A Case Report of a Tragic Story of Pott's paraplegia Cured after Four Years

Pott's disease is a form of spondylodiscitis caused by mycobacterium tuberculosis. It is a serious form of spinal infections that can lead to terrible disabilities in case of undiagnosed and treated early. To document a case of Pott's paraplegia cured after four years. This report details the case of a patient with an undiagnosed case of spinal tuberculosis in a 55-year-old man who had complained of lower back pain and tenderness over the course of several months. The case progressed to the point that he had difficulty standing and numbness, then weakness, of the lower limbs. This patient was only treated with analgesics and antibiotics. Herbal remedies, massage and amulets also played a major role in his treatment. The patient remained bed-bound and paraplegic for four years, after which, he was referred for a thoracolumbar Magnetic Resonance Imaging (MRI) and was diagnosed with tuberculous spondylodiscitis. The patient underwent decompression surgery and started anti-tuberculous drugs. He regained his ability to walk. His lifestyle has improved and he has been living independently for eight years. In conclusion, diagnosis and correct treatment can result in a patient who was previously handicapped becoming independent once again. Medical imaging using MRI can play an essential role in the diagnosis of spinal lesions, including those present in cases of Pott's disease.

Minimally invasive direct lateral interbody fusion in the treatment of the thoracic and lumbar spinal tuberculosisMini-DLIF for the thoracic and lumbar spinal tuberculosis

BACKGROUND

To investigate the clinical efficacy of minimally invasive direct lateral approach debridement, interbody bone grafting, and interbody fusion in the treatment of the thoracic and lumbar spinal tuberculosis.

METHODS

From January 2013 to January 2016, 35 cases with thoracic and lumbar spinal tuberculosis received direct lateral approach debridement, interbody bone grafting, and interbody fusion. Of the 35 cases, 16 patients were male and 19 were female and the median age was 55.2 (range 25-83). The affected segments were single interspace, and the involved vertebral bodies included: 15 cases of thoracic vertebrae (1 cases of T5/6, 2 cases of T6/7, 4 cases of T7/8, 3 cases of T8/9, 5 cases of T9/10) and 20 cases of lumbar spine (2 cases of L1/2, 6 cases of L2/3, 6 cases of L3/4, 6 cases of L4/5). After MIDLIF operation, all the patients received medication of four anti-tubercular drugs for 12 to18 months.

RESULTS

The patients were followed up for 7 to 40 months with an average of 18.5 months. The visual analogue scale (VAS) at the last follow-up was 2.8 ± 0.5, which was significantly different from the preoperative VAS (8.2 ± 0.7). After MIDLIF, there was 5 cases occurred with transient numbness in one side of the thigh or inguinal region, and 10 cases suffered from flexion hip weakness. All the bone grafts were fused within 6~ 18 months (average of 11.5 months) after the operation.

CONCLUSION

Minimally invasive lateral approach interbody fusion technology have the advantage of less injury and quick recovery after surgery, which is the effective and safe treatment for thoracic and lumbar spinal tuberculosis.

Treatment of tuberculous aortic pseudoaneurysm associated with vertebral tuberculosis: A case series and a literature review

RATIONALE

Tuberculous aortic pseudoaneurysm associated with vertebral tuberculosis is a rare disease but with very high mortality. We review the literature and find 19 reports with 22 patients. Here we report three cases with vertebral tuberculosis, who also have tuberculous pseudoaneurysm of the aorta. These patients were treated by different methods. We try to analyze the epidemiology, pathogenesis, presentation, and management of this disease to find the best treatment.

PATIENT CONCERNS

The patients presented with different symptoms such as pain (chest, abdominal or back), fever, blood volume reduction or hemorrhagic shock symptoms. Large mass also could be observed by imaging. In addition to clinical manifestations, enhanced computed tomography or magnetic resonance imaging could also help the diagnosis of this disease.

DIAGNOSES

Tuberculous aortic pseudoaneurysm associated with vertebral tuberculosis.

INTERVENTIONS

Three patients were treated with anti-tuberculosis(TB) drugs or combined with different sequences surgical treatment: Case 1 refused to receive pseudoaneurysm surgery and only had anti-TB drug treatment; Case 2 received thoracic spinal surgery first; Case 3 received endovascular stent grafting.

OUTCOMES

Two patients (case 1 and case 2) who refused to undergo aneurysm surgery died. The last patient (case 3) underwent endovascular repair and antibiotic therapy for tuberculosis, and the postoperative course was uneventful; the patient recovered and survived.

LESSONS

Once the diagnosis of tuberculous pseudoaneurysm is confirmed, surgical treatment should be provided immediately combined with anti-tuberculosis drugs. The aim of the treatment is to save lives, prevent relapse, and facilitate the return to normal life, regardless of the size of the pseudoaneurysm. The pseudoaneurysm should be treated first to prevent aneurysm rupture before the vertebral tuberculosis surgery.

Noncontiguous multi-tiered spinal tuberculosis associated with sternal localization: a case report

BACKGROUND

Tuberculous spondylodiscitis is a frequent localization of tuberculosis. Multi-tiered involvement and an association with sternal localization are rare.

CASE PRESENTATION

We report a case of multi-tiered tuberculous spondylodiscitis with sternal localization in an immunocompetent 41-year-old Arab woman who had inflammatory bilateral sciatica L5 and S1 and a history of low back pain caused by a trauma. Radiography, computed tomography, and a vertebral biopsy were useful for diagnosis. She reacted well to anti-bacillary treatment despite the occurrence of multiple paravertebral and subcutaneous abscesses. The medullar magnetic resonance imaging control performed at 4 months, 12 months, and 1 year after the end of treatment showed a favorable evolution.

CONCLUSIONS

To avoid the delay of diagnosis, especially in our endemic context, tuberculosis must be evoked usually. This will improve the prognosis of our patients.

One-stage surgical treatment for thoracic and lumbar Spinal tuberculosis by transpedicular fixation, debridement, and combined interbody and posterior fusion via a posterior-only approach

This study examined the clinical outcomes of one-stage surgical treatment for patients with spinal tuberculosis via a posterior-only approach. Twenty-four patients with thoracic or lumbar spinal tuberculosis whose lesions were confined to adjacent segments were admitted to our hospital and treated. The American Spinal Injury Association (ASIA) impairment scale was used to assess the neurological function. All patients were treated with one-stage surgical treatment via a posterior-only approach. The clinical efficacy was evaluated by the Japanese Orthopaedic Association (JOA) scores and oswestry disability index (ODI) of nerve function. Patients were evaluated preoperatively and postoperatively by measurement of spinal deformity using Cobb angle and radiological examination. All the patients were followed up for 13 to 27 months. They had significantly postoperative improvement in JOA score, ODI and ASIA classification scores. The kyphotic angles were significantly corrected and maintained at the final follow-up. Bone fusion was achieved within 4-12 months. It was concluded that one-stage surgical treatment via a posterior-only approach is effective and feasible for the treatment of spinal tuberculosis.

