Features of 921 Patients With Spinal Tuberculosis: A 16-Year Investigation of a General Hospital in Southwest China

A ten-year experience of musculoskeletal tuberculosis at a tertiary care hospital in South India

Background

The delayed identification and management of musculoskeletal tuberculosis (MSTB) poses substantial health challenges and leads to significant morbidity. This study aimed to collate ten years of hospital data and provide valuable insights into the clinical, diagnostics, and outcomes of the patients diagnosed with MSTB.

Methods

A retrospective study was undertaken to review clinic records from 2013 to 2022 for all individuals diagnosed with MSTB in a tertiary care hospital in South India.

Results

Over a decade, 400 cases of MSTB were diagnosed, revealing 57 % males and 43 % females with a mean age of 43.2 ± 18.9 years. Spinal TB constituted 72 % of cases, with the most common involvement of thoracic vertebrae (50.9 %). Extra-spinal MSTB accounted for 28 %, prevalent more in the pediatric age group (p < 0.05). Surgical intervention was required for 80 % of spinal TB cases and 58 % of extra-spinal MSTB cases. The average follow-up duration was two years, with 73 % completing treatment. Unfortunately, seven patients died, and three experienced relapse.

Conclusion

Spinal TB is the most common type of MSTB and is predominant in young and middle-aged adults, while extra-spinal MSTB is more frequently observed in children. Where use of MRI facilitates early detection of spinal TB; histopathological and microbiological examination confirm the diagnosis. Combining anti-tubercular drugs with modern surgical approaches is essential for obtaining favorable outcomes and improving the quality of life of such patients. It is crucial to have advanced and affordable diagnostic facilities, along with increased public awareness, to reinforce tuberculosis control strategies.

Tuberculosis of the spine

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

Analysis of Clinical Characteristics of 556 Spinal Tuberculosis Patients in Two Tertiary Teaching Hospitals in Guangxi Province

Spinal tuberculosis (STB), which accounts for half of musculoskeletal tuberculosis, is among the leading causes of extrapulmonary tuberculosis. Guangxi Province, located in southern China, is among the most severely affected provinces in China. In this study, we collected and analyzed data from 2 Class-A tertiary teaching hospitals in Nanning City, Guangxi Province, from 2011 to 2019, with the aim of providing reference points for the prevention, diagnosis, treatment, and prognosis analysis of STB, using the epidemiological characteristics of 556 STB cases. Our results revealed that males had a slightly higher incidence (50.17%) compared to females (49.83%), with 64.93% of cases falling between the ages of 18 and 45 years. Cases from rural communities accounted for 63.49% of the reviewed cases. The average time between onset of symptoms and hospitalization was 18.0 months (range: 1 day-220 months). The most commonly reported symptoms were lower back pain (78.60%), radicular pain (51.98%), and systemic toxemia (43.53%). Additionally, 53.98% of the reviewed cases had varying degrees of neurological impairment. The main pathological lesion locations were the lumbar spine (43.53%) and thoracic spine (32.55%). Among them, 72.66% of cases involved at least 2 vertebral segments, and 62.77% of cases presented with paravertebral abscesses. Among the cases reviewed, 90.65% underwent antituberculosis chemotherapy prior to surgery. Following treatment, the cure rate was 78.41%, while 3.78% of patients had postoperative relapse. There were cases of concomitant illnesses among the cases reviewed, 40.65% of patients also had pulmonary tuberculosis, 15.29% had hepatitis B, 13.30% had diabetes, and 7.91% had hypertension. Our results still demonstrate that spinal tuberculosis remains a serious public health problem in Guangxi Province. Thus, preventive measures should be directed towards rural residents with comorbidities such as the elderly and diabetic.

[Polymethylmethacrylate-augmented screw fixation in treatment of senile thoracolumbar tuberculosis combined with severe osteoporosis]

Objective

To explore the safety and effectiveness of polymethylmethacrylate-augmented screw fixation (PASF) in the treatment of elderly thoracolumbar tuberculosis combined with severe osteoporosis.

