Natural history of Pott's kyphosis

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

BACKGROUND

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

PURPOSE

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

STUDY DESIGN

Retrospective analysis of prospectively collected data.

PATIENT SAMPLE

About 114 patients undergoing surgical correction for kyphotic deformity.

OUTCOME MEASURES

Intraoperative neuromonitoring alerts and postoperative neurological status using AIS grading.

METHODS

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

RESULTS

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

CONCLUSION

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

Pott's Spine Unveiled: A Comprehensive Case Report and Surgical Intervention

This case report describes the presentation, diagnosis, and surgical management of a 61-year-old female admitted to a tertiary care hospital with a two-month history of neck pain and weakness in all four limbs. Despite the absence of a clear history of trauma, a detailed examination revealed restricted neck flexion, paraspinal muscle spasm, and neurological deficits. Contrast-enhanced MRI indicated vertebral osteomyelitis and discitis at the C5-C6 level, with a suspected infective etiology, possibly tuberculosis spondylitis. The patient underwent anterior cervical decompression, corpectomy of C5-C6, and fusion of C4-C7. Postoperative management included intravenous antibiotics, physiotherapy, and anti-tubercular treatment. The patient exhibited satisfactory recovery, and this case underscores the importance of comprehensive evaluation and prompt intervention in managing complex spinal infections.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Comprehensive Spinal Tuberculosis Score: A Clinical Guide for the Management of Thoracolumbar Spinal Tuberculosis

STUDY DESIGN

A newly proposed scoring tool was designed to assist in the clinical management of adult thoracolumbar spinal tuberculosis (TB).

PURPOSE

To formulate a comprehensive yet simple scoring tool to guide decision-making in the management of adult thoracolumbar spinal TB.

OVERVIEW OF LITERATURE

Spine surgeons have differing consensus in defining the threshold grade for clinico-radiological parameters when deciding between operative or conservative treatment for adult thoracolumbar spinal TB. Currently, the void in decision-making from the lack of well-defined guidelines is compensated by the surgeon's experience in treating these patients. To the best of our knowledge, no scoring system holistically integrates multiple facets of spinal TB to guide clinical decision-making.

METHODS

The RAND/University of California, Los Angeles appropriateness method was employed among an expert panel of 10 spine surgeons from four apex tertiary care centers. Vital characteristics that independently influenced treatment decisions in spinal TB were identified, and a scoring tool was formulated. Points were assigned for each component based on their severity. The cutoff scores to guide clinical management were determined from the receiver operating characteristic curve based on the retrospective records of 151 patients treated operatively or non-operatively with improved functional outcomes at the 1-year follow-up.

RESULTS

The components of the comprehensive spinal TB score (CSTS) are pain, kyphosis angle, vertebral destruction, and neurological status. A score classification of <5.5, 5.5-6.5, and >6.5 was established to guide the patient toward conservative, conservative/ operative, and operative management, respectively.

CONCLUSIONS

The CSTS was designed to reflect the essential indicators of mechanical stability, neurological stability, and disease process stabilization in spinal TB. The scoring tool is devised to be practical and serve as a common language in the spine community to facilitate discussions and decision-making in thoracolumbar spinal TB. The validity, reliability, and reproducibility of this tool must be assessed through multicenter long-term studies.

A Validated Score for Evaluating Spinal Instability to Assess Surgical Candidacy in Active Spinal Tuberculosis-An Evidence Based Approach and Multinational Expert Consensus Study

STUDY DESIGN

Modified Delphi Consensus and Observational Study.

OBJECTIVE

Instability in spinal tuberculosis (STB) leads to disabling spinal deformity and neurodeficit. Identifying and estimating instability remains subjective, mainly based on experience. This study aims to develop an objective scoring system to determine instability in STB.

MATERIALS AND METHODS

The study included 4 phases. (1) A panel of 10 experienced spine surgeons developed a questionnaire based on literature. (2) 68 spine surgeons from 12 countries opined on the importance of each factor in a survey. Five factors deemed important by >70% of participants were further analyzed (3) 60 representative cases of STB were analyzed for instability. A preliminary scoring system was developed, a threshold score for determining instability was derived, and (4) Results were validated.

RESULTS

All the 5 factors ("Spine at risk" signs, severity of vertebral body loss, Cervicothoracic/Thoracolumbar junction involvement, age ≤15, and kyphotic deformity ≥30°) considered important by >70% of participants were associated with instability and included in scoring: age ≤15 years (P-value, 0.05), cervicothoracic/thoracolumbar junction involvement (P-value, 0.028), sagittal deformity angle ratio (DAR) ≥ 15° (P-value, <.001), vertebral body loss-segmental ratio ≥.5 (P-value, <.001), and presence of spine at risk signs (P-value, <.001). A total score of ≥3/09 indicated definite instability with good sensitivity (77%) and excellent specificity (100%). Repeatability assessment showed a good agreement (.9625), and Cohen's kappa coefficient was strong (.809).

CONCLUSION

A simple objective scoring system for predicting instability in STB has been developed using 5 main factors; young age, junctional involvement, severity of the deformity, vertebral body loss, and presence of spine at risk signs.

Cervicothoracic dislocation due to congenital and bone-dysplasia-related vertebral malformations

PURPOSE

To evaluate the approaches to treatment of congenital and bone-dysplasia-related pediatric cervicothoracic dislocations and define the optimal treatment method.

METHODS

The publications available in PubMed and Google Scholar data bases were selected following such criteria as the disease in question, pediatric age, the treatment description, and follow-up results. The paper also includes the descriptions of our own six cases of the cervicothoracic dislocations detected in children with different vertebral malformations.

RESULTS

Only eight patients meeting the abovementioned selection criteria were found in the publications: three of them had the Klippel-Feil syndrome (KFS), two had one-level vertebral anomaly, one had neurofibromatosis (NF type 1), one had the Larsen syndrome, and one had a variation of VACTERL association. Their treatment was long term, multi stage, and complicated. Among six our own cases, four patients also had KFS, one had a variation of VACTERL association, and one had NF type 1. All the patients suffered from preoperative neurological disorders. Posterior instrumental fixation with posterior vertebral body resection was performed in four cases and one patient underwent a combined surgery. The parents of one of the patients refused the operation, so he was observed while receiving bracing treatment. Since the treatment was long term and complicated by reoperations, the average follow-up period comprised 5 years.

CONCLUSION

Congenital cervicothoracic dislocations are an extremely rare pathology that manifests itself in early age and requires an early surgical treatment. Failure to provide the treatment leads to the patient's disability. The surgical tactics for such patients is determined individually, but the published data and our own experience demonstrate that early multi-stage combined treatment has been the best option available so far. The cervicothoracic dislocations due to NF 1 manifest later and have a more favorable forecast.

