Diagnosis Of Tuberculous Spondylitis Research Articles

Differentiation of tuberculous and brucellar spondylitis using conventional MRI-based deep learning algorithms

PurposeTo investigate the feasibility of deep learning (DL) based on conventional MRI to differentiate tuberculous spondylitis (TS) from brucellar spondylitis (BS). MethodsA total of 383 patients with TS (n = 182) or BS (n = 201) were enrolled from April 2013 to May 2023 and randomly divided into training (n = 307) and validation (n = 76) sets. Sagittal T1WI, T2WI, and fat-suppressed (FS) T2WI images were used to construct single-sequence DL models and combined models based on VGG19, VGG16, ResNet18, and DenseNet121 network. The area under the receiver operating characteristic curve (AUC) was used to assess the classification performance. The AUC of DL models was compared with that of two radiologists with different levels of experience. ResultsThe AUCs based on VGG19, ResNet18, VGG16, and DenseNet121 ranged from 0.885 to 0.973, 0.873 to 0.944, 0.882 to 0.929, and 0.801 to 0.933, respectively, and VGG19 models performed better. The diagnostic efficiency of combined models outperformed single-sequence DL models. The combined model of T1WI, T2WI, and FS T2WI based on VGG19 achieved optimal performance, with an AUC of 0.973. In addition, the performance of all combined models based on T1WI, T2WI, and FS T2WI was better than that of two radiologists (P<0.05). ConclusionThe DL models have potential guiding value in the diagnosis of TS and BS based on conventional MRI and provide a certain reference for clinical work.

A diagnostic model for differentiating tuberculous spondylitis from pyogenic spondylitis: a retrospective case–control study

The purpose of this study was to describe and compare the clinical data, laboratory examination and imaging examination of tuberculous spondylitis (TS) and pyogenic spondylitis (PS), and to provide ideas for diagnosis and treatment intervention. The patients with TS or PS diagnosed by pathology who first occurred in our hospital from September 2018 to November 2021 were studied retrospectively. The clinical data, laboratory results and imaging findings of the two groups were analyzed and compared. The diagnostic model was constructed by binary logistic regression. In addition, an external validation group was used to verify the effectiveness of the diagnostic model. A total of 112 patients were included, including 65 cases of TS with an average age of 49 ± 15 years, 47 cases of PS with an average of 56 ± 10 years. The PS group had a significantly older age than the TS group (P = 0.005). In laboratory examination, there were significant differences in WBC, neutrophil (N), lymphocyte (L), ESR, CRP, fibrinogen (FIB), serum albumin (A) and sodium (Na). The difference was also statistically significant in the comparison of imaging examinations at epidural abscesses, paravertebral abscesses, spinal cord compression, involvement of cervical, lumbar and thoracic vertebrae. This study constructed a diagnostic model, which was Y (value of TS > 0.5, value of PS < 0.5) = 1.251 * X1 (thoracic vertebrae involved = 1, thoracic vertebrae uninvolved = 0) + 2.021 * X2 (paravertebral abscesses = 1, no paravertebral abscess = 0) + 2.432 * X3 (spinal cord compression = 1, no spinal cord compression = 0) + 0.18 * X4 (value of serum A)−4.209 * X5 (cervical vertebrae involved = 1, cervical vertebrae uninvolved = 0)−0.02 * X6 (value of ESR)−0.806 * X7 (value of FIB)−3.36. Furthermore, the diagnostic model was validated using an external validation group, indicating a certain value in diagnosing TS and PS. This study puts forward a diagnostic model for the diagnosis of TS and PS in spinal infection for the first time, which has potential guiding value in the diagnosis of them and provides a certain reference for clinical work.

Positivity rates of mycobacterial culture in patients with tuberculous spondylitis according to methods and sites of biopsies: An analysis of 206 cases

