Single-Stage Combined Anterior Corpectomy and Posterior Instrumented Fusion in Tuberculous Spondylitis With Varying Degrees of Neurological Deficit

Should dry spinal tuberculosis be managed differently than wet spinal tuberculosis?

BACKGROUND CONTEXT

On radiopathological examination of spinal tuberculosis (TB), 2 predominant forms are known: dry and wet types. Wet TB, as the name suggests, has abscess formation as its predominant presenting feature and is the exudative form; dry TB includes caseation and sequestration with minimal exudate. Dry TB often exhibits poorer recovery patterns than the wet counterparts, which can be possibly ascribed to vasculitis, ischemia, or tubercular myelitis, rather than isolated mechanical compression. These pathologic processes may lead to neurological deficit which is less responsive to treatment.

PURPOSE

To quantify the recovery and prognosis, and test for the significance of difference between neurological recovery pattern and prognosis of the 2 forms of spinal TB.

DESIGN

A retrospective analytical observational study design in the form of a cohort study was performed.

PATIENT SAMPLE

Single-center patient data over 6 years was analyzed. Of 217 patients with spinal TB, 18 had dry TB (Group 1). Two patients were excluded because they presented very late after the onset of neurological deficit, which could have played a role in the nonrecovering nature of motor weakness. The remaining patients had wet TB, of which 22 patients were selected for propensity score matching to form a comparison group.

OUTCOME MEASURES

Radiological measures included vertebral body height loss, deformity, canal encroachment, cord diameter, altered cord signal intensity and loss of CSF space. Functional measures were ambulatory status of the patient at final follow-up and neurologic status measured by ASIA (American Spinal Injury Association) and LEMS (Lower Extremity Motor Score) scoring.

METHODS

The criteria for dry TB were imaging suggestive of granulation tissue (heterogenous hypo- or hyper-intensity on T2WI sequence), with at least 1 of the 2 factors (1) absence of anterior or posterior epidural abscess formation within the spinal canal (2) a canal encroachment of <30%. The groups were compared with respect to their differences in demographic distribution, symptom complex, mycobacterial drug sensitivity and presence of history of tuberculosis elsewhere in the body. Analysis was done by various tests of significance depending on the type of variable. Bar charts and Pie charts were used for visual representation of the analyzed data. Level of significance was set at 0.05.

RESULTS

Dry TB showed partial or no return to ambulation (75% vs. 31.5% in wet, p=.01) at 12-months and took more time to reach final ambulatory level (9.16 months vs. 2.9 months in wet), despite having a lower average Cobb angle (16.5 degrees versus 20.95 in wet (p=.132), lower mean canal-encroachment (24.9% vs. 50.09% in wet, p<.01) and preserved posterior-CSF flow as compared to wet TB (p=.02). At final follow-up, 4/16 (25%) of dry and 0% of wet TB were ASIA A, and 9/16 (56.25%) dry and 18/22 (72.7%) of wet TB were ASIA E (p=.04).

CONCLUSION

Dry TB of the spine has poorer functional outcome in terms of time to ambulation and final ambulatory status despite having minimal destruction and abscess formation causing mechanical cord compression.

Bridging the gap: Gardner-Wells tongs utilization in pediatric spinal tuberculosis: A case report

INTRODUCTION

Spinal Tuberculosis (TB), or Pott's disease, is a significant form of extrapulmonary TB affecting the spine, especially in children. Standard treatments include anti-tuberculosis medications, immobilization, and surgery. The use of Gardner well tongs (GWT) in pediatrics spinal TB is rare due to associated risks and lack of supporting evidence. This case report aims to document the application of GWT traction in conjunction with surgical intervention for a pediatric patient with tuberculosis spondylitis.

CASE PRESENTATION

An 8-year-old boy presented with progressive weakness in both legs over 2.5 years, culminating in his inability to stand or walk. Physical examination revealed asymmetrical back, gibbus formation, tenderness, limited range of motion, and upper motor neuron neurological deficits. Radiographic imaging showed vertebral body destruction from T1-6, causing an 81-degree kyphotic curve. The patient underwent 5 kg of GWT traction for 2 weeks, resulting in a 10-degree improvement in curvature. Subsequent surgical procedures included laminectomy, posterior stabilization, deformity correction, and post-operative application of a SOMI brace. By discharge, the patient's kyphotic angle had improved from 81 to 63°, and there was notable improvement in motor strength and neurological function.

