Early diagnosis of spinal tuberculosis

Disparities in the Clinical Profile of Spinal Tuberculosis in Africa: A Scoping Review of Management and Outcome

BACKGROUND

Spinal tuberculosis (STB) is a significant contributor to nontraumatic myelopathy. There is a rising burden in Africa, in parallel with the high prevalence of human immunodeficiency virus. We conducted a scoping review to highlight the disparities in the management and outcomes of STB in Africa.

METHODS

This study was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for scoping review guidelines. AJOL, Embase, MEDLINE, Google Scholar, and Cochrane CENTRAL databases were searched to identify all relevant peer-reviewed articles published on the management of STB in African centers, excluding abstract-only articles, literature reviews, and meta-analyses.

RESULTS

Sixty studies were eligible for inclusion, comprising data from 3416 patients aged 8 months to 89 years (median, 32 years). Thoracic and lumbar segments were the most commonly affected vertebral regions (thoracic = 42.7%; lumbar = 35.9%). The most common clinical features were back pain and neurological deficits. Lack of essential laboratory and imaging diagnostic infrastructure was a common problem. Patients received antitubercular therapy (ATT) for varying durations, and only 18.3% underwent surgery. A favorable outcome was achieved in 51.6% of patients, 20.3% developed a permanent disability, and the mortality rate was 2.1%. Treatment outcome was adversely affected by a high rate of late presentation and treatment default.

CONCLUSIONS

ATT remains the mainstay of treatment; however, the duration of treatment varied widely among studies. Further research is required to explore the feasibility and efficacy of short-course ATT in treating STB in the African population.

Spine tuberculosis with an intercurrent active pulmonary location in a high incidence country: A rare case report

Spinal tuberculosis usually presents as destroyed contiguous vertebral bodies associated with intervertebral discs and paravertebral or psoas abscesses. Atypical forms are uncommonly reported. Vertebral involvement without disk destruction is a rare form that improves satisfactorily after appropriate medical management. We report the case of a 36-year-old male who had spine tuberculosis without disk involvement, associated with intercurrent active pulmonary location with good clinical improvement after treatment and follow-up imaging showing spectacular regression of bone lesions. By reporting this case, we also review the literature on this rare form of tuberculosis.

Sternal Puncture-Induced Acute Spinal Cord Syndrome in a Myeloma-Remissive Patient Revealing Pott Disease: A Case Report

Cord compression is not a known complication of sternal puncture. We report the case of a patient with a history of multiple myeloma who presented acute onset paraplegia brought on during sternal puncture. Neuroimaging revealed focal spondylodiscitis and cord compression by an abscess. Neurosurgical decompression was not carried out on the patient because of her fragile general state of health and tardy consultation. Workup revealed the patient in remission from her multiple myeloma thus making decompressive radiotherapy unnecessary. The diagnosis of Pott disease was made by taking into account the clinical presentation, spine imaging and extra neurological imaging findings. Empiric anti-tuberculosis treatment was initiated which resulted in spectacular outcomes with a patient being able to walk with little aid by the end of her nine-month treatment course.

Diagnosis of extra pulmonary tuberculosis: An update on novel diagnostic approaches

Tuberculosis (TB) remains a major global public health problem worldwide. Though Pulmonary TB (PTB) is mostly discussed, one in five cases of TB present are extrapulmonary TB (EPTB) that manifests conspicuous diagnostic and management challenges with respect to the site of infection. The diagnosis of EPTB is often delayed or even missed due to insidious clinical presentation, pauci-bacillary nature of the disease, and lack of laboratory facilities in the resource limited settings. Culture, the classical gold standard for the diagnosis of tuberculosis, suffers from increased technical and logistical constraints in EPTB cases. Other than culture, several other tests are available but their feasibility and effciacy for the detection of EPTB is still the matter of interest. We need more specific and precise test/s for the various forms of EPTB diagnosis which can easily be applied in the routine TB control program is required. A test that can contribute remarkably towards improving EPTB case detection reducing the morbidity and mortality is the utmost requirement. In this review we described the scenario of molecular and other noval methods available for laboratory diagnosis of EPTB, and also discussed the challenges linked with each diagnostic method. This review will make the readers aware of new emerging diagnostic techniques in the field of EPTB diagnosis. They can make an informed decision to choose the appropriate one according to the test availability, their clinical settings and financial considerations.

Trends and prospects in spinal tuberculosis research: a future-oriented approach

PURPOSE

Tuberculosis is one of the oldest diseases in human history, and spinal tuberculosis (STB) is the most common form of extrapulmonary tuberculosis. A large number of research has been conducted in this field. However, there has been no bibliometric analysis performed in recent years in STB. The aim of this study was to analyze trends and hotspots in research on STB.

METHODS

Publications regarding STB between 1980 and 2022 were extracted from the Web of Science database. CiteSpace (V5.7.R2) and VOSviewer (1.6.10) were used to perform global analyses of the number of publications, countries, institutions, authors, journals, keywords, and cited references.

RESULTS

A total of 1262 articles were published between 1980 and 2022. We observed rapid growth in the number of publications since 2010. Spine had the highest number of publications (47, 3.7%). Zhang HQ and Wang XY were key researchers. The Central South University published the most papers (90, 7.1%). China was the leading contributor in this field with 459 publications and 29 H-index. National partnerships are dominated by the USA, and there is a lack of active cooperation between other countries and authors.

CONCLUSION

research on STB has achieved great progress, with an increasing number of publications since 2010. Surgical treatment and debridement are current research hots pots, and diagnosis, drug resistance, and kyphosis are likely research frontiers. Cooperation between countries and authors needs to be further strengthened.

Current Insights into Diagnosing and Treating Neurotuberculosis in Adults

Neurotuberculosis has the highest morbidity and mortality risk of all forms of extrapulmonary tuberculosis (TB). Early treatment is paramount, but establishing diagnosis are challenging in all three forms of neurotuberculosis: tuberculous meningitis (TBM), spinal TB and tuberculomas. Despite advancements in diagnostic tools and ongoing research aimed at improving TB treatment regimens, the mortality rate for neurotuberculosis remains high. While antituberculosis drugs were discovered in the 1940s, TB treatment regimens were designed for and studied in pulmonary TB and remained largely unchanged for decades. However, new antibiotic regimens and host-directed therapies are now being studied to combat drug resistance and contribute to ending the TB epidemic. Clinical trials are necessary to assess the effectiveness and safety of these treatments, addressing paradoxical responses in neurotuberculosis cases and ultimately improving patient outcomes. Pharmacokinetic-pharmacodynamic analyses can inform evidence-based dose selection and exposure optimization. This review provides an update on the diagnosis and treatment of neurotuberculosis, encompassing both sensitive and resistant antituberculosis drug approaches, drawing on evidence from the literature published over the past decade.