Children with back pain - a radiologist's approach

Purpose

The aim of the study was to analyse magnetic resonance imaging (MRI) of paediatric patients referred because of back pain.

Material and methods

The retrospective analysis included the medical records of 328 patients referred in 2020-2022 to the Department of Paediatric Radiology for spine examination. The criterion for inclusion in the analysed group was back pain as the dominant symptom. This symptom occurred in 20% (68 patients) of referrals for MRI examinations. The examination was performed with the 3T Magnetom Spectra.

Results

In 68 patients aged 2 to 17 years, with back pain as the first diagnosis, 53% (36 patients - 16 girls and 20 boys) showed abnormalities. The rest of the tests were assessed as normal. Among the patients with an abnormal MR image, the largest group were children with degenerative changes diagnosed: 10 children (28%) aged 13-17 years. In 9 patients (25%) aged 2-16 years the final diagnosis qualified the patients to the group of oncological diagnoses. Another group of 7 (19%) patients, aged 6-14 years, comprised children diagnosed with inflammation. The group of 5 patients, aged 3-17 years, presented symptoms most likely related to the trauma. One 7-year-old boy was diagnosed with large calcifications within the intervertebral disc.

Conclusions

Back pain, with accompanying neurological symptoms, should not be underestimated. Although in most clinical situations the MR image is normal, in the case of persistent symptoms and neurological abnormalities confirmed by the clinician, extending the diagnostics with MR imaging should be considered. This imaging can accelerate the correct diagnostic path or make a very precise diagnosis.

Tuberculosis of the spine

Pott's spine, commonly known as spinal tuberculosis (TB), is an extrapulmonary form of TB caused by Mycobacterium TB. Pott's paraplegia occurs when the spine is involved. Spinal TB is usually caused by the hematogenous spread of infection from a central focus, which can be in the lungs or another location. Spinal TB is distinguished by intervertebral disc involvement caused by the same segmental arterial supply, which can result in severe morbidity even after years of approved therapy. Neurological impairments and spine deformities are caused by progressive damage to the anterior vertebral body. The clinical, radiographic, microbiological, and histological data are used to make the diagnosis of spinal TB. In Pott's spine, combination multidrug antitubercular therapy is the basis of treatment. The recent appearance of multidrug-resistant/extremely drug-resistant TB and the growth of human immunodeficiency virus infection have presented significant challenges in the battle against TB infection. Patients who come with significant kyphosis or neurological impairments are the only ones who require surgical care. Debridement, fusion stabilization, and correction of spinal deformity are the cornerstones of surgical treatment. Clinical results for the treatment of spinal TB are generally quite good with adequate and prompt care.

Single-Posterior Revision Surgery for Recurrent Thoracic/Thoracolumbar Spinal Tuberculosis With Kyphosis

BACKGROUND AND OBJECTIVES

The treatment of thoracic/thoracolumbar spinal tuberculosis (STB) remains challenging. The spinal deformity, long disease history, heterogeneous lesion, and poor drug response make the treatment of recurrent and kyphosis cases even more difficult. This study aims to investigate the efficacy and safety of single-posterior revision surgery in patients with recurrent thoracic/thoracolumbar STB and kyphosis.

METHODS

Patients with recurrent thoracic/thoracolumbar STB with kyphosis and treated with single-posterior debridement, osteotomy, correction, bone graft, and fusion in our center from 2009 to 2019 were enrolled. The clinical data, radiographs, and erythrocyte sedimentation rate (ESR) at different stages were collected. ESR, kyphotic angle, Visual Analog Scale, and neurological functions were analyzed.

RESULTS

A total of 27 patients (16 male, 11 female) with an average age of 48.4 ± 13.0 years were included. The average surgery time was 320.6 ± 46.4 minutes, and the average estimated blood loss was 1470.6 ± 367.4 mL. From admittance to the latest follow-up, the average Visual Analog Scale significantly reduced from 5.6 ± 1.3 to 0.5 ± 0.7, the average ESR was improved from 69.4 ± 15.8 mm/h to normal, and the average kyphotic angle was corrected from 66.6° ± 11.7° to 34.5° ± 6.6°. For patients with preoperative neurological deficits, their neurological functions were improved to normal. In drug susceptibility tests, 70.5% (11/17) of specimens had bacteria resistant to at least 1 first-line drug.

CONCLUSION

Single-posterior debridement, osteotomy, correction, bone graft, and fusion are effective and safe in the treatment of recurrent thoracic/thoracolumbar spinal tuberculosis with kyphosis. The drug treatment of recurrent spinal tuberculosis should be carefully tailored.

Post-TB health and wellbeing

TB affects around 10.6 million people each year and there are now around 155 million TB survivors. TB and its treatments can lead to permanently impaired health and wellbeing. In 2019, representatives of TB affected communities attending the '1st International Post-Tuberculosis Symposium´ called for the development of clinical guidance on these issues. This clinical statement on post-TB health and wellbeing responds to this call and builds on the work of the symposium, which brought together TB survivors, healthcare professionals and researchers. Our document offers expert opinion and, where possible, evidence-based guidance to aid clinicians in the diagnosis and management of post-TB conditions and research in this field. It covers all aspects of post-TB, including economic, social and psychological wellbeing, post TB lung disease (PTLD), cardiovascular and pericardial disease, neurological disability, effects in adolescents and children, and future research needs.

Posterior-Only Approach for the Correction of Severe Post-tubercular Kyphosis

Tuberculosis of the vertebral column (Pott's disease) accounts for up to one-half of musculoskeletal tuberculous infections. The eradication of the infective organism (Mycobacterium tuberculosis) is achievable with chemotherapy. However, such patients with spinal tuberculosis are at risk of developing spinal deformity, and 3%-5% of the patients develop severe deformity greater than 60°. A 30-year-old female presented with back pain of 11 years, discharging sinus, and progressively worsening kyphotic deformity of eight-year duration. She had completed a full course of anti-tubercular chemotherapy. Her neurological examination was within normal limits. Antero-posterior and lateral view radiographs showed osteolytic destruction and collapsed T12 and L1 vertebrae with a thoracic kyphosis of 90°. We did a single-stage posterior-approach closing-opening osteotomy surgery utilizing costotransversectomy (T12 and L1 corpectomy, the insertion of expandable titanium cage, T10 to L3 pedicle screw, and rod fusion). Postoperative kyphosis was 25°. Her motor and sensory functions remained preserved following surgery. The duration of follow-up was 18 months post operation. The mainstay of treatment of severe post-tubercular kyphosis (PTK) is surgery. The correction is complex and could be staged or with multiple approaches and consequent high risk of complications. A single-stage posterior-approach surgery is less invasive.

