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Kumar V, Neradi D, Sherry B, Gaurav A, Dhatt SS. Tuberculosis of the spine and drug resistance: a review article. Neurosurg Rev 2021; 45:217-229. [PMID: 34176000 DOI: 10.1007/s10143-021-01595-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 06/02/2021] [Accepted: 06/21/2021] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Vishal Kumar
- Department of Orthopedics, PGIMER, Chandigarh, India
| | - Deepak Neradi
- Department of Orthopedics, PGIMER, Chandigarh, India
| | | | - Ankit Gaurav
- Department of Orthopedics, PGIMER, Chandigarh, India
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Oldest evidence of tuberculosis in Argentina: A multidisciplinary investigation in an adult male skeleton from Saujil, Tinogasta, Catamarca (905-1030 CE). Tuberculosis (Edinb) 2020; 125:101995. [PMID: 32979676 DOI: 10.1016/j.tube.2020.101995] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 09/07/2020] [Accepted: 09/18/2020] [Indexed: 01/17/2023]
Abstract
The Mycobacterium tuberculosis complex (MTC) has affected South American populations since ca. 200 years BCE. In Argentina, possible cases date from ca. 1000-1400 Common Era (CE). This paper describes the oldest (905-1030 CE) confirmed case of tuberculosis (TB) in a young adult male from Lomitas de Saujil (Tinogasta, Catamarca, Argentina). Osteolytic lesions on the bodies of the lower spine were macroscopically and radiographically identified. Bilateral new bone formation was seen on the visceral vertebral third of several ribs and in long bones, compatible with hypertrophic osteoarthropathy. Representative rib and hand bones gave profiles for MTC-specific C27-C32 mycocerosic acid lipid biomarkers; these were strongest in one heavily-lesioned lower rib, which also had MTC-diagnostic C76-C89 mycolic acids and positive amplification of MTC-typical IS6110 aDNA fragments. During the first millennium CE, the intense social interaction, the spatial circumscription of villages among the pre-Hispanic societies in the mesothermal valleys of Catamarca and the fluid contacts with the Eastern lowlands, valleys and puna, were factors likely to favor disease transmission. It is proposed that TB arrived from northern Chile and dispersed towards the northeast into the Yocavil valley, where several cases of TB infection were macroscopically identified for a later chronology.
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Abstract
BACKGROUND Spondylodiscitis in children is rare. The condition has an incidence of 2 to 4 % of all infectious skeletal diseases in children. AIM Aim of the article is the presentation of epidemiology, the clinical signs, radiological findings as well the treatment options of non-specific and specific spondylodiscitis in children. METHODS The available literature was reviewed. RESULTS Non-specific spondylodiscitis in children is caused by haematogenous spread of pathogens. Staphylococcus aureus is the most frequently detected bacterium. The clinical signs are unspecific and an Magnetic Resonance Imaging of the spine is the standard radiological procedure to detect spondylodiscitis. In general, the treatment is conservative and includes an antibiotic therapy as well an immobilization of the spine. In endemic areas of the world, specific spondylodiscitis is more common and is caused by Mycobacterium tuberculosis or Brucellae. The treatment is also conservative. For all entities of spondylodiscitis in children, a surgical intervention is only necessary in the case of severe deformities due to the infection or in the case of neurological symptoms. CONCLUSION Elevated infectious laboratory values and back pain or other unspecific symptoms can indicate spondylodiscitis in children. MRI of the spine is necessary to rule out spondylodiscitis.
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Affiliation(s)
- A Völker
- Klinik und Poliklinik für Orthopädie, Unfallchirurgie und plastische Chirurgie, Bereich Wirbelsäulenchirurgie, Universitätsklinikum Leipzig, Liebigstraße 20, 04103, Leipzig, Deutschland
| | - S Schubert
- Klinik für Gastroenterologie und Rheumatologie, Fachbereich Infektions- und Tropenmedizin, Universitätsklinikum Leipzig, Liebigstraße 20, 04103, Leipzig, Deutschland
| | - C-E Heyde
- Klinik und Poliklinik für Orthopädie, Unfallchirurgie und plastische Chirurgie, Bereich Wirbelsäulenchirurgie, Universitätsklinikum Leipzig, Liebigstraße 20, 04103, Leipzig, Deutschland.
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Sarat Chandra P. The changing trends in management of spinal tuberculosis: Are we hitting a better road? INDIAN JOURNAL OF NEUROSURGERY 2017. [DOI: 10.4103/2277-9167.124225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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He QY, Xu JZ, Zhou Q, Luo F, Hou T, Zhang Z. Treatment effect, postoperative complications, and their reasons in juvenile thoracic and lumbar spinal tuberculosis surgery. J Orthop Surg Res 2015; 10:156. [PMID: 26427381 PMCID: PMC4590253 DOI: 10.1186/s13018-015-0300-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 09/24/2015] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE Fifty-four juvenile cases under 18 years of age with thoracic and lumbar spinal tuberculosis underwent focus debridement, deformity correction, bone graft fusion, and internal fixation. The treatment effects, complications, and reasons were analyzed retrospectively. MATERIAL AND METHOD There were 54 juvenile cases under 18 years of age with thoracolumbar spinal tuberculosis. The average age was 9.2 years old, and the sample comprised 38 males and 16 females. The disease types included 28 thoracic cases, 17 thoracolumbar cases, and 9 lumbar cases. Nerve function was evaluated with the Frankel classification. Thirty-six cases were performed with focus debridement and deformity correction and were supported with allograft or autograft in mesh and fixed with pedicle screws from a posterior approach. Eight cases underwent a combined anterior and posterior surgical approach. Nine cases underwent osteotomy and deformity correction, and one case received focus debridement. The treatment effects, complications, and bone fusions were tracked for an average of 52 months. RESULTS According to the Frankel classification, paralysis was improved from 3 cases of B, 8 cases of C, 18 cases of D, and 25 cases of E preoperatively. This improvement was found in 3 cases of C, 6 cases of D, and 45 cases of E at a final follow-up postoperatively. No nerve dysfunction was aggravated. VAS was improved from 7.8 ± 1.7 preoperatively to 3.2 ± 2.1 at final follow-up postoperatively. ODI was improved from 77.5 ± 17.3 preoperatively to 28.4 ± 15.9 at final follow-up postoperatively. Kyphosis Cobb angle improved from 62.2° ± 3.7° preoperatively to 37° ± 2.4° at final follow-up postoperatively. Both of these are significant improvements, and all bone grafts were fused. Complications related to the operation occurred in 31.5% (17/54) of cases. Six cases suffered postoperative aggravated kyphosis deformity, eight cases suffered proximal kyphosis deformity, one case suffered pedicle penetration, one case suffered failure of internal devices, and one case suffered recurrence of tuberculosis. CONCLUSION As long as the treatment plan is fully prepared, the surgical option can achieve a satisfactory curative effect in treating juvenile spinal tuberculosis despite some complications.