Non-contiguous Rare Presentation of Spinal Tuberculosis: A Case Report

Spinal tuberculosis (TB), also known as Pott's disease, is a severe form of extrapulmonary TB that affects the vertebral bodies and intervertebral discs. While the typical presentation involves the contiguous involvement of multiple vertebrae, atypical forms, such as non-contiguous multilevel spinal TB (NMLST), can occur. However, diagnosing spinal TB poses challenges due to its gradual onset, nonspecific symptoms, and varying imaging results. The timely diagnosis and treatment of spinal TB are critical to prevent serious consequences, including vertebral damage, irreversible neurological impairment, or even death. In this report, we present the case of a 58-year-old South Asian female who presented with several months of back pain, fatigue, and weight loss. Despite initially negative TB test results, spinal magnetic resonance imaging (MRI) raised suspicion of NMLST, which was later confirmed by bone biopsy. This case highlights the complexities of diagnosing and managing atypical spinal TB presentations while discussing the case findings and reviewing relevant research.

Diagnosis and Treatment of Skipped Multifocal Spinal Tuberculosis Lesions

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

Multifocal tuberculosis in children: A case of spinal tuberculosis

Multifocal tuberculosis (TB) accounts for up to one-third of all cases of TB and children are at higher risk for extrapulmonary TB than adults. Spinal TB is the regular form of skeletal TB. Spondylodiscitis TB represents 47%-94% of spinal TB. Cervical localization is rare but remains dangerous because of diagnostic difficulties and severe complications. We report a case of a 10-year-old Moroccan girl, bacille Calmette-Guerin vaccinated, with no medical history or trauma, parents and siblings are healthy and no contact with TB. The patient was complaining of neck pain, asthenia, and loss of weight for 1 year. During this period, she had been treated with analgesics and anti-inflammatory drugs, with no clinical evolution. The parents consulted the pediatric emergency room when they noticed a tumefaction in the middle thoracic region. Physical examination found a pectus carinatum deformity, palpable axillary, and submandibular lymph node, and a fixed palpable median thoracic mass fistulized to the skin. The GeneXpert MTB/RIF and QuantiFERON-TB Gold assay were positive. Chest computed tomography showed cervicodorsal spondylodiscitis staged at C5-D10, with abscessed perivertebral and peristernal collections, with epidural extension at C5-C6 and pleural level. The presence of an axillary lymph node with necrotic center. The skin biopsy showed a morphological appearance of epithelial and gigantocellular granulomatous inflammation. The patient had pharmacological treatment anti-TB drug with fixed-dose combination regimen and supportive therapy for pain management.

The Relative Lymphocyte Count is Lower when the Etiological Agent in Pott Disease is Successfully Isolated

Objective  To describe the clinico-epidemiological, laboratory, and radiological characteristics of tuberculous spondylodiscitis in the Brazilian population, and to assess whether there are differences between patients in whom the etiological agent in Pott disease was isolated or not. Methods  Patients diagnosed with tuberculosis (TB) of the spine (Pott disease) underwent follow-up between 2009 and 2019 at a quaternary hospital and were divided into 2 groups: successful isolation (SI) of the etiological agent (through bacilloscopy, culture, or positive molecular rapid test) and unsuccessful isolation (UI) of the etiological agent. Results  From a total of 26 patients diagnosed with TB of the spine, 21 (80.7%) were male, with a mean age of 40 ± 22.5 years. The average lymphocyte counts were higher in the UI group (25.35 ± 13.08; p  = 0.025) compared to the SI group (14.18 ± 7.48). Moreover, the monocyte/lymphocyte ratio was lower in the UI group (0.39 ± 0.22; p  = 0.009) than in the SI group (0.89 ± 0.65). Relative lymphocyte counts higher than or equal to 16.7 had a sensitivity of 76.9% and specificity of 62.5% in the UI group. Values higher than or equal to 0.58 for the monocyte/lymphocyte ratio showed a sensitivity of 84.6% and specificity of 75.0% in the UI group. Conclusion  No differences were observed regarding the clinico-epidemiological and radiological characteristics of the two experimental groups. However, the UI group had higher lymphocyte counts and a lower monocyte/lymphocyte ratio.

Pathogenesis, Diagnostic Challenges, and Risk Factors of Pott's Disease

Tuberculosis (TB) prevalence is increasing in developed nations and continuing to cause significant mortality in low- and middle-income countries. As a result of the uptick in cases, there also exists an increased prevalence of extrapulmonary TB. TB is caused by Mycobacterium tuberculosis (M. tb). When M. tb disseminates to the vertebral column, it is called Pott's disease or spinal TB. The frequency, symptoms, and severity of the disease range by the location of the spine and the region of the affected vertebrae. While the current literature shows that timely diagnosis is crucial to reduce the morbidity and mortality from Pott's disease, there is a lack of specific clinical diagnostic criteria for Pott's disease, and the symptoms may be very non-specific. Studies have shown that novel molecular diagnostic methods are effective and timely choices. Research has implicated the risk factors for the susceptibility and severity of Pott's disease, such as HIV and immunosuppression, poverty, and malnutrition. Based on the current literature available, our group aims to summarize the pathogenesis, clinical features, diagnostic challenges, as well as the known risk factors for Pott's disease within this literature review.

Development and validation of a diagnostic model for differentiating tuberculous spondylitis from brucellar spondylitis using machine learning: A retrospective cohort study

Background

Tuberculous spondylitis (TS) and brucellar spondylitis (BS) are commonly observed in spinal infectious diseases, which are initially caused by bacteremia. BS is easily misdiagnosed as TS, especially in underdeveloped regions of northwestern China with less sensitive medical equipment. Nevertheless, a rapid and reliable diagnostic tool remains to be developed and a clinical diagnostic model to differentiate TS and BS using machine learning algorithms is of great significance.

Methods

A total of 410 patients were included in this study. Independent factors to predict TS were selected by using the least absolute shrinkage and selection operator (LASSO) regression model, permutation feature importance, and multivariate logistic regression analysis. A TS risk prediction model was developed with six different machine learning algorithms. We used several metrics to evaluate the accuracy, calibration capability, and predictability of these models. The performance of the model with the best predictability was further verified with the area under the curve (AUC) of the receiver operating characteristic (ROC) curve and the calibration curve. The clinical performance of the final model was evaluated by decision curve analysis.