One-stage anterior focus debridement, interbody bone graft, and anterior instrumentation and fusion in the treatment of short segment TB

To evaluate the clinical efficacy of 1-stage anterior focus debridement, interbody bone graft, and anterior instrumentation and fusion in the treatment of short segment thoracic tuberculosis with paraplegia or incomplete paralysis. A total of 16 adult patients with short segment thoracic spinal thoracic tuberculosis who underwent surgery were enrolled in this retrospective study. All patients received anterior focus debridement, interbody bone graft and anterior instrumentation and fusion. All patients were followed up for 24 to 48 months. Clinical manifestations, laboratory examinations, neurological symptoms, bone fusion and imaging results were analyzed. All patients successfully underwent operations. The symptoms of chest and back pain were alleviated and even disappeared during postoperative 1 to 6 months. There was no recurrence. All patients got bony spinal fusion within postoperative 4 to 8 months assessed by spinal X-ray film. The levels of erythrocyte sedimentation rate and C-reactive protein were significantly decreased from 72.6 ± 27.5 mm/h and 75.7 ± 25.9 mg/L to 15.9 ± 4.6mm/h and 4.7 ± 2.0mg/L at the final follow-up, respectively (P < .05). The thoracic kyphosis angle was also notably decreased from 15.0 ± 3.4° to 9.1 ± 1.9° after operation(P < .05). During the follow-up, the symptom of paraplegia or incomplete paralysis was significantly improved. Neurologic status in all patients was also improved to some extent. The combination of 1-stage anterior focus debridement, interbody bone graft and anterior instrumentation and fusion is an effective and feasible treatment method for short segmental thoracic tuberculosis with paraplegia or incomplete paralysis.

Posterior instrumentation combined with anterior debridement and reconstruction using allogenic strut bone for the treatment of children with multilevel lumbar spinal tuberculosis: minimum 5-year follow-up

OBJECTIVES

To evaluate the clinical outcomes of one-stage posterior instrumentation combined with anterior debridement and reconstruction using allogenic strut bone for the surgical treatment of multilevel lumbar spinal tuberculosis in children younger than 10 years of age with at least 5 years of follow-up.

METHODS

A total of 16 children with multilevel lumbar spinal tuberculosis who underwent one-stage posterior instrumentation combined with anterior debridement and reconstruction using allogenic strut bone were enrolled from January 2003 to January 2017. Among them, 6 were females and 10 were males with an average age of 6.9 ± 2.2 years (range 3-10 years). Patients' clinical outcomes, including C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), kyphosis angle, and neurologic function, were assessed before and after surgery. P < 0.05 was considered statistically significant.

RESULTS

The average follow-up was 7.8 ± 2.4 years. CRP and ESR of all patients returned to the normal range within 1 year. Compared with preoperative neurological deficits, postoperative and final follow-up neurological deficits improved significantly by grades 0.9 and 1.6, respectively. No instrumentation failure occurred, and all patients achieved solid bone fusion. The preoperative kyphosis angle was 29.9 ± 8.1°, which decreased significantly to 5.9 ± 2.6° postoperatively. There was a mild loss (2.5°) and the kyphosis angle was 8.4 ± 2.9° at final follow-up, with an overall correction rate of 71.3%.

CONCLUSION

One-stage posterior instrumentation combined with anterior debridement and reconstruction using allogenic strut bone is a safe and effective procedure for children with multilevel lumbar spinal tuberculosis. This approach facilitates the removal of lesions and decompression of the spinal cord and is effective in restoring spinal stability, correcting kyphosis, and preventing deterioration of the deformity.

Two-stage treatment for severe spinal kyphotic deformity secondary to tuberculosis: halo-pelvic traction followed by a posterior-only approach correction

Background and purpose

Several surgical procedures are used to treat tuberculous kyphosis. However, the treatment of extreme spinal kyphosis is challenging, and associated with various complications. Halo traction has been used as an adjunctive method in the treatment of severe spinal deformities. However, there are few reports about the effectiveness of halo-pelvic traction (HPT) for the treatment of extreme spinal kyphosis secondary to tuberculosis. This study evaluated the effectiveness of halo-pelvic traction followed by a posterior-only approach correction in the treatment of severe spinal kyphosis secondary to tuberculosis.

Methods

The records of 19 patients with severe spinal kyphosis secondary to tuberculosis were retrospectively reviewed. All 19 patients were treated with a two-stage approach: HPT combined with posterior fusion surgery by a posterior-only approach. Radiographic parameters were measured and evaluated. America Spinal Injury Association grade (ASIA), Scoliosis Research Society outcome (SRS-22) score, and complications were also evaluated.

Results

There were 9 males and 10 females, with an average age of 29.7 years at the time of surgery. The average HPT duration was 10.4 weeks. The mean kyphosis angle decreased from 131.40 ± 10.7° pre-traction to 77.1 ± 7.4° post-traction (P < 0.01). The traction correction rate was 41.3%. The mean postoperative kyphosis angle was 65.7 ± 8.5°, and the surgical correction rate was 8.7%. Of the total correction, 82.6% was the result of HPT. At a mean follow-up of 26.5 months, the average kyphosis correction loss was 2.9°. The mean sagittal balance was 11.1 ± 45.2 mm before traction, − 25.0 ± 37.4 mm after traction, 7.0 ± 13 mm after surgery, and 2.8 ± 9.6 mm at the final follow-up. The mean preoperative SRS-22 score was 3.0 and postoperative was 4.2 (P < 0.01). The neurological status of most patients was improved. The total complication rate was 15.7%, including 1 neurological and 2 non-neurological complications.

Conclusions

HPT is effective in the management of severe spinal kyphotic deformity secondary to tuberculosis. Preoperative HPT can greatly reduce global kyphosis, and the need for corpectomy.

Vertebral destruction in an 11-month-old child with spinal tuberculosis: a case report and review of literature

Background

The incidence of tuberculosis is increasing especially in endemic countries. Spinal tuberculosis represents nearly the 50% of reported cases of skeletal tuberculosis. This is the youngest case of spinal tubercular disease that has been reported. The objective of this report is to describe a spinal tuberculosis case in an infant in thoracic spine, in order to show the importance of early diagnosis in this population, to limit the progression of this highly destructive disease and reduce the severe sequelae that this disease is associated.

Case presentation

An 11-month-old infant previously healthy born in the northeast Mexico. Physical examination revealed a mass lesion in the dorsal region, fixed to deep planes, indurated. Neurological examination found Frankel C paraparesis showing muscle strength 2/5 on the Lovett scale in both lower extremities, anal reflex present, and preserved sensitivity.

