Spinal tuberculosis, a severe form of extrapulmonary tuberculosis, poses significant diagnostic and therapeutic challenges, often leading to neurological complications and deformity. Microbiological confirmation is crucial for diagnosis and effective treatment. We aim to evaluate the microbiological profile and diagnostic yield of various methods in spinal TB cases at a tertiary care centre and to correlate with clinical features and treatment outcomes. A prospective study was conducted on samples from patients with suspected spinal TB (n=58) from July 2023 to September 2024. All samples were processed using Ziehl-Neelsen (ZN) staining for acid-fast bacilli (AFB), culture on Lowenstein-Jensen (LJ) medium, BACTEC MGIT 960 liquid culture system, and GeneXpert MTB/RIF assay for rapid detection of MTB and rifampicin sensitivity. Relevant demographic, clinical, and radiological data were collected and analyzed. Based on susceptibility to drugs of culture isolates, treatment was started to see the outcome, and follow-ups were done with the patients. A total of 19 spinal TB cases were microbiologically confirmed, out of 58 clinically suspected spinal TB cases, with a male predominance (57.9%) and age range of 13-72 years. The most common symptom was lower back pain (89.5%). GeneXpert was positive in all cases, detecting rifampicin resistance in 7(36.8%). Culture was positive in 11 cases. ZN staining was positive in 15.8% of direct samples. Histopathology showed granulomatous inflammation in 9 (47.3%) of cases. MRI confirmed infective spinal involvement in 17(89.5%) patients. MDR-TB regimen was initiated in 7 patients. Overall recovery was good, except one case of neuropathy and one mortality. A combination of smear microscopy, culture, and molecular diagnostics significantly improves the microbiological diagnosis of spinal TB. GeneXpert offers rapid, reliable results, especially in rifampicin resistance detection. Early and accurate microbiological confirmation, coupled with clinical-radiological correlation, is essential for effective management and improved patient outcomes.

Central nervous system tuberculosis (CNS-TB) is a rare but highly lethal form of TB with heterogeneous clinical and radiological features. We evaluated objective clinical grading, CSF indices, and MRI findings associated with in-hospital mortality. In this single-center retrospective cohort (2010-2023), all consecutive adults with CNS-TB were included (n = 15). Patients were grouped as survivors (n = 6) and non-survivors (n = 9). We extracted BMRC stage, baseline GCS, symptom-to-presentation and symptom-to-treatment durations, CSF cyto-biochemistry and microbiology (culture/PCR), and a standardized MRI checklist (basal exudates, hydrocephalus, ventriculitis, infarcts, tuberculoma/abscess, cranial nerve enhancement, spinal involvement). Treatment protocols (ATT, dexamethasone indications, neurosurgery) were documented. Results are primarily reported as counts/proportions with exploratory effect sizes. The mortality rate was 60%. Non-survivors were significantly older (57.8 ± 22.8 vs. 29.2 ± 6.9 years; P = 0.029, d = 1.56) and had higher serum AST levels (28.9 ± 6.4 vs. 15.0 ± 2.9 U/L; P = 0.007, d = 2.14). CSF leukocyte count was also significantly elevated in non survivors (P = 0.041, d = 0.95). Cerebral ischemia was present only in non-survivors (56% vs. 0%; P = 0.04, h = 0.98). PCR positivity in non-CSF samples (0% vs. 78%) was significantly associated with mortality (P = 0.007). Other parameters showing moderate to large effect sizes included focal neurological deficits, ventriculitis, and increased CSF opening pressure. Advanced age, elevated AST levels, increased CSF leukocyte count, cerebral ischemia, and extraparenchymal PCR positivity emerged as major predictors of mortality in CNS-TB. These factors may aid early risk stratification and treatment planning. Larger prospective studies are warranted to validate these findings.