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Affiliation(s)
- Qing-Yi He
- Department of Orthopedics, Southwest Hospital, Third Military Medical University, No. 30 Gaotanyan Street Shapingba District, Chongqing, 400038, China.
| | - Jian-Zhong Xu
- Department of Orthopedics, Southwest Hospital, Third Military Medical University, No. 30 Gaotanyan Street Shapingba District, Chongqing, 400038, China.
| | - Qiang Zhou
- Department of Orthopedics, Southwest Hospital, Third Military Medical University, No. 30 Gaotanyan Street Shapingba District, Chongqing, 400038, China.
| | - Fei Luo
- Department of Orthopedics, Southwest Hospital, Third Military Medical University, No. 30 Gaotanyan Street Shapingba District, Chongqing, 400038, China.
| | - Tianyong Hou
- Department of Orthopedics, Southwest Hospital, Third Military Medical University, No. 30 Gaotanyan Street Shapingba District, Chongqing, 400038, China.
| | - Zehua Zhang
- Department of Orthopedics, Southwest Hospital, Third Military Medical University, No. 30 Gaotanyan Street Shapingba District, Chongqing, 400038, China.
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Jiang T, Zhao J, He M, Wang K, Fowdur M, Wu Y. Outcomes and Treatment of Lumbosacral Spinal Tuberculosis: A Retrospective Study of 53 Patients. PLoS One 2015; 10:e0130185. [PMID: 26121685 PMCID: PMC4485466 DOI: 10.1371/journal.pone.0130185] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Accepted: 05/17/2015] [Indexed: 11/18/2022] Open
Abstract
Study Strategy A retrospective clinic study. Purpose To evaluate the efficacy of conservative and surgical treatment for lumbosacral tuberculosis. Methods This study retrospectively reviewed 53 patients with lumbosacral tuberculosis who were treated in our institution between January 2005 and January 2011. There were 29 males and 24 females with average ages of 37.53 ± 17.28 years (range 6–72 years). 11 patients were given only anti-TB drugs; the remainder underwent anterior debridement, interbody fusion with and without instrumentation, or one-stage anterior debridement combined with posterior instrumentation. Outcome data for these patients included neurologic status, lumbosacral angle, erythrocyte sedimentation rate value(ESR) and C-reactive protein value(CRP) were assessed before and after treatment. Results The mean lumbosacral angles were 23.00°± 2.90°in the conservatively treated patients and 22.36°± 3.92o in the surgically treated patients. At the final follow-up, this had improved to 24.10o ± 2.96°in the conservatively treated patients and 28.13° ± 1.93°in the surgically treated patients (all P < 0.05). There were statistically significant differences before and after treatment in terms of ESR and CRP (all P < 0.05). All patients achieved bone fusion. The mean follow-up period was 32.34 ± 8.13 months (range 18 to 55 months). The neurological deficit did not worsen in any of the patients. Conclusions It has been proven that conservative and surgical treatments are safe and effective and produce good clinical outcomes for patients with lumbosacral tuberculosis. The advantages of operation include thoroughness of debridement, decompression of the spinal cord, and adequate spinal stabilization.
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Affiliation(s)
- Tenglong Jiang
- Division of Spinal Surgery, The First Affiliated Hospital of Guangxi Medical University, No.6 Shuang Yong Rd, Nanning, Guangxi, China
- Guangxi Key Laboratory of Regenerative Medicine, Nanning, Guangxi, China
| | - Jinming Zhao
- Department of Orthopedic Trauma and Hand Surgery, The First Affiliated Hospital of Guangxi Medical University, No.6 Shuang Yong Rd, Nanning, Guangxi, China
- Guangxi Key Laboratory of Regenerative Medicine, Nanning, Guangxi, China
| | - Maolin He
- Division of Spinal Surgery, The First Affiliated Hospital of Guangxi Medical University, No.6 Shuang Yong Rd, Nanning, Guangxi, China
- Guangxi Key Laboratory of Regenerative Medicine, Nanning, Guangxi, China
- * E-mail:
| | - Kun Wang
- Division of Spinal Surgery, The First Affiliated Hospital of Guangxi Medical University, No.6 Shuang Yong Rd, Nanning, Guangxi, China
- Guangxi Key Laboratory of Regenerative Medicine, Nanning, Guangxi, China
| | - Mitra Fowdur
- Division of Spinal Surgery, The First Affiliated Hospital of Guangxi Medical University, No.6 Shuang Yong Rd, Nanning, Guangxi, China
- Guangxi Key Laboratory of Regenerative Medicine, Nanning, Guangxi, China
| | - Yang Wu
- Department of Orthopedic Trauma and Hand Surgery, The First Affiliated Hospital of Guangxi Medical University, No.6 Shuang Yong Rd, Nanning, Guangxi, China
- Guangxi Key Laboratory of Regenerative Medicine, Nanning, Guangxi, China
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Late onset of progressive neurological deficits in severe angular kyphosis related to tuberculosis spondylitis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2015; 25:1039-46. [DOI: 10.1007/s00586-015-3997-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Revised: 05/03/2015] [Accepted: 05/03/2015] [Indexed: 11/28/2022]
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Nas K, Karakoç M, Aydın A, Öneş K. Rehabilitation in spinal infection diseases. World J Orthop 2015; 6:1-7. [PMID: 25621205 PMCID: PMC4303778 DOI: 10.5312/wjo.v6.i1.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Revised: 05/29/2014] [Accepted: 09/17/2014] [Indexed: 02/06/2023] Open
Abstract
Spinal cord infections were the diseases defined by Hypocrite yet the absence of modern medicine and there was not a real protocol in rehabilitation although there were many aspects in surgical treatment options. The patients whether surgically or conservatively treated had a lot of neurological, motor, and sensory disturbances. Our clinic has quite experience from our previous researchs. Unfortunately, serious spinal cord infections are still present in our region. In these patients the basic rehabilitation approaches during early, pre-operation, post-operation period and in the home environment will provide significant contributions to improve the patients’ sensory and motor skills, develop the balance and proriocaption, increase the independence of patients in daily living activities and minimize the assistance of other people. There is limited information in the literature related with the nature of the rehabilitation programmes to be applied for patients with spinal infections. The aim of this review is to share our clinic experience and summarise the publications about spinal infection rehabilitation. There are very few studies about the rehabilitation of spinal infections. There are still not enough studies about planning and performing rehabilitation programs in these patients. Therefore, a comprehensive rehabilitation programme during the hospitalisation and home periods is emphasised in order to provide optimal management and prevent further disability.
