Noncontiguous Spinal Tuberculosis Research Articles

Single Sequence Whole-Spine Screening Magnetic Resonance Imaging: Diagnostic and Therapeutic Role in Multiple-Level Spinal Tuberculosis.

Spinal tuberculosis (TB) is the most common form of skeletal tuberculosis. Paradiscal continuous vertebral involvement at a single level is the most prevalent pattern among all forms of spinal TB. There is a wide range of reported incidences of multiple-level non-contiguous spinal TB in the literature. We would like to discuss on the utility of single whole spine screening T2-weighted (T2W) mid-sagittal magnetic resonance imaging (MRI) film in diagnosing multiple-level spinal TB and therapeutic benefits it can provide. We have done a retrospective review of the collected data of patients in Vardhman Mahavir Medical College and Safdarjung Hospital from August 2017 to October 2021 to find the incidence of multiple-level spinal TB and possible factors attributed to this specific disease pattern. All the patients who had been diagnosed of spinal TB either microbiologically or histopathologically or by a good clinical response to anti-tubercular treatment (ATT) and had a whole spine screening MRI film, were included. Patients of spinal TB who did not have a whole spine screening MRI were excluded from the study. Multiple-level spinal TB was diagnosed when lesions were identified in vertebral levels other than a typical paradiscal lesion, and additional lesions were separated from the primary disease by at least one normal spinal segment. Among the patients, 242 met the inclusion criteria, and 76 showed multiple-level non-contiguous spinal TB on MRI, incidence being 31.4%. The rest of the 166 patients showed typical single-segment contiguous lesions. By doing multivariate analysis to determine the independent risk factors for multiple-level spinal TB, extremes of age (<20 years and >50 years) have been found to be a significant factor with p value of 0.0001. Though drug resistance was not found to be a significant risk factor (p value 0.051), the proportion of patients having multiple-level TB was far more in the drug-resistant group (13/76). Single sequence whole spine screening MRI film is an effective, economical, and time-saving tool to detect multiple-level spinal TB. Along with its diagnostic accuracy, it also provides therapeutic benefits like access to a more approachable site for biopsy.

Skipped multilevel lesion as an atypical tuberculous spondylitis mimicking spinal metastasis: A case report

Tuberculosis (TB) is one of major global health threats and leads to morbidity and mortality. TB is prevalent in low and middle income countries especially in Sub-Saharan Africa and South East Asia. M. tuberculosis usually affects the lungs. Spine is the most common extrapulmonary sites for TB after lymph nodes, accounts for 1% of all TB cases, and 50 to 60% of osteoarticular TB. In the case of spinal TB, two or more adjacent vertebrae are usually involved due to hematogenous spread of bacteria in which the vertebral arteries feed the two adjacent vertebrae. The incidence of multiplelevel non-contiguous spinal TB is 1.1 to 16% of all skeletal TB. Multiple-level non-contiguous, an atypical form of spinal TB is rare. It has insidious symptoms, often with diagnostic delays and a higher risk of permanent neurological deficits. We report a case of atypical TB spondylitis with non-contiguous multiple level of lesions mimicking multiple bone metastases.

Short-term outcome of lamina-sparing decompression in thoracolumbar spinal tuberculosis.