Tuberculous Spondylitis Following Kyphoplasty: A Case Report and Review of the Literature

Tuberculous spondylitis of the augmented vertebral column following percutaneous vertebroplasty or kyphoplasty has rarely been described. We report an unusual case of tuberculous spondylitis diagnosed after percutaneous kyphoplasty (PKP). A 61-year-old woman presented to our institution complaining of back pain following a fall 7 days before. Radiologic studies revealed an acute osteoporotic compression L1 fracture. The patient denied history of pulmonary tuberculosis (TB) and there were no signs of infection. The patient was discharged from hospital 4 days after undergoing L1 PKP with a dramatic improvement in her back pain. Two years later, the patient was readmitted with a 1 year history of recurrent back pain. Imaging examinations demonstrated long segmental bony destruction involving L1 vertebra with massive paravertebral abscess formation. The tentative diagnosis of tuberculous spondylitis was made, after a serum T-SPOT. The TB test was found to be positive. Anterior debridement, L1 corpectomy, decompression, and autologous rib graft interposition, and posterior T8-L4 instrumentation were performed. The histologic examination of the resected tissue results confirmed the diagnosis of spinal TB. Anti-TB medications were administered for 12 months and the patient recovered without sequelae. Spinal TB and osteoporotic vertebral compression fractures are similar clinically and radiologically. Spinal surgeons should consider this disease entity to avoid misdiagnosis or complications. Early surgical intervention and anti-TB treatment should be instituted as soon as the diagnosis of spinal TB after vertebral augmentation is made.

[Mid-term outcome of surgical operation for thoracolumbar tuberculosis]

OBJECTIVE

To investigate the mid-term outcome of operation for thoracolumbar tuberculosis. METHODS : Twenty-eight patiens with thoracolumbar tuberculosis underwent one stage anterior debridement,interbody fusion with bone graft and posterior pedicle screw internal fixation treatment from July 2006 to July 2011. There were 17 males and 11 females. Total 17 patients had nerve injuries ,including 6 cases of grade B, 5 cases of grade C, 6 cases of grade D according to Frankel classification. The poisoning symptoms of tuberculosis and recovery of spinal function were observed. The bone fusion and recovery of [umbar function were evaluated.

RESULTS

All the patients were followed up ,and the duration ranged from 39 to 85 months (mean 57 months). The clinical symptoms were controlled gradually, and the thoracolumbar back pain was alleviated after operation. Among the 17 patients with complications of nerve injuries, 3 patients were improved from preoperative grade B to postoperative grade D, 3 patients were improved from preoperative grade B to postopertive E, 5 patients with preoperative grade C and 6 patients with preoperative D were almostly recovered to normal after operation. According to JOA scoring system for curative effect evaluation, the excellent and good rate at the 3rd month, the 1st year, the 3rd year and the 5th year after operation were 67.86% ,82.14% ,85.71% ,89.29% and 91.30% respectively. The results at the 6th month and the 1st year had no statistical differences compared to the results at the 3rd month (P > 0.05); but the results at the 3rd year and the 5th year were better than that at 3 months after operation (P < 0.05); and the results between 3 yesrs and 5 years after operation had no statistical differences (P < O.05). The degeneration of adjacent segments were evaluated according to the California University (Universith of California at Los Angeles , UCLA) score. The degeneration rate was 53.57% (15/28) at the 3rd year after surgery, which was better than that before surgery. Twenty-three patients were followed up for 5 years ,and the degeneration rate was 86.96% (20/23) ,which was better than those of before surgery and 3 years after surgery.

CONCLUSION

The surgical treatment for thoracolumbar spinal tuberculosis can achieve the thorough debridement, reconstruction of spinal stability, recovery of lumbar function and promote the functional recovery of the spinal cord, which is an effective method of treatment. However, the mid term follow-up showed that more severe degenerative changes were found in the postoperative adjacent segment.

Immunohistological characterization of spinal TB granulomas from HIV-negative and -positive patients

Tuberculosis (TB) is mainly a disease of the lungs, but Mycobacterium tuberculosis (Mtb) can establish infection in virtually any organ in the body. Rising rates of extrapulmonary (EP) TB have been largely associated with the HIV epidemic, as patients co-infected with HIV show a four-fold higher risk of EPTB. Spinal TB (Pott's Disease), one of the most debilitating extrapulmonary forms of disease, is difficult to diagnose and can cause deformity and/or neurological deficits. This study examined the histopathology and distribution of immune cells within spinal TB lesions and the impact of HIV on pathogenesis. The overall structure of the spinal granulomas resembled that seen in lung lesions from patients with pulmonary TB. Evidence of efficient macrophage activation and differentiation were detectable within organized structures in the spinal tissue, irrespective of HIV status. Interestingly, the granulomatous architecture and macroscopic features were similar in all samples examined, despite a reversal in the ratio of infiltrating CD4 to CD8 T cells in the lesions from HIV-infected patients. This study provides a foundation to understand the mechanism of tissue destruction and disease progression in Spinal TB, enabling the future development of novel therapeutic strategies and diagnostic approaches for this devastating disease.

Role of magnetic resonance imaging in evaluation of tubercular spondylitis: pattern of disease in 100 patients with review of literature

INTRODUCTION

The purpose of this study is to evaluate the role of magnetic resonance imaging (MRI) in evaluation of tubercular spondylitis and to correlate imaging findings with clinical severity of the disease.

METHODS

One hundred consecutive patients, who presented with features suggestive of spinal infections, were subjected to MRI examination. T1W and STIR images were obtained followed by T2W and post-contrast T1W images. Various imaging characteristics of spinal infections were noted and correlated with the clinical severity of the disease.

