study.

Purpose

To assess the chronological changes of the disease-related kyphosis after chemotherapy alone, secondly to clarify the role of growth cartilage in the healed lesion on kyphosis change, and to define the accurate prediction time in assessing residual kyphosis.

Overview of Literature

None of the previous papers up to now dealt with the residual kyphosis, stability and remodeling processes of the affected segments.

Methods

One hundred and one spinal tuberculosis children with various stages of disease processes, age 2 to 15 years, were the subject materials, between 1971 to 2010. They were treated with two different chemotherapy formula: before 1975, 18 months of triple chemotherapy (isoniazid [INH], para-aminosalicylic acid, streptomycin); and since 1976, 12 months triple chemotherapy (INH, rifampicin, ethambutol, or pyrazinamide). The first assessment at post-chemotherapy one year and at the final discharge time from the follow-up (36 months at minimum and 20 years at maximum) were analyzed by utilizing the images effect of the remaining growth plate cartilage on chronological changes of kyphosis after initiation of chemotherapy.

Results

Complete disc destruction at the initial examination were observed in two (5.0%) out of 40 cervical spine, eight (26.7%) out of 30 dorsal spine, and six (19.4%) out of 31 lumbosacral spine. In all those cases residual kyphosis developed inevitably. In the remainders the discs were partially preserved or remained intact. Among 101 children kyphosis was maintained without change in 20 (19.8%), while kyphosis decreased in 14 children (13.7%), and increased in 67 children (66.3%) with non-recoverably damaged growth plate, respectively.

Conclusions

It could tentatively be possible to predict the deformity progress or non-progress and spontaneous correction at the time of initial treatment, but it predictive accuracy was low. Therefore, assessment of the trend of kyphotic change is recommended at the end of chemotherapy. In children with progressive curve change, the deformity assessment should be continued till the maturity

Surgical Treatment of Lower Cervical TuberculosisWith Kyphosis Deformity

The objective of this paper was to investigate the outcome of the patients with lower cervical tuberculosis with kyphosis deformity who underwent 1-stage anterior debridement, autograft fusion combined anterior or posterior fixation. From January 2007 to December 2012, 10 cases were enrolled in this retrospective study. There were 7 patients with cervical deformity and 3 with cervicothoracic kyphosis. Seven patients underwent anterior debridement and reconstruction, using iliac crest or cage with autograft, while 3 patients with cervicothoracic kyphosis received single-stage kyphosis correction and posterior fixation combined anterior debridement and autograft fusion. Neurologic function of all the patients was evaluated by JOA score and visual analogue scale (VAS) score. Patients were followed up for 26 months on average. The mean preoperative focal kyphotic angle was 49.1° (range, 25–90°), reducing to −4.9° (range, −15 to 13°) postoperatively at the last follow-up visit. Neurologic assessment of all the patients using the JOA and VAS score was improved significantly after surgery. All patients had solid fusion and no major complications were observed in the follow-up. One-stage anterior debridement, autograft fusion combined anterior or posterior fixation was demonstrated to be a safe and effective method to achieve spinal decompression and kyphosis correction in patients with lower cervical tuberculosis.

Mycobacterium Tuberculosis in Spinal Tuberculosis

Even in an era of remarkable medical advances, there is an issue of why tuberculosis remains in the list of disastrous diseases, afflicting humans and causing suffering. There has not been a plausible answer to this, and it has been suggested that clinicians and medical scientists could presently not win the war against the tubercle bacilli. With regards to this issue, based on the authors' own clinical and research experiences, in this review, the available literature was revisited in order to address the raised questions and to provide recent information on characteristics of tubercle bacilli and possible ways to more effectively treat tuberculosis.

One-year multidrug treatment for tuberculosis of the cervical spine in children

PURPOSE

To review the clinical and radiological features and treatment outcome in 22 children who underwent one-year antitubercular multidrug treatment for tuberculosis of the cervical spine.

