Magnetic resonance evaluation of tubercular lesion in spine

Healing Assessment of Spinal Tuberculosis: A Systematic Review

OBJECTIVE

Deciding the healing end point in spinal tuberculosis (STB) remains a controversial topic. The current systematic review aims to address the controversy existing in the literature to find a comprehensive method to assess healing in STB.

METHODS

A thorough literature search was carried out for studies with the assessment of healing parameters in STB. Data extraction was carried out manually, which included study characteristics and healing criteria evaluated in each study.

RESULTS

Qualitative analysis of 8 included studies showed that healing parameters were described in 3 domains: clinical, hematologic, and radiologic response of the patient to antitubercular chemotherapy. Each domain included various individual parameters, with clinical and radiologic assessment criteria being used in most of the studies. Improvement in terms of pain, constitutional symptoms, weight gain, neurology; variation in erythrocyte sedimentation rate and C-reactive protein; and changes in radiography, magnetic resonance imaging, and positron emission tomography/computed tomography were found to be promising predictors in the assessment of healing.

CONCLUSIONS

Radiologic response parameters emerged as the maximally used criteria to assess healing in STB. However, in the absence of any statistical analysis and an observed lag in radiologic response, the cumulative effect of all the parameters in 3 domains (clinical, hematologic, and radiologic) can be used to declare a spinal tubercular lesion nonhealing, healing, or healed.

Cervicodorsal spine tuberculosis-- surgical approach

Background

Tuberculosis (TB) of CT junction is uncommon (5 % of all spinal TB), and difficult to approach surgically in view of its deep location with sternum in front and scapula in the back. We present 7 consecutively treated cases of cervico-thoraccic TB for outcome of treatment and discuss rationale of choosing surgical approach.

Methods

Present study includes 7 freshly diagnosed cases of CT junction TB. Plain radiographs, sagittal reconstruction of CT spine that included sternum on CT/MRI was performed in all cases. Disc space below the distal healthy vertebrae was identified and a line parallel to disc space was drawn. If this line passes above suprasternal notch, it was inferred that this VB can be accessed by anterior cervical approach. If disease focus was at or below suprasternal notch level, manubriotomy/sternotomy was added for better visualization of the lesion.

Results

All seven cases were female, with mean age of 20 years (9-45 years). The vertebral lesion involved 2VB (n = 3), 3VB (n = 2) and >3 VB (n = 2). The average Cervico-thoracic kyphosis was 15° (range 10-25°). All 7 cases were operated for anterior decompression, kyphotic deformity correction and instrumented stabilization. Anterior cervical approach and manubriotomy/sternotomy approach was performed in three cases each. In two pan-vertebral cases we performed 360° procedure. Six cases have shown first sign of neural recovery within 3 weeks of surgery and almost complete neural recovery at 3 months follow-up while one case showed partial recovery. ATT was stopped after 12 months once healed stage was demonstrated on contrast MRI in all.

Conclusions

CT junction TB usually presents with severe kyphotic deformity/neural deficit. These cases require anterior decompression/corpectomy, deformity correction, gap grafting and instrumented stabilization with anterior cervical plate. Lesion with pan-vertebral disease is stabilized 360°. These lesions can be decompressed by lower anterior cervical approach with/without manubriotomy. The Karikari method was useful in deciding the need for manubriotomy to decompress the lesion.

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.

Magnetic resonance imaging features for differentiating tuberculous from pyogenic spondylitis: a meta-analysis

OBJECTIVE

To perform a meta-analysis comparing the MRI features of tuberculous and pyogenic spondylitis, using histopathological results and/or blood culture as the standard reference.

MATERIALS AND METHODS

PubMed, Embase, Web of Science, and Cochrane Library were searched for English-language studies on the MRI features of tuberculous and pyogenic spondylitis published between January 2010 and February 2023. Risk for bias and concerns regarding applicability were assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Pooled MRI features' proportions were calculated using a bivariate random-effects model.

RESULTS

Thirty-two studies met the inclusion criteria: 21 for tuberculous spondylitis, three for pyogenic spondylitis, and eight for both. Of the nine informative MRI features comparing tuberculous spondylitis to pyogenic spondylitis, involvement of ≥ 2 vertebral bodies (92% vs. 88%, P = .004), epidural extension (77% vs. 25%, P < .001), paravertebral collection (91% vs. 84%, P < .001), subligamentous spread (93% vs. 24%, P < .001), thin and regular abscess wall (94% vs. 18%, P < .001), vertebral collapse (68% vs. 24%, P < .001), and kyphosis (39% vs. 3%, P < .01) were more suggestive of tuberculous spondylitis, while disc signal change (82% vs. 95%, P < .001) and disc height loss (22% vs. 59%, P < .001) were more suggestive of pyogenic spondylitis.

CONCLUSION

Involvement of ≥ 2 vertebral vertebral bodies, soft tissue attribution, thin and regular abscess wall, vertebral collapse, and kyphosis were MRI features more common in tuberculous spondylitis, while disc signal change and height loss were more common in pyogenic spondylitis.

Predictive Value of Vertebral Bone Destruction Classification Based on Computed Tomography in Diagnosing on Adult Spinal Tuberculosis

OBJECTIVE

Although magnetic resonance imaging (MRI) is well-established for evaluation of spinal tuberculosis (TB), the importance of computed tomography (CT) should not be overlooked. The purpose of this study was to determine the characteristics of spinal TB and the relationship between spinal TB and the bone lesion pattern seen on three-dimensional CT images.

METHODS

One hundred and sixty-one subjects were divided into a TB-positive group and a TB-negative group based on laboratory (X-pert mycobacterium tuberculosis/ rifampin) results and then subdivided further according to whether the bone lesion pattern seen on three-dimensional CT images was fragmentary, osteolytic, sclerotic, or had no evidence of bone destruction. The diagnostic value of the bone lesion pattern was compared between the TB-positive and TB-negative groups.

RESULTS

Ninety-nine of the 161 patients were TB-positive and 62 were TB-negative. Fifty-six (34.8%) of the 161 patients had fragmentary/osteolytic lesions, seventy-four (45.9%) had absolute osteolytic lesions, 13 (8.1%) had osteosclerotic lesions, and 18 (11.2%) had no evidence of bone destruction. The fragmentary/osteolytic lesion pattern was strongly predictive of spinal TB (odds ratio 3.33), and when combined with 3 MRI findings (thin abscess wall, more than one half of the vertebral body destroyed, and subligamentous spread) had an even stronger diagnostic value (odds ratio 15.58).

CONCLUSIONS

The absolute osteolytic pattern was the most common of the bone lesion patterns. The fragmentary/osteolytic pattern is highly suggestive of spinal TB, especially when combined with MRI findings of a thin abscess wall, destruction of more than one half of the vertebral body, and subligamentous spread.