Methods

The clinical data of 20 elderly patients with thoracolumbar tuberculosis and severe osteoporosis who underwent PASF after anterior or posterior debridement and bone grafting and met the selection criteria between December 2012 and December 2014 were retrospectively analyzed. There were 8 males and 12 females with an average age of 68.5 years (range, 65-72 years). T value of bone mineral density was -4.2 to -3.6, with an average of -3.9. There were 12 cases of thoracic tuberculosis, 3 cases of thoracolumbar tuberculosis, and 5 cases of lumbar tuberculosis. The diseased segments involved T ₃-L ₄, including 11 cases of single-segment disease, 6 cases of double-segment disease, and 3 cases of multi-segment disease. The disease duration was 3-9 months, with an average of 6 months. The preoperative spinal nerve function of the patients was evaluated by the American Spinal Injury Association (ASIA) grading. There were 2 cases of grade A, 5 cases of grade B, 6 cases of grade C, 4 cases of grade D, and 3 cases of grade E. Postoperative imaging examination was used to evaluate the bone graft fusion and paravertebral abscess absorption, and to measure the Cobb angle of the segment to evaluate the improvement of kyphosis. The levels of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were tested. The visual analogue scale (VAS) score, Oswestry disability index (ODI), and ASIA grading were used to evaluate the effectivreness before operation, at 1 month after operation, and at last follow-up. The clinical cure of tuberculosis was also evaluated.

Results

All operation successfully completed. The operation time was 154-250 minutes, with an average of 202 minutes; the intraoperative blood loss was 368-656 mL, with an average of 512 mL. All 20 patients were followed up 18-42 months, with an average of 26.8 months. The postoperative pain and symptoms of tuberculosis in all patients relieved, and the paravertebral abscess was absorbed, reaching the cure standard for spinal tuberculosis. All bone grafts fusion achieved within 1 year after operation. Only 1 case had asymptomatic bone cement leakage into the paravertebral veins, and the remaining patients had no serious complications such as bone cement leakage in the spinal canal, pulmonary embolism, and neurovascular injury. At last follow-up, spinal cord nerve function significantly improved when compared with preoperative one. Among them, ASIA grading were 7 cases of grade C, 8 cases of grade D, and 5 cases of grade E, showing significant difference when compared with preoperative one ( Z=2.139, P=0.000). VAS score, ODI score, segmental Cobb angle, ESR, and CRP at 1 month after operation and at last follow-up were significantly improved when compared with preoperative ones ( P<0.05); there was no significant difference between 1 month after operation and last follow-up ( P>0.05). During the follow-up, no complications such as failure of internal fixation, proximal junctional kyphosis, or tuberculosis recurrence occurred.

Conclusion

For elderly patients with thoracolumbar tuberculosis and severe osteoporosis, PASF treatment is safe and effective.

Biomechanical Evaluation and the Assisted 3D Printed Model in the Patient-Specific Preoperative Planning for Thoracic Spinal Tuberculosis: A Finite Element Analysis

Posterior fixation is superior to anterior fixation in the correction of kyphosis and maintenance of spinal stability for the treatment of thoracic spinal tuberculosis. However, the process of selecting the appropriate spinal fixation method remains controversial, and preoperative biomechanical evaluation has not yet been investigated. In this study, we aimed to analyze the application of the assisted finite element analysis (FEA) and the three-dimensional (3D) printed model for the patient-specific preoperative planning of thoracic spinal tuberculosis. An adult patient with thoracic spinal tuberculosis was included. A finite element model of the T7−T11 thoracic spine segments was reconstructed to analyze the biomechanical effect of four different operative constructs. The von Mises stress values of the implants in the vertical axial load and flexion and extension conditions under a 400-N vertical axial pre-load and a 10-N⋅m moment were calculated and compared. A 3D printed model was used to describe and elucidate the patient’s condition and simulate the optimal surgical design. According to the biomechanical evaluation, the patient-specific preoperative surgical design was prepared for implementation. The anterior column, which was reconstructed with titanium alloy mesh and a bone graft with posterior fixation using seven pedicle screws (M+P) and performed at the T7–T11 level, decreased the von Mises stress placed on the right rod, T7 pedicle screw, and T11 pedicle. Moreover, the M+P evaded the left T9 screw without load bearing. The 3D printed model and preoperative surgical simulation enhanced the understanding of the patient’s condition and facilitated patient-specific preoperative planning. Good clinical results, including no complication of implants, negligible loss of the Cobb angle, and good bone fusion, were achieved using the M+P surgical design. In conclusion, M+P was recommended as the optimal method for preoperative planning since it enabled the preservation of the normal vertebra and prevented unnecessary internal fixation. Our study indicated that FEA and the assisted 3D printed model are tools that could be extremely useful and effective in the patient-specific preoperative planning for thoracic spinal tuberculosis, which can facilitate preoperative surgical simulation and biomechanical evaluation, as well as improve the understanding of the patient’s condition.

