Management of spinal tuberculosis: a systematic review and meta-analysis

Clinical Features and Outcomes of Spinal Tuberculosis in Central China

Purpose

The appropriate management of spinal tuberculosis (TB) is challenging for clinicians and the key to treat spinal TB. Surgery and long course anti-TB chemotherapy may not be necessary to all situations. This study aimed to characterize the clinical features and factors affecting treatment outcomes.

Patients and Methods

A retrospective study of patients with spinal TB over a 5-year period at a teaching hospital in central China was conducted. Features of patients with spinal TB who received different treatment modalities and factors associated with patient outcomes at the end of chemotherapy were analyzed.

Results

Forty-five patients (21 men and 24 women) with spinal TB were available for analysis. The mean age was 55.39 ± 14.94 years. The most common vertebral area involved was the lumbar (42.2%). The mean number of vertebrae involved was 2.20 ± 0.59. 27 patients (60.0%) received surgical treatment, of which 21 (77.8%) received radical surgical treatment. Thirty-five patients (77.8%) had achieved a favorable status. Statistically, there was no significant correlation between favorable status and surgery, but among 27 surgical patients with spinal tuberculosis, patients receiving radical surgery tended to achieve good prognosis (P = 0.010; odds ratio = 0.053; 95% confidence interval 0.006–0.493). Moreover, there was no significant difference between long course and short course of anti-TB chemotherapy in prognosis in different treatment modalities.

Conclusion

Although the patients with spinal TB who needed surgical treatment often got a better prognosis when they had radical surgery, surgery was not actually a factor for the favorable outcomes of patients with spinal TB. In different treatment modalities, there was no additional benefit in longer anti-TB chemotherapy periods.

Clinical effectiveness of posterior-only approach using polyetheretherketone cage combined with single-segment instrumentation for lumbar tuberculosis in children

We sought to investigate the outcomes of posterior-only approach using polyetheretherketone (PEEK) cage combined with single-segment instrumentation (modified-approach) for mono-segment lumbar tuberculosis in children. Between February 2008 and August 2017 in our hospital, 18 children with single-segment lumbar tuberculosis enrolled in this study were treated by modified-approach. Medical records and radiographs were retrospectively analyzed. Mean follow-up time was 54.6 ± 12.1 months. No severe complications were noted to have occurred. Measures indicated there was satisfactory bone fusion for all patients. Mean Cobb angles were significantly decreased from preoperative angle (19.8° ± 13.1°) to those both postoperatively (− 4.9° ± 7.6°) and at final follow-up (− 3.5° ± 7.3°) (both P < 0.05), with a mean angle loss of 1.7° ± 0.9°. The erythrocyte sedimentation rate (ESR) returned to normal levels for all patients within 3 months postoperatively. All patients had significant postoperative improvement in neurological performance. The modified-approach was an effective and feasible treatment option for mono-segment children with lumbar tuberculosis. Such procedures can likely help patients by increasing retainment of lumbar mobility and reducing invasiveness.

Posterior-only approach with titanium mesh cages versus autogenous iliac bone graft for thoracic and lumbar spinal tuberculosis

Objective: This study aimed to compare the effectiveness of titanium mesh cages (TMCs) with autogenous iliac bone grafts (AIBG) in posterior-only surgery for thoracic and lumbar spinal tuberculosis.Design: Retrospective investigative design.Setting: The First Affiliated Hospital of Fujian Medical University, Fuzhou, China.Participants: A total of 146 patients with thoracic or lumbar tuberculosis.Interventions: All patients underwent a posterior-only approach with either a TMC (86 cases) or AIBG (60 cases).Outcomes measures: Operation duration, intraoperative blood loss, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), visual analogue scale (VAS), and related complications were used to compare the effectiveness and feasibility of the two techniques. Frankel grading system, Cobb angle, and loss of angular correction were employed to assess neurological and kyphotic improvements.Results: There were significant improvements in ESR, CRP, VAS, Frankel grade, and Cobb angle at the last follow-up (P < 0.05) when compared with the preoperative state. The TMC group was superior in operation duration (P < 0.001), intraoperative blood loss (P = 0.007), VAS (P < 0.001), loss of angular correction (P < 0.001), and surgical complications as compared with the AIBG group. There were no significant differences in the improvement of the Frankel grade and Cobb angle between the TMC and AIBG groups (P > 0.05). A recurrence of tuberculosis was not found in either of the groups.Conclusion: Compared to autogenous iliac bone grafts, titanium mesh cages could serve as a superior material in posterior-only operative therapy for thoracic and lumbar spinal tuberculosis.