Single Sequence Whole-Spine Screening Magnetic Resonance Imaging: Diagnostic and Therapeutic Role in Multiple-Level Spinal Tuberculosis

INTRODUCTION

Spinal tuberculosis (TB) is the most common form of skeletal tuberculosis. Paradiscal continuous vertebral involvement at a single level is the most prevalent pattern among all forms of spinal TB. There is a wide range of reported incidences of multiple-level non-contiguous spinal TB in the literature. We would like to discuss on the utility of single whole spine screening T2-weighted (T2W) mid-sagittal magnetic resonance imaging (MRI) film in diagnosing multiple-level spinal TB and therapeutic benefits it can provide.

METHODS

We have done a retrospective review of the collected data of patients in Vardhman Mahavir Medical College and Safdarjung Hospital from August 2017 to October 2021 to find the incidence of multiple-level spinal TB and possible factors attributed to this specific disease pattern. All the patients who had been diagnosed of spinal TB either microbiologically or histopathologically or by a good clinical response to anti-tubercular treatment (ATT) and had a whole spine screening MRI film, were included. Patients of spinal TB who did not have a whole spine screening MRI were excluded from the study. Multiple-level spinal TB was diagnosed when lesions were identified in vertebral levels other than a typical paradiscal lesion, and additional lesions were separated from the primary disease by at least one normal spinal segment.

RESULTS

Among the patients, 242 met the inclusion criteria, and 76 showed multiple-level non-contiguous spinal TB on MRI, incidence being 31.4%. The rest of the 166 patients showed typical single-segment contiguous lesions. By doing multivariate analysis to determine the independent risk factors for multiple-level spinal TB, extremes of age (<20 years and >50 years) have been found to be a significant factor with p value of 0.0001. Though drug resistance was not found to be a significant risk factor (p value 0.051), the proportion of patients having multiple-level TB was far more in the drug-resistant group (13/76).

CONCLUSIONS

Single sequence whole spine screening MRI film is an effective, economical, and time-saving tool to detect multiple-level spinal TB. Along with its diagnostic accuracy, it also provides therapeutic benefits like access to a more approachable site for biopsy.

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.

Does computed tomography-guided percutaneous catheter drainage is effective for spinal tuberculous abscess: a midterm results

STUDY DESIGN

Retrospective cohort study.

PURPOSE

To evaluate an effectiveness and report a midterm clinical outcome in pain and neurological status in spinal tuberculous abscess after treated by CT-guided percutaneous catheter drainage.

OVERVIEW OF LITERATURE

Spinal tuberculosis is one of the destructive forms of tuberculosis infection, which can cause undesirable consequences. The gold standard of surgical treatment of spinal tuberculosis with tuberculous abscess is radical debridement, abscess drainage, and bone grafting of the defect via anterior approach. However, this treatment may lead to several serious complications. CT-guided percutaneous catheter drainage is an alternative procedure for this condition and may reduce the serious complications from standard surgical treatment.

MATERIALS AND METHODS

The medical record of the patients with spinal tuberculosis with tuberculous abscess who underwent CT-guided percutaneous catheter drainage (CT-guided PCD) from 2015 to 2021. The visual analog pain scale (VAS), Frankel grading scale, duration of drainage, amount of spinal tuberculous abscess, and complications were evaluated.

RESULTS

Twenty-nine patients (mean age 44 years old) were included in the study. All patients were followed up for 24 to 72 months with an average of 36 months. Level involvements were mostly found in L1-L2 followed by L2-L3 and T12-L1 levels. A 14-Fr catheter was the mostly use followed by 16-Fr catheter. Amount of abscess drainage ranged from 110 to 2,490 ml (mean 599 ml). The drainage duration ranged from 6 to 42 days (mean 17 days). Additional surgery was performed in three patients due to subsequent mechanical instability developed despite successful drainage of abscess. At the last follow-up, VAS, Frankel grading scale were improved significantly in all patients without complications.

CONCLUSIONS

CT-guided percutaneous catheter drainage is a safe and effective alternative procedure in the treatment of spinal tuberculous abscess patients with high success rate, less complications, and satisfied midterm outcomes.

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.

Differentiating tubercular from pyogenic causes of spine involvement on Magnetic Resonance Imaging

Introduction

Based on clinical parameters alone, it is difficult to differentiate between tubercular (TB) and pyogenic spondylodiscitis. Therefore, this study aimed to identify imaging features that can help to differentiate these two entities.

Methodology

This retrospective observational study included microbiologically confirmed cases of TB and pyogenic spondylitis over three years. Magnetic resonance imaging of included cases was reviewed for a predefined set of imaging findings. A multivariable logistic regression analysis was done to compare the radiological features of both groups. A scoring system was created using the features that were significant in univariate and multivariable analysis.

Results

Of the 90 included cases, 44 were TB and 46 were pyogenic. Involvement of the thoracic vertebra, paravertebral abscess, epidural abscess, posterior element involvement, loss of height, spine deformity, nerve compression, destruction of the disc and larger abscess size were more common in patients with TB. Involvement of the thoracic spine, posterior element involvement and spine deformity were independent predictors of diagnosing TB spine. At a score of 7 (out of 11) or above, the scoring system had a sensitivity and specificity of 86% and 94%, respectively, in diagnosing the TB spine.

Conclusion

In the presence of relevant clinical findings, specific MRI findings can help to differentiate TB from pyogenic spondylitis.

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.

Diagnostic values of peripheral blood T-cell spot of tuberculosis assay (T-SPOT.TB) and magnetic resonance imaging for osteoarticular tuberculosis: a case-control study

OBJECTIVE

Early diagnosis of osteoarticular tuberculosis helps improve patients' outcomes, but little is known about the accuracy of noninvasive diagnostic methods. This case-control study aimed to assess the diagnostic value of peripheral blood T-cell spot of tuberculosis assay (T-SPOT.TB) and magnetic resonance imaging (MRI).

METHODS

Patients suspected with osteoarticular tuberculosis were retrospectively included and diagnosed according to the composite reference standard. T-SPOT.TB was used to detect the number of cells secreting Interferon gamma. Diagnostic performance of T-SPOT.TB and MRI alone and combined were evaluated.

RESULTS

Among the suspected patients, 92 had osteoarticular tuberculosis and 137 non- osteoarticular tuberculosis. T-SPOT.TB assay alone had a higher sensitivity (0.73 vs. 0.60) but a lower specificity (0.69 vs. 0.91 P>0.05) in diagnosing osteoarticular tuberculosis. Combined serial test showed a sensitivity and specificity 0.47, 0.97, respectively, whereas combined parallel test showed a sensitivity and specificity of 0.86, 0.65, respectively. Specificity was higher in the combined serial test than in the T-SPOT.TB assay (P=0.007) or MRI alone (P < 0.001). Furthermore, sensitivity was higher in the combined parallel test than in the T-SPOT.TB assay (P < 0.001) or MRI alone (P < 0.001).

CONCLUSIONS

Combined blood T-cell spot of tuberculosis assay and osteoarticular MRI have higher sensitivity and specificity for noninvasive osteoarticular tuberculosis diagnosis, compared with either method alone.