RESULTS

Backache was the most common presenting symptom present in 86 %, while paraparesis was the most common sign seen in 62 %. The neurological status of the patients correlated well with MRI findings in the majority of the cases with an overall good correlation obtained in 96 % of cases. The majority of the vertebrae and intervertebral discs affected showed hypointensity or isointensity on T1W images and hyperintensity on T2W images. Epidural/dural disease was present in 74 % while 68 % of patients demonstrated decreased intervertebral disc height. Epidural extension and subligamentous spread was in 74 % and 90 % of patients respectively.

CONCLUSIONS

MRI plays a vital role in early and accurate diagnosis of spinal infections. It is non-invasive and clearly demonstrates soft tissue anatomy and pathology which makes it superior to X-rays and Computed Tomography (CT). Imaging findings of tubercular spondylitis were also found to have a good correlation with the clinical status of the patients. Hence, it is of much help in the evaluation and assessment of patients presenting with features of spinal infections.

[Function reconstruction of anterior and middle column in thoracolumbar spinal tuberculosis by one-stage anterior radical debridement]

OBJECTIVE

To summarize the effect of one-stage anterior debridement of infection in function reconstruction of anterior and middle column for the treatment of thoracolumbar spinal tuberculosis.

METHODS

From January 2001 to January 2007, 65 patients with thoracolumbar spinal tuberculosis were treated with one-stage anterior debridement, decompression, autogenous bone grafts and internal fixation. There were 43 males and 22 females with an average age of 40.2 years (range, 19-64 years), including 18 cases of thoracic tuberculosis (T(4-l0)), 44 cases of thoracolumbar tuberculosis (T11-L2) and 3 cases of lumbar tuberculosis (L(3-5)). The disease course was 3 months to 10 years (median 10 months). One segment was involved in 7 cases, two segments in 54 cases and three segments in 4 cases. In 14 cases with spinal cord injury, there were 5 cases of grade C and 9 cases of grade D according to Frankel classification. The kyphotic Cobb angle was 20-65 degrees (41 degrees on average).

RESULTS

The operative time was 120-210 minutes (170 minutes on average), and the blood loss was 300-1500 mL (600 mL on average). Fifty-eight patients were followed up for 1-6 years (23 months on average). Abscess occurred in 2 cases at 40 days and 3 months, and healed after symptomatic management. The other incisions achieved healing by first intention. The X-ray films showed bony fusion 4-12 months (6 months on average) after operation. No tuberculosis recurred. At 12 months after operation, pain disappeared, and there were 7 cases of grade D and 7 cases of grade E according to Frankel classification. The kyphotic Cobb angle was 0-33 degrees (24 degrees on average), showing statistically significant difference (P < 0.05) when compared with preoperation.

CONCLUSION

Early reconstruction of load-bearing function and stability of anterior and middle column in the treatment of spinal tuberculosis is great significant. The application of one-stage anterior surgery with debridement, decompression, autogenous bone grafts and internal fixation in the operative treatment of thoracolumbar tuberculosis is safe and effective after a rigorous anti-tuberculosis treatment.

[ADRENAL TUBERCULOSIS: A CLINICAL NOTE]

The paper presents a note of adrenal tuberculosis. The latter is difficult to diagnose and even a large lesion cannot be diagnosed by traditional means. Computed tomography fails to differentiate a tumor process from specific inflammation. The diagnosis can be verified only when invasive procedures are applied and in cases of destructive lesion or suspected tumor adrenalectomy is not only a diagnostic, but also therapeutic technique.

[SPECIFIC IMMUNE RESPONSE AND PROTECTIVE FACTORS OF NEUTROPHIL GRANULOCYTES IN PULMONARY AND EXTRAPULMONARY TUBERCULOSIS]

An immune response and protective factors of neutrophil granulocytes were comparatively studied in 61 patients with pulmonary tuberculosis, 70 with nephrotuberculosis, and 45 with tuberculous spondylitis. It was shown that there were elevated serum levels of neutrophil cationic proteins in both pulmonary and extrapulmonary tuberculosis. Lower content of intracellular cationic proteins along with suppressed cellular immunity was observed in pulmonary tuberculosis patients with disseminated actively progressive changes. This combination may be regarded as a poor predictor. Higher values of a specific cellular immune response and elevated levels of intracellular cationic proteins of neutrophils were found in extrapulmonary tuberculosis. This was also seen in patients with severe clinical manifestations of the disease. Thus, there is reason to believe that there is a regulatory association of the protective factors of neutrophil granulocytes with cellular immunity in tuberculosis.

Case report. Cervical spinal tuberculosis

Cervical spinal tuberculosis is a rare variant of extra-pulmonary tuberculosis. We present the case of Vietnamese woman, aged 48, who was admitted to the Department of Neurosurgery because of a cervical spine (C7) compression fracture. Several months earlier, the patient complained of neck pain and numbness of the hands. On physical examination, the woman was subfebrile and complained of pain over the cervical spinal area. Neurological examination revealed no focal motor weakness. The roentgenograms of chest, pelvis and cranium were without pathological changes. Abdominal ultrasonography was normal. Radioisotope bone-scanning showed abnormal accumulation of isotope in the lower cervical region, thoracic vertebra, as well as in the articulations of knees and shoulders and in the left tibial bone. An MRI scan revealed compression fracture of the C7 vertebral body with infiltration of paraspinal tissues at the vertebral column with indentation of osseous masses into the spinal canal. The lesion resembled neoplasm metastasis. The neoplasm infiltrating vertebral body C7, two discs, C6-C7 and C7-Th1, and ligament were removed surgically. Neuropathological examination of the removed material showed typical granulomatous inflammation with characteristic infiltrate of lymphocytes, epithelioid macrophages and Langhans-type multi-nucleated giant cells. The spoligotyping method confirmed the presence of Mycobacterium tuberculosis complex in the specimens.

[Spinal cord involvement by tuberculosis]

INTRODUCTION

We are observing an increase of patients with tuberculosis in Spain. Within the forms of extrapulmonary presentation, the involvement of the central nervous system by the bacillus that cause this disease is a relatively frequent location. Although sometimes is affected the spinal cord of secondary form, rarely is observed isolated involvement.

DEVELOPMENT AND CONCLUSIONS

We describe the diverse forms of spinal cord tuberculosis presentation, attending of its location within the spinal cord or adjacent annexes, in order that the clinician knows and remembers this infrequent but possible infection of the spinal cord, because their knowledge and prompt treatment modifies clearly their final prognosis. We analyze the treatment rules for each case according to the last recommendations, and finally, the differences in two groups of population, immunodepressant patients, like human immunodeficiency virus infected patients, as well as in paediatric age patients, because both groups have more possibility of tuberculosis infection generally, and therefore spinal cord involvement, with a differential clinical and therapeutic behaviour.