Minimally invasive surgery for paravertebral or psoas abscess with spinal tuberculosis - a long-term retrospective study of 106 cases

Background

Minimally invasive surgery (MIS) is a common treatment option for paravertebral or psoas abscesses (PAs) in patients with spinal tuberculosis (ST). However, its efficacy remains controversial. The aim of the study was to evaluate the efficacy of MIS for PA with ST combined with anti-tuberculous chemotherapy.

Methods

A total of 106 consecutive patients who underwent MIS for ST with PA from January 2002 to Oct 2012 were reviewed. The MIS involved computed tomography (CT)-guided percutaneous catheter drainage and percutaneous catheter infusion chemotherapy. Clinical outcomes were evaluated based on the changes observed on preoperative and postoperative physical examination, inflammatory marker testing, and magnetic resonance imaging (MRI).

Results

The mean follow-up period was 7.21 ± 3.15 years. All surgeries were successfully completed under CT-guidance without intraoperative complications and all patients experienced immediate relief of their symptoms, which included fever and back pain. The preoperatively elevated erythrocyte sedimentation rate and C-reactive protein values returned to normal at a mean period of 3 months postoperatively. Solid bony union was observed in 106 patients and no abscesses were found on MRI examination.

Conclusion

MIS carries advantages in terms of less invasiveness, precise drainage, and enhanced local drug concentration. While the technique has not been fully characterized and clinically prove, its use in addition to conservative chemotherapy and open debridement and instrumental fixation may be recommended for patients with ST and PA.

Challenges and controversies in the treatment of spinal tuberculosis

Current guidelines regarding management of spinal TB are mostly extrapolated from trials on pulmonary disease. Since the British Medical Research Council (BMRC) trials in the 1970s, there are not many good quality studies that substantiate best practice guidelines for the management of this entity. Tuberculous infection of the spine behaves much differently from bacterial osteomyelitis and limited data leads to ambiguity in many cases. Although a few studies have been conducted in patients with spinal TB, most were in the era preceding short course chemotherapy and prior to current radiological and surgical advances. While spinal TB is primarily managed medically, surgical intervention may be needed in certain cases. We discuss areas of uncertainty and challenges that exist with regards to medical treatment, diagnosis, therapeutic endpoints, and a few surgical considerations. Substantial delay in diagnosis continues to be common with this disease even in the developed nations, leading to substantial morbidity. In light of limited evidence, there is an emerging recognition of the need to individualize various aspects of its treatment such as duration, frequency and acknowledging the limitations of various diagnostic and radiological modalities. We aim to consolidate potential areas of research in the diagnosis and management of spinal TB and to revisit the latest published evidence on its redressal.

Trends in Spinal Surgery for Pott's Disease (2000-2016): An Overview and Bibliometric Study

STUDY DESIGN

Systematic review.

OBJECTIVES

(1) What are the surgical indications? Have they changed over time since the year 2000? (2) What is the current surgical approaches of choice? Have they changed over time since the year 2000? Do they vary by geographical region? (3) What are the most common outcome measures following surgery?

METHODS

Electronic databases and reference lists of key articles were searched from database inception from January 1, 2000 to December 31, 2016 to identify studies specifically evaluating surgical indications, current surgical approaches, and outcome measures for spinal tuberculosis.