Results

Six variables were incorporated in the final model, namely, pain severity, CRP, x-ray intervertebral disc height loss, x-ray endplate sclerosis, CT vertebral destruction, and MRI paravertebral abscess. The analysis of appraising six models revealed that the logistic regression model developed in the current study outperformed other methods in terms of sensitivity (0.88 ± 0.07) and accuracy (0.79 ± 0.07). The AUC of the logistic regression model predicting TS was 0.86 (95% CI, 0.81-0.90) in the training set and 0.86 (95% CI, 0.78-0.92) in the validation set. The decision curve analysis indicated that the logistic regression model displayed a higher clinical efficiency in the differential diagnosis.

Conclusions

The logistic regression model developed in this study outperformed other methods. The logistic regression model demonstrated by a calculator exerts good discrimination and calibration capability and could be applicable in differentiating TS from BS in primary health care diagnosis.

A predictive model for early clinical diagnosis of spinal tuberculosis based on conventional laboratory indices: A multicenter real-world study

Background

Early diagnosis of spinal tuberculosis (STB) remains challenging. The aim of this study was to develop a predictive model for the early diagnosis of STB based on conventional laboratory indicators.

Method

The clinical data of patients with suspected STB in four hospitals were included, and variables were screened by Lasso regression. Eighty-five percent of the cases in the dataset were randomly selected as the training set, and the other 15% were selected as the validation set. The diagnostic prediction model was established by logistic regression in the training set, and the nomogram was drawn. The diagnostic performance of the model was verified in the validation set.

Result

A total of 206 patients were included in the study, including 105 patients with STB and 101 patients with NSTB. Twelve variables were screened by Lasso regression and modeled by logistic regression, and seven variables (TB.antibody, IGRAs, RBC, Mono%, RDW, AST, BUN) were finally included in the model. AUC of 0.9468 and 0.9188 in the training and validation cohort, respectively.

Conclusion

In this study, we developed a prediction model for the early diagnosis of STB which consisted of seven routine laboratory indicators.

Culture filtrate supplementation can be used to improve Mycobacterium tuberculosis culture positivity for spinal tuberculosis diagnosis

Culture remains the gold standard to diagnose spinal tuberculosis (STB) despite the paucibacillary nature of the disease. Current methods can take up to 42 days to yield a result, delaying the ability to rapidly detect drug resistance. Studies have demonstrated the use of supplementation with culture filtrate (CF) from an axenic culture of Mycobacterium tuberculosis (Mtb) as a source of growth factors to improve culture rates. Our objective was to test a modified culture assay, utilizing CF supplemented media (CFSM), to improve culture positivity rates for suspected STB. Twelve patients with suspected STB were assessed by conventional culture (BACTEC™ MGIT 960), GeneXpert™ and standard histopathological examination. Spinal biopsies were taken from areas of diseased vertebral tissue or abscess, predetermined from MRI. Additional biopsies were obtained to assess CFSM for improved detection and faster culture of Mtb. All cases were diagnosed as STB and treated empirically for tuberculosis based on either bacteriological evidence (GeneXpert™, MGIT and/or CFSM positive), or based on clinical presentation. 5 specimens (45.45%) were positive for Mtb DNA as detected by GeneXpert™ and 1 specimen (8.33%) was cultured using MGIT (time to detection; 18 days). CFSM was able to culture 7 specimens (58.3%), with all CFSM positive specimens yielding a culture within 14 days. Two samples were positive only using the CFSM assay pointing to additional yield for diagnostic workup. Modification of standard culture can improve detection of Mtb and reduce time to positivity in individuals with STB where culture material is a requirement.

Analysis of the diagnostic efficacy of the QuantiFERON-TB Gold In-Tube assay for preoperative differential diagnosis of spinal tuberculosis

Background

Differential diagnosis of spinal tuberculosis is important for the clinical management of patients, especially in populations with spinal bone destruction. There are few effective tools for preoperative differential diagnosis in these populations. The QuantiFERON-TB Gold In-Tube (QFT-GIT) test has good sensitivity and specificity for the diagnosis of tuberculosis, but its efficacy in preoperative diagnosis of spinal tuberculosis has rarely been investigated.

Method

A total of 123 consecutive patients with suspected spinal tuberculosis hospitalized from March 20, 2020, to April 10, 2022, were included, and the QFT-GIT test was performed on each patient. We retrospectively collected clinical data from these patients. A receiver operating characteristic (ROC) curve was plotted with the TB Ag-Nil values. The cutoff point was calculated from the ROC curve of 61 patients in the study cohort, and the diagnostic validity of the cutoff point was verified in a new cohort of 62 patients. The correlations between TB Ag-Nil values and other clinical characteristics of the patients were analyzed.

Results

Of the 123 patients included in the study, 51 had confirmed tuberculosis, and 72 had non-tuberculosis disease (AUC=0.866, 95% CI: 0.798-0.933, P<0.0001). In patients with spinal tuberculosis, the QFT-GIT test sensitivity was 92.16% (95% CI: 80.25%-97.46%), and the specificity was 67.14% (95% CI: 54.77%-77.62%). The accuracy of diagnostic tests in the validation cohort increased from 77.42% to 80.65% when a new cutoff point was selected (1.58 IU/mL) from the ROC curve of the study cohort. The TB Ag-Nil values in tuberculosis patients were correlated with the duration of the patients’ disease (r=0.4148, P=0.0025).

Conclusion

The QFT-GIT test is an important test for preoperative differential diagnosis of spinal tuberculosis with high sensitivity but low specificity. The diagnostic efficacy of the QFT-GIT test can be significantly improved via application of a new threshold (1.58 IU/mL), and the intensity of the QFT-GIT test findings in spinal tuberculosis may be related to the duration of a patient’s disease.

A case of acute-onset paraplegia due to spinal tuberculosis in term pregnancy

Acute paraplegia in pregnancy is uncommon but can result from pathology including Guillain-Barre syndrome, acute transverse myelitis, and spinal tuberculosis, also known as Pott's disease of the spine. India has a high incidence of tuberculosis (2.8 million cases annually) therefore spinal tuberculosis is a particularly important disease to consider during pregnancy. Management of spinal tuberculosis in pregnancy poses a challenge especially at term gestation as immobilization of the spine and maintaining supination is difficult, particularly at delivery.

Application of the ARIMA Model in Forecasting the Incidence of Tuberculosis in Anhui During COVID-19 Pandemic from 2021 to 2022

Objective

Forecasting the seasonality and trend of pulmonary tuberculosis is important for the rational allocation of health resources. In this study, we predict the incidence of pulmonary tuberculosis by establishing the autoregressive integrated moving average (ARIMA) model and providing support for pulmonary tuberculosis prevention and control during COVID-19 pandemic.