The efficacy of allograft bone using titanium mesh in the posterior-only surgical treatment of thoracic and thoracolumbar spinal tuberculosis

Background

The bony fusion of allograft bone using titanium mesh in the posterior-only surgical treatment of thoracic and thoracolumbar spinal tuberculosis has not been explained in detail. We aimed to analyze the efficacy of bony fusion of allograft bone using titanium mesh in the posterior-only surgical treatment of thoracic and thoracolumbar spinal tuberculosis.

Methods

We treated 32 thoracic or thoracolumbar tuberculosis patients by one-stage posterior debridement, allograft bone graft using titanium mesh, posterior instrumentation, and fusion from May 2011 to September 2015. The American Spinal Injury Association neurological classification, visual analog scale, and Oswestry disability index scores were analyzed preoperatively, postoperatively, and at final follow-up. The Cobb angles were recorded to evaluate the kyphosis correction and the loss of correction. The bony fusion was evaluated by X-ray and computed tomography images, and the bony fusion classifications were recorded.

Results

All patients had pain relief. The erythrocyte sedimentation rate, C-response protein, and hepatorenal function were normal at final follow-up. The American Spinal Injury Association neurological classification, visual analog scale, and Oswestry disability index scores were improved in all the patients. All patients achieved bone fusion. Twenty-eight patients achieved complete fusion (Grade I), whereas only four patients achieved partial fusion (Grade II). The preoperative Cobb angle was 33.6 ± 9.3°. The Cobb angle was reduced to 10.6 ± 2.6° postoperatively and was found to be 11.4 ± 3.1° at the final follow-up. The mean angle correction was 23.0 ± 8.9°, and the correction rate was 66.2 ± 12.2%. The mean angle lost was 0.8 ± 0.9°, and the lost rate was 5.8 ± 5.4% at the final follow-up.

Conclusions

Allograft bone using titanium mesh in the posterior-only surgical treatment is effective for patients with thoracic and thoracolumbar spinal tuberculosis. It can correct kyphosis, and most patients can achieve complete bony fusion.

Multi-drug resistant spinal tuberculosis-epidemiological characteristics of in-patients: a multicentre retrospective study

Tuberculosis (TB) is the leading cause of death among infectious diseases. China has a high burden of TB and accounted for almost 13% of the world's cases of multi-drug resistant (MDR) TB. Spinal TB is one reason for the resurgence of TB in China. Few large case studies of MDR spinal TB in China have been conducted. The aim of this research was to observe the epidemiological characteristics of inpatients with MDR spinal TB in six provinces and cities of China from 1999–2015. This is a multicentre retrospective observational study. Patients' information was collected from the control disease centre and infectious disease database of hospitals in six provinces and cities in China. A total of 3137 patients with spinal TB and 272 patients with MDR spinal TB were analysed. The result showed that MDR spinal TB remains a public health concern and commonly affects patients 15–30 years of age (34.19%). The most common lesions involved the thoracolumbar spine (35.66%). Local pain was the most common symptom (98.53%). Logistic analysis showed that for spinal TB patients, reside in rural district (OR 1.79), advanced in years (OR 1.92) and high education degree (OR 2.22) were independent risk factors for the development of MDR spinal TB. Women were associated with a lower risk of MDR spinal TB (OR 0.48). The most common first-line and second-line resistant drug was isoniazid (68.75%) and levofloxacin (29.04%), respectively. The use of molecular diagnosis resulted in noteworthy clinical advances, including earlier initiation of MDR spinal TB treatment, improved infection control and better clinical outcome. Chemotherapy and surgery can yield satisfactory outcomes with timely diagnosis and long-term treatment. These results enable a better understanding of the MDR spinal TB in China among the general public.

Prognostic factors for unfavourable outcomes of patients with spinal tuberculosis in a country with an intermediate tuberculosis burden

Aims

Spinal tuberculosis (TB) remains an important concern. Although spinal TB often has sequelae such as myelopathy after treatment, the predictive factors affecting such unfavourable outcomes are not yet established. We investigated the clinical manifestations and predictors of unfavourable treatment outcomes in patients with spinal TB.