[Tuberculous spondylitis]

Although tuberculous spondylitis is a rare disease in Japan at the present time, it still occurs sporadically. This article presents clinical features, pathogenesis, radiologic appearance and principles of therapy of spinal tuberculosis.

Tuberculosis of lower cervical spine--a prospective study

Tuberculosis was a leading cause of mortality in the beginning of the twentieth century. Tuberculosis of the spine is one of the oldest diseases afflicting humans. A prospective study was carried out among 45 cases of tuberculosis of lower cervical spine and an attempt was made to highlight some of its features. Pain and stiffness were important and dominant complaints. Commonest level affected was C5-C6 vertebrae. The overall incidence of cord compression was 37.8 per cent. The commonest modality of treatment was antituberculous drugs, anterior excision of diseased bone and tricortical bone grafting. This regime rapidly relieves pain, compressive respiratory symptoms due to large abscess and neurological deficit.

Craniovertebral tuberculosis: a retrospective review of 13 cases managed conservatively

STUDY DESIGN

Retrospective review of 13 cases with craniovertebral tuberculosis treated conservatively.

OBJECTIVE

To evaluate the results of conservative treatment of craniovertebral tuberculosis and compare with the literature.

SUMMARY OF BACKGROUND DATA

Craniovertebral tuberculosis is a rare entity even in endemic countries, and there is no consensus in the literature regarding conservative or surgical management for the same. Reports range from radical surgery to totally conservative approach. We report our experience in treating such patients conservatively.

METHODS

A retrospective review of 13 patients diagnosed with craniovertebral tuberculosis was performed. All patients were treated conservatively with cervical traction for initial 3 months followed by a brace along with multidrug antitubercular drugs for 18 months.

RESULTS

All patients responded favorably to conservative treatment. Follow-up averaged 43 months (range, 16-65 months). No patient deteriorated neurologically. All patients had symptomatic improvement. Failure to reduce atlantoaxial dislocation/lateral subluxation of the dens completely was seen in 2 cases.

CONCLUSIONS

We think that all patients with craniovertebral junction tuberculosis can be managed adequately using conservative means regardless of the extent of bony destruction with a good patient outcome. Surgery should be reserved for only a selective few where diagnosis is in doubt and there is initial severe or progressive neural deficit with/without respiratory distress in presence of documented mechanical compression and documented dynamic instability following conservative treatment.

Autonomic dysfunction and adrenal insufficiency in thoracic spine tuberculosis

While autonomic dysfunction has been reported in patients with spinal TB, little is known of the consequences. We matched 25 paraplegic patients with thoracic spine tuberculosis scheduled for spinal surgery (Group S) with 25 nontubercular American Society of Anesthesiologists Grade I patients scheduled for nonspinal surgeries (Group C) under identical operative conditions. All patients underwent four autonomic tests in the operating room, and a preoperative adrenocorticotropic hormone stimulation test was performed for patients in Group S. Compared to Group C, Group S had higher resting heart rate (103 +/- 20 beats/minute versus 81 +/- 10 beats/minute), lower expiratory:inspiratory ratio (1.14 +/- 0.11 versus 1.22 +/- 0.10), and higher heart rate variability (20 +/- 12 beats/minute versus 14 +/- 7 beats/minute), indicating probable parasympathetic dysfunction along with a relative sympathetic overactivity. Eight of the 17 patients who received an adrenocorticotropic hormone stimulation test had evidence of adrenal insufficiency. Incidence of hypotension in Group S and Group C was 100% and 44%, respectively. Mean systolic and diastolic blood pressure in Group S showed substantial decrease after induction and positioning of patients not associated with compensatory tachycardia. Coexisting pulmonary tuberculosis appears an important determinant of surgical approach as well as postoperative respiratory morbidity.

The Incidence of Multiple Level Noncontiguous Vertebral Tuberculosis Detected Using Whole Spine MRI

The commonest site of osseous tuberculosis is the spine. Most vertebral lesions are contiguous. Current research indicates the incidence of multiple level noncontiguous vertebral tuberculosis is 1.1% to 16%. The aim of this study was to identify the incidence of multiple level noncontiguous vertebral tuberculosis using whole spine magnetic resonance imaging (MRI). A retrospective review was undertaken of case notes and whole spine MRI studies of all acute spinal infection cases that presented to a regional Spinal Unit over 3 years. Patients were included if spinal infection was identified by whole spine MRI and confirmed as tuberculosis by a combination of histology and microbiology. The incidence of multiple level noncontiguous vertebral tuberculosis was 71.4%. This is higher than previously quoted when MRI is not undertaken. Tuberculosis may affect the spine at multiple noncontiguous sites more frequently than thought previously. A large proportion of the affected noncontiguous sites may also be asymptomatic. We currently perform whole spine MRI on all patients with suspected spinal infection to aid detection of multiple level noncontiguous tuberculosis.

[Neurorehabilitation in myelopathies caused by tuberculosis-induced ostitis and other diseases of the vertebral column]

An algorithm of stepwise neurorehabilitation has been developed for patients with vertebrogenic myelopathy. The algorithm is constructed as a hierarchy of parallel and series tasks to recovery movement capacities of a paralyzed patient. Their solution requires the use of original procedures, such as initiation of locomotor activity by dermal and epidural spinal cord electrostimulation, propriospinal stimulation, dynamic vertical posture training, as well as treadmill therapy, tetrapedal walk, and therapeutic exercises. Neurorehabilitative treatment by the proposed algorithm was performed in 41 patients with vertebrogenic myelopathy, including 41 patients with clinically complete plegia. In baseline complete plegias, recovery of varying degree or compensation of locomotor capacities was achieved in 71% of the patients, in incomplete plegias, improvement of motor function was observed in all the patients.

Pott's disease occurring after percutaneous vertebroplasty: An unusual illustration of the principle of locus minoris resistentiae

We report an unusual case of a multifocal tuberculous spondylitis that has been diagnosed after several percutaneous vertebroplasty. This event supports the theory that surgical or radiological intervention such as a percutaneous vertebroplasty should be considered as an intentional traumatism that can lead to the initiation of a locus minoris resistentiae, probably by reactivating an inactive tuberculous lesion.