Methods

Registered tuberculosis(TB) cases from January 2013 to December 2020 in Anhui province were analysed using traditional descriptive epidemiological methods. Then we used the monthly incidence rate of TB from January 2013 through June 2020 to construct ARIMA model, and used the incidence rate from July 2020 to December 2020 to evaluate the forecasting accuracy. Ljung Box test, Akaike's information criterion(AICc), Bayesian information criterion(BIC) and Realtive error were used to evaluate the model fitting and forecasting effect, Finally, the optimal model was used to forecast the expected monthly incidence of tuberculosis for 2021 and 2022 to learn about the incidence trend.

Results

A total of 255,656 TB cases were registered. The reported rate of tuberculosis was highest in 2013 and lowest in 2020. The peak incidence was in March, Tongling (71.97/100,000), Chizhou (59.93/100,000), and Huainan (58.36/100,000) had the highest number of cases. The ratio of male to female incidence was 2.59:1, with the largest proportion of people being between 66 and 75 years old. The main occupation of patients was farmer. ARIMA (0, 1, 1) (0, 1, 1)₁₂ model was the optimal model to forecast the incidence trend of TB.

Conclusion

Tongling, Chizhou, and Huainan should strengthen measures for TB. In particular, the government should pay more attention on elderly people to prevent tuberculosis infections. The rate of TB patient registration and reporting has decreased under the pandemic of COVID-19. The ARIMA model can be a useful tool for predicting future TB cases.

A Case of Posttraumatic Pott’s Disease

Tuberculosis infection, which is caused by the bacterium Mycobacterium tuberculosis (Mtb), most commonly manifests in patients with respiratory systems. However, it can also colonize other tissues including skeletal. In our case, a 77-year-old Caucasian male presented to the emergency department following a rollover motor vehicle collision with chief complaints of neck and lower back pain. After clinical improvement and a preliminary negative workup, the patient was deemed stable for discharge. Four months later, the patient was subsequently admitted for worsening back pain with workup suspicious for T9 and T10 discitis osteomyelitis and abscess formation on computed tomography (CT). During this admission, spinal Mtb was confirmed by acid-fast stain and real-time polymerase chain reaction of a CT-guided disc space aspirate of a left paraspinal cystic collection at approximately T9-T10. Given these findings, the patient was subsequently put on standard four-drug therapy for Mtb. Our case demonstrates the importance of considering Pott’s disease in the diagnosis of lumbar spinal pain, especially in patients living in areas with high international migration and travel.

Evaluation of host biomarkers for monitoring treatment response in spinal tuberculosis: A 12-month cohort study

BACKGROUND

Monitoring treatment response is an important precaution in spinal tuberculosis (TB), particularly when the condition was clinically diagnosed rather than bacteriologically confirmed and when drug susceptibility testing was not performed. Conventional monitoring measures have limitations and there is a need for favourable alternatives. Therefore, this study aimed to investigate changes in immune biomarkers over the course of treatment for spinal TB and to compare these responses to the conventional monitoring measure, erythrocyte sedimentation rate (ESR).

METHODS

Patients with spinal TB were recruited from a tertiary hospital in the Western Cape, South Africa, and provided blood samples at 0, 3, 6, 9 and 12 months of TB treatment. Blood samples were analysed for ESR, using standard techniques, and for 19 cytokines, using a multiplex platform. Changes in ESR and cytokine levels were investigated using a mixed model ANOVA and Least Significant Difference post-hoc testing.

RESULTS

Twenty-six patients with spinal TB were included in the study although only fifteen remained in follow-up at 12 months. Seven biomarkers changed significantly over the course of treatment (CRP, Fibrinogen, IFN-γ, Ferritin, VEGF-A, ApoA1 and NCAM, p < 0.01) with a further three showing a strong trend towards change (CCL1, CXCL9 and GDF-15, 0.05 ≥ p ≤ 0.06). Responsive biomarkers could be approximately grouped according to patterns of progressive, initial or delayed change. ESR performed similarly to CRP, Fibrinogen and IFN-γ with all showing significant decreases between 0, 6 and 12- months of treatment. Individual ESR responses were variable.

DISCUSSION

Individual ESR responses may be unreliable and support the investigation of multi-marker approaches to evaluating treatment response in spinal TB. Biomarkers of treatment response identified in the current study require validation in a larger study, which may also incorporate aspects such as evaluating biomarkers within the first week of treatment and the inclusion of a healthy control group.

Monocyte-to-Lymphocyte Ratio Was an Independent Factor of the Severity of Spinal Tuberculosis

Purpose

The purpose was to explore the relationship between monocyte-to-lymphocyte ratio (MLR) and the severity of spinal tuberculosis.

Methods

A total of 1,000 clinical cases were collected, including 496 cases of spinal tuberculosis and 504 cases of nonspinal tuberculosis. Laboratory blood results were collected, including C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), white blood cells (WBC), hemoglobin (HGB), platelets (PLT), neutrophil count, percentage of neutrophils, lymphocyte count, percentage of lymphocytes, monocyte count, percentage of monocytes, MLR, platelets -to- monocyte ratio (PMR), platelets -to- lymphocyte ratio (PLR), neutrophil -to- lymphocyte ratio (NLR), and platelets -to- neutrophil ratio (PNR). The statistical parameters analyzed by the Least Absolute Shrinkage and Selection Operator (LASSO) and receiver-operating characteristic (ROC) curves were used to construct the nomogram. The nomogram was assessed by C-index, calibration curve, ROC curve, and decision curve analysis (DCA) curve.

Results

The C-index of the nomogram in the training set and external validation set was 0.801 and 0.861, respectively. Similarly, AUC was 0.801 in the former and 0.861 in the latter. The net benefit of the former nomogram ranged from 0.1 to 0.95 and 0.02 to 0.99 in the latter nomogram. Furthermore, there was a correlation between MLR and the severity of spinal tuberculosis.

Conclusion

MLR was an independent factor in the diagnosis of spinal tuberculosis and was associated with the severity of spinal tuberculosis. Additionally, MLR may be a predictor of active spinal tuberculosis.

Positivity rates of mycobacterial culture in patients with tuberculous spondylitis according to methods and sites of biopsies: An analysis of 206 cases

OBJECTIVES

We aimed to evaluate the mycobacterial culture positivity rates according to biopsy methods and sites in patients with tuberculous spondylitis (TS) and identify which tissues are the best sites for the diagnosis of TS.

