Pott's Spine: Diagnostic Imaging Modalities and Technology Advancements

Sociodemographic patterns of spinal tuberculosis patients from a tertiary care teaching hospital: A 5-year cross-sectional study

Background

The distribution of spinal tuberculosis (STB) differs due to variations in lifestyles, socio-economic conditions, geographical locations, available medical services, and other factors. In the literature, very few studies have been done on demographic profile and morphological distribution of tuberculosis (TB) spine. We conducted this study to identify the disease distribution and various parameters affecting the disease in our area which caters to populations from both plains and hills.

Materials and Methods

This was a cross-sectional study using 5-year retrospective data retrieved from medical records, Department of Orthopaedics of a tertiary care teaching hospital, from April 2015 to October 2020. The patient distribution was studied according to the different variables.

Results

A total of 286 patients were enrolled in the study. Females amounted to 54.96% (n = 159) of the total and 46.1% (n = 127) were males. The mean age of the demographic group was 36.9 years (2.5-80 years) (±SD = 17.63). The majority (46.5%) of the patients were young adults in the age group (21-40 years). The majority of deficits were seen in the dorsal spine (n = 27) followed by multifocal contiguous lesions (n = 22). Among the patients having single-segment disease, 33.9% (n = 61) involved the lumbar spine and 28.7% (n = 52) involved the dorsolumbar spine. Multifocal Potts disease amounted to 36.25% (n = 105) of the total patients.

Conclusions

Female preponderance was observed in our study. Involvement of the lumbar spine was the most common form involving single-segment disease followed by dorsolumbar, dorsal, and cervical spine. The multifocal contiguous type of affection of STB was found to be the most common type of STB.

Navigating Perioperative Challenges in Pott's Spine: A Comprehensive Review

Pott's spine, or tuberculous spondylitis, remains a significant public health concern in regions where tuberculosis is endemic. The management of Pott's spine poses unique perioperative challenges due to the complexity of the disease process, including vertebral destruction, spinal instability, and neurological compromise. This comprehensive review explores the intricacies of navigating perioperative challenges in Pott's spine surgery. Beginning with an overview of Pott's spine, including its etiology, clinical presentation, and classification, the review delves into the significance of perioperative challenges in this condition. Emphasis is placed on the need for multidisciplinary collaboration, meticulous preoperative assessment, and tailored surgical planning to optimize outcomes while minimizing the risk of complications. Critical considerations in the preoperative, intraoperative, and postoperative phases of care are discussed in detail, including patient assessment, imaging modalities, surgical techniques, anesthesia considerations, and postoperative rehabilitation. Special considerations such as pediatric Pott's spine and multidrug-resistant tuberculosis are also addressed. The review concludes by summarizing key points, highlighting implications for clinical practice, and providing recommendations for future research. By synthesizing current evidence and clinical expertise, this review offers valuable insights into the optimal management of perioperative challenges in Pott's spine, ultimately aiming to improve patient outcomes and reduce the burden of this debilitating condition.

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

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

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

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

Mistaken identity: Reporting two cases of rare forms of extrapulmonary tuberculosis in Solomon Islands

INTRODUCTION AND IMPORTANCE

Extrapulmonary tuberculosis (EPTB) is a relatively rare and difficult-to-diagnose manifestation of Myobacterium tuberculosis (TB) infection.

CASE PRESENTATION

This study reports the cases of a 47-year-old male and a 35-year old female with rare forms of EPTB who sought medical care in Solomon Islands. Both patients presented with nondescript symptoms and a chief complaint of pain. Initial diagnosis for the male and female patient was an abacterial colon polypoid mass and a urinary tract infection (UTI) respectively. Following unsuccessful treatment for UTI and further investigation, the surgical team diagnosed the female patient with a tuberculosis spondylitis and a bilateral psoas abscess. The male patient was subsequently diagnosed with isolated colonic tuberculosis. After starting medication, the patients were discharged and prescribed 9-month treatment regimens. During outpatient treatment both patients reported suboptimal adherence. The female patient resumed treatment and showed improvement while the male patient discontinued treatment, experienced worsening symptoms, and ultimately died.

CLINICAL DISCUSSION

The nonspecific symptoms of extrapulmonary TB infection make it difficult to diagnose. Cases of rare forms of EPTB are particularly challenging to identify. Misdiagnosis may further increase the likelihood of mortality and morbidity in these cases. Intensive medication counseling, patient outreach, and regularly scheduled follow-up visits may reduce the incidence of poor adherence and reduce the risk of developing drug-resistant TB.

CONCLUSION

Medical practitioners in tuberculosis-endemic countries like Solomon Islands should maintain a high clinical index of suspicion in diagnosing EPTB. Future research should investigate the prevalence of TB and EPTB in the Solomon Islands.

Bilateral Percutaneous Transpedicular Drainage under Local Anesthesia for Thoracic Tuberculous Spondylitis

Tuberculous spondylitis is a common spinal infection. If surgical intervention is necessary, anterior debridement and anterior fixation are typically performed. However, a minimally invasive surgical strategy under local anesthesia seems rarely implemented. A 68-year-old man presented with severe pain in the left flank. Whole spinal magnetic resonance imaging revealed abnormal intensity of vertebral bodies from T6-9. A bilateral paravertebral abscess extending from T4-10 was suspected. The T7/T8 intervertebral disc was destroyed, but severe vertebral deformity or spinal cord compression was not observed. Bilateral percutaneous transpedicular drainage under local anesthesia was planned. The patient was set in the prone position. Under the guide of a biplanar angiographic system, the bilateral drainage tubes were placed paravertebrally in the abscess cavity. The left flank pain improved after the procedure. Laboratory culture of the pus specimen confirmed a diagnosis of tuberculosis. A chemotherapy regimen for tuberculosis was soon initiated. The patient was discharged during postoperative week 2, with continuation of chemotherapy for tuberculosis. Percutaneous transpedicular drainage under local anesthesia can be effective in the management of thoracic tuberculous spondylitis without severe vertebral deformity or compression of the spinal cord by an abscess.