DISCUSSION

While surgical intervention is often necessary for vertebral deformity restoration, GWT offers advantages in spinal TB management, such as achieving stable cervical segments without skin incision and aiding gradual kyphotic correction. Serious complications from GWT, like skull perforation or neurovascular damage, are infrequent.

CONCLUSION

A comprehensive, holistic approach incorporating GWT traction and surgical intervention is essential for improving clinical outcomes in pediatric tuberculosis spondylitis.

Lumbosacral tuberculosis, a rare manifestation of Pott's disease - How identified human skeletons from the pre-antibiotic era can be used as reference cases to establish a palaeopathological diagnosis of tuberculosis

The macromorphological examination of identified human osteological collections from the pre-antibiotic era (e.g., Terry Collection) can provide invaluable information about the skeletal manifestations of tuberculosis (TB) in individuals who did not receive pharmaceutical therapy. With analysis of such collections, new diagnostic criteria for TB can be recognised which can be used in palaeopathological interpretation. The aim of our paper is to provide a reference and aid for the identification of TB in past populations by demonstrating and discussing in detail the vertebral alterations indicative of one of its rare skeletal manifestations, lumbosacral TB. These changes were detected in two individuals from the Terry Collection (Terry No. 760 and Terry No. 1093). These two case studies furnish palaeopathologists with a stronger basis for diagnosing lumbosacral TB in skeletons which exhibit similar vertebral lesions from osteoarchaeological series. To illustrate this, an archaeological case from Hungary (KK146) is also presented, displaying vertebral alterations resembling that of the two cases from the Terry Collection. Through the demonstrated case studies, we can derive a better insight into the disease experience of people who lived in the past and suffered from TB.

Multiple Spinal Tuberculosis with Severe Kyphosis: A Case Report

Background

The purpose of this study was to analyze the clinical efficacy of a patient with multiple tuberculosis of the spine combined with severe kyphosis.

Case Summary

A 56-year-old male patient presented with low back pain with numbness and fatigue in both lower extremities for 5 months. Chest and back showed intermittent acid pain. The patient had not a history of constitutional symptoms. Preoperative X-ray and CT examination revealed multiple vertebral segmental bone destruction, multiple abscess calcification, and severe kyphosis. Preoperative MRI examination showed that the tuberculous abscess broke through the spinal canal and compressed the spinal cord and nerve roots. The patient underwent posterior lumbar abscess debridement, expanded decompression of the spinal canal, and nerve lysis in our hospital. The operation time was 70 min, and the intraoperative blood loss was 200 ml. The postoperative drainage volume was 250 ml. The patient was hospitalized for a total of 13 days, and the patient’s vital signs were stable before and after surgery. The patient was satisfied with the treatment.

Conclusion

For the patient with multiple spinal tuberculosis complicated with severe kyphosis and multiple calcified abscesses in this study, we considered performing abscess debridement to relieve the symptoms of back pain and achieved good clinical efficacy.

Blood transfusion risk prediction in spinal tuberculosis surgery: development and assessment of a novel predictive nomogram

Objective

The present study attempted to predict blood transfusion risk in spinal tuberculosis surgery by using a novel predictive nomogram.

Methods

The study was conducted on the clinical data of 495 patients (167 patients in the transfusion group and 328 patients in the non-transfusion group) who underwent spinal tuberculosis surgery in our hospital from June 2012 to June 2021. The least absolute shrinkage and selection operator (LASSO) and multivariable logistic regression analyses were used to screen out statistically significant parameters, which were included to establish a novel predictive nomogram model. The receiver operating characteristic (ROC) curve, calibration curves, C-index, and decision curve analysis (DCA) were used to evaluate the model. Finally, the nomogram was further assessed through internal validation.

Results

The C-index of the nomogram was 0.787 (95% confidence interval: 74.6%–.82.8%). The C-value calculated by internal validation was 0.763. The area under the curve (AUC) of the predictive nomogram was 0.785, and the DCA was 0.01–0.79.

Conclusion

A nomogram with high accuracy, clinical validity, and reliability was established to predict blood transfusion risk in spinal tuberculosis surgery. Surgeons must prepare preoperative surgical strategies and ensure adequate availability of blood before surgery.