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Scherer J, Mukasa SL, Wolmarans K, Guler R, Kotze T, Song T, Dunn R, Laubscher M, Pape HC, Held M, Thienemann F. Comparing gene expression profiles of adults with isolated spinal tuberculosis to disseminated spinal tuberculosis identified by 18FDG-PET/CT at time of diagnosis, 6- and 12-months follow-up: classifying clinical stages of spinal tuberculosis and monitoring treatment response (Spinal TB X cohort study). J Orthop Surg Res 2024; 19:376. [PMID: 38918806 PMCID: PMC11202394 DOI: 10.1186/s13018-024-04840-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Accepted: 06/07/2024] [Indexed: 06/27/2024] Open
Abstract
BACKGROUND Tuberculosis (TB) is one of the top ten causes of death worldwide, with approximately 10 million cases annually. Focus has been on pulmonary TB, while extrapulmonary TB (EPTB) has received little attention. Diagnosis of EPTB remains challenging due to the invasive procedures required for sample collection. Spinal TB (STB) accounts for 10% of EPTB and often leads to lifelong debilitating disease due to devastating spinal deformation and compression of neural structures. Little is known about the extent of disease, although both isolated STB and a disseminated form of STB have been described. In our Spinal TB X cohort study, we aim to describe the clinical phenotype of STB using whole-body 18FDG-PET/CT, identify a specific gene expression profile for different stages of dissemination and compare findings to previously described gene expression signatures for latent and active pulmonary TB. METHODS A single-centre, prospective cohort study will be established to describe the distributional pattern of STB detected by whole-body 18FDG-PET/CT and gene expression profile of patients with suspected STB on magnetic resonance imaging (MRI) at point of diagnosis, six months, and 12 months. Blood biobanking will be performed at these time points. Specimens for microbiology will be obtained from sputum/urine, from easily accessible sites of disease (e.g., lymph nodes, abscess) identified in the first 18FDG-PET/CT, from CT-guided biopsy and/or surgery. Clinical parameters and functional scores will be collected at every physical visit. Data will be entered into RedCap® database; data cleaning, validation and analysis will be performed by the study team. The University of Cape Town Ethics Committee approved the protocol (243/2022). DISCUSSION The Spinal TB X cohort study is the first prospective cohort study using whole-body 18FDG-PET/CT scans in patients with microbiologically confirmed spinal tuberculosis. Dual imaging techniques of the spine using 18FDG-PET/CT and magnetic resonance imaging as well as tissue diagnosis (microbiology and histopathology) will allow us to develop a virtual biopsy model. If successful, a distinct gene-expression profile will aid in blood-based diagnosis (point of care testing) as well as treatment monitoring and would lead to earlier diagnosis of this devastating disease. TRIAL REGISTRATION The study has been registered on ClinicalTrials.gov (NCT05610098).
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Affiliation(s)
- Julian Scherer
- General Medicine & Global Health (GMGH), Department of Medicine and Orthopaedic Research Unit (ORU), Division of Orthopaedic Surgery, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Department of Traumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Sandra L Mukasa
- Department of Medicine, Faculty of Health Science, General Medicine and Global Health (GMGH), University of Cape Town, 4Th Floor, Chris Barnard Building, Anzio Road, Observatory, Cape Town, 7925, South Africa
| | - Karen Wolmarans
- Department of Medicine, Faculty of Health Science, General Medicine and Global Health (GMGH), University of Cape Town, 4Th Floor, Chris Barnard Building, Anzio Road, Observatory, Cape Town, 7925, South Africa
| | - Reto Guler
- Institute of Infectious Diseases and Molecular Medicine (IDM), Department of Pathology, Division of Immunology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- International Centre for Genetic Engineering and Biotechnology (ICGEB), Cape Town Component, Cape Town, South Africa
| | - Tessa Kotze
- Department of Medicine, CUBIC, PETCT, University of Cape Town, Cape Town, South Africa
| | - Taeksun Song
- Division of Medical Microbiology, Department of Pathology, Faculty of Health Sciences, Institute of Infectious Diseases and Molecular Medicine (IDM), University of Cape Town, Cape Town, South Africa
| | - Robert Dunn
- Orthopaedic Research Unit (ORU), Division of Orthopaedic Surgery, Faculty of Health Science, University of Cape Town, Cape Town, South Africa
| | - Maritz Laubscher
- Orthopaedic Research Unit (ORU), Division of Orthopaedic Surgery, Faculty of Health Science, University of Cape Town, Cape Town, South Africa
| | - Hans-Christoph Pape
- Department of Traumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Michael Held
- Orthopaedic Research Unit (ORU), Division of Orthopaedic Surgery, Faculty of Health Science, University of Cape Town, Cape Town, South Africa
| | - Friedrich Thienemann
- Department of Medicine, Faculty of Health Science, General Medicine and Global Health (GMGH), University of Cape Town, 4Th Floor, Chris Barnard Building, Anzio Road, Observatory, Cape Town, 7925, South Africa.