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.

Diagnosis and Treatment of Skipped Multifocal Spinal Tuberculosis Lesions

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

Multifocal tuberculosis in children: A case of spinal tuberculosis

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

Short-term outcomes of one-stage debridement and fusion for ankle joint tuberculosis

PURPOSE

Tuberculosis remains a worldwide health problem, as well as its complications including arthritis in various joints. End-stage arthritis in weight-bearing joint would require surgery either arthroplasty or arthrodesis, in order to achieve painless and stable gait. In general, staged surgery consisted of debridement and subsequent definitive procedure is accepted. However, multiple surgery would be disadvantageous in terms of clinical and economic burdens. This study reported the short-term result of one-stage debridement and fusion for ankle joint tuberculosis.

METHODS

Retrospective evaluation of twenty-six patients with history of one-stage debridement and ankle fusion was conducted. Basic anthropometric measurement, local status, and surgical technique were recorded. Functional score using Foot and Ankle Ability Measures (FAAM) activities of daily living (ADL) was assessed pre-operatively and at two and half year post-surgery follow-up visit along with radiological fusion rate. Paired t test was used to analyse the improvement of the clinical scores.

RESULTS

There was improvement in FAAM score from 43.38 ± 9.51 to 62.19 ± 6.63% (p < 0.001). All sinuses had been subsided, albeit at various time spans. Modified radiographic union score for tibia (RUST) revealed various fusion rate results, ranged from 5 to 11.

CONCLUSION

One-stage debridement and fusion is proven efficacious for end-stage joint tuberculosis, with less surgery occasion compared with staged surgery. However, patient selection is important since any comorbidities or secondary infection may complicate the fusion.

Diagnosis, Management, and Prognosis of Spinal Tuberculosis: A Case Report

Spinal tuberculosis (TB) is a condition that affects numerous people around the world. The incidence of TB prior to the pandemic was decreasing by about 1.8% per year; however, COVID-19 has complicated this incidence rate leading to an increase of 4.5% in 2020 and 2021. Spinal TB is a rare event in all TB patients. The management could be multifactorial including location, severity, and symptom, and this case demonstrates an example of issues to consider in the diagnosis and management of patients. This is a case of a patient presenting with back pain which was subsequently diagnosed as spinal TB. We will review this patient's presentation and consideration for multifactorial opinions in the literature. This literature review demonstrates that there is no one treatment option available. Providers need to tailor treatment to each individual case. This is an example of a case that illustrates that diagnosis of spinal TB is not straightforward and clinicians may have to make a judgment call and treat prophylactically to prevent a poor prognosis.

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

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

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

Background

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

Methods

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

Results

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

Conclusions

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

One-stage surgical treatment of upper thoracic spinal tuberculosis by posterolateral costotransversectomy using an extrapleural approach

BACKGROUND

Due to the complexity of the anatomical structure and the difficulty of exposing the surgical area, the surgery for spinal tuberculosis in the upper thoracic vertebra (above T6-T7) is complicated and the prognosis is not good. This study aimed to investigate the clinical effects of posterolateral costotransversectomy using an extrapleural approach in patients with upper thoracic spinal tuberculosis.

METHODS

This was a retrospective analysis of 132 patients (including 78 males and 54 females) with upper thoracic spinal tuberculosis who underwent one-stage internal fixation and debridement followed by combined interbody and posterior fusion via posterolateral costotransversectomy using an extrapleural approach. The age ranged from 23 to 82 years (54.5 ± 13.2 years). Lesion segments were distributed from T2 to T7. According to Frankel's spinal cord function evaluation, there were 2 cases of grade A, 6 of grade B, 6 of grade C, 12 of grade D, and 106 of grade E. The preoperative Cobb angle was 16-40° (29.1° ± 6.5°). Operation time, bleeding volume, incision healing, bone graft fusion, deformity correction, and improvement of nerve function were analyzed.

RESULTS

The operation time ranged from 2.8 to 4.1 h (3.4 ± 0.3 h), and blood loss ranged from 350 to 550 mL (460 ± 47 mL). All incisions healed in the first stage. The bone graft fusion time was 3-6 months (median of 4 months). There was no loosening or broken of the internal fixation. The C-reactive protein and erythrocyte sedimentation rate were significantly improved at the end of follow-up in comparison with before surgery. The Cobb angle of the fusion segment was corrected and ranged from 5° to 17° (average of 10.7° ± 3.3°) at the end of follow-up. The nerve function of all patients improved at different degrees by the time of the last follow-up. In the last follow-up, the Frankel grade distribution was 1 case in B grade, 2 cases in grade C, 6 cases in grade D, and 123 cases in grade E.

CONCLUSION

Posterolateral costotransversectomy using an extrapleural approach is a safe and effective surgical method that can expose the upper thoracic spine lesions and reduce trauma.

