Efficacy of extended DOTS category I chemotherapy in spinal tuberculosis based on MRI-based healed status

Healing Assessment of Spinal Tuberculosis: A Systematic Review

OBJECTIVE

Deciding the healing end point in spinal tuberculosis (STB) remains a controversial topic. The current systematic review aims to address the controversy existing in the literature to find a comprehensive method to assess healing in STB.

METHODS

A thorough literature search was carried out for studies with the assessment of healing parameters in STB. Data extraction was carried out manually, which included study characteristics and healing criteria evaluated in each study.

RESULTS

Qualitative analysis of 8 included studies showed that healing parameters were described in 3 domains: clinical, hematologic, and radiologic response of the patient to antitubercular chemotherapy. Each domain included various individual parameters, with clinical and radiologic assessment criteria being used in most of the studies. Improvement in terms of pain, constitutional symptoms, weight gain, neurology; variation in erythrocyte sedimentation rate and C-reactive protein; and changes in radiography, magnetic resonance imaging, and positron emission tomography/computed tomography were found to be promising predictors in the assessment of healing.

CONCLUSIONS

Radiologic response parameters emerged as the maximally used criteria to assess healing in STB. However, in the absence of any statistical analysis and an observed lag in radiologic response, the cumulative effect of all the parameters in 3 domains (clinical, hematologic, and radiologic) can be used to declare a spinal tubercular lesion nonhealing, healing, or healed.

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

BACKGROUND

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

METHODS

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

RESULTS

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

DISCUSSION

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

PEEK vs Titanium Cage for Anterior Column Reconstruction in Active Spinal Tuberculosis: A Comparative Study

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.

Biomarkers to predict FDG PET/CT activity after the standard duration of treatment for spinal tuberculosis: An exploratory study

OBJECTIVES

18F-Fluorodeoxyglucose (FDG) Positron Emission Tomography- Computed Tomography (PET/CT) scans can be used to assess healing following treatment for spinal tuberculosis (TB) but have limited accessibility and high cost. This study investigated the association between immune biomarkers and FDG-PET/CT activity after ≥9 months of treatment for spinal TB.

METHODS

Patients who had completed ≥9 months of treatment for spinal TB were recruited from a major hospital in the Western Cape, South Africa. Participants underwent a FDG-PET/CT scan and FDG- PET/CT activity was quantified for all spinal and extra-spinal sites. Participants also provided a blood sample, which was evaluated for 19 cytokines along with erythrocyte sedimentation rate (ESR). Correlations and multiple regression analyses were used to investigate the association between biomarkers and PET/CT measures.

RESULTS

Twenty-eight patients were recruited, of whom 24 (86%) had spinal and/or extra-spinal FDG-PET/CT activity. In the strongest multiple regression model, CXCL10/IP-10, VEGFA, IFN-γ, CRP and Factor D/Adipsin explained 52% of the variation in overall maximal FDG uptake. Conventional monitoring marker ESR showed no significant association with PET/CT measures.

CONCLUSIONS

The current findings offered encouragement that biomarkers to predict FDG-PET/CT activity may show some promise and identified candidate biomarkers for further investigation in this regard.

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.

Comparison of anterior, posterior, and anterior combined with posterior surgical treatment of thoracic and lumbar spinal tuberculosis: a systematic review

Background

This study was performed to compare different surgical approaches in the treatment of spinal tuberculosis.

Methods

We conducted a literature search to identify and analyze papers published from January 1966 to April 2018 relevant to comparison of the anterior, posterior, and anterior combined with posterior approaches in the treatment of spinal tuberculosis of the thoracic and lumbar regions.

Results

Twenty-five studies involving 2295 patients were identified in this systematic review. The operative time was significantly longer in the anterior combined with posterior approach than in the other two approaches. Blood loss was significantly greater in the anterior combined with posterior approach (1125.0 ± 275.5 mL) than in the posterior approach (710.4 ± 192.4 mL). The difference in correction of the kyphosis angle among the three procedures was not significant. The overall surgical and transthoracic complications were significantly lower in the posterior approach. The clinical outcome of all patients improved, but there was no significant difference among the three procedures.

Conclusions

Blood loss, overall surgical and transthoracic complications, and the operative time are different among the three approaches. Therefore, different factors must be carefully assessed in deciding among the three procedures.