ObjectivesWe aimed to evaluate the mycobacterial culture positivity rates according to biopsy methods and sites in patients with tuberculous spondylitis (TS) and identify which tissues are the best sites for the diagnosis of TS. MethodsWe retrospectively identified and reviewed medical records of all patients with TS in three university-affiliated hospitals in the Republic of Korea from January 2003 to December 2020. TS was diagnosed by culture or histopathologic examination of vertebral bodies or paraspinal tissues and characteristic clinical and radiologic features. Patients with TS who received a needle biopsy or underwent surgical biopsy were investigated. The sites of needle biopsy were classified as vertebral bodies or paraspinal tissues. ResultsDuring the study period, 206 tissues from 200 patients with TS were included in the analysis. The culture positivity rates of vertebral bodies obtained by needle biopsy, paraspinal tissues obtained by needle biopsy, and tissues obtained by surgery were 69.0%, 85.3%, and 83.2%, respectively. Multivariate logistic regression identified that paraspinal tissues as biopsy sites were independently associated with mycobacterial culture positivity in TS undergoing needle biopsy (adjusted odds ratio, 3.68; 95% confidence interval: 1.13–11.99, P = 0.030). ConclusionsWe demonstrated that the positivity rates of mycobacterial culture in TS were 69.0–85.3%. Paraspinal tissues as biopsy sites were significantly associated with culture positivity in needle biopsy, suggesting that targeting paraspinal tissues during needle biopsy may be the best method for diagnosing TS.

Загальні принципи діагностики туберкульозного спондиліту

Актуальність. Епідеміологічна ситуація щодо кістково-суглобового туберкульозу (КСТ) характеризується значною кількістю невиявлених хворих. Метою даної публікації є привернення уваги практичних лікарів до важливої проблеми діагностики туберкульозного спондиліту (ТС) і підвищення її ефективності. Матеріали та методи. В основу дослідження покладені дані протоколів обстежень та медична документація 175 хворих, які у період з 2006 по 2015 рік знаходились у відділенні кістково-суглобового туберкульозу КЗОЗ «Обласна туберкульозна лікарня № 1» Харківської обласної ради та хірургічному відділенні КЗОЗ «Обласний протитуберкульозний диспансер № 1» Харківської обласної ради з активним уперше діагностованим ТС. Усі проліковані хворі були розподілені на дві групи. До першої групи ввійшли 93 (53,1 %) хворі, у яких лікування проводилося з оперативним втручанням на уражених специфічним деструктивним процесом хребцях, до другої — 82 (46,9 %) хворі, яких лікували без оперативних втручань, тобто консервативно. Вік хворих був у межах від 17 до 75 років. Результати. При ретельному зборі анамнезу у пацієнтів, яких обстежували, вдалося визначити наявність контактів із хворими на туберкульоз, особливо з бактеріовиділеннями, у 14 хворих І групи (15,1 %) і 16 — ІІ групи (19,5 %), отримані відомості про перенесені захворювання (про туберкульоз інших локалізацій) у 8 пацієнтів І групи (8,6 %) і 10 — ІІ групи (12,2 %). Після значного загального переохолодження захворіли 3 пацієнти І групи (3,2 %) і 2 — ІІ групи (2,4 %). Травма і тяжка фізична робота передували першим ознакам ТС у 9 хворих І групи (9,7 %) і 7 — ІІ групи (8,5 %). У результаті обробки бази даних серед уперше виявлених хворих на ТС нами відібрані та проаналізовані провокуючі фактори для розвитку захворювання, що зустрічалися в обстежених хворих. Ці фактори умовно поділялися на дві групи: А — органні (клінічні), Б — соціальні. Наявність органних факторів було виявлено у 72 пацієнтів І групи (77,4 %) і 68 — ІІ групи (82,9 %). Різні комбінації цих факторів визначали один із трьох ступенів ризику — високий, середній, низький. Нозологічна діагностика ТС включала в усіх випадках оглядову рентгенографію у двох площинах, яка виконувалась на основі даних огляду хворого. Подальша діагностика поглиблювалась за задачами хірургічного лікування. Розробка ряду нових технологій променевої діагностики хребта значно поширила діагностичні можливості ТС. До традиційного рентгенологічного методу додалися контрастна мієлографія, комп’ютерна томографія, магнітно-резонансна томографія. За відсутності бактеріологічного, цитологічного та гістологічного підтверджень діагнозу останній встановлювали за всією сукупністю результатів досліджень. Використання запропонованих принципів діагностики ТС з урахуванням групи ризику дозволило значно скоротити кількість запущених та ускладнених форм цього захворювання. Якщо у 2005 р. серед хворих, які надійшли до спеціалізованих відділень КСТ із вперше діагностованим активним ТС, запущені та ускладнені форми були в 77,6 %, то у 2012 р. — у 39,2 % пацієнтів (зниження майже у 2 рази), що свідчить про високу ефективність цих методів діагностики. Діагностика ТС базувалася на зіставленні клінічних, лабораторних, бактеріологічних і рентгенологічних даних, нових методів променевої діагностики. Враховували характер розвитку захворювання, звичайно поступовий і тривалий, попередні або супутні туберкульозні ураження інших органів або систем, наявність умов, що сприяють контакту з туберкульозними хворими. Висновки. Таким чином, діагноз туберкульозу хребта порівняно легко встановити, якщо своєчасно подумати про можливість цього захворювання, здійснити первинне обстеження хворого в межах діагностичного мінімуму і, при необхідності, запросити відповідного спеціаліста для консультації.