Patients and Methods

We performed a multicentre retrospective cohort study of patients with spinal TB. Unfavourable outcome was defined according to previous studies. The prognostic factors for unfavourable outcomes as the primary outcome were determined using multivariable logistic regression analysis and a linear mixed model was used to compare time course of inflammatory markers during treatment. A total of 185 patients were included, of whom 59 patients had unfavourable outcomes.

Results

In multivariate regression analysis, the factors associated with unfavourable outcome were old age (odds ratio (OR) 2.51; 95% confidence interval (CI) 1.07 to 5.86; p = 0.034), acid-fast bacilli (AFB) smear positivity in specimens obtained through biopsy (OR 3.05; 95% CI 1.06 to 8.80; p = 0.039), and elevated erythrocyte sedimentation rate (ESR) at the end of treatment (OR 3.85; 95% CI 1.62 to 9.13; p = 0.002). Patients with unfavourable outcomes had a significant trend toward higher ESR during treatment compared with patients with favourable outcome (p = 0.009). Duration of anti-TB and surgical treatment did not affect prognosis.

Conclusion

Elevated ESR at the end of treatment could be used as a marker to identify spinal TB patients with a poor prognosis. Patients whose ESR is not normalized during treatment, as well as those with old age and AFB smear positivity, should be aware of unfavourable outcomes. Cite this article: Bone Joint J 2019;101-B:1542–1549

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.

Comparison of three surgical approaches for thoracolumbar junction (T12-L1) tuberculosis: a multicentre, retrospective study

Background

The surgical approaches to thoracolumbar junction (T12-L1) tuberculosis were controversial. We aimed to compare the safety and efficacy of three different procedures through a multicentre retrospective study.

Methods

The medical records of thoracolumbar junction tuberculosis patients (n = 177) from January 2005 to January 2015 were collected and reviewed. Forty-five patients underwent anterior debridement and instrumented fusion (Group A), 52 underwent anterior combined with posterior debridement and instrumented fusion (Group B) and 80 underwent posterior-only debridement and instrumented fusion (Group C). Patients with neurological deficit were 10 in Group A, 23 in Group B, 36 in Group C. All patients had a standard preoperative and postoperative anti - tuberculous therapy regimen. Clinical outcomes, laboratory indexes and radiological evaluation of the three groups were compared. Operations at each centre were performed by the respective senior medical teams of the six different hospitals.

Results

All three surgical approaches achieved bone fusion and pain relief. Cases with neurological deficits had different degrees of improvement after surgery. The operative time was 330.2 ± 45.4 min, 408.0 ± 54.3 min, 227.9 ± 58.5 min, and the blood loss was 744.0 ± 193.8 ml, 1134.6 ± 328.2 ml, 349.8 ± 289.4 ml in groups A, B and C respectively.

The average loss of correction was 5.5 ± 3.7° in group A, 1.6 ± 1.9° in group B, 1.7 ± 2.2° in group C, and the difference between groups except B vs C were of statistically significant (P < 0.05).

Conclusions

For patients with thoracolumbar junction (T12-L1) tuberculosis, the posterior-only procedure is the better than the anterior-only procedure in the correction of kyphosis and maintenance of spinal stability. The posterior-only procedure is recommended because it achieves the same efficacy as combined procedure with shorter operation time, less blood loss and trauma.

One stage posterior debridement, non-structural bone graft in the surgical treatment of single segment thoracic tuberculosis: A retrospective single-center cohort study

OBJECTIVE

To compare the clinical efficacy of non-structural with structural bone graft in the surgical treatment of single segment thoracic tuberculosis after one stage posterior debridement.

METHODS

61 patients with single segment thoracic tuberculosis treated by one stage posterior debridement, bone graft fusion and internal fixation were retrospectively analyzed. Among them, 35 cases were admitted from 2015 to 2017 in the non-structural bone graft group and 26 cases were admitted from 2011 to 2015 in the structural bone graft group. The visual analogue scale (VAS), erythrocyte sedimentation rate (ESR), C reactive protein (CRP), neurological function, operation time, operative blood loss, hospital stay, correction and loss of Cobb angle, bone graft fusion time and complications were recorded and analyzed.

