Tuberculosis of the spine: a review

Pelvic support osteotomy with subsequent femoral lengthening: a reliable treatment for late tuberculous coxitis in skeletally immature patients

INTRODUCTION

Tuberculous (TB) coxitis, constituting 15-20% of musculoskeletal tuberculosis cases, often leads to late-stage complications. Joint replacement yields unsatisfactory results. This study aims to know about the efficacy of pelvic support osteotomy (PSO) with subsequent femoral lengthening in treating late TB coxitis in skeletally immature patients.

METHODS

Thirteen pediatric patients with late TB coxitis underwent retrospective analysis from 2016 to 2024. PSO with femoral lengthening, utilizing limb reconstruction systems (LRS) external fixator, was performed. Outcomes were assessed using pain scale, Harris Hip Score (HHS), leg length discrepancy (LLD), hip range of motion (ROM), Trendelenburg gait, and complications. Radiographs evaluated surgical results and remodeling at the PSO site since all patients were skeletally immature.

RESULT

All patients exhibited improved outcomes. Pain was decreased significantly, and hip ROM increased significantly from pre- to postoperative. LLD was found in 9 patients due to premature consolidation with two had to be re-lengthened due to LLD exceeding 5 cm. Trendelenburg gait re-appeared in 7/13 patients after 2 years. HHS was increased significantly, and the PSO angle decreased significantly.

DISCUSSION

This study introduces PSO with femoral lengthening as a reliable method, showcasing favorable clinical outcomes and addressing complications associated with other procedures.

CONCLUSION

PSO with subsequent femoral lengthening proves to be a dependable approach for managing late TB coxitis in children. Further research with a larger sample size and long-term follow-up is warranted to assess the durability of this procedure and identify potential late complications necessitating alternative reconstruction strategies.

A scientometric analysis of highly cited papers in Indian spine research (1995-2024): navigating the impact

PURPOSE

The spine research within India has seen significant advancement, yet detailed examinations of its impact and evolution still need to be made sparse. To conduct a comprehensive scientometric review of the most frequently cited papers in Indian spine research from 1995 to 2024, aiming to map the field's evolution and its global impact.

METHODS

Utilizing the Scopus database, a search was performed with keywords related to spine research, identifying 105 highly cited papers. This study focused on trends in publications, document types, affiliations, collaboration networks, and citation patterns.

RESULTS

The period between 2005 and 2014 saw a significant increase in publications, with a notable emphasis on international collaborations, especially with the United States and Canada. Clinical research, particularly on the lumbar spine and surgical advancements, emerged as the primary focus. The average citations per document stood at 102.37, with original research articles constituting 73.33% of the total. Collaboration spanned across 31 countries, with the United States being the foremost partner. Indian institutions like Ganga Hospital, Coimbatore, and the All India Institute of Medical Science, New Delhi, were among the top contributors. Indian authors, notably with S. Rajasekaran leading, followed by AK Jain.

CONCLUSION

The findings highlght the pivotal role of Indian spine research in contributing to the global knowledge base, highlighting significant areas of strength and opportunities for future research. The study offers valuable insights for researchers, policymakers, and healthcare planners, aiming to enhance spinal health care in India and internationally.

Delphi-Based Survey for Surgical Indications in Biopsy Proven Active Adult Spinal Tuberculosis

STUDY DESIGN

Delphi survey.

OBJECTIVES

To obtain an expert consensus on various dilemmas in the surgical treatment of adult spinal tuberculosis (TB) patients.

METHODS

Stage I included a literature review, stage II the identification of 40 Key Opinion leaders (KOLs) and a set of 46 questions, stage III included analysis of 3 rounds of the Delphi survey, and stage IV had final analysis and recommendations. For each question, the level of agreement needed to reach a consensus was set at greater than or equal to 70.0%.

RESULTS

The first and second Delphi survey rounds received 62 and 58 responses, respectively, with 16 questions having more than 70% and two questions having 100% agreement in the first stage. The second stage saw a 70% agreement on six questions. Thus, a consensus was obtained on 22 questions. The recommendations that emerged were as follows: neurodeficit with corresponding radiology and neurological deficit appearing/deteriorating while on anti-tubercular chemotherapy(ATT) are absolute indications for surgery, duration of ATT before neurological deterioration need not be considered, epidural abscess does not need decompression unless concordant clinical neurological findings are present, pain not responding to medical management is not a surgical indication, active pulmonary TB, drug-resistant TB, and tubercular sacroiliitis are not considered as surgical indications, and hemoglobin and other health markers have little contribution to surgical indications.

CONCLUSION

In order to resolve several conundrums in the surgical treatment of adult spinal TB, this Delphi survey is the first to achieve a national consensus from spine experts. The final recommendations cover the serological, radiographic, and clinical aspects of spinal TB.

Risk predictive score and cord morphology classification for intraoperative neuromonitoring alerts in kyphosis surgery

BACKGROUND

Intraoperative neuromonitoring (IONM) alert is one of the worrying events of kyphosis corrective surgery, which can result in a postoperative neurological deficit. To our knowledge, there is no risk prediction score to predict such events in patients undergoing kyphosis surgery.

PURPOSE

To develop a new preoperative MRI-based cord morphology classification (CMC) and risk prediction score for predicting IONM alerts in patients with kyphotic deformity.

STUDY DESIGN

Retrospective analysis of prospectively collected data.

PATIENT SAMPLE

About 114 patients undergoing surgical correction for kyphotic deformity.

OUTCOME MEASURES

Intraoperative neuromonitoring alerts and postoperative neurological status using AIS grading.

METHODS

Kyphotic deformity patients undergoing posterior spinal fusion were retrospectively reviewed. Based on the morphology of the spinal cord and surrounding CSF in MRI, there are 5 types of cord. Type 1 (normal cord): circular cord with surrounding visible CSF between the cord and the apex, Type 2 (flattened cord): cord with <50% distortion at the apex with obliteration of the anterior CSF; Type 3 (deformed cord): cord with >50% distortion at the apex with complete obliteration of the surrounding CSF; Type 4 (stretched cord): the cord is stretched and atrophied over the apex of the curve. Type 5 (translated cord): horizontal translation of the cord at the apex with buckling collapse of the vertebral column. Preoperative radiographs were used to measure the preoperative sagittal cobbs angle, sagittal deformity angular ratio (S-DAR), sagittal vertical axis (SVA), apex of the curve, and type of kyphosis. Clinical data like the duration of symptoms, clinical signs of myelopathy, neurological status (AIS grade), grade of myelopathy using the mJOA score, and type of osteotomy were documented. Multivariate logistic regression was used to determine the risk factors for IONM alerts and the risk prediction score was developed which was validated with new cohort of 30 patients.

RESULTS

A total of 114 patients met the inclusion criteria. IONM alerts were documented in 33 patients (28.9%), with full recovery of the signal in 25 patients and a postoperative deficit in 8 patients. Rate of IONM alerts was significantly higher in Type 5 (66%), followed by Type 4 (50%), Type 3 (21.1%), Type 2 (11.1%), and Type 1 (11.1%) (p-value<.001). Based on multiple logistic regression, 7 factors, namely preoperative neurological status, mJOA score≤6, presence of signs of myelopathy, apex of the curve above T5, preoperative sagittal cobbs, S-DAR, and MRI-based CMC, were identified as risk predictors. The value for the risk factors varies from 0 to 4, and the maximum total risk score was 13. The cut-off value of 6 had good sensitivity (84.9%) and specificity (77.8%) indicating a high risk for IONM alerts. The AUC of the predictive model was 0.92, indicating excellent discriminative ability.

CONCLUSION

We developed and validated a risk predictive score that identifies patients at risk of IONM alerts during kyphosis surgery. Identification of such high-risk patients (risk score≥6) helps in proper evaluation and preoperative counselling and helps in providing a proper evidence-based reference for treatment strategies.

Tuberculous Paraplegia: Outcome of Operative Intervention

BACKGROUND

Tuberculosis of the spine, a common manifestation of extra-pulmonary tuberculosis is characterized by vertebral destruction, paradiscal involvement, abscess collection and varying degrees of neurologic affectation. The primary disease caused by mycobacterium tuberculosis complex infects the lungs, lymph nodes of the mediastinum and gastrointestinal tract/ viscera with spinal involvement being secondary and caused by haematogenous spread. Tuberculous paraplegia arises as a complication of spinal involvement.

AIM

To determine the outcome of operative intervention in tuberculous paraplegia. Methodology: This was a retrospective study involving 10 patients with tuberculous spinal involvement with varying degrees of neurological deficit as defined by both Tuli and ASIA grading. The VAS score, ESR, ASIA grade (both pre-op and post op), Tuli's grade (pre-op and post op) were used to analyze the therapeutic effects of the surgery.