RESULTS

Six randomized controlled trials were identified from our search (1 excluded: no surgical arm identified after review) Neurological deficit, instability and deformity were common indications identified. Surgical approach included predominantly anterior for cervical spine and posterior for thoracic and lumbar spine. Combined approach was preferred in pediatric cases. Degree of deformity correction, neurological outcomes, and fusion formed the main bases of assessing surgical outcomes.

CONCLUSIONS

Majority of the current literature is from South Asia. The presence of neurological compromise, deformity, and instability were the primary criteria for surgical intervention. The preferred approach varied with the anatomical region of the spine in adults. Outcome measures predominantly involved deformity correction, neurological deficit, and fusion.

Utilization of ring-shaped bone allograft for surgical treatment of adolescent post-tubercular kyphosis: A retrospective study

This study aimed to investigate the mid-term outcome of ring-shaped bone allografts in the surgical treatment of adolescent post-tubercular kyphosis secondary to spinal tuberculosis.The records of adolescent patients diagnosed with spinal tuberculosis who received treatment in our department between 2009 and 2013 were retrospectively reviewed. The anterior approach was used in cases of cervical kyphosis and the posterior approach was used in cases of thoracic and lumbar kyphosis. During the surgery, the ring-shaped bone was used as a structural bone graft associated with the cancellous bone filing in the center portion of the ring shape. Cobb's angle, signs of spinal infusion on computed tomography, and complications were followed up.A total of 25 patients were included in our study. Among them, 3 involved the cervical region, 5 involved the thoracic region, 8 involved the thoracolumbar region, and 9 involved the lumbar region. The preoperative kyphosis deformity was a mean 65° Cobb's angle (40°-97°) compared to the postoperative 14° Cobb's angle (10°-21°) for an average correction of 51°. All wounds healed well without graft rejection. All patients achieved bone fusion 3 months postoperative for a 100% fusion rate.Our results show that the ring-shaped allograft bone is an effective option for the treatment of adolescent kyphosis. The ring-shaped allograft bone demonstrated satisfactory mechanical strength and vertebral fusion without mid-term metallic toxicity.

Is nonstructural bone graft useful in surgical treatment of lumbar spinal tuberculosis?: A retrospective case-control study

Surgical intervention is an important option for treating spinal tuberculosis. Previous studies have reported different surgical procedures and bone grafts for it. To our knowledge, few studies demonstrated the clinical results of using nonstructural autogenous bone graft in surgical treatment of spinal tuberculosis.The purpose of this study is to compare the clinical outcomes of surgical management lumbar spinal tuberculosis by one-stage posterior debridement with nonstructural autogenous bone grafting and instrumentation versus anterior debridement, strut bone grafting combined with posterior instrumentation.A total of 58 consecutive patients who underwent surgical treatment due to lumbar spinal tuberculosis from January 2011 to December 2013 were included. A total of 22 patients underwent one-stage posterior debridement, nonstructural autogenous bone grafting, and instrumentation (group A), and 36 patients received anterior debridement, strut bone grafting combined with posterior instrumentation (group B). The operative duration, total blood loss, perioperative transfusion, length of hospital stay, hospitalization cost, and complications were recorded. The bony fusion of the graft was assessed by computed tomography scans. American Spinal Injury Association (ASIA) Impairment Scale was used to evaluate the neurological function of patients in the 2 groups.All the patients were followed up, with a mean follow-up duration of 21.6 ± 5.7 months in group A and 22.3 ± 6.2 months in group B (P = 0.47). The average operative duration was 257.5 ± 91.1 minutes in group A and 335.7 ± 91.0 minutes in group B (P = 0.002). The mean total blood loss was 769.6 ± 150.9 mL in group A and 1048.6 ± 556.9 mL in group B (P = 0.007). Also, significant differences were found between the 2 groups in perioperative transfusion volumes, length of hospital stay, and hospitalization cost (P < 0.05), which were less in group A compared with group B. Patients with ASIA grade C/D in the 2 groups were improved with 1 to 2 grades after the surgery with no statistical difference (P = 1.000). The perioperative complications rate was 9.1% (2/22) in group A and 13.9% (5/36) in group B (P = 0.897).Based on a retrospective study, the procedure of one-stage posterior debridement, nonstructural autogenous bone grafting, and instrumentation has a significant shorter operative duration, lower blood loss and perioperative transfusion, shorter hospital stay, and less hospitalization cost compared with the one of anterior debridement, strut bone grafting combined with posterior instrumentation for treating lumber spinal tuberculosis.