METHODS

We retrospectively identified and reviewed medical records of all patients with TS in three university-affiliated hospitals in the Republic of Korea from January 2003 to December 2020. TS was diagnosed by culture or histopathologic examination of vertebral bodies or paraspinal tissues and characteristic clinical and radiologic features. Patients with TS who received a needle biopsy or underwent surgical biopsy were investigated. The sites of needle biopsy were classified as vertebral bodies or paraspinal tissues.

RESULTS

During the study period, 206 tissues from 200 patients with TS were included in the analysis. The culture positivity rates of vertebral bodies obtained by needle biopsy, paraspinal tissues obtained by needle biopsy, and tissues obtained by surgery were 69.0%, 85.3%, and 83.2%, respectively. Multivariate logistic regression identified that paraspinal tissues as biopsy sites were independently associated with mycobacterial culture positivity in TS undergoing needle biopsy (adjusted odds ratio, 3.68; 95% confidence interval: 1.13-11.99, P = 0.030).

CONCLUSIONS

We demonstrated that the positivity rates of mycobacterial culture in TS were 69.0-85.3%. Paraspinal tissues as biopsy sites were significantly associated with culture positivity in needle biopsy, suggesting that targeting paraspinal tissues during needle biopsy may be the best method for diagnosing TS.

Comparison of Clinical Data Between Patients With Complications and Without Complications After Spinal Tuberculosis Surgery: A Propensity Score Matching Analysis

Purpose

This study used a propensity score matching (PSM) analysis to explore the risk factors of post-operative complications and compared the differences in clinical data between them following spinal tuberculosis surgery.

Methods

The clinical data of patients with spinal tuberculosis were collected in our hospital from June 2012 to June 2021, including general information, laboratory results, surgical information, and hospitalization costs. The data were divided into two groups: complication and without complication groups. The baseline data of the two groups were obtained using the PSM analysis. Univariate and multivariate logistic analyses were used to analyze the differences between the two groups.

Results

A total of 292 patients were included in the PSM analysis: 146 patients with complications and 146 patients without complications. The operation time, incision length, hospital stay, and albumin quantity in the complications group were 162 ± 74.1, 11.2 ± 4.76, 14.7 ± 9.34, and 1.71 ± 2.82, respectively, and those in the without complication group were 138 ± 60.5, 10.2 ± 3.56, 11.7 ± 7.44, and 0.740 ± 2.44, respectively. The laboratory costs, examination costs, guardianship costs, oxygen costs, and total costs in the complications group were higher than those in the without complication group. A significant difference was observed in the albumin quantity by logistic regression analysis (P < 0.05).

Conclusion

Several costs in the complication group were higher than in the without complication group. The albumin quantity may be an independent factor to predict post-operative complications of spinal tuberculosis by logistic regression analysis.

Cantilever method for severe kyphotic deformity correction in spondylitis tuberculosis: A technical note and literature review

Background

The kyphotic deformity is more than just a cosmetic disfigurement. It is potentially life-threatening and disturbs the quality of life by causing cardiopulmonary dysfunction, spinal imbalance, and other associated problems. Corrective surgery is challenging but it is needed to bring the spinal balance back thus halting the progressiveness of the deformity. The cantilever technique is a gold standard to correct the sagittal plane deformity.

Methods

This is a review article with some case illustrations from Author's experience.

Objective

We aim to review the cantilever technique for kyphotic correction in spondylitis tuberculosis patients.

Conclusion

The cantilever technique is the standard for sagittal plane deformity correction that can be applied for kyphotic deformity correction in spondylitis tuberculosis cases. Developing the safest techniques and instrumentation is crucial to achieving spinal balance with minimal risk of morbidities.

•

Kyphotic deformity is more than just a cosmetic problem.

•

Kyphotic deformity is potentially life-threatening and disturbs quality of life.

•

Deformity correction surgery is challenging.

•

Cantilever technique is a gold standard to correct sagittal plane deformity.

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.

Efficacy and safety of short-term chemotherapy for patients with spinal tuberculosis undergoing surgery in Chinese population: a meta-analysis

Objective

The aim of this meta-analysis was to systematically evaluate the clinical efficacy and safety of short-course chemotherapy (≤ 6 months) compared with the standard therapy (9–18 months) for patients with spinal tuberculosis (TB) undergoing surgery in Chinese population.

Methods

In this meta-analysis, we searched electronic databases in the Cochrane Library, PubMed, Embase, China National Knowledge Infrastructure (CNKI), Chinese Science and Technology Periodical Database (VIP), and Wanfang data to determine the equivalence of short-course therapy (group A) and standard therapy (group B) for the drug therapy of TB in Chinese population up to December 24, 2019. Weighted mean difference (WMD), odds risk (OR), and their 95% confidence interval (CI) were calculated. All analyses of relevant outcome indicators were managed by using the Review Manager (RevMan) 5.2 software.

Results

This meta-analysis included six trials published involving 851 patients (group A, 397; group B, 454) with spinal TB. Results showed there were no significant differences between group A and group B in clinical cure rate (OR = 0.61; 95% CI 0.19–2.00, p > 0.05), change of erythrocyte sedimentation rate (ESR) (WMD = − 0.75; 95% CI − 3.33 to 1.83; p > 0.05) and bone graft fusion rate (OR = 2.32; 95% CI 0.36–14.81, p > 0.05). Meanwhile, there were fewer side effects (OR = 0.37; 95% CI 0.24–0.58, p < 0.05) in group A compared with group B.

Conclusions

The results of this meta-analysis showed that for patients with spinal TB undergoing surgery in Chinese population, short-course chemotherapy could be equivalent to the standard chemotherapy in terms of efficacy and have less side effects than the latter.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-021-02375-9.

Digital gangrene in spinal tuberculosis

Though tuberculosis is commonly seen in India, uncommon manifestations like peripheral gangrene is also a possibility. Here we present a case of spinal tuberculosis, with peripheral gangrene.

Development and Validation of a Scoring System for Differential Diagnosis of Tuberculosis and Metastatic Tumor in the Spine

Purpose

Spinal tuberculosis (TB) and metastatic tumor (MT) are common diseases with similar manifestations. Although pathological evaluation is the gold standard to confirm diagnosis, performing biopsies in all patients is not feasible. This study is aimed to create a scoring system to facilitate the differential diagnosis of spinal TB and MT before invasive procedures.