Reliable Sarcoidosis Detection Using Chest X-rays with EfficientNets and Stain-Normalization Techniques

Sarcoidosis is frequently misdiagnosed as tuberculosis (TB) and consequently mistreated due to inherent limitations in radiological presentations. Clinically, to distinguish sarcoidosis from TB, physicians usually employ biopsy tissue diagnosis and blood tests; this approach is painful for patients, time-consuming, expensive, and relies on techniques prone to human error. This study proposes a computer-aided diagnosis method to address these issues. This method examines seven EfficientNet designs that were fine-tuned and compared for their abilities to categorize X-ray images into three categories: normal, TB-infected, and sarcoidosis-infected. Furthermore, the effects of stain normalization on performance were investigated using Reinhard’s and Macenko’s conventional stain normalization procedures. This procedure aids in improving diagnostic efficiency and accuracy while cutting diagnostic costs. A database of 231 sarcoidosis-infected, 563 TB-infected, and 1010 normal chest X-ray images was created using public databases and information from several national hospitals. The EfficientNet-B4 model attained accuracy, sensitivity, and precision rates of 98.56%, 98.36%, and 98.67%, respectively, when the training X-ray images were normalized by the Reinhard stain approach, and 97.21%, 96.9%, and 97.11%, respectively, when normalized by Macenko’s approach. Results demonstrate that Reinhard stain normalization can improve the performance of EfficientNet -B4 X-ray image classification. The proposed framework for identifying pulmonary sarcoidosis may prove valuable in clinical use.

Pott's disease with extensive cold abscess in the abdominal cavity which was misinterpreted as malignancy

Pott's disease is a distinctive presentation of tuberculosis that occurs in approximately 5% of extrapulmonary cases that progressively developed a voluminous paravertebral abscess. While the disease is marked only by the occurrence of inflammatory symptoms and low-grade pain, the advanced mimics other infections and malignancies. Therefore, early recognition is important for proper treatment preventing deformity of the residual spinal and permanent neurological deficit. We present a 20-years-old woman who experienced low back pain for 2 years and presented with a right-side lump in the abdomen. CT and MRI were performed in this case. CT image showed bone destruction and extensive abscess formation, while on an MRI there was epidural granulation and compacted cauda equina resulting in severe central canal stenosis. To clarify the diagnosis, a chest radiograph and Mantoux test were performed and the patient was confirmed positive for lung tuberculosis. After antituberculosis drug treatment, (Isoniazid, Rifampicin, Pyrazinamide, and Ethambutol) initial phase, the patient had difficulty walking.

Expression and Clinical Significance of lncRNA NEAT1 in Patients with Spinal Tuberculosis

Background

Spinal tuberculosis (STB) often leads to irreversible neurological injury, resulting in serious social and economic problems. With the emergence of drug resistance, the management becomes even more challenging, given the treatment courses are generally longer for skeletal than pulmonary tuberculosis (PTB). The development and validation of nonsputum biomarkers for diagnosis and tailoring of treatment duration to enable personalized and evidence-based management of such diseases to improve treatment outcomes is being called for globally. Studies have demonstrated that lncRNA NEAT1 was highly expressed in pulmonary tuberculosis (TB) and was related to its progression and recovery. However, the expression and clinical significance of lncRNA NEAT1 in STB remains unclear.

Methods

The relative expression of lncRNA NEAT1 was quantified by relative real-time reverse transcription PCR (RT-PCR). The prognostic value was assessed by receiver-operating characteristic (ROC) curve analysis. Pearson and Spearman correlation coefficient and chi-square test were used to analyze the correlation between the lncRNA NEAT1 expression and the clinical characteristics. Univariate and multivariate logistic regression analyses were used to analyze independent predictors of STB recurrence.

Results

Compared with normal healthy individuals, the expression level of lncRNA NEAT1 in peripheral blood and granulomatous tissues of STB patients was significantly increased. The results of the in vitro Mycobacterium tuberculosis- (Mtb-) infected cell model showed that the expression level of lncRNA NEAT1 was significantly upregulated in macrophages infected with Mtb, and the difference was statistically significant compared with Mtb-uninfected group. The expression level of lncRNA NEAT1 in granulomatous tissue of STB was significantly higher than that in peripheral blood. The expression of lncRNA NEAT1 was related to segments of the lesions, paraspinal abscesses, anti-TB treatment, drug resistance, interleukin-6 (IL-6), C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR). Multivariate analysis results showed that relatively high expression of lncRNA NEAT1_1, the shorter transcript of the NEAT1 gene, was an independent prognostic factor of STB outcome.

Conclusion

LncRNA NEAT1 was highly expressed in peripheral blood mononuclear cells (PBMCs) and granulomatous tissue from patients with STB, as well as in Mtb-infected THP-1 cell lines. LncRNA NEAT1 expression was significantly associated with clinical characteristics (paraspinal abscesses, segments of the lesions and anti-TB treatment, IL-6, CRP, and ESR) of patients in STB. Increased expression of lncRNA NEAT1_1 predicted good prognosis of STB and might become a prognostic biomarker for STB.

Physiotherapeutic Methods in the Treatment of Cervical Discopathy and Degenerative Cervical Myelopathy: A Prospective Study

Spinal dysfunctions are very common in the population. However, there is still a lack of information on how to diagnose and treat them properly. The common causes of spinal dysfunctions are cervical discopathy and degenerative cervical myelopathy. The aims of the study are to examine whether a combination of manual therapy and stabilometer platform exercises can be effective in treating cervical discopathy and degenerative cervical myelopathy, and the possibility of observing the differences between patients suffering from the above diseases. The study involved 40 patients referred for rehabilitation, who formed two groups of 20 people. The first group consisted of patients suffering from cervical discopathy, the second group consisted of patients affected by degenerative cervical myelopathy. During therapy, manual therapy techniques and a stabilometric platform were used. The Neck Disability Index and Pain Numeric Rating Scale were used for clinical evaluation. The correlation between the existing diseases and the results obtained in the Neck Disability Index and Pain Numeric Rating Scale was examined. The distribution of patient responses in questions of the Neck Disability Index was also checked. Clinical evaluation was performed twice, before the start of therapy and after a two-week rehabilitation treatment. The study showed a significant difference between the patients’ results before the start of therapy and after the end of the rehabilitation stay in both used questionnaires (p = 0.00). A difference in the distribution of responses between the two groups after therapy was also found in the Neck Disability Index (p = 0.018) and in the Pain Numeric Rating Scale (p = 0.043). The study shows that manual therapy and exercises using the stabilometric platform are effective methods of treating both patients with cervical discopathy and patients with degenerative cervical myelopathy. It was also noted that, when comparing groups of patients, patients with degenerative cervical myelopathy tend to have greater disturbances in concentration-related activities, such as reading, focusing, driving, sleeping, and resting.

