Tubercular Spondylodiscitis Research Articles

Spondylodiscitis: A Diagnostic and Management Dilemma.

Aims Spondylodiscitis (SpD), a debilitating infective condition of the spine, mandates early diagnosis and institution of appropriate therapy, for which accurate microbiology and histological evaluation of the affected tissue is vital. The objectives of the study were to assess the correlation between clinical and magnetic resonance imaging (MRI) findings with histopathology (HPE) and microbiology (MB) in clinically diagnosed spondylodiscitis. Settings and design This was a prospective study of 34 consecutive patients reporting at the outpatient department of a tertiary hospital with clinical and imaging features of SpD, who underwent image-guided/surgical biopsy of lesions. Methods and material The provisional diagnosis of SpD in all patients was made on the combined basis of clinical profile and MRI Spine findings. Tissue samples in all patients, obtained by either open surgery or CT-guided biopsy, were subjected to HPE and MB analysis. Results SpD has a bimodal age distribution with the majority of patients being males in the fourth to fifth decades. Only raised erythrocyte sedimentation rate (ESR) was consistently seen amongst laboratory parameters, with leucocytosis being added pointer towards pyogenic etiology. MRI remained the imaging modality of choice for SpD but was not dependable for etiologic differentiation. On HPE and MB evaluations, 24 patients (71%) had findings consistent with infective SpD, while combined results augmented etiologic confirmation for 28 patients (82.4%). HPE was more sensitive than traditional MB methods to determine etiology in SpD, but the addition of the GeneXpert (Cepheid,Sunnyvale, California, United States) technique improved the MB positivity rate, especially in patients with tubercular SpD. Six patients (17.6%) with both negative HPE and MB results were categorized as 'Non-specific' SpD. Conclusions SpD poses a challenge to determine the etiology for the administration of specific antimicrobial therapy. A stratified standard institutional approach needs adoption to systematically evaluate SpD patients by having a high index of clinical suspicion, early imaging, followed by tissue biopsy for HPE and MB. Despite efforts to reach a diagnosis, a subset of patients without conclusive etiologic agent identification would remain as 'Non-specific', needing empiric antibiotic treatment based on clinico-radiologic profile.

Apparent Provisional Diagnosis Validated by Histopathology: 2 Case Report that mimics TB Spine Conflict of interest: There is no Conflict of interest relevant to this paper to disclose

Background: The incidence of atypical clinic-radiological presentations of spinal TB is on the upsurge. Lesions that share similar features should be evaluated thoroughly. Tissue diagnosis remains the only foolproof investigation to confirm diagnosis before initiation of treatment. Methods: We present 2 cases who were provisionally diagnosed as a case of Tubercular spondylodiscitis based on clinic-radiological findings. After failure of response from anti tubercular drugs, they underwent operative management for decompression of neural elements and histological confirmation of the provisional diagnosis. Results: Clinical features like back pain, weight loss, gait abnormalities with radiological features like Magnetic resonance imaging and GeneXpert, CT guided FNAC helps in early detection and initiation of treatment of spinal TB. But in our case, 58year old female and 13 years old male presented with clinic-radiological features consistent with Spinal TB. Histopathology and immunohistochemistry confirm that first case is due to Aspergillus Spinal Epidural Abscess (ASEA) and second case due to round blue cell neoplasm consistent with Ewings Sarcoma. Conclusion: This article highlights the importance of awareness of the different clinic-radiographic features of spinal lesions, which can mimic a Tubercular Spondylodiscitis. In order to avoid delayed diagnosis, clinicians must be aware of differential diagnosis from common to rare entity which may interfere with other clinical conditions. Bang. J Neurosurgery 2022; 12(1): 29-36

Immune reconstitution inflammatory syndrome following disseminated TB with cerebral venous thrombosis in HIV-negative women during their postpartum period: a case report.

We report an exceptional case of a 19-year-old HIV-negative lady who presented as IRIS following disseminated TB with cerebral venous thrombosis during her postpartum period. After 1 month of starting anti-TB therapy, we found a paradoxical worsening of her symptoms and further deterioration of radiological features showing extensive tubercular spondylodiscitis involving almost all the vertebral with extensive prevertebral and paravertebral soft tissue collections. Significant improvement was observed after 3 months of continuation of steroids along with an adequate dose of anti-TB therapy. The possible mechanism that could explain this dysregulated and exuberant immune response in HIV-negative postpartum women would be rapidly changing immunologic repertoire, as the recovery of the immune system causes an abrupt shift of host immunity from an anti-inflammatory and immunosuppressive status toward a pathogenic proinflammatory state. Its diagnosis mostly depends on having a high degree of suspicion and ruling out alternative etiology. Therefore, clinicians should be aware of the paradoxical worsening of TB-related symptoms and/or radiological features at the primary site of infection or new location following an initial improvement in adequate anti-TB therapy despite HIV status.

Mimics of Spinal Tuberculosis

Background: The incidence of atypical clinicoradiological presentations of spinal tuberculosis (TB) is on the upsurge. Lesions that share similar features should be evaluated thoroughly. Tissue diagnosis remains the only foolproof investigation to confirm the diagnosis before initiation of treatment. Objectives: To evaluate the lesions of spine masquerading as tuberculosis Materials and Methods: We present two cases who were provisionally diagnosed with a case of tubercular spondylodiscitis based on clinicoradiological findings. After failure of response from anti-tubercular drugs, they underwent operative management for decompression of neural elements and histological confirmation of the provisional diagnosis. Results: Clinical features such as back pain, weight loss, gait abnormalities with radiology such as magnetic resonance imaging, computed tomography-guided fine-needle aspiration cytology and GeneXpert helps in the early detection and initiation of treatment of spinal TB. However, in our case, 58-year-old female and 13-year-old male presented with clinic-radiological features consistent with spinal TB. Histopathology and immunohistochemistry confirm that the first case is due to Aspergillus spinal epidural abscess and second case due to round blue cell neoplasm consistent with Ewing’s sarcoma. Conclusion: This article highlights the importance of awareness of the different clinic-radiographic features of spinal lesions, which can mimic a tuberculous spondylodiscitis. In order to avoid delayed diagnosis, clinicians must be aware of differential diagnosis from common to rare entity which may interfere with other clinical conditions.

A case report of a young woman with spinal tuberculosis: Pharmacological managements and rehabilitation approach (CARE- compliant)

A case report of a young woman with spinal tuberculosis: Pharmacological managements and rehabilitation approach (CARE- compliant) Spinal tuberculosis (TB) is one of the rare form of TB in young patient. This can result in serious complications if left untreated or treated inadequately. A different rehabilitation approach is needed for this spinal condition without which there is a chance of poor prognosis. Our patient, 21 years old women, presented with complaints of upper back pain for 7-month and occasional fever for 5-month. This chronic upper back pain was mild to moderate in nature and shared both mechanical and inflammatory features. Fever was occasional, low grade and evening rise of temperature was present. She had anemia, tender upper thoracic area and normal neurological findings. She was diagnosed as tubercular spondylodiscitis from histopathology, MRI and biochemical evidence. She was treated with antiTB chemotherapies for 6 months with inadequate response and continued long for 12 months after further evaluation. A customized, extensive rehabilitation program was planned for her considering short term and long-term outcomes. Duration of anti TB drugs in extra pulmonary TB is a debate. Medical diagnosis and rehabilitation both are equally necessary for improving quality of life. Early diagnosis, proper drug treatment and customized rehabilitation can give nearly full remedy.

Minimally Invasive Iliac Screw Insertion: Clinical Case Series and Technical Note

Objective: Iliac screw fixation has numerous indication and techniques. To describe the technique of minimally invasive screw insertion of the iliac screw by freehand and navigated iliac screw placement using intraoperative image guidance.Methods: Bilateral iliac screws were inserted in a total of seven patients. Five patients underwent navigation guided iliac screw placement and the freehand technique was used in 2 patients. Results: A total of 7 patients underwent minimally invasive iliac screw fixation in our series. The pathology in 4 of the cases was spondylodiscitis, among them 2 cases each at L5-S1 and L4-L5, one with the destruction of L5 vertebral body and the other with the destruction of both L4 and L5 vertebral bodies. Of the remaining cases, two cases had sacral insufficiency fracture and the last case was implant failure after L2-L5 oblique lumbar fusion. None of the cases required conversion to open procedure and none had wound or hardware related complications till the last follow-up. All patients had an uneventful post-operative period with improvement in pain scores and were mobilized on the 1st postoperative day. One 50-year-old female patient suffering from L5-S1 tubercular spondylodiscitis died due to underlying chronic kidney disease three months post-surgery. Conclusion: Minimal invasive iliac screw placement with or without navigation offers the same biomechanical stability as the open approach but without the need for extensive soft tissue exposure needed for a conventional/open procedure; thereby reducing exposure-related complications and enhancing post-operative recovery and early mobilization. Incorporating intra-operative 3D navigation provides real-time multi-planar images which help in easy planning and safe screw placement whilst reducing radiation exposure.

Spinal pain revealing brucellar spondylodiscitis: a case report

BackgroundBrucellosis is an anthropozoonosis. It is an endemic disease in the Mediterranean basin. The clinical presentation is polymorphic. The osteoarticular form is the most frequent of the focal forms affecting mainly the spine. In our endemic context, the diagnosis can lead to confusion with tuberculosis.Case presentationWe report a case of brucellar spondylodiscitis treated initially as tubercular spondylodiscitis with a good initial evolution. Then, the diagnosis was rectified towards a Brucella origin, after a clinical and biological relapse. Diagnostic confirmation was based on the isolation of Brucella spp in the disco-vertebral CT-guided biopsy and the positive Brucella serology. Then, the patient was put on three antibacterial treatments with doxycycline, rifampicin, plus streptomycin over a period of 6 months with a good evolution.ConclusionBrucellar spondylodiscitis is still common in the Maghreb. It is generally insidious and leads to a delay in diagnosis. The clinician must always mention it when faced with spondylodiscitis in an endemic country and ask for brucella serology.

Spondylodiscitis in Children: A Retrospective Study and Comparison With Non-vertebral Osteomyelitis.

Objectives: The aim of this study is to provide new data on pediatrics spondylodiscitis for an optimal clinical management of this site-specific osteomyelitis.Methods: We reported 48 cases of pediatric spondylodiscitis and made three comparisons between: (1) tubercular and non-tubercular cases; (2) patients aged more or less than 5 years; (3) children with spondylodiscitis and 62 controls with non-vertebral osteomyelitis.Results: A higher rate of sequelae was reported in patients with tubercular spondylodiscitis, but no significant differences were noted at the cut-off of 5 years of age. Compared to non-vertebral osteomyelitis, pediatric spondylodiscitis affects younger children of both genders, usually presenting with afebrile back pain, and requiring longer time to admission, hospitalization, and antibiotic therapy.Conclusion: Pediatric spondylodiscitis is an insidious disease with a non-specific presentation in childhood and peculiarities of its own. However, when clinical remission is obtained by an early start of broad-spectrum antibiotics, prolonging the therapy does not improve, nor worsens, the outcome. Surgical management is mandatory in case of vertebral instability and neurological signs but can be avoided when the infection is promptly treated with antibiotic therapy.

Bugs and bones: a study of 25 cases of infectious spondylodiscitis

Background: Infectious spondylodiscitis (IS) is an illness that presents a diagnostic dilemma. It is often associated with significant neurological morbidity, hence early diagnosis and treatment is crucial. As only a few Indian studies have dealt with IS, our study analyses the unique clinico-epidemiological profile of this disease in India and assesses the current management trends and outcome in these patients.Methods: A retrospective study of 25 cases of microbiologically confirmed IS in a single unit at a tertiary care hospital over an 18-month period (January 2018 to June 2019).Results: A total of 25 cases of IS were considered with a mean age of 49 years. Among the cases of non-tubercular spondylodiscitis (NTS), the organisms isolated were methicillin-resistant Staphylococcus aureus (MRSA), Brucella, Escherichia coli and Citrobacter. The average time taken from onset of symptoms to diagnosis was 3 months in tubercular spondylodiscitis (TS) cases and 5 months in NTS cases. Neurological complications were seen in 32% of the patients. Magnetic resonance imaging (MRI) was the imaging modality used to confirm diagnosis in up to 80% of the patients. Medical and surgical management were required in 84% of the cases.Conclusions: The clinical conundrum in IS primarily due to its atypical presentation. The higher tubercular burden of IS was also confirmed in our study and the time taken to presentation was markedly longer compared to the western data. Therefore, understanding the clinical spectrum of this disease helps overcome hurdles of recurrence and debilitating neurological morbidity.

Brucellar, pyogenic and tubercular infections of spine: comparative study of haematological, radiological features and treatment outcome

Spinal infections can also be described as pyogenic, granulomatous (tuberculous, brucella, fungal) and parasitic. Tubercular spondylodiscitis is the commonest. Although a wide range of organisms have been associated with spondylodiscitis, it remains primarily a monomicrobial bacterial infection. A detailed evaluation of clinical features- fever, back pain (Visual Analogue score), discharging sinus, swelling, deformity, neurological status (graded as per charting by Kumar and Tuli; ASIA scale (American Spinal Injury Association). In 7.6% of NTS and 9.1% of TS, the tissue specimen was obtained by closed vertebral biopsy and in 80.7% of NTS and 90.9% of TS by open biopsy at the time of surgery. The yield of culture of the biopsy specimen was 100% in PS and 21% In BS. AFB stain was positive in 32.1% and PCR was positive in 82.8% of TS. 119 (83.3%) patients were treated by anterior decompression, biopsy posterior spinal instrumentation and global fusion.13 (8.6%) patients were treated by debridement, abscess drainage +/-antibiotic bead application.

Is there a change in trend towards pyogenous spondylodiscitis compared to tubercular spondylodiscitis in India–A study of percutaneous biopsy evaluation in spondylodiscitis

BackgroundIn Indian subcontinent where tuberculosis is endemic, the spinal infection was thought to be due to mycobacterium tuberculosis in most of the cases. Hence there is a practice of treating these patients with empirical antitubercular treatment. However, recent guidelines advice biopsy and tissue diagnosis before starting antibiotics. Objective of studyOur retrospective study analyses the role of biopsy in establishing the microbiological diagnosis and thus identifying the incidence of pyogenic and tubercular spondylodiscitis presented to a tertiary care centre. Materials and methodsAll patients who were diagnosed as spondylodiscitis by clinical and radiological criteria and who underwent biopsy were included in the study and data was retrieved from medical records and PACS. Criteria for tubercular spondylodiscitis included presence of mycobacterium tuberculosis either in smear/gene Xpert, or histopathological evidence of tuberculosis. Organism isolation other than MTB or absence of tubercular granuloma and response to antibiotics were considered as non-tubercular aetiology. ResultsOur study achieved 84% (n-63) accuracy for first biopsy and 34 patients (53.96%) were diagnosed as pyogenic spondylodiscitis. Organisms were isolated in 11 cases (32%) of pyogenic spondylodiscitis and tubercular bacilli in 17 cases (65%) of tubercular spondylodiscitis. Aspiration of pus yielded better isolation of organisms (P < 0.001) in pyogenic spondylodiscitis. 11% of cases showed drug resistant tuberculosis. ConclusionWe conclude that there is an increasing trend of pyogenous spondylodiscitis compared to tubercular spondylodiscitis in patients presenting to tertiary care centre, hence biopsy is essential to start antimicrobials.

Mycobacterium abscessus mimicking tubercular spondylodiscitis following ozone therapy: A case report and review of literature

Background: The incidence of Mycobacterium abscessus (MA), a rapidly growing species of nontuberculous mycobacteria (NTM)-related infections, has been steadily rising over the past decade. Despite the increased prevalence of NTM-related infections, it is largely underreported from TB-endemic countries due to lack of awareness and limited laboratory facilities. Here, we report a rare case of L4–L5 spondylodiscitis caused by MA following ozone therapy (a noncondoned method of lumbar disc management). Case Description: A healthy, nonimmunocompromised 43-year-old female presented with bilateral lower extremity radiculopathy. She underwent a fluoroscopically guided percutaneous ozone treatment for degenerated disc disease at the L4–L5 level. She was symptom free for 3 months duration. She then presented with severe low back pain, bilateral lower extremity radiculopathy, and spondylodiscitis at the L4–L5 level. This was treated with a L4–L5 transforaminal lumbar interbody fusion. MA was cultured from the epidural purulent material collected during the surgery. The patient was discharged on oral clarithromycin 500 mg twice daily and intravenous amikacin 500 mg twice daily for 6 weeks. The plan was to then continue oral clarithromycin for another 6 weeks till resolution of primary infection. Conclusion: Early diagnosis and appropriate therapy is required to treat NTM which is more prevalent in epidemic/endemic regions.

Mycobacterium abscessus mimicking tubercular spondylodiscitis following ozone therapy: A case report and review of literature

Background:The incidence of Mycobacterium abscessus (MA), a rapidly growing species of nontuberculous mycobacteria (NTM)-related infections, has been steadily rising over the past decade. Despite the increased prevalence of NTM-related infections, it is largely underreported from TB-endemic countries due to lack of awareness and limited laboratory facilities. Here, we report a rare case of L4–L5 spondylodiscitis caused by MA following ozone therapy (a noncondoned method of lumbar disc management).Case Description:A healthy, nonimmunocompromised 43-year-old female presented with bilateral lower extremity radiculopathy. She underwent a fluoroscopically guided percutaneous ozone treatment for degenerated disc disease at the L4–L5 level. She was symptom free for 3 months duration. She then presented with severe low back pain, bilateral lower extremity radiculopathy, and spondylodiscitis at the L4–L5 level. This was treated with a L4–L5 transforaminal lumbar interbody fusion. MA was cultured from the epidural purulent material collected during the surgery. The patient was discharged on oral clarithromycin 500 mg twice daily and intravenous amikacin 500 mg twice daily for 6 weeks. The plan was to then continue oral clarithromycin for another 6 weeks till resolution of primary infection.Conclusion:Early diagnosis and appropriate therapy is required to treat NTM which is more prevalent in epidemic/endemic regions.

Outcomes and risk factors for spontaneous spondylodiscitis: Case series and meta-analysis of the literature

Despite recent improvements in surgical and antimicrobial therapies, few generally applicable guidelines exist for spondylodiscitis management. We reviewed a consecutive series of patients as well as the past 18 years of the literature and analyzed outcomes for either conservative or surgical treatment. We analyzed a consecutive series of adults with spontaneous spondylodiscitis treated at our institution over the last 6 years. We analyzed predictors for neurological deficits, vertebral collapse, and surgical treatment. We also performed a meta-analysis of the literature between 2000 and 2018, stratifying the results between surgical and conservative treatment outcomes. A younger age at diagnosis, cervical location, tubercular infection, coexistence of morbidities, and vertebral collapse were predictors of surgical intervention. Cervical spondylodiscitis, vertebral collapse, and epidural collection were associated with a higher risk of developing neurological deficits, while tubercular spondylodiscitis was associated with a higher risk of vertebral collapse. Based on the current literature, conservative treatment has success rates similar to those of surgical treatment but lower complication and mortality rates. In cases without an absolute indication for surgery, a conservative approach should be considered as the first-line treatment. A closer diagnostic and clinical follow-up should be recommended in patients with cervical tract or tubercular spondylodiscitis because of the higher risk of developing bone collapse and neurological deficits.

Comprehensive treatment algorithm for management of thoracic and lumbar tubercular spondylodiscitis by single-stage posterior transforaminal approach.

Surgery in tubercular spondylodiscitis involves radical debridement and fusion by combined anterior and posterior or all posterior approaches with a posterolateral window with its associated morbidities. This study evaluates the outcome of a comprehensive treatment algorithm for thoracic and lumbar tubercular spondylodiscitis by a single-stage posterior transforaminal approach. One hundred and twenty-six patients with tubercular spondylodiscitis between T1 and S1 who underwent posterior surgery with/without fusion by transforaminal approach with a minimum follow-up of 2years were analyzed. Radiological outcome was assessed by documenting healing with magnetic resonance imaging/computed tomography and radiographical fusion, while clinical outcome was assessed by visual analog score (VAS) for pain and Frankel grading for neurological recovery. Of the 114 patients available for follow-up with a mean age of 53years, complete radiological healing was observed in all patients (100%) with radiographical fusion in 97.4% and neurology recovered to Frankel E in all 37 patients with deficit. The preoperative VAS score of 9.2 improved significantly to 1.7 postoperatively, and all patients returned to their preoperative occupational activities at the final follow-up. This comprehensive treatment algorithm of single-stage posterior surgery by transforaminal approach in thoracic and lumbar tubercularspondylodiscitis provided good clinical and radiological outcomes. It aids in achieving the same surgical goals, obviating the need for extensive posterior or combined surgical approaches.

Standalone Instrumented Posterior Approach Used as Universal Approach for Tuberculosis Spondylodiscitis.

Background:Surgical management of spinal tuberculosis (TB) has been classically the anterior, then combined, and of late increasingly by the posterior approach. The posterior approach has been successful in early disease. There has been a paradigm shift and inquisitive to explore this approach in the more advanced and even long-segment disease. Our study is a retrospective analysis by authors in variable disease pattern of TB Spine operated at an institute using a single posterior approach.Settings and Design:A retrospective case study series in a tertiary level hospital.Aims:The aim of this study is to evaluate the functional and radiological results of an all posterior instrumented approach used as a “universal approach” in tubercular spondylodiscitis of variable presentation.Materials and Methods:The study is from January 2015 to May 2018. Twenty-four of 38 patients met the inclusion criterion with a male: female = 8:16, and mean age 44.26 years. The initial diagnosis of TB was based on clinic-radiologic basis. Their level of affection, number of vertebrae affected, and vertebral body collapse, the kyphosis (preoperative, predicted, postoperative, and final residual) and bony fusion were measured in the preoperative, postoperative, and final X rays. Functional scoring regarding visual analog scale and Frankel neurology grading was done at presentation and follow-up of patients. Histopathological data of all patients were collected and anti-tubercular therapy completed for a period of 1 year with 4 drugs (HRZE) for 2 months and 2 drugs (HR) for rest of period.Statistical Analysis Used:The descriptive data were analyzed by descriptive statistics, and other parameters were calculated using the appropriate statistical tests such as the Student paired t-test for erythrocyte sedimentation rate, visual analog scale score, and kyphosis.Results:The mean number of vertebrae involved was 3.29 ± 0.86 (2–6) with mean vertebral body destruction was 0.616. Preoperatively, the mean kyphosis angle was 22.42° ± 12.56° and was corrected postoperatively to 13.08° ± 11.34° with an average correction of 9.34° (41.66%). At the latest follow-up, there was mean loss of correction of 0.80° resulting in 13.88° of final correction. Bony fusion was achieved in 20 patients (83.33%) cases. Neurological recovery occurred in all patients (100%), and 92% could be ambulatory at 1 year follow-up. There was improvement of visual analog scale from 6.33 ± 1.05 preoperatively to 1.042 ± 0.75 at 3 months of postoperative period. Two patients had bed sore, two had urinary infection, and one had neurological worsening requiring re exploration and cage removal eventually recovering to Frankel E. Two patients died due to unrelated cause.Conclusions:The procedure in safe and has satisfactory results in variable group affection of Pott's spine including early and late disease, multisegment involvement using pedicle screw fixation with/without cage support.

MRI Findings in Pott’s Spine with its Histopathological Correlation

Background: MRI is now the preferred imaging modality and preferred technique to define the activity and extent of infection for patients with suspected spinal tuberculosis. The objective of the study was to describe diagnostic accuracy, sensitivity and specificity of MRI in diagnosis of spinal tuberculosis and various radiological features of spinal tuberculosis (TB) on magnetic resonance imaging (MRI). Subjects and Methods: Out of total 45 cases of suspected tuberculosis in our study we given 38 case as spinal spondylo-discitis out of which 36 cases accurately diagnosed by MRI proved by histopathology or culture reports.&nbsp; And 7 cases of given non tubercular out of which 1 case came to be tubercular spondylodiscitis on histopathology.&nbsp; MRI case records of these 37 patients with proven tuberculosis retrospectively analysed. Results: The majority of the patients were males 60% (22/37) and most common age group is 31 to 50 years age group (45%). The most common clinical presentation was backache 81% (n=30) followed by fever 22/37 cases (59.45%). The Thoraco-lumbar spine was the commonest site of the disease (38.64%) followed by the lumbar region (31.82%). An intervertebral disc involvement, pre and paravertebral collections, subligamental extension of the abscess were commonly seen, with an epidural collection occurring in more than 75 % of the cases. In addition few cases also showed single vertebral involvement (n-3) and few cases shows skip lesions. Conclusion: The MRI scan is highly sensitive in the detection of various pathological processes of spinal tuberculosis and their pattern of occurrence. The extent of soft tissue involvement disease is best assessed by MRI which help in guiding the surgical treatment as well as to monitor the response to treatment during follow up.

'Need of the Hour': Early Diagnosis and Management of Multidrug Resistant Tuberculosis of the Spine: An Analysis of 30 Patients from a "High Multidrug Resistant Tuberculosis Burden" Country.

Study DesignRetrospective study.PurposeTo report the prevalence of patients with multidrug-resistant (MDR) tubercular spondylodiscitis and their outcomes. Additionally, to assess the role of Xpert MTB/RIF assay in early detection of MDR tuberculosis. Overview of LiteratureMDR tuberculosis is increasing globally. The World Health Organization (WHO) has strongly recommended Xpert MTB/RIF assay for early detection of tuberculosis.MethodsFrom 2006 to 2015, a retrospective study was conducted on patients treated for MDR tuberculosis of the spine. Only patients whose diagnosis was confirmed using either culture and/or the Xpert MTB/RIF assay were included. Diagnostic method, treatment regimen, time taken to initiate second-line antituberculosis treatment (ATT), drug-related complications, and cost of medications were analyzed. All patients with MDR were treated according to the WHO recommendations for 2 years. The outcome parameters analyzed included clinical, biochemical, and radiological criteria to assess healing status.ResultsFrom 2006 to 2015, a total of 730 patients were treated for tubercular spondylodiscitis. Of those, 36 had MDR tubercular spondylitis (prevalence, 4.9%), and three had extremely drug resistant tubercular spondylitis (prevalence, 0.4%). In this study, 30 patients, with a mean age of 29 years and a mean post-treatment follow-up of 24 months, were enrolled. The majority (77%) had secondary MDR, 17 (56%) underwent surgery, and 26 (87%) completed treatment for 2 years and were healed. Drug-related complications (33%) included ototoxicity, hypothyroidism, and hyperpigmentation of the skin. The average time taken for initiation of second line ATT for MDR patients with Xpert MTB/RIF assay as the diagnostic tool was 18 days, when compared to patients for whom the assay was not available which was 243 days.ConclusionsThe prevalence of MDR tubercular spondylodiscitis was 4.9%. In total, 87% of patients were healed with adequate treatment. The sensitivity and specificity of the Xpert MTB/RIF assay to detect MDR was 100% and 92.3%, respectively.

Early Detection and Analysis of Children with Multidrug-Resistant Tuberculosis of the Spine.

Study DesignRetrospective case series.PurposeThe aim of the study is to report the clinical characteristics, early diagnosis, management, and outcome of children with multidrug-resistant (MDR) tubercular spondylodiscitis and to assess the early detection of rifampicin resistance using the Xpert MTB/ RIF assay.Overview of LiteratureMDR tuberculosis is on the rise, especially in developing countries. The incidence rate of MDR has been reported as 8.9% in children.MethodsA retrospective study of children aged <15 years of age who were diagnosed and treated for MDR tuberculosis of the spine was conducted. Confirmed cases of MDR tuberculosis and patients who had completed at least 18 months of second-line antituberculous treatment (ATT) were included. Children were treated with ATT for 24 months according to drug-susceptibility-test results. Outcome measures included both clinical and radiological measures. Clinical measures included pain, neurological status, and return to school. Radiological measures included kyphosis correction and healing status.ResultsSix children with a mean age of 10 years were enrolled. The mean follow-up period was 12 months. All the children had previous history of treatment with first-line ATT, with an average of 13.6 months before presentation. Clinically, 50% (3/6 children) had psoas abscesses and 50% had spinal deformities. Radiologically, 50% (three of six children) had multicentric involvement. Three children underwent surgical decompression; two needed posterior stabilization with pedicle screws posteriorly followed by anterior column reconstruction. Early diagnosis of MDR was achieved in 83.3% (five of six children) with Xpert MTB/RIF assay. A total of 83.3% of the children were cured of the disease.ConclusionsXpert MTB/RIF assay confers the advantage of early detection, with initiation of MDR drugs within an average of 10.5 days from presentation. The cost of second-line ATT drugs was 30 times higher than that of first-line ATT.

Pott’s Disease in a 3 Years Old Italian Child: Case Report and Review of the Literature

Introduction:Tuberculosis (TB) is currently a major health problem, in particular in developing countries and in HIV positive people. Tubercular spondylodiscitis is the most common type of skeletal TB, more frequent in children than adults. It is rarely reported in developed countries.Case Report:We describe a 3 years-old Italian girl who referred to our hospital with back pain and walking deficiency; she had a very good outcome with anti-tubercular treatment and orthopedic follow-up.Conclusion:Early recognition and treatment of this tubercular complication are very important due to its possible complications: bone destruction, spinal deformity, neurologic and orthopedic complications.