RESULTS

The mean pre-operative VAS score was 5.9 ±1.8, which significantly decreased to 2.2 ±1.3 six weeks post operatively. The mean pre-operative ESR and CRP was 78.9 ± 11.3mm/hr and 83 ± 13.5 respectively; which both showed a statistically significant decrease post-operatively, p<0.05. All cases achieved an increase of more than one ASIA grade post-operatively.

CONCLUSION

Early surgical intervention is beneficial in patients with tuberculous spinal disease with neurologic involvement.

One-stage posterior transpedicular debridement, hemi-interbody and unilateral-posterior bone grafting, and instrumentation for the treatment of thoracic spinal tuberculosis: a retrospective study

PURPOSE

To investigate the clinical efficacy and feasibility of the surgical treatment of thoracic spinal tuberculosis using one-stage posterior instrumentation, transpedicular debridement, and hemi-interbody and unilateral posterior bone grafting.

METHODS

Fifty-six patients with thoracic spinal tuberculosis who underwent surgery performed by a single surgeon between September 2009 and August 2020 were enrolled in this study. Based on data from the erythrocyte sedimentation rate (ESR), Visual Analog Scale (VAS), and Cobb angle before surgery, after surgery, and at the most recent follow-up, clinical effectiveness was assessed using statistical analysis. The variables investigated included operating time, blood loss, complications, neurological function, and hemi-interbody fusion.

RESULTS

None of the patients experienced significant surgery-associated complications. At the last follow-up, 23 of the 25 patients (92%) with neurological impairment showed improvement. The thoracic kyphotic angle was significantly decreased from 24.1 ± 9.9° to 13.4 ± 8.6° after operation (P < 0.05), and the angle was 14.44 ± 8.8° at final follow-up (P < 0.05). The Visual Analog Scale significantly decreased from 6.7 ± 1.4 preoperatively to 2.3 ± 0.8 postoperatively (P < 0.05) and finally to 1.2 ± 0.7 at the last follow-up (P < 0.05). Bone fusion was confirmed in 56 patients at 3-6 months postoperatively.

CONCLUSIONS

One-stage posterior transpedicular debridement, hemi-interbody and unilateral posterior bone grafting, and instrumentation are effective and feasible treatment methods for thoracic spinal tuberculosis.

Active tuberculosis of spine: Current updates

Background

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

Methods

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

Results

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

Conclusions

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

Comparative evaluation of multi-fold rib and structural iliac bone grafts in single-segment thoracic and thoracolumbar spinal tuberculosis: clinical and radiological outcomes

OBJECTIVE

To compare clinical and radiological outcomes of multi-fold rib and structural iliac bone grafts, the primary autologous graft techniques in anterolateral-only surgery for single-segment thoracic and thoracolumbar spinal tuberculosis.

METHODS

This retrospective study included 99 patients treated from January 2014 to March 2022, categorized into 64 with multi-fold rib grafts (group A) and 35 with structural iliac bone grafts (group B). Outcomes assessed included hospital stay, operation time, intraoperative blood loss, postoperative drainage, complications, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), the Visual Analog Scale (VAS) for pain, the Oswestry Disability Index (ODI), bone fusion time, and the American Spinal Injury Association (ASIA) impairment scale grade. Segmental kyphotic angle and intervertebral height were measured radiologically before surgery and follow-up.

RESULTS

The mean follow-up was 63.50 ± 26.05 months for group A and 64.97 ± 26.43 months for group B (P > 0.05). All patients had achieved a clinical cure. Group A had a shorter operation time (P = 0.004). Within one week post-surgery, group B reported higher VAS scores (P < 0.0001). Neurological performance and quality of life significantly improved in both groups. No significant differences were observed in segmental kyphotic angle and intervertebral height between the groups pre- and postoperatively (P > 0.05). However, group A showed a greater segmental kyphotic angle at the final follow-up, while group B had better maintenance of kyphotic angle correction and intervertebral height (P < 0.05). Bone fusion was achieved in all patients without differences in fusion time (P > 0.05).

CONCLUSIONS

Multi-fold rib grafts resulted in shorter operation times and less postoperative pain, while structural iliac bone grafts provided better long-term maintenance of spinal alignment and stability, suggesting their use in cases where long-term outcomes are critical.

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

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

Closed system paravertebral abscess evacuation on spinal infection: A case series

INTRODUCTION

Paravertebral abscess is a common complication of spondylitis tuberculosis which has high prevalence in Indonesia. Surgical intervention such as open surgery or endoscopic debridement is needed to remove and drainage the abscess in addition to chemotherapy. However, this surgeries have several complications such as soft tissue damage and abscess contamination to the healthy tissue. We reported closed system strategy to evacuate the paravertebral abscess on spinal infection.

METHODS

The technique is performed by orthopaedic team under guidance of the C-Arm and ultrasound sonography (USG) in March-June 202. The needle which connected to 20 cc syringe is inserted into the lesion to aspirate the abscess. After evacuation of the abscess, 2-g broad spectrum antibiotic is injected through the needle to eradicate the bacteria locally.

RESULTS

We performed the closed system paravertebral abscess evacuation in three patients, a 30-year-old male, 43-year-old male, and 22-year-old female. All the patients had back pain and limitation spine movement due to pain and were diagnosed with spondylitis and paravertebral abscess based on the plain radiography and magnetic resonance imaging (MRI). It reported that up to 2000 cc abscess can be evacuated with this micro invasive technique.

CONCLUSION

The closed system is a micro-invasive procedure result in minimal soft tissue injury and faster recovery. It succesfully remove paravertebral abscess followed by direct antibiotic eradication on spinal infection.

Application of next-generation metagenomic sequencing in the diagnosis and treatment of acute spinal infections

Objectives

The purpose of this study was to verify the value of metagenomic next-generation sequencing (mNGS) in detecting the pathogens causing acute spinal infection by reviewing the results of mNGS in 114 patients.

Methods

A total of 114 patients were included from our hospital. Samples (tissue/blood) were sent for mNGS detection, and the remaining samples were sent to the microbiology laboratory for pathogen culture, smear, histopathological analysis, and other tests. Patients' medical records were reviewed to determine their rates of detection, time needed, guidance for antibiotic treatment and clinical outcomes.

Results

mNGS showed a satisfying diagnostic positive percent agreement of 84.91% (95% confidence interval (CI): 6.34%-96.7%), compared to 30.19% (95% CI: 21.85%-39.99%) for culture and 43.40% (95% CI: 31.39%-49.97%) for conventional methods (p < 0.0125), and mNGS was found positive in 46 culture and smear negative samples. The time required for pathogen identification using mNGS ranged from 29 h to 53 h, which showed an advantage over culture (90.88 ± 8.33 h; P < 0.05). mNGS also played an important role in optimizing antibiotic regimens in patients with negative results obtained using conventional methods. The treatment success rate (TSR) of patients using mNGS-guided antibiotic regimens (20/24, 83.33%) was significantly higher than that of patients using empirical antibiotics (13/23, 56.52%) (P < 0.0001).

Conclusions

mNGS shows promising potential in the pathogenic diagnosis of acute spinal infections and may enable clinicians to make more timely and effective adjustments to antibiotic regimens.

Tuberculous spondylitis following intravesical Bacillus Calmette-Guérin therapy for bladder cancer surgically treated through the anterior approach

Intravesical BCG therapy is commonly used to treat superficial bladder cancer. Although various complications associated with this therapy have been reported, tuberculous spondylitis is uncommon. Here, we report a rare case of tuberculous spondylitis that occurred after intravesical BCG therapy for bladder cancer. A man in his 80s received BCG immunotherapy for bladder cancer and developed low back pain after treatment. Remarkably, he presented with neurological symptoms. Spondylitis was suspected on imaging. CT-guided biopsy was performed to confirm the diagnosis. Consequently, Mycobacterium bovis was identified as the causative pathogen by multiplex PCR. Multidrug therapy, administered for several months, was ineffective. Therefore, surgery was performed through an anterior approach. The symptoms, including low back pain, improved and postoperative C reactive protein tests were within the normal range. Tuberculous spondylitis following BCG therapy should be considered in cases with a history of bladder cancer treatment.

Posterior limited unilateral fenestration approach for treating patients with single-segment thoracic and lumbar tuberculosis

BACKGROUND

Posterior limited unilateral fenestration approach is extensively used in the treatment of many spinal diseases. But whether it is suitable for spinal tuberculosis (TB) is rarely reported. Hence, the current study evaluated the feasibility and efficacy of the posterior limited unilateral fenestration (PLUF) debridement, bone grafting fusion, and instrumentation to treat single-segment thoracic and lumbar TB.