Pulmonary embolism following the third thoracic tuberculosis surgery: A case report and literature review

Background

The study aimed to analyze the clinical effects of pulmonary embolism succeeding a third surgery conducted for multiple recurrences in thoracic tuberculosis (TB).

Case report

A 74‐year‐old female patient developed thoracic tuberculosis and was subsequently treated in our hospital in March 2019, October 2020, and February 2021. The third surgical intervention included anterolateral thoracic lesion resection, internal fixation, posterior spinal tuberculous sinus resection, and debridement with suture. The operative time was 172 min resulting in a substantial intraoperative blood loss (2321 ml). Postoperative re‐examination of chest CTPA indicated a strip filling defect and pulmonary embolism in the external branch of the right middle lobe of the lung. After completing the active treatment, the D‐dimer quantification, WBC, CRP, and ESR values were 1261 ng/ml, 7.71 × 10⁹/L, 74.66 mg/L, and 63 mm, respectively. Chest CTPA re‐examination after the treatment showed no signs of pulmonary embolism.

Conclusion

Patients with a long‐term history of multiple operations, high BMI, cerebral infarction, diabetes, and older age group were more likely to develop pulmonary embolism after spinal tuberculosis surgery. Thus, the possibility of postoperative pulmonary embolism should be thoroughly analyzed before any subsequent surgical treatment in patients with recurrent spinal tuberculosis.

Tubercular Osteomyelitis of Pubis with Labial Abscess: A Rare Presentation of a Common Disease

Introduction

Skeletal tuberculosis (TB) accounts for 10-15% of all cases of extra-pulmonary TB. The involvement of pubis is extremely rare with only 40 cases of pubic bone TB reported in the medical literature. The presentation of the disease with labial abscess is much rarer with only one case reported till now.

Case Report

A 23-year-old female presented with symptoms of pain and swelling in the right groin. The patient was evaluated with hematological and radiological investigations and the diagnosis of Tubercular osteomyelitis of pubis with labial abscess was confirmed using AFB staining and culture of the aspirate. The patient was subsequently managed with Anti-tubercular chemotherapy for 18 months and the lesion healed with excellent functional outcome.

Conclusion

Tubercular Osteomyelitis of the pubis is a rare disease with varied clinical presentation. Timely diagnosis and anti-tubercular chemotherapy usually result in complete recovery.

Cervical spine TB - Current concepts in management

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.

Infections of the Spine and Spinal Cord

PURPOSE OF REVIEW

Infections of the spine and spinal cord are associated with a high risk of morbidity and mortality and, therefore, require prompt clinical recognition, efficient diagnostic evaluation, and interdisciplinary treatment. This article reviews the pathophysiology, epidemiology, clinical manifestations, diagnosis, and treatment of infections of the spine and spinal cord to help practicing clinicians recognize, evaluate, and manage patients with such infections.

RECENT FINDINGS

Aging of the population, increasing use of immunosuppressive medications, and other factors have contributed to increasing rates of spinal infections. Although the most common agents responsible for spinal infections remain bacteria and viruses, fungal infections occur in individuals who are immunocompromised, and parasitic infections are common in endemic regions, but patterns are in evolution with migration and climate change. Recent outbreaks of acute flaccid myelitis in children have been associated with enteroviruses A71 and D68.

SUMMARY

Infections of the spine and spinal cord can be challenging to diagnose, requiring a thorough history and neurologic examination, laboratory studies of serum and CSF, neuroimaging (particularly MRI), and, in some instances, biopsy, to establish a diagnosis and treatment regimen. Interdisciplinary management including collaboration with experts in internal medicine, infectious disease, and neurosurgery is important to improve clinical outcomes.

Imaging in spinal posterior epidural space lesions: A pictorial essay

Spinal epidural space is a real anatomic space located outside the dura mater and within the spinal canal extending from foramen magnum to sacrum. Important contents of this space are epidural fat, spinal nerves, epidural veins and arteries. Due to close proximity of posterior epidural space to spinal cord and spinal nerves, the lesions present with symptoms of radiculopathy and/or myelopathy. In this pictorial essay, detailed anatomy of the posterior epidural space, pathologies affecting it along with imaging pearls to accurately diagnose them are discussed. Various pathologies affecting the posterior epidural space either arising from the space itself or occurring secondary to vertebral/intervertebral disc pathologies. Primary spinal bone tumors affecting the posterior epidural space have been excluded. The etiological spectrum affecting the posterior epidural space ranges from degenerative, infective, neoplastic - benign or malignant to miscellaneous pathologies. MRI is the modality of choice in evaluation of these lesions with CT scan mainly helpful in detecting calcification. Due to its excellent soft tissue contrast, Magnetic Resonance Imaging is extremely useful in assessing the pathologies of posterior epidural space, to know their entire extent, characterize them and along with clinical history and laboratory data, arrive at a specific diagnosis and guide the referring clinician. It is important to diagnose these lesions early so as to prevent permanent neurological complication.