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Surgery-related complications and sequelae in management of tuberculosis of spine. Asian Spine J 2014; 8:435-45. [PMID: 25187860 PMCID: PMC4149986 DOI: 10.4184/asj.2014.8.4.435] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Revised: 12/26/2013] [Accepted: 12/28/2013] [Indexed: 12/05/2022] Open
Abstract
Study Design Medical record-based survey. Purpose To survey the overall incidence of the intra- and postoperative complications and sequelae, and to propose the preventive measures to reduce complications in the spinal tuberculosis surgery. Overview of Literature There is no study focused on the surgery-related complications and sequelae, with some touching lightly on the clinical problems. Methods There were 901 patients in this study, including 92 paraplegics. One hundred eighty-six patients had no visible deformity, while those of 715 patients were visible. Six hundred fifty-nine patients had slight to moderate non-rigid kyphosis, and 56 had severe rigid kyphosis. Sixty-seven out of 92 paraplegics had slight to moderate non-rigid kyphosis, and 25 had severe kyphosis. There were 134 cervical and cervicodorsal lesions, 518 thoracic and thoracolumbar lesions, and 249 lumbar and lumbosacral lesions. Seven hundred sixty-four patients had primarily anterior surgeries, and 137 had posterior surgeries. Instrumentation surgery was combined in 174 patients. Results There were intra- and postoperative complications: direct large vessel and neurological injuries (cord, roots, nerves), late thrombophlebitis, various thoracic cavity problems, esophagus and ureter injuries, peritoneum perforation, ileus, wound infections, stabilization failure, increase of deformity and late adjacent joint and bone problems. Thrombophlebitis and sympatheticolysis symptoms and signs in the lower limbs were the most common complications related with anterior lumbar and lumbosacral surgeries. Kyphosis increased in 31.5% of the non-instrumented anterior surgery cases (42% in children and 21% in adults). Conclusions The safe, effective and most familiar surgical procedure should be adopted to minimize complications and sequelae. Cosmetic spinal surgery should be withheld if functional improvement could not be expected.
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Moon MS. Tuberculosis of spine: current views in diagnosis and management. Asian Spine J 2014; 8:97-111. [PMID: 24596613 PMCID: PMC3939378 DOI: 10.4184/asj.2014.8.1.97] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2009] [Revised: 10/19/2013] [Accepted: 10/19/2013] [Indexed: 02/07/2023] Open
Abstract
Tuberculosis is the chronic consumptive disease and currently the world's leading cause of death. Tuberculous spondylitis is a less common yet the most dangerous form of skeletal tuberculosis. The recent re-emergence of Mycobacterium tuberculosis (M. tuberculosis) hints at a possible resurgence of tuberculosis in the coming years. This article discusses the clinical manifestations, diagnosis and treatment of tuberculous spondylitis, and updates material that the author has previously published on the subject. Treatment should be individualized according to different indications which is essential to recovery. A treatment model is suggested on the basis of the author's vast personal experiences.
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Affiliation(s)
- Myung-Sang Moon
- Department of Orthopedic Surgery, Cheju Halla General Hospital, Jeju, Korea
- Moon-Kim's Institute of Orthopedic Research, Seoul, Korea
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A large tuberculosis abscess causing spinal cord compression of the cervico-thoracic region in a young child. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2013; 22:1459-63. [PMID: 23604937 DOI: 10.1007/s00586-013-2729-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2012] [Revised: 02/18/2013] [Accepted: 02/20/2013] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Despite numerous descriptive publications, the guidelines for treatment of cervical spinal tuberculosis (TB) are not very clear. The authors report a case of a young girl with cervico-thoracic spinal TB extending from C5 to T3 vertebrae presenting with weakness of the right hand and unsteady gait. CASE REPORT An 11-year-old female who is an immigrant to the UK from Afghanistan, presented to our clinic with a 10-day history of difficulty in walking with an unsteady gait and 3-month history of progressive weakness in both her arms, the right side more affected than the left. Her immunisation history was unclear. Examination of the arms showed bilateral thenar and hypothenar wasting, more so on the right than the left. An MRI scan revealed a large para-spinal abscess extending from C3/4 to T4/5 with a significant anterior epidural cord compression from C5/6 to T2/3. Therapeutic/diagnostic aspiration was performed under ultrasound guidance and the aspirate was sent for microbiology. She was started empirically on multidrug anti-tubercular treatment and steroids. Although Ziehl-Neelsen stain was negative for acid-fast bacilli, microbiological confirmation of TB was obtained by positive TB culture sensitive to all first-line anti-TB drugs. She made a dramatic improvement within 3 weeks of anti-tubercular treatment. A follow-up MRI scan at 8 months showed complete resolution of the abscess. At 2 years of follow-up, she was a healthy looking child, back to her school with no residual clinical signs/symptoms of the disease. CONCLUSION Our case of cervico-thoracic tuberculous abscess in a young child suggests that even with incomplete neurological deficit caused by epidural cord compression, ultrasound (or CT)-guided aspiration and anti-tubercular medication provide acceptable results at 2 years of follow-up.
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Chandra SP, Singh A, Goyal N, Laythalling RK, Singh M, Kale SS, Sharma MS, Suri A, Singh P, Garg A, Sarkar C, Tripathi M, Sharma BS, Mahapatra AK. Analysis of changing paradigms of management in 179 patients with spinal tuberculosis over a 12-year period and proposal of a new management algorithm. World Neurosurg 2013; 80:190-203. [PMID: 23348057 DOI: 10.1016/j.wneu.2012.12.019] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2011] [Revised: 08/10/2012] [Accepted: 12/12/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To describe management and outcome in a large cohort of patients with spinal tuberculosis (TB). METHODS Of 212 patients with spinal TB treated between January 1999 and June 2011, 179 patients were included in the study (≥6 months follow-up; mean age, 34.8 years; age range, 10-75 years). The cohort was divided into two groups (n = 89 and n = 90); group I was treated from 1999-2003, and group II was treated from 2004-2011. RESULTS The study cohort comprised 93 male patients. Mean age was 34.8 years ± 7.2 (range, 10-75 years). Mean duration of symptoms was 2.4 months. Sensorimotor deficits were present in 167 patients (93.5%; 74 patients were paraplegic), pain was present in 156 patients (87%), bladder involvement was present in 127 patients (71.7%), and extraspinal TB was present in 36 patients (22.3%). Of patients, 92% were receiving prior chemotherapy; one fifth of these patients were on second-line chemotherapy. Thoracic spine involvement was most common (n = 86; 57%), followed by cervical spine (n = 50; 29%), craniovertebral junction (n = 22; 15%), and lumbosacral spine (n = 20; 10.5%). Surgery was performed in 146 patients (68% instrumented fusions and 16% circumferential fusions). Mean follow-up was 20.2 months (range, 6-60 months). Sensorimotor deficits improved in 89% of patients, pain improved in 71%, bladder symptoms improved in 88%, and paraplegia improved in 77%. Patients in group II had a higher incidence of cord compression (P < 0.01), severe vertebral body collapse (P < 0.001), and paraplegia (P < 0.001). Group II patients underwent more instrumented surgeries (P < 0.01), especially circumferential fusions (P < 0.001). The improvement in paraplegia was better after 2004 (group II). Bladder symptoms correlated with the timing of surgery (P < 0.1). CONCLUSIONS Medical treatment of spinal TB is the mainstay; however, radical, instrumented surgeries should be offered when indicated. The presence of paraplegia should not preclude surgery. A practical management paradigm is also suggested.
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Affiliation(s)
- Sarat P Chandra
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India.