METHODS

Eighty-three patients (45 male and 38 female) aged 17-79 years old with the single-segment thoracic and lumbar TB who underwent PLUF debridement, bone grafting fusion, and instrumentation from our hospital were recruited for this study. The operation time, blood loss volume, postoperative complication rate, kyphotic Cobb angle, neurological functional improvement defined by the American Spinal Injury Association (ASIA) classification, the visual analogue scale (VAS) score, and the bone fusion time were utilized for assessing the clinical feasibility and efficacy.

RESULTS

The average follow-up time was 46.9 ± 13.1 (24-72) months. At the last follow-up, the mean kyphotic Cobb angle was significantly reduced from preoperative 23.0° ± 15.3° to postoperative 8.3° ± 11.0° (p < 0.001). Based on the ASIA classification, 89.2% (33 out of 37) patients with preoperative neurological impairment indicated good neurological improvement after the surgery. The VAS pain score significantly decreased from preoperative 6.9 ± 1.1 to 1.3 ± 0.7 3 months after operation (p < 0.001). All the patients achieved solid bony fusion within 13 months of surgery.

CONCLUSIONS

For patients with single-segment thoracic and lumbar TB, PLUF debridement, bone grafting fusion, and instrumentation are a feasible and effective surgical treatment.

A follow-up case of relapsing tuberculous spondylodiscitis, complicated with soft-tissues abscess and percutaneous fistula

Spinal tuberculosis (Pott's disease) is a frequent manifestation of Mycobacterium tuberculosis infection. It manifests as destruction of 2 or more adjacent vertebral bodies followed with destruction of the intervertebral disc, leading to a condition known as spondylodiscitis. Tuberculous spondylodiscitis represents with back pain, fever, joint stiffness, loss of spinal mobility, neurological symptoms, vertebral body collapse, gibbus formation and kyphosis. Persistent Pott's disease might lead to soft tissues abscesses, frequently involving iliopsoas muscle. We, herein, present a 20 years long follow-up case of a Pott's disease patient. The patient got diagnosed as tuberculous spondylodiscitis, almost 10 years after first symptoms onset. She underwent frequent computed tomography and magnetic resonance scanning, with spinal spondylodiscitis being its only significant finding, while lung parenchyma and other organs were not infected. Patient got treated with multidrug anti-tubercular regimen for 18 months in 2 different periods of time; nonetheless she complicated with iliopsoas muscle abscess and percutaneous fistula. Early diagnosis and treatment of spinal tuberculosis (TB) are of great importance in ensuring a good clinical outcome. Delaying the diagnosis and proper management can lead to spinal cord compression, deformity and irreversible neurological complications. Thus, multidrug anti-tubercular therapy must be started timely and the duration of anti-tubercular therapy needs to be individualized. The decision to terminate anti-tubercular therapy should be based on clinical, radiological, pathological and microbiological indices, rather than being based on specific guidelines.

Development of Tuberculosis Spine Instability Score (TSIS): An Evidence-Based and Expert Consensus-Based Content Validation Study Among Spine Surgeons

STUDY DESIGN

An expert-panel consensus-based content validation and case-based clinical validation study.

OBJECTIVE

To develop a novel scoring system for diagnosing instability in tuberculosis (TB) spine using an expert-panel consensus followed by clinical validation for validating the content.

SUMMARY OF BACKGROUND DATA

Currently, diagnosis of instability is primarily experience-based which may lead to considerable variability and misdiagnosis in the hands of a relatively in-experienced spine surgeon. Considering the potential complications this entity entails, a universally accepted scoring criteria is very important for accurate and uniform diagnosis of instability in TB spine.

METHODS

The development of TB spine instability score (TSIS) followed a two-step process, one designing the instrument and the other obtaining judgemental evidence. For judgemental evidence a panel of experts was appointed to make appropriate modifications and content validation for finalizing the scoring instrument. This score was applied on 30 patients of TB spine and receiver operating characteristic (ROC) curves were drawn for sensitivity and specificity analysis.

RESULTS

The comprehensive scoring criteria to diagnose instability in TB spine was approved after three rounds of expert panel discussions with an index of content validation more than 0.75 after final round of panel discussion. On case-based validation after plotting ROC curves, sensitivity and specificity for diagnosing stable and potentially unstable lesions at a cut-off score of 6 was 92.9% and 86.8% respectively whereas for diagnosing potentially unstable and unstable lesions at a cut-off score of 10 was 94.3% and 81.9%, respectively.

CONCLUSION

TSIS is a comprehensive scoring system integrating demographic, anatomical, clinical, and radiological factors aimed at diagnosing instability in TB spine. The classification determines indications for surgical stabilization in patients with TB spine, with no or little neurological deficit.Level of Evidence: 4.

Pott's paraplegia and role of neuroimaging in resource limited setting: A case report and brief review of the literatures

BACKGROUND

Tuberculosis (TB) is the leading cause of morbidity and mortality in low and middle income countries (LMIC). Approximately 50% of cases of skeletal TB involve the spine. Failure to identify and treat these areas of involvement at an early stage may lead to serious complications such as vertebral collapse, spinal compression, and spinal deformity. The clinical and radiologic features of Pott's disease may mimic other spine diseases such as, metastatic lesions and other infectious etiologies, this is especially imperative in older patients.

CASE REPORT

We report a 60-year-old right handed male patient presented with back pain, paraparesis, and sensory symptoms 2 weeks duration. He has history of dry cough, fatigue, and reduced appetite, but no history of weight loss, fever, night sweat, and bowel/bladder incontinence. No contact history with TB patients. He has a borderline hypertension and diabetes mellitus. Serology for HIV was negative. Thoraco-lumbar magnetic resonance image (MRI) showed destruction of L2 and L3 vertebral body and the inter-vertebral disc; with T2 hyper and T1 hypointensity of the affected vertebral bodies. Probable tuberculous spondylitis with paraparesis was considered and the patient was initiated on antituberculous regimen and short course steroid therapy. After five months treatment, the patient showed significant clinical and radiological improvement.

CONCLUSION

In summary, the present case describes, a patient with Pott's paraplegia due to probable spine tuberculosis and showed significant clinical and radiological improvement following initiation of antituberculous drugs and short course of steroid; indicating the crucial role of imaging in the diagnosis of TB, especially in resource limited settings.

Kyphotic angle correction and neurological status evaluation after operation in spinal tuberculosis patients: Single center retrospective study

BACKGROUND

Previous studies have indicated that correction of an established kyphosis in spine tuberculosis is both difficult and hazardous. There has not been any publication about evaluation of surgical correction of spine tuberculosis in Indonesia, despite of high incidence of spine tuberculosis cases. Therefore, we evaluated the outcome of kyphotic angle correction and neurological status after surgery of spinal tuberculosis patients for better understanding.

METHODS

Retrospectively, 96 patients with spinal tuberculosis that underwent operation in Soeharso Orthopedic Hospital from June 2016 to July 2019 were selected. Operation procedure includes laminectomy, debridement and posterior stabilization. We obtained plain x-ray of spine to evaluate the kyphotic deformity before and after surgery. We also examined neurological status of the patient before and after surgery.

RESULTS

The average pretreatment kyphotic angle in thoracic tuberculosis was 33.69° (range 8°-86°), which improved into a significant change to 13.27° (range 0°-56°). Correction angle was <25° in 34 people, 25°-50° in 17 people, and >50° in 4 people. While in the lumbar tuberculosis, it was 25.52° (range 6°-80°), and improved into 11.51° (range 2°-48°). Correction angle was <25° in 35 people, 25°-50° in 4 people, and >50° in 2 people. Improved neurological deficit was shown in 12% of patient with lumbar tuberculosis, and the rest had constant neurological deficit. While in thoracic tuberculosis found that 7% have improved neurological deficit and the rest is constant. None of them have worsen neurological status after the surgery.

CONCLUSIONS

Surgical treatment for kyphotic deformity in patient with thoracolumbar tuberculosis are effective and safe, even in high corrective angle (>50°).

A Scoring System for Outpatient Orthopedist to Preliminarily Distinguish Spinal Metastasis from Spinal Tuberculosis: A Retrospective Analysis of 141 Patients

Objective

Spinal tuberculosis (TB) misdiagnosed of spinal metastasis was not rarely reported, especially in outpatients department. This study was aimed to establish an outpatient scoring system to preliminarily distinguish spinal metastasis from spinal TB.