Predicting neurological deficit in patients with spinal tuberculosis - A single-center retrospective case-control study

BACKGROUND

Identifying the risk factors for the neurological deficit in spine tuberculosis would help surgeons in deciding on early surgery, thus reducing the morbidity related to neurological deficit. The main objective of our study was to predict the risk of neurological deficit in patients with spinal tuberculosis (TB).

METHODS

The demographic, clinical, radiological (X-ray and MRI) data of 105 patients with active spine TB were retrospectively analyzed. Patients were divided into two groups - with a neurological deficit (n = 52) as Group A and those without deficit (n = 53) as Group B. Univariate and multivariate logistic regression analysis was used to predict the risk factors for the neurological deficit.

RESULTS

The mean age of the patients was 38.1 years. The most common location of disease was dorsal region (35.2%). Paradiscal (77%) was the most common type of involvement. A statistically significant difference (p < 0.05) was noted in the location of disease, presence of cord compression, kyphosis, cord oedema, loss of CSF anterior to the cord, and degree of canal compromise or canal encroachment between two groups. Multivariate analysis revealed kyphosis > 30° (OR - 3.92, CI - 1.21-12.7, p - 0.023), canal encroachment > 50% (OR - 7.34, CI - 2.32-23.17, p - 0.001), and cord oedema (OR - 11.93, CI - 1.24-114.05, p - 0.03) as independent risk factors for predicting the risk of neurological deficit.

CONCLUSION

Kyphosis > 30°, cord oedema, and canal encroachment (>50%) significantly predicted neurological deficit in patients with spine TB. Early surgery should be considered with all these risk factors to prevent a neurological deficit.

Non-contrast versus contrast-enhanced MR in the diagnosis of spondylitis: A quantitative concordance-analysis

Introduction

: Magnetic Resonance (MR) imaging using gadolinium contrast media is an essential imaging modality in diagnosing spondylitis. However, gadolinium contrast is not widely available in Indonesia and relatively expensive. Many MR studies in Indonesia are performed without contrast administration. It is unclear how confident non-contrast MR can diagnose tuberculous spondylitis in comparison to standard contrast MR.

Purposes

: This study aims to evaluate the concordance between the contrast MR and non-contrast spine MR in diagnosing tuberculous spondylitis. We also evaluate the interobserver agreement between the general radiologist and musculoskeletal radiologist in interpreting non-contrast MR of spondylitis.

Materials and Methods

: A cross-sectional study using secondary data was performed to evaluate the concordance between the MR results regarding the usage of contrast media in diagnosing spondylitis. The inclusion criteria were patients over 17 years old who underwent complete sequences of contrast-enhanced MR examination of the spine, referred to radiology with the clinical diagnosis of suspected tuberculous spondylitis, spondylodiscitis, or both. All of the non-contrast and contrast-enhanced MR results were read and interpreted by two independent observers, a musculoskeletal radiologist and a general radiologist, blindly. The interobserver agreement analysis of the MR examination was conducted using Kappa and McNemar test.

Results

: There was no significant difference between the contrast and non-contrast MR in diagnosing spondylitis (P= 0.368) and no significant difference in the interpretation of MR between the first and the second observer (P =  0.343). The concordance between the contrast and non-contrast spine MR in diagnosing spondylitis (R: 0.88, P < 0.001) and the interpretation of MR between both observers (R: 0.65, P < 0.001) were showed in this study.

Conclusion

: There is a high concordance between the contrast and non-contrast MR in diagnosing tuberculous spondylitis. Although contrast MR is preferred as the standard imaging method of spondylitis, in case gadolinium contrast is unavailable, non-contrast MR can still provide valuable information in diagnosing spondylitis.

Treatment of Bone and Joint Tuberculosis in France: A Multicentre Retrospective Study

Background: Nine percent of all cases of tuberculosis are bone and joint tuberculosis (BJTB). BJTB occurs in two main forms: spinal (STB) and extraspinal (ESTB). The aim of this study was to compare STB with ESTB in terms of diagnosis, treatment and outcomes. Methods: We collected demographic, clinical, microbiological, treatment duration and outcome data for patients with BJTB in a retrospective multicentre study over a 17-year period. Results: Of the 116 patients included in the study, 69 (59.5%) had STB and 47 (40.5%) had ESTB. The median age was higher in the ESTB group. There were significantly more foreign-born patients in the STB group. The median time for diagnosis was longer for ESTB (6 months) than STB (4 months) (p = 0.017). Magnetic resonance imaging was highly reliable for the diagnosis. Direct examination and histology allowed the diagnosis to be made in more than 80% of cases. The median treatment duration of 12 months, regardless of the type of BJTB, was longer than recommended. A favourable outcome was achieved in 91.9% of cases. Conclusion: The management of BJTB remains challenging. An earlier diagnosis should be more effective, reducing the total duration of treatment and leading to better tolerance.

Predictive factors for neurological deficit in patients with spinal tuberculosis

BACKGROUND

Spinal tuberculosis (TB) is a leading cause of damage to the spine and associated neural structures.

PURPOSE

This study aims to identify the risk factors for neurological deterioration in spinal TB patients to promptly care for the patients before paralysis develops.

METHODS

The demographics, clinical characteristics, laboratory results, and radiographic findings of spinal TB patients were collected between 1993 and 2016. The data were analyzed using logistic regression methods. The predictive factors for neurological deficit were identified.

RESULTS

There were 125 spinal TB patients (70 men and 55 women). The average age ± standard deviation was 55.7 ± 2.0 and 52.3 ± 2.4=years, respectively. According to the univariate analysis, the significant risk factors associated with neurological deterioration were signal cord changes, notable Cobb angle (>30°), radiating pain, and epidural abscess. The multivariate analysis revealed that only signal cord change and notable Cobb angle significantly influenced neurological status.

CONCLUSION

The predictive factors for neurological deterioration in spinal TB patients are signal cord change and notable Cobb angle. Surgery should be considered in patients who present with these factors before the development of neurological deterioration.

Vertebral column resection for post tuberculosis severe kyphotic deformity: Results of 5 year follow-up

Background

Spinal TB is endemic in our study region and many patients present with severe kyphotic deformities and neurological deficit. We corrected such deformities with all posterior single stage surgeries. This study was undertaken to evaluate the results, efficacy and safety of this technique.

Methods

Deformity correction of 16 patients was done during January 2012 to December 2014. All patients underwent posterior only approach for vertebral column resection at peri-apical region, posterior instrumentation with pedicular screws and anterior reconstruction using mesh cage. Postoperative X-ray films were evaluated. All patients were followed up at six weeks, 12 weeks, 18 weeks, six months and yearly thereafter. At follow-up patients were evaluated neurologically and radio-graphically.