Methods

Altogether, 447 patients with spinal TB (n=198) and MT (n=249) were retrospectively analyzed. Patients were randomly assigned at 2:1 ratio to a training cohort and a validation cohort. Clinical, laboratory, and radiological diagnostic factors were identified by χ² and multiple logistic regression analyses. The scoring system was then established based on the identified independent diagnostic factors scored by regression coefficient β value, with the cut-off value being determined by ROC curve. The sensitivity and specificity of the system was calculated by comparing the predicted diagnosis with their actual pathological diagnosis.

Results

This scoring system was composed of 5 items: pain worsens at night (0 or 2 points), CRP value (0 or 3 points), tumor marker values (0 or 2 points), skip lesions (0 or 3 points), and intervertebral space destruction (0 or 3 points). Patients scoring higher than 7.5 could be diagnosed as spinal TB, otherwise, MT. According to the internal validation, the sensitivity and specificity of the system were 87.9% and 91.6%, respectively.

Conclusion

This study established and validated a scoring system which could be used to differentiate spinal TB from MT, thus helping clinicians in quick and accurate differential diagnosis.

Proteomic analysis reveals critical molecular mechanisms involved in the macrophage anti-spinal tuberculosis process

Tuberculosis infection activates the autoimmune system. However, the role of host-pathogen interactions involved in Mycobacterium tuberculosis infection is unclear. In this study, we analyzed 6 spinal tuberculosis tissues and 6 herniated disc tissues by using liquid chromatography-tandem mass spectrometry coupled with tandem mass spectrometry, and immunohistochemical staining was performed for validating the results. We identified 42 differential immune-related proteins and 3 hub genes that are primarily localised in the tertiary granule and involved in biological processes such as cellular response to the presence of cadmium ions, regulation of ion transmembrane transport, transmembrane transport, and inflammatory responses. Genes encoding cytochrome B-245 beta chain (CYBB), matrix metallopeptidase 9 (MMP9), and C-X-C motif chemokine ligand 10 (CXCL10) were identified as the hub genes that exhibited anti-tuberculosis activity and were responsible for macrophage resistance against M. tuberculosis. In conclusion, CYBB, MMP9, and CXCL10 resist M. tuberculosis infection through chemotaxis and macrophage activation. Our results indicate that CYBB, MMP9, and CXCL10 could be considered as molecular targets for spinal tuberculosis treatment, which may significantly improve patients' quality of life and prognosis.

Spinal Tuberculosis Treatment: An Enduring Bone of Contention

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

Spinal tuberculosis: A systematic review of case studies and development of an evidence-based clinical guidance tool for early detection

RATIONALE, AIMS, AND OBJECTIVES

Despite research being done on spinal tuberculosis, diagnosing this condition at an early stage remains problematic due to its insidious onset and the varying symptoms being associated. Most individuals present to the health care facility with either simple back pain at an early stage or neurological complications at a later stage, when spinal compression and vertebral collapse have occurred as a result of delayed diagnosis. The prevention of secondary complications is therefore dependent on early recognition and diagnosis. The objective of this review was to identify common clinical patterns in case presentations and develop an evidence-based clinical guidance tool to assist clinicians in the early identification of spinal tuberculosis.

METHOD

A comprehensive literature search was conducted for published spinal tuberculosis case studies, which yielded 28 cases after critical appraisal. Data from the studies were categorized in order to assist with a factor analysis and the development of an evidence framework for screening and diagnosing spinal tuberculosis. An evidence-based clinical guidance tool was then designed from the data obtained.

RESULTS

Factors associated with spinal tuberculosis and frequently reported symptoms and physical signs with which the patient could present upon assessment were identified. Options for investigations at primary, secondary, and tertiary levels were also identified.

CONCLUSION

Through the use of an evidence-based clinical guidance tool, the clinician could be guided in the early suspicion and management of individuals with spinal tuberculosis and prevention of secondary complications.

Epidemiological characteristics of pulmonary tuberculosis in Anhui Province, Eastern China from 2013 to 2018

OBJECTIVE

Pulmonary tuberculosis (TB) is a severe infectious respiratory disease, the burden of which remains high in China. To provide scientific evidence for developing more targeted prevention and control strategies, this study aimed to determine the incidence trends and explore the epidemiological characteristics of pulmonary TB in Anhui Province, Eastern China between 2013 and 2018.

METHODS

The retrospective study analyzed information regarding pulmonary TB cases reported by the National Infectious Disease Reporting System and census data collected from the Anhui Provincial Bureau of Statistics.

RESULTS

Overall, 211,892 cases of TB patients were reported in Anhui Province, China between 2013 and 2018, with an average annual reported incidence rate of 57.7 per 100,000 persons. A significant decrease in the incidence rate of pulmonary TB (p < 0.001) was observed during the study period. Men had a higher incidence rate of pulmonary TB than women (p < 0.001). The highest annual average reported incidence rate was 204.2 per 100,000 persons in those aged 70-74 years. The number of farmers with pulmonary TB, i.e., 155,415, accounted for 73.4% of all cases. Moreover, the peak period of reported cases was from January to March. Four cities along the Yangtze River-Anqing, Tongling, Chizhou, and Wuhu-reported significantly higher incidence rates of pulmonary TB than other cities (p < 0.001).

CONCLUSIONS

From 2013 to 2018, there was a significant decline in the incidence rate of pulmonary TB in Anhui Province, with peaks occurring from January to March. Prevention and control strategies targeting men, people aged 70-74 years, farmers, and the four cities along the Yangtze River should be strengthened.

International Framework for Red Flags for Potential Serious Spinal Pathologies

The International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) led the development of a framework to help clinicians assess and manage people who may have serious spinal pathology. While rare, serious spinal pathology can have devastating and life-changing or life-limiting consequences, and must be identified early and managed appropriately. Red flags (signs and symptoms that might raise suspicion of serious spinal pathology) have historically been used by clinicians to identify serious spinal pathology. Currently, there is an absence of high-quality evidence for the diagnostic accuracy of most red flags. This framework is intended to provide a clinical-reasoning pathway to clarify the role of red flags. J Orthop Sports Phys Ther 2020;50(7):350-372. Epub 21 May 2020. doi:10.2519/jospt.2020.9971.

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

Study Design

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

Overview of Literature

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

Methods

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

Results

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

Conclusions

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

The Value of Histology in the Diagnosis of Tuberculous Spondylodiscitis

BACKGROUND

Tuberculous spondylodiscitis (TS) is the most common form of musculoskeletal tuberculosis. Currently, histology is widely used to distinguish tuberculous from nontuberculous disease.

OBJECTIVES

The aim of the present study was to assess the accuracy of histology compared with bacteriology in the diagnosis of TS.

METHODS

This is a single-center case series carried out from January 2014 to February 2018 in a pathology department. It included 121 discovertebral biopsies of infective spondylodiscitis. The measures of diagnostic accuracy of histology were determined taking bacteriology as criterion standard.