A modern approach to the diagnosis of tuberculous spondylitis (literature review)

Objective — provide a systematic analysis of the scientific literature on the current state of diagnosis of patients with tuberculous spondylitis (TS), and identify prospects for improving the diagnosis of this disease. Materials and methods. To carry out this work, we analyzed 118 literature sources from the Pub Med database on the records of Diagnosis of extrapulmonary tuberculosis. Diagnosis of tuberculous spondylitis, and 26 of them tacked for detailed study. Results and discussion. It was found that TS is the most severe clinical form of osteoarticular tuberculosis (OATB), which is a serious medical and social problem. The percentage of diagnostic errors in TS is very high and its level in recent decades has a clear tendency to increase. The diagnostic pause in this disease usually lasts at least three months. Clinico-radiological examinations are the most accessible and widely used in the world, being the basis for the diagnosis of OATB. From the standpoint of evidence-based medicine, a verified (proven) diagnosis of OATB should be based on data from bacteriological and histological examination of pathological material. Quite often the course of the TS is accompanied by the phenomena of pathomorphosis, which significantly complicates the differential diagnosis. In scientific publications, insufficient attention is paid to the issue of etiological diagnosis of the disease, but traditional methods of clinical and radiological studies have a significant percentage of diagnostic errors. Conclusions. Diagnosis of TS in modern conditions in the vast majority of cases occurs at a later stage (in the advanced form), which causes significant difficulties in the treatment this category of patients.It is important to improve the methods of etiological diagnosis of TS with the following studies sensitivity of the pathogen to antibacterial drugs, which is one of the main conditions for successful treatment.

Diagnosis of tuberculous spondylitis

Diagnosis of tuberculous spondylitis in adults, especially in the absence of kyphosis and a characteristic response to the load of the spine, is often very difficult. Barr (Bulk md., No. 10, 1923) advises in such cases to pay special attention to various "neuralgic" phenomena, unilateral increase in tendon reflexes and Babinsk'oro symptom, as well as to limited rigidity of the spinal muscles.

Change of Pyogenic and Tuberculous Spondylitis between 2007 and 2016 Year : A Nationwide Study.

ObjectiveWe attempted to compare the incidence of pyogenic spondylitis (PS) and tuberculous spondylitis (TS) between 2007 and 2016. Furthermore, we investigated the patients who underwent surgery in 2016 compared to that in 2007. MethodsWe used a nationwide database managed by the Korean National Health Insurance Service (NHIS) in 2007 and 2016. Total 9655 patients with a newly diagnosis of PS or TS were enrolled in PS or TS group. Among them, 1721 patients underwent either fusion or decompression surgery. We analyzed demographic distribution of patients according to gender and age and year of diagnosis. ResultsComparing between 2007 and 2016, the incidence of PS has increased in 2016 than in 2007 (4874 vs. 2431, p<0.0001). Conversely, declination of incidence of TS was discovered in 2016 compared to 2007 (594 vs. 1756, p<0.0001). Females showed predominance over males regarding both PS and TS (5228 vs. 4427, p<0.0001). Among them, the number of PS patients who underwent surgery increased significantly in 2016 relative to that in 2007 (979 vs. 592, p<0.0001). ConclusionThis nationwide study suggests that PS may increase and TS may decrease in Korea. In addition, demand for surgery regarding PS may increase.

