Spinal Tuberculosis In Children Research Articles

Thoracic spinal tuberculosis in a 2.5-year-old child treated by surgical procedure with a transthoracic approach: a case report.

A 2-year-old and 6-month-old boy was admitted with fever and unspecific generalized pain, the examination revealed mild hyperreflexia in the lower extremities, isotope scan showed increased uptake in the T8 vertebra. MRI demonstrated destruction in the T8 vertebra with kyphotic deformity and abscess anterior to T7, T8, and T9 levels with an epidural abscess at the T8 level extending to the spinal canal and compressing the spinal cord. The patient underwent a surgical procedure with a transthoracic approach, the decompression of the spinal canal was performed through T8 corpectomy, the reduction of kyphosis was performed and the internal fixation with a dynamic cylinder and lateral titanium plate was carried out. Microbiologic examination suggests Mycobacterium tuberculosis. Pott's disease (spinal TB) is extremely rare in the young children population, and surgical treatment is reported only in a few reports, and it is considered a technical challenge. There are several surgical approaches during childhood, for upper thoracic spinal TB, the posterior approach is easy, minimally invasive, safe, reliable, and effective. But it had the worst outcomes. In contrast, the anterior approach provides direct access to the lesions. More research are needed to detect the best choice in the management of thoracic spinal TB in children.

Spinal Tuberculosis in Children

Tuberculosis continues to be the leading cause of morbidity and mortality, with an estimated annual incidence of 10.4 million worldwide. It has been estimated that 10% of patients with extrapulmonary tuberculosis have musculoskeletal involvement, with the spine being the most common. Spinal tuberculosis (TB) accounts for 50% of cases of musculoskeletal tuberculosis.
 Spinal tuberculosis is the result of infection with Mycobacterium tuberculosis. It is a secondary infection, the primary lesion of which is in the lungs, genitourinary system, or gastrointestinal tract and can be active or latent. Involvement of the vertebral segment is the result of hematogenous spread of infection along the arterial pathway or Batson's vein plexus, lymphatic spread, or direct invasion from adjacent internal organs. 
 Computed tomography (CT) is better suited for assessing the extent of the lesion when contrast is used to enhance granulomatous tissues and abscesses, but exposes the patient to high radiation. Magnetic resonance imaging (MRI) can detect changes that occur in the early stages of the disease. WHO has suggested that any extrapulmonary tuberculosis should require sputum examination and chest x-ray, as there is a high risk of pulmonary infection. Thus, computed tomography (CT) and magnetic resonance imaging (MRI) are the main modalities for detecting tuberculous spondylitis.
 

The prevalence, diagnosis and surgical risk factors of spinal tuberculosis in children.

To date, the burden of childhood spinal TB in China has not been estimated, and current treatment is hindered by a lack of evidence. This study aimed to review our experience of childhood spinal TB. We reviewed the medical records of paediatric patients (≤15years) admitted for spinal TB (confirmed or possible) at Shandong Provincial Chest Hospital from January 2006 to December 2019. Demographic, clinical, laboratory and radiological data were collected from medical records and analysed retrospectively. Seventy-two patients were diagnosed with spinal TB. 45 were male (62.5%), and 27 female (37.5%), with a mean age of 8.42±4.47 (SD) years. During this 14-year period, the overall prevalence of spinal TB among childhood TB was 4.5%. T-SPOT.TB, AFB smear, mycobacterial culture, TB RT-PCR and biopsies were positive in 29.6%, 14.3%, 23.3%, 43.8% and 88.5% of assayed patients, respectively. The overall surgical rate of the studied patients was 40.3%. The requirement of surgery in childhood spinal TB was associated with pulmonary TB (OR=4.000, 95% CI: 1.197, 13.367). Spinal TB in children cannot be neglected. It remains a severe problem to public health, and more attention should be paid to initiating treatment early.

The Spine Crasher: A Challenging Diagnosis

Introduction: Spinal tuberculosis in children is an established preventable disease in developing countries. Complications are devastating due to its aptitude to cause bone destruction, spinal deformity and paraplegia. Case report: We present an eight-month old girl with isolated gross motor regression and evolving spastic paraplegia. It highlights the challenge we encountered due to delay in garnering the pertinent investigation. She presented to clinic with history of legs weakness and loss of rolling after a period of prolonged febrile illness. Both parents are medical practitioners. Mother had history of SVT during pregnancy in spite on anti-arrhythmic treatments. Her father is a thalassaemia carrier. A thorough examination revealed gross motor delay and upper motor neuron signs. She had raised inflammatory markers, anaemia and thrombocytosis with persistent low-grade temperature. CT brain with contrast showed meningeal enhancement. Full septic work up revealed the CSF result reflecting partially treated meningitis. She was treated with third generation cephalosporin and acyclovir. Mother claimed exposure to TB patients hence Mantoux test was recommended which came positive. Her chest x-ray, sputum culture, CSF culture and NAA studies came non-conclusive for pulmonary tuberculosis. MRI for brain and spine showed features of tuberculous spondylodiscitis of T4-T5 vertebrae with associated subligamentous paravertebral spread and epidural extension causing spinal cord compression and T3-T6 hydro-syringomyelia. After multidisciplinary team discussion, patient started on intensive antituberculosis regimen with good initial response. Discussion: Clinically lower limbs power improved with good antigravity movement. Laboratory and radiological investigations have improved inflammatory markers and dropping trend thrombocytosis, and spinal gibbous stay stationary with improvement in plain radiology. She is under regular follow up awaiting serial MRI. Conclusion: The challenge in diagnosis of extra pulmonary tuberculosis in infants is getting them excluded early. High index of suspicion along with radiological investigation is vital to aid the diagnosis and establishment of treatment to expect a good outcome.

POSTERIOR VERTEBRAL COLUMN RESECTION IN MULTIPLE LEVELS IN CHILDREN WITH VERTEBRAL TUBERCULOSIS

ABSTRACT Objective To evaluate the clinical and radiological results of posterior vertebral column resection in the treatment of kyphosis due to vertebral tuberculosis in children under 9 years of age with neurological deficit. Methods Retrospective study of a series of 5 cases, 4 females and 1 male, mean age of 4.7 years at the time of surgery, with spinal tuberculosis and mean kyphosis of 89 degrees. Results All patients underwent surgical treatment with PVCR in multiple levels, with a mean number of 3.6 resected vertebrae, mean surgical time of 359 minutes, mean postoperative stay of 21.2 days. The mean follow-up was 29 months. The mean kyphosis correction was 62.6%. Before surgery, all patients had signs of spinal cord injury, one of which did not present a deficit of strength or sensibility (ASIA E), but there were pyramidal signs and a history of falls. The other 4 had some degree of sensory-motor dysfunction, with ASIA score varying from A to D. Postoperative complications included two dehiscences of suture, one pneumothorax and one pneumonia, all with favorable evolution. Four patients progressed with neurological improvement and one of them had persistence of the neurological deficit until the last follow-up. Conclusions Multiple-level PVCR has proven to be a safe and effective option for the treatment of kyphotic deformity in spinal tuberculosis in children with neurological deficit. Level of evidence IV; Case Series.

Pott's Disease: An Emerging Source of Potentially Inappropriate Treatment.

Spinal Tuberculosis in children is uncommon, even more so in cases of involvement of posterior vertebral elements, and its diagnosis is often delayed. Here we report the case of a young female presenting neuroradiological features and clinical symptoms suspicious for malignant tumor. Histological examination of biopsy specimen evidenced a Pott's disease. We highlight the importance of suspecting this disorder in children with both aspecific systemic and neurological symptoms, in order to reach a timely diagnosis for appropriate and targeted intervention, avoiding the risk of overtreatment and malpractice claims.

Conservatively Treated Spinal Tuberculosis in Children:Ambulatory Chemotherapy

Conservatively Treated Spinal Tuberculosis in Children:Ambulatory Chemotherapy

TUBERCULOSIS OF THE SPINE IN CHILDREN: A MODERN CONCEPT

The data presented in the lecture are based on the modern concept of diagnosis and treatment of spinal tuberculosis in children and on the last 25 years’ experience of surgical treatment of more than 350 such patients aged 8 months to 17 years. Being the head of the Clinic of Pediatric Surgery and Orthopedics (formerly the Children’s Bones and Joints Tuberculosis Surgery Department) of the St. Petersburg Institute of Phthisiopulmonology for the past 17 years, the author expresses gratitude to his teachers and colleagues - surgeons, anaesthesiologists, phthisiatricians, rehabilitologists, pediatricians, surgical and desk nurses, without whom the results would hardly have been achieved, which allow considering the national experience in the surgical treatment of bone tuberculosis in children one of the most successful in the world today.

Spinal Tuberculosis in Children: Predictable Kyphotic Deformity after Cure of the Tuberculosis

Purpose: To assess the chronological changes of disease-related kyphosis after chemotherapy alone. Materials and Methods: A total of 101 children aged 2 to 15 years with spinal tuberculosis, accompanied by various stages of disease processes were enrolled for analysis. By utilizing the images in them, the growth plate condition and chronological changes of kyphosis after chemotherapy were analyzed at two points in time; the first assessment was at post-chemotherapy one-year and second at the final discharge. Results: Complete disc destruction in the cervical, dorsal and lumbosacral spines was observed in 2 out of 40 children (5.0%), 8 out of 30 children (26.7%), and 6 out of 31 children (19.4%), respectively. In those cases, the residual kyphosis inevitably developed. In the remaining children, the discs were intact or partially damaged. Among the 101 children kyphotic deformity was maintained without change in 20 children (19.8%). Kyphosis decreased in 14 children (13.9%), while it increased in 67 children (66.3%) with non-recoverably damaged growth plate. Conclusion: Although it is tentatively possible to predict the deformity progress or non-progress and spontaneous correction at the time of the initial treatment, its predictive accuracy is low. Therefore, assessment of the chronological changes should be performed at the end of chemotherapy. In children with progressive curve change, assessment of deformity should be continued until maturity.

Commentary: One-year multidrug treatment for tuberculosis of the cervical spine in children.

likely to cause deformity, neurological deficit, and growth alteration in children than in adults,1 owing to a lack of restraint, greater mobility, and cartilaginous open physeal plates at both ends of the vertebra in the paediatric cervical spine.2 In this issue, Agarwal et al.3 report the short-term outcome in 22 children (mean age, 9.1 years) after one-year antitubercular multidrug treatment for tuberculosis of the cervical spine. The study shows excellent clinical outcome with chemotherapy alone in 86% of patients and reversal of neurological impairment in all 3 affected patients. This finding is consistent with a Cochrane Database Systemic Review,4 guidelines of the Royal College of Physicians5 (which demonstrated no additional benefit of surgical debridement or resection of the spinal focus and bone grafting on top of chemotherapy, compared with chemotherapy alone), and a report from the Medical Research Council Working Party on Tuberculosis of the Spine6 (which showed 24 of 30 patients in one study and 74 of 85 patients in another in Korea had complete resolution of myelopathy and function after medical treatment). Agarwal et al.3 reported that the only obvious complications were kyphosis (n=2), kyphoscoliosis (n=1), and scoliosis (n=1) attributed to contiguous multilevel involvement at the mid-cervical or cervicodorsal region. The period of immobilisation Commentary: One-year multidrug treatment for tuberculosis of the cervical spine in children

Treatment of pediatric spinal tuberculosis abscess with percutaneous drainage and low-dose local antituberculous therapy: a preliminary report.

The purpose of this study was to evaluate the outcomes of computed tomography (CT) guidance using percutaneous catheter with low-dose drainage local chemotherapy (modified PCD) and antituberculous therapy (ATT) for the treatment of spinal tuberculosis in children. Twenty-seven children suffering from spinal tuberculosis were treated with modified PCD and ATT in our institute from 2002 to 2012. We describe our treatment, which involves CT-guided percutaneous puncture and local chemotherapy (continuous low-dose (20mL) irrigation). The patients were evaluated based on the Frankel scoring system, the kyphotic Cobb angle, and the erythrocyte sedimentation rate (ESR). All patients were followed up for an average of 31.00 ± 13.94months. No sinus formation was detected. All patients responded well to this treatment. The ESR values were decreased to normal at last follow-up. The neurological functions show significant improvement after operation. Preoperatively, the kyphotic angle was 22.89 ± 7.06°, and it was measured as 21.19 ± 8.73° at the last visit. Our results showed that percutaneous intubation and low-dose irrigation under CT guidance (modified percutaneous catheter drainage (MPCD)) and ATT are easy, safe, efficient, and less invasive methods for the treatment of spinal tuberculosis in children.

Active thoracic and lumbar spinal tuberculosis in children with kyphotic deformity treated by one-stage posterior instrumentation combined anterior debridement: preliminary study

The aim of this study was to retrospectively evaluate the safety, feasibility and efficacy of one-stage posterior instrumentation combined anterior debridement and interbody fusion for treatment of active thoracic and lumbar spinal tuberculosis (TB) in children with kyphotic deformity. A total of 20 children (12 boys, 8 girls) were enrolled in this study from January 2006 to January 2011. All patients underwent one-stage posterior instrumentation combined anterior debridement and interbody fusion. Clinical and radiographic results were analyzed. Patients were followed up for 28.9months on average. Improvement was shown in all patients with neurologic dysfunction according to American Spinal Injury Association Impairment Scale. The mean preoperative angle of kyphosis was 35.2°±6.8° (range 26°-47°), which reduced to 9.7°±1.8° (range 6°-13°) postoperatively. The mean angle of kyphosis at the last follow-up was 12.0°±1.9° (range 9°-15°). Erythrocyte sedimentation rate and C-reactive protein returned to normal in all patients within 6months after surgery. All patients acquired bony fusion, and no major complications were observed through the final follow-up visit. One-stage posterior instrumentation combined anterior debridement and fusion were demonstrated to be a safe and effective method to achieve spinal decompression and kyphosis correction in children with thoracic and lumbar spinal TB.

Video-Assisted Thoracoscopic Anterior Surgery Combined Posterior Instrumentation for Children with Spinal Tuberculosis

The use of thoracoscopy for the treatment of spinal disorders has been applied mostly in adults. However, thoracoscopic decompression of spinal tuberculosis in children has probably been rarely documented. To assess the efficacy of video-assisted thoracoscopic anterior surgery (VATS) combined with posterior instrumentation for children with spinal tuberculosis. Total 15 consecutive children with spinal tuberculosis with VATS combined with posterior instrumentation were included. Overall 15 cases of spinal tuberculosis were treated with the procedure of posterior internal fixation and anterior debridement by VATS combined with posterior instrumentation between January 2002 and December 2006.There were nine males and six females with an average age of 11.6 years (8-15 y). All patients were given appropriate chemotherapy for 4 to 12 weeks preoperatively and 12 to 15 months postoperatively. All patients were followed up with evaluation of the changes of kyphotic deformity noted. All the cases were followed up over an average of 37.3 months (range, 12-48 mo).The wounds were healed without chronic infection or sinus formation. Four patients improved three grades, two patients improved two grades, and seven patients improved one grade. The average neurological recovery in the patients was 1.44 grades on the scale by Frankel et al. The average preoperative kyphosis was 37 degrees (range, 23-59 degrees) and the average postoperative kyphosis was 25 degrees (range, 18-35 degrees) at final follow-up. Also, minimal progression of kyphosis was seen at final follow-up with an average kyphosis of 28 degrees (range, 20-40 degrees); and average loss of correction of 3 degree was seen at final follow-up. VATS combined with posterior instrumentation achieve satisfactory results for children with spinal tuberculosis.

English

Abstract This work aims to investigate the efficacy of debridement for paediatric thoracolumbar spinal tuberculosis (TB) by using the anterior approach and the allogeneic bone graft. The lesions of 16 children diagnosed with thoracolumbar spinal TB were exposed via the anterior approach. The pleura and peritoneum, granulation tissue, pus and dead bones of the TB, and the intervertebral disc with pathological changes and necrosis were completely eliminated. The anterior column of the spine was reconstructed using the allogeneic bone (mother's ilium of the suffering child) graft. The postoperative immobilization protection conferred by gyp lasted from three to six months, and the regular anti-TB treatment was performed for more than a year. The follow-up procedure was completed within nine months to three years. All bone grafts of the 16 cases fused with no rejection, recurrence, deformity or paraplegia aggregation and pseudarthrosis formation. The children had normal growth and development and were capable of living a normal life. The lesions of spinal TB in children were removed via the anterior approach. The mothers' iliac bone was obtained to reconstruct the graft of the children's anterior spinal column, thereby inducing new bone formation without affecting the growth and development of the children. The efficacy of debridement was definite.

Thoracolumbar spinal tuberculosis in children with severe post-tubercular kyphotic deformities treated by single-stage closing–opening wedge osteotomy: preliminary report a 4-year follow-up of 12 patients

The correction of severe post-tubercular kyphosis (PTK) is complex and has the disadvantage of being multistaged with a high morbidity. In this study, we evaluated the outcomes of children who underwent single-stage closing-opening wedge osteotomy as a surgical treatment of PTK of the thoracolumbar spine. Our study group included 12 children with thoracolumbar PTK (seven boys and five girls) with an average age of 9.4 years (range 6-12 years), who were treated at our institution from January 2004 to October 2009. The American Spinal Injury Association Impairment Scale and visual analog scale score were used to classify neurologic function. All patients underwent halo-pelvic traction before surgery and were treated with single-stage closing-opening wedge osteotomy. The duration of surgery averaged 99 min (range 70-150 min). Average blood loss was 782 ml (range 560-1,200 ml), and the average length of hospital stay was 12 days (range 8-16 days). The neurological function of all patients improved significantly after the procedure. The mean preoperative kyphotic angle was 83.3° (range 59-118°), which had reduced to 27.6° (range 20-38°) at the final follow-up visit. All patients had solid fusion, and no major complications were observed through the final follow-up visit. Single-stage closing-opening wedge osteotomy is an effective method to correct severe thoracolumbar PTK. A main advantage of the procedure is that it is a posterior-only, single-staged surgery, allowing for significant correction with minimal complications.

Central nervous system and spinal tuberculosis in children at a tertiary care center in Saudi Arabia.

BACKGROUND AND OBJECTIVESTuberculosis (TB) remains a global health problem. There is limited data on pediatric central nervous system tuberculosis (CNSTB) in Saudi Arabia on diagnosis and therapy.DESIGN AND SETTINGRetrospective review of health record of pediatric patients <14 years old who were diagnosed as having CNSTB or spinal TB and admitted to a tertiary care center.PATIENTS AND METHODSHealth records and microbiology data of pediatric patients diagnosed with CNSTB were over 20-year period were reviewed. Data on demographics, clinical presentation, surgical interventions, neuroimaging, mycobacterial cultures and susceptibility and treatment were collected.RESULTSThirteen children were diagnosed with CNSTB or spinal TB. Tuberculoma was the most frequent in 8 cases (62%), followed by TB of the spine in 4 cases (31%), and one case of meningitis. Six patients had a history of TB contact (46%) and 8 (62%) patients had a positive tuberculin skin test (TST). Seizure and weakness was the most frequent symptoms (38% each), while fever was less frequently encountered (23%). Tissue cultures (brain tissues/spinal tissues) showed a high yield (92%) of Mycobacterium tuberculosis with positive cultures for 11 surgical specimens out of 12 for whom cultures were done. There were no surgical complications from biopsies. All of MTB isolates were sensitive to first-line agents.CONCLUSIONSBrain or spinal biopsy is safe and has a high culture yield for MTB so it is advisable to perform a biopsy for any child in whom CNSTB is suspected and when there is no other less risky involved site for biopsy. All MTB isolates in this series were sensitive to first-line anti-tubercular agents.

Spinal tuberculosis in children

ObjectivesTo review our experience of spinal tuberculosis (TB) at a major UK paediatric tertiary referral centre.MethodsThe authors performed a retrospective case survey of 21 patients admitted to Great Ormond Street...

Spinal tuberculosis in children: Retrospective analysis of 124 patients

Background:There is a paucity of report on spinal tuberculosis in children. We report a retrospective analysis of 124 children with TB spine treated over 30 years.Materials and Methods:We retrospectively reviewed 124 children; of cervical (n=36), cervicothoracic (n=4), thoracic (n=53), and lumbar and lumbosacral tuberculosis (n=31) with no skip or multifocal lesions treated between 1971-2004. The age ranged from 2 to 15 years of age with 28 children less than 5 years of age, 58 were between 6 and 10 years, and 38 were over 10 years, 18 had paraplegia of various degrees. Ninety-one children were treated conservatively, while 33 children were subjected to surgery for focal debridement (n=23), posterior interspinous wiring and cementation (n=4), and posterior instrumentation with rods and segmental wiring (n=14). Triple chemotherapy (isoniazid, streptomycin, and PAS) was given for 18 months (3HSPa, 15Hpa) between 1971 and 1975, and triple or quadruple chemotherapy (isoniazid, rifampicin, ethambutol, or pyrazinamide) after 1976 to 2004 for 12 months (12RHZ or 12 RHZE). Some of the children in the current series belonged to the British MRC conservative study patients. The average duration of followup was 5 years and 8 months (range 1.6-20 years).Results:All children attained healed status and showed neural recovery (n=18). The patients attained healed status at 18 months in the first series and at 12 months in the second series after chemotherapy. Spontaneous intercorporal fusion occurred only in 10 (8.06%) of 124 children. Sagittal curve during growth showed three different patterns: Unchanged, decreased, and increased curves. The residual kyphosis was unavoidable in cases with growth plate damage. Kyphosis increased in cases with wedged monovertebra and fused wedged block vertebra, though it was different at different level.Conclusion:The vertebral reformation and curve correction were possible only through the growth plates. The posterior instrumented stabilization alone could correct and/or prevent progress of the kyphosis. However, for active tuberculosis, posterior instrumented stabilization combined with anterior radical surgery should be reserved only for the advanced tuberculosis with instability, rapid progress of kyphosis, and/or unacceptable pre-existing kyphosis, though there is a new trend of prophylactic posterior instrumentation even for the early tuberculosis.

Spinal tuberculosis in children: Retrospective analysis of 124 patients

Spinal tuberculosis in children: Retrospective analysis of 124 patients

An unusual case of lumbosacral tuberculosis

A 12-year-old Somalian girl was investigated for tuberculosis (TB) via contact tracing of her elder brother. She gave a 6-month history of general malaise, weight loss (documented over two clinic visits), night sweats and non-productive cough. At presentation Mantoux test (23 mm in diameter) and T spot were positive while chest radiograph and sputum culture were negative. Abdominal ultrasound scan revealed only minimal paraspinal lymphadenopathy. Positioning of the lymph nodes made biopsy confirmation difficult. In addition, she gave a 2-month history of lower back pain and possible altered sensation in her feet. Neurological examination revealed weakness on flexion of the right hip and right-sided paraesthesia of L5–S1 dermatome distribution. During her admission she complained of difficulty in micturation. Bladder ultrasound showed complete voiding. MRI scan of her lower back illustrated a large anterior paraspinal abscess with lumbosacral changes consistent with osteomyelitis. Vertebral crush fracture of L5 and S1 was also evident. In view of the abscess position and clinical findings, neurosurgical opinion was sort. It was advised she complete a 6-week programme of bed rest with use of spinal brace on mobilisation. She was commenced on quadruple anti-TB medication as well as vitamin D supplementation. She has now been discharged to home. Subsequent MRI scans have revealed a marked improvement of paraspinal abscess size and vertebral changes have remained stable. She continues to mobilise well with limited pain and the symptoms of parasethiae and difficulty in micturation have now resolved. She will receive a prolonged course of quadruple anti TB therapy, at least 9 months. This case report highlights a rare case of lumbosacral TB together with excellent images illustrating the initial lesion with marked improvement on initiation of treatment. We will discuss the evidence for and against spinal immobilisation and surgery in spinal TB in children.