In the magnetic resonance of the spine, hyperintensities in the vertebral bodies of D6-D9 were observed in the T2 with destruction of the D7 and D8 bodies. A thoracotomy was performed with total mass resection with corpectomy of vertebrae D7 and D8, medullary decompression, and placement of fibula allograft between vertebrae D6 and D9. In the histopathological sample, a chronic granulomatous inflammatory process associated with acid-fast bacilli was observed, in addition to presenting a positive result in quantitative real-time PCR GeneXpert MTB/RIF sensitive to rifampicin. Twelve months later, he presented 5/5 muscular strength, without alterations in sensitivity, in addition to presenting ambulation onset at 18 months of age.

Conclusion

The spinal tuberculosis is a disease that occurs in endemic countries. A prompt diagnosis is necessary to limit the progression of a highly destructive disease. In addition, the fact of presenting at an early age produces hard making decisions for the adequate treatment of the disease and reduces the adverse effects of these procedures.

Microarchitecture of historic bone samples with tuberculosis

Tuberculosis is among the leading causes of death from infectious diseases and affects many organ systems, including the skeleton. Skeletal tuberculosis is an extrapulmonary stage of tuberculosis, which occurs after the early and post-primary pulmonary stages of the disease. The aim of our study was to assess the microarchitecture of historic dry bone samples of subjects who have died of tuberculosis documented by post-mortem examinations. These preparations date to the pre-antibiotic era, and were provided by the Pathological-Anatomical Collection in the “Fools Tower” of the Natural History Museum Vienna (PASiN-NHM).

We investigated macerated samples of 20 vertebral bodies, 19 femoral heads, and 20 tibiae of a total of 59 individuals diagnosed with tuberculosis from the nineteenth and early twentieth century. 10 femora and 10 tibiae from body donors that did not exhibit signs of infection and 10 (unaffected) vertebrae kept at the PASiN-NHM were studied as controls. The affected regions of the bone samples (and the corresponding regions of the control bones) were analyzed by microcomputed tomography using a Viscom X 8060 II system. Obtained images were analyzed semi-quantitatively. In samples with tuberculosis, independent of the investigated skeletal region, trabecular defects and decreased trabecular thickness were observed. Cortical porosity was seen in affected vertebrae and tibia; in tuberculous tibiae (but not in the femora) cortical thickness was decreased. In half of the individuals, cortical sclerosis was present; signs of ankylosis were observed mainly at the femoral heads affected with tuberculosis. We conclude that a combination of several alterations at the trabecular compartment could be suggestive of the presence of tuberculosis in historic skeletal remains.

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.

Clinical, radiological and functional outcome of posterior-only three-column osteotomy in healed, post-tubercular kyphotic deformity: a minimum of 2-year follow-up

PURPOSE

To describe clinical, radiological and functional outcomes of patients with post-tubercular healed kyphosis operated by posterior-only three-column osteotomy.

METHODS

The hospital records of 47 patients from a single center, operated for healed, post-tubercular kyphosis were retrospectively analyzed. Deformity correction in all patients was done utilizing a three-column osteotomy by a single-stage, posterior-only approach. Radiological parameters (local kyphosis angle; KA, thoracic kyphosis; TK, lumbar lordosis; LL, pelvic tilt; PT, sacral slope; SS, C7 sagittal vertical axis; C7 SVA, pelvic incidence minus lumbar lordosis; PI-LL), functional scores and clinical details of complications were recorded.

RESULTS

The median age of the study population was 16 years (6-45). The apex of deformity was in thoracic, thoracolumbar and lumbar spine in 22, 19 and 6 cases, respectively. The mean operative time was 197.2 ± 30.5 min and the mean operative blood loss was 701 ± 312 ml. KA (preoperative: 68.2° ± 26.9° v/s postoperative: 29.6° ± 20.3°; p value < 0.0001), C7 SVA (preoperative 20.9 ± 37.9 mm v/s postoperative: 5.5 ± 16.3 mm; p value = 0.005) and TK (preoperative 47.7° ± 33.2° v/s postoperative: 37.8° ± 19.8°; p value = 0.0024) underwent a significant change with surgery. Mean SRS-22r score improved after surgical correction (preoperative: 2.7 ± 0.2 v/s final follow-up: 4 ± 0.2; p < 0.0001) with the maximum improvement occurring in self-image domain. The overall complication rate was 29.7%-including 4 neurological and 10 non-neurological complications. Permanent neurological deterioration was seen in one patient.

CONCLUSION

Three-column osteotomies through posterior-only approach are safe and effective and offer good clinic-radiological and function outcome in post-tubercular kyphotic deformity correction.

Cervical spine TB - Current concepts in management

OBJECTIVE

Cervical tubercular disease (CTB) is a rare pathology and constitutes 3-5% of all spinal TB. It includes atlantoaxial TB and sub-axial TB. As the literature evidence on this subject is scarce, majority of issues concerning CTB are still controversial. The current narrative review comprehensively discusses the various aspects related to CTB. Literature search: An elaborate search was made using keywords cervical tuberculosis, atlantoaxial tuberculosis, sub-axial tuberculosis, and cervico-thoracic tuberculosis, on pubmed and google (scholar.google.com) databases on 2 December 2020. We identified crucial questions regarding CTB and included relevant articles pertaining to them.

RESULTS

The initial search using keywords cervical tuberculosis, atlantoaxial tuberculosis, sub-axial tuberculosis, and cervico-thoracic tuberculosis yielded 4128, 76, 3 and 9 articles on 'pubmed' database, respectively. A similar search using the aforementioned keywords yielded 1,96,000, 2130, 117 and 728 articles on 'google scholar' database. The initial screening resulted in the identification of 178 articles. Full manuscripts were obtained for these articles and thoroughly scrutinised at the second stage. Review articles, randomised controlled trials and level 1 studies were given preference. Overall, 41 articles were included.

CONCLUSION

AATB and SACTB constitute 0.3 to 1% and 3% of spinal TB, respectively. The incidence of neuro-deficit in CTB is significantly more than other spinal TB. The general principles of management of CTB are similar to spinal TB elsewhere and medical therapy remains the cornerstone. Surgery is advocated in specific scenarios involving gross neuro-deficit, later stages of disease with significant bony/ligamentous disruptions, altered sagittal balance, drug resistance, and poor response to medications. The surgical approaches for AATB include anterior-alone, posterior-alone and combined approaches, although posterior access is the most preferred. Most of the studies on SACTB have supported the role of anterior approach. Additionally, posterior stabilisation may be necessary in specific scenarios. The overall long-term outcome in CTB is favourable.

Sagittal Balance, Pulmonary Function, and Spinopelvic Parameters in Severe Post-Tubercular Thoracic Kyphosis

Study Design

Cross-sectional study.

Purpose

To evaluate sagittal balance, pulmonary function, and spinopelvic parameters in patients with healed spinal tuberculosis with severe thoracic kyphosis.