Neuroblastoma is the second most common childhood malignancy. Only a minority of children with metastatic disease present initially to orthopedic surgeons, despite musculoskeletal complaints such as back pain, limb pain, limp, extremity swelling, or findings mimicking osteomyelitis. These vague and nonspecific presentations increase the risk of delayed diagnosis. To study orthopedic manifestations that present as the initial presenting symptoms of neuroblastoma in children and to characterize their clinical, radiological, and laboratory profiles. Forty-six consecutive patients with neuroblastoma were retrospectively evaluated. Medical records were reviewed, with particular attention given to the presence of orthopedic manifestations preceding the diagnosis of neuroblastoma. The children who were presented primarily to the orthopedics department were identified. The details of musculoskeletal symptoms and radiological and laboratory investigations were analyzed. Seven children (20%) presented initially with orthopedic complaints. Three patients had spinal involvement, including paraplegia from hydromyelia or vertebral metastasis with lytic-sclerotic lesions. Three children presented with persistent hip pain and limp and were initially diagnosed with osteomyelitis before biopsy confirmed neuroblastoma. One child presented with nontraumatic forearm swelling, initially presumed as osteomyelitis, with radiographs showing lysis of the ulnar metaphysis. A biopsy was used to establish the diagnosis. Six children had severe anemia with elevated ESR and CRP, and three had markedly elevated LDH levels. Approximately one-fifth of children with neuroblastoma initially present to orthopedic surgeons. Persistent or atypical musculoskeletal complaints-especially hip pain or back pain accompanied by anemia, high ESR, or high CRP-should prompt the consideration of neuroblastoma and early histopathological evaluation to avoid diagnostic delays.

Clinical characteristics and surgical outcomes of spinal infection caused by methicillin-resistant staphylococcus aureus.

Predictors of functional impairment after pyogenic vertebral osteomyelitis: a retrospective cohort study in the central Denmark region, 2017-2023.

Rationale:Paget disease of bone (PDB) is a metabolic disorder typically regarded as benign, yet it carries a <1% risk of malignant transformation into osteosarcoma malignant transformation into osteosarcoma, particularly with spinal involvement. Differentiation from other aggressive spinal lesions can be challenging. In Asian populations, prognostic data on Paget sarcoma are scarce. The significance of dual SQSTM1 and ZNF687 mutations and a rapid alkaline phosphatase (ALP) surge as indicators of malignant transformation remains to be fully elucidated.Patient concerns:We report a case of spinal Paget sarcoma in a patient with a 5-year history of PDB. The patient presented with progressive symptoms culminating in acute neurological deterioration, including bilateral lower limb weakness and bowel/bladder dysfunction, indicating severe spinal cord compromise.Diagnoses:The diagnosis of malignant transformation was based on the clinical course, serial imaging showing progressive spinal involvement, a sharp rise in ALP (a hydrolase enzyme that is predominantly found in the liver and bone, and elevated serum levels of which serve as a key biomarker for hepatobiliary disorders or abnormal bone metabolism) from >800 U/L to 3100 U/L, and genetic testing confirming dual SQSTM1 and ZNF687 mutations.Interventions:The patient underwent surgical intervention, targeted therapy, and other supportive treatments. An emergency workup was performed due to rapid neurological decline.Outcomes:Despite treatment, the patient experienced a rapid functional decline, with lower limb strength dropping to grade 1 by postoperative day 40, reflecting a poor prognosis associated with advanced Paget sarcoma. During the 2025 follow-up, the family was approached but declined to disclose the patient’s status. The patient’s survival status remains unknown as of the last follow-up.Lessons:In patients with PDB and spinal involvement, a rapid increase in ALP, especially in the context of specific genetic mutations like SQSTM1 and ZNF687, may be a critical indicator of malignancy. This case highlights the need for heightened clinical vigilance, enhanced genetic monitoring, and consideration of early biopsy to enable timely intervention and improve patient outcomes in this rare but devastating complication.

Predicting survival of patients with spinal involvement in multiple myeloma using PATHFx 3.0 - a validation study of 100 patients in Germany.