Tuberculosis of the spine and drug resistance: a review article

Pott's spine is tuberculosis of spine caused due to hematogenous spread of mycobacterium from a primary focus. It constitutes about 50% of skeletal tuberculosis cases. Paradiscal type is the most common type of spinal tuberculosis. Untreated cases can lead to complications like a cold abscess, paraplegia, and deformity which may require surgical intervention. Rapid molecular methods have made the diagnosis of spinal tuberculosis and drug resistance faster and easier but it still remains a problem due to difficulties in sample collection and the paucibacillary nature of the Pott spine. Antitubercular drug therapy forms the mainstay of management. The emergence of MDR TB and XDR TB has posed a big challenge in the management of spinal tuberculosis. The literature regarding drug resistance in spinal tuberculosis and its management is lacking. We conducted a literature review of 29 studies and presented information on pathogenesis, diagnosis, and management of spinal tuberculosis and drug resistance. New shorter regimens for MDR and XDR TB are under trial in different parts of the world. We believe this article will provide information on spinal tuberculosis and drug resistance and help clinicians outline important research areas.

The Pediatric Spine

The spine, a frequently investigated site in children, has a complex development in relation to both nervous and bone/cartilaginous structures and shows several particular features in children compared with adults. We report the main normal variants and pathologies of the pediatric spine, from the prenatal period to adolescence, focusing on a multimodality imaging approach.

Cancer or Tuberculosis: A Comprehensive Review of the Clinical and Imaging Features in Diagnosis of the Confusing Mass

Confusing masses constitute a challenging clinical problem for differentiating between cancer and tuberculosis diagnoses. This review summarizes the major theories designed to identify factors associated with misdiagnosis, such as imaging features, laboratory tests, and clinical characteristics. Then, the clinical experiences regarding the misdiagnosis of cancer and tuberculosis are summarized. Finally, the main diagnostic points and differential diagnostic criteria are explored, and the characteristics of multimodal imaging and radiomics are summarized.

Retrospective Study of Bone-TB in Oman: 2002-2019

Objective: Little information is available about the etiology, pathophysiology, risk factors, and epidemiologic features of Bone Tuberculosis (Bone-TB). In this work, we present the epidemiological data about the Bone-TB in the Sultanate of Oman.

Methods: Retrospectively, we identified and assessed those patients who were diagnosed with Bone-TB between January 2002 and December 2019 at Khoula Hospital. The following data were collected: demographics, clinical presentation, anatomical location, diagnosis, and treatment of the Bone-TB.

Results: During the study period, 115 cases of Bone-TB were diagnosed. Males were affected more than females (57.4% and 42.6%, respectively). About 30% of Bone-TB cases were primary diagnosed in other organs particularly the lungs and then after disseminated to the bone. However, the Bone-TB was detected in hip, leg, hand, shoulder, and skull bones, the most detected Bone-TB was in spine (66% of cases). After vaccination the Bacillus Calmette–Guérin (BCG) strains were identified in the bones of eight babies. Tubercle bacilli were detected by Acid-Fast Stain (AFS) in 59% of cases, and the rest of cases were confirmed using polymerase chain reaction (PCR) tests. There are two used treatment regimens, with 12.4% relapse. The gastrointestinal tract (GIT) disturbances were the most related side effects. The resistance has been detected to pyrazinamide in six cases, rifampicin in three cases, and isoniazid, streptomycin and kanamycin were detected in one case.

Conclusion: The most predominant Bone-TB cases were spine-TB that were mainly disseminated from the lungs. AFS failed to detect tubercle bacilli in 40% of cases. There is no statistical significance in relapse between the used two regimens. The death was predominant among skull-TB cases.

Perioperative concerns in Pott's spine: A review

Pott's disease is the most common granulomatous spine infection caused by tubercle bacilli and is a common site of osseous tuberculosis, accounting for 50–60% of cases. The delay in establishing diagnosis and management results in complications such as spinal cord compression and spinal deformity. The aim of this narrative review is to discuss the perioperative concerns in patients for spine surgery. The literature source for this review was obtained via PubMed, Medline, Google Scholar, Cochrane database of systematic reviews, and textbooks until December 2019. On the literature search, we could not retrieve any review article specifically discussing the perioperative concerns of spinal tuberculosis. Therefore, the aim of the present narrative review is to discuss the perioperative concerns of patients for spine surgery along with the specific concerns related to spinal tuberculosis.

Surgical outcomes of posterior trans-facetal decompression and stabilisation in tuberculous spondylodiscitis with neuro-deficit

STUDY DESIGN

Retrospective study.

PURPOSE

To evaluate the functional, neurological and radiological outcomes of posterior trans-facetal decompression and stabilisation in tuberculous spondylodiscitis patients with neuro-deficit.

OVERVIEW OF LITERATURE

Spinal tuberculosis mainly involves anterior column and for that anterior approach has been the most frequently used surgical technique in the past as it allows direct access to the infected tissue providing a good decompression. However, anterior surgery is associated with higher morbidity which can be reduced by posterior trans-facetal approach.

MATERIALS AND METHODS

The study included 100 Tuberculous Spondylodiscitis patients with neuro-deficit who underwent posterior trans-facetal decompression and stabilisation from 2009 to 2014. Demographic data, clinical parameters (back pain score-VAS, ODI), neurological status (Frankel's grade), radiological parameters (Kyphosis angle) and complications were evaluated.

RESULTS

Out of the total 100 patients there were 58 males and 42 females. 84 patients had thoracic and 16 had thoracolumbar region involvement. The mean age of the patients was 34.7 years. The extent of fixation was 2 segments in 52 patients and >2 segments in 48 patients. Postoperatively significant improvement in VAS (pre-op 6.5 ± 0.65 to post-op 1.73 ± 0.64) and ODI (pre-op 76.54 ± 6.96 to post-op 30.5 ± 6.56) were noted. The mean kyphosis angle was corrected from 22.33° ± 5.59° to 5.14° ± 1.32°. 86 patients showed at least 1 grade of improvement in neurology (Frankel's grading) and there was no deterioration in any patient. 3 patients developed superficial infection and 2 had an intra-operative dural tear. 94 patients showed bony fusion at 2 years follow-up.