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Abstract
Every genus of microorganism, as well as prions, has been associated with disease of the spinal cord. The spectrum of pathogens resulting in myelopathy varies with the population. Myelopathy is uniquely associated with certain retroviruses, particularly HIV type 1 and human T-cell lymphotropic virus type I, but the myelopathies that occur with these viruses are chiefly limited to "at risk" populations. In the immunocompromised population, a diverse array of pathogens may cause spinal cord disease, especially viruses from the Herpesviridae family, most notably cytomegalovirus and varicella-zoster virus. The prototypical myelopathy resulting from bacterial infection is tabes dorsalis, but this disorder is vanishingly rare in the modern era. In developing countries, Mycobacterium tuberculosis and schistosomiasis remain significant causes of myelopathy.
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Zaoui A, Kanoun S, Boughamoura H, Ben Maitigue M, Bouaziz MA, Khachnaoui F, Rejeb N. Patients with complicated Pott's disease: management in a rehabilitation department and functional prognosis. Ann Phys Rehabil Med 2012; 55:190-200. [PMID: 22445109 DOI: 10.1016/j.rehab.2012.02.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2011] [Revised: 02/07/2012] [Accepted: 02/10/2012] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The objective is to study the rehabilitation management and to assess autonomy in daily life activities as well as walking recovery in patients with complicated Pott's disease. PATIENTS AND METHODS Retrospective study in nine patients over a period of 8 years extending from 2000 to 2008, collated in the Department of Physical Medicine and Functional Rehabilitation, CHU Sahloul, Sousse, Tunisia. RESULTS The mean age of our patients was 43.8 years; sex ratio was 5/4. The spine involvement of tuberculosis was dorsal in seven cases, dorso-lumbar in one patient, and multiple (cervical, dorsal and lumbar) in one case. All patients were paraplegic with a neurological involvement of the bladder. They had prior antituberculosis chemotherapy for at least 8 months. Decompression surgery was performed in six cases. Two female patients presented disorders of spinal posture during treatment requiring surgical revision with osteosynthesis. All patients received additional rehabilitation care. Following a mean duration of hospitalisation in the Rehabilitation department of 47 days with twice-daily sessions of tailored physiotherapy, three patients remained in complete paraplegia, autonomous in wheel-chair and with vesical and sphincter incontinence. The measure of functional independence (MFI) was at admission/discharge 71/92. CONCLUSION Rehabilitation takes an important place in the medico-surgical management in Pott's disease, to limite or compensate the disabilities and handicap related to this pathology.
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Affiliation(s)
- A Zaoui
- Service de médecine physique et de réadaptation fonctionnelle, CHU Sahloul, Sousse, Tunisia.
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Zhang Z. Late onset Pott's paraplegia in patients with upper thoracic sharp kyphosis. INTERNATIONAL ORTHOPAEDICS 2011; 36:381-5. [PMID: 21656306 DOI: 10.1007/s00264-011-1285-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2011] [Accepted: 05/18/2011] [Indexed: 11/29/2022]
Abstract
PURPOSE The purpose of this study was to determine the clinical results of patients with late onset upper thoracic sharp Pott's kyphosis and to predict the prognosis for Pott's paraplegics. METHOD The study included five patients who developed late onset upper thoracic (T1-T4) sharp Pott's kyphosis/kyphoscoliosis within a period from 19 to 37 years after the active disease was healed. The kyphosis angle of the patients ranged from 95° to 105°. Among them, three patients suffered onset of paraplegia ranging from 26 to 31 years after spinal tuberculosis was healed. The duration of neurological deterioration before surgery ranged from four to five years. All patients underwent decompressive surgery with an attempt to correct the curve. Neurological status was evaluated using the ASIA impairment classification and the motor score. RESULTS Postoperatively, kyphosis correction ranged from 20° to 30° for five patients. No neurological deficit occurred in two patients with normal neurological status. Two ASIA D paraplegics remained unchanged after surgery and no further improvement was found at one year follow-up. One ASIA C paralysis deteriorated neurologically to ASIA B after surgery and persisted to a deterioration of neurological status at one year follow-up. CONCLUSION Upper thoracic sharp Pott's kyphosis and neurological deficits occur progressively. The neurological recovery or improvement of Pott's paraplegics with upper thoracic severe sharp kyphosis results in poor prognosis after decompressive surgery.
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Affiliation(s)
- Zhengfeng Zhang
- Department of Orthopaedics, Xinqiao Hospital, Third Military Medical University, Shapingba District, Chongqing, China.
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Donald P. The chemotherapy of osteo-articular tuberculosis with recommendations for treatment of children. J Infect 2011; 62:411-39. [DOI: 10.1016/j.jinf.2011.04.239] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2011] [Accepted: 04/29/2011] [Indexed: 02/07/2023]
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Abstract
STUDY DESIGN An observational study. OBJECTIVE We report clinical, MRI and urodynamic findings in spinal tuberculosis. SETTING Tertiary care teaching hospital. METHOD Patients with spinal tuberculosis having micturition disturbances or high postvoidal residual (PVR) urine were subjected to clinical evaluation, urodynamic and spinal MRI. Urinary symptoms were scored as per the American Urological Association Symptom (AUAS) Index. The outcome was defined at 12 months into complete, partial and poor. RESULTS Of 30 spinal tuberculosis patients, 15 had micturition disturbance and included urinary retention in 4, stress incontinence in 2, hesitancy in 6, urgency in 11 and urge incontinence in 9 patients. Thirteen patients had paraparesis and one had quadriparesis. Spinal MRI revealed granuloma in 2, dorsal vertebral involvement in 12 and cervical and lumbar vertebral involvement in 1 patient each. On urodynamic study, detrusor hyperreflexia (DH) with high-pressure voiding was present in six, detrusor areflexia (DA) in four, normal study in one and increased PVR urine in the remaining patients. AUAS score improved on follow-up. DA changed to DH with high-pressure voiding in one patient. The 15 patients without micturition disturbance had no horizontal sensory level, milder or no weakness and only 2 had spinal cord signal changes. Patients with micturition disturbances had poorer functional recovery at 1 year compared to those without micturition disturbances. CONCLUSION Bladder symptoms were present in 50% of the admitted patients with spinal tuberculosis and related to severity of paraplegia, horizontal sensory level, cord signal abnormality and poorer outcome compared to those without spinal tuberculosis. Urodynamic study helped in categorization and management.
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Merrell C, McKinley W. Infection-Related Spinal Cord Injury: Etiologies and Outcomes. Top Spinal Cord Inj Rehabil 2008. [DOI: 10.1310/sci1402-31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Moon MS. Tuberculosis of spine—Contemporary thoughts on current issues and perspective views. ACTA ACUST UNITED AC 2007. [DOI: 10.1016/j.cuor.2007.09.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Moon MS, Moon JL, Kim SS, Moon YW. Treatment of tuberculosis of the cervical spine: operative versus nonoperative. Clin Orthop Relat Res 2007; 460:67-77. [PMID: 17414165 DOI: 10.1097/blo.0b013e31805470ba] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
We retrospectively reviewed 15 children (four with paralysis) and 39 adults (10 with paralysis) with tuberculosis of the cervical spine to assess the drug responses, disease arrest, and healing times. Ten children and 13 adults were treated nonoperatively, while anterior débridement was performed in five children (two with paralysis) and anterior radical surgery in 26 adults (10 with paralysis). Triple chemotherapy (isoniazid, rifampin, ethambutol [or pyrazinamide for children]) was given to all patients for 12 months. The tuberculosis began to arrest after 3 months of chemotherapy and healed within 12 months. Spontaneous fusion occurred in all adults but only two of the 10 children. Surgical fusion was achieved within 12 to 16 weeks in adults. In nonoperated patients, an initial kyphosis of 12 degrees progressed to 17 degrees at final followup in the children and an initial kyphosis of 9 degrees progressed to 13 degrees in 13 adults. In operated patients, the initial kyphosis of 13 degrees in adults became 2 degrees at the time of the fusion, while the initial kyphosis of 14 degrees in the five children progressed to 18 degrees. Patients with paraplegia recovered completely within 14 days on average (range, 1-42 days) after treatment. Recovery was gradual in the nonoperative group, while it occurred within 3 days in the operative group.