METHODS

Records of 13 boys and 9 girls aged 2 to 12 (mean, 9.1) years who underwent one-year antitubercular multidrug treatment for tuberculosis of the cervical spine were reviewed. Tuberculosis involved the atlantoaxial region (C1-C2) in 7 patients, mid-cervical region (C3-C7) in 8, cervicodorsal region (C6-T3) in 3, contiguous multilevels in 2, and non-contiguous multifocal areas in 2. The mean number of vertebrae involved was 2.8 (range, 1-8). The mean symptom duration was 2.5 (range, 0.25-6) months. Three patients had neurological deficits. Antitubercular multidrug treatment included an intensive phase for 2 months and a continuation phase for 10 months, using isoniazid, rifampicin, pyrazinamide, and ethambutol.

RESULTS

At a mean of 2.25 (range, 0.5-5) years after treatment, no patient had recurrence, pain, or dynamic instability. Full range of movement was achieved after a mean of 2.7 (range, 1-4) months in all but 3 patients. In the 3 patients with neurological deficits, recovery was achieved after a mean of 8 (range, 5-14) weeks. Soft tissue swelling resolved after a mean of 11 (range, 8-12) weeks. Remineralisation of vertebrae occurred after a mean of 2 (range, 2-6) months. Spontaneous vertebral fusion occurred in only 6 of 22 patients after a mean of 36 (range, 18-72) months. Three patients developed kyphotic deformity.

CONCLUSION

Antitubercular multidrug treatment is a viable option for children with tuberculosis of the cervical spine, even in the presence of neurological deficits. Development of deformity is not common; interbody fusion is usually delayed. Patients with contiguous multilevel involvement with vertebral erosion or collapse should be closely monitored for development of late deformity.

Clinical characteristics and neurologic recovery of patients with cervical spinal tuberculosis: should conservative treatment be preferred? A retrospective follow-up study of 115 cases

OBJECTIVE

To present the clinical characteristics and prognostic factors of neurologic recovery in patients with cervical spinal tuberculosis (CST).

METHODS

General description and multivariate analysis were used to detect possible predictors of the outcome of patients with neurologic deficit. Follow-up data were used to generate a Kaplan-Meier curve of neurologic recovery.

RESULTS

Protective factors in neurologic recovery included less involved vertebrae, surgery, and higher Japanese Orthopaedic Association score before treatment; not shorter symptom duration was not a protective factor. Normal neurologic function was present in 30% of patients 6 months after treatment, in 56% of patients 12 months after treatment, and in 93% of patients 28 months after treatment. The cumulative complete neurologic recovery rates at 6 months, 12 months, and 28 months were 44%, 68%, and 91.7% in the surgery group and 16.7%, 38.8%, and 94.4% in the nonsurgery group.

CONCLUSIONS

Surgery and Japanese Orthopaedic Association score before treatment are important predictors of neurologic recovery in patients with CST. A neurologic recovery curve could predict neurologic recovery in patients with CST and indicate in patients with neurologic deficit how long it will take to achieve complete neurologic recovery. The effect of surgery is quick, and the effect of conservative treatment is slower, but no difference in neurologic recovery was found in the long-term. Conservative treatment should be tried in every patient with CST with no obvious indication for surgery. In contrast to patients with tuberculosis without cervical spine involvement but with more complications, comprehensive conservative therapy should be preferred for patients with neurologic deficit to avoid unnecessary surgery and overtreatment and to conserve medical resources. Indications for surgical intervention for CST should be carefully selected.

Anterior debridement, decompression, bone grafting, and instrumentation for lower cervical spine tuberculosis

BACKGROUND CONTEXT

Cervical spine tuberculosis (TB) is uncommon, accounting for 3% to 5% of spinal TB. Although the development of anti-TB chemotherapy decreases the mortality rate significantly, it may not be applicable for all situations, especially for those with risk of instability, progression of neurologic deficit, and failure of medical treatment.

PURPOSE

To evaluate the efficacy of anterior instrumentation after debridement and bone grafting in patients with lower cervical TB over a 5-year period at a single institution.

STUDY DESIGN

A retrospective study examining the results of anterior debridement, decompression, bone grafting, and instrumentation for lower cervical spine TB.

PATIENT SAMPLE

The procedure was performed in 25 patients.