The authors sought to assess the outcomes of lamina-sparing decompression using a posterior-only approach in patients with thoracolumbar spinal tuberculosis (TB). In patients with spinal TB with paraplegia, anterior decompression yields excellent results because it allows direct access to the diseased part of the vertebra, but the anterior approach has related morbidities. Posterior and posterolateral decompression mitigate approach-related morbidities; however, these approaches destabilize the already diseased segment. Lamina-sparing decompression through a posterior-only approach is a modification of posterolateral and anterolateral decompression that allows simultaneous decompression and instrumentation while preserving the posterior healthy bony structure as much as possible. Thirty-five patients with spinal TB underwent lamina-sparing decompression and instrumentation. Outcomes were determined by using a visual analog scale (VAS) and the Oswestry Disability Index (ODI) for functional assessment, the American Spinal Injury Association (ASIA) impairment grade for neurological assessment, blood loss and duration of surgery for surgical outcome assessment, and Cobb angles to measure kyphosis correction. In total, 35 patients (12 men and 23 women) with an average age of 35.8 ± 18.7 (range 4-69) years underwent lamina-sparing decompression. Eight patients had dorsal, 7 had dorsolumbar, 7 had lumbar, 9 had multifocal contiguous, and 4 patients had multifocal noncontiguous spinal TB; 33 patients had paradiscal Pott's spine (tuberculous spondylodiscitis), and 2 had central-type disease. The average preoperative Cobb angle was 28.4° ± 14.9° (range 0°-60°) and the postoperative Cobb angle was 16.3° ± 11.3° (44° to -15°). There was loss of 1.6° ± 1.5° (0°-5°) during 16 months of follow-up. Average blood loss was 526 ± 316 (range 130-1200) ml. Duration of surgery was 228 ± 79.14 (range 60-320) minutes. Level of vertebral instrumentation on average was 0.97 ± 0.8 (range 0-4) vertebra proximal and 1.25 ± 0.75 (0-3) distal to the diseased segment. Neurological recovery during the immediate postoperative period occurred in 23 of 27 patients (85.1%). All patients had recovered at the final follow-up at 16 months. The preoperative ODI score improved from 76.4 ± 17.9 (range 32-100) to 6.74 ± 17.2 (0-60) at 16 months. The preoperative VAS score improved from 7.48 ± 1.16 (6-10) to 0.47 ± 1.94 (0-8). Surgical site infection occurred in 2 patients, and 1 patient had an intraoperative dural tear that was successfully repaired. One patient developed implant loosening at 3 months, which was managed by extended instrumentation. To achieve stability, lamina-sparing decompression allows fixation of lower numbers of vertebrae proximal and distal to the diseased segment. This method has a fair outcome in terms of kyphosis correction, good functional and neurological recovery, shorter surgical duration than conventional methods, and less blood loss.

Debridement, interbody graft using titanium mesh cages, posterior instrumentation and fusion in the surgical treatment of multilevel noncontiguous spinal tuberculosis in elderly patients via a posterior-only

PurposeTo analyse the efficacy and feasibility of surgical management for elderly patients with multilevel non-contiguous spinal tuberculosis(MNSTB)by using one-stage posterior focus debridement, interbody graft using titanium mesh cages, posterior instrumentation and fusion. MethodsFrom September 2009 to October 2013, 15 elderly patients with MNSTB were treated with one-stage posterior focus debridement, interbody graft using titanium mesh cages, posterior instrumentation and fusion. There were 10 males and 5 females with a mean age of 63.2 years (range: 60–68 years) at the time of surgery. The mean follow-up time was 40 months(range 26–68 months). Patients were evaluated before and after surgery in terms of erythrocyte sedimentation rate(ESR), neurological status, pain and kyphotic angle. ResultsThe spinal tuberculosis was completely cured, and the grafted bones were fused in all 15 patients. There were no recurrent tuberculous infections. The ESR reached a normal level within 3 months in all patients. The ASIA neurological classification improved in all cases, and pain relief was reported by all patients. The average preoperative kyphosis was 20.1° (range 8–38°) and decreased to 7.6° (range 1–18°) postoperatively. There was no significant loss of the correction at the latest follow-up. ConclusionsOur results showed that one-stage posterior focus debridement, interbody graft using titanium mesh cages, posterior instrumentation and fusion was an effective treatment for elderly patients with MNSTB. It is characterized by minimum surgical trauma, good neurological recovery, and good correction of kyphosis.

Retrospective Study of 967 Patients With Spinal Tuberculosis.

China is a country with a high tuberculosis (TB) burden. Spinal TB is one reason for the resurgence of TB in China. The objective of this study was to investigate the clinical and epidemiological features of patients with spinal TB in a teaching hospital of Southwest China. The study group comprised 967 patients with spinal TB who were admitted to the authors' institution from 1999 to 2013. Demographic characteristics, prevalence of symptoms and clinical manifestations, prevalence of multidrug resistance and extensive drug resistance of spinal TB, management and outcome, and incidence of complications were recorded and analyzed. The patients included 473 women and 494 men with a mean age of 35.86±15.68 years. The most common presentation of spinal TB was back pain, followed by night sweats and fever. The thoracic spine was the most commonly involved level, followed by the lumbar spine and cervical spine. The incidence of neurological involvement in spinal TB is 33.3%. Noncontiguous spinal TB was seen in 3.41% of cases. The incidence of concomitant pulmonary TB was 14.37%. A total of 740 patients were successfully treated with surgery and anti-TB drugs. No mortality was related to spinal TB. Spinal TB increased every year from 1999 to 2013 in Southwest China. Back pain is the most common clinical symptom, and the thoracic spine is the vertebral body most often involved. The most commonly used first- and second-line anti-TB drugs are isoniazid and levofloxacin, respectively. [Orthopedics.2016; 39(5):e838-e843.].

