Vertebral Involvement Research Articles

Escherichia coli Spondylodiscitis: A Case Report and Literature Review

Introduction: Spondylodiscitis is an infectious inflammatory disease with the involvement of an intervertebral disk and adjacent vertebral bodies. Hematogenic spreading of microorganisms from an infectious site is the most common pathophysiologic cause of vertebral osteomyelitis. In this report, a case of Escherichia coli spondylodiscitis was described and a review of literature was also performed on cases with E. coli spondylodiscitis. Case Presentation: A 68-year-old woman referred to our hospital with a 2-month history of intermittent fever, weight loss, and low back pain. On physical examination, we found obvious bulging with the dimensions of 4 × 20 cm on about L1 - L4 vertebral area. Lumbosacral MRI revealed the evidence of L2 - L3 spondylodiscitis. She had positive blood and urine cultures with ciprofloxacin-sensitive E. coli and successfully treated without surgery after 8 weeks. Nine articles (including 9 patients) regarding E. coli spondylodiscitis or vertebral osteomyelitis have been published from the 1st of January 1985 to the 10th of August 2019. In addition to these cases, here we report 10th case of E. coli vertebral osteomyelitis. Four patients were female and 6 were male. The mean age was 52 years with a range of 12 - 69. Seven cases had a history of fever, and overall, fever and pain at the site of vertebral involvement were the most common symptoms. Conclusions: In our reported patient, returning to the patient’s medical history and finding a previous urinary tract infection and E. coli bacteremia was crucial in helping to diagnose and treat the patient. In our review, 7 patients had positive blood cultures, a finding that emphasizes the diagnostic value of this test. Escherichia coli spondylodiscitis is a relatively rare disease that has usually a source of urinary tract infection and its clinical signs and symptoms are not distinguishable from vertebral osteomyelitis due to other agents and finally, blood culture can be helpful as a diagnostic method.

Abstract TP84: Prognostic Factor of Intracranial Vertebral Artery Dissection: High Resolution Vessel Wall Magnetic Resonance Imaging Study

Background: Vertebral artery dissection (VAD) is well recognized cause of stroke in young and middle aged individuals. But, prognostic factor of posterior circulation ischemic stroke or transient ischemic attack (TIA) caused by intracranial VAD has been rarely discussed. Our aim was to evaluate the predictors of poor outcomes in posterior circulation ischemic stroke caused by intracranial VAD. Methods: We retrospectively reviewed patients with posterior circulation ischemic stroke or TIA caused by intracranial VAD using high-resolution vessel wall MRI who were recruited from Samsung Medical Center Stroke Registry (between January 1, 2011 and April 30, 2019). Poor outcomes were defined as a 3-months modified Rankin scale (mRS) score ≥ 2. Results: We registered 96 patients (74 males; mean age, 58.9±14.2 years) with acute posterior circulation ischemic stroke or TIA caused by intracranial VAD. Trauma history associated with VAD was presented in 23 (24%) of patients. Headache and neck pain around neurological symptom onset were presented in 41 (42.7%) and 19 (19.8%) of patients, respectively. Dissecting aneurysm, bilateral vertebral artery involvement, basilar artery involvement and wall hematoma with dissection were presented in 26 (27.1%), 26 (27.1%), 12 (12.5%) and 66 (68.8%) of patients, respectively. Of the 96 VADs, 26 (27.1%) presented with focal stenosis, 21 (21.9%) with multifocal stenosis, and 57 (59.4%) with occlusion. Lateral medulla involvement and multiple territory involvement were presented in 35 (36.5%) and 31 (32.3%) of patients. Recurrence rate of ischemic stroke or TIA within 90 days of symptom onset was 6.25%. Twenty-nine patients (30.2%) had poor outcomes at 3 months. Lateral medulla involvement was an independent predictor for poor outcome (odds ratio=3.293, 95% confidence interval=1.301-8.333, p=0.012). Conclusion: Posterior circulation ischemic stroke or TIA caused by intracranial VAD is associated with relatively benign clinical course. But the presence of lateral medulla involvement is independent predictor for poor outcome. Patients presenting lateral medullary infarction caused by intracranial VAD should be monitored closely.

Multi-Level forestier syndrome in the cervical vertebra with an unusual radiographic appearance: Case report

We present a rare case of Forestier disease with multi-level vertebra involvement from the upper cervical to the thoracic area which has not been reported in the literature before. A 65- year old male patient was admitted to our outpatient clinic with neck pain, dysphagia and sleep apnea for over 5 months. On his cervical CT scan revealed broad ossification of the anterior longitudinal ligament from C2 to T1 with anteriorly beaking osteophytes surrounding the vertebral bodies causing compression of the trachea and esophagus on C2 and C3. With the diagnosis of Diffuse Idiopathic Skeletal Hyperostosis (DISH), the patient underwent surgery. With an anterolateral approach the ossified pathological segment was removed with a high-speed drill and the patient’s symptoms revealed immediately after the surgery.

Tuberculoma of the conus medullaris

A 52 year old female presented with a one month history of progressive back pain radiating to the right lower limb. She reported unintentional weight loss of seven kilograms over three months and drenching night sweats. There was no history of cough. Her physical examination was unremarkable. A HIV ELISA test was positive. Her CD4 count was 27 cells/mm3 and viral load was 1.8 million copies/ml. An MRI spine (A,B) to evaluate the back pain revealed a single spinal ring enhancing lesion at T12 with minimal perilesional edema. A chest CT scan was in keeping with miliary tuberculosis. Sputum TB GeneXpert was positive for Mycobacterium tuberculosis. Anti TB therapy was initiated with subsequent resolution of back pain. Back pain in a patient with miliary TB may indicate vertebral involvement or rarely, as in this case, intramedullary tuberculomas. Prognosis is usually good.

Diagnostic yield and technical aspects of fluoroscopy-guided percutaneous transpedicular biopsy of the spine: A single-center retrospective analysis of outcomes and review of the literature.

Background:The technique of a percutaneous transpedicular biopsy of spinal lesions has been shown to be a useful alternative to paraspinal biopsy for vertebral body lesions in the thoracic and lumbosacral spine. Percutaneous vertebral biopsy is less invasive, cost-effective, and is suitable for patients with intractable back pain and vertebral body lesions that are detected with noninvasive imaging modalities.Objective:The purpose of this study was to establish the diagnostic utility and spectrum of fluoroscopy-guided percutaneous transpedicular biopsies of the thoracolumbar spine performed at our institution.Materials and Methods:This retrospective descriptive study to establish the diagnostic utility and spectrum of percutaneous fluroscopic guided transpedicular biopsy of lower thoracic and lumbar vertebral lesions has been performed on 42 patients in a tertiary care hospital between April 2017 and December 2019. There were 28 male patients and 14 female patients. The mean age was 48 years (range: 12–66 years). There were one 14 thoracic, 26 lumbar, and 2 sacral biopsy specimens. The lesion level was determined under fluoroscopy. Biopsy was taken with a trephine needle under local anesthesia. Accuracy and effectiveness of the technique were analyzed on histopathologic confirmation.Results:The fluoroscopic guided percutaneous transpedicular spine biopsies of 42 patients with spinal pathology were performed through the posterior transpedicular approach percutaneously. Of the 42 patients, 28 were male (66.7%) and 14 were female (33.3%). Vertebral involvement was observed to be more in the lower thoracic region (26.2%), followed by the upper dorsal region (7.1%), L1 (23.6%), L2 (6.4%), L3 (14.6%), L5 (17.3%), and sacrum (4.8%). There were 21 cases with tumor etiology (14 metastasis, 2 malignant round cell tumor, 2 multiple myeloma, and 3 lymphomas), 14 tuberculosis (TB), 4 osteomyelitis, 2 inflammatory, and 1 isolated compression fractures. Twelve patients of the 14 diagnosed cases who were diagnosed with TB on histopathology had positive TB culture and sensitivity pattern.Conclusion:Percutaneous transpedicular fluoroscopy-guided biopsy with a Jamshidi trocar with an internal diameter of 3.1 mm is a simple, safe, and reliable method for the etiological diagnosis of vertebral lesions. The use of this technique, however, is dependent on the accurate placement of the trocar and on close qualified interdisciplinary clinical cooperation. This minimally invasive technique is simple, safe, and effective in the diagnosis of malignant and infective lesions.

Treatment Results of Posterior Instrumentation Applied to Thoracolumbar Spine in Multiple Segment Involvement in Seronegative Rheumatoid Arthritis

Spinal segment involvement is a common symptom in rheumatoid arthritis. The cervical region is the most commonly involved spinal segment in individuals with rheumatoid arthritis. Multiple involvement of thoracic and lumbar vertebrae is known to be rare. In patients with seronegative rheumatoid arthritis, this type of segment involvement is more severe and conservative treatment is insufficient in some cases and surgical interventions are taken. In our study, the clinical features of a 66-year-old female patient with multiple involvement in thoracolumbar segments were evaluated before and after physiotherapy and rehabilitation sessions with conservative treatment and the changes in the clinical condition were emphasized. The unique feature of our study is the discussion of the evaluation and treatment results of this rare pathological condition with this case report.

Are We Neglecting Long Term Effects of Vertebral Shortening on Pulmonary Function in Spinal Tuberculosis?

Background: In developing part of world, it is common to see near complete destruction of vertebral bodies in TB due to contiguous involvement of multiple vertebrae. This leads to frequent occurrence of spinal deformities including kyphosis. Resultant loss of vertebral column height & its effects on pulmonary function haven't been studied previously. Our study aims to assess effect of spinal TB with vertebral shortening on pulmonary function. Methods: 50 cases consisted of both operative & non operatively managed cases of spinal TB who presented to tertiary care institute between the years 2011 to 2016 were assessed. Vertebral height loss was assessed by SDI. All patients underwent pulmonary function testing and various spirometry variables were considered. Arm span was used as a surrogate marker for height. Findings: Study group consisted of 14 males & 36 females