OUTCOME MEASURES

The clinical outcomes of infection activity, deformity, pain, and neurologic function were evaluated using erythrocyte sedimentation rate value and C-reactive protein value, kyphotic angle, visual analog scale pain score, and Frankel grade, respectively.

METHODS

Between 2005 and 2010, 25 patients (18 males and seven females; average age, 39 years) with lower cervical spine tuberculosis (C3-C7) underwent anterior debridement, decompression, bone grafting, and instrumentation. The average follow-up period was 37.4 months (range 24-57 months). The medical records and radiographic findings of the patients were reviewed.

RESULTS

There were three patients who had involvement of one vertebra, 18 had two vertebrae of involvement, and four had three vertebrae of involvement. Before surgery, there were three patients with Frankel grade B, five with grade C, 12 with grade D, and five with grade E. During the last follow-up examination, in 20 patients with neurological deficit, 11 patients improved one grade, six patients improved two grades, one patient improved three grades, and the neurologic status remained unchanged in two patients. Stable bone union was observed in all cases and the average time required for fusion was 6.8 months. The kyphosis Cobb angle improved from the preoperative average of 15.48° (range 0°-55°) to a postoperative average of -4.8° (range -12° to 4°) and there was no significant correction loss during the follow-up period. During the follow-up period, there were no grafts or instrumentation-related stabilization problems. There was no other recurrence of TB infection.

CONCLUSIONS

Anterior debridement, decompression, bone grafting, and instrumentation are safe and effective methods in the surgical management of lower cervical spine tuberculosis.

Tuberculosis of spine: current views in diagnosis and management

Tuberculosis is the chronic consumptive disease and currently the world's leading cause of death. Tuberculous spondylitis is a less common yet the most dangerous form of skeletal tuberculosis. The recent re-emergence of Mycobacterium tuberculosis (M. tuberculosis) hints at a possible resurgence of tuberculosis in the coming years. This article discusses the clinical manifestations, diagnosis and treatment of tuberculous spondylitis, and updates material that the author has previously published on the subject. Treatment should be individualized according to different indications which is essential to recovery. A treatment model is suggested on the basis of the author's vast personal experiences.

A large tuberculosis abscess causing spinal cord compression of the cervico-thoracic region in a young child

INTRODUCTION

Despite numerous descriptive publications, the guidelines for treatment of cervical spinal tuberculosis (TB) are not very clear. The authors report a case of a young girl with cervico-thoracic spinal TB extending from C5 to T3 vertebrae presenting with weakness of the right hand and unsteady gait.

CASE REPORT

An 11-year-old female who is an immigrant to the UK from Afghanistan, presented to our clinic with a 10-day history of difficulty in walking with an unsteady gait and 3-month history of progressive weakness in both her arms, the right side more affected than the left. Her immunisation history was unclear. Examination of the arms showed bilateral thenar and hypothenar wasting, more so on the right than the left. An MRI scan revealed a large para-spinal abscess extending from C3/4 to T4/5 with a significant anterior epidural cord compression from C5/6 to T2/3. Therapeutic/diagnostic aspiration was performed under ultrasound guidance and the aspirate was sent for microbiology. She was started empirically on multidrug anti-tubercular treatment and steroids. Although Ziehl-Neelsen stain was negative for acid-fast bacilli, microbiological confirmation of TB was obtained by positive TB culture sensitive to all first-line anti-TB drugs. She made a dramatic improvement within 3 weeks of anti-tubercular treatment. A follow-up MRI scan at 8 months showed complete resolution of the abscess. At 2 years of follow-up, she was a healthy looking child, back to her school with no residual clinical signs/symptoms of the disease.

CONCLUSION

Our case of cervico-thoracic tuberculous abscess in a young child suggests that even with incomplete neurological deficit caused by epidural cord compression, ultrasound (or CT)-guided aspiration and anti-tubercular medication provide acceptable results at 2 years of follow-up.

The surgical treatment and related management for post-tubercular kyphotic deformity of the cervical spine or the cervico-thoracic spine

PURPOSE

The outcomes of surgical treatment and related complications of post-tubercular kyphotic (PTK) deformity of the cervical spine or the cervico-thoracic spine were evaluated.