- Department of Internal Medicine, University Hospital Zurich, University of Zurich, Zurich, Switzerland.
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Scherer J, Kotze T, Mdiza Z, Lawson A, Held M, Thienemann F. Tuberculous Spondylodiscitis with Psoas Abscess Descending into the Anterior Femoral Compartment Identified Using 2-deoxy-2-[18F]fluoroglucose Positron Emission Tomography Computed Tomography. Diagnostics (Basel) 2024; 14:1018. [PMID: 38786316 PMCID: PMC11119091 DOI: 10.3390/diagnostics14101018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Revised: 05/02/2024] [Accepted: 05/15/2024] [Indexed: 05/25/2024] Open
Abstract
A 24-year-old immunocompetent woman underwent whole-body 18F-FDG PET/CT for the evaluation of MRI-suspicious tuberculous spinal lesions. The PET/CT results showed no pathological uptake in either lung, and there were no pathological changes on CT. There was increased uptake in the right psoas muscle, extending continuously down anterior to the right hip joint, posterior to and around the trochanteric region of the right femur, and into the right thigh, with an SUVmaxbw of 17.0. Subsequently, the patient underwent CT-guided biopsy as per protocol, which revealed drug-sensitive Mycobacterium tuberculosis, and the patient was started on standard tuberculosis treatment for 12 months.
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Affiliation(s)
- Julian Scherer
- Orthopaedic Research Unit, Division of Orthopaedic Surgery, Department of Surgery, Faculty of Health Science, University of Cape Town, Cape Town 7925, South Africa
- Department of Traumatology, University Hospital Zurich, University of Zurich, 8091 Zurich, Switzerland
- General Medicine & Global Health Research Unit, Department of Medicine and Cape Heart Institute, Faculty of Health Science, University of Cape Town, Cape Town 7925, South Africa
| | - Tessa Kotze
- CUBIC, PET/CT, Department of Medicine, University of Cape Town, Cape Town 7925, South Africa
| | - Zintle Mdiza
- CUBIC, PET/CT, Department of Medicine, University of Cape Town, Cape Town 7925, South Africa
| | - Andrew Lawson
- CUBIC, PET/CT, Department of Medicine, University of Cape Town, Cape Town 7925, South Africa
| | - Michael Held
- Orthopaedic Research Unit, Division of Orthopaedic Surgery, Department of Surgery, Faculty of Health Science, University of Cape Town, Cape Town 7925, South Africa
| | - Friedrich Thienemann
- General Medicine & Global Health Research Unit, Department of Medicine and Cape Heart Institute, Faculty of Health Science, University of Cape Town, Cape Town 7925, South Africa
- CUBIC, PET/CT, Department of Medicine, University of Cape Town, Cape Town 7925, South Africa
- Department of Internal Medicine, University Hospital Zurich, University of Zurich, 8091 Zurich, Switzerland
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Al Tobing SD, Malau VD. Anterior and posterior fusion via a posterior and costotransversectomy approach for thoracic spinal tuberculosis: A case report. Int J Surg Case Rep 2023; 111:108698. [PMID: 37757733 PMCID: PMC10539854 DOI: 10.1016/j.ijscr.2023.108698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 08/14/2023] [Accepted: 08/15/2023] [Indexed: 09/29/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE Left untreated, spinal tuberculosis can lead to irreversible neurological deficit in patients, lowering quality of life. Combination of antitubercular drugs and surgical approach is important in managing spinal tuberculosis. We report a case of thoracic spinal tuberculosis treated by anterior and posterior fusion via a posterior and costotransversectomy approach. PRESENTATION OF CASE A 38 years-old woman diagnosed with paraplegia due to spinal tuberculosis of the thoracic vertebra (Th8) with Frankel A grade for spinal function. Pre-op kyphotic