Methods

We retrospectively reviewed consecutive 141 patients with a pathological diagnosis of spinal metastasis (82 cases) or spinal TB (59 cases) in our hospital from January 2017 to June 2018. The following clinical characteristics which can be obtained by outpatient orthopedist were recorded and analyzed: age, gender, malignant tumor history, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and imaging features including distribution characteristics of vertebral lesions, subligamentous spread, paravertebral or psoas abscess, involved vertebral element, intervertebral disc, and sequestra formation. The prevalence of clinical characteristics in spinal metastasis was evaluated, and the scoring system was established using logistic regression analysis. The performance of the scoring system was also prospectively validated.

Results

The outpatient scoring system was based on five clinical characteristics confirmed as significant predictors of spinal metastasis, namely, malignant tumor history, subligamentous spread, posterior element lesions, preserved discs, and no sequestra formation. Spinal metastasis showed a significant higher score than spinal TB (8.17 points vs. 1.97 points, t = 18.621, P < 0.001), and the optimal cut-off value for the scoring system was 5 points. The sensitivity and specificity of the scoring system for predicting spinal metastasis were 97.85% and 88.33%, respectively, in the validation set.

Conclusion

Spinal lesions with the score of 5 to 10 would be considered a diagnosis of spinal metastasis, while the score of 0 to 4 may be spinal TB. Because the scoring system is mainly based on the clinical characteristics that can be obtained by an outpatient orthopedist, it is suitable to be used as a diagnostic tool in the outpatient department.

Is spinal tuberculosis changing with changing time?

Introduction

Spinal tuberculosis is a chronic destructive disease with long-term morbidity. Patients are usually young especially from a poor socioeconomic background. Destruction of the intervertebral disk space and the adjacent vertebral bodies is the characteristic lesion. The dorsal spine is the most affected region with multi-level noncontiguous involvement being detected more frequently. Patients usually present with chronic back pain associated with spinal tenderness, paraplegia, spinal deformities, as well as with constitutional symptoms. Magnetic resonance imaging has proved to be more sensitive and specific for its diagnosis, but availability and affordability of this investigation remain a problem in developing countries. Anti-tuberculous drug therapy has revolutionized the treatment of this debilitating disease. Surgery is still required in selected cases especially with evolving neurological deficit, progressive deformity, intractable pain and lack of response to drug therapy. With early diagnosis and effective treatment, prognosis is generally good.

Materials/Methods: After getting permission from the clinical governance department, We collected the retrospective data of 305 patients with diagnosed spinal tuberculosis, who underwent surgical intervention.

Results

There was no significant difference in incidence among males and females. Housewives were the most affected. Lower dorsal spinal was the commonest site involved but our study didn't confirm the incidence of multi-level disease process. Anterior decompression along with Cage fixation was most frequently performed procedure.

Conclusion

Despite the availability of highly effective antituberculous drugs, advanced surgical procedure, the spinal tuberculosis still maintains its demographic profile. There has been no change in characteristics of spinal presentation of this chronic debilitating disease. Patients continue to suffer the same way as they were suffering decades ago.

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Spinal tuberculosis is a chronic destructive disease with long-term morbidity.

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The dorsal spine is the most affected region with multi-level involvement being detected.

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Analysis of data of 305 patients with diagnosed spinal tuberculosis, who underwent surgical intervention.

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Despite the availability of highly effective drugs, and surgical procedure, the spinal tuberculosis still maintains its demographic profile.

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There has been no change in characteristics of spinal presentation of this chronic debilitating disease.

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

STUDY DESIGN

Retrospective review of consecutive series.

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Defining mechanical instability in tuberculosis of the spine: a systematic review

Over the years, a number of authors have used different working definitions of instability in tuberculosis of the spine (TB spine). However, no clear consensus exists to define instability in TB spine. The current systematic review addresses the question 'What defines instability in TB spine'?A comprehensive medical literature search was carried out to identify all the studies which defined instability in the setting of spinal TB. The extracted data included the clinical, X-ray and CT or MRI-based definitions.The current review identified lesser age, junctional region of the spine, mechanical pain and 'instability catch', kyphotic deformity above 40 degrees, pan-vertebral or bilateral facetal involvement and multifocal contiguous disease involving more than three vertebrae as predictors for spinal instability in the dorso-lumbar spine.Cervical kyphosis more than 30 degrees and facetal or pan-vertebral involvement were found to be the factors used to define instability in subaxial cervical spine.With respect to C1-C2 TB spine, migration of the tip of the odontoid above the McRae or McGregor line or anterior translation of C1 over C2 were considered as determinants for instability.Although definitive conclusions could not be drawn due to lack of adequate evidence, the authors identified factors which may contribute towards instability in TB spine. Cite this article: EFORT Open Rev 2021;6:202-210. DOI: 10.1302/2058-5241.6.200113.

Single-stage posterior-only debridement, decompression and interbody fusion for the treatment of thoracolumbar spinal tuberculosis complicated with psoas abscesses

Background

To explore the clinical safety and efficacy of single-stage posterior-only debridement, decompression, allograft bone using titanium mesh and interbody fusion combined for the treatment of thoracolumbar spinal tuberculosis complicated with psoas abscesses.

Methods

A total of 38 patients diagnosed with thoracolumbar spinal tuberculosis complicated with psoas abscesses underwent surgery via single-stage posterior-only debridement, decompression, allograft bone using titanium mesh and interbody fusion from January 2010 to September 2016 were enrolled in the study. The clinical efficacy of the approach was assessed based on parameters including operating time, blood loss, Cobb angle, visual analogue scale (VAS) scores, Frankel grade, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP).

Results

The surgery duration was 224.4 ± 71.1 min with a blood loss of 731.8 ± 585.8 ml. The Cobb angle was corrected from 16.0 ± 15.4° preoperatively to 8.1 ± 7.4° postoperatively (P < 0.001, t = − 4.38), and returned to a level of 11.0 ± 8.5° at the final follow-up (P = 0.002, t = 3.38). Back pain was relieved, with the mean preoperative VAS of 3.5 ± 1.1 decreased to 0.7 ± 0.8 postoperatively (P < 0.001, t = 23.21) and then to 0.6 ± 0.5 at the final follow-up (P < 0.001, t = 17.07). Neurological function was improved in various degrees and psoas abscesses disappeared in all patients. The ESR and CRP decreased gradually after surgery and returned to normal at the final follow-up in all patients. All patients achieved bone fusion thoroughly and no recurrence of TB or surgical related complications was found at the final follow-up.

Conclusion

Single-stage posterior-only debridement, decompression, allograft bone using titanium mesh and interbody fusion is a safe and effective approach for the management of thoracolumbar spinal tuberculosis complicated with psoas abscesses.

Surgical outcomes of posterior trans-facetal decompression and stabilisation in tuberculous spondylodiscitis with neuro-deficit

STUDY DESIGN

Retrospective study.

PURPOSE

To evaluate the functional, neurological and radiological outcomes of posterior trans-facetal decompression and stabilisation in tuberculous spondylodiscitis patients with neuro-deficit.

OVERVIEW OF LITERATURE

Spinal tuberculosis mainly involves anterior column and for that anterior approach has been the most frequently used surgical technique in the past as it allows direct access to the infected tissue providing a good decompression. However, anterior surgery is associated with higher morbidity which can be reduced by posterior trans-facetal approach.

MATERIALS AND METHODS

The study included 100 Tuberculous Spondylodiscitis patients with neuro-deficit who underwent posterior trans-facetal decompression and stabilisation from 2009 to 2014. Demographic data, clinical parameters (back pain score-VAS, ODI), neurological status (Frankel's grade), radiological parameters (Kyphosis angle) and complications were evaluated.

RESULTS

Out of the total 100 patients there were 58 males and 42 females. 84 patients had thoracic and 16 had thoracolumbar region involvement. The mean age of the patients was 34.7 years. The extent of fixation was 2 segments in 52 patients and >2 segments in 48 patients. Postoperatively significant improvement in VAS (pre-op 6.5 ± 0.65 to post-op 1.73 ± 0.64) and ODI (pre-op 76.54 ± 6.96 to post-op 30.5 ± 6.56) were noted. The mean kyphosis angle was corrected from 22.33° ± 5.59° to 5.14° ± 1.32°. 86 patients showed at least 1 grade of improvement in neurology (Frankel's grading) and there was no deterioration in any patient. 3 patients developed superficial infection and 2 had an intra-operative dural tear. 94 patients showed bony fusion at 2 years follow-up.