RESULTS

Compared with structural bone graft group, the operation time of non-structural bone graft group was shorter and the operative blood loss was less, but the hospital stay was longer (P < 0.05). With the follow-up of 14-44 months, the VAS score, ESR, CRP and neurological function in the two groups were both improved (P < 0.05). The correction and loss of Cobb angle in the non-structural bone graft group were both smaller than those in the structural bone graft group (P < 0.05). The bone graft fusion time of the non-structural bone graft group was significantly shorter than the structural bone graft group (P < 0.05). No significant difference was found in the incidence of complications between the two groups (n.s.).

CONCLUSION

Non-structural bone graft has less surgical trauma and shorter bone fusion time compared with structural bone graft in the surgical treatment of single segment thoracic tuberculosis. The two methods may achieve comparable clinical efficacy in alleviating symptoms, correcting kyphosis and improving neurological function for appropriate cases.

Single-stage posterior debridement, decompression and transpedicular screw fixation for the treatment of thoracolumbar junction (T12-L1) tuberculosis with associated neurological deficit: a multicentre retrospective study

BACKGROUND

A multicentre retrospective study was conducted to evaluate the safety and efficacy of single-stage posterior debridement, decompression and transpedicular screw fixation for the treatment of thoracolumbar junction (T12-L1) tuberculosis in patients with associated neurological deficit.

METHODS

Thoracolumbar junction (T12-L1) tuberculosis patients (n = 69) with neurological deficit who underwent single-stage posterior debridement, decompression and transpedicular screw fixation from January 2005 to January 2015 were included in the study. Antituberculosis therapy was performed both before and after surgery. The surgery duration and patient blood loss were evaluated, in addition to the change in pain visual analogue score (pVAS), kyphotic angle, Oswestry disability index (ODI) score and American Spinal Injury Association (ASIA) grade assessed preoperatively, immediate postoperatively and at the final follow-up visit.

RESULTS

The average blood loss was 354 ± 291 mL. The average kyphosis angle was corrected from 21 ± 9° preoperatively to 9 ± 4° postoperatively, with a mean decrease in pVAS and ODI scores of 3.4 and 16, respectively. The postoperative ASIA grading was grade A for five patients, grade C for 15 and grade D for 49 patients, which had improved to grade C for four patients, grade D for three patients and grade E for 62 patients at the final follow-up. The neurological deficit did not worsen in any of the patients.

CONCLUSIONS

Single-stage posterior debridement, decompression and transpedicular screw fixation is an effective treatment method in thoracolumbar junction (T12-L1) tuberculosis patients with neurological deficit, with good neurological recovery and no progression of kyphosis.

Preliminary experience in treating thoracic spinal tuberculosis via a posterior modified transfacet debridement, instrumentation, and interbody fusion

BACKGROUND

Posterior transfacet approach has been proved to be a safe and effective access to treat thoracic disc herniation. However, the therapeutic effect and safety of modified transfacet approach for treating thoracic spinal tuberculosis (TST) has not been reported in the clinical literature. In this study, the clinical efficacy and safety of a single-stage posterior modified transfacet debridement, posterior instrumentation, and interbody fusion for treating TST were retrospectively evaluated.

PATIENTS AND METHODS

From 2009 to 2014, 37 patients with TST underwent a posterior modified transfacet debridement, interbody fusion following posterior instrumentation, under the cover of 18 months of antituberculosis chemotherapy. The patients were evaluated preoperatively and postoperatively in terms of Frankel Grade, visual analog scale (VAS) pain score, kyphotic Cobb angle, and bony fusion.

RESULTS

The follow-up time was 39.8 ± 5.1 months (29-50 months). No postoperative complication or recurrence of spinal tuberculosis was observed. Definitive bony fusion was achieved in all patients. At the final follow-up, 2 cases were rated as Frankel grade D, 35 as grade E. VAS was recovered from 8.4 ± 1.0 cm to 0.4 ± 0.8 cm. The kyphotic angles were corrected from 29.4 ± 10.9° to 17.6 ± 6.3°. Using the Kirkaldy-Willis criteria, functional outcome was excellent in 29 patients, good in 7, and fair in 1.

CONCLUSIONS

Our preliminary results showed that single-stage posterior modified transfacet debridement, posterior instrumentation, and interbody fusion are effective and safe surgical options for treating TST.