Unusual presentations of craniovertebral junction tuberculosis: a report of 2 cases and literature review

BACKGROUND

CVJ tuberculosis is a described entity requiring challenging ways of management. Severe neck pain, causing restricted neck movements and torticollis, is a characteristic presentation of neurologically asymptomatic suboccipital Pott's disease.

CASE DESCRIPTION

Two patients with unusual CVJ tuberculosis form the basis for the present communication. The first patient presented with tubercular otitis media, causing progressive erosion of the petrous part of temporal bone, and destruction of the occipital condyle, along with the lateral mass of atlas, leading to CVJ instability. This is a first report of such a presentation, according to our knowledge. Detailed bony architectural destruction demonstrable on CT scan has been described. The second patient, with CVJ tuberculosis, presented with skull base syndrome and with multiple cranial nerve palsies. Both patients were managed without surgical intervention and showed clinical and radiological recovery.

CONCLUSION

In such patients with unusual clinical presentations, histopathologic examination is necessary to arrive at a correct diagnosis. The management of patients with tubercular involvement of CVJ remains controversial. In the present communication, both the patients were managed successfully with full dose of antitubercular drugs and immobilization.

Vertebral osteomyelitis: long-term disability assessment and prognostic factors

In the present study, we quantified the long-term sequelae of a series of patients diagnosed with vertebral osteomyelitis during the period 1990-2002 in Albacete (Spain), using two validated questionnaires of spinal dysfunction and also one pain and one global health assessment. It was possible to interview 69 (78%) patients diagnosed with vertebral osteomyelitis, and an additional 90 "normal" people were recruited as controls to establish normal values. We also carried out a multivariate analysis to identify independent risk factors. We found only a 33% rate of spinal disability, only 3% severe, assessed by the Oswestry and HAQ for ankylosing spondylitis questionnaires, a median of 5.4 years after treatment. Pain and global health assessment did not correlate with spinal function questionnaires. Independent predictors of long-term disability were the followings: neurological impairment at the time of diagnosis (RR=7.1, 95% CI 1.3-10.2), time to diagnosis > or = 8 weeks (RR=4.4, 95% CI 1.5-7.9) and debilitating disease (RR=3.9, 95% CI 1.2-7.5). Standardized spinal function questionnaires are useful measures to assess long-term outcome of vertebral osteomyelitis that facilitates comparison between case series and identification of risk factors.

Tuberculoma of the cervical spinal canal mimicking en plaque meningioma

A previously healthy, HIV-negative, 40-year-old man presented with a 2-month history of progressive weakness of his left arm. Magnetic resonance imaging revealed an intradural, extramedullary plaque-shaped lesion at C6-T1 levels with high contrast enhancement. Based on the patient's clinical and radiologic findings, it was believed that the patient had an en plaque meningioma, and he was operated on. Histologic examination of the mass revealed granulomas with multinucleated and Langhans-type giant cells, typical of a tuberculoma. Intradural extramedullary tuberculomas should be considered in the differential diagnosis of en plaque meningioma as a rare entity.

Prognosis of conservatively treated patients with Pott's paraplegia: logistic regression analysis

OBJECTIVE

To evaluate the prognostic significance of various clinical, radiological, and neurophysiological findings in conservatively treated patients with Pott's paraplegia, using multiple regression analysis.

METHODS

The study included 43 patients with Pott's paraplegia, managed conservatively. The diagnosis of Pott's spine was based on clinical, magnetic resonance imaging, and computed tomography or ultrasound guided aspiration biopsy. All patients were examined clinically, and motor evoked potentials (MEPs) to lower limbs and tibial somatosensory evoked potentials (SEP) were recorded. Outcome at six months was defined as good or poor. For evaluating predictors of outcome, 15 clinical, investigative, and evoked potential variables were analysed, using multiple logistic regression analysis.

RESULTS

The age range of the patients was 16-70 years, and 22 were female. Mild spasticity with hyperreflexia only was seen in 13 patients. In the remaining, weakness was severe in eight, and moderate and mild in 11 patients each. Twenty patients had loss of joint position sensation. MEP and SEP were abnormal in 19 and 18 patients, respectively. On multiple regression analysis, the best model predicting six month outcome included power, paraplegia score, SEP, and MEP.

CONCLUSION

Patients with Pott's paraplegia are likely to recover completely by six months if they have mild weakness, lower paraplegia score and normal SEPs and MEPs.

Spinal tuberculosis: with reference to the children of northern India

BACKGROUND

Tuberculosis is a necrotizing bacterial infection with protean manifestation and wide distribution. There has been a great fall in the prevalence of tuberculosis in the United States since 1990, although the impact of acquired immunodeficiency syndrome (AIDS) has increased the resurgence of tuberculosis (TB). Spinal tuberculosis is the commonest form of skeletal tuberculosis. In this article, an overview of spinal tuberculosis and the personal experience of 19 children with spinal tuberculosis are presented. All the children required surgical intervention, because they manifested neurological deficit. PATHOGENESIS AND CLINICAL FEATURES: The spinal tuberculosis is a result of hematogenous dissemination from primary focus in the lungs or the lymph nodes. The central type of vertebral tuberculosis spreads along with Batson's plexus of veins, while paradiscal infection spreads through the arteries. The anterior type of vertebral body tuberculosis results from the extension of the abscess beneath the anterior longitudinal ligament and periosteum. Two types of bone and joint tuberculosis are recognized: the caseous, exudative type with abscess formation, which is more common in children, and the granular type is frequent in adults. Only 7 of the 19 children had an abscess, while 10 manifested mainly granulation tissue. Although spinal tuberculosis is an extradural disease, 2 children had intramedullary granulomas and presented a tumor-like syndrome as rare manifestations. It was interesting to encounter intradural granulation and organized intradural granuloma causing cord compression in 2 children. A frank abscess with clumping of nerve roots was encountered in the cauda of another child without vertebral involvement. There is a controversy regarding the age predilection of the disease; it is documented that it is a disease of adults in affluent countries, and a disease of the first three decades in other regions.

DIAGNOSIS

Magnetic resonance imaging is extremely useful in diagnosing the difficult and rare sites of disease like the craniovertebral junction. It detects the marrow changes, exudative and granulation types, extra- and intradural disease, and radiological response to treatment in the early follow-up period around 6-8 weeks.