Results

Mean age of the patients was 19.43 years. (Range 3-37) An average 1.62 vertebrae were excised and 5.93 vertebral levels were instrumented. Mean blood loss was 1013 ml and the mean duration of surgery was 6.78 h. The decrease in mean kyphotic deformity from preoperative 90.08⁰ to postoperative 38.06⁰ was statistically significant. (P < 0.000) Mean percentage correction was 57.59%. No pseudoarthrosis was found on X-rays. The decrease in Oswestry's Disability Index was from 55.43 to 10.06 was statistically significant. (P < 0.000) Two patients had neurological complications and one patient had wound complication.

Conclusion

The safety and efficacy of Posterior VCR technique for post tuberculosis severe kyphotic deformity is favorable with no severe late stage complications. Excision of ribs, careful handling of cord and gradual correction of deformity with good hemostasis is important.

Diagnostic accuracy of whole spine magnetic resonance imaging in spinal tuberculosis validated through tissue studies

INTRODUCTION

Conventional diagnosis of spinal tuberculosis (TB) is based on a combination of clinical features, laboratory tests and imaging studies, since none of these individual diagnostic features are confirmatory. Despite the high sensitivity of MRI findings in evaluating spinal infections, its efficacy in diagnosing spinal TB is less emphasized and remains unvalidated through tissue studies.

METHODOLOGY

We reviewed consecutive patients evaluated for spondylodiscitis with documented clinical findings, MRI spine, and tissue analysis for histopathology, TB culture and genetic TB PCR. MRI features documented include location, contiguous/non-contiguous skip lesions, para/intraosseous abscess, subligamentous spread, vertebral collapse, abscess size/wall, disc involvement, end plate erosion and epidural abscess. Based on the results, patients were divided into two groups-CONFIRMED TB with positive culture/histopathology and NON-TB. The efficacy of MRI findings in accurately diagnosing spinal TB was compared between the two groups.

RESULTS

Among 150 patients, 79 patients were TB positive, and 71 were TB negative. Three MRI parameters showed significant differences (p < 0.001), namely subligamentous spread (67/79, 84.8%), vertebral collapse > 50% (55/79, 69.6%) and large abscess collection with thin abscess wall (72/79, 91.1%) being strongly predictive of TB. Combination of MRI findings had a higher predictive value. 97.5% of TB positive patients had at least one of these three MRI features, 89.8% patients had any two and 58.2% had all three.

CONCLUSION

Our study validated different MRI findings with tissue studies and showed spinal infections with large abscess with thin wall, subligamentous spread of abscess and vertebral collapse were highly suggestive of spinal tuberculosis. These slides can be retrieved under Electronic Supplementary Material.

Evaluation of Healed Status in Tuberculosis of Spine by Fluorodeoxyglucose-positron Emission Tomography/Computed Tomography and Contrast Magnetic Resonance Imaging

BACKGROUND

The healed status (end-point of treatment) in tuberculosis (TB) spine is not defined; hence optimum antitubercular therapy (ATT) duration is unresolved. We, for the first time, prospectively evaluated the healed status in TB spine by fluorodeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT) and contrast magnetic resonance imaging (MRI) with the objective to define end-point of treatment in TB spine.

MATERIALS AND METHODS

Thirty seven patients of TB spine diagnosed on clinicoradio imaging/cytology/histologically/molecular methods were enrolled, treated and were evaluated radiologically, by contrast MRI and FDG-PET/CT at 9 months. ATT was stopped on contrast MRI-based healing or absence of FDG uptake on PET-CT. ATT was continued in active/resolving lesion. Repeat evaluation was done at 12, 18, 24, and 30 months till healing is demonstrated. In this research work, we got contrast MRI and FDG-PET/CT done for the patients from government institution free of cost, so patients did not have to bear the burden of cost of these investigations.

RESULTS

Twenty-eight patients achieved healed status out of which 11 demonstrated healed status on contrast MRI and FDG-PET/CT both, 6 were MRI active (contrast enhancement) but FDG-PET/CT healed, 2 were MRI healed but FDG-PET/CT active (soft-tissue standardized uptake value <2.0), 9 patients were MRI incompatible due to stainless steel implants (n = 6), and in 3 patients MRI could not be done due to financial constraints and were declared healed on FDG-PET/CT. FDG-PET/CT showed healed bone lesion in 28/28 (100%) and on MRI 13/19 (68.42%), respectively. We had 6 patients whose spine was stabilized with stainless steel implants where MRI could not be performed, MRI was useful in 13/25 cases (52%) to demonstrate healed lesion. 7, 6, 6, 5, 1, 2, and 1 cases achieved healed status at 9, 12, 18, 24, 30, 36, and 48 months of ATT intake, respectively.

CONCLUSIONS

FDG-PET/CT is more useful to demonstrate the healed status than MRI and is the only imaging to demonstrate healed status when MRI could not be performed due to metallic implants. All patients achieved healed status at variable length of ATT intake; hence TB spine should be treated by ATT till healed status (end-point of treatment) is demonstrated by FDG-PET/CT (absence of FDG uptake) or contrast MRI.

A comparative study to evaluate the feasibility of preoperative percutaneous catheter drainage for the treatment of lumbar spinal tuberculosis with psoas abscess

Background

Spinal tuberculosis is a frequent cause of psoas abscess (PA), and PA largely negates the efficacy of antituberculosis therapy. This study aimed to investigate the clinical outcome of preoperative percutaneous catheter drainage (PCD) in patients with lumbar spinal tuberculosis and PA.

Methods

Between January 2015 and January 2017, 72 patients with lumbar spinal tuberculosis with PA were assigned to group A (preoperative PCD) and group B (n = 36 per group). All patients received posterior pedicle screw fixation and anterior focal debridement and fusion. Data on intraoperative blood loss, the duration of the surgery, and the length of the anterior incision were recorded, as well as the postoperative anal exhaust time, visual analogue scale (VAS), Cobb angle, lumbar vertebra function, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) level, and sinus tract formation.

Results

Sixty-eight patients were followed up for an average time of 13 months (range 6–21 months). Until the final follow-up, no mixed infections, recurrence of tuberculosis, pedicle screw loosening, or screw pullout had occurred. There were significant between-group differences in blood loss, surgery duration, anterior incisional length, postoperative anal exhaust time, and sinus tract formation. As compared with group B, the ESR and CRP levels of the patients in group A were markedly improved following 3 weeks of antituberculosis therapy and 1 week postsurgery.

Conclusion

Preoperative PCD helps to increase the efficacy of antituberculosis therapy prior to surgery, reduce surgical trauma, and avoid postoperative complications, making it a safe and feasible treatment option for lumbar spinal tuberculosis with PA.

Spinal Tuberculosis - Directly Observed Treatment and Short Course or Daily Anti Tubercular Therapy -Are We Over Treating?

Study Design:

Prospective randomised control trial.

Purpose:

To compare the effectiveness of Directly Observed Treatment and Short Course (DOTS) and Daily Anti Tubercular Therapy (ATT) in spinal tuberculosis with no neurological deficit.

Overview of Literature:

Spinal tuberculosis is rampant in India with a major cause of morbidity and mortality. There is a lot of conflict regarding management with anti tubercular drugs, the regimen to be followed and the duration the drugs needed for complete cure.