Overview of Literature

Deterioration of neurological function is an absolute indication of surgical intervention in severe post-tubercular kyphosis, but the relationship of compromise in lung function and spinal alignment with severity of kyphosis is still unclear.

Methods

Twenty patients (age, 14–60 years) with healed spinal tuberculosis with thoracic kyphosis >50° were included. Lateral-view radiography of the whole spine, including both hips, was performed for assessment of kyphotic angle (K angle), sagittal balance, lumbar lordosis, and spinopelvic parameters. Pulmonary function was assessed by measuring the forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), and their ratio (FEV1/FVC) by spirometry.

Results

A positive correlation between severity of kyphosis and sagittal imbalance was noted, with compensatory mechanisms maintaining the sagittal balance in only up to 80° of dorsal kyphosis. In >80° of kyphosis, FVC was found to be markedly decreased (mean FVC=50.6%). The mean K angle was lower in subjects with lower thoracic kyphosis. In lower thoracic kyphosis, due to short lordotic and long kyphotic curves, both lumbar lordosis and pelvic retroversion worked at compensation, whereas, in middle thoracic kyphosis, due to long lordotic curve, only lumbar lordosis was required. Normal pulmonary function (mean FVC, 83.0%) and lesser kyphotic deformity (mean K angle in adolescents, 69.8°; in adults, 94.4°) were found in adolescents.

Conclusions

In >80° of thoracic kyphosis, there is sagittal imbalance and a markedly affected pulmonary function. Such patients should be offered corrective surgery if they are symptomatic and medically fit to undergo the procedure. However, whether the surgical procedure would result in improved pulmonary function and sagittal balance needs to be evaluated by a follow-up study.

Avoiding Radical Removal of Posterior Elements in Posterior Vertebral Column Resections: A Modified Schwab Grade 6 Osteotomy for Severe Post-Tuberculous Kyphotic Deformity

OBJECTIVE

Posterior vertebral column resection (PVCR) is a versatile technique for correction of severe and rigid spinal deformities, but the high rate of neurological complications is a major disadvantage of this procedure. This study aimed to describe a modified PVCR technique for safe treatment of severe post-tuberculous kyphotic deformity.

METHODS

Four consecutive patients with severe post-tuberculous kyphosis underwent modified PVCRs. Radical removal of the posterior elements was avoided by performing laminectomy in stages, and the posterior vertebral wall and the bases of the spinous processes were maintained throughout the procedure. Perioperative clinical presentation, imaging data, and operative variables were recorded.

RESULTS

Desirable efficacy and clinical outcomes were obtained, including satisfactory correction rates and low estimated blood loss. Neurological status improved in all patients with preoperative neurological deficits, and no postoperative neurological complications were reported.

CONCLUSIONS

Modified PVCRs could prevent excessive handling or overstretching of the spinal cord, reduce bleeding, and provide more security in the correction of severe spinal deformities. Our initial experience showed that this modified procedure might be an alternative to conventional Schwab grade 6 osteotomy for the correction of severe post-tuberculous kyphotic deformity.

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

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

[Tuberculous Spondylitis - Diagnosis and Management]

Tuberculous Spondylitis - Diagnosis and Management Abstract. Despite a decreasing incidence of tuberculosis (TB) over the last decades in Switzerland, the frequency of newly diagnosed tuberculous spondylitis has remained stable. It occurs most frequently in old, immunocompromised persons and/or persons who have moved to Switzerland from TB endemic areas. It is a chronic manifestation of TB, which is characterized by 'cold abscesses', neurological deficits and kyphotic spinal deformity. Tuberculous spondylitis is often diagnosed with a delay, which can lead to higher morbidity and treatment complexity. Antibiotic therapy is essential in tuberculous spondylitis. Surgical interventions aim to obtain samples, decompress nervous structures, obtain pain control and, if necessary, deformity correction/stabilization. This paper provides an overview of the modern diagnostic and therapeutic management of tuberculous spondylitis in Switzerland.

Transforaminal debridement with a posterior-only approach involving placement of an interbody bone graft combined with diseased vertebral fixation for the treatment of thoracic and lumbar tuberculosis: Minimum 5-year follow-up

The aim of this study was to evaluate the clinical and imaging results of transforaminal debridement with a posterior-only approach involving placement of an interbody bone graft combined with diseased vertebral fixation for the treatment of thoracic and lumbar tuberculosis (TB) with a minimum 5-year follow-up.Sixty-five patients who presented with active thoracic and lumbar TB between October 2006 and August 2013 were retrospectively analyzed: 20 were thoracic TB (group A), 17 were thoracolumbar TB (group B), and 28 were lumbar TB (group C). The patient data, operating time, blood loss, Visual Analog Scale score, Oswestry Disability Index score, correction of kyphosis, recovery of neurological function, and complications were recorded and analyzed.The patients were followed for 68.7 ± 17.8 months. The preoperative average Cobb angles of kyphosis in patients in groups A, B, and C significantly decreased from 28.2 ± 11.9°, 30.5 ± 16.9°, and 10.9 ± 8.8° before surgery to 8.0 ± 5.4°, 5.0 ± 4.1°, and -4.4 ± 1.6° (- indicates lordosis) after surgery, respectively. At the final follow-up time, the Cobb angles were 9.2 ± 6.1°, 6.8 ± 10.0°, and -3.7 ± 2.0°, respectively. The postoperative Cobb angles of kyphosis were significantly improved in all groups (P < .05). The correction loss angles were larger in groups A and B than in group C (P > .05). The operating time, blood loss, and complications were not significantly different between the groups (P > .05). Three (4.6%) patients developed unhealed TB during postoperative anti-TB treatment, and 6 patients (9.2%) with TB relapsed after healing from surgery.The posterior-only approach for the surgical treatment of thoracic and lumbar TB achieved satisfactory outcomes over long-term follow-up. The implantation of pedicle screws in diseased vertebrae reduced the range of fixation, but patients with thoracic and thoracolumbar TB should undergo fixation to at least 1 adjacent normal segment. There were some cases of recurrence after TB healed, and long-term follow-up is therefore necessary.

The prevalence, diagnosis and surgical risk factors of spinal tuberculosis in children

OBJECTIVE

To date, the burden of childhood spinal TB in China has not been estimated, and current treatment is hindered by a lack of evidence. This study aimed to review our experience of childhood spinal TB.

METHODS

We reviewed the medical records of paediatric patients (≤15 years) admitted for spinal TB (confirmed or possible) at Shandong Provincial Chest Hospital from January 2006 to December 2019. Demographic, clinical, laboratory and radiological data were collected from medical records and analysed retrospectively.