METHODS

From January 2005 to October 2010, 12 cases with PTK (7 males, 5 females) with an average age of 30 years (range 21-43 years) formed the study group. There were ten patients with cervical deformities and two with cervico-thoracic kyphosis. Neurological function of all the patients was evaluated by the Japanese Orthopaedic Association (JOA) score and visual analogue scale (VAS) score. Two patients with severe cervico-thoracic deformity received modified skeleton traction pre-operatively. Ten patients underwent anterior debridement and reconstruction, using iliac crest or cages with autografts, while two patients with cervico-thoracic kyphosis received posterior instrumentation and fusion.

RESULTS

The mean pre-operative focal kyphotic angle was 42.58° (range 30-67°), reducing to -8° (range -15-11°) postoperatively (at the last follow-up visit). The average operating time was 117.50 min (80-200 min) with an average blood loss of 110 ml (range 50-300 ml). Neurological assessment of all the patients, using the Japanese Orthopaedic Association (JOA) score and visual analogue scale (VAS) score, was improved significantly after surgery. All patients had solid fusion and no major complication was observed in the follow-up.

CONCLUSION

One-stage anterior debridement, instrumentation and fusion for cervical spinal TB and single posterior instrumentation for cervico-thoracic spinal TB followed by chemotherapy is practical to correct PTK. The procedure has the advantage of lower blood loss, effective kyphosis correction and minimal complications. To patients with severe deformity, skeletal traction seemed indispensible.

Spinal tuberculosis in children: Retrospective analysis of 124 patients

BACKGROUND

There is a paucity of report on spinal tuberculosis in children. We report a retrospective analysis of 124 children with TB spine treated over 30 years.

MATERIALS AND METHODS

We retrospectively reviewed 124 children; of cervical (n=36), cervicothoracic (n=4), thoracic (n=53), and lumbar and lumbosacral tuberculosis (n=31) with no skip or multifocal lesions treated between 1971-2004. The age ranged from 2 to 15 years of age with 28 children less than 5 years of age, 58 were between 6 and 10 years, and 38 were over 10 years, 18 had paraplegia of various degrees. Ninety-one children were treated conservatively, while 33 children were subjected to surgery for focal debridement (n=23), posterior interspinous wiring and cementation (n=4), and posterior instrumentation with rods and segmental wiring (n=14). Triple chemotherapy (isoniazid, streptomycin, and PAS) was given for 18 months (3HSPa, 15Hpa) between 1971 and 1975, and triple or quadruple chemotherapy (isoniazid, rifampicin, ethambutol, or pyrazinamide) after 1976 to 2004 for 12 months (12RHZ or 12 RHZE). Some of the children in the current series belonged to the British MRC conservative study patients. The average duration of followup was 5 years and 8 months (range 1.6-20 years).

RESULTS

All children attained healed status and showed neural recovery (n=18). The patients attained healed status at 18 months in the first series and at 12 months in the second series after chemotherapy. Spontaneous intercorporal fusion occurred only in 10 (8.06%) of 124 children. Sagittal curve during growth showed three different patterns: Unchanged, decreased, and increased curves. The residual kyphosis was unavoidable in cases with growth plate damage. Kyphosis increased in cases with wedged monovertebra and fused wedged block vertebra, though it was different at different level.

CONCLUSION

The vertebral reformation and curve correction were possible only through the growth plates. The posterior instrumented stabilization alone could correct and/or prevent progress of the kyphosis. However, for active tuberculosis, posterior instrumented stabilization combined with anterior radical surgery should be reserved only for the advanced tuberculosis with instability, rapid progress of kyphosis, and/or unacceptable pre-existing kyphosis, though there is a new trend of prophylactic posterior instrumentation even for the early tuberculosis.

Odontoid process pathologic fracture in spinal tuberculosis

Craniovertebral junction tuberculosis is a rare lesion in which treatment remains controversial. Options range from conservative treatment to surgery, independently of any associated neurological threat. We here report the first case of pathologic odontoid fracture in a context of spinal tuberculosis, complicated by unusual neurological evolution. The patient presented with non-contiguous multifocal tuberculosis, of which there have previously been only 6 reported cases.