A Novel Magnetic Resonance Imaging Scoring System in Making Specific Diagnosis of Tubercular Spondylitis in Advanced Infection

Objective: The diagnosis of tuberculous spondylitis by microbiological and histopathological analysis is time consuming. Non-invasive methods such as magnetic resonance imaging (MRI) are useful for early diagnosis of infective spondylitis; however, the usefulness of MRI in accurate prediction of tuberculosis rather than non-specific infections is still not elucidated. There is a lacuna in the literature with regard to this. Non-invasive identification of tubercular etiology help in initiation of appropriate treatment and thus a better therapeutic response. We intend to devise a novel MRI score in making a confident diagnosis of tubercular spondylitis rather than non-specific infective spondylitis. Materials and Methods: A retrospective observational analysis was performed on 125 biopsy-proven infective spondylitis patients which included 70 tubercular (Group A) and 55 pyogenic (Group B) patients. Tubercular spondylitis was confirmed by either positive result of tissue gene expert test, histopathology or culture results. Eight MRI findings described in literature to be favorable for tubercular spondylitis were selected and analyzed for their predictive value, and a scoring system is derived based on the observations. Results: Statistically significant differentiation was noted in six out of selected eight MRI parameters, namely, (1) involvement of more than two contiguous vertebrae, (2) presence of para or intraosseous abscess, (3) subligamentous spread, (4) vertebral collapse, (5) large collection with thin abscess wall, and (6) presence of hypointense debris/wall on T2WI. Positive predictive value for tubercular spondylitis was obtained for the following MRI parameters by multivariate regression analysis: (1) Sub-ligamentous spread, (2) vertebral collapse, (3) large collection with thin abscess wall, and (4) presence of T2 hypointense debris. These MRI parameters having an independent prediction of tuberculosis were given two points score for each. Less significant MRI findings of more than two contiguous vertebral involvement and presence of intraosseous abscess were given a score of one for each. A total score of 10 was formulated and scoring for both groups was tabulated and analyzed. Contrary to that available in literature, no significant statistical correlation for differentiation was observed in our group for the presence of skip lesions and absence of intervertebral disc involvement. Hence, these were not included in our scoring system. Distribution of scores among the subjects aged 53.4 ± 17 years showed P &lt; 0.001 (t-test and Mann–Whitney U-test) with mean of 7.4 for tubercular and 2.9 for pyogenic group (SD of 1.9). A score of 6 or above suggested tuberculosis and score below 6 suggested pyogenic infection (Chi-square value of 87.67 and P &lt; 0.00001). Conclusion: MRI can thus be used for accurate diagnosis of spinal tuberculosis, and our novel MRI scoring system can be applied to exclude non-specific spondylodiscitis, help in reducing the burden of additional invasive investigations, expenditure and the time delay for initiating antitubercular treatment.

Tuberculous spondylitis after percutaneous vertebroplasty: A case series of 9 cases

BackgroundPercutaneous vertebroplasty has become the treatment of choice for compression fractures. Although the incidence is low, infection after vertebroplasty is a serious complication. The pathogens most often responsible for infection are bacteria. Meanwhile, mycobacterium tuberculosis-induced infection is extremely rare. In this study, we reported our treatment experience with 9 cases of tuberculous spondylitis after vertebroplasty. MethodsBetween January 2001 and December 2015, 5749 patients underwent vertebroplasty or kyphoplasty in our department. Nine cases developed tuberculous spondylitis after vertebroplasty (0.16%). Data on clinical history, laboratory examinations, image, treatment and outcomes were examined. ResultsOne male and 8 female patients with a mean age of 75.1 years developed tuberculous spondylitis after vertebroplasty. 5 patients had a history of pulmonary tuberculosis (TB). Revision surgeries were performed from 5 days to 1124 days after vertebroplasty. Seven patients underwent anterior debridement and fusion with or without posterior instrumentation, and 2 cases received posterior decompression and instrumentation only. After operation, the diagnosis of tuberculous spondylitis was confirmed by TB polymerase chain reaction (TB-PCR) or mycobacteria culture. Mean follow-up period after revision surgery was 36.8 months. At the end of follow-up, 1 patient with paraplegia had passed away, 2 needed a wheel chair, 4 required a walker and 2 were able to walk unassisted. ConclusionsVertebroplasty is a minimally invasive procedure but still retains some possibility of complications, including TB infection. Patients with a history of pulmonary TB or any elevation of infection parameters should be reviewed carefully to avoid infective complications.