TREATMENT

Opinion varies regarding the operative indication for Pott's spine. A large group of surgeons perform debridement and decompression in all cases, irrespective of neurological involvement. Others perform operative decompression only in those patients who do not respond to chemotherapy. We did surgical interventions in children with moderate to severe neurological deficits manifesting radiological compression of their neuraxis. Depending on the site of involvement and type of disease the surgical approach was decided in individual cases. Two children with healed Pott's spine also required surgery because of their spinal deformations, which caused gradual neurological deficits and pain in both. Prognosis depends on many factors; the magnitude of cord compression, duration of neural complication, age and general condition of patient. Fifteen of our children made a remarkable recovery. Children with paraplegia also made an excellent recovery of their strength and sensations.

The results of rehabilitation on motor and functional improvement of the spinal tuberculosis

OBJECTIVES

To evaluate the result of rehabilitation on motor and functional improvement in spinal tuberculosis.

METHOD

Prospective case study. Data were collected from 47 patients with spinal tuberculosis medically and/or surgically treated, and rehabilitated over 6 months of period, after spinal decompression and fusion. The main outcome measures were motor development of the patients who were evaluated at the beginning, in the 1st week, in the 3rd month, and in the 6th month. Functional development of the patients was evaluated at the beginning and in the 6th month. Functional assessment was made according to Modified Barthel Index (MBI), and motor examination was made according to American Spinal Injury Association (ASIA).

RESULTS

The study population consisted of 47 patients (22 males and 25 females) mean aged 37.9 +/- 18.3 years (range 5-76 years). The most common site of spinal tuberculosis was the thoracic region. Localized back pain, paraparesis, sensory dysfunction and fever were typical clinical manifestations. Surgical management was performed as anterior or posterior drainage of abscess and/or stabilization of the spine. The rehabilitation program was performed in all patients during the preoperative, early postoperative and late postoperative 6 month periods. Muscle-strengthening exercises on necessary localization such as pectoral, abdominal, lower extremities; truncal and sacrospinal extensors were started for the rehabilitation. The motor score for the lower limbs and the MBI scores for activities of daily living (ADL) and mobility improved significantly (P < 0.001). The self-care and mobility categories of the MBI on admission; were 14.8% severely dependent and 10.6% independent. However, at the end of the rehabilitation program, 4.2% were severely dependent and 70.2% independent.

IN CONCLUSION

Early diagnosis and appropriate medical and/or surgical treatment together with a rehabilitation program will improve the life quality of patients with spinal tuberculosis.

The role of sensory and motor evoked potentials in the prognosis of Pott's paraplegia

OBJECTIVE

In view of paucity of evoked potential changes in Pott's paraplegia, it is proposed to evaluate the role of motor and somatosensory evoked potentials in predicting the outcome.

METHODS

Consecutive patients with Pott's paraplegia during 1993-2003 were subjected to detailed clinical, radiological and evoked potential study. The latter comprised of tibial somatosensory evoked potential (SEP) and motor evoked potential (MEP) study to tibialis anterior. The patients were clinically evaluated at 6 and 12 months and the outcome was defined into poor (bed ridden), partial (dependent for activities of daily living) and complete recovery (independent). The evoked potential findings were correlated with clinical and radiological findings and outcome.

RESULTS

There were 39 patients whose age ranged between 16 and 70 (mean 42.1) years and 22 were females. The mean duration of symptoms was 8.2 months. Sensory motor deficit was present in 18 and pure motor signs in 21 patients. Five patients had quadriplegia and remaining had paraplegia. The muscle weakness was severe in 12 and moderate in 15 patients. In 12 patients, lower limb power was normal but they had lower limb hyper-reflexia with or without spasticity suggesting pyramidal dysfunction. Pinprick and joint position sensations were abnormal in 18 patients. MRI was abnormal in all and revealed cervical involvement in 7, thoracic in 22 and lumbar in 10 patients. Paravertebral soft tissue shadow was present in 36 and cord compression in 30 patients. Motor evoked potential was abnormal in 19 patients (unrecordable in 11 patients, 21 sides and prolonged in 8 patients, 14 sides). SEP was abnormal in 18 patients (unrecordable in 15 patients, 25 sides and prolonged central conduction in 8 patients, 9 sides). Both MEP and SEP were abnormal in 16, normal in 18, and only MEP was abnormal in 3 and only SEP in 2 patients. At 6 month 25 patients had complete, 9 partial and 5 poor recovery. At 1 year 33 had complete and 4 partial recovery. SEP and MEP abnormalities correlated with respective sensory and motor functions, vertebral level and outcome at 6 and 12 months.

CONCLUSIONS

MEP and SEP both are helpful in predicting 6-month outcome. Combining SEP and MEP gives stronger correlation with 6-month outcome compared to only MEP or SEP. The potential role of evoked potentials in deciding different therapeutic strategies needs further studies.

Imaging of tuberculosis of the spine

Tuberculosis (TB) is the leading cause of death worldwide that can be attributed to a single infectious agent. With the onset of the AIDS epidemic, there has been a resurgence of TB in recent years. Skeletal TB constitutes 1% to 3% of extrapulmonary cases, and typically involves the spine. TB of the spine should be considered in the differential diagnosis of many spinal conditions affecting patients of all ages. The pathophysiology, clinical and imaging features of TB of the spine are reviewed, with illustrations of findings on radiography, computed tomography and magnetic resonance imaging. Familiarity with the imaging features of TB of the spine may enable a more rapid diagnosis to be made, thereby preventing a delay in diagnosis with its consequent complications.

[Dysfunctions of respiration and blood circulation in patients with concomitant tuberculosis of the spinal column and lungs]

Functional disorders in the respiratory apparatus and blood circulation were studied in 76 patients with tuberculosis of the spinal column concomitant with pulmonary tuberculosis. Spirography, pneumotachography, elctrocardiography, integral rheography and the method variability of cardiac rate were made use of in the diagnostics of the mentioned disorders. Combined tuberculosis of the spinal column and lungs was found to be accompanied, in case of an active pulmonary process, by instable hemodynamic indices, a reduced contractive myocardium function, an insufficient hemodynamic provision and an increased tension in the respiratory system (impaired ventilation and bronchial patency). Simultaneously, a significant vegetative imbalance with an extremely pronounced hypersympathicotonia and over-tension of the adaptation mechanisms in an active pulmonary process, were registered. The detected dysfunctions need to be corrected due to a forthcoming surgical treatment of tuberculous spondylitis.