CONCLUSION

Posterior trans-facetal decompression and stabilisation is an effective procedure in the management of thoracic & thoracolumbar tuberculous spondylodiscitis patients with neuro-deficit. It offers circumferential decompression with stabilisation and also maintains kyphosis correction.

Spinal Tuberculosis Treatment: An Enduring Bone of Contention

Spinal tuberculosis is the most common form of extrapulmonary tuberculosis. It is of great importance to neurologists because of the potentially devastating complication of paraplegia, which may set in during active disease or the healed phase. Due to the deep-seated nature of the disease, definitive diagnosis is often challenging. There is no clear consensus on the appropriate duration of therapy for spinal tuberculosis, with various guidelines recommending treatment from as short as 6 months to up to 18 months. In this article, we present a critical appraisal of the evidence on the same. In our opinion, the duration of antitubercular therapy needs to be individualized and the decision to terminate therapy should be multifactorial (clinical, radiological, pathological/microbiological where possible) rather than being enmeshed within any particular guideline.

Intramedullary tuberculoma of the Spinal Cord, Clinical features & imaging: Possibility of early diagnosis with imaging?

Involvement of vertebral column is common in tuberculosis(TB) but intramedullary tuberculomas are rare. Spinal intramedullary tuberculoma are extremely rare, seen in only 2 of 100,000 cases of TB and 2 of 1000 cases of CNS TB^. Intramedullary tuberculomas normally respond well to conventional antituberculous medications, requiring surgery only occasionally. MRI is optimal diagnostic modality in intramedullary tuberculoma as it can show specific findings. This report describes a case of Intramedullary Tuberculoma of the Spinal Cord with clinical features and specific MRI findings with review of litreture.

Minimally invasive far lateral debridement combined with posterior instrumentation for thoracic and lumbar tuberculosis without severe kyphosis

Background

Anti-tuberculous therapy (ATT) alone cannot easily cure spine tuberculosis (STB) though it is the most essential treatment. Many studies have confirmed the efficacy of the surgical treatment of STB through anterior, anterolateral, posterior debridement, and intervertebral fusion or combined with internal fixation. However, the conventional surgical approach requires extensive exposure of the affected areas with high rates of morbidity and mortality. Recently, minimally invasive surgery has come into use to reduce iatrogenic trauma and relevant complications. Here, we introduced a novel technique for the treatment of thoracic and lumbar spine tuberculosis: minimally invasive far lateral debridement and posterior instrumentation (MI-FLDPI). In this study, we evaluated the technical feasibility, the clinical outcomes, and the postoperative complications.

Methods

We did a prospective, non-randomized study on this new technique. Twenty three patients (13 males) with thoracic or lumbar spine tuberculosis who underwent minimally invasive far lateral debridement and posterior instrumentation were included in the study. The preoperative comorbidities, operation duration, intra-operative hemorrhage, Cobb’s angles, and postoperative complications were recorded and analyzed. Clinical outcomes were evaluated by Visual Analog Scale (VAS), Oswestry Disability Index (ODI), neurological recovery, and eradication of tuberculosis. Radiological outcomes were evaluated by changes in Cobb’s angle and fusion status of the affected segments.

Results

The patients were followed for an average of 19 months (ranging from 12 to 36 months). At the final follow-up, CRP and ESR of all patients were normal. The VAS and ODI were significantly improved compared with preoperative values (P < 0.05). No evident progression of the kyphotic deformity was found after surgery. Twenty two patients showed spontaneous peripheral interbody fusion 1 year after surgery. There were no failure of the instrumentation even though a young female with drug-resistant tuberculosis showed no sign of interbody fusion at the third year follow-up. All the patients with preoperative neurological deficit showed complete recovery at the final follow-up.

Conclusions

MI-FLDPI using expandable tubular retractor could be recommended to treat thoracic and lumbar spine tuberculosis for the advantages of less trauma, earlier recovery, and less complications. Spontaneous peripheral interbody fusion was observed in nearly all the cases even without bone grafting.

Tuberculous Myelopathy Associated with Longitudinally Extensive Lesion: A Clinicoradiological Review of Reported Cases

Acute transverse myelitis is an inflammatory disorder of the spinal cord in which there is no evidence of spinal cord compression. Longitudinally extensive transverse myelitis (LETM) is a specific subtype of acute transverse myelitis that usually affects three or more vertebral levels and produces marked neurological deficits. While the most-common cause of LETM is neuromyelitis optica or neuromyelitis optica spectrum disorder, there are rare cases of other causes mimicking this condition, including tuberculosis (TB). We sought to review the clinicoradiological features of TB myelopathy associated with longitudinally extensive lesion, which may mimic LETM, in the English literature. We searched the PubMed, Google Scholar, Web of Science, and Scopus databases for relevant articles using search terms including “longitudinally extensive transverse myelitis,” “tuberculosis,” “TB spinal cord,” and various combinations of these expressions. Full-text papers were selected without limiting the publication year. We also examined the reference lists of key papers to identify further articles that are potentially relevant. We found 10 cases in 7 papers describing TB myelopathy associated with longitudinally extensive lesion. The demographics, clinical features, relevant cerebrospinal fluid findings, and radiological findings were compiled and summarized. TB myelopathy associated with longitudinally extensive lesion is very rare, with no documented prevalence. Early and accurate diagnosis is important since the condition is potentially treatable.

Tuberculous meningomyelitis in magnetic resonance imaging: A Chinese case report

Tuberculous meningomyelitis is a relatively rare but serious type of nervous system tuberculosis. This disease is caused by invasion of the spinal cord or the spinal meninges tuberculosis. The early symptoms are not typical and lack specificity. It can cause early changes in the MRI. Analysis of the MRI manifestations combined with the clinical manifestations and cere- brospinal fluid examination can facilitate accurate diagnosis of the disease. Early treatment has a clear effect, we want to increase knowledge of the dis- ease by sharing this case in order to reduce clinical misdiagnosis and allow more patients to be treated in time.

Improved case detection using Xpert Mycobacterium tuberculosis/rifampicin assay in skeletal tuberculosis

Background

In India, musculoskeletal tuberculosis (TB) accounts for 10%-25% of extrapulmonary TB. Data on drug-resistant skeletal TB are lacking. At present, the diagnosis is based mainly on radiological techniques. Laboratory confirmation of skeletal TB is delayed as 6-8 weeks are required for culture results. Xpert Mycobacterium tuberculosis/rifampicin (MTB/RIF) assay is a fully automated test which simultaneously detects MTB and RIF resistance within 3 h. Hence, this study was done to compare the yield of case detection using Xpert assay in comparison with culture in specimens received from clinically suspected skeletal TB cases.

Methods

Retrospective analysis of microscopy, culture and Xpert assay results was carried out on specimens received in laboratory from skeletal TB cases from January 2016 to December 2017.

Results

Of the 201 patients analysed, majority of the specimens were obtained from the spine (55.72%). MTB was detected in 48.68% of tissue and 24% of pus specimens. Xpert assay was detected MTB in 67 (33.33%) specimens of which 53 (47.32%) were from the spine. Culture was detected MTB in 66 (32.83%) specimens. Xpert assay was detected two specimens more than culture. One specimen was positive by only culture. RIF-resistant MTB was detected in 10 (14.92%) specimens by Xpert assay.

Conclusion

The spine is the most common site involved. Tissue specimen is better for early diagnosis. High RIF resistance in skeletal TB is an alarming situation. Ability of Xpert MTB/RIF assay for rapid and simultaneous detection of MTB and RIF resistance in comparison with culture makes it a useful diagnostic tool in skeletal TB.

Role of Additional Coronal Magnetic Resonance Imaging in Decompression and Reconstruction with or without Segment Salvage in Thoracic Spine Tuberculosis

Study Design

Retrospective and observational study.

Purpose

The present study aimed to develop guidelines for segment salvage or sacrifice based on the amount and status of the remnant portion of the vertebra as assessed by coronal magnetic resonance imaging (MRI) in addition to sagittal and axial images in thoracic spine tuberculosis (TB).

Overview of Literature

Indications for surgery have not changed significantly since the ‘middle path regimen’ was proposed by Tuli. Goals of modern surgical management of spinal TB include debridement of diseased vertebrae, spinal cord decompression, deformity correction, and spine stabilization. However, the extent of decompression has not been defined previously. Too less decompression will lead to compromised neurological recovery, whereas large extent of decompression is associated with increased surgical morbidity and longer segment to reconstruct.