angle was 27.2°. Antitubercular drugs prescribed did not improve paraplegia symptom. Thoracal X-ray and MRI showed pathological fracture on Th8 and paravertebral abscess along anterior corpus of the Th6-9. We performed Sapardan's alternative VI approach that consists of debridement and abscess evacuation, decompression by laminectomy of the Th8, flavectomy and costotransversectomy of the Th8, posterior stabilization of the Th6-7 and Th9-10, and interbody fusion of the Th8. One month postoperative follow up showed improvement on motor function and sensory function. Post op kyphotic angle was 26.7°. CLINICAL DISCUSSION Adequate debridement followed by costotransversectomy, interbody fusion and surgical stabilization relieves pain, improves neurologic function, and prevents deformity of spinal tuberculous patient. CONCLUSION Although costotransversectomy approach is rarely used in surgical management of spinal TB, it is beneficial in cases with massive abscess involvement since it provides better view to collect and drain massive abscess.
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Affiliation(s)
- S Dohar Al Tobing
- Department of Orthopaedic and Traumatology, Dr. Cipto Mangunkusumo Hospital, Faculty of Medicine Universitas Indonesia, Indonesia
| | - Vino Daniel Malau
- Department of Orthopaedic and Traumatology, Dr. Cipto Mangunkusumo Hospital, Faculty of Medicine Universitas Indonesia, Indonesia.
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Gao S, Hu Y, Mamat F, Liang W, Mamat M, Xun C, Zhang J, Sheng W. Application of cement-augmented pedicle screws in elderly patients with spinal tuberculosis and severe osteoporosis: a preliminary study. J Orthop Surg Res 2023; 18:624. [PMID: 37626361 PMCID: PMC10463792 DOI: 10.1186/s13018-023-04099-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 08/14/2023] [Indexed: 08/27/2023] Open
Abstract
OBJECTIVE Surgical management of elderly patients with spinal tuberculosis and severe osteoporosis is challenging. Cement-augmented pedicle screws (CAPS) have been specifically designed for elderly patients with osteoporotic spines. Herein, we investigated the feasibility of CAPS applied in elderly patients with spinal tuberculosis and severe osteoporosis. METHODS We retrospectively analyzed data of patients with spinal tuberculosis and severe osteoporosis between January 2017 and January 2021. Surgical data, including surgical duration and intraoperative blood loss, were recorded. Radiological parameters, such as correction of regional kyphotic angle and screw loosening, were also evaluated. Additionally, visual analog scores (VAS) and Oswestry disability index (ODI) were used to evaluate back pain and functional recovery, respectively. Erythrocyte sedimentation (ESR) and C-reactive protein (CRP) concentrations were detected to assess tuberculosis activity. The presence of complications and fusion rate was also assessed. RESULTS A total of 15 patients were included in this study. The surgical duration was 263.0 ± 56.2 min, with an average blood loss of 378.7 ± 237.0 ml. The correction of regional kyphotic angle was 12.4° ± 15.0°, and it was well maintained until the final follow-up. The mean VAS decreased from 6.0 ± 1.2 points to 0.5 ± 0.6 points, and ODI reduced from 37.8% ± 7.6% to 8.3% ± 2.8% (P < 0.01). At the final follow-up, ESR and CRP levels were within normal range. Bony fusion occurred in all patients, with an average fusion duration of 8.8 ± 1.5 months. No cases of pedicle screw pullout, screw loosening, or pseudoarthrosis occurred. Tuberculosis recurrence and dissemination were not observed during the follow-ups. CONCLUSIONS CAPS fixation is an effective and safe technique to achieve solid fixation and favorable clinical outcomes in elderly patients with spinal tuberculosis and severe osteoporosis.