Tuberculosis of the spine (Pott's disease) presenting as 'compression fractures'

STUDY DESIGN

Case reports and survey of literature.

OBJECTIVE

Case reports of two women with tuberculosis (TB) of the spine (Pott's disease) presenting with severe back pain and diagnosed as compression fracture are described. Physicians should include Pott's disease in the differential diagnosis when patients present with severe back pain and evidence of vertebral collapse.

SETTING

Ohio, USA METHODS: A review of the literature on the pathogenesis, pathophysiology, clinical presentation, diagnostic methods, treatment and prognosis of spinal TB was conducted.

RESULTS

After initial delay, proper diagnosis of spinal TB was made in our patients. Microbiologic diagnosis confirmed M. tuberculosis, and appropriate medical treatment was initiated.

CONCLUSIONS

Although uncommon, spinal TB still occurs in patients from developed countries, such as the US and Europe. Back pain is an important symptom. Vertebral collapse from TB may be misinterpreted as 'compression fractures' especially in elderly women. Magnetic resonance imaging scan (MRI) is an excellent procedure for the diagnosis of TB spine. However, microbiologic diagnosis is essential. Mycobacterium tuberculosis may be cultured from other sites. Otherwise, biopsy of the spine lesion should be done for pathologic diagnosis, culture and stain for M. tuberculosis. Clinicians should consider Pott's disease in the differential diagnosis of patients with back pain and destructive vertebral lesions. Proper diagnosis and anti-tuberculosis treatment with or without surgery will result in cure.

[Observation of body temperature and erythrocyte sedimentation rate in spinal tuberculosis patients with anterior interbody autograft and internal fixation]

This study was designed to observe the changes in the body temperature and erythrocyte sedimentation rate of patients with thoracolumbar tuberculosis who received anterior interbody autograft and internal fixation. The observation conducted in 21 cases establishes the 2 parameters as simple and reliable indicators for post-operative assessment of the patients.

Spinal tuberculosis: a 15 year review at OAUTHC Ile-Ife

A review of the hospital records over 15 years was made. The objective of the study was to describe the clinical presentation, management and outcome of spinal tuberculosis. Thirty-four patients were studied. There were 15(44.16%) males and 19 (55. 9%) females. Their age range was 2-80 years with mean (+/- SD) of 25.28 +/- 22.33 years. The occupations most commonly affected are Students (44.1%), Pre-school Children (17.6%) and Traders (14.7%). Back pain (100%), weight loss (47.1%), paraparesis (47.1%), kyphotic spinal deformity (32.4%) and night sweats (29.4%) were common features. Only 26.5% patients had active pulmonary tuberculosis. All the vertebral segments were involved. The Lumbar spine was the most involved vertebral segment in 50% patients. Using the Westergren method the mean (+/- SD) Erythrocyte Sedimentation Rate (ESR) mm/hour at the initial diagnosis was 83.58 +/- 31.11 mm/hour whereas three months after the commencement of antituberculosis chemotherapy it was 30.06 +/- 11.96 mm/hour. All the patients were given multiple antituberculosis drugs therapy and spinal traction. Spinal support was offered when the patients became ambulant. At the end of two years follow-up, 94.1% patients were alive, while 5.9% patients died during the course of treatment due to overwhelming sepsis. Among the patients that were alive, 14.7% still had persistence of their neurological deficit ie. paraparesis. Ten percent of the patients were mobilised on crutches while 5.96% were confined to wheelchair. This study shows that in tuberculosis endemic areas, symptom of back pain especially in the younger age group should be thoroughly investigated as this group constituted the largest affected population.

Value of radiologically guided fine needle aspiration cytology (FNAC) in the diagnosis of spinal tuberculosis: a study of 29 cases

FNAC is a simple diagnostic tool for the initial evaluation of various deep seated pathological lesions. This study describes the applicability and practical aspects of the technique in establishing the diagnosis of spinal tuberculosis (TB) with the aid of radiographic guidance. The study was conducted in a major teaching hospital in Kuwait between the years 1985 and 1994. Twenty-nine patients (M:F = 18:11 and age range 8-72 years) with clinically and/or radiologically suspected spinal TB were seen in the Department of Cytology, Mubarak Al Kabeer Hospital. The patients were re-examined by either computed tomography (CT) scanning (n = 19) or fluoroscopy (n = 10) to localize the lesion for FNAC. FNAC smears were routinely stained with Papanicolaou and Diff Quik stains and one smear of each case was stained with Ziehl-Neelsen (Z-N) stain for acid-fast bacilli (AFB). Aspirated purulent material or syringe washings of dry aspirates were also submitted for microbiological cultures including AFB. Radiological and cytological findings were recorded in each case. Radiological findings included: bony rarefaction and destruction (93.1%), narrowed disc space (89.7%), soft tissue calcification (65.5%) and para-vertebral abscess formation (51.7%). Cytological findings included: epithelioid cell granulomas (89.7%), granular necrotic background (82.8%) and lymphocytic infiltration (75.9%). Smears were positive for AFB in 51.7% of cases. A positive AFB culture was obtained in 82.8% of cases, including all cases with positive AFB on smear by Z-N stain. Radiologically guided FNAC with AFB culture is a simple, reliable and practical approach to diagnosing spinal TB lesions. With a high diagnostic yield, it allows immediate initiation of specific treatment, helps to avoid invasive diagnostic procedures, and decreases hospitalization time.

Late onset paraplegia--a sequela to Pott's disease. A report on imaging, prevention and management

Late onset paraplegia is a neurological complication that develops after a variable period in a patient with healed tuberculous disease of the vertebrae. In this retrospective analysis clinical features, imaging in diagnosis and treatment of this condition are described among 5 cases seen over a period of 5 years. This complication occurred even after successful treatment of initial spinal lesions with rifampicin-containing regimens. Magnetic resonance imaging was useful in pinpointing the exact pathology; one case had syrinx and two cases had marked internal gibbus with cord atrophy. Of the two cases who accepted surgical treatment, one improved.

Growth changes of solidly fused kyphotic bloc after surgery for tuberculosis. Comparison of four procedures

STUDY DESIGN

A study to analyze the changes of the spinal deformity during the growth period, with regard to different operations for spinal tuberculosis in children.

OBJECTIVES

To quantify the changes in the kyphotic angle and the growth ratio of the fusion bloc during spinal growth for different fusion techniques.