Material and Methods:

This prospective study was conducted during the period of 2006 to 2009. Thirty cases of spinal tuberculosis were randomly divided equally into two groups of fifteen each and treated with DOTS and Daily ATT and compared at the end of follow up on clinical, radiological and Erythrocyte Sedimentation Rate values (ESR).

Results:

Pain score on Visual Analogue Scale (VAS) exhibits that mean pain score was 5.93+_1.54 at start and 0.64+_1.01 at the end of follow up with 89.39% change with DOTS therapy whereas mean pain score was 7.08 +_1.61at start of therapy and 0.69+_0.95 at end of follow up with 91.73% change in patients treated with Daily ATT with p value >0.05 (not significant). The radiological recovery in patients with DOTS and Daily ATT have similar results after 1.5 years with p value > 0.05 showing that the radiological recovery by both treatment modalities are comparable. Mean change in ESR scores in DOTS therapy patients and patients on daily ATT were 74.57+_9.34% and 75.69+_9.38% change with p value >0.05 which was not significant.

Conclusion:

DOTS therapy is an effective means of management of spinal tuberculosis cases with no neurological involvement, however its efficacy in patients with neurological deficit is further to be evaluated.

Role of percutaneous transpedicular biopsy in diagnosis of spinal tuberculosis and its correlation with the clinico-radiological features

INTRODUCTION

Tuberculosis (TB) has long been an important cause of destructive lesions of spine in India. However the scenario is fast changing with atypical presentations and increasing reports of non-tubercular conditions. This poses a great diagnostic dilemma.

AIM

The present study is aimed at evaluating the diagnostic efficacy of percutaneous transpedicular needle biopsy and the correlation of the histology with clinico-radiological features.

METHODS

Forty-one patients diagnosed of TB spine by magnetic resonance imaging (MRI) were revaluated of their clinical presentations, radiological and MRI features and underwent transpedicular needle biopsy under fluoroscopic guidance. Quality of the sample and radiological/MRI features between the tubercular and non-tubercular lesions were studied.

RESULTS

A good sample obtained in 92.7% patients. Of these 28 patients had TB, 3 non-specific inflammatory lesion and 7 with other non-tubercular conditions (3 pyogenic, 3 metastasis, 1 multiple myeloma). Statistically there is no significant difference among the TB and non-TB groups in terms of vertebral involvement and MRI features. However risk of presentation with cord compression, cord changes and neurodeficit are higher with TB spine.

CONCLUSION

It is very difficult to differentiate between tubercular and non-tubercular pathology of spine on the basis of most of the clinical and MRI features. It is more difficult in early cases without any neurodeficit. Thus histopathological confirmation is must for further management and percutaneous needle biopsy is the best option considering the simplicity and minimally invasive nature of the procedure.

Cervical Spinal Epidural Abscess Due to Mycobacterium tuberculosis without Osseous Involvement: A Case Report

CASE

We present a rare case of cervical spinal epidural abscess due to Mycobacterium tuberculosis without osseous involvement that was treated with decompression and arthrodesis in a 2-stage procedure.

CONCLUSION

Spinal epidural abscess due to Mycobacterium tuberculosis is the least common of the various forms of spinal tuberculosis. This abscess represents a severe infection of the epidural space that can compromise neural elements and can require urgent surgical intervention to avoid permanent neurological deficits. Early diagnosis and early decompression remain the 2 most important predictors of a successful neurological outcome.

Comparison of the Anteroposterior and Posterior Approaches for Percutaneous Catheter Drainage of Tuberculous Psoas Abscess

Background

Tuberculous infection of the lumbar spine may be associated with psoas abscess. The aim of this clinical study was to compare the outcome of posterior lumbar debridement and spinal fusion, combined with either a one-stage anteroposterior (AP) or posterior (P) approach to percutaneous catheter drainage (PCD) for the treatment of lumbar tuberculosis with psoas abscess.

Material/Methods

From January 2008 to June 2012, 74 patients were diagnosed at our hospital with lumbar tuberculosis with unilateral or bilateral psoas abscess. Forty-three patients underwent P-PCD (group A), and 31 patients underwent AP-PCD (group B). Operative duration, blood loss, the length of hospital stay, spinal correction, clinical cure rate, and other clinical outcomes in the two groups were compared.

Results

Comparison of the outcome for the P-PCD and AP-PCD patients showed that there was no significant difference in outcome for spinal bone fusion, correction of spinal deformity, or cure rate from tuberculosis infection (P>0.05). Blood loss, operative time, and the length of hospital stay for patients in group A, the P-PCD group, were significantly less than for group B, the AP-PCD group (P<0.05). Also, group B, the AP-PCD group, had an increased incidence of complications than group A, the P-PCD group, leading to increased hospital stay (OR 3.04, CI 0.52–17.75).

Conclusions

For the treatment of tuberculous psoas abscess using PCD, the posterior approach may achieve the same clinical efficacy as the anteroposterior approach, but is associated with reduced length of hospital stay, and lower risk of complications.

Tuberculosis of the spine with severe angular kyphosis

Aims

To address the natural history of severe post-tuberculous (TB) kyphosis, with focus upon the long-term neurological outcome, occurrence of restrictive lung disease, and the effect on life expectancy.

Patients and Methods

This is a retrospective clinical review of prospectively collected imaging data based at a single institute. A total of 24 patients of Southern Chinese origin who presented with spinal TB with a mean of 113° of kyphosis (65° to 159°) who fulfilled inclusion criteria were reviewed. Plain radiographs were used to assess the degree of spinal deformity. Myelography, CT and MRI were used when available to assess the integrity of the spinal cord and canal. Patient demographics, age of onset of spinal TB and interventions, types of surgical procedure, intra- and post-operative complications, and neurological status were assessed.

Results

All except one of the 24 patients were treated with anti-TB chemotherapy when they were first diagnosed with spinal TB. They subsequently received surgery either for neurological deterioration, or deformity correction in later life. The mean follow-up was 34 years (11 to 59) since these surgical interventions. Some 16 patients (66.7%) suffered from late neurological deterioration at a mean of 26 years (8 to 49) after the initial drug treatment. The causes of neurological deterioration were healed disease in nine patients (56.2%), re-activation in six patients (37.5%) and adjacent level spinal stenosis in one patient (6.3%). The result of surgery was worse in healed disease. Eight patients without neurological deterioration received surgery to correct the kyphosis. The mean correction ranged from 97° to 72°. Three patients who were clinically quiescent with no neurological deterioration were found to have active TB of the spine. Solid fusion was achieved in all cases and no patient suffered from neurological deterioration after 42 years of follow-up. On final follow-up, six patients were noted to have deceased (age range: 47 years to 75 years).