Methods

Sixty-five patients with thoracic spine TB were divided into two groups (segment salvage/sacrifice) based on the thickness of the subchondral bone and endplate morphology of the vertebra as seen on MRI. The operative procedure in the form of instrumentation with Hartshill loop rectangle and sublaminar wire using the simultaneous anterior posterior approach in lateral position (versatile approach) was performed. The patients were analyzed for postoperative fusion, improvement in kyphosis angle, and followed up for development of complications.

Results

This method of deciding the level of fixation and segment salvage based on coronal MRI in addition to the sagittal and axial images provided good result in 64 of 65 patients, except for one patient in the segment sacrifice group who had graft buckling and resultant kyphosis.

Conclusions

For segment salvage, having a clear three-dimensional idea about the viable remnant bone is important. Viable salvaged segment reduces the morbidity of the procedure, length of the construct, and unnecessary debridement without compromising on the neural recovery and fusion rate. Hence, additional cone down coronal cuts must be required when MRI is suggestive for spinal TB because it will help in the decision making.

Comparison of anterior, posterior, and anterior combined with posterior surgical treatment of thoracic and lumbar spinal tuberculosis: a systematic review

Background

This study was performed to compare different surgical approaches in the treatment of spinal tuberculosis.

Methods

We conducted a literature search to identify and analyze papers published from January 1966 to April 2018 relevant to comparison of the anterior, posterior, and anterior combined with posterior approaches in the treatment of spinal tuberculosis of the thoracic and lumbar regions.

Results

Twenty-five studies involving 2295 patients were identified in this systematic review. The operative time was significantly longer in the anterior combined with posterior approach than in the other two approaches. Blood loss was significantly greater in the anterior combined with posterior approach (1125.0 ± 275.5 mL) than in the posterior approach (710.4 ± 192.4 mL). The difference in correction of the kyphosis angle among the three procedures was not significant. The overall surgical and transthoracic complications were significantly lower in the posterior approach. The clinical outcome of all patients improved, but there was no significant difference among the three procedures.

Conclusions

Blood loss, overall surgical and transthoracic complications, and the operative time are different among the three approaches. Therefore, different factors must be carefully assessed in deciding among the three procedures.

Development of dual delivery antituberculotic system containing rifapentine microspheres and adipose stem cells seeded in hydroxyapatite/tricalcium phosphate

Background

Low drug concentration in the tuberculosis (TB) lesion and bone defects or nonunion after debridement are two major problems that occur in the course of treating osteo-articular TB. Thus, the combination of drug-delivery system and bone tissue repair appears to be the most promising option for osteoarticular TB treatment.

Materials and methods

Herein, we report a novel anti-TB dual delivery system based on rifapentine polylactic acid microspheres (RPMs) to treat infections, with the addition of adipose-derived mesenchymal stem cells (ASCs) seeded in hydroxyapatite/tricalcium phosphate (HA/TCP) to promote bone formation. Cell proliferation, osteogenesis, and apoptosis were performed to investigate the effects of rifapentine on ASCs. The RPMs were synthesized by emulsion-solvent evaporation method, and then the monolayer composite (ASC + RPM) and three-dimensional (3D) composite scaffold (ASC + RPM + HA/TCP) were constructed, respectively. The alkaline phosphatase (ALP) activity and real-time PCR were used for determining the osteogenic differentiation. The concentrations of rifapentine resulting from the composites were detected.

Results

The results showed that rifapentine has no influence on ASCs proliferation and osteogenesis when the drug concentration was below 20 µg/mL, which was significantly higher than minimal inhibitory concentration. The drug loading and encapsulation efficiency of RPMs were 40.56%±2.63% and 70.24%±2.18%, respectively. The proliferation of the cells in monolayer was higher than that in 3D composite, and the addition of RPMs slightly increased the proliferation. The ALP activity and gene expression of osteocalcin and osteopontin were higher in the 3D composite than those in the monolayer. Good biocompatibility was observed by microscopic image and H&E stain. The release tests revealed that the 3D composite exhibited sustained release profiles of rifapentine for 76 days. The dual delivery systems in 3D composite could moderate the burst release and extend the length of release time when compared to single delivery in monolayers.

Conclusion

In conclusion, such dual delivery antituberculotic scaffold represents a potential new strategy for TB infections and bone defects.

Unusual Presentation of Koch's Spine Involving Posterior Elements of Vertebra- A Case Report

Introduction:

Spinal Koch involving posterior elements of the neural arch is one of the atypical presentations which are often missed.

Case presentation:

A 40-year-old female presented with radiculopathy and bilateral lower limb claudication for 5 months. Radiological investigations showed compressive lesion resembling flavum hypertrophy and a degenerative etiology was thus suspected. However, histopathology report pointed toward tuberculosis (TB) of the posterior elements (atypical form). Management with surgical decompression and anti-Koch treatment gave a successful outcome.

Conclusion:

TB affecting posterior elements of spine is a rare entity and needs a high degree of suspicion for accurate diagnosis. Newer radiological interventions such as computed tomography and magnetic resonance imaging along with histopathological evidence will help to clinch the diagnosis of Koch’s spine early before neurological problems or deformity sets in. Keeping a high index of suspicion will help to avoid missing the atypical forms of the disease.

Evaluation and Management of Pyogenic and Tubercular Spine Infections

PURPOSE OF REVIEW

To review the most current diagnostic tools and treatment options for pyogenic and tubercular spine infection.

RECENT FINDINGS

Recent studies have focused on risk factors for failed nonoperative management in order to improve patient selection. Also, spine instrumentation and different grafting options have been safely utilized in the setting of an active infection without increasing the incidence of reoccurrence. However, the optimal surgical technique has yet to be established and instead should be patient specific. Spine infections include a broad spectrum of disorders including discitis, vertebral osteomyelitis, and spinal epidural abscess. It is paramount to recognized spine infections early due to the potential catastrophic consequences of paralysis and sepsis. The management of spine infections continues to evolve as newer diagnostic tools and surgical techniques become available. Magnetic resonance imaging with contrast is the imaging study of choice and computed tomography-guided biopsies are crucial for guiding antibiotic selection. Antibiotics are the mainstay of treatment and surgery is indicated in patients with neurological deficits, sepsis, spinal instability, and those who have failed nonoperative treatment.

Spinal Tuberculosis: Current Concepts

STUDY DESIGN

Review article.

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Symptomatic Tuberculous Ligamentum Flavum Cyst Treated by Full Endoscopic Resection: Review with Technical Notes

BACKGROUND

Tuberculosis (TB) of the posterior spinal element is an uncommon condition. In a developed country its diagnosis is becoming difficult due to low incidence.

CASE DESCRIPTION

A 60-year-old lady presented with low back pain and right leg pain for 6 months. On examination there was tenderness over L4 and L5, a positive straight leg raise test at 70 degrees on the right side and free on the left, and sensory involvement on the right L5 dermatome. Initial magnetic resonance imaging (MRI) showed an L4-5 ligamentum flavum cyst, high signal intensity in the right pedicle and facet joint. It was considered to be a degenerative spinal disorder. Later MRI showed increased size of the cyst, and computed tomography revealed erosion of the right pedicle of the L5 vertebrae, which raised the suspicion of the tubercular pathology. Initially the patient was managed for a degenerative spinal disorder. Later, when tubercular pathology was suspected, she underwent full endoscopic uniportal stenosis decompression and excision biopsy of the cyst. The histology of the cyst revealed chronic granulomatous inflammation with central necrosis. The diagnosis of a TB cyst was confirmed, and antitubercular therapy was started.

CONCLUSION

TB of the posterior elements of the spine is a diagnostic challenge in developed parts of the world. We describe the first likely case of tubercular ligamentum flavum cyst, which was managed by a full endoscopic uniportal approach.

The Epidemiology of Skeletal Tuberculosis in Northeast of Iran: A Review of 229 Cases

BACKGROUND

The incidence of tuberculosis (TB) has increased in recent years in both developed and developing countries. Skeletal tuberculosis occurs in approximately 1% of patients with tuberculosis. The present study aimed to evaluate the epidemiology of skeletal tuberculosis in Golestan province in northeastern Iran during 2005-2014.

METHODS

In the present retrospective study, the epidemiology of skeletal tuberculosis was studied in 229 skeletal tuberculosis patients who were diagnosed during 2005-2014. The prevalence rate of skeletal TB has been reported according to demographic and clinical features.

RESULTS

Over the 10-year period of this study, 229 known skeletal TB cases were identified in which 56.3% were male. The mean age of the patients was 44.0±17.7 (range 7-87). All of the patients were new cases. Most of the patients (56.8%) were from the rural areas and most were diagnosed by the private healthcare system (63.8%). The highest rate of skeletal TB was seen in 2013 (15.3%). Spinal TB (81.2%) scored the highest rate and pain (96.9%) was the most prevalent symptom of skeletal TB.