SUMMARY OF BACKGROUND DATA

Most of the publications dealing with spinal tuberculosis in children focused on the clinical outcome with regard to different conservative and operative treatments. There is little reliable information concerning the growth of the solidly fused kyphotic bone bloc and its influence on the changes of the kyphotic deformity after different operative procedures.

METHODS

The study included 117 children operated on for spinal tuberculosis at the age of 2-6 years at the Ruttonjee Sanatorium in Hong Kong during the 1950s and 1960s. Lateral radiographs obtained postoperatively and 5 and 10 years after the operation were analyzed for the growth changes of the solidly fused bone bloc. These results were compared with the different operation techniques (e.g., anterior fusion, posterior fusion, combined anterior and posterior fusion, and anterior debridement without fusion).

RESULTS

The patients treated by anterior fusion showed the worst results with respect to the kyphotic angle. This was especially true when the lesion was located in the thoracic spine and several segments were involved. Regarding the growth ratio of the fusion bloc, only the combined fusion and the anterior debridement guaranteed an equal growth of the anterior and posterior height.

CONCLUSIONS

Radical anterior surgery for spinal tuberculosis destroys the anterior growth and limits the capacity for spinal remodeling. Therefore, it should be avoided, if it is not absolutely necessary, for the healing of the infection or the primary correction of the tuberculous deformity.

[Spinal tuberculous arachnoiditis]

Tuberculous arachnoiditis of the spine is a rare complication of tuberculous meningitis and can occur despite correct treatment. We report two cases of arachnoiditis in patients with tuberculous meningitis. In both cases, clinical signs included flaccid paraparesia and sphincter dystonia. Evidence for diagnosis was obtained with magnetic resonance imaging of the lombosacral spine after a 3 or 11 week course. Adding corticosteroids to the anti-tuberculosis therapy provided spectacular clinical improvement within 8 days in both cases. The diagnosis of tuberculous arachnoiditis of the spine is often made late but can be confirmed easily with magnetic resonance imaging. Our cases emphasize the importance of oral corticosteroid therapy to avoid severe sequellae.

Increased limb lengths in patients with shortened spines due to tuberculosis in early childhood

STUDY DESIGN

The spine and limb lengths of 26 patients who had a severe spinal deformity due to tuberculosis in childhood were measured and compared with similar data from 79 normal adult volunteers.

OBJECTIVES

The aim of the study was to assess whether there are any compensatory growth mechanisms present in patients who had stunted spinal growth in childhood.

SUMMARY OF BACKGROUND DATA

Previous studies have documented increased leg lengths in patients with adolescent idiopathic scoliosis who have had spinal fusions done. The aim of this study was to ascertain if this response was unique to scoliosis or was a more general response to the interruption of normal spine growth.

METHODS

The standing height, spine height, leg length, and upper limb length were measured in 26 adults with stunted spinal growth due to tuberculosis of the spine contracted in early childhood, and compared with similar measurements in 79 normal volunteers.

RESULTS

The patients with spinal deformity due to tuberculosis had significantly shorter mean standing and spine heights compared to the volunteers. However, the mean leg length of these patients was 19.4 mm longer than the volunteers and their mean upper limb length was 18.9 mm longer than the volunteers. These differences were statistically significant.

CONCLUSION

Patients whose spinal growth was stunted due to disease in childhood have longer legs and upper limbs than healthy people. A compensatory stimulatory growth mechanism may be responsible for this. This has implications for the whole gamut of childhood spinal disorders that result in stunted spinal growth.

Somatosensory and motor evoked potential changes in patients with Pott's paraplegia

The evoked potential changes in patients with Pott's paraplegia have not been reported in the literature. We conducted median and tibial somatosensory evoked potential (SEP) and central motor conduction studies to the upper and lower limbs in seven patients with this condition. The patients' age ranged from 20 to 71 years; four were males. The vertebral involvement was commonest in the lower thoracic region (4), and a cold abscess was present in five of the patients. Central motor conduction time (CMCT) to the lower limbs was unrecordable in 3 (six sides) and prolonged in 3 patients (four sides). The tibial SEP was unrecordable in 4 patients (seven sides). Motor evoked potentials and SEP correlated with respective motor and sensory impairments, as well as with the outcome.

Neural arch tuberculosis: a morbid disease. Radiographic and computed tomographic findings

We have reviewed the clinical features, together with the radiographs and computerised tomography, in 9 patients with tuberculosis of the vertebral body and neural arch. All presented with paraparesis or paraplegia. The morbidity associated with this disease is so serious that it is essential to have an accurate means of evaluating the lesion as early as possible. Routine radiographs can only indicate the level of the disease and the loss of disc space, but cannot define the full extent of the lesion. Computed tomography shows details of the tuberculous involvement of the neural arch, as well as the vertebral body and spinal canal; the site and extent of the soft tissue lesions can also be seen. This is essential for evaluation of the neural arch involvement which will enable the clinician to select the appropriate treatment, and so prevent neurological complications.

Atypical spinal tuberculosis in children

Spinal tuberculosis characteristically involves two contiguous vertebral bodies with narrowing of the disk space. We report on 11 children with atypical spinal tuberculosis. Three had disease confined to a single body, four had extradural extraosseous involvement presenting as an abscess, and isolated infection of the neural arch was seen in four children. Seven children had neurological involvement. Treatment included posterior decompression for the extradural extraosseous involvement, biopsy and drainage for the neural arch infection, and anterior decompression and fusion for the single-body disease. The patients had antituberculosis treatment for 18 months, and all seven children with neurological involvement recovered.

[Spondylodiscitis with spinal and radicular involvement. Limits of conservative treatment]

During 1988 to 1992 18 patients with spondylodiscitis and neurological deficits were treated in our clinic. Tuberculous spondylodiscitis was diagnosed in 4 patients and 14 suffered from non specific spondylodiscitis. The mean age was 59 years (range 25-77). 16 (89%) of the patients had risk factors like diabetes mellitus, genitourinary tract infection, respiratory tract infection, rheumatism, intervertebral disc operation and old spine fracture. MR-tomography revealed the most valuable diagnostic method. 14 patients with progressive spinal cord compression, and root lesions because of gross vertebral damage and epidural abscess underwent operative removal of the focus with intercorporal spondylodesis. Postoperative neurological examination revealed improvement in 7 and no changes in the other 7 patients. In 4 patients with non specific spondylodicitis and radicular deficits conservative treatment was performed and spontaneous interbody fusion without persisting neurological complaints occurred.