Conclusion

Our study presents one of the longest assessments of spinal TB with severe kyphosis. Severe post-TB kyphosis may lead to significant health problems many years following the initial drug treatment. Early surgical correction of the kyphosis, solid fusion and regular surveillance may avoid late complications. Paraplegia, restrictive lung disease and early onset kyphosis might relate to early death. Clinically quiescent disease does not mean cure. Cite this article: Bone Joint J 2017;99-B:1381–8.

[Spondylodiscitis in children and adolescents]

BACKGROUND

Spondylodiscitis in children is rare. The condition has an incidence of 2 to 4 % of all infectious skeletal diseases in children.

AIM

Aim of the article is the presentation of epidemiology, the clinical signs, radiological findings as well the treatment options of non-specific and specific spondylodiscitis in children.

METHODS

The available literature was reviewed.

RESULTS

Non-specific spondylodiscitis in children is caused by haematogenous spread of pathogens. Staphylococcus aureus is the most frequently detected bacterium. The clinical signs are unspecific and an Magnetic Resonance Imaging of the spine is the standard radiological procedure to detect spondylodiscitis. In general, the treatment is conservative and includes an antibiotic therapy as well an immobilization of the spine. In endemic areas of the world, specific spondylodiscitis is more common and is caused by Mycobacterium tuberculosis or Brucellae. The treatment is also conservative. For all entities of spondylodiscitis in children, a surgical intervention is only necessary in the case of severe deformities due to the infection or in the case of neurological symptoms.

CONCLUSION

Elevated infectious laboratory values and back pain or other unspecific symptoms can indicate spondylodiscitis in children. MRI of the spine is necessary to rule out spondylodiscitis.

Magnetic Resonance Imaging and GeneXpert: A Rapid and Accurate Diagnostic Tool for the Management of Tuberculosis of the Spine

Study Design

Retrospective study.

Purpose

The aim of this study was to analyze various diagnostic tools, including GeneXpert, for the management of tuberculosis of the spine.

Overview of Literature

Traditional diagnostic methods of microscopy, histology, and culture have low sensitivity and specificity for the management of tuberculosis of the spine.

Methods

Of the 262 treated cases of spinal tuberculosis, data on 1 year follow-up was available for 217 cases. Of these, only 145 cases with a confirmed diagnosis were selected for retrospective analysis.

Results

In 145 of the 217 patients (66.80%), diagnosis was confirmed on the basis of a culture. Of the 145 patients with a confirmed diagnosis, 98 (66.20%) patients were diagnosed on the basis of clinical presentation, whereas 123 (84.8%) exhibited a typical magnetic resonance imaging (MRI) picture. In 99 surgically treated patients, the diagnosis was confirmed on the basis of an intraoperative tissue biopsy. Among the 46 patients treated conservatively, 35 underwent a transpedicular biopsy, 4 patients underwent computed tomography-guided biopsy, 6 patients were diagnosed on the basis of material obtained from a cold abscess, and 1 patient underwent an open biopsy. The sensitivity of the culture for the detection of Mycobacterium tuberculosis was 66.80% (145/217) in our patients. Among the cases in which GeneXpert was used, the sensitivity for the detection of Mycobacterium tuberculosis was 93.4% (43/46). Moreover, the sensitivity of GeneXpert to detect rifampicin resistance was 100% (7/7) in our study.

Conclusions

Majority of the patients with tuberculosis of the spine can be diagnosed on the basis of a typical radiological presentation via MRI. In our study, 84.8% cases exhibited typical MRI findings. For patients presenting with atypical MRI features, a rapid and accurate diagnosis is possible by combining GeneXpert with MRI. The combined use of MRI and GeneXpert is a rapid and highly sensitive tool to diagnose tuberculosis and rifampicin resistance in patients with tuberculosis of the spine. Furthermore, we achieved a 97.9% sensitivity for the detection of Mycobacterium tuberculosis and 100% sensitivity for the detection of rifampicin resistance in our study.

Demographics of tuberculosis of spine and factors affecting neurological improvement in patients suffering from tuberculosis of spine: a retrospective analysis of 312 cases

OBJECTIVES

The purpose of the study was to study demographics of tuberculosis of spine and analyze factors that might affect neurological improvement in such patients.

METHODS

Of the 638 suspected cases of spinal tuberculosis, 312 cases with confirmed diagnosis with at least 1-year follow-up were selected for retrospective analysis. Two hundred cases who presented with neurological deficit were further divided into three groups-completely improved, partially improved and no improvement according to American Spinal Injury Association impairment scale (AIS) grading. All continuous variables and categorical variables were compared across groups.

RESULTS

A total of 209 (66.99%) patients had typical clinical presentation. A total of 264 (84.62%) had typical magnetic resonance imaging (MRI) presentation. Among 356 involved vertebrae, thoracic levels (T1-10) were most commonly affected in 163 (45.78%) followed by thoracolumbar (T11-L2) vertebrae in 98 (27.52%). In 250 patients (80.12%), disease was restricted to one or two adjoining vertebrae. At presentation, 112 (35.89%) patients were neurologically intact, whereas 97 (31%) were AIS D, 65 (20.83%) were AIS C, 8 (2.5%) were AIS B and 30 (9.61%) were AIS A. On statistical analysis, although three groups of patients with complete improvement, partial improvement and no improvement were similar in age, sex, radiological presentation, and co-morbidities and the presence of pulmonary tuberculosis, they were significantly different with regard to the levels of vertebral involvement, AIS grade at presentation, bladder and bowel involvement and its duration.

CONCLUSIONS

In management of patients suffering from tuberculosis of spine, levels of vertebral involvement, AIS grade at presentation, bladder and bowel involvement and its duration significantly affect the final neurological improvement.

Vertebral osteomyelitis in adults: an update

INTRODUCTION

The incidence of vertebral osteomyelitis is increasing, attributed to an ageing population with inherent co-morbidities and improved case ascertainment.

SOURCES OF DATA

References were retrieved from the PubMed database using the terms 'vertebral osteomyelitis' and 'spondylodiscitis' between January 1, 2009 and April 30, 2014 published in English as checked in May 2014 (>1000 abstracts checked).

AREAS OF AGREEMENT

Blood cultures and whole spine imaging with magnetic resonance imaging are essential investigations. Thorough debridement is the mainstay of surgical management, although placing metalwork in active infection is becoming increasingly common.

AREAS OF CONTROVERSY

The extent of pursuing spinal biopsies to determine aetiology, antimicrobial choices and duration, monitoring the response to treatment, and surgical techniques and timing all vary widely in clinical practice with heterogeneous studies limiting comparisons. Surgery, rather than conservative approaches, is being proposed as the default management choice, because it can, in carefully selected patients, offer faster reduction in pain scores and improved quality of life.

AREAS TIMELY FOR DEVELOPING RESEARCH

Further studies are needed to define the most effective technique for spinal biopsies to maximize determining aetiology. High-quality trials are required to provide an evidence base for both the medical and surgical management of vertebral osteomyelitis, including challenging medical management as the default option.