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Affiliation(s)
- Myung-Sang Moon
- Department of Orthopedic Surgery, Sun General Hospital, Dae-jeon, Korea
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21
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Abstract
We analyzed 124 papers published in the English language literature to define the indications and timing of surgery in spinal TB and to evaluate the outcome of various surgical procedures for kyphosis and neural outcome. Surgery in spinal tuberculosis is indicated for diagnostic dilemma, neural complications, and prevention of kyphosis progression. Up to 76% canal encroachment is compatible with a normal neurologic state as the spinal cord tolerates gradually developing compression. Patients with relatively preserved cord size, but with edema/myelitis and predominantly fluid compression on MRI respond well to nonoperative treatment. We believe patients with extradural compression by granulation tissue with little fluid component compressing or constricting the cord circumferentially with cord edema/myelitis or myelomalacia need early surgical decompression. Transthoracic transpleural anterior decompression and extrapleural anterolateral decompression have similar results in the dorsal spine. Instrumented stabilization helps prevent graft-related complications when postdébridement defects exceed two disc spaces (4-5 cm). Progression of kyphosis may occur in a short-segment disease despite instrumented stabilization. Its outcome in a long-segment disease needs observation. The correction of healed kyphosis requires multistage surgery and is fraught with complications. Prospective studies are needed to define surgical approach, steps, stages, problems, and obstacles to correct severe kyphosis in spinal TB.
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Affiliation(s)
- Anil K Jain
- University College of Medical Sciences, Delhi - 110095, India.
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Abstract
Although most lumbar lesions associated with spinal tuberculosis can be satisfactorily resolved with nonoperative treatment, there are cases in which surgery is indicated. Between July 1982 and December 2003 we retrospectively reviewed 51 patients who were operated by anterior débridement and fusion. Twelve patients were lost to followup and one died due to inferior vena cava tear. Followup of 38 patients ranged from 2 to 10 years (average 4 years). There were 22 male and 16 female patients, average age 35 years (range, 8-65 years); upper lumbar area (L1-L3) was involved in 17 cases, lower lumbar (L3-L5) in 19 and lumbosacral area in two patients; 28 patients had two-body and 10 had three-body involvement. In 35 patients we performed single stage débridement and fusion. More recently three patients had two stage (instrumentation plus débridement and fusion) procedure. Followup was based on subjective relief, recovery of neural deficit and consolidation at fusion site. Thirty-six out of 38 patients had complete relief from pain and discomfort along with radiographic fusion. Five patients who had neural deficit recovered completely. Surgical treatment of lumbar spinal tuberculosis in selected cases gives satisfactory results.
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Affiliation(s)
- S K Mukherjee
- Department of Orthopaedics, Pt. J. N. M. Medical College and Dr. B. R. Ambedkar Memorial Hospital, Raipur, India.
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Kotil K, Alan MS, Bilge T. Medical management of Pott disease in the thoracic and lumbar spine: a prospective clinical study. J Neurosurg Spine 2007; 6:222-8. [PMID: 17355021 DOI: 10.3171/spi.2007.6.3.222] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The aim of this study was to evaluate conservative medical management of 44 patients with Pott disease. The prognostic significance of various clinical, radiological, and long-term follow-up findings in these patients was also evaluated. METHODS Between January 1990 and January 2005 data were collected prospectively at the authors' clinic in 44 patients with Pott disease in the thoracic or lumbar spine. These patients had no major neurological deficits or severe spinal deformities. The study population consisted of 21 male (48%) and 23 female (52%) patients, with a mean age of 42.1 years (range 10-70 years). The most common region of Pott disease was the thoracolumbar junction (18 cases; 41%), followed by the thoracic (16 cases; 36%) and lumbar (10 cases; 23%) regions. All patients presented with abscesses. With the exception of two cases, all had kyphotic angles smaller than 30 degrees. At presentation, 20 patients had neurological signs of spinal cord compression during clinical examination. Both clinical and biopsy findings were used in all cases for diagnosis. A diagnosis was confirmed by a positive biopsy specimen culture in 19 (43.2%) of 44 cases, and histopathological findings were compatible with the results of these cultures in all cases. All patients were treated with antituberculous chemotherapy, and the diseases in only two (4.5%) was resistant to the regimen. An independent observer assessed the clinical and imaging findings after a mean follow-up duration of 40 months. Forty-two (95.4%) of the 44 patients were successfully treated with conservative medical management and attained acceptable spinal deformity angles, and none of these patients had any residual instability, radiculopathy, or neurological compromise. Only 4.5% of the patients experienced residual spine deformity (as much as a 30 degrees kyphotic angle), which was clinically obvious but biomechanically stable. CONCLUSIONS Patients with Pott disease in the lumbar or thoracic region, without neurological deficits or kyphosis, can be treated conservatively in the vast majority of cases. Indications for surgery need to be redefined given these new data.
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Affiliation(s)
- Kadir Kotil
- Department of Neurosurgery, Haseki Education and Research Hospital, Istanbul, Turkey.
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Sai Kiran NAS, Vaishya S, Kale SS, Sharma BS, Mahapatra AK. Surgical results in patients with tuberculosis of the spine and severe lower-extremity motor deficits: a retrospective study of 48 patients. J Neurosurg Spine 2007; 6:320-6. [PMID: 17436920 DOI: 10.3171/spi.2007.6.4.6] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Significant numbers of patients with spinal tuberculosis (TB), especially in developing countries, still present late after disease onset with severe neurological deficits. The authors conducted a study to assess the outcome in these patients.
Methods
Fifty-nine patients with spinal TB and severe motor deficits underwent surgery at the authors' center during the past 10 years. Data obtained in 48 patients with a minimum of 3 months of follow up (mean follow-up period 12.8 months) were analyzed. The disease in 34 patients was characterized by Frankel Grade A/B (Medical Research Council Grade 0/5) and in 14 patients by Frankel Grade C (unable to walk even with support) at admission. Thirty (88%) of the 34 patients with Frankel Grade A/B status and 13 (92.8%) of the 14 patients with Frankel Grade C status at admission experienced improvement to Frankel Grade D/E (walking with or without support) at the last follow-up examination 3 or more months after surgery. The degree of improvement exhibited by patients with a Frankel Grade A/B spinal cord injury was comparable to that shown by patients with Frankel Grade C status. Even patients with flaccid paraplegia, gross sensory deficit, prolonged weakness, spinal cord signal changes demonstrated on magnetic resonance imaging, and bladder involvement have experienced dramatic improvement in motor function since surgery. A significant number of the patients have shown remarkable improvement in other symptoms such as pain (91.6%), spasticity (88%), and bladder symptoms (88%).