Current diagnostic approaches of leptomeningeal disease (LMD) rely heavily on cerebrospinal fluid (CSF) cytology, which shows significant limitations and the requirement for invasive procedures. We aim to develop an MRI-based grading scores for LMD diagnosis and prognosis that address current diagnostic limitations and provide standardized, reproducible assessment criteria. We conducted a retrospective analysis of 32 adult cancer patients evaluated for suspected LMD. Two experienced neuroradiologists independently assessed MRI studies using our novel grading system, which incorporates leptomeningeal enhancement/intensity patterns (grades 1-6), Evans index for hydrocephalus assessment, brain metastases characteristics, and spinal involvement. Confirmation of LMD cases was employed using dual confirmation approach combining CSF cytology and follow-up MRI. Our MRI grading system demonstrated promising inter-observer performance. Inter-rater reliability between two attending level neuroradiologists was excellent (ICC = 0.953, P-value < 0.001) using a cutoff score of 2 or higher, the system demonstrated comparable performance. Risk stratification analysis revealed clear prognostic value, with mortality rates of 8.6% for low-risk patients (Grade 1-2), 50% for medium-risk patients (Grade 3-4), and 80.0% for high-risk patients (Grade 5 +). The Kaplan-Meier survival curves demonstrate a statistically significant difference in overall survival between patients with varying grades (p-value of 0.00011). Notably, survival probability drops steeply in the Grade 5 + group early on, suggesting that higher LMD burden is associated with rapid clinical deterioration. In contrast, low risk patients appear to have a more indolent course. Our preliminary findings detail a promising approach in evaluating LMD patients which offers valuable prognostic information for clinical decision making. Furthermore, the high inter-rater reliability across various tumor types further encourages the potential utility of this approach, although further research on a broader population is needed before clinical implementation.

Meningeal melanocytoma of the central nervous system is a rare primary melanocytic neoplasm arising from the leptomeninges' melanocytes. It chiefly occurs in the posterior cranial fossa and rarely involves the spinal cord. The literature is bereft of lumbar spinal involvement by meningeal melanocytomas. Herein, we present a 17-year-old male patient who was incidentally diagnosed with a lumbar spinal meningeal melanocytoma during an imaging workup for backache following a fall. It was an extramedullary intradural tumor and was amenable to complete surgical removal in the spinal region. This case report highlights the importance of keeping the possibility of meningeal melanocytoma as a differential diagnosis of circumscribed intradural extramedullary neoplasms.

The prognostic value of lesion distribution in renal cell carcinoma bone metastasis (RCC-BM) is unclear. This study aimed to quantify the association between BM distribution and prognosis in RCC-BM patients and to employ a predictive model based on the random survival forests(RSF) algorithm. At first BM diagnosis, 122 patients were stratified by Memorial Sloan-Kettering Cancer Center (MSKCC)/Motzer risk score and classified into locoregional (21.3%), stochastic (56.6%), and extensive (22.1%) groups based on bone lesion distribution. Spinal and pelvic involvement was observed in 39.3% and 35.2% of patients. Univariate, logistic regression, and Kaplan-Meier survival analyses indicated that locoregional spread, spinal involvement (odds ratio [OR] 3.30; 95% confidence interval [CI] 1.20-9.09), and advanced age (OR 1.04; 95% CI 1.00-1.08; p < .05) correlated with higher risk stratifications, while pelvic metastasis was linked to shorter median overall survival (32 vs. 49 months; p < .05). The RSF model was trained in 70% and validated in 30% of the series, incorporating spatial lesion involvement (pelvic, spinal, and upper extremities involvement), MSKCC/Motzer score, and age as principal contributing variables. Time-dependent area under the curve (AUC) values achieved in single-split validation for 1- and 3-year survival were 0.90 and 0.87. Consistent performance was observed across 100 repeated splits, with median AUCs of 0.89, 0.86, and 0.89 for 1-, 3-, and 5-year survival, respectively. A cut-off value of 15.03 effectively separated high- and low-risk groups (p < .05). RSF demonstrated superior accuracy over Cox regression (median AUC 0.89 vs. 0.59 for 1-year survival). Overall, integrating bone lesion patterns into RSF modeling facilitates personalized prognosis and supports more precise care in RCC-BM.

Malignant peripheral nerve sheath tumors (MPNSTs) are rare, aggressive soft tissue sarcomas. Spinal involvement is uncommon, representing only 2-3% of all cases, and is typically associated with poor prognosis. Early diagnosis is challenging due to non-specific clinical and imaging findings. A 34-year-old woman presented with progressive lower limb weakness and numbness. Cerebrospinal fluid analysis revealed elevated protein and decreased glucose and chloride levels. MRI showed spinal meningeal enhancement, initially suggestive of tuberculous myelitis. Despite prolonged anti-tuberculous treatment, her condition worsened. Repeat imaging revealed an intradural extramedullary mass compressing the spinal cord. Surgical biopsy confirmed MPNST based on spindle-shaped tumor cells and complete loss of H3K27me3 expression. This case illustrates the diagnostic challenges of spinal MPNSTs, which may mimic tuberculous myelitis. When clinical features and imaging are inconclusive and response to treatment is poor, early histopathological examination remains essential for accurate diagnosis and timely management.