CONCLUSION

Posterior trans-facetal decompression and stabilisation is an effective procedure in the management of thoracic & thoracolumbar tuberculous spondylodiscitis patients with neuro-deficit. It offers circumferential decompression with stabilisation and also maintains kyphosis correction.

Examining variation in skeletal tuberculosis in a late pre-contact population from the eastern mountains of Peru

OBJECTIVE AND MATERIALS

This research evaluates the presence and chronology of tuberculosis (TB) in the northeastern highlands of Peru (CE 800-1535) through the analysis of osseous lesions from Pre-Contact Kuelap, Chachapoyas.

METHODS

We examined macroscopic lesion morphology and distribution from the skeletal series (MNI = 207).

RESULTS

We determined that skeletal evidence was highly consistent with advanced multifocal and spinal tuberculosis in 13 individuals. Destructive lesions of the lower thoracic and/or lumbar vertebra bodies and sacroiliac joints are evident in most cases, but we also observed lesions within the manubriosternal, hip, and knee joints. Both adult males (n = 7) and females (n = 6) present skeletal lesions from young adult to older adults, but there is only one late adolescent. Only three individuals demonstrate similar lesion distributions.

CONCLUSIONS

Variation in lesion distribution in this population-based study shows the importance of identifying extra-vertebral tuberculosis and suggests that the disease may have manifested differently than at other coastal sites. These cases confirm the presence of tuberculosis both before and after Inca occupation across this central Andean highlands region.

SIGNIFICANCE

This evidence for the likely endemic presence of TB in the New World prior to European Contact furthers our understanding of the distribution of this infectious disease across the region as well as elucidating lesion distribution.

LIMITATIONS

The diagnosis of tuberculosis is based on skeletal lesions and it should be confirmed by molecular analysis.

FUTURE RESEARCH

Additional examination of vertebral bodies (including juvenile remains) for evidence of earlier manifestations of infection.

Torticollis as a sign of spinal tuberculosis

Bone localization of tuberculosis mainly affects the thoracolumbar spine. The cervical spine is rare. Its diagnosis is often late which exposes to great instability and potentially serious complications. We report the case of a 12-year old girl with no medical history, showing torticollis and high temperature without neurological complication. In the physical examination, he had torticollis and pain in the third, fourth and fifth cervical vertebra. When the biopsy was performed, we find an inter apophysis (between C7 and D1) collection. The histological examination confirmed the diagnosis of apophysis tuberculosis. The management based on tuberculosis chemotherapy and immobilization started as soon as possible.

L5 Fracture Dislocation Secondary to Cold Abscess Treated by Posterior Corpectomy With Expandable Cage Placement

Infections of the lumbar spine can have serious sequelae, including neurological deficits, paralysis, and death. Prolonged infection can result in fracture of the vertebrae, local abscesses, and infiltration and compression of local vascular structures. In cases with significant instability or neurological compromise, a common treatment approach is vertebral corpectomy with interbody cage followed by long-term antibiotics.

The following case describes a patient with a three-month history of progressively worsening lower back pain, lower extremity radiculopathy, and bilateral lower extremity edema, in the setting of a nontraumatic three-column fracture dislocation of L5 with grade 4 retrolisthesis of L4 on L5. A posterior-only corpectomy with placement of an expandable cage, to be followed by pedicle screw placement from L3-S1/ilium, was performed. The procedure was successful, and the patient was discharged on postoperative day 5 without complication and with resolution of his edema. Histopathological analysis demonstrated acute and chronic inflammation, but extensive tests and cultures failed to identify a causative organism.

This case highlights several interesting features, including a technically challenging and seldom-performed procedure, as well as the ability of lumbar spinal infections to present with leg edema due to involvement the inferior vena cava and iliac vessels. For patients with three-column fractures of L5 due to an inflammatory process or trauma, a single-stage posterior corpectomy with placement of an expandable cage may be considered as an appropriate treatment option.

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.

Tuberculosis: a focused review for the emergency medicine clinician

INTRODUCTION

Tuberculosis (TB) is a common disease worldwide, affecting nearly one-third of the world's population. While TB has decreased in frequency in the United States, it remains an important infection to diagnose and treat.

OBJECTIVE

This narrative review discusses the evaluation and management of tuberculosis, with an emphasis on those factors most relevant for the emergency clinician.

DISCUSSION

TB is caused by Mycobacterium tuberculosis and is highly communicable through aerosolized particles. A minority of patients will develop symptomatic, primary disease. Most patients will overcome the initial infection or develop a latent infection, which can reactivate. Immunocompromised states increase the risk of primary and reactivation TB. Symptoms include fever, prolonged cough, weight loss, and hemoptysis. Initial diagnosis often includes a chest X-ray, followed by serial sputum cultures. If the patient has a normal immune system and a normal X-ray, active TB can be excluded. Newer tests, including nucleic acid amplification testing, can rapidly diagnose active TB with high sensitivity. Treatment for primary and reactivation TB differs from latent TB. Extrapulmonary forms can occur in a significant proportion of patients and involve a range of different organ systems. Patients with human immunodeficiency virus are high-risk and require specific considerations.

CONCLUSIONS

TB is a disease associated with significant morbidity and mortality. The emergency clinician must consider TB in the appropriate setting, based on history and examination. Accurate diagnosis and rapid therapy can improve patient outcomes and reduce the spread of this communicable disease.

