Skipped multifocal extensive spinal tuberculosis involving the whole spine: A case report and literature review

Role of Gene Xpert MTB/RIF assay for detecting tuberculous spondylitis in specimens obtained by CT-guided aspiration/biopsy and spectrum of imaging findings in spinal tuberculosis

OBJECTIVE

To evaluate the utility of the GeneXpert MTB/RIF assay for the diagnosis of tuberculous spondylitis in samples obtained by CT-guided aspiration/biopsy. The effect of anti-tubercular treatment, specimen type, and imaging findings on laboratory results was also assessed along with a comparison of imaging findings in tubercular versus non-tubercular cases.

METHODS

This prospective observational study, planned for CT-guided aspiration/ biopsy, included 70 adults with suspected tuberculous spondylitis. Specimens were sent for microscopy, histopathology, TB culture, and Gene Xpert MTB/RIF assay. The correlation of sampling location, specimen type, anti-tubercular treatment, and imaging findings on microbiology results was documented.

RESULTS

A definite diagnosis of tuberculous spondylitis was obtained in 50 cases. The assay had a 100 % agreement for smear-positive, culture-positive, specimens while the overall agreement was 41.3 %. Rifampicin resistance was detected in 8 cases. Seventy-one percent of patients were on empiric ATT. Imaging findings such as end plate destruction, paravertebral soft tissue thickening and abscess, disc involvement, sequestrum, and bony fragments were significantly associated with a final diagnosis of spinal tuberculosis.

CONCLUSIONS

The Gene Xpert MTB/RIF assay performed on specimens obtained by CT-guided aspiration/biopsy is a sensitive and rapid method of establishing a diagnosis of tuberculous spondylitis even in cases on ATT.

Diagnosis and Treatment of Skipped Multifocal Spinal Tuberculosis Lesions

Spinal tuberculosis, also known as Pott's disease or tuberculous spondylitis, is usually secondary to primary infection in the lungs or other systems, and in most instances, is thought to be transmitted via blood. Typical manifestations of infection include narrowing of the intervertebral disc by erosion and bone destruction of adjacent vertebrae. Atypical spinal tuberculosis is a specific type of spinal tuberculosis. It mainly consists of single vertebral lesions, single posterior structure lesions, multiple vertebral lesions, and intra-spinal lesions. Skipped multifocal spinal tuberculosis is one of these types and is characterized by two or more vertebral lesions without the involvement of the adjoining intervertebral discs, regardless of their location. To date, only a few cases have been reported. Upon clinical admission, it can be treated conservatively or surgically, depending on the patient's symptoms. In addition, gene or biological therapies are being investigated. However, because of the exceptional imaging findings and insidious symptoms, it is often misdiagnosed as a neoplastic lesion, osteoporotic fracture, or other infectious spondylitis, increasing the risk of neurological deficit and kyphotic deformity, and delaying the optimal treatment window. In this study, we review the diagnosis and treatment strategies for skipped multifocal spinal tuberculosis lesions and enumerate the common differential diagnoses, to provide reference and guidance for clinical treatment and diagnosis direction.

Multifocal Tuberculous Spondylitis and Extensive Extraspinal Tubercular Osteomyelitis without Immunocompromise: Case Report and Literature Review

Multifocal extensive spinal and extraspinal tuberculosis is very rare. So far, fewer than 10 cases have been reported. We hereby report two such cases to highlight their rarity, the diagnostic and therapeutic challenges they presented, and the overall prognosis of the condition. The two patients (a 19-year-old woman and another 20-year-old woman) had multifocal extensive tuberculosis involving spine and appendicular skeleton with neurological deficit. Both patients presented with back and neck pain and gradual neurological deficit. The insidious onset and malignancy-like spread pattern mimicked neoplasm. After thorough investigations with magnetic resonance imaging, positron emission tomography scan, and biopsy, antitubercular drug therapy was started, and debridement and fixation were done for significant thoracic and cervical vertebral lesions, respectively. Both patients showed excellent neurological recovery after the procedure. Early surgical treatment of the cases with large abscesses helped provide decompression and stabilization and prevented neurological deterioration and deformity. In patients with noncontiguous spinal tuberculosis, high percentage of surgical treatment may be required due to the aggressive behavior of the disease.

Single posterior approach for circumferential debridement and anterior reconstruction using fibular allograft in patients with skipped multifocal spinal tuberculosis

Background

Skipped multifocal spinal tuberculosis (TB) is an atypical presentation of spinal TB. Surgical treatment for these unusual cases remains a challenge for spine surgeons. In our institute, we used single-stage circumferential debridement and anterior reconstruction with fibular allograft followed by posterior instrumentation through posterior-only approach for these patients. This study aimed to determine the efficacy and feasibility of this technique.

Methods

Twelve patients with skipped multifocal spinal TB who received our treatment method from January 2012 to June 2020 were enrolled in this study. The visual analog score (VAS), laboratory data, comorbidities, complications, and neurologic status based on Frankel scale were recorded. The patients’ clinical conditions were evaluated based on modified Brodsky’s criteria and Oswestry Disability Index (ODI).