Evaluation of Healed Status in Tuberculosis of Spine by Fluorodeoxyglucose-positron Emission Tomography/Computed Tomography and Contrast Magnetic Resonance Imaging

BACKGROUND

The healed status (end-point of treatment) in tuberculosis (TB) spine is not defined; hence optimum antitubercular therapy (ATT) duration is unresolved. We, for the first time, prospectively evaluated the healed status in TB spine by fluorodeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT) and contrast magnetic resonance imaging (MRI) with the objective to define end-point of treatment in TB spine.

MATERIALS AND METHODS

Thirty seven patients of TB spine diagnosed on clinicoradio imaging/cytology/histologically/molecular methods were enrolled, treated and were evaluated radiologically, by contrast MRI and FDG-PET/CT at 9 months. ATT was stopped on contrast MRI-based healing or absence of FDG uptake on PET-CT. ATT was continued in active/resolving lesion. Repeat evaluation was done at 12, 18, 24, and 30 months till healing is demonstrated. In this research work, we got contrast MRI and FDG-PET/CT done for the patients from government institution free of cost, so patients did not have to bear the burden of cost of these investigations.

RESULTS

Twenty-eight patients achieved healed status out of which 11 demonstrated healed status on contrast MRI and FDG-PET/CT both, 6 were MRI active (contrast enhancement) but FDG-PET/CT healed, 2 were MRI healed but FDG-PET/CT active (soft-tissue standardized uptake value <2.0), 9 patients were MRI incompatible due to stainless steel implants (n = 6), and in 3 patients MRI could not be done due to financial constraints and were declared healed on FDG-PET/CT. FDG-PET/CT showed healed bone lesion in 28/28 (100%) and on MRI 13/19 (68.42%), respectively. We had 6 patients whose spine was stabilized with stainless steel implants where MRI could not be performed, MRI was useful in 13/25 cases (52%) to demonstrate healed lesion. 7, 6, 6, 5, 1, 2, and 1 cases achieved healed status at 9, 12, 18, 24, 30, 36, and 48 months of ATT intake, respectively.

CONCLUSIONS

FDG-PET/CT is more useful to demonstrate the healed status than MRI and is the only imaging to demonstrate healed status when MRI could not be performed due to metallic implants. All patients achieved healed status at variable length of ATT intake; hence TB spine should be treated by ATT till healed status (end-point of treatment) is demonstrated by FDG-PET/CT (absence of FDG uptake) or contrast MRI.

Spinal Tuberculosis - Directly Observed Treatment and Short Course or Daily Anti Tubercular Therapy -Are We Over Treating?

Study Design:

Prospective randomised control trial.

Purpose:

To compare the effectiveness of Directly Observed Treatment and Short Course (DOTS) and Daily Anti Tubercular Therapy (ATT) in spinal tuberculosis with no neurological deficit.

Overview of Literature:

Spinal tuberculosis is rampant in India with a major cause of morbidity and mortality. There is a lot of conflict regarding management with anti tubercular drugs, the regimen to be followed and the duration the drugs needed for complete cure.

Material and Methods:

This prospective study was conducted during the period of 2006 to 2009. Thirty cases of spinal tuberculosis were randomly divided equally into two groups of fifteen each and treated with DOTS and Daily ATT and compared at the end of follow up on clinical, radiological and Erythrocyte Sedimentation Rate values (ESR).

Results:

Pain score on Visual Analogue Scale (VAS) exhibits that mean pain score was 5.93+_1.54 at start and 0.64+_1.01 at the end of follow up with 89.39% change with DOTS therapy whereas mean pain score was 7.08 +_1.61at start of therapy and 0.69+_0.95 at end of follow up with 91.73% change in patients treated with Daily ATT with p value >0.05 (not significant). The radiological recovery in patients with DOTS and Daily ATT have similar results after 1.5 years with p value > 0.05 showing that the radiological recovery by both treatment modalities are comparable. Mean change in ESR scores in DOTS therapy patients and patients on daily ATT were 74.57+_9.34% and 75.69+_9.38% change with p value >0.05 which was not significant.

Conclusion:

DOTS therapy is an effective means of management of spinal tuberculosis cases with no neurological involvement, however its efficacy in patients with neurological deficit is further to be evaluated.