The outcomes of chemotherapy only treatment on mild spinal tuberculosis

Background

The treatments for spinal tuberculosis (TB) patients without absolute surgical indications have been controversial. Some people believed that most spinal TB patients were indicated for surgery, while other people believed in chemotherapy only. To help clarify the treatment over spinal TB patients without absolute surgical indications, we characterized a subtype spinal TB and then analyzed the treatment outcomes of standard chemotherapy alone.

Methods

In this retrospective study, 740 adult patients of spinal TB from January 2005 to January 2013 in our institution were reviewed. Patients who fit into the characterizations of mild spinal TB were started by standard chemotherapy for 18 months and followed up for at least 2 years upon the completion of treatment. The overall outcome, neurological function, local kyphosis, and level of pain at different time points were assessed.

Results

After starting the conservative treatment, 89 out of 740 patients were chosen for chemotherapy alone, and all patients were followed up for at least 2 years (ranging from 24 to 50 months) upon the completion of the treatment. Of 89 patients, 95.4 % of patients showed a definite and clinical response within 1 month after starting the treatment, 69 % of patients had excellent to good results, with no complications of the disease, and 77.5 % had asymptomatic local kyphosis with intact neurological function; solid bony fusion of adjacent segment was achieved in 88.8 % of patients.

Conclusions

We believe that the mild spinal TB respond well to the standard chemotherapy, and the detailed description of mild TB would provide crucial guidance in determination of conservative treatment.

One-stage posterior focus debridement, fusion, and instrumentation in the surgical treatment of lumbar spinal tuberculosis with kyphosis in children

OBJECTIVE

The purpose of this study is to investigate the clinical efficacy and feasibility of one-stage posterior focus debridement, fusion, and instrumentation in the surgical treatment of lumbar spinal tuberculosis with kyphosis in children.

METHODS

From December 2007 to May 2012, 13 patients (six males and seven females) suffering from lumbar spinal tuberculosis with kyphosis were admitted. All patients were treated with one-stage posterior focus debridement, fusion, and instrumentation. Then, the clinical efficacy was estimated by statistical analysis based on the data about Frankel grade, the Cobb angle of kyphosis, and erythrocyte sedimentation rate (ESR), which were collected at certain time.

RESULTS

The age of all patients ranged from 5 to 13 years (average, 8.8 years). Operation time ranged from 120 to 190 min (average, 165 min). Intraoperative blood loss ranged from 200 to 800 ml (average, 460 ml). All patients were followed up for 24 to 57 months postoperatively (average, 33.5 months). The Cobb angle was changed significantly between preoperation and postoperation (P < 0.05), and there was no significant loss at the last follow-up. The preoperation ESR (62.5 ± 15.7) returned to normal (16.6 ± 8.1) within 3 months postoperatively in all patients (P < 0.05). Bone fusion was achieved within 3-5 months (average, 3.5 months). In the 13 cases, no postoperative severe complications occurred and neurologic function improved in various degrees.

CONCLUSION

The outcomes of follow-up showed that one-stage posterior focus debridement, fusion, and instrumentation can be an effective treatment method for the lumbar spinal tuberculosis with kyphosis in children.