Tubercular Spinal Epidural Abscess of the Lumbosacral Region without Osseous Involvement: Comparison of Spinal MRI and Pathological Findings of the Resected Tissue

We herein present a case of tubercular spinal epidural abscess (SEA) without osseous involvement that mimicked an acute bacterial abscess. This case manifested quite unusual findings not only radiographically, but also clinically compared with previously reported cases of tubercular SEA.

Clinicoradiologic Profile of Involvement and Healing in Tuberculosis of the Spine

BACKGROUND

There is no much information about how tuberculous lesions of the spine progress/heal; what clinical and radiological features suggest progression/healing; what is the optimal duration of antitubercular treatment; and what clinical, laboratory, and radiological investigations and their frequency should be done to monitor the disease course.

AIMS

The present study aimed to evaluate what specific clinicoradiologic features suggest involvement and healing in tuberculosis of the spine.

SUBJECTS AND METHODS

Fifty spinal tuberculosis patients (30 males and 20 females) diagnosed clinicoradiologically were enrolled in the study. Patients were evaluated clinically, radiographically, and by magnetic resonance imaging (MRI) at regular intervals to monitor the disease course till 24 months of the initial presentation.

RESULTS

Wedge/collapse (23/50 cases), soft tissue mass (29/50 cases), disc narrowing (45/54 discs), and endplate erosions (89/107 endplates) were the plain radiological findings of tubercular spinal involvement. Earliest sign of healing on plain radiography was decrease in fuzziness of endplate, ultimately leading to either sclerosis of endplate or fusion of adjacent vertebrae. Initial MRI findings included bone marrow edema (50/50 cases), discitis (53/62 discs), endplate erosions (105/123 endplates), pre- and para-vertebral collections (45/50 cases), epidural involvement (26/50 cases), epidural spread (77/109 vertebrae), and subligamentous spread (42/50 cases). Earliest feature of healing on magnetic resonance (MR) examination was decrease in inflammatory soft-tissue masses and reduction in marrow edema.

CONCLUSIONS

Salient features of spinal involvement in tuberculosis on plain radiograph were paradiscal involvement, endplate destruction, and soft tissue masses. Marrow edema, paravertebral collections, subligamentous spread, extradural component, endplate erosion, and discitis suggested tubercular involvement of the spine on MRI. A decrease in these was observed to have prognostic value both in monitoring disease course and response to chemotherapy. Based on the clinicoradiologic findings of the present study, we propose decision-making algorithm, follow-up algorithm, and MR examination protocol for spinal tuberculosis.

LEVEL OF EVIDENCE

This was a Level II study.

Spinal Tuberculosis

Spinal tuberculosis (TB) is a significant form of TB, causing spinal deformity and paralysis. Early diagnosis and treatment are crucial for avoiding multivertebral destruction and are critical for improving outcomes in spinal TB. We believe that appropriate treatment method should be implemented at the early stage of this disease and that the Gulhane Askeri Tıp Akademisi classification system can be considered a practical guide for spinal TB treatment planning in all countries.

Spinal infections: clinical and imaging features

Spinal infections represent a group of rare conditions affecting vertebral bodies, intervertebral discs, paraspinal soft tissues, epidural space, meninges, and spinal cord. The causal factors, clinical presentations, and imaging features are a challenge because the difficulty to differentiate them from other conditions, such as degenerative and inflammatory disorders and spinal neoplasm. They require early recognition because delay diagnosis, imaging, and intervention may have devastating consequences especially in children and the elderly. This article reviews the most common spinal infections, their pathophysiologic, clinical manifestation, and their imaging findings.

Diagnosis and treatment of extrapulmonary tuberculosis

Extrapulmonary tuberculosis (EPTB) constitutes about 20% of all cases of tuberculosis (TB) in Korea. Diagnosing EPTB remains challenging because clinical samples obtained from relatively inaccessible sites may be paucibacillary, thus decreasing the sensitivity of diagnostic tests. Whenever practical, every effort should be made to obtain appropriate specimens for both mycobacteriologic and histopathologic examinations. The measurement of biochemical markers in TB-affected serosal fluids (adenosine deaminase or gamma interferon) and molecular biology techniques such as polymerase chain reaction may be useful adjuncts in the diagnosis of EPTB. Although the disease usually responds to standard anti-TB drug therapy, the ideal regimen and duration of treatment have not yet been established. A paradoxical response frequently occurs during anti-TB therapy. It should be distinguished from other causes of clinical deterioration. Surgery is required mainly to obtain valid diagnostic specimens and to manage complications. Because smear microscopy or culture is not available to monitor patients with EPTB, clinical monitoring is the usual way to assess the response to treatment.

Tuberculosis of ultralong segmental thoracic and lumbar vertebrae treated by posterior fixation and cleaning of the infection center through a cross-window

BACKGROUND CONTEXT

Surgical treatment of thoracolumbar tuberculosis (TB) aims at spinal cord decompression, focus debridement, spine stability, and deformity correction. However, several problems exist in treating multiple segmental thoracolumbar TB, including reducing surgical trauma with effective incision exposure; ensuring the effective long-armed fixation, and maintaining the possibility for revisionary surgery in cases of treatment failure.

PURPOSE

To investigate the clinical efficacy and surgical technique of the single posterior midline approach for screw-rod fixation and debridement through the sacrospinalis muscle outer cross-window to treat multiple segmental thoracolumbar spinal TB.

STUDY DESIGN

A retrospective cohort study.

PATIENT SAMPLE

A group of 17 patients with spinal TB after surgical treatment, with a mean follow-up of 27.9 months (range, 18-48 months).

OUTCOME MEASURES

Neurologic recovery, Cobb angle, and graft union assessed by the Moon standard.

METHODS

This study was approved by the local ethical committee and recruited patients from January, 2005 to January, 2011. We used a posterior midline incision for internal fixation of a pedicle screw system in the gap of the longissimus and spinal multifidus. Anterior lesion debridement and interbody fusions were performed through bilateral cross-windows in the outer edge of the sacrospinalis muscle. Using this technique, we treated 17 patients (10 men; aged 19 to 68 years; mean 39.8 years) with spinal TB involving more than four vertebrae. Nerve damage was classified by the Frankel classification. All patients were treated with regular anti-TB chemotherapy and were followed for 18 to 48 (mean: 27.9 months) months.

RESULTS

The mean (range) for operative time was 4.7 (3.6-6.3) hours, for blood loss during surgery was 1,100 (850-2,300) mL, and for time of interbody fusion was 6.3 (4 to 11) months. The Cobb angle correction rate is 67.1%. Nine of 11 patients' neurologic function returned to normal, which was statistically significant (p=.004). There was no TB recurrence or internal fixation failure.

CONCLUSIONS

Combined with anti-TB chemotherapy, the discussed surgical technique can show improved lesion clearance, decompression of the anterior aspect of the spine, bone graft fusion, internal fixation of outside lesions, drainage and lead to positive treatment outcomes.