RESULTS

Seventy-two patients were diagnosed with spinal TB. 45 were male (62.5%), and 27 female (37.5%), with a mean age of 8.42 ± 4.47 (SD) years. During this 14-year period, the overall prevalence of spinal TB among childhood TB was 4.5%. T-SPOT.TB, AFB smear, mycobacterial culture, TB RT-PCR and biopsies were positive in 29.6%, 14.3%, 23.3%, 43.8% and 88.5% of assayed patients, respectively. The overall surgical rate of the studied patients was 40.3%. The requirement of surgery in childhood spinal TB was associated with pulmonary TB (OR = 4.000, 95% CI: 1.197, 13.367).

CONCLUSION

Spinal TB in children cannot be neglected. It remains a severe problem to public health, and more attention should be paid to initiating treatment early.

The association between skeletal lesions and tuberculosis diagnosis using a probabilistic approach

Sensitivity and specificity estimates for 18 skeletal lesions were generated from modern skeletons for future paleoepidemiological analyses of tuberculosis prevalence in archaeological samples. A case-control study was conducted using 480 skeletons from 20^th century American skeletal collections. One-half of the skeletons were documented tuberculosis cases (Terry Collection). The remaining age and sex-matched skeletons were controls (Bass Collection). The association between 18 candidate skeletal lesions and tuberculosis was established by comparing lesion distributions in case and control groups. Lesion indicators at six locations - visceral surface of ribs, ventral vertebral bodies, lateral part of ilium, acetabular fossa, iliac auricular surface, and ulna olecranon process - occurred significantly more often among cases than in controls, and were associated with one another. The most useful indicator proved to be a bony reaction on ventral thoracic and lumbar vertebral bodies. Its presence means a 53.3% probability of a true tuberculosis diagnosis. Because of the nature of the reference sample - 20th century American cases - sensitivity and specificity estimates will better estimate disease prevalence in archaeological samples from cultural settings where pulmonary tuberculosis predominated. The general approach of this proof-of-concept study is applicable to other diseases that occur commonly and affect bone.

Spinal tuberculosis: a comprehensive review for the modern spine surgeon

Nearly one-third of the human population is infected with tuberculosis. Of those with active disease, approximately 10% are impacted by skeletal tuberculosis. Though, traditionally a disease of the developing world and susceptible populations, with the rise of immigration, patients may present in developed countries. The microbe responsible is the mycobacterium tuberculosis complex bacillus. The infection begins in the anterior vertebral bodies. The natural history and presentation are notable for cold abscesses causing mass effect, early or late neurological deficit, and kyphotic deformity of the spine caused by anterior vertebral body destruction. The disease can be diagnosed with laboratory studies and characteristic imaging findings, but tissue diagnosis with cultures, histology, and polymerase chain reaction is the gold standard. The cornerstone of medical management is multidrug chemotherapy to minimize relapse and drug resistance, and can be curative for spinal tuberculosis with minimal residual kyphosis. Surgical management is reserved for patients presenting with neurological deficits or severe kyphosis. The mainstays of surgical management are debridement, correction of spinal deformity and stable fusion. With appropriate and timely management, clinical outcomes of the treatment of spinal tuberculosis are overall excellent.

POSTERIOR VERTEBRAL COLUMN RESECTION IN MULTIPLE LEVELS IN CHILDREN WITH VERTEBRAL TUBERCULOSIS

ABSTRACT Objective To evaluate the clinical and radiological results of posterior vertebral column resection in the treatment of kyphosis due to vertebral tuberculosis in children under 9 years of age with neurological deficit. Methods Retrospective study of a series of 5 cases, 4 females and 1 male, mean age of 4.7 years at the time of surgery, with spinal tuberculosis and mean kyphosis of 89 degrees. Results All patients underwent surgical treatment with PVCR in multiple levels, with a mean number of 3.6 resected vertebrae, mean surgical time of 359 minutes, mean postoperative stay of 21.2 days. The mean follow-up was 29 months. The mean kyphosis correction was 62.6%. Before surgery, all patients had signs of spinal cord injury, one of which did not present a deficit of strength or sensibility (ASIA E), but there were pyramidal signs and a history of falls. The other 4 had some degree of sensory-motor dysfunction, with ASIA score varying from A to D. Postoperative complications included two dehiscences of suture, one pneumothorax and one pneumonia, all with favorable evolution. Four patients progressed with neurological improvement and one of them had persistence of the neurological deficit until the last follow-up. Conclusions Multiple-level PVCR has proven to be a safe and effective option for the treatment of kyphotic deformity in spinal tuberculosis in children with neurological deficit. Level of evidence IV; Case Series.

Transpedicular Decompression/Debridement and Posterior Spinal Fusion With Instrumentation for Single-Level Thoracic Spinal Tuberculosis With Myelopathy-Is Anterior Column Reconstruction Necessary?

OBJECTIVES

The purpose of this study is to study the safety and efficacy of single-stage transpedicular decompression/debridement and instrumented posterior spinal fusion for single-level thoracic spinal tuberculosis with myelopathy without anterior column reconstruction.

SUMMARY OF BACKGROUND DATA

Existing literature has many reports of transpedicular decompression/debridement and instrumented posterior spinal fusion with anterior column reconstruction. The quoted loss of correction is around 2°, but there is no strong evidence analyzing the loss of kyphosis correction, assessment of fusion in the same, without anterior column reconstruction.

STUDY DESIGN

Retrospective study.

METHODS

Study consisted of 57 patients of single-level thoracic tuberculosis with myelopathy from a single center who fulfilled the selection criteria. All underwent pedicle screw-rod instrumentation (2 up and 2 down), bilateral transpedicular decompression/debridement of granulation tissue/abscess, followed by instrumented posterior spinal fusion with local bone/B-tri-calcium phosphate. Patients were analyzed clinically (ASIA scoring) and radiologically by radiographs for kyphosis correction and CT scans at 2 years (for assessment of fusion). The grade of destruction was correlated with loss of kyphosis correction and neurologic improvement.

RESULTS

There are 43 female and 14 male patients with a mean age of 46.7 years (18.4-74.2), mean follow-up of 3.4 years (2.1-8.4). The mean pre-op Cobb angle is 26.4° and mean correction obtained is 12.6° (47.8%). The mean loss of kyphosis after 2 years' follow-up is 3.6° (13.6%). The mean American Spinal Injury Association (ASIA) grade improvement after surgery is 1.05 (p = .001). There is no correlation observed between neurologic recovery and grade of destruction (R = -0.11). There is no correlation between the improvement in kyphosis and neurologic recovery (R = -0.05). Two-year postoperative CT scan showed solid interbody (55 patients) and posterior fusion (57 patients).

CONCLUSION

Significant neurologic recovery, kyphosis correction, and posterior/interbody bony fusion can be obtained by transpedicular decompression/debridement and instrumented posterior spinal fusion (without anterior reconstruction) with maintained correction at 2 years.