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Affiliation(s)
- Shutao Gao
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, 137 Liyushan Avenue, Xinshi District, Ürümqi, 830054 Xinjiang China
| | - Yukun Hu
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, 137 Liyushan Avenue, Xinshi District, Ürümqi, 830054 Xinjiang China
| | - Fulati Mamat
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, 137 Liyushan Avenue, Xinshi District, Ürümqi, 830054 Xinjiang China
| | - Weidong Liang
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, 137 Liyushan Avenue, Xinshi District, Ürümqi, 830054 Xinjiang China
| | - Mardan Mamat
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, 137 Liyushan Avenue, Xinshi District, Ürümqi, 830054 Xinjiang China
| | - Chuanhui Xun
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, 137 Liyushan Avenue, Xinshi District, Ürümqi, 830054 Xinjiang China
| | - Jian Zhang
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, 137 Liyushan Avenue, Xinshi District, Ürümqi, 830054 Xinjiang China
| | - Weibin Sheng
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, 137 Liyushan Avenue, Xinshi District, Ürümqi, 830054 Xinjiang China
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Duan S, Dong W, Hua Y, Zheng Y, Ren Z, Cao G, Wu F, Rong T, Liu B. Accurate Differentiation of Spinal Tuberculosis and Spinal Metastases Using MR-Based Deep Learning Algorithms. Infect Drug Resist 2023; 16:4325-4334. [PMID: 37424672 PMCID: PMC10329448 DOI: 10.2147/idr.s417663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 06/28/2023] [Indexed: 07/11/2023] Open
Abstract
Purpose To explore the application of deep learning (DL) methods based on T2 sagittal MR images for discriminating between spinal tuberculosis (STB) and spinal metastases (SM). Patients and Methods A total of 121 patients with histologically confirmed STB and SM across four institutions were retrospectively analyzed. Data from two institutions were used for developing deep learning models and internal validation, while the remaining institutions' data were used for external testing. Utilizing MVITV2, EfficientNet-B3, ResNet101, and ResNet34 as backbone networks, we developed four distinct DL models and evaluated their diagnostic performance based on metrics such as accuracy (ACC), area under the receiver operating characteristic curve (AUC), F1 score, and confusion matrix. Furthermore, the external test images were blindly evaluated by two spine surgeons with different levels of experience. We also used Gradient-Class Activation Maps to visualize the high-dimensional features of different DL models. Results For the internal validation set, MVITV2 outperformed other models with an accuracy of 98.7%, F1 score of 98.6%, and AUC of 0.98. Other models followed in this order: EfficientNet-B3 (ACC: 96.1%, F1 score: 95.9%, AUC: 0.99), ResNet101 (ACC: 85.5%, F1 score: 84.8%, AUC: 0.90), and ResNet34 (ACC: 81.6%, F1 score: 80.7%, AUC: 0.85). For the external test set, MVITV2 again performed excellently with an accuracy of 91.9%, F1 score of 91.5%, and an AUC of 0.95. EfficientNet-B3 came second (ACC: 85.9, F1 score: 91.5%, AUC: 0.91), followed by ResNet101 (ACC:80.8, F1 score: 80.0%, AUC: 0.87) and ResNet34 (ACC: 78.8, F1 score: 77.9%, AUC: 0.86). Additionally, the diagnostic accuracy of the less experienced spine surgeon was 73.7%, while that of the more experienced surgeon was 88.9%. Conclusion Deep learning based on T2WI sagittal images can help discriminate between STB and SM, and can achieve a level of diagnostic performance comparable with that produced by experienced spine surgeons.
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Affiliation(s)
- Shuo Duan
- Department of Orthopaedic Surgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Weijie Dong
- Department of Orthopedics, Beijing Chest Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Yichun Hua
- Department of Medical Oncology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Yali Zheng
- Department of Respiratory, Critical Care, and Sleep Medicine, Xiang’an Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, People’s Republic of China
| | - Zengsuonan Ren
- Department of Orthopaedic Surgery, People’s Hospital of Hainan Tibetan Autonomous Prefecture, Hainan Tibetan Autonomous Prefecture, Qinghai Province, People’s Republic of China
| | - Guanmei Cao
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Fangfang Wu
- Department of Respiratory, Critical Care, and Sleep Medicine, Xiang’an Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, People’s Republic of China
| | - Tianhua Rong
- Department of Orthopaedic Surgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Baoge Liu
- Department of Orthopaedic Surgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
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Na S, Lyu Z, Zhang S. Diagnosis and Treatment of Skipped Multifocal Spinal Tuberculosis Lesions. Orthop Surg 2023. [PMID: 37186216 DOI: 10.1111/os.13744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 03/04/2023] [Accepted: 03/24/2023] [Indexed: 05/17/2023] Open
Abstract
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.