[Voluminous Pott's abscess]

Osteoarticular tuberculosis was frequent throughout the world a decade ago but antituberculous chemotherapy and prophylactic measures have clearly contributed to the reduction of its frequency. However, Pott's disease is frequently complicated by an abscess and some locations are exceptional on account of their gravity. We report a case of dorsal spondylodiscitis with a voluminous Pott's abscess compressing the mediastinal structures with a risk of perforating into the trachea.

[A case of spinal tuberculosis in a young Filipino man]

A 19-year-old Filipino man was admitted to our hospital because of persisting fever and back pain. He had recognized his symptoms 6 months previously, but a definite diagnosis was not made. Image testing demonstrated a compressed fracture of the thoracic vertebrae accompanied with a perivertebral abscess. A biopsy specimen revealed granuloma compatible with tuberculosis (TB). Anti-TB drugs were initiated, and his clinical symptoms steadily improved. However, he developed neuropathic symptoms due to exacerbation of the abscess two months after starting the anti-TB drugs. An immediate laminectomy was performed resulting in symptom relief; however severe kyphosis remained. Polymerase chain reaction testing of the abscess collected during the operation was positive for Mycobacterium tuberculosis, confirming the diagnosis of spinal TB. The diagnosis of spinal TB has been a challenge world-wide. Clinicians should be aware of the demographic background as well as the clinical and laboratory features of spinal tuberculosis, facilitating earlier diagnosis.

Magnetic Resonance Image findings of Spinal Tuberclosis at first presentation

Background

Spinal tuberculosis presents in various pathological patterns. The clinical presentation and often the management depend on exact pathological findings. Objective of study was to evaluate the Pathology of spinal tuberculosis as depicted by MRI findings in 119 consecutive cases of spinal TB.

Methodology

It was a cross sectional and observational study conducted at Civil Hospital, Karachi from July 2010 to December 2012.Total numbers of participants were 119. Diagnosis was based on positive histopathology results along with the supportive evidence in MRI. A pre-structured questionnaire was constructed to record the data. Study was ethically approved by Institutional Review Board of Dow University of Health Sciences. Sample size was calculated by using Open-EPI software. All the data was entered and analyzed through SPSS 19.

Result

There were 119 patients who participated in this study out of which 52 were males and 67 were females. Most common level was Dorso-lumbar (33.6%) and 87.5% of them had spondylodiscitis while 90% had cord compression. All 6 (100%) patients who had their upper- dorsal region affected had gibbus formation while all those patients having lumbosacral region involved had thecal compression 4 (100%). Most common mode of treatment used in patients having Spinal TB at Lumbar region was conservative (86.2%).

Conclusion

MRI findings were mostly shadowed with features such as disc destruction and thecal or cord compression. MRI scan could be used for early detection of spinal TB which can reduce disability and deaths in patients. Major clinical findings in spinal TB were fever, Para paresis and back pain.

Correlation between neurological recovery and magnetic resonance imaging in Pott's paraplegia

BACKGROUND

Spinal cord/nerve root compression secondary to a tubercular epidural abscess leads to neurological deficit. Depending on the extent and duration of compression, the end result after treatment may vary from complete recovery to permanent deficit. ASIA has been used extensively to correlate between MRI and neurological status due to traumatic spine injuries. MRI has stood as an invaluable diagnostic tool out of the entire range of current imaging modalities. However, inspite of considerable literature on the applications of MRI in spinal tuberculosis, there have been few studies to assess the relationship between the MRI findings and the neurological deficit as assessed by clinical examination.

AIMS

The objective of this study was to ascertain whether the findings of magnetic resonance imaging (MRI) correlate well with the actual neurological recovery status using the American Spinal Injury Association impairment scale (ASIA) in patients with spinal compression secondary to tuberculous spondylitis.

MATERIALS AND METHODS

60 patients (mean age 43.6 years) diagnosed as spinal tuberculosis by MRI/cytology/histopathology were examined and classified into ASIA impairment scale A-E based on the ASIA and again reclassified after 6 months of therapy to assess functional recovery. Similarly, they underwent MR imaging at the start and at the completion of 6 months of therapy to assess the structural recovery. The MRI features of recovery were correlated with the actual neurological recovery as ascertained by the ASIA.

RESULTS

Before starting treatment 1 patient (2.08%) was in ASIA A, 2 (4.16%) were in ASIA B, 9 (18.75%) were in ASIA C, 36 (75%) were in ASIA D and 12 (20%) were in ASIA E. There was a significant difference in the epidural abscess thickness, thecal compression and cord compression between ambulatory (ASIA D and ASIA E) and non ambulatory patients (ASIA A, ASIA B and ASIA C). After 6 months of therapy 30 (90%) patients in ASIA D and 5 (55.5%) in ASIA C had complete neurological recovery. Both patients from ASIA B improved to ASIA D. Single patient who was in ASIA A before treatment remained non ambulatory (ASIA C) after treatment. Overall 33 (78.5%) patients showed complete recovery at final followup. Out of all the MRI features, only size of epidural abscess was found to be a poor prognostic factor for recovery of neurological deficit.

CONCLUSIONS

There are several parameters on MRI which correlate with the severity of neurological impairment according to ASIA score and resolution of those features on treatment is also correlated well with neurological recovery.

The efficacy of diagnostic battery in Pott's disease: A prospective study

BACKGROUND

The diagnosis of Pott's disease is mostly based on clinicoradiological observations substantiated by the bacterial culture, staining and histopathology. Since, no single technique is enough to conclude Pott's disease in diagnosis, the present study was undertaken to correlate the clinicoradiological, microbiological, histopathological and molecular method to evaluate the effectiveness in diagnosis of Pott's disease.

MATERIALS AND METHODS

62 clinicoradiologically suspected cases of Pott's disease were included in this study. The specimens for diagnostic work up were collected either during surgery or by computed tomography guided fine needle aspiration. All these specimens were tested for tuberculosis (TB) through Ziehl-Neelsen (ZN) microscopy, BACTEC culture, histopathology and polymerase chain reaction (PCR). The final diagnosis was established by the results of performed tests and clinicoradiological improvement of cases at the end of 6 months on anti tubercular treatment.

RESULTS

Out of 62 cases, 7 were excluded from this study as these were turned out to be neoplastic lesions on histopathology. Amongst remaining 55 cases, the TB was diagnosed in 39 (71%) on histopathology, 37 (67.5%) on PCR, 27 (49%) on BACTEC culture and 20 (36.3%) on ZN microscopy. Ultimately 45 cases were tested as positive and 10 were detected as negative for TB in combination of ZN microscopy, BACTEC culture and histopathology. PCR was positive in 37 of 45 cases and 10/55 cases remained negative. On clinical analysis of these 10 cases, it was noted that these were cases of relapse/poor compliance. The combination of PCR and histopathology was also shown positive for TB in 45 cases. Hence, the PCR showed a fair positive agreement (Κ(c) = 0.63) against the combined results of all performed traditional methods.

CONCLUSIONS

The combination of PCR and histopathology is a rapid and efficient tool for diagnosis of Pott's disease.