RESULTS

Among the 121 cases, 55 (45.4%) were diagnosed as TS by histological and/or bacteriological findings, 17 (30.9%) were classified as definite TS by bacteriology, and the remaining 38 (69.1%) had positive histology and negative bacteriology. There were 2 false-negatives, which histologically displayed suppuration without granuloma, and 3 false-positives; in one case, histology displayed granulomas without necrosis and culture isolated Brucella. In the 2 others, histology revealed granulomas with caseous-like necrosis and microbiology isolated fungal species. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of histology in the diagnosis of TS were 88.2%, 93.4%, 83.3%, 95.5%, and 92%, respectively.

CONCLUSIONS

Histology is proved to be an accurate diagnostic tool in TS. Suppurative forms of TS without granuloma are rare and represent the main cause of false-negative histology. Suggestive histology of TS does not rule out fungal and brucellar spondylodiscitis. Caseous necrosis is not pathognomonic of tuberculosis. Fungal infection can also exhibit such type of necrosis.

Granulomatous infective spondylitis in a patient presenting with progressive difficulty in walking: the differential between tuberculosis and brucellosis

We report a case of infectious spondylitis in a 52-year-old woman who presented with progressive difficulty in walking. The patient had a 2-month long history of neurological symptoms, which progressed rapidly to paraplegia, following her admission. Imaging studies demonstrated the presence of vertebral lesions as well as additional tissue with inflammatory elements in the spinal canal, which caused a mass effect. In combination with the presence of increased cells and protein in the cerebrospinal fluid (CSF), the differential was steered towards causes of infectious spondylitis, primarily tuberculosis. However, brucellosis was also considered, as it is endemic in our area. Prompt surgical decompression produced biopsy samples, which confirmed the presence of granulomatous inflammation. The patient was started on an empiric regimen covering both for tuberculosis and brucellosis, and gradually regained full mobility in her lower limbs. The differential of infectious spondylitis is discussed, with an emphasis on the differentiation between tuberculosis and brucellosis.

Misdiagnosed and mismanaged atypical spinal tuberculosis: A case series report

Compared to other diseases, early or atypical spinal tuberculosis (TB) is prone to being misdiagnosed due to the lack of specific clinical manifestations and misleading negative results of various laboratory analyses and imaging examinations. Various methods for diagnosing spinal TB have become research hotspots. Recently, it has been proposed that effective vaccination is a mainstay of long-term policies to combat and control the TB epidemic. However, some new TB vaccines require further evaluation and clinical trials to demonstrate their efficiency and safety. Thus, early diagnosis and effective treatment are the other essential long-term strategies for controlling the TB epidemic immunization is closely associated with the diagnosis of spinal TB, which will become the focus of future research and set the direction for future developments. The present study provides a case series and a literature review of the characteristics of spinal TB to provide guidance for the diagnosis, treatment and prognosis of spinal TB.

The efficiency of the posterior-only approach using shaped titanium mesh cage for the surgical treatment of spine tuberculosis in children: A preliminary study

PURPOSE

The study aimed to evaluate the efficiency of the posterior-only approach using shaped titanium mesh cage for surgical treatment of spinal tuberculosis (TB) in children.

METHODS

Between January 2011 and July 2013, 22 children with a single motion spinal segment involved, including 10 with thoracic, 4 with thoracolumbar, and 8 with lumbar, were enrolled in the study. The patients were treated by the posterior-only approach using the shaped titanium mesh cages. Their medical records and radiographs were retrospectively analyzed.

RESULTS

The mean operating time was 163 min (ranging from 120 min to 200 min). Blood loss was 210-550 ml with an average of 300 ml. The mean follow-up period was 41.1 months. At the final follow-up, all patients showed a solid bony fusion without the infection recurrence. The average bone fusion time was 6.2 months. The average correction of the local segment kyphosis angle was 6.9° (from 9.2° preoperative to 2.3° postoperative). Minimal loss in correction angle was noted in these patients at the final follow-up (only 1.5°). Changes in erythrocyte sedimentation rate, local segment kyphosis angle, and neurological status demonstrated a significant clinical improvement in all children at their last follow-up.

CONCLUSION

Children with spinal TB of a single motion spinal segment involved can be successfully treated by the posterior-only approach using shaped titanium mesh cage. It is a minimally invasive, safe, and effective surgical procedure.

Delayed Diagnosis of Spinal Tuberculosis in a 44-year-old Male with Acute on Chronic Low Back Pain

Spinal tuberculosis (STB), also known as tuberculous spondylitis, tuberculous vertebral osteomyelitis, or Pott’s disease is a rare subset of extrapulmonary tuberculosis. Although rare in developed countries, STB is an important diagnosis for the emergency physician to consider. We report a case of a 44-year-old African-American male with STB presenting as an acute exacerbation of chronic low back pain complicated by urinary retention and difficulty ambulating. Our patient had no known predisposing risk factors for tuberculosis. This patient’s STB was mistakenly diagnosed as nontuberculous vertebral osteomyelitis. This is not uncommon, as it is often difficult to distinguish the two clinically. This patient experienced advanced neurologic features at the time of initial presentation, which improved with surgical decompression. Ultimately, he re-presented to the emergency department 10 days after hospital discharge with recurrence of symptoms due to inaccurate antimicrobial selection. The diagnosis may hinge on the astute physician recognizing the characteristic, albeit subtle, imaging findings of STB.

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.

APPLICATION OF DIGITAL TOMOSYNTHESIS IN DIAGNOSING SPINAL TUBERCULOSIS – FIRST CLINICAL EXPERIENCE IN UKRAINE

Diagnosis of tuberculous spondylitis is based on the comparison of clinical-laboratory, bacteriological data and radiological methods. Digital tomosynthesis is a new method of X-ray diagnostics for performing with high-resolution limited-angle tomography at short-pulsed exposures in one pass of the tube with reconstruction of several hundred longitudinal sections of the research object without superposition of tissues. Possibilities of tomosynthesis are studied for various clinical situations. Aim of research. To study and apply the possibilities of digital tomosynthesis in the diagnosis of tuberculous spondylitis, conduct a comparative analysis with other radiological methods. Materials and methods. Digital tomosynthesis was performed for 95 patients with various spine diseases (select group 8.4 % with tuberculous spondylitis) at the domestic digital roentgen-diagnostic complex with the mode of digital tomosynthesis after performing digital projectional radiography of spine. Results and discussion. The benefits of tomosynthesis were shown and a comparative analysis with other visualization methods in the diagnosis of spondylitis was performed. Cases of the first clinical application of the method in Ukraine were demonstrated. Conclusion. Digital tomosynthesis of the spine is a new promising diagnostic tool by which you can obtain qualitative spine images in the form of numerical thin sections with no exaggeration effect. Results are comparable to CT data for detecting bone destruction at lower radiation load levels. Digital tomosynthesis provides better visualization of the small joints of the spine and the ability to evaluate each anatomical element of the vertebra at different depths, helps to detect pulmonary manifestation of tuberculosis.