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Affiliation(s)
- Shibo Na
- Department of Spinal Surgery, Orthopaedic Center, The First Hospital of Jilin University, Changchun City, China
| | - ZhenShan Lyu
- Department of Spinal Surgery, Orthopaedic Center, The First Hospital of Jilin University, Changchun City, China
| | - Shaokun Zhang
- Department of Spinal Surgery, Orthopaedic Center, The First Hospital of Jilin University, Changchun City, China
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Yasin P, Mardan M, Xu T, Cai X, Abulizi Y, Wang T, Sheng W, Mamat M. Development and validation of a diagnostic model for differentiating tuberculous spondylitis from brucellar spondylitis using machine learning: A retrospective cohort study. Front Surg 2023; 9:955761. [PMID: 36684365 PMCID: PMC9852539 DOI: 10.3389/fsurg.2022.955761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 11/02/2022] [Indexed: 01/09/2023] Open
Abstract
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.
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Affiliation(s)
- Parhat Yasin
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | | | - Tao Xu
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Xiaoyu Cai
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Yakefu Abulizi
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Ting Wang
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Weibin Sheng
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Mardan Mamat
- Department of Spine Surgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China,Correspondence: Mardan Mamat
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Dahlan RH, Ompusunggu SE, Gondowardojo YRB, Priambodo R, Anugerah SW. Spinal tuberculosis: A case series and a literature review. Surg Neurol Int 2022; 13:196. [PMID: 35673664 PMCID: PMC9168402 DOI: 10.25259/sni_1201_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 03/02/2022] [Indexed: 11/20/2022] Open
Abstract
Background: Spinal tuberculosis (TB) is a common form of extrapulmonary TB. Although the first line of the treatment is anti-TB medications, patients with severe neurological deficits, spinal instability, and/or kyphotic deformity often warrant surgery. Here, we report five cases of spinal TB requiring operative intervention at Hasan Sadikin General Hospital, Bandung, Indonesia. Case Description: We operated on five patients with spinal TB cases from 2019 to October 2021. In addition to appropriate medical management, all five patients successfully underwent laminectomy with or without posterior stabilization. Conclusion: It is essential to establish the diagnosis and surgically manage patients with spinal TB early in the clinical course to minimize residual post-operative neurological deficits.
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Goyal N, Ahuja K, Yadav G, Gupta T, Ifthekar S, Kandwal P. PEEK vs Titanium Cage for Anterior Column Reconstruction in Active Spinal Tuberculosis: A Comparative Study. Neurol India 2021; 69:966-972. [PMID: 34507423 DOI: 10.4103/0028-3886.325384] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background Posterolateral decompression and debridement in patients with TB spine led to defect in the anterior column which makes the spinal column unstable, thus making anterior column reconstruction an important step in surgical management. Objective Through the study, authors sought to answer the following questions: 1) What are the differences in clinical outcomes between patients with TB spine undergoing anterior column reconstruction using titanium mesh cage versus PEEK cage? 2) What are the differences in radiological outcomes between these two groups of patients? Methods This is a retrospective comparative study including patients with TB spine undergoing surgical management. The included subjects were divided into groups A and B depending on the implantation of PEEK or titanium mesh cage respectively for anterior column reconstruction. Outcome criteria analyzed included clinical criteria like VAS and ODI scores, radiological criteria like kyphosis correction, loss of kyphosis at follow-up, cage subsidence, and bony fusion on a 2D CT scan. Results The study population included 14 patients in Group A and 15 patients in Group B. Improvement in VAS and ODI scores was comparable between groups. There was no significant difference in radiological outcome measures between the two groups, however, two patients from group B showed implant-related complications needing revision. All patients showed good bony fusion at the final follow-up. Conclusion PEEK and titanium cages have comparable clinico-radiological outcomes for anterior column reconstruction in patients with active TB spine. Its advantages for being radiolucent and its ease of use may make it a choice of implant.