Results

All the patients were infection free at the end of the treatment. The average VAS score was 7.5 (range, 7–8) before surgery and decreased to 2.1 (range, 1–3) one year postoperatively. No one experienced any severe complications such as neurologic deterioration, fixation failure, or bone graft dislodgement. Out of the three patients requiring debridement surgery, two had wound infection and one had seroma formation. The ODI score improved from 76.8 (range, 70–84) preoperatively to 25.5 (range, 22–28) one year after surgery. All patients achieved good or excellent outcome based on modified Brodsky’s criteria one year postoperatively.

Conclusions

In our study, the patients could achieve a good clinical outcome. This technique could be an alternative for patients with skipped spinal TB.

Non-contiguous extensive multifocal spinal tuberculosis- treating uncommon scenarios

Noncontiguous multiple tuberculous spondylitis is not uncommon, and most of the reported cases have lesions only on 2 or 3 levels. To the best of our knowledge, multifocal extensive spinal TB involving the whole spine is rarely reported in the literature, which may be presented as asymptomatic and have a higher incidence of neurological complications. It is noticeable that the possibility of TB is considered for any skip lesions involving the spine cautiously. Diagnosis and treatment at early stages would resolve the neurological deficits without operation.

Extend of Skipped Multifocal Noncontiguous Spinal Tuberculosis Beyond Imagination: A Rare Case Report and Literature Review

Skipped multifocal extensive spinal tuberculosis involving the whole spine is very rare, which presents with atypical presentations and imaging features. So far, only five cases have been reported. Most of these patients have only two noncontiguous lesions. We are reporting a case of an 18-year-old boy with noncontiguous multifocal spinal tuberculosis involving cervical, thoracic, thoracolumbar, and lumbar segments. The patient was treated with antituberculous drug therapy and was operated for thoracolumbar spinal lesion. He made an excellent recovery. The possibility of tuberculosis is considered for any skip lesions involving the spine cautiously. Careful physical examination, trials of antitubercular therapy, and using the whole spine magnetic resonance imaging routinely also play an important role in the diagnosis and treatment of this disease. In patients with noncontiguous spinal involvement, there is a high percentage of requirement of surgical treatment due to fulminant behavior of the disease in these patients.

Assessment of Clinical and Radiological Parameters in Spinal Tuberculosis: Comparison between Human Immunodeficiency Virus-Positive and Human Immunodeficiency Virus-Negative Patients

Study Design

Prospective comparative study.Purppse: A prospective comparative analysis of 30 patients with spinal tuberculosis (15 human immunodeficiency viruses [HIV] positive and 15 HIV negative). We compared the clinical and radiological parameters of the two groups.

Overview of Literature

With the increasing incidence of HIV and tuberculosis co-infection, spinal tuberculosis is increasing globally, especially in developing countries. The diagnosis of spinal tuberculosis presents a challenge due to nonspecific constitutional symptoms and late presentation.

Methods

A prospective study was conducted of 30 patients with spinal tuberculosis (15 HIV positive and 15 HIV negative) from August 2014–July 2016 for assessment of clinical and radiological parameters. Neurological assessment was done by classification of tuberculous paraplegia, and the amount of kyphosis was assessed by Cobb angle on a plain radiograph. Abscess size in anterior epidural space, the number of vertebral bodies involved and collapsed, and skip lesions were noted on magnetic resonance imaging.

Results

In the prospective analysis of 30 patients, HIV positive (n=15) and HIV negative (n=15), there was no significant difference in neurological grading between the two groups. The amount of vertebral body destruction and degree of kyphosis was significantly greater in HIV-negative patients as compared with HIV-positive patients. There was a significant difference in Cobb angle between the two groups. The amount of anterior epidural space abscess formation was greater in HIV-positive patients as compared with HIVnegative patients.

Conclusions

HIV-negative patients had greater vertebral body destruction and resultant kyphosis as compared with HIV-positive patients, who had greater anterior epidural abscess formation.

More complications in cervical than in non-cervical spine tuberculosis

Purpose: Cervical spine tuberculosis (CST) is a rare disease that may lead to severe neurological complications. The goal of the study was to compare the characteristics of patients with CST with those of patients with non-cervical spine tuberculosis (NCST).Methods: Between 1997 and 2016, we reviewed all cases of proven tuberculosis from a cohort of spine infections in a tertiary care hospital. Clinical, biological, and imaging data were collected at baseline and after treatment.Results: Fifty-one cases of spine tuberculosis were included: 14 with CST on imaging (27%) and 37 with no cervical localization. Median age was 39 y. Demographic characteristics, duration of symptoms and neurological findings of spine compression were similarly present at presentation in CST and NCST patients. On imaging, lesions were more often multifocal in CST than in NCST patients (9/14 [64%] versus 10/37 [27%], p = .014). Spinal surgery was required in 32/51 (63%) patients. At the end of follow-up (median: 20 months), cure rates were similar in CST and NCST patients but motor and/or sensitive functional sequel were more frequent in CST than NCST patients (6/14 [43%] versus 2/37 [5%], p = .003).Conclusions: Cervical involvement is present in more than a quarter of patients with spinal tuberculosis. Patients with CST had more frequent neurological sequelae than patients with NCST. This was mainly due to a more multifocal disease at presentation. Screening for cervical localization should be systematic in patients with spinal tuberculosis even in the absence of cervical symptoms.

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.