CONCLUSION

The findings suggest that skeletal tuberculosis in northeastern Iran should always be considered as a differential diagnosis for fever and pain on the spinal column. Due to the high level of tuberculosis in the Golestan province (Iran), further research on continued awareness of skeletal TB is stressed.

Role of Posterior Stabilization and Transpedicular Decompression in the Treatment of Thoracic and Thoracolumbar TB: A Retrospective Evaluation

STUDY DESIGN

A retrospective study.

OBJECTIVE

To evaluate the results of posterior pedicle-screw fixation with transpedicular decompression in 21 cases of thoracic and thoracolumbar spinal tuberculosis (TB) in terms of functional, neurological, and radiologic outcomes.

SUMMARY OF BACKGROUND DATA

Spinal TB is predominantly an anterior disease that can lead to kyphotic deformity. Hence, anterior debridement and fusion was considered as the gold standard. However, with remarkable improvements in chemotherapy regimens and diagnostic tools, it is possible to detect the disease process early and treat them with less radical approaches. In the present study, authors have shown the results of posterior pedicle-screw fixation with transpedicular decompression in thoracic and thoracolumbar spinal TB.

MATERIALS AND METHODS

The study reviewed 21 patients with thoracic or thoracolumbar TB with kyphotic deformity who were operated with posterior pedicle-screw fixation and transpedicular decompression (pus aspiration through a Jamshidi needle) with kyphosis correction for either neurological deficits (11) or intractable pain (10), not responding to at least 4-6 weeks of chemotherapy. Patients with <3 spinal segment involvement, <30 degrees kyphosis, and <50% vertebral body destruction were included in the study.

RESULTS

The mean age of patients was 43.9 years and the mean kyphosis angle at the level of involvement was 21.61±3.72 degrees. Kyphosis improved postoperatively to 5.79±3.48 degrees. The mean follow-up period was 24.09 months, and final kyphosis correction was maintained at 8.74±3.65 degrees. Bony fusion was achieved in 80.5% cases. Eleven patients had neurological deficits, and all of them recovered. All patients had a Visual Analog score improvement from 9.52 to 2.57 postoperatively.

CONCLUSIONS

Posterior stabilization with transpedicular decompression can be considered as a good treatment option for the management of thoracic and thoracolumbar TB in patients with <50% vertebral body destruction and <30-degree kyphosis. It provides rapid relief of instability pain, improvement of neurological deficit, and prevents progression of deformity.

Smith-Petersen osteotomy combined with anterior debridement and allografting for active thoracic and lumbar spinal tuberculosis with kyphotic deformity in young children: A prospective study and literature review

The purpose of this study is to determine the efficacy and safety of Smith-Petersen osteotomy combined with anterior debridement and allogenic strut bone grafting for the treatment of active thoracic and lumbar spinal tuberculosis with kyphotic deformity in young children.Spinal tuberculosis is more destructive in young children and often causes severe kyphosis and paraplegia. Despite much progress has been made, surgical treatment is still controversial and technically challenging.From October 2010 to August 2014, 25 children (11 males, 14 females; aged under 6 years) with active thoracic and lumbar spinal tuberculosis treated by Smith-Petersen osteotomy combined with anterior debridement and allogenic strut bone grafting were enrolled in this study. The pre- and postoperative data, follow-up medical records, imaging studies, and laboratory data were collected prospectively. Clinical outcomes were evaluated on the basis of kyphotic angle and the Frankel motor score system. The changes in C-reactive protein (CRP) levels, erythrocyte sedimentation rate (ESR), clinical symptoms, and complications were investigated. Graft fusion was evaluated using the Bridwell grading criteria.The mean age was 3.5 ± 1.76 years (range, 1-6 years). All patients were followed up for 25 to 45 months (average, 34.3 ± 5.86 months). The average kyphotic angle was changed significantly from a preoperative value of 44.1 ± 10.8° to a postoperative value of 11.4 ± 3.9°, with an average correction rate of 74% (P < .05). According to the Frankle motor score system, neurological deficits were significantly improved by the time of the last follow-up, with an average improvement of 1.7 grades (P < .05). There were 2 cases of rod breakage and 1 case of graft bone displacement. No patients experienced a recurrence of tuberculosis. According to Bridwell criteria, the degree of fusion was grade I in 23 patients and grade II in 2 patients with a fusion rate of 92%.For young children with active thoracic and lumbar spinal tuberculosis, Smith-Petersen osteotomy combined with anterior debridement and allogenic strut bone grafting is a safe and simple procedure to achieve sufficient kyphosis correction, good neurological recovery, and reliable anterior column reconstruction.

Atlantoaxial TB with paralysis: posterior-only cervical approach with good results

Early posterior cervical approach is an effective strategy for patients with cervical tuberculosis in the appropriate circumstances.

The Versatile Approach: A Novel Single Incision Combined with Anterior and Posterior Approaches for Decompression and Instrumented Fusion to Treat Tuberculosis of the Thoracic Spine

STUDY DESIGN

Retrospective case series.

PURPOSE

To describe a novel single incision that combines anterior and posterior approaches for decompression and instrumented fusion to treat tuberculosis of the thoracic spine and study the neurological and radiological outcomes.

OVERVIEW OF LITERATURE

Tuberculosis of the spine remains a major health issue in many developing countries. The options for treating tuberculosis of the thoracic spine include the anterior, posterior, and combined approaches, each with its advantages and disadvantages.

METHODS

Totally, 143 patients with tuberculosis of the thoracic spine were surgically treated using the "Versatile approach". Posterior fixation was performed using sublaminar wires and a Hartshill rectangle in all patients. Anterior reconstruction was accomplished using bone graft harvested from autologous rib, iliac crest, or fibula.

RESULTS

The study included 45 males and 98 females, with a mean age of 33.18±18.65 years (range, 3-82 years) and a mean follow-up of 60.23±24.56 months (range, 18-156 months). Kyphosis improved from a mean value of 24.02 preoperatively to 10.25 postoperatively. A preoperative neurological deficit was observed in 131 patients, with 130 patients regaining ambulatory power. No patient had deterioration of neurological status following surgery. Fusion was achieved in all cases. The visual analogscale score improved from an average score of 7.02 preoperatively to 1.51 at final follow-up. Eight patients had superficial macerations, which healed spontaneously. One patient had buckling of the anterior graft, and one patient had implant breakage following road traffic accident.

CONCLUSIONS

The "Versatile approach" is an effective, single-stage, single-incision method that combines anterior and posterior approaches for the surgically treating tuberculosis of the thoracic spine. It offers the advantage of direct visualization for decompression and reconstruction of the anterior and posterior vertebral columns, thus providing an excellent, long-lasting clinical outcome.

Spinal Intramedullary Tuberculosis

Tuberculosis of the central nervous system accounts for approximately 1% of all cases of tuberculosis and 50% of these involve the spine. Intramedullary involvement is rare in tuberculosis. Clinical presentation of spinal intramedullary tuberculosis (SIMT) is similar to intramedullary spinal cord tumor. Here, we report the case of a 49-year-old female with dull aching pain of both upper limbs of 1-week duration. On examination, she had no motor deficits. All the deep tendon reflexes were normal. The plantar responses were flexor bilaterally. Cervical spine imaging favored intramedullary tumor. She had partial relief of symptoms with steroid treatment. Repeat imaging done 1 month later revealed mild interval enlargement of the intramedullary lesions and multiple enlarged mediastinal and hilar nodes. Endoscopic ultrasound-guided fine-needle aspiration cytology of mediastinal nodes was suggestive of granulomatous inflammation. Hence, SIMT was considered as the probable diagnosis. The patient was started on antituberculosis therapy.

India contribution to Spine Surgery: 15 most influential articles

OBJECTIVE

To determine the number of articles published by Indian authors related to spine surgery and to enumerate the 15 most influential articles from India published in the field of spine surgery in national & international journals based on the citations they have received both in pubmed and google scholar.

MATERIAL AND METHODS

A retrospective study using Pubmed database was performed for the years between 1960 and 2015, for the articles published from India in the field of spine surgery in various national and international journals. A total of 3181 citations were received for top 15 most influential articles in the field of spine surgery from India.

RESULTS

A total of 885 papers from India were identified which were published by Indian authors related to spine surgery between year 1960 to 2015. The largest numbers of papers were published in International journals such as Spine (82) and in European Spine Journal (47).

CONCLUSION

There are an increasing number of papers from India in the field of spine surgery literature. Most of the highly cited papers were related to tuberculosis. We expect further contributions from our country to the medical literature in the future.