Conclusions
A significant proportion of patients with spinal TB and severe motor deficits experience remarkable improvement after surgical decompression and hence should undergo surgery even though they may be suffering from paraplegia of considerable duration.
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Ozyemici-Takiran O, Celk GE, Altunçekç A, Sepici V. Cervical spinal tuberculous abscess managed successfully by conservative approach. Disabil Rehabil 2007; 29:255-60. [PMID: 17375395 DOI: 10.1080/09638280600756372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE To draw attention to the increasing number of cases of spinal tuberculosis by an additional case presentation of cervical tuberculous abscess. METHOD A 54-year-old diabetic woman with neck and arm pain, weakness in four limbs was diagnosed spinal tuberculosis. MRI demonstrated epidural mass at C4-C5 level with destruction of these vertebral bodies. Diagnosis was confirmed by the clinical improvement after administration of antituberculous drugs. RESULTS After the drug therapy, improvement was observed in her neurological status. Follow-up MRI studies after 3 and 5 months showed disappearance of the mass lesion. CONCLUSIONS To treat this spinal infection effectively, it should be considered in the differential diagnosis. Early diagnosis increases the chance of conservative therapy. In our case, despite neurological complications, management was accomplished by nonoperative approach.
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Affiliation(s)
- Ozden Ozyemici-Takiran
- Department of Physical Medicine and Rehabilitation, Gazi University Faculty of Medicine, Ankara, Turkey.
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Thoracic Pott Disease (Tuberculous Spondylitis) Presenting as Cervical Lymphadenitis. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2006. [DOI: 10.1097/01.idc.0000206489.97798.f9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Swanson AN, Pappou IP, Cammisa FP, Girardi FP. Chronic infections of the spine: surgical indications and treatments. Clin Orthop Relat Res 2006; 444:100-6. [PMID: 16523133 DOI: 10.1097/01.blo.0000203447.44146.55] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
UNLABELLED Chronic vertebral osteomyelitis is a disease of substantial morbidity. Although uncommon to most spinal surgeons, the incidence of pyogenic and granulomatous spondylitis worldwide is on the rise. Although antibiotic therapy remains the initial treatment for most patients, surgical debridement with or without stabilization may be required for effective eradication of the disease. Indications for surgery in pyogenic and granulomatous osteomyelitis include the need to obtain a bacteriologic diagnosis when other methods have failed, the presence of a clinically significant abscess, an infection refractory to prolonged nonoperative treatment, cord compression with considerable neurologic deficit, and substantial deformity or spinal instability. Currently, controversy remains regarding the timing of surgery, the approach used, and the use of instrumentation. We reviewed the contemporary literature available through the Medline database, focusing on larger case series and, when existing, prospective randomized trials. The rationale for surgical treatment of the most common pathogens (eg, Mycobacterium tuberculae and Staphylococcus aureus) is reviewed. Commonly, anterior debridement with or without posterior instrumentation is used for cases of advanced disease, but more limited approaches may have a role in less severe cases or patients unable to tolerate extensive surgery. LEVEL OF EVIDENCE Therapeutic study, level III (systematic review of level III studies). Please see the Guidelines for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Andrew N Swanson
- Department of Spinal Surgery, Hospital for Special Surgery, New York, New York 10021, USA.
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Pappou IP, Papadopoulos EC, Swanson AN, Mermer MJ, Fantini GA, Urban MK, Russell L, Cammisa FP, Girardi FP. Pott disease in the thoracolumbar spine with marked kyphosis and progressive paraplegia necessitating posterior vertebral column resection and anterior reconstruction with a cage. Spine (Phila Pa 1976) 2006; 31:E123-7. [PMID: 16481941 DOI: 10.1097/01.brs.0000199900.56446.ee] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Case report. OBJECTIVES To report on a patient with Pott disease, progressive neurologic deficit, and severe kyphotic deformity, who had medical treatment fail and required posterior/anterior decompression with instrumented fusion. Treatment options will be discussed. SUMMARY OF BACKGROUND DATA Tuberculous spondylitis is an increasingly common disease worldwide, with an estimated prevalence of 800,000 cases. METHODS Surgical treatment consisting of extensive posterior decompression/instrumented fusion and 3-level posterior vertebral column resection, followed by anterior debridement/fusion with cage reconstruction. RESULTS Neurologic improvement at 6-month follow-up (Frankel B to Frankel D), with evidence of radiographic fusion. CONCLUSIONS A 70-year-old patient with progressive Pott paraplegia and severe kyphotic deformity, for whom medical treatment failed is presented. A posterior vertebral column resection, multiple level posterior decompression, and instrumented fusion, followed by an anterior interbody fusion with cage was used to decompress the spinal cord, restore sagittal alignment, and debride the infection. At 6-month follow-up, the patient obtained excellent pain relief, correction of deformity, elimination of the tuberculous foci, and significant recovery of neurologic function.
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Jutte PC, van Altena R, Pras E, Thijn CJP. Causes of misdiagnosis and mistreatment of spinal tuberculosis with radiotherapy in nonendemic areas: a pitfall in diagnosis and treatment: hazards of radiotherapy on the tuberculous lesion. Spine (Phila Pa 1976) 2005; 30:E300-4. [PMID: 15928539 DOI: 10.1097/01.brs.0000163886.20464.02] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Report of initially misdiagnosed and mistreated cases. OBJECTIVES To report a previously undescribed misdiagnosis and subsequent mistreatment with radiation for tuberculosis of the spine and to promote awareness for tuberculosis in nonendemic areas. SUMMARY OF BACKGROUND DATA It is not seldom that radiation therapy is provided for suspected malignant spinal lesions without histologic confirmation. Literature is not available on harmful effects of radiation therapy for tuberculosis of the spine. METHODS Clinical case analysis for initial misdiagnosis and mistreatment, analysis of subsequent clinical course. RESULTS Two patients received radiotherapy on spinal lesions of suspected malignant origin. In both patients, the lesions were of tuberculous origin and the lesions increased during radiotherapy. In Case 2, the paraplegia did not heal. CONCLUSION In cases of a spinal lesion of unknown origin, tuberculosis should always be considered. Adequate biopsy for cultures and histology is mandatory. Radiotherapy locally aggravates tuberculous spinal lesions.
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Affiliation(s)
- Paul C Jutte
- Department of Orthopaedic Surgery, Groningen University Medical Centre, Groningen, The Netherlands.