Neurosarcoidosis masquerading as recurrent tumefactive demyelinating-appearing brain lesions: An 8-year diagnostic odyssey.

Pott disease, or spinal tuberculosis, is the most frequent form of osteoarticular tuberculosis and can manifest with diverse radiological patterns and potentially serious complications. Cold abscesses are a hallmark feature but may remain clinically silent until late in the disease course. We report the case of a patient with thoracolumbar Pott disease complicated by large bilateral retroperitoneal muscular abscesses, initially undetected on physical examination. Cross-sectional imaging, including CT and MRI, was pivotal in delineating the extent of spinal involvement and associated soft tissue collections, guiding timely surgical and medical management. This case highlights the importance of maintaining a high index of suspicion for atypical presentations of spinal tuberculosis and demonstrates the critical role of imaging in early diagnosis, assessment of disease severity, and planning of appropriate interventions to prevent further morbidity.

Introduction: Pyogenic spondylodiscitis (PS) incidence is rising globally, but microbial profiles vary significantly by region. Local data is crucial for effective empirical therapy. This study aimed to analyze the clinical and microbiological characteristics of microbiologically confirmed PS cases at a tertiary hospital in Kathmandu, Nepal. Method: We retrospectively reviewed 19 patients with culture-positive PS treated at Manmohan Memorial Teaching Hospital from January 2017 to December 2024. Data on demographics, comorbidities, inflammatory markers (CRP/ESR), pathogen identity, treatment modality, and clinical outcome were collected. Statistical analysis was performed using SPSS. Result: The mean age was 58.8±15.4 years, and 78.9% were male. Neurological deficits were observed in 7 patients (36.8%). Lumbar/Dorso-lumbar spine involvement was most common (63.2%). Mean initial C-Reactive Protein (CRP) and Erythrocyte Sedimentation Rate (ESR) were 148.6±50.3 mg/L and 68.7±11.2 mm/h, respectively. The dominant pathogens were Staphylococcus aureus (47.4%) and Escherichia Coli (31.6%). Surgical intervention was required in 52.6% of patients. The overall clinical success rate was 94.7%. Conclusion: The high prevalence of Gram-negative organisms, particularly E. Coli and endemic pathogens like Salmonella typhi, mandates that local empirical antibiotic protocols in Nepal ensure adequate coverage for Gram-negative bacilli. Aggressive, pathogen-specific treatment leads to excellent outcomes in this population.