Lung adenocarcinoma presumed to be Pott's disease in a 28-year-old patient: A case report and review of literature

Background:

Tuberculous spondylitis (Pott’s disease), a common extrapulmonary manifestation of tuberculosis (TB), typically presents with back pain, tenderness, paraparesis/paraplegia, and various constitutional symptoms. Due to radiological similarities between Pott’s disease and lung cancer, some lung cancer patients may initially be erroneously diagnosed and treated for TB, allowing for extensive progression of their cancer.

Case Description:

A 28-year-old male presented with a chronic dry cough, weight loss, and 2 months of increased back pain accompanied by bilateral lower extremity weakness. Magnetic resonance imaging revealed an epidural collection causing compression of the spinal cord at the T5-T6 level. The initial diagnosis was Mycobacterium tuberculosis/Pott’s disease. A thoracic T4-T8 decompression fusion was performed; however, pathologic examination of the tissue revealed adenocarcinoma. Postoperatively, after the patient experienced several episodes of acute respiratory distress and a tension pneumothorax, lung imaging confirmed multiple tumor infiltrates along with lung cancer extending into the thoracic vertebrae. Pelvic studies also confirmed the presence of pelvic metastases. The patient passed away 3 weeks following surgery.

Conclusion:

In this case report, a 28-year-old male was treated for thoracic Pott’s disease that proved to be metastatic lung adenocarcinoma. To avoid such misdiagnoses in the future, physicians should better differentiate spinal TB from other malignancies that may affect the spine. This study underscores the importance of obtaining at least a chest X-ray in any patient with suspected Pott’s disease, irrespective of age, to help rule out lung cancer or other pathologies.

Misdiagnosed and mismanaged atypical spinal tuberculosis: A case series report

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

Extrapulmonary Tuberculosis Presenting as a Suspected Case of Metastatic Breast Cancer

Extrapulmonary tuberculosis (TB) represents a diagnostic challenge. Bone TB is an uncommon and important presentation of extrapulmonary TB, which can lead to bone destruction, deformity and even paraplegia. Breast TB is rare and often confused with neoplasia, since the clinical and imaging presentations are not specific. Any of these extrapulmonary TB presentations, in the absence of cultural isolation of mycobacteria, oblige the exclusion of other diseases (secondary or infectious diseases). The authors report a case of multifocal extrapulmonary TB, as an example of the problem with the differential diagnosis of the disease.

LEARNING POINTS

Extrapulmonary TB remains a diagnostic challenge.Consider breast TB as a differential diagnosis of mammary nodules.A high level of suspicion is necessary to make an early diagnosis and start appropriate treatment before irreversible damage takes place.

Clinical-Morphological Aspects in Spinal Tuberculosis

Osteoarticular tuberculosis (OATB) Aim: The authors made a clinical morphological assessment of tissue samples from patients admitted in Surgical Departments of the Emergency County Hospital of Craiova, Romania, between 1990 and 2015, proved as presenting tuberculous lesions of the spine in the Department of Pathology of the same Hospital. Materials and Methods: The studied material consisted of bone, joint and sometimes muscle tissue fragments resulted from biopsies or surgical excisions from 7 cases coming out of 54 patients investigated in the above-mentioned period of time, where the established histological diagnosis was tuberculosis (TB). For diagnostic confirmation, Ziehl-Neelsen staining has been used as a rule but, in some cases, immunohistochemistry was also used. Results: TB lesions have prevailed in men and around the age of 50 years. Thoracic segment of the spine was the most involved. Epithelioid and giant Langhans cells dominated the inflammatory cellular population. Necrosis was always present, usually in its classical acidophilic form. Fibrosis was almost always absent. On the whole, the granulomatous reaction was in almost half of the cases hyporeactive and disorganized. Conclusions: The clinical morphological profile of our series is fitting with data described in the literature. Because of its life threatening potential, spinal TB should be investigated thoroughly especially in its morphological features in order to obtain as quickly as possible an etiological diagnosis.

Spinal Tuberculosis: Current Concepts

STUDY DESIGN

Review article.

OBJECTIVES

A review of literature on the epidemiology, diagnosis, and management of spinal tuberculosis (TB).

METHODS

A systematic computerized literature search was performed using Cochrane Database of Systematic Reviews, EMBASE, and PubMed. Studies published over the past 10 years were analyzed. The searches were performed using Medical Subject Headings terms, and the subheadings used were "spinal tuberculosis," "diagnosis," "epidemiology," "etiology," "management," "surgery," and "therapy."

RESULTS

Tissue diagnosis remains the only foolproof investigation to confirm diagnosis. Magnetic resonance imaging and Gene Xpert help in early detection and treatment of spinal TB. Uncomplicated spinal TB has good response to appropriately dosed multimodal ambulant chemotherapy. Surgery is warranted only in cases of neurological complications, incapacitating deformity, and instability.

CONCLUSIONS

The incidence of atypical clinicoradiological presentations of spinal TB is on the rise. Improper dosing, inadequate duration of treatment, and inappropriate selection of candidates for chemotherapy has not only resulted in the resurgence of TB but also led to the most dreadful consequence of multidrug resistant strains. In addition, global migration phenomenon has resulted in worldwide spread of spinal TB. The current consensus is to diagnose and treat spinal TB early, prevent complications, promote early mobilization, and restore the patient to his or her earlier functional status.

Central Nervous System Tuberculosis : Etiology, Clinical Manifestations and Neuroradiological Features

PURPOSE

As a result of multilateral migration and globalization in times of humanitarian crises, western countries face a possible increase in the incidence of central nervous system tuberculosis (CNS TB). The diagnosis of CNS TB is challenging and often delayed due to the manifold and often non-specific presentation of the disease. The aim of this review is to analyze and summarize imaging features and correlated clinical findings of CNS TB.