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Affiliation(s)
- Nikhil Goyal
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Kaustubh Ahuja
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Gagandeep Yadav
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Tushar Gupta
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Syed Ifthekar
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Pankaj Kandwal
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
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Shetty AP, Viswanathan VK, Rajasekaran S. Cervical spine TB - Current concepts in management. J Orthop Surg (Hong Kong) 2021; 29:23094990211006936. [PMID: 34711081 DOI: 10.1177/23094990211006936] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
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.
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Affiliation(s)
- Ajoy Prasad Shetty
- Department of Spine surgery, 76290Ganga Medical Centre and Hospital, Coimbatore, Tamil Nadu, India
| | | | - S Rajasekaran
- Department of Spine surgery, 76290Ganga Medical Centre and Hospital, Coimbatore, Tamil Nadu, India
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Zhuang QK, Li W, Chen Y, Bai L, Meng Y, Li Y, Gu YT. Application of Oblique Lateral Interbody Fusion in Treatment of Lumbar Spinal Tuberculosis in Adults. Orthop Surg 2021; 13:1299-1308. [PMID: 33955680 PMCID: PMC8274156 DOI: 10.1111/os.12955] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 01/18/2021] [Accepted: 01/20/2021] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE The purpose of the present paper was to evaluate the safety and clinical efficacy of mini-open retroperitoneal oblique lumbar interbody fusion (OLIF) for the treatment of lumbar spinal tuberculosis. METHODS A total of 115 patients who suffered from lumbar spinal tuberculosis from June 2014 to December 2017 were included in this research. A total of 59 patients underwent OLIF and percutaneous pedicle screw fixation (OLIF group) and 56 patients underwent the anterior-only approach (anterior-only group). All patients were followed up for at least 24 months. Operation time, blood loss, and rate of complications were used to assess the safety of these two techniques. The visual analog scale (VAS) and the Oswestry disability index (ODI) were used to evaluate the relief of neurological and functional symptoms. The erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were measured to investigate the activity and recurrence of spinal tuberculosis. The Cobb angle, the sagittal vertical axis of the spine (SVA), the pelvic tilt (PT), the sacral slope (SS), the pelvic incidence (PI), and postoperative Frankel classification were also used to assess the efficiency of the spine deformity correction and the recovery of long-term neurological function. RESULTS Most patients were successfully treated with OLIF and the anterior-only technique and attained satisfactory clinical efficiency during the 24-month follow-up period. In the perioperative period, the mean operative time (154.68 ± 23.64 min, P < 0.001), the mean blood loss (110.57 ± 87.67 mL, P < 0.001), and the mean hospital stay (9.55 ± 3.62 days, P < 0.001) of the OLIF group were all significantly lower than in the anterior-only group (172.49 ± 25.67 min, 458.56 ± 114.89 mL, and 14.89 ± 3.89 days, respectively). A total of 10 patients (16.95%) experienced complications in the OLIF group, including neurological injury, segmental artery and iliac vein lacerations, peritoneal injury, instrument failure, and infection of incisions; this rate of complications was lower than in the anterior-only group (37.50%, P = 0.013). Regard to spinal deformity correction, the Cobb angle (9.42° ± 1.72°, P = 0.032), the SVA (2.23 ± 1.07 cm, P = 0.041), the PT (14.26° ± 2.37°, P = 0.037), and the SS (39.49° ± 2.17°, P = 0.042) of the OLIF group at last follow-up were all significantly different when compared to the anterior-only group (14.75° ± 2.13°, 3.48 ± 0.76 cm, 18.58° ± 1.45°, and 36.78° ± 1.96°, respectively). The VAS and the ODI of the OLIF group at 1 week postoperatively (3.15 ± 0.48, 21.85 ± 3.78, P = 0.032, 0.037) and at the last follow-up (2.12 ± 0.35, 16.70 ± 5.25, P = 0.043, 0.035) were both lower than for the anterior-only group (5.18 ± 0.56, 29.83 ± 5.42 and 3.67 ± 0.62, 20.68 ± 6.23). The Frankel classification was improved for both OLIF and anterior-only patients; however, there were 35 cases (59.32%) classified as Frankel grade E in the OLIF group and 22 cases (39.29%, P = 0.021) in the anterior-only group CONCLUSION: The OLIF surgical technique for single lumbar (L2 -L5 ) spinal tuberculosis is less invasive, has lower complication rates, and is more efficient than the anterior-only approach. However, the long-term effects of this surgical technique still need to be explored.