Surgical approach and management outcomes for junction tuberculous spondylitis: a retrospective study of 77 patients

Background

Junction tuberculous spondylitis involves the stress transition zone of the spine and has a high risk of progression to kyphosis or paraplegia. Problems still exist with treatment for spinal junction tuberculosis. This study investigated the surgical approach and clinical outcomes of junction spinal tuberculosis.

Methods

From June 1998 to July 2014, 77 patients with tuberculous spondylitis were enrolled. All patients received 2–3 weeks of anti-tuberculous treatment preoperatively; treatment was prolonged for 2–3 months when active pulmonary tuberculosis was present. The patients underwent anterior debridement and were followed up for an average of 29.4 months clinically and radiologically.

Results

The cervicothoracic junction spine (C7-T3) was involved in 15 patients. The thoracolumbar junction spine (T11-L2) was involved in 39 patients. The lumbosacral junction spine (L4-S1) was involved in 23 patients. Two patients with recurrence underwent reoperation; the drugs were adjusted, and all patients achieved bone fusion. The preoperative cervicothoracic and thoracolumbar kyphosis angle and lumbosacral angle were 31.4 ± 10.9°, 32.9 ± 9.2°, and 19.3 ± 3.7°, respectively, and the corresponding postoperative angles were ameliorated significantly to 9.1 ± 3.2°, 8.5 ± 2.9°, and 30.3 ± 2.8°. The preoperative ESR and C-reactive protein level of all patients were 48.1 ± 11.3 mm/h and 65.5 ± 16.2 mg/L which decreased to 12.3 ± 4.3 mm/h and 8.6 ± 3.7 mg/L at the final follow-up, respectively. All patients that had neurological symptoms achieved function status improvement at different degrees.

Conclusion

For spinal tuberculosis of spinal junctions, anterior debridement, internal fixation, and fusion can be preferred and achieved. If multiple segment lesions are too long or difficult for operation of anterior internal fixation, combining posterior pedicle screw fixation is appropriate.

Spinal Tuberculosis: Current Concepts

STUDY DESIGN

Review article.

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Child and adult spinal tuberculosis at tertiary hospitals in the Western Cape, South Africa: 4-year burden and trend

The aim of this retrospective review was to assess the overall burden and trend in spinal tuberculosis (TB) at tertiary hospitals in the Western Cape Province of South Africa. All spinal TB cases seen at the province's three tertiary hospitals between 2012 and 2015 were identified and clinical records of each case assessed. Cases were subsequently classified as bacteriologically confirmed or clinically diagnosed and reported with accompanying clinical and demographic information. Odds ratios (OR) for severe spinal disease and corrective surgery in child vs. adult cases were calculated. A total of 393 cases were identified (319 adults, 74 children), of which 283 (72%) were bacteriologically confirmed. Adult cases decreased year-on-year (P = 0.04), however there was no clear trend in child cases. Kyphosis was present in 60/74 (81%) children and 243/315 (77%) adults with available imaging. Corrective spinal surgery was performed in 35/74 (47%) children and 80/319 (25%) adults (OR 2.7, 95% confidence interval 1.6-4.5, P = 0.0003). These findings suggest that Western Cape tertiary hospitals have experienced a substantial burden of spinal TB cases in recent years with a high proportion of severe presentation, particularly among children. Spinal TB remains a public health concern with increased vigilance required for earlier diagnosis, especially of child cases.

The position of the aorta relative to the spine in patients with Pott's thoracolumbar angular kyphosis

STUDY DESIGN

Analyze the position of the aorta in patients with Pott's thoracolumbar angular kyphosis by computed tomography.

OBJECTIVE

To investigate the anatomic position of the aorta relative to spine in patients with Pott's thoracolumbar angular kyphosis.

SUMMARY OF BACKGROUND DATA

The complication of aorta injury is rare in the procedure of spinal osteotomy for the correction of Pott's thoracolumbar angular kyphotic deformity. However, there would be a disastrous consequence once it happened. Therefore, knowing about the position of aorta relative to the spine is of great importance. From the authors' knowledge, there are no reports about the research on the position of the aorta relative to the spine in patients with Pott's thoracolumbar angular kyphosis.

METHODS

Thirty patients with Pott's thoracolumbar angular kyphosis and thirty patients without spine deformity were recruited and divided into two groups. The CT images of both groups from T10 to L1 were obtained to evaluate the left pedicle-aorta angle and distance. In the patients with Pott's thoracolumbar angular kyphosis, the affected vertebral bodies were fused, so we measured the left pedicle-aorta angle and distance of the fused vertebral bodies. For the normal group, we measured the left pedicle-aorta angle and distance from T10 to L1 and got the average data, then compared with the Pott's group with independent sample t test. The Pearson correlation analysis was used to evaluate the association between the change of the aortic position and Konstam's angle and LL.

RESULTS

The left pedicle-aorta angles (-8.95 + 2.89°) in Pott's group are smaller and the distances (6.36 + 0.77 cm) are larger than those in normal group (P < 0.05). In patients with Pott's thoracolumbar angular kyphosis, with increased Konstam's angle, the left pedicle-aorta angles becomes smaller (r = -0.495, P < 0.05) and the left pedicle-aorta distances becomes larger (r = 0.486, P < 0.05). However, there is no remarkable correlation between lumbar lordosis and the left pedicle-aorta angles or distances.

CONCLUSION

In patients with Pott's thoracolumbar angular kyphosis, the aorta of the fused vertebrate shifts anteromedially to the vertebral body, and the aorta is relatively farther away from the vertebral body compared with the normal subjects. Therefore, the surgeon should be aware of the change of the position of the aorta to avoid the disastrous complication vessel injury.

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.

Osteoraticular Tuberculosis-Brief Review of Clinical Morphological and Therapeutic Profiles

Osteoarticular tuberculosis (OATB) is a rare form of tuberculosis (TB) whose incidence rose significantly nowadays especially in the underdeveloped countries. The main risk factors predisposing to this new challenge for the medical system are the Human Immunodeficiency Virus (HIV) epidemic, the migration from TB endemic areas and the development of drug and multidrug-resistant strains of Mycobacterium tuberculosis (Mt). The disease affects both genders and any age group although the distribution depending on gender is controversial and that depending on age has a bimodal pattern. In most cases the initial focus is elsewhere in the organism and the most frequent pathway of dissemination is lympho-haematogenous. The clinical picture includes local symptoms as pain, tenderness and limitation of motion, with some particularities depending on the segment of the osteoarticular system involved, sometimes accompanying systemic symptoms specific for TB and other specific clinical signs as cold abscesses and sinuses. The radiographic features are not specific, CT demonstrates abnormalities earlier than plain radiography and MRI is superior to plain radiographs in showing the extent of extraskeletal involvement. Both CT and MRI can be used in patient follow-up to evaluate responses to therapy. TBhas been reported in all bones of the body, the various sites including the spine (most often involved) and extraspinal sites (arthritis, osteomyelitis and tenosynovitis and bursitis). Two basic types of disease patterns could be present: the granular type (most often in adults) and the caseous exudative type (most often in children) one of which being predominant. The algorithm of diagnosis includes several steps of which detection of Mt is the gold standard. The actual treatment is primarily medical, consisting of antituberculosis chemotherapy (ATT), surgical interventions being warranted only for selected cases. It is essential that clinicians know and refresh their knowledge about manifestations of OATB.