BackgroundTuberculous spondylitis (TS, Pott’s disease) accounts for up to 50% of extrapulmonary TB cases and presents a significant clinical challenge due to destructive spinal involvement, frequent neurological complications and difficulties in detecting Mycobacterium tuberculosis (Mtb) in bone tissue. Molecular diagnostics have improved pathogen detection; however, cases with concomitant HIV andHCV infections remain problematic. These conditions, marked by immunosuppression, systemic inflammation, endothelial dysfunction and altered host-pathogen interactions, are linked to atypical TS progression, rapid disease course and reduced treatment efficacy. Analysing Mtb genome mutations is critical for rational chemotherapy selection, especially when rapid drug susceptibility results are unavailable.ObjectivesTo define the mutation patterns and frequency associated with resistance to isoniazid, rifampicin, fluoroquinolones and aminoglycosides in Mtb isolated from bone tissue of TS patients coinfected with HIV and HCV, and to justify including this group in the high-risk category for MDR TB.MethodsA retrospective and prospective study included 300 patients with a confirmed diagnosis of TS, who were observed from 2016 to 2021 in a specialized clinic. Patients were grouped as follows: 20% without viral infections, 8% infected only with HCV, 6% with HIV alone and 66% with combined HIV+HCV infection. Surgical bone specimens were analysed using microscopy, culture on solid media and molecular-genetic techniques (PCR/PCR reverse hybridization). When detecting MBT DNA in amounts insufficient for identifying mutations, a repeat study was conducted. Among 324 PCR-positive cases, 267 samples contained sufficient DNA for mutation detection. Key genetic loci examined included rpoB, katG, gyrA/gyrB, rrs and eis. Results were correlated with patients’ viral infection status.ResultsPCR showed the highest sensitivity, detecting Mtb DNA in 83% of bone samples, compared to 28% with microscopy and 24% with culture. Resistance-related mutations were common: rpoB mutations (rifampicin resistance) were found in 72.3% of strains, predominantly the S531L substitution (86.5%); katG mutations (isoniazid resistance) in 79.4%, mainly S315T (96.2%). Fluoroquinolone resistance (gyrA/gyrB) was present in 31.6% of samples, aminoglycoside resistance (rrs, eis) in 51.6%. HIV infection increased the risk of MDR Mtb 4.16-fold (95% CI 2.11–7.67) and HCV 2.29-fold (95% CI 1.36–4.86). Patients with dual HIV+HCV infection showed the lowest proportion of drug-susceptible strains and the highest frequency of pre- XDR Mtb. Overall, the likelihood of detecting at least MDR Mtb in this subgroup was nearly four times higher than in patients without viral infections.ConclusionMolecular diagnostics outperform traditional bacteriology in detecting the TS pathogen and its drug resistance mutations. The high frequency of rpoB and katG mutations, combined with changes in gyrA/gyrB, rrs and eis, confirms a significant risk of MDR/pre-XDR Mtb in TS patients with HIV/HCV coinfections. Given the time required for results and low culture sensitivity, personalized therapy based on molecular-genetic analysis of bone specimens is optimal. When such data are unavailable, empirical treatment targeting MDR/pre-XDR Mtb is justified. Molecular diagnostics thus serve both as a rapid detection tool and a key to stratifying patients by MDR Mtb risk for informed personalized or empirical treatment decisions.

ABSTRACTHydatid disease is a parasitic infection that primarily affects the liver and lungs, but spinal involvement is very rare. We report a case of recurrent primary vertebral and paravertebral hydatid cysts and discuss the diagnostic and therapeutic challenges associated with this condition. A 48‐year‐old woman with a history of spinal hydatidosis resection involving the T2 to T7 and T11 to the distal lumbar spine 8 years earlier presented with mid‐back pain and intermittent fever. Magnetic resonance imaging (MRI) showed two masses, measuring 21 mm and 22 mm, located at the anterolateral border of the T3 vertebral body and in the adjacent soft tissues. The patient underwent spinal revision surgery, and histopathological evaluation confirmed the diagnosis of hydatid cysts. Since spinal hydatidosis is associated with high morbidity and is often misdiagnosed, it should be considered in the differential diagnosis of spinal cystic lesions, particularly in regions endemic for echinococcosis.

Study Design: Case report. Objective: To present a rare case of hereditary multiple exostosis with cervical spine exostosis and its surgical management. Summary of Background Data: Hereditary multiple exostosis (HME), which is attributed to mutations in the EXT1 and EXT2 genes, is a rare genetic disorder that is autosomal dominant. Although commonly associated with exostosis mass in upper and lower limbs, the association with cervical spine exostosis is unusual and remarkable. Most of the time, the patients are observed and kept in conservative management until puberty, but surgical intervention may be required when the patient is symptomatic. Case: A 12-year-old boy presented with gradually increasing swellings around multiple joints, noticed since he was 5 years old, associated with similar swelling on the back of his neck, with difficulty in neck movements, making it difficult for him to carry out daily activities. The patient was diagnosed with a case of hereditary multiple exostosis associated with cervical spine exostosis after thorough clinical examination and advanced radiologic investigations. Due to the symptoms associated with the cervical spine exostosis, excision of the exostosis of the neck was carried out for better patient outcome. Conclusions: Hereditary multiple exostosis is a rare genetic disorder, and more so with association to cervical spine exostosis. The management protocol is to observe till maturity and intervene surgically with excision if the swelling obstructs normal movement or has associated complications.