Efficacy of alternate day Directly Observed Treatment Short-course (DOTS) in skeletal tuberculosis - A retrospective study

OBJECTIVE

To assess the efficacy of alternate day (thrice a week) Directly Observed Treatment Short-course (DOTS) regimen spanning six to nine months in providing sustained cure for skeletal tuberculosis (TB) under programmatic conditions.

DESIGN

Retrospective cohort study.

SETTING

An urban district tuberculosis centre in India under the Revised National Tuberculosis Programme.

PARTICIPANTS

A cohort of 218 patients treated with alternate day DOTS regimen for skeletal TB between 2007 and 2012.

METHODS

All patients with the diagnosis of skeletal TB registered between 2007 and 2012 who successfully completed treatment were followed up for evidence of disease recurrence or relapse using structured interviews conducted between August 2013 and October 2015 after ensuring a minimum follow up of two years.

RESULTS

Of the 200 patients eligible for follow up in this study, 117 (58.5%) had a minimum follow up of two years. The remaining 83 cases could not be traced. 105 (89.7%) of these 117 patients were symptom free for two years or more after the completion of treatment. There were four cases who had a relapse of the disease within two years of completion of treatment. Eight cases were administered further ATT soon after the completion of treatment under DOTS.

CONCLUSIONS

This study confirms the efficacy of the alternate day DOTS regimen in successfully treating all forms of skeletal TB, including spinal TB, with a success rate of 89.7%.

Evaluation of Outcome of Transpedicular Decompression and Instrumented Fusion in Thoracic and Thoracolumbar Tuberculosis

Study Design

Retrospective analysis.

Purpose

We evaluated the functional, neurological, and radiological outcome in patients with thoracic and thoracolumbar tuberculosis operated through the transpedicular approach.

Overview of Literature

For surgical treatment of thoracic and thoracolumbar tuberculosis, the anterior approach has been the most popular because it allows direct access to the infected tissue, thereby providing good decompression. However, anterior fixation is not strong, and graft failure and loss of correction are frequent complications. The transpedicular approach allows circumferential decompression of neural elements along with three-column fixation attained via pedicle screws by the same approach.

Methods

A total of 47 patients were diagnosed with tuberculosis of the thoracic or thoracolumbar region from August 2012 to August 2013. Of these, 28 patients had progressive neurological deterioration or increasing back pain despite conservative measures and underwent transpedicular decompression and pedicle screw fixation with posterior fusion. Antituberculosis therapy was given till signs of radiological healing were evident (9–16 months). Functional outcome (visual analog scale [VAS] score for back pain), neurological recovery (Frankel grading), and radiological improvement were evaluated preoperatively, immediate postoperatively, and at 3 months, 6 months, and 1 year.

Results

Mean VAS score for back pain improved from 8.7 preoperatively to 1.1 at 1 year follow-up. Frankel grading preoperatively was grade B in 7, grade C in 11, and Grade D in 10 patients, which improved to grade D in 6 and grade E in 22 patients at the last follow-up. Radiological healing was evident in the form of reappearance of trabeculae formation, resolution of pus, fatty marrow replacement, and bony fusion in all patients. Mean correction of segmental kyphosis postoperatively was 10.5°. Mean loss of correction at final follow-up was 4.1°.

Conclusions

Transpedicular decompression with instrumented fusion is a safe and effective approach for management of patients with thoracic and thoracolumbar tuberculosis.

Evaluation of Outcome of Posterior Decompression and Instrumented Fusion in Lumbar and Lumbosacral Tuberculosis

Background

For surgical treatment of lumbar and lumbosacral tuberculosis, the anterior approach has been the most popular approach because it allows direct access to the infected tissue, thereby providing good decompression. However, anterior fixation is not strong, and graft failure and loss of correction are frequent complications. The posterior approach allows circumferential decompression of neural elements along with three-column fixation attained via pedicle screws by the same approach. The purpose of this study was to evaluate the outcome (functional, neurological, and radiological) in patients with lumbar and lumbosacral tuberculosis operated through the posterior approach.

Methods

Twenty-eight patients were diagnosed with tuberculosis of the lumbar and lumbosacral region from August 2012 to August 2013. Of these, 13 patients had progressive neurological deterioration or increasing back pain despite conservative measures and underwent posterior decompression and pedicle screw fixation with posterolateral fusion. Antitubercular therapy was given till signs of radiological healing were evident (9 to 16 months). Functional outcome (visual analogue scale [VAS] score for back pain), neurological recovery (Frankel grading), and radiological improvement were evaluated preoperatively, immediately postoperatively and 3 months, 6 months, and 1 year postoperatively.