A Multi-Level Noncontiguous Vertebral Tuberculosis in Taif Province , Saudi Arabia : A Single Center Study

Background and aim of the study: Multilevel noncontiguous spinal tuberculosis is an atypical form of the spinal tuberculosis, which leaves not less than two adjacent vertebrae intact between the two foci. The aim of this study is to record the incidence, pattern of presentation, risk factors; and diagnostic tools of multi-level noncontiguous vertebral tuberculosis in a single center (King Abdul Aziz Specialist Hospital) Taif, Saudi Arabia. Patients and method: In this retrospective chart review study, we reviewed the records and data of all patients presented to King Abdul Aziz Specialist Hospital, Taif, Saudi Arabia from January 2009 to January 2014 and their diagnosis were proved to be spinal tuberculosis. Results: the study included76 patients with spinal tuberculosis; multilevel noncontiguous tuberculosis was detected in 18.4% and a single spinal lesion was identified in the other 81.6%of patients. There was no statistically significant difference between the 2 groups regarding their demographic, clinical, and their laboratory findings except for the hepatitis B virus (HBV) positivity and elevated serum transaminases which were significantly higher in the multilevel non contagious group of patients. Plain film detected multiple non contagious lesions in 64.3% of patients, and in 35.7%of them, they were first diagnosed as single lesion but MRI detected the multiplicity. The thoracic and lumbar vertebrae were involved in 85.7% of the multilevel lesions and in the other 14.3% of patients the cervical and lumbar involvement was detected. In the single focus group the thoracic and thoracolumbar vertebrae were involved in 75.8% of cases. Diagnosis was confirmed by culture and histopathology. Conclusion: This study suggested a strong relation between hepatitis B and spinal tuberculosis, specially the multilevel non contagious form, however, till similar results of larger series of patients are obtained, the orthopedic surgeon must be with high index of suspicion in patients with spinal tuberculosis to detect multiplicity by MRI and any co infection with hepatitis B virus.

The Clinical Outcomes of Surgical Treatment of Noncontiguous Spinal Tuberculosis: A Retrospective Study in 23 Cases

Study designA retrospective clinical study.ObjectiveTo evaluate the clinical efficacy of the surgical treatment of noncontiguous spinal tuberculosis (NSTB), and to discuss its therapeutic strategies.MethodsWe performed a retrospective review of clinical and radiographic data that were prospectively collected on 550 consecutive spinal tubercular patients including 27 patients who were diagnosed and treated as NSTB in our institution from June 2005 to June 2011. Apart from 4 patients being treated conservatively, the remainder received surgery by posterior transforaminal debridement, interbody fusion with instrumentation, posterior instrumentation and anterior debridement with fusion in a single or two-stage operation. The clinical outcomes were evaluated before and after treatment in terms of hematologic and radiographic examinations, bone fusion and neurologic status. The Oswestry Disability Index score was determined before treatment and at the last follow-up visit.Results23 patients (15 M/8F), averaged 44.6±14.2 years old (range, 19 to 70 yd), who received surgical treatment, were followed up after surgery for a mean of 52.5±19.5 months (range, 24 to 72 months). The kyphotic angle was changed significantly between pre- and postoperation (P<0.05). The mean amount of correction was 12.6±7.2 degrees, with a small loss of correction at last follow-up. All patients achieved solid bone fusion. No patients with neurological deficit deteriorated postoperatively. Neither mortalities nor any major complications were found. There was a significant difference of Oswestry Disability Index scores between preoperation and the final follow-up.ConclusionThe outcomes of follow-up showed that posterior and posterior-anterior surgical treatment methods were both viable surgical options for NSTB. Posterior transforaminal debridement, interbody fusion and posterior instrumentation, as a less invasive technique, was feasible and effective to treat specific tubercular foci.

Non-contiguous spinal tuberculosis with a previous presumptive diagnosis of lung cancer spinal metastases

Non-contiguous spinal tuberculosis with a previous presumptive diagnosis of lung cancer spinal metastases

The radiographic classification and presentations of atypical spinal tuberculosis