Clinical Improvement with Non-Surgical Management of Tuberculous Spondylitis

Background: Tuberculosis is the second most common fatal infectious disease after Acquired Immunodeficiency Syndrome (AIDS) in the world. The spine is involved in 50% of osteoarticular tuberculosis cases. Tuberculous Spondylitis (TS) is the most dangerous form of osteoarticular tuberculosis, because of its ability to destroy the vertebral body with subsequent permanent kyphosis and neurological deficits such as paraplegia. The treatment goals of TS are to eradicate the infection and provide stability for the affected spine. There is little information in the literature about systemic non-surgical treatment under the condition of spinal cord compression in TS. We report two cases of TS which was improved with non-surgical treatment. We believe that the clinico-radiological signs of spinal cord compression in these cases are not an emergency indication for surgery. Clinical Presentation and Intervention: Two women aged 34 and 26 years were hospitalized because of the upper motor neuron type weakness in both legs worsened gradually, descending numbness, without urinary or defecation problems. Magnetic resonance imaging depicted lesions on vertebral bodies supporting the diagnosis of TS. Both patients were received oral antituberculous therapy and their muscle force improved despite the kyphotic deformity in the first patient. Conclusion: Neuro-radiological evidence of spinal cord compression is not an emergency indication of surgery in the management of TS and clinical improvement can be obtained by non-surgical treatment.

APPLICATION OF DIGITAL TOMOSYNTHESIS IN DIAGNOSING SPINAL TUBERCULOSIS – FIRST CLINICAL EXPERIENCE IN UKRAINE

Diagnosis of tuberculous spondylitis is based on the comparison of clinical-laboratory, bacteriological data and radiological methods. Digital tomosynthesis is a new method of X-ray diagnostics for performing with high-resolution limited-angle tomography at short-pulsed exposures in one pass of the tube with reconstruction of several hundred longitudinal sections of the research object without superposition of tissues. Possibilities of tomosynthesis are studied for various clinical situations. Aim of research. To study and apply the possibilities of digital tomosynthesis in the diagnosis of tuberculous spondylitis, conduct a comparative analysis with other radiological methods. Materials and methods. Digital tomosynthesis was performed for 95 patients with various spine diseases (select group 8.4 % with tuberculous spondylitis) at the domestic digital roentgen-diagnostic complex with the mode of digital tomosynthesis after performing digital projectional radiography of spine. Results and discussion. The benefits of tomosynthesis were shown and a comparative analysis with other visualization methods in the diagnosis of spondylitis was performed. Cases of the first clinical application of the method in Ukraine were demonstrated. Conclusion. Digital tomosynthesis of the spine is a new promising diagnostic tool by which you can obtain qualitative spine images in the form of numerical thin sections with no exaggeration effect. Results are comparable to CT data for detecting bone destruction at lower radiation load levels. Digital tomosynthesis provides better visualization of the small joints of the spine and the ability to evaluate each anatomical element of the vertebra at different depths, helps to detect pulmonary manifestation of tuberculosis.

Descriptiveness ray method in the diagnosis of tuberculous spondylitis

Descriptiveness ray method in the diagnosis of tuberculous spondylitis

Case report: a student of Asian origin with Pott’s disease

We describe a case report of a student of Asian origin who presented with fever of unknown origin, cough, recent onset low back pain and weight loss. Initial physical examination was unremarkable. Laboratory results showed inflammation, but extensive testing for bacteriological and viral serology was negative. While the chest Computed Tomography (CT) scan did not show any abnormal findings, pelvic CT scan revealed an osteolytic sacral mass, with extension to the soft tissues and muscles, and concomitant nerve compression. An ultrasonography-guided puncture of the lesion eventually showed Mycobacterium tuberculosis, leading to the diagnosis of tuberculous spondylitis or Pott’s disease. The standard tuberculostatic treatment was applied during 9 months with a good clinical result. Skeletal tuberculosis is not common in Western countries and it can be overlooked in foreign patients with fever of unknown origin.

Anterior Coloumn Reconstruction with Stand Alone Titanium Cage, without Anterior Plating in Tuberculosis Cervical Spine. An Experience of 47 Patients

Introduction Tuberculosis is a common problem specially in under developed countries. Tuberculosis of the vertebral column constitutes nearly 50% of all lesions of osteoarticular tuberculosis. The commonest site for the disease is in the peridiscal region. Treatment option usually is anti tuberculous chemotherapy but in some patients usually with severe pain and involving neurology, instability, large abcess, surgery is recommended. To our knowledge there is not a single publication in literature in which standalone titanium cage and bone graft without anterior plating is used in the treatment of TBS. The aim of this study is to evaluate the efficacy of standalone titanium mesh cages in TB cervical spine. Material and Methods A retrospective study of 47 patients with cervical tuberculous spondylitis (TBS) was performed at Ghurki trust teaching hospital. This study approved by the Institutional Review board and the ethics committee, included 47 patients with TBS of cervical spine who gave their informed consent to be included in the research. All patients had radical debridement, decompression, anterior coloumn reconstruction and instrumentation with standalone titanium cage without anterior plating filled with autologous iliac bone graft. The diagnosis of TBS was based on clinical correlation including night fever, loss of weight, fatigue and neck pain, laboratory investigations including ESR, CRP and tuberculin test were done in all patients. Visual analogue score (VAS) and frankel scoring system was used to score pain severity and grade neurological status. ATT was started preoperatively. The radiographic assessment included preoperative standard anteroposterior and lateral views. Cobbs methos was used to measure the sagittal profile. Results 61.6% patients fell in age group 3–35 years and 28.4% fell in group 36–70 years of age. 26 were men and 21 were women. Out of all patients 26 had pre op frankel grade E and 4pts had grade D and 10 pts had grade C and 2 pts had grade B and five pts had grade A preoperatively. Post operatively one patient of grade A remained same while other four improved to grade C in follow up and rest of all pts. improved to grade E in two year follow up. Pre-op cob's angle was 39.06 ± 10.92 (Mean±SD) which improved to -5.51 ± 4.77 (Mean±SD). P value is &lt; 0.05. In comparison of visual analogue score there is also statistically significant difference in pain improvement. All patients had single stage radical debridement, decompression and instrumentation. Anterior coloumn reconstruction was done in all patients using standalone titanium cage. Conclusion The use of titanium cages effectively restores the sagittal deformity in TB spine with no donor site morbidity.

Facilities of radiography, computed tomography and magnetic resonance imaging in diagnostics of tuberculous spondylitis

In Ukraine tuberculous spondylitis (TS) occupies a central position within the osteoarticular tuberculosis both by specific weight and severity of the clinical course. Establishing and differential diagnosis of TS remains relevant multimodal problem of beam diagnostics. Objective: to study the possibilities of radiography, computed tomography (CT) and magnetic resonance imaging (MRI ), the advantages of each method for improvement the efficiency of diagnosis of TS. Data of beam diagnostics in dynamics were analyzed in 20 patients examined and treated at the Department of osteoarticular tuberculosis. The indications for using of each method as well as advantages of visualization for improvement of the efficiency in detection and differential diagnosis of spondylitis were defined. Conclusion: only one radiography is not sufficient for diagnostics of TS because negative or questionable data on x-ray films do not exclude disorder in the initial stages. CT and MRI examination have significantly increased the efficiency of diagnostics of TS.

Magnetic resonance imaging and computerised tomography findings in an intraspinal extradural hydatid cyst mimicking tuberculous spondylitis: a case report

Spinal hydatid cyst with thoracic vertebra involvement is rare but serious condition. We present a 63-year old woman with spinal hydatid disease mimicking tuberculous spondylitis. A case study with Computerised Tomography and Magnetic Resonance Imaging diagnostic findings and surgical treatment is reported in this article. Primary spinal hydatid disease should be considered in the differential diagnosis of tuberculous spondylitis in endemic area. Familiarity with typical imaging appearances of spinal hydatid disease may be helpful in making a correct diagnosis and treatment.

Tuberculous Spondylitis (Pott’s Disease)

A 46-year old Caucasian male nurse presented with a 12-month history of myalgias and leg weakness, remitting thoracic and lumbar back pain, fever, weight loss and night sweats. Blood tests revealed elevated inflammatory activity and anemia. Suspecting vasculitis, an 18F-fluorodeoxyglucose positron-emission tomographic (18FDG-PET) scan was performed, which demonstrated enhanced uptake in the thoracic and lumbar spine (Figure a). Consistent with these findings, computed tomography (CT) of the spine revealed a large paravertebral abscess (Figure b and Figure c, white arrow) as well as severe spondylodiscitis with destruction of the vertebrae Th 7 and L 1 (Figure c, black arrow). Additionally, CT detected osteolytic lesions of the pelvis, multiple pulmonary lesions and mediastinal lymphadenopathy. The paravertebral abscess was drained and histological examination (Figure d, HE, original magnification × 100) demonstrated epitheloidgranulomatous (black arrow) and necrotizing inflammation (white arrow). Polymerase chain reaction and culture of the paravertebral and sputum specimens revealed infection with Mycobacterium tuberculosis. Radiological and microbiological findings thus indicated the diagnosis of tuberculous spondylitis (Pott's disease) resulting from disseminated postprimary pulmonary tuberculosis. Treatment was started with isoniazid, ethambutol, rifampicin and pyrazinamide. Symptoms improved markedly after several weeks and the patient recovered well. CT scans performed after 3, 6 and 9 months demonstrated regression of all lesions. The spine is the most frequent site of osseous tuberculous with predominant affection of the upper lumbar and lower thoracic spine. The infection commonly begins in the anterior part of the vertrebal bodies and subsequently involves the disk space, adjoining ligaments and soft tissues. Spinal tuberculosis is frequently accompanied by paraspinal abscesses.

Diagnosing tuberculous spondylitis: patients with back pain referred to a rheumatology outpatient department

The onset of tuberculous spondylitis is insidious in nature, with various clinical presentations, slow development of radiographic abnormalities, and nonspecific constitutional symptoms. This lack of specific symptoms causes delays in diagnosis. Magnetic resonance imaging demonstrates osteitis, intraosseous abscesses, paravertebral and epidural soft tissue extensions and abscesses, discitis, multilevel involvement of spinal cord or nerve root compression, and scoliosis. We present six patients with tuberculous spondylitis referred to our outpatient department with back pain resistant to medical therapy. All of them were women aged from 25 to 58 years (mean 44.6). The diagnosis of tuberculous spondylitis was based on clinical presentation, radiographic and/or MRI evidence of focal destructive vertebral lesions (with paravertebral mass), and positive bacteriological findings of Mycobacterium tuberculosis. The combined antituberculous chemotherapy consisted of 1.0 g/day streptomycin for 1 month, 25 mg/kg ethambutol or 25 mg/kg pyrazinamide, 600 mg/day rifampicin, and 300 mg/day isoniazid. The duration of therapy was 12 months. All the patients recovered without any sequelae. The mean follow-up period was 28 months (range 12-48). Magnetic resonance imaging is considered the main imaging modality for patients with suspected tuberculous spondylitis; it must be included in differential diagnosis of back pain and, if it is diagnosed in early stages, antituberculous chemotherapy enables satisfactory outcome.

Errors in the diagnosis of tuberculous spondylitis

From 1983 to 1986, 42 patients (25 men and 17 women) with tuberculous spondylitis were treated in the department of bone and joint tuberculosis at the Almetyevsk Anti-Tuberculosis Dispensary. Two patients were under the age of 18, 15 patients were between 19 and 40, 17 patients were between 41 and 60, and 8 patients were older than 61. These data do not agree with the idea that children are predominantly affected by this disease. We attribute tuberculous spondylitis detected in our patients at an older and elderly age to the exacerbation of latent infection suppressed in their childhood.

Evidence of spinal tuberculosis at the beginning of the fourth millennium BC from Arene Candide cave (Liguria, Italy)

This paper describes tuberculosislike lesions affecting the spine of Neolithic skeleton found in Arene Candide cave (Liguria, Italy) and representing one of the earliest cases of this disease in Europe. The burial is attributed to middle Neolithic (square-mouthed pottery culture) whose layers date, by 14C, to the first half of the fourth millennium BC. The skeleton, well preserved in the postcranial portion, belongs to a male aged about 15 years having a very light body build. Resorptive lesions localized to the lower thoracic and upper lumbar vertebral bodies, collapse and angular kyphosis, resulting from complete destruction of T11 and T12 and partial destruction of T10 and L1, are the main pathologic features. The morphology of the lesions, sites involved, and age of the specimen are consistent with a diagnosis of tuberculous spondylitis (Pott's disease). The extreme gracility of the skeleton, along with other signs of stress (Harris lines, enamel hypoplasia) suffered during the last years of life, and the limited bony regeneration point to a disease process in its late phase having arisen at the beginning of adolescence. The funerary ritual suggests that the social integration of this adolescent was not prevented by the severe infirmity.