Granulomatous Vertebral Osteomyelitis: An Update

A granulomatous infection of the spine is characterized by an infectious process within the spinal elements that results in the formation of a granuloma, an organized collection of transformed macrophages (ie, epithelioid cells), matrix, and other inflammatory cells. Causative organisms include various bacteria, fungi, or other parasites; however, the most frequently encountered causative organism is Mycobacterium tuberculosis (ie, Pott disease). The onset of these infections is often insidious, frequently leading to a delay in diagnosis. Left untreated, this disease process may lead to a compromise in the structural integrity of the spine and subsequent spinal deformity that may eventually result in compression of neural elements. Successful treatment of a granulomatous infection requires timely diagnosis, prompt medical management, and potential surgical intervention directed at the decompression of neural elements and the correction of spinal malalignment. Of granulomatous infections, tuberculous infections are the most thoroughly understood and serve as the standard to which other less commonly reported organisms are compared.

Anterolateral radical debridement and interbody bone grafting combined with transpedicle fixation in the treatment of thoracolumbar spinal tuberculosis

This retrospective cohort study was conducted to evaluate the clinical outcomes of radical anterolateral debridement and autogenous ilium with rib or titanium cage interbody autografting with transpedicle fixation for the treatment of thoracolumbar tuberculosis. Spinal tuberculosis operation aims to remove the lesions and necrotic tissues, remove spinal cord compression, and reconstruct spinal stability. However, traditional operation methods cannot effectively correct cyrtosis or stabilize the spine. In addition, the patient needs to stay in bed for a long time and may have many complications. So far, the best surgical method and fixation method for spinal tuberculosis remain controversial. There were a total of 43 patients, 16 involving spinal cord injury, from January 2004 to January 2011. The patients were surgically treated for radical anterolateral debridement via posterolateral incision and autogenous ilium with rib or titanium cage interbody autografting and single-stage transpedicle fixation. All the patients were followed up to determine the stages of intervertebral bone fusion and the corrections of spinal kyphosis with the restoration of neurological deficit. The erythrocyte sedimentation rate (ESR) of these patients decreased to normal levels for a mean of 2.8 months. The function of feeling, motion, and sphincter in 16 paraplegia cases gradually recovered after 1 week to 3 months postoperatively, and the American Spinal Injury Association scores significantly increased at the final follow-up. Intervertebral bone fusions were all achieved postoperatively. No internal fixation devices were loose, extracted, or broken. There was no correction degree loss during the follow-up. The method of radical anterolateral debridement and autogenous ilium with rib or titanium cage interbody autografting and single-stage transpedicle fixation was effective for the treatment of thoracolumbar tuberculosis, correcting kyphotic deformity, and reconstructing spinal stability, obtaining successful intervertebral bony fusion and promoting the recovery of paraplegia. These results showed satisfactory clinical outcomes.

In vitro comparison of three rifampicin loading methods in a reinforced porous β-tricalcium phosphate scaffold

The antibiotic compound, rifampicin (RFP), was loaded into porous reinforced β-tricalcium phosphate (β-TCP) scaffolds using three different solution adsorption methods. This resulted in drug delivery systems (DDS) generated by vacuum adsorption (VA), dynamic adsorption (DA), and static adsorption (SA). In vitro examination of the drug loading and release profiles of the DDS indicated that the unit mass of RFP loaded into the scaffold by the VA method (0.44 mg/g) was higher than that achieved by SA (0.42 mg/g) or DA (0.38 mg/g) (P < 0.05). The mechanical strength had no significant change after RFP-loading (P > 0.05). Moreover, there were no significant differences among the mechanical strength of three β-TCP DDS generated by loading RFP using SA, DA, and VA (P > 0.05). In vitro release testing showed an initial burst release of RFP from the three different DDS within the first 3 h and in the first 51 h, the cumulative release of RFP from VA-DDS, DA-DDS, and SA-DDS had reached 56.2, 83.6, and 88.6 %, respectively. Complete RFP release had occurred from VA-DDS, DA-DDS, and SA-DDS after 23, 17, and 15 days, respectively. As the VA-DDS method showed improved RFP loading and a more sustained drug release, this method is recommended for solution adsorption drug loading into porous β-TCP scaffolds to form a DDS.

Magnetic Resonance Image findings of Spinal Tuberclosis at first presentation

Background

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

Methodology

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

Result

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

Conclusion

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