Objective To investigate the radiographic classification and presentation of atypical spinal tuberculosis in adults.Methods Data of 45 consecutive patients who had suffered from atypical spinal tuberculosis confirmed by surgical interventions and pathologic examinations at our department from February 2000 to August 2012 were retrospectively analyzed.There were 29 males and 16 females,aged from 20 to 71 years (mean,46.2 years).Twenty-five patients presented with low-grade fever,lassitude and loss of weight,and the other 20 patients denied the constitutional symptoms of tuberculosis.An increased erythrocyte sedimentation rate (range,25-107 mm/1 h) was found in 37 patients.All patients were investigated by the following imaging resources:plain X-rays,CT scan and MRI.3D reconstruction CT was performed in 12 patients and PET-CT was performed in 2 patients.All patients were treated surgically and confirmed by pathologic examinations and 3 patients had undergone CT-guided biopsy.Results Atypical spinal tuberculosis presented in different radiographic presentation forms.Nine patients had involvement of a single vertebral body,which was depicted with nonuniformly increased signal intensity on T2-weighted MR images.CT scan showed irregular bony destruction in old patients and solitary osteolytic lesion with well-defined margins in young adults.There were 2 cases of isolated affection in the posterior elements (vertebral appendages type),and the involved vertebral appendages demonstrated hyperintense signal on T2-weighted MR images and bony destruction on CT scan.There were 8 cases of simultaneous affection in the anterior and posterior element of one vertebra (circumferential vertebral involvement type),and CT scan showed multiple bony destruction in vertebral body and neural arch.There were 5 cases of affection in disc (intervertebral disc involvement type),which presented decreased signal in MRI and protruding disc pressing the dural sac could be found.There were 14 cases of multiple vertebral tuberculosis in continuity (contiguous spinal tuberculosis),which presented multiple tuberculosis lesions on 3D-CT.There were 7 cases of multiple vertebral tuberculosis in noncontinuity (noncontiguous spinal tuberculosis),which presented destructive tubercular lesions affected different levels in different regions of the spine on MRI.Conclusion Atypical spinal tuberculosis had multiply radiographic presentation forms and atypical radiographic features.Worm-eaten destruction of bone or vertebral endplate,marrow edema and increased signal intensity of paraspinal ligament are features of radiographic presentation in diagnosis of atypical spinal tuberculosis. Key words: Tuberculosis, Spinal; Diagnostic imaging; Classification

Outcomes of Different Surgical Procedures in the Treatment of Spinal Tuberculosis in Adults

Objective: To investigate surgical methods and outcomes in the treatment of spinal tuberculosis (TB) in adults. Subjects and Methods: One hundred and eighty-one patients (average age 39 years) without multiple-level noncontiguous spinal TB were followed up for 22-72 months. The patients were divided into four groups according to surgical procedure on the basis of the position and extension of the foci: group A (74 cases): anterior radical debridement and strut grafting with instrumentation; group B (83 cases): posterior instrumentation and bone grafting with anterior radical debridement and strut grafting in a single- or two-stage procedure; group C (10 cases): extrapleural anterolateral decompression and strut grafting with posterior instrumentation in thoracic or thoracolumbar spine, and group D (27 cases): single-stage transforaminal decompression and posterior instrumentation and fusion. Results: There was a significant decrease (p < 0.05) in mean preoperative (81%) Oswestry's Disability Index. Except for 24 patients with lumbosacral TB who were only instrumented posteriorly, kyphosis degrees were corrected by a mean of 11.5° in the anterior instrumentation group and 12.6° in the posterior instrumentation group (p < 0.01). The correction loss was 6.8° in the anterior instrumentation group and 6.1° in the posterior instrumentation group at the last follow-up (p < 0.01). Conclusion: The four surgical procedures obtained good results for correction and maintenance of the correction, clearance of the foci, decompression of the spinal cord and pain relief in the treatment of spinal TB in adults, providing that the operative indication is accurately identified. However, the posterior approach was superior to anterior instrumentation for correcting deformity and maintaining the correction.

Surgical treatment of noncontiguous spinal tuberculosis with gibbus deformity: A case report

Noncontiguous tuberculous spondylitis, especially with involvement of the cervicothoracic junction, is uncommon. The disease is usually accompanied by severe neurologic deficits. The surgical approach to this junction is quite difficult. We present here a 21-year-old woman who had had paraplegia and ascending numbness for over 1 month. Magnetic resonance imaging revealed noncontiguous spinal tuberculosis at the cervical, thoracic, and lumbar levels complicated by cervicothoracic gibbus deformity. She underwent staged operations including anterior decompression, halo ring traction, posterior decompression, and posterolateral fusion with internal fixation. After surgery, the muscle power in her lower limbs improved gradually, she could walk without aids after 8 months, and she was disease-free 2 years and 4 months after surgery. For a patient with noncontiguous tuberculous spondylitis with cervicothoracic junction involvement, staged surgeries at the critical levels combined with adequate medication can result in a good neurologic recovery.