Eosinophilic granuloma (EG) is the most benign and localized form of Langerhans cell histiocytosis (LCH), a rare disorder. Spinal involvement is uncommon, particularly in very young children; Methods: In this report, we present a rare case of a 23-month-old boy with progressive neck deviation and difficulty walking following an unwitnessed fall. Imaging revealed a lytic lesion causing complete collapse of the T1 vertebral body (vertebra plana) with soft tissue extension and spinal cord compression. The patient underwent urgent posterior spinal instrumentation from C7 to T2, tumor debulking, spinal cord decompression, and biopsy; Results: Histopathological examination confirmed the diagnosis of EG (LCH). Postoperatively, the patient showed marked neurological improvement without complications; Conclusion: This case emphasizes the importance of considering EG in the differential diagnosis of spinal lesions in very young children and highlights the challenges in its diagnosis and management. The case is complemented by a focused review of pediatric spinal EG, outlining clinical presentation, diagnostic approach, and management strategies..

Abstract Neurenteric cysts are rare, benign congenital lesions of endodermal origin that primarily affect the spinal cord. Their clinical and radiological presentations can vary significantly, especially in pediatric patients, complicating diagnosis and management. We report two pediatric cases of spinal neurenteric cysts and review the relevant literature. An 11-month-old infant presented with progressive lower limb weakness. Magnetic resonance imaging (MRI) revealed a nonenhancing intradural cystic lesion at the thoracic level. A 14-year-old female reported neck pain and upper limb paresthesia; cervical spine MRI showed a well-demarcated T2-hyperintense cystic lesion. Both patients underwent complete surgical excision. Histopathology confirmed neurenteric cysts, showing pseudostratified or columnar epithelium with interspersed goblet cells. Postoperative recovery was uneventful, with no recurrence at 6-month and 1-year follow-up, respectively. These cases underscore the variability in presentation and spinal level involvement of neurenteric cysts in children. MRI plays a central role in preoperative assessment, though definitive diagnosis relies on histopathology. Complete surgical excision remains the treatment of choice, offering favorable outcomes with low recurrence risk. The age extremes and differing anatomical locations in our cases reflect the broad clinical spectrum seen in pediatric patients. Spinal neurenteric cysts should be considered in children with unexplained spinal cord-related symptoms. Early imaging, accurate histological diagnosis, and total surgical excision are critical for optimal outcomes. Increased clinical awareness and case reporting will aid in improving recognition and management of this rare spinal lesion.

Objectives: The purpose of this study is to identify clinical subtypes of SAPHO syndrome using cluster analysis, and to systematically investigate the associated clinical characteristics, therapeutic approaches, and short-term prognostic outcomes in order to enhance patient management. Methods: We recruited patients who had been diagnosed with SAPHO syndrome at Beijing Jishuitan Hospital. Bone lesions were assessed using a 99Tc bone scan. Based on bone lesions and clinical features, patients were categorized using a hierarchical clustering algorithm. Laboratory test results and prognostic differences were compared among clusters. Results: Overall, 135 patients were included. Cluster analysis identified three distinct clusters. Eighty-seven patients were assigned to cluster 1, characterized by anterior chest wall involvement; 74.7% also had skin involvement. Nineteen patients were assigned to cluster 2, characterized by spinal involvement, and 10.5% showed skin manifestations. Twenty-nine patients were assigned to cluster 3, characterized by peripheral bone involvement, with 24.1% exhibiting skin manifestations. Patients in cluster 3 were younger at disease onset (36.92 ± 16.62 years); their BASDAI and BASFI scores were lower (2.51 ± 1.18 and 0.89 ± 1.37, respectively). In cluster 1, significant reductions in Visual Analog Scale scores were observed at 1 and 6 months after treatment compared with baseline (7.08 vs. 2.59, p < 0.001, n = 63; 7.09 vs. 1.93, p < 0.001, n = 45). Similar improvements were noted in clusters 2 and 3 (7.18 vs. 3.00, p < 0.001, n = 11; 7.00 vs. 3.00, p < 0.001, n = 7; 6.70 vs. 2.65, p < 0.001, n = 20; 6.60 vs. 2.47, p < 0.001, n = 15). Conclusions: SAPHO syndrome may be classified into three subtypes: typical, axial, and peripheral. All subtypes show rapid improvement with timely treatment. Defining the clinical characteristics of these three subtypes can aid diagnosis and provide pathogenesis insights regarding this heterogeneous syndrome.