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Affiliation(s)
- Quan-Kui Zhuang
- Department of Orthopaedic Surgery, No. 2 People's Hospital of Fu Yang, Fuyang, China
| | - Wei Li
- Department of Orthopaedic Surgery, No. 2 People's Hospital of Fu Yang, Fuyang, China
| | - Yong Chen
- Department of Orthopaedic Surgery, No. 2 People's Hospital of Fu Yang, Fuyang, China
| | - Liang Bai
- Department of Orthopaedic Surgery, No. 2 People's Hospital of Fu Yang, Fuyang, China
| | - Yong Meng
- Department of Orthopaedic Surgery, No. 2 People's Hospital of Fu Yang, Fuyang, China
| | - Yang Li
- Department of Orthopaedic Surgery, No. 2 People's Hospital of Fu Yang, Fuyang, China
| | - Yu-Tong Gu
- Department of Orthopaedic Surgery, Zhongshan Hospital Fudan University, Shanghai, China.,Department of Orthopaedic Surgery, Shanghai Public Health Clinical Center, Fudan University, Shanghai, China
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Louw QA, Tawa N, Van Niekerk SM, Conradie T, Coetzee M. Spinal tuberculosis: A systematic review of case studies and development of an evidence-based clinical guidance tool for early detection. J Eval Clin Pract 2020; 26:1370-1382. [PMID: 31770823 DOI: 10.1111/jep.13309] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 10/10/2019] [Accepted: 10/11/2019] [Indexed: 12/29/2022]
Abstract
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.
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Affiliation(s)
- Quinette A Louw
- Department of Health and Rehabilitation Sciences, Division of Physiotherapy, Faculty of Medicine and Health Sciences, University of Stellenbosch, Tygerberg, South Africa
| | - Nassib Tawa
- Department of Health and Rehabilitation Sciences, Division of Physiotherapy, Faculty of Medicine and Health Sciences, University of Stellenbosch, Tygerberg, South Africa.,Department of Rehabilitation Sciences, School of Medicine, College of Health Sciences, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Sjan-Mari Van Niekerk
- Department of Health and Rehabilitation Sciences, Division of Physiotherapy, Faculty of Medicine and Health Sciences, University of Stellenbosch, Tygerberg, South Africa
| | - Thandi Conradie
- Department of Health and Rehabilitation Sciences, Division of Physiotherapy, Faculty of Medicine and Health Sciences, University of Stellenbosch, Tygerberg, South Africa
| | - Marisa Coetzee
- Department of Health and Rehabilitation Sciences, Division of Physiotherapy, Faculty of Medicine and Health Sciences, University of Stellenbosch, Tygerberg, South Africa
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Stienen MN, Sprengel K, Butsch R, Achermann Y, Wolfensberger A, Regli L, Bellut D. [Tuberculous Spondylitis - Diagnosis and Management]. PRAXIS 2020; 109:775-787. [PMID: 32752962 DOI: 10.1024/1661-8157/a003518] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
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.