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Asazuma T, Toyama Y, Suzuki N, Fujimura Y. Posterior circumferential decompression for late onset paraparesis caused by kyphotic deformity due to infantile tuberculosis--case report. Neurol Med Chir (Tokyo) 2005; 44:554-7. [PMID: 15633470 DOI: 10.2176/nmc.44.554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
A 46-year-old male presented with late onset of paraparesis caused by kyphotic deformity due to infantile tuberculosis. A posterior circumferential decompression was performed from the sixth thoracic to the eighth thoracic levels. His neurological status improved with no evidence of kyphosis progression at the last follow up (2 years 5 months postoperatively). The paraparesis was caused by bony compression following increasing kyphosis above and below the block vertebrae due to growth. Posterior circumferential decompression is a less invasive surgical intervention for this condition.
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Affiliation(s)
- Takashi Asazuma
- Department of Orthopaedic Surgery, National Defense Medical College, Tokorozawa, Saitama, Japan.
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Nene A, Bhojraj S. Results of nonsurgical treatment of thoracic spinal tuberculosis in adults. Spine J 2005; 5:79-84. [PMID: 15653088 DOI: 10.1016/j.spinee.2004.05.255] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2004] [Accepted: 05/24/2004] [Indexed: 02/03/2023]
Abstract
BACKGROUND The indications for surgery in spinal tuberculosis have been controversial, and more so recently, in the era of renewed understanding of the concept of multi-drug-resistant tuberculosis along with newer modalities of spinal instrumentation. Indications for surgery need to be redefined in this context. PURPOSE To assess the efficacy and results of nonsurgical treatment in thoracic spinal tuberculosis in adult patients, and redefine indications for surgery. STUDY DESIGN We present a retrospective analysis of 70 adults with thoracic spinal tuberculosis, with varying presentations, including abscesses and neurological deficits, seen at our spine clinic, in a period between August 1998 and August 2000, treated largely nonsurgically, with rewarding results. METHODS A retrospective study was made of 70 adult patients with thoracic spinal tuberculosis presenting at our spine clinic, between August 1998 and August 2000. All patients were subjected to medical management, unless there were specific indications for surgery, as per our protocol, wherein absolute indications of surgery in adults included advanced neurological deficit (less than Grade 3 by 5, by the 5-point grading system of the Medical Research Council), neurology worsening while on antituberculous chemotherapy, diagnosis in doubt on clinicoradiological evaluation and significant kyphosis (greater than 40 degrees) on presentation. Clinical and radiological assessment of results was made by an independent observer, at a mean follow up of 40 months. RESULTS Forty-four patients presented with abscesses, 21 of which were epidural. Seven had neurological signs of cord compression on clinical examination at presentation. Over 98% of our patients (69 of 70) were successfully treated conservatively, and none of these had any residual instability, radiculopathy or neurological compromise. Seventy-four percent had excellent to good results, with no mechanical residues of the disease, and 23% had residual kyphosis, which was clinically obvious, but biomechanically irrelevant. CONCLUSIONS We think that tuberculous spondylodiscitis in adults can be well managed conservatively in a vast majority of cases, and indications for surgery are few and specific.
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Affiliation(s)
- Abhay Nene
- The Spine Clinic, P.D. Hinduja National Hospital and Medical Research Centre, Veer Savarkar Road, Mahim, Mumbai 400-016, India.
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Spinal Tuberculosis. Tuberculosis (Edinb) 2004. [DOI: 10.1007/978-3-642-18937-1_30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Al Sebai MW, Madkour MM, Al Moutaery KR. Surgical Management of Spinal Tuberculosis. Tuberculosis (Edinb) 2004. [DOI: 10.1007/978-3-642-18937-1_31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Abstract
BACKGROUND CONTEXT Pott disease and tuberculosis have been with humans for countless millennia. Before the mid-twentieth century, the treatment of tuberculous spondylitis was primarily supportive and typically resulted in dismal neurological, functional and cosmetic outcomes. The contemporary development of effective antituberculous medications, imaging modalities, anesthesia, operative techniques and spinal instrumentation resulted in quantum improvements in the diagnosis, management and outcome of spinal tuberculosis. With the successful treatment of tuberculosis worldwide, interest in Pott disease has faded from the surgical forefront over the last 20 years. With the recent unchecked global pandemic of human immunodeficiency virus, the number of tuberculosis and secondary spondylitis cases is again increasing at an alarming rate. A surgical revisitation of Pott disease is thus essential to prepare spinal surgeons for this impending resurgence of tuberculosis. PURPOSE To revisit the numerous treatment modalities for Pott disease and their outcomes. From this information, a critical reappraisal of surgical nuances with regard to decision making, timing, operative approach, graft types and the use of instrumentation were conducted. STUDY DESIGN A concise review of the diagnosis, management and surgical treatment of Pott disease. METHODS A broad review of the literature was conducted with a particular focus on the different surgical treatment modalities for Pott disease and their outcomes regarding neurological deficit, kyphosis and spinal stability. RESULTS Whereas a variety of management schemes have been used for the debridement and reconstruction of tuberculous spondylitis, there has also been a spectrum of outcomes regarding neurological function and deformity. Medical treatment alone remains the cornerstone of therapy for the majority of Pott disease cases. Surgical intervention should be limited primarily to cases of severe or progressive deformity and/or neurological deficit. Based on the available evidence, radical ventral debridement and grafting appears to provide reproducibly good long-term neurological outcomes. Furthermore, recurrence of infection is lowest with such techniques. Posterior operative techniques are most effective in the reduction and prevention of spinal deformity. CONCLUSIONS Unlike historical times, effective medical and surgical management of tuberculous spondyitis is now possible. Proper selection of drug therapy and operative modalities, however, is needed to optimize functional outcomes for each individual case of Pott disease.
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Affiliation(s)
- Larry T Khoo
- Institute for Spine Care, Chicago Institute of Neurosurgery and Neuroresearch, Rush Presbyterian Medical Center, Chicago, IL 60614, USA
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Moon MS, Moon JL, Moon YW, Kim SS, Kim SS, Sun DH, Choi WT. Pott's paraplegia in patients with severely deformed dorsal or dorsolumbar spines: treatment and prognosis. Spinal Cord 2003; 41:164-71. [PMID: 12612619 DOI: 10.1038/sj.sc.3101366] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN Pott's paraplegic patients with severe spinal deformity were reviewed retrospectively after being treated with chemotherapy and/or decompressive surgery. OBJECTIVES To determine the most appropriate treatment protocol and to predict the prognosis for Pott's paraplegics with severe spinal deformity. SETTING Catholic University of Korea Medical Center and Moon-Kim's Institute of Orthopedic Research, Seoul, Korea from 1971 to 1996. METHOD In this study, there were 33 patients (eight children and 25 adults), ranging from 13 to 56 years of age. They developed spinal tuberculosis at the age of 9 years (range, 2-29 years), and remained neurologically symptom free from an average of 16 years (range, 4-27 years). Four adults who responded well to treatment initially suffered relapses of paraplegia. Only six patients had previously received a full course of triple chemotherapy. Seven (two children, five adults) had healed disease, and 26 (six children, 20 adults) had active disease. Eleven cases had frequent drainage from the sinuses. Kyphoscoliosis was found in 11 patients: four children and seven adults. The remaining patients had kyphosis only. Among the 26 patients with active tuberculosis, 10 had triple chemotherapy itself and the rest had additional decompression surgery (10 anterior and six posterior). All seven patients with healed tuberculosis were subjected only to surgery (two anterior and five posterior). RESULTS In seven patients with healed tuberculosis, surgery did not improve neurologically except in one child patient. In four patients, the severity of paralysis remained unchanged and two patients, deteriorated neurologically after surgery. In six children with active tuberculosis, there were remarkable neurological recoveries by either conservative treatment or surgical decompression. Seven adults with active tuberculosis recovered slowly, improving by one or two Frankel grades (three Frankel C, three D, one E). In 11 out of 13 surgically treated adults with active disease, paralysis that had persisted for less than 3 months gradually improved by one or two Frankel grades. One Frankel A and one Frankel B paraplegic patients who had paralysis that had lasted through 6 months did not recover after surgery. CONCLUSION The neurological recovery of Pott's paraplegics with severe spinal deformity resulted in three different outcomes: (1) severe deformity is different from moderate and mild deformities; (2) patients with healed tuberculosis had poorer prognosis than patients with active tuberculosis; (3) children had better prognosis than adults. Furthermore, patients with paralysis persisting over 6 months did not recover neurologically after surgery.