Surgical Treatment of Angular Pott's Kyphosis with Posterior Approach, Pedicular Wedge Osteotomy and Canal Widening

Background:

It has been observed that the correction of severe posttuberculous angular kyphosis is still a challenge, mainly because of the neurologic risk.

Methods:

Nine patients were reviewed after surgery (mean follow-up 18 months). There were 2 thoracic, 4 thoraco-lumbar and 3 lumbar kyphosis. The mean age at surgery was 23.

Clinical results were evaluated by the Oswestry Disability Index (ODI) and by the neurologic evaluation. Preoperative, postoperative and final follow-up X-rays were assessed.

The surgery included a posterior approach with cord release and correction by transpedicular wedge osteotomy and widening of the spinal canal.

Results:

Average kyphotic angulation was 72° before surgery, 10° after surgery and 12° at follow-up. Three out of four patients with neural deficit showed improvement. Neurologic complications included a transitory quadriceps paralysis, likely by foraminal compression of the root.

Conclusion:

A posterior transpedicular wedge osteotomy allows a substantial correction of the kyphosis, more by deflexion than by elongation, with limited neurologic risks. However it is mandatory to widely enlarge the spinal canal on the levels adjacent to the osteotomy, in order to allow the dura to expand backwards.

Pediatric orthopedic surgery in humanitarian aid

Pediatric orthopedic surgery in humanitarian aid is conducted mainly in cooperation with emerging countries. Each mission is different, and depends on numerous parameters such as the country, the frequency of such missions, the pathologies encountered, the local structure and team, and the non-governmental organization (NGO) involved. Pathologies vary in etiology (tuberculosis, poliomyelitis) and severity. Each mission requires the presence of an experienced surgeon. Working conditions are often rudimentary. Surgical indications should be restricted to procedures that are going to be effective, with minimal postoperative complications, without any surgical "acrobatics". Teaching should be in association with the local university, and adapted to local needs. Mission objectives need to be realistic. Surgical indications should be adapted to local conditions, and the surgeon needs to be able to say "no" to procedures involving undue risk. The surgeon on mission should cooperate with local teams and be able to adapt to unusual situations. Assessment of results is essential to improving efficacy and evaluating the success of the mission.

Treatment effect, postoperative complications, and their reasons in juvenile thoracic and lumbar spinal tuberculosis surgery

OBJECTIVE

Fifty-four juvenile cases under 18 years of age with thoracic and lumbar spinal tuberculosis underwent focus debridement, deformity correction, bone graft fusion, and internal fixation. The treatment effects, complications, and reasons were analyzed retrospectively.

MATERIAL AND METHOD

There were 54 juvenile cases under 18 years of age with thoracolumbar spinal tuberculosis. The average age was 9.2 years old, and the sample comprised 38 males and 16 females. The disease types included 28 thoracic cases, 17 thoracolumbar cases, and 9 lumbar cases. Nerve function was evaluated with the Frankel classification. Thirty-six cases were performed with focus debridement and deformity correction and were supported with allograft or autograft in mesh and fixed with pedicle screws from a posterior approach. Eight cases underwent a combined anterior and posterior surgical approach. Nine cases underwent osteotomy and deformity correction, and one case received focus debridement. The treatment effects, complications, and bone fusions were tracked for an average of 52 months.

RESULTS

According to the Frankel classification, paralysis was improved from 3 cases of B, 8 cases of C, 18 cases of D, and 25 cases of E preoperatively. This improvement was found in 3 cases of C, 6 cases of D, and 45 cases of E at a final follow-up postoperatively. No nerve dysfunction was aggravated. VAS was improved from 7.8 ± 1.7 preoperatively to 3.2 ± 2.1 at final follow-up postoperatively. ODI was improved from 77.5 ± 17.3 preoperatively to 28.4 ± 15.9 at final follow-up postoperatively. Kyphosis Cobb angle improved from 62.2° ± 3.7° preoperatively to 37° ± 2.4° at final follow-up postoperatively. Both of these are significant improvements, and all bone grafts were fused. Complications related to the operation occurred in 31.5% (17/54) of cases. Six cases suffered postoperative aggravated kyphosis deformity, eight cases suffered proximal kyphosis deformity, one case suffered pedicle penetration, one case suffered failure of internal devices, and one case suffered recurrence of tuberculosis.

CONCLUSION

As long as the treatment plan is fully prepared, the surgical option can achieve a satisfactory curative effect in treating juvenile spinal tuberculosis despite some complications.

Risk factors and prognosis of vertebral compressive fracture in pyogenic vertebral osteomyelitis

OBJECTIVES

To analyse the clinical, microbiological and radiological characteristics, and to identify risk factors of vertebral compressive fracture (VF) in spontaneous pyogenic vertebral osteomyelitis (VO).

METHODS

A retrospective clinical study and blinded radiological review of adult patients with VO.

RESULTS

Eighty-eight patients were included: 57 (65%) had a definitive diagnosis of VO (positive microbiology), and 31 (35%) had a probable diagnosis of VO. Of these, 27 (30.7%) presented with VF at diagnosis of VO, and 4 afterwards (total 31, 35.2%). Patients with VF were considered to be at higher risk of osteopenia--they were older (74 vs 66 years, p = 0.013), and included high percentage of women (33 vs 41%, NS)--; and presented more dorsal involvement (56 vs 21%; p < 0.007). Causal microorganisms were similar between groups (VF, no VF). The time to diagnosis of VO was longer in the presence of VF (65 vs 23 days, p = 0.001), and also in cases with no isolated organisms. All patients received antibiotics, and just one patient required spinal stabilisation (VF). After 357 median days of follow-up, all patients were cured. Clinical improvement (residual pain, functional recovery) tended to be slower in patients with VF (log-rank 0.19 and 0.15, respectively), but clinical symptoms were similar in most patients at the last follow-up (VF, no VF).

CONCLUSIONS

VF is a common complication in pyogenic VO that causes slower clinical recovery. Risk factors of VF are: osteopenia, a delayed diagnosis and dorsal involvement. Conservative management is probably appropriate for most cases, but spinal stabilisation should be considered in some specific cases.