Diagnostic efficiency of Xpert MTB/RIF assay for osteoarticular tuberculosis in patients with inflammatory arthritis in China

BACKGROUND

Both osteoarticular tuberculosis (OA-TB) and inflammatory arthritis can lead to osteoarticular structural damage. These conditions exhibit similar symptoms, physical signs, and imaging features. Rapidly and accurately diagnosing OA-TB in patients with inflammatory arthritis presents a challenge to clinicians. Xpert MTB/RIF (Xpert) has been endorsed by the World Health Organization (WHO) as a rapid diagnostic tool for diagnosis of pulmonary and extrapulmonary TB. This study was designed to investigate diagnostic efficiency of Xpert for OA-TB in patients with inflammatory arthritis in China.

METHODS

A total of 83 consecutive patients with inflammatory arthritis and suspected OA-TB were enrolled prospectively from June 2014 to May 2018. Demographic, clinical, and biological data were recorded. Xpert assay, smear microscopy examination (smear), BACTEC MGIT 960 (MGIT 960), pathological examination, and T-SPOT.TB test were performed for each patient who received operations. Diagnostic efficiency of Xpert was evaluated based on a composite reference standard (CRS).

RESULTS

A total of 49 out of 83 patients with inflammatory arthritis and suspected OA-TB received operations, and 49 specimens were obtained during operations. According to CRS, 36 out of 49 patients with inflammatory arthritis were diagnosed with OA-TB, and 13 were not affected by the condition. Sensitivity of Xpert assay, smear, MGIT 960, pathological examination, and T-SPOT.TB test reached 66.70% (24/36), 25.00% (9/36), 30.55% (11/36), 47.22% (17/36), and 80.55% (29/36), respectively. Specificity of Xpert assay, smear, MGIT 960, and pathological examination was all 100% (13/13). Specificity of T-SPOT.TB test was 53.84% (7/13). Sensitivity of Xpert was higher than that of smear, MGIT 960 and pathological examination, but the sensitivity of Xpert was lower than that of T-SPOT.TB. Sensitivity of Xpert was statistically different from that of smear and MGIT 960 (P<0.001, P = 0.002), but the sensitivity of Xpert was not significantly different from that of pathological examination and T-SPOT.TB (P = 0.096, P = 0.181). Specificity of T-SPOT.TB was less than that of Xpert, smear, MGIT 960, and pathological examination, and the difference between them was statistically significant (P = 0.015). Among the 27 OA-TB patients with smear negative results, Xpert had the highest sensitivity, but sensitivity of Xpert was not significantly different from that of pathological examination and T-SPOT.TB (P = 0.413, P = 0.783). 2 of 36 OA-TB patients exhibited RIF resistance. Xpert was concordant with MGIT 960-based drug susceptibility testing (DST) in detecting rifampin (RIF) resistance.

CONCLUSIONS

Xpert is an efficient tool with high sensitivity and specificity for OA-TB diagnosis in patients with inflammatory arthritis in high-TB prevalence countries. Compared with conventional methods, Xpert has two advantages: one is fast, and the other is able to provide RIF resistance information simultaneously.

Development of Criteria Highly Suggestive of Spinal Tuberculosis

BACKGROUND

In a developing country there is a need for development of criteria that can be used for the diagnosis of spinal tuberculosis, which is common in that region.

METHODS

Demographic, clinical, and radiologic features of spinal tuberculosis and spinal epidural tumors have been compared statistically, and inferences have been drawn in terms of P values, sensitivity, specificity, positive predictive values, and negative predictive values.

RESULTS

A statistically significant relationship was found between spinal tuberculosis and spinal pain, fever, gradually progressive lower limb weakness, contrast-enhancing epidural ± paravertebral lesions, continuous levels affected, spinal deformity, and raised erythrocyte sedimentation rate.

CONCLUSIONS

These relationships were considered the most probable criteria for the diagnosis of spinal tuberculosis.

Cervical facet joint septic arthritis: a real pain in the neck

A 64-year-old man with a complex medical history and previous cervical arthritis with discectomy presents with a 2-day history of neck and lower back pain and shortness of breath, associated with left-sided muscle weakness. He has a fever with severe sepsis causing acute renal failure. MRI spine shows evidence of left cervical facet joint septic arthritis at C6-T1. He required 6 weeks of intravenous antibiotics and intensive support with ventilation and haemofiltration. After completion of antibiotics, he made a full recovery and regained neurological function before discharge.

The role of Xpert MTB/RIF assay in the diagnosis of tubercular spondylodiscitis

PURPOSE

This study aims to assess the accuracy of the Xpert MTB/RIF assay in the diagnosis of tubercular spondylodiscitis and to identify its role in detecting Rifampicin resistance in patients with infective spondylodiscitis.

METHODS

A retrospective study including 348 patients suspected to have infective spondylodiscitis was done. Tissue/pus samples obtained were sent for culture, histopathology and Xpert MTB/RIF assay. All patients who were confirmed to have tubercular spondylodiscitis and those patients who were suspected on clinico-radiological basis were also treated with anti-tuberculous chemotherapy for a period of 9 months. The efficacy of the Xpert MTB/RIF assay was assessed in terms of sensitivity and specificity when compared to culture, histopathology, and Composite reference standard (CRS).

RESULTS

During this study period of 24 months, a total of 348 patients were treated for infective spondylodiscitis. 254 patients were treated for tuberculosis following a smear positivity, culture positivity, and histopathology report or empirically based on clinico-radiological findings. The sensitivity and specificity of the Xpert MTB/RIF assay when compared to culture were 88.4 and 63.7%, respectively. When compared to both culture and histopathology reports it was 80.9 and 80.6%. The sensitivity and specificity of the Xpert MTB/RIF assay when compared to composite reference standard were 71.2 and 100%, respectively. The sensitivity of the assay to detect Rifampicin resistance was 100%. The prevalence of Rifampicin resistance was 5.1%.

CONCLUSION

This study recommends Xpert MTB/RIF assay for early detection of Mycobacterium tubercular spondylodiscitis and Rifampicin resistance.