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Affiliation(s)
- Myung-Sang Moon
- Spine Center, Department of Orthopedic Surgery, Sun General Hospital, Taejon, Korea
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Abstract
Neurologic complications are the most dreaded complication of spinal tuberculosis. The patients who have paraplegia develop in the active stage of tuberculosis of the spine require active treatment for spinal tuberculosis and have a better prognosis than the patients who have paraplegia develop many years after the initial disease has healed. Neurologic dysfunctions in association with active tuberculosis of the spine can be prevented by early diagnosis and prompt treatment. Prompt treatment can reverse paralysis and minimize the potential disability resulting from Pott's paraplegia. When needed, a combination of conservative therapy and surgical decompression yields successful results in most patients with tuberculosis of the spine who have neurologic complications. The vertebral body primarily is affected in tuberculosis; therefore, decompression has to be anterior. Laminectomy is advocated in patients with posterior complex disease and spinal tumor syndrome. Late onset paraplegia is best avoided by prevention of the development of severe kyphosis. Patients with tuberculosis of the spine who are likely to have severe kyphosis develop (< 60 degrees) on completion of treatment should have surgery in the active stage of disease to improve kyphus.
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Affiliation(s)
- Anil K Jain
- Department of Orthopedics, University College of Medical Sciences And G.T.B. Hospital, Delhi, India
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Affiliation(s)
- R J Osguthorpe
- Department of Pediatrics and Section of Infectious Diseases, The Children's Hospital, University of Colorado Health Sciences Center, Denver, Colorado, USA.
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Abstract
The literature includes no studies on the use of video-assisted thoracoscopic surgery in the management of tuberculous spondylitis, and its role in the management of tuberculosis involving the thoracic spine remains unclear. The authors experience with 10 consecutive patients (six women, four men) who underwent video-assisted thoracoscopic surgery for the treatment of spinal tuberculosis involving levels from T5 to T11, from January 1996 to December 1997, was analyzed. Using the extended manipulating channel method (2.5-3.5 cm portal incisions), video-assisted thoracoscopic surgery was performed with a three-portal technique (seven patients) or a modified two-portal minithoracotomy technique that required a small incision for the thoracoscope and a larger incision, measuring 5 to 6 cm, for the procedures in three patients. All the patients were studied prospectively. The followup ranged from 17 to 42 months (mean, 24 months). Postoperative complications included one lung atelectasis. Pleural adhesions, owing to local inflammation or paravertebral abscess, were seen in four patients and one patient with severe pleurodesis needed an open technique for treatment. Postoperative air leaks were seen in four (40%) of 10 patients but all were transient. The average neurologic recovery was 1.1 grades on the Frankel's scale. The data from this series of patients with tuberculous spondylitis show that video-assisted thoracoscopic surgery has diagnostic and therapeutic roles in the management of tuberculous spondylitis. Technically, a combination of thoracoscopy and conventional spinal instruments to perform video-assisted thoracoscopic surgery through the extended manipulating channels, which were placed slightly more posterior than usual, was effective and safe.
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Affiliation(s)
- T J Huang
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
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Balagué F, Borenstein DG. How to recognize and treat specific low back pain? BAILLIERE'S CLINICAL RHEUMATOLOGY 1998; 12:37-73. [PMID: 9668956 DOI: 10.1016/s0950-3579(98)80005-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
A wide variety of mechanical and non-mechanical disorders are associated with the clinical symptom of low back pain. Mechanical disorders are the cause of the vast majority of low back pain. Despite this frequency, the specific cause of mechanical low back pain can not be elucidated in spite of extensive diagnostic evaluation in a majority of individuals. Specific causes of low back pain are associated with less frequently occurring systemic illnesses including rheumatic, infectious, neoplastic, gynaecological and vascular disorders. The diagnostic process is more successful in identifying systemic disorders as the specific cause of low back pain. Non-surgical management is effective therapy with most patients with mechanical disorders of any form. Systemic illnesses require interventions directed specifically at healing the affected organ system.
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Affiliation(s)
- F Balagué
- Service de Rhumatologie, Médecine Physique et Rééducation, Hôpital Cantonal, Fribourg, Switzerland
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Abstract
Tuberculosis is a deadly disease affecting many people in the world. The prevalence of spinal tuberculosis is likely to rise as the numbers of those infected with human immunodeficiency virus rises. This presentation summarizes present knowledge of spinal tuberculosis and its management. It describes and updates material the author has previously published on this subject. The scientific basis for the clinical management of spinal tuberculosis has been well established by the British Medical Research Council group and Hong Kong surgeons. It is believed, however, that well-controlled basic and clinical studies are required if the incidence of the three unwanted complications of spinal tuberculosis is to be reduced further. Antituberculosis agents are the mainstay of management, with chemotherapy for 12 months preferred to shorter courses. The standard is a combination of isoniazid, rifampin, and pyrazinamide, with or without ethambutol. Anterior surgery consisting of radical focal debridement without fusion does not prevent vertebral collapse. The major advantage of anterior arthrodesis is the decreased tendency for progression of the deformity. Patients who present late with deformity are candidates for anterior debridement and stabilization with corrective instrumentation. Posterior stabilization with instrumentation has been found to help arrest the disease and to bring about early fusion. Posterior instrumented stabilization to prevent kyphosis in early spinal tuberculosis is indicated, however, only when anterior and posterior elements of the spine are involved, particularly in children. With early detection, institution of chemotherapy, and improved surgical techniques, patients with kyphosis rarely are seen today, particularly in urban centers that have an effective medical system. For these same reasons, patients with spinal tuberculosis who present with paraplegia and no deformity usually respond well to treatment. It is concluded that spinal tuberculosis without unsightly kyphosis and neurologic symptoms is a medical, rather than a surgical, condition. Surgery should be reserved for those patients who have advanced tuberculosis with unacceptable complications such as paraplegia and/or deformity.
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Affiliation(s)
- M S Moon
- Moon-Kim's Institute of Orthopaedic Research, Seoul, Korea
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