One-stage posterior focus debridement, interbody grafts, and posterior instrumentation and fusion in the surgical treatment of thoracolumbar spinal tuberculosis with kyphosis in children: a preliminary report

PURPOSE

The purpose of this study was to determine the efficacy and feasibility of surgical management of children with thoracolumbar spine tuberculosis with kyphosis by using one-stage posterior focus debridement, interbody grafts, and posterior instrumentation and fusion.

METHODS

From October 2010 to September 2013, 21 children with thoracolumbar spinal tuberculosis accompanied by kyphosis were treated with one-stage posterior decompression, interbody grafts, and posterior instrumentation and fusion. There were 13 males and 8 females, aged from 7 to 13 years old (average age 9.9 years). The mean follow-up was 34 months (range26-48 months). Patients were evaluated before and after surgery in terms of ESR, neurologic status, pain, and kyphotic angle.

RESULTS

Spinal tuberculosis was completely cured, and the grafted bones were fused in all 21 patients. There was no recurrent tuberculous infection. ESR got normal within 3 months in all patients. The ASIA neurologic classification improved in all cases. Pain relief was obtained in all patients. The average preoperative kyphosis was 29.7° (range 12-42°) and decreased to 5.5° (range 2-10°), postoperatively. There was no significant loss of the correction at the latest follow-up.

CONCLUSIONS

Our results show that one-stage posterior decompression, interbody grafts, and posterior instrumentation and fusion were an effective treatment for children with thoracolumbar spinal tuberculosis. It is characterized as minimum surgical trauma, good neurologic recovery, good correction of kyphosis, and prevention of progressive kyphosis.

Is nonstructural bone graft useful in surgical treatment of lumbar spinal tuberculosis?: A retrospective case-control study

Surgical intervention is an important option for treating spinal tuberculosis. Previous studies have reported different surgical procedures and bone grafts for it. To our knowledge, few studies demonstrated the clinical results of using nonstructural autogenous bone graft in surgical treatment of spinal tuberculosis.The purpose of this study is to compare the clinical outcomes of surgical management lumbar spinal tuberculosis by one-stage posterior debridement with nonstructural autogenous bone grafting and instrumentation versus anterior debridement, strut bone grafting combined with posterior instrumentation.A total of 58 consecutive patients who underwent surgical treatment due to lumbar spinal tuberculosis from January 2011 to December 2013 were included. A total of 22 patients underwent one-stage posterior debridement, nonstructural autogenous bone grafting, and instrumentation (group A), and 36 patients received anterior debridement, strut bone grafting combined with posterior instrumentation (group B). The operative duration, total blood loss, perioperative transfusion, length of hospital stay, hospitalization cost, and complications were recorded. The bony fusion of the graft was assessed by computed tomography scans. American Spinal Injury Association (ASIA) Impairment Scale was used to evaluate the neurological function of patients in the 2 groups.All the patients were followed up, with a mean follow-up duration of 21.6 ± 5.7 months in group A and 22.3 ± 6.2 months in group B (P = 0.47). The average operative duration was 257.5 ± 91.1 minutes in group A and 335.7 ± 91.0 minutes in group B (P = 0.002). The mean total blood loss was 769.6 ± 150.9 mL in group A and 1048.6 ± 556.9 mL in group B (P = 0.007). Also, significant differences were found between the 2 groups in perioperative transfusion volumes, length of hospital stay, and hospitalization cost (P < 0.05), which were less in group A compared with group B. Patients with ASIA grade C/D in the 2 groups were improved with 1 to 2 grades after the surgery with no statistical difference (P = 1.000). The perioperative complications rate was 9.1% (2/22) in group A and 13.9% (5/36) in group B (P = 0.897).Based on a retrospective study, the procedure of one-stage posterior debridement, nonstructural autogenous bone grafting, and instrumentation has a significant shorter operative duration, lower blood loss and perioperative transfusion, shorter hospital stay, and less hospitalization cost compared with the one of anterior debridement, strut bone grafting combined with posterior instrumentation for treating lumber spinal tuberculosis.

Diagnostic yield of computed tomography-guided bone biopsy and clinical outcomes of tuberculous and pyogenic spondylitis

BACKGROUND/AIMS

This study aimed to evaluate the efficacy of computed tomography (CT)-guided bone biopsy for the diagnosis of spinal infection and compared the clinical outcomes between tuberculous and pyogenic spinal infections.

METHODS

The retrospective cohort study included patients who received CT-guided bone biopsy at a tertiary hospital over the 13 years.

RESULTS

Among 100 patients, 67 had pyogenic spondylitis and 33 had tuberculous spondylitis. Pathogens were isolated from bone specimens obtained by CT-guided biopsy in 42 cases, with diagnostic yields of 61% (20/33) for tuberculous spondylitis and 33% (22/67) for pyogenic spondylitis. For 36 culture-proven pyogenic cases, Staphylococcus aureus was the most commonly isolated organism. Patients with pyogenic spondylitis more frequently presented with fever accompanied by an increase in inflammatory markers than did those with tuberculosis. Among all patients who underwent surgery, the incidence of late surgery performed one month after diagnosis was higher in patients with tuberculous infection (56.3%) than in those with pyogenic disease (23.3%, p = 0.026).

CONCLUSIONS

Results obtained by CT-guided bone biopsy contributed to prompt diagnoses of spinal infections, especially those caused by tuberculosis. Despite administration of anti-tuberculous agents, patients with tuberculous spondylitis showed an increased tendency to undergo late surgery.

Anterior debridement may not be necessary in the treatment of tuberculous spondylitis of the thoracic and lumbar spine in adults

Aim

Many aspects of the surgical treatment of patients with tuberculosis (TB) of the spine, including the use of instrumentation and the types of graft, remain controversial. Our aim was to report the outcome of a single-stage posterior procedure, with or without posterior decompression, in this group of patients.

Patients and Methods

Between 2001 and 2010, 51 patients with a mean age of 62.5 years (39 to 86) underwent long posterior instrumentation and short posterior or posterolateral fusion for TB of the thoracic and lumbar spines, followed by anti-TB chemotherapy for 12 months. No anterior debridement of the necrotic tissue was undertaken. Posterior decompression with laminectomy was carried out for the 30 patients with a neurological deficit.

Results

The mean kyphotic angle improved from 26.1° (- 1.8° to 62°) to 15.2° (-25° to 51°) immediately after the operation. At a mean follow-up of 68.8 months (30 to 144) the mean kyphotic angle was 16.9° (-22° to 54°), with a mean loss of correction of 1.6° (0° to 10°). There was a mean improvement in neurological status of 1.2 Frankel grades in those with a neurological deficit. Bony union was achieved in all patients, without recurrent infection.

Conclusions

Long posterior instrumentation with short posterior or posterolateral fusion is effective in the treatment of TB spine. It controls infection, corrects the kyphosis, and maintains correction and neurological improvement over time. Take home message: With effective anti-TB chemotherapy, a posterior only procedure without debridement of anterior lesion is effective in the treatment of TB spondylitis, and an anterior procedure can be reserved for those patients who have not improved after posterior surgery. Cite this article: Bone Joint J 2016;98-B:834–9.

The outcomes of chemotherapy only treatment on mild spinal tuberculosis

Background

The treatments for spinal tuberculosis (TB) patients without absolute surgical indications have been controversial. Some people believed that most spinal TB patients were indicated for surgery, while other people believed in chemotherapy only. To help clarify the treatment over spinal TB patients without absolute surgical indications, we characterized a subtype spinal TB and then analyzed the treatment outcomes of standard chemotherapy alone.

Methods

In this retrospective study, 740 adult patients of spinal TB from January 2005 to January 2013 in our institution were reviewed. Patients who fit into the characterizations of mild spinal TB were started by standard chemotherapy for 18 months and followed up for at least 2 years upon the completion of treatment. The overall outcome, neurological function, local kyphosis, and level of pain at different time points were assessed.

Results

After starting the conservative treatment, 89 out of 740 patients were chosen for chemotherapy alone, and all patients were followed up for at least 2 years (ranging from 24 to 50 months) upon the completion of the treatment. Of 89 patients, 95.4 % of patients showed a definite and clinical response within 1 month after starting the treatment, 69 % of patients had excellent to good results, with no complications of the disease, and 77.5 % had asymptomatic local kyphosis with intact neurological function; solid bony fusion of adjacent segment was achieved in 88.8 % of patients.

Conclusions

We believe that the mild spinal TB respond well to the standard chemotherapy, and the detailed description of mild TB would provide crucial guidance in determination of conservative treatment.