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Affiliation(s)
- Martin N Stienen
- Interdisziplinäres Wirbelsäulenzentrum, Universitätsspital Zürich, Universität Zürich
- Klinik für Neurochirurgie, Universitätsspital Zürich, Universität Zürich
- Klinisches Neurozentrum, Universität Zürich
| | - Kai Sprengel
- Interdisziplinäres Wirbelsäulenzentrum, Universitätsspital Zürich, Universität Zürich
- Klinik für Traumatologie, Universitätsspital Zürich, Universität Zürich
| | - Raphael Butsch
- Interdisziplinäres Wirbelsäulenzentrum, Universitätsspital Zürich, Universität Zürich
- Klinik für Rheumatologie, Universitätsspital Zürich, Universität Zürich
| | - Yvonne Achermann
- Klinik für Infektionskrankheiten und Spitalhygiene, Universitätsspital Zürich, Universität Zürich
| | - Aline Wolfensberger
- Klinik für Infektionskrankheiten und Spitalhygiene, Universitätsspital Zürich, Universität Zürich
| | - Luca Regli
- Interdisziplinäres Wirbelsäulenzentrum, Universitätsspital Zürich, Universität Zürich
- Klinik für Neurochirurgie, Universitätsspital Zürich, Universität Zürich
- Klinisches Neurozentrum, Universität Zürich
| | - David Bellut
- Interdisziplinäres Wirbelsäulenzentrum, Universitätsspital Zürich, Universität Zürich
- Klinik für Neurochirurgie, Universitätsspital Zürich, Universität Zürich
- Klinisches Neurozentrum, Universität Zürich
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Sagane SS, Patil VS, Bartakke GD, Kale KY. Assessment of Clinical and Radiological Parameters in Spinal Tuberculosis: Comparison between Human Immunodeficiency Virus-Positive and Human Immunodeficiency Virus-Negative Patients. Asian Spine J 2020; 14:857-863. [PMID: 32160725 PMCID: PMC7788368 DOI: 10.31616/asj.2019.0251] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 10/13/2019] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
| | - Vishal Supda Patil
- Department of Orthopaedics, B.J. Govt Medical College and Sassoon General Hospital, Pune, India
| | | | - Kaustubh Yeshwant Kale
- Department of Orthopaedics, B.J. Govt Medical College and Sassoon General Hospital, Pune, India
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Spinal tuberculosis: a comprehensive review for the modern spine surgeon. Spine J 2019; 19:1858-1870. [PMID: 31102727 DOI: 10.1016/j.spinee.2019.05.002] [Citation(s) in RCA: 111] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 05/07/2019] [Accepted: 05/07/2019] [Indexed: 02/03/2023]
Abstract
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.
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Abstract
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.
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Affiliation(s)
- S. Rajasekaran
- Ganga Hospital, Coimbatore, India,S. Rajasekaran, Department of Spine Surgery, Ganga Hospital, 313, Mettupalayam Road, Coimbatore 641043, India.
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Galloway KM, Parker R. Could an increase in vigilance for spinal tuberculosis at primary health care level, enable earlier diagnosis at district level in a tuberculosis endemic country? Afr J Prim Health Care Fam Med 2018; 10:e1-e9. [PMID: 29943617 PMCID: PMC6018652 DOI: 10.4102/phcfm.v10i1.1666] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 03/06/2018] [Accepted: 03/13/2018] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Expert clinicians and researchers in the field of spinal tuberculosis (STB) advocate for early identification and diagnosis as a key to reducing disability, severity of disease, expensive surgery and death, especially in tuberculosis (TB) endemic countries like South Africa. South Africa has the highest incidence per capita of tuberculosis in the world, and a conservative estimate of the incidence of STB in South Africa is 8-16:100 000. People living with STB may initially present to primary health care (PHC) centres, where the opportunity exists for early identification. Spinal pain is the most common presentation of STB, but even this symptom may not be present. Occasionally the only symptoms are neurological injury, dysphagia or referred pain. Computerised tomography-guided biopsy remains the diagnostic gold standard for STB. AIM A narrative review was undertaken to investigate the evidence available that could assist with the early diagnosis of STB. METHOD Articles were searched for and retrieved from three databases and assessed for quality and relevance to primary settings in a TB endemic country. RESULTS The following evidence-based, affordable and available tools could facilitate early diagnosis of STB at PHC and district hospital levels: (1) back pain screening questions, undressed spinal physical examination, HIV and antiretroviral therapy history, (2) erythrocyte sedimentation rate, C-reactive protein, platelets, haemoglobin, white cell count (WCC), sputum for GeneXpert and accurate weight measurement, (3) physiotherapy and/or medical and/or speech therapy assessment, (4) full spinal radiograph, chest radiograph, abdominal ultrasound, urine lipoarabinomannan (LAM) if CD4 < 200 and ultrasound-guided biopsy of superficial abscesses, (5) clear referral guidelines at all levels, (6) a positive response to treatment to confirm the diagnosis. CONCLUSION These affordable and simple actions at PHC and district levels could facilitate earlier diagnosis of STB.
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