METHODS

The different manifestations of CNS TB are explained and illustrated by characteristic neuroradiological as well as neuropathological findings. An overview on diagnostic and therapeutic approaches is provided. For clarity, tables summarizing the lesion patterns, differential diagnoses and diagnostic hints are added.

RESULTS

The CNS TB can be manifested (1) diffuse as tuberculous meningitis (TBM), (2) localized as tuberculoma or (3) tuberculous abscess or (4) in extradural and intradural spinal infections. Information on clinical presentation, underlying pathology and the distinguishing features is demonstrated. The TBM is further described, which may lead to cranial nerve palsy, hydrocephalus and infarction due to associated arteritis of the basal perforators. The differential diagnoses are vast and include other infections, such as bacterial, viral or fungal meningoencephalitis, malignant causes or systemic inflammation with CNS. Complicating factors of diagnosis and treatment are HIV coinfection, multi-drug resistance and TB-associated immune reconstitution inflammatory syndrome (IRIS).

CONCLUSIONS

Neurologists and (neuro-)radiologists should be familiar with the neuroradiological presentation and the clinical course of CNS TB to ensure timely diagnosis and treatment.

Could an increase in vigilance for spinal tuberculosis at primary health care level, enable earlier diagnosis at district level in a tuberculosis endemic country?

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.

Pott's Disease in a Patient with Subtle Red Flags

BACKGROUND

Tuberculosis (TB) is now rare in developed countries; however, it is an important diagnosis for the Emergency Physician to be able to make. Classically thought of as a respiratory disease, TB can present in other ways, making it more challenging to recognize.

CASE REPORT

We report the case of a 41-year-old woman who presented to the Emergency Department with a 4-week history of back pain. A diagnosis of T12 osteomyelitis and right psoas muscle abscess was made after magnetic resonance imaging. The concurrent finding raised concern for TB as psoas muscle abscess is usually found along with spinal TB. A computed tomography-guided fine-needle aspiration confirmed the diagnosis. This patient's social history was negative for many of the classic predisposing factors associated with TB: immunosuppression, personal travel, crowded living conditions. Repeated investigation into the patient's history revealed a visit several months prior from a family member from Vietnam who had been treated for TB. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: It is important for Emergency Physicians to be aware of the relatively high incidence of TB as a cause for concurrent psoas abscess and vertebral osteomyelitis.

Functional and Radiological Outcomes of Anterior Decompression and Posterior Stabilization via Posterior Transpedicular Approach in Thoracic and Thoracolumbar Pott's Disease: A Retrospective Study

Study Design

This is a retrospective study.

Purpose

To determine the efficacy and safety of a posterior transpedicular approach with regard to functional and radiological outcomes in people with thoracic and thoracolumbar spinal tuberculosis.

Overview of Literature

Spinal tuberculosis can cause serious morbidity, including permanent neurological deficits and severe deformities. Medical treatment or a combination of medical and surgical strategies can control the disease in most patients, thereby decreasing morbidity incidence. A debate always existed regarding whether to achieve both decompression and stabilization via a combined anterior and posterior approach or a single posterior approach exists.

Methods

The study was conducted at the Indian Spinal injuries Centre and included all patients with thoracic and thoracolumbar Pott's disease who were operated via a Posterior transpedicular approach. Data regarding 60 patients were analyzed with respect to the average operation time, preoperative and postoperative, 6 months and final follow-up American Spinal Injury Association (ASIA) grading, bony fusion, implant loosening, implant failure, preoperative, postoperative, 6 months and final follow-up kyphotic angles, a loss of kyphotic correction, Oswestry disability index (ODI) score, and visual analog scale (VAS) score. Data were analyzed using either a paired t -test or a Wilcoxon Signed Rank test.

Results

The mean operation time was 260±30 minutes. Fifty-five patients presented with evidence of successful bony fusion within a mean period of 6±1.5 months. Preoperative dorsal and lumbar angles were significantly larger than postoperative angles, which were smaller than final follow-up angles. The mean kyphotic correction achieved was 12.11±14.8, with a mean decrease of 5.97 and 19.1 in VAS and ODI scores, respectively.

Conclusions

Anterior decompression and posterior stabilization via a posterior transpedicular approach are safe and effective procedures, with less intraoperative surgical duration and significant improvements in clinical and functional status.

Association of IFNG gene polymorphisms with pulmonary tuberculosis but not with spinal tuberculosis in a Chinese Han population

Spinal tuberculosis (STB) is an extrapulmonary form of tuberculosis (TB) caused by Mycobacterium tuberculosis (Mtb), which accounts for around 2% of all TB cases and can lead to spine degeneration. It is widely accepted that host genetic factors participate in the pathogenesis of active TB, but the factors controlling which TB form will manifest after Mtb infection remain unknown. We hypothesized that a genetic difference may exist between the development of STB and pulmonary tuberculosis (PTB). Here, three single nucleotide polymorphisms (SNPs) in the IFNG gene (rs2069718), IRGM gene (rs10065172), and MBL2 gene (rs11003125) were genotyped among 183 PTB patients, 177 STB patients, and 360 healthy controls from the Chinese Han population. We found that rs2069718 genotypes were significantly associated with PTB (TT, p = 0.007; CT, p = 0.008) but not STB, and the TT genotype (p = 0.046) of rs2069718 were less common in PTB than in STB. In contrast, neither PTB nor STB were found to be associated with rs10065172 and rs11003125. Overall, we found a difference in the rs2069718 genetic distribution between the STB and PTB patients in a Chinese Han population. The rs2069718 TT genotype was associated with a protective role in PTB but not STB development during active Mtb infection.