Results

The mean VAS score for back pain improved from 7.89 (range, 9 to 7) preoperatively to 2.2 (range, 3 to 1) at 1-year follow-up. Frankel grading was grade B in 3, grade C in 7, and grade D in 3 patients preoperatively, which improved to grade D in 7 and grade E in 6 patients at the last follow-up. Radiological healing was evident in the form of reappearance of trabeculae formation, resolution of pus, fatty marrow replacement, and bony fusion in all patients. The mean correction of segmental kyphosis was 9.85° postoperatively. The mean loss of correction at final follow-up was 3.15°.

Conclusions

Posterior decompression with instrumented fusion is a safe and effective approach for management of patients with lumbar and lumbosacral tuberculosis.

Early diagnosis of spinal tuberculosis

Spinal tuberculosis (STB) is a common manifestation of extrapulmonary tuberculosis (TB). STB accounts for around 2% of all cases of TB and around 15% of extrapulmonary TB cases. The World Health Organization has proposed a global strategy and targets for TB prevention, care, and control after 2015. Under this strategy, patients will receive standard care according to the recommendations and guidelines after confirmation of STB diagnosis. However, current recommendations and guidelines focus on disease and medication therapy management, and recommendations for early detection or decision-making algorithms regarding STB are lacking. In this review, we identified five key components for early diagnosis: (1) risk factors for STB; (2) common symptoms/signs of STB; (3) significant neuroradiological findings of STB; (4) significant laboratory findings of STB, including positive interferon-γ release assays and nonpyogenic evidence in initial laboratory data; and (5) significant clinical findings of STB. Individualized consideration for each patient with STB is essential, and we hope that the algorithm established in this review will provide a valuable tool for physicians who encounter cases of STB.

V, Jayaswal A. Management of Tuberculous Infection of the Spine

Spinal tuberculosis accounts for nearly half of all cases of musculoskeletal tuberculosis. It is primarily a medical disease and treatment consists of a multidrug regimen for 9-12 months. Surgery is reserved for select cases of progressive deformity or where neurological deficit is not improved by anti-tubercular treatment. Technology refinements and improved surgical expertise have improved the operative treatment of spinal tuberculosis. The infected spine can be approached anteriorly or posteriorly, in a minimally invasive way. We review the various surgical techniques used in the management of spinal tuberculosis with focus on their indications and contraindications.

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.

Pott's Spine: Diagnostic Imaging Modalities and Technology Advancements

Spinal tuberculosis (TB) or Pott's spine is the commonest extrapulmonary manifestation of TB. It spreads through hematogenous route. Clinically, it presents with constitutional symptoms, back pain, tenderness, paraplegia or paraparesis, and kyphotic or scoliotic deformities. Pott's spine accounts for 2% of all cases of TB, 15% of extrapulmonary, and 50% of skeletal TB. The paradiscal, central, anterior subligamentous, and neural arch are the common vertebral lesions. Thoracic vertebrae are commonly affected followed by lumbar and cervical vertebrae. Plain radiographs are usually the initial investigation in spinal TB. For a radiolucent lesion to be apparent on a plain radiograph there should be 30% of bone mineral loss. Computed tomographic scanning provides much better bony detail of irregular lytic lesions, sclerosis, disc collapse, and disruption of bone circumference than plain radiograph. Magnetic resonance imaging (MRI) is the best diagnostic modality for Pott's spine and is more sensitive than other modalities. MRI frequently demonstrates disc collapse/destruction, cold abscess, vertebral wedging/collapse, marrow edema, and spinal deformities. Ultrasound and computed tomographic guided needle aspiration or biopsy is the technique for early histopathological diagnosis. Recently, the coexistence of human immunodeficiency virus infections and TB has been increased globally. In recent years, diffusion-weighted MRI (DW-MRI) and apparent diffusion coefficient values in combination with MRI are used to some extent in the diagnosis of spinal TB. We have reviewed related literature through internet. The terms searched on Google scholar and PubMed are TB, extrapulmonary TB, skeletal TB, spinal TB, Pott's spine, Pott's paraplegia, MRI, and computed tomography (CT).