Surgical treatment of multiple-level noncontiguous spinal tuberculosis.

Objective To investigate the methods and results of surgical treatment of multiple-level noncontiguous spinal tuberculosis. Methods A retrospective review of 23 patients with multiple-level non-contiguous spinal tuberculosis who were surgically treated in our department from January 2000 to March 2007. The average age at the time of surgery was 41.5 years(range, 21-65 years). The sites of infection locat-ed at cervical and thoracic region in 3 cases, both at thoracic region in 3, thoracic and thoracolumbar in 6,thoracic and lumbar in 4, thoracolumbar and lumbar in 5, cervical, thoracic and thoracolumbar in 1, cervical, thoracolumbar and lumbar in 1. The mean preoperative angle of kyphotie deformity was 30.6° (range, -5.0°-65.0°). Eleven cases complicated with paraplegia. The surgical procedures of each site include: anterior de-bridement and bony grafting with anterior instrumentation fixation, anterior debridement and bony grafting with posterior fixation, posterolateral eostotransversectomy debridement and interbody fusion with posterior fixation, posterior debridement and posterior fixation,focus debridement only and conservative treatment. The patients were followed up for 1.5-6.0 years, with a mean period of 3.2 years. Results Tuberculous infection was controlled in all patients with no recurrence or reactivation occurred. Bony fusion was achieved in all patients who performed bony grafting. The mean angle of kyphotic deformity was reduced to 14.2 degrees at the final follow-up. Among 11 cases with paraplegia, 7 were completely recovered, 4 were partly improved. Conclusion The selection of the treatment of multiple-level noncontiguous spinal tuberculosis depends on the location, stability, deformity and neurologie status of each focus site. Under the condition of effective an-ti-tuberculosis chemotherapy, nutritional support and accurate preoperative management, all focus sites canbe treated in one-stage operation in most patients with multiple-level noncontiguous spinal tuberculosis. Key words: Tuberculosis; spinal; Surgical procedures; operative; Internal fixators

Noncontiguous spinal tuberculosis: incidence and management

Tuberculosis (TB) has a worthy reputation as one of the great mimickers in medicine with a multitude of clinical pictures and variations. Noncontiguous spinal TB is described as atypical and case reports are published as rarities in the mainstream academic journals. The aim of the study was to asses the incidence and review of the management of non-contiguous spinal TB. We identified 16 cases of noncontiguous spinal TB from a single surgeon series of 98 patients, who were managed surgically between 2001 and 2006. These were diagnosed on whole spine MRI. This represents the largest series reported in literature to date and is higher than the expected incidence. Case notes and imaging were retrospectively reviewed in an attempt to ascertain if there were any parameters to differentiate this group from the rest of the TB spine population. Our incidence of noncontiguous spinal TB is 16.3%. There was a higher incidence of neurology in the noncontiguous group (75%) compared to the rest of our group (58.5%). Non-contiguous TB was not found to be a manifestation of HIV, MDR TB or of chronicity in our series. Most noncontiguous lesions were evident on plain radiology. Noncontiguous spinal TB is common in areas of high prevalence such as South Africa. Despite being frequently missed initially, noncontiguous involvement is evident on plain radiography and simply requires a higher index of suspicion. When investigating spine TB patients, simple radiology of the entire spine is mandatory. If available, a full spine sagittal MRI is extremely useful in identifying noncontiguous lesions. Treatment of noncontiguous tuberculosis is as for standard spinal TB cases in our unit with similar outcomes, but care needs to be taken in surgical planning as patients may have multiple areas of neurological compromise.

Non-contiguous multifocal spinal tuberculosis involving cervical, thoracic, lumbar and sacral segments: a case report

There are only a few cases reported with non-contiguous spinal tuberculosis in the literature. Most of these patients have only two non-contiguous lesions, and in almost all of these cases, surgical treatment is required. A 17-year-old girl with non-contiguous multifocal spinal tuberculosis involving cervical, thoracic, thoracolumbar, lumbar and sacral segments is reported. The patient presented with systemic tuberculosis symptoms and signs, and progressive paraparesis. The patient was treated with antituberculous drug therapy and was operated twice for thoracolumbar and cervical spinal lesions. She made an excellent neurological recovery. In the patients with non-contiguous spinal involvement, there is a high percentage of requirement of surgical treatment. This may be due to "fulminant" behaviour of the disease in these patients. Early surgical treatment of the cases with large abscesses and systemic tuberculosis may provide early improvement, and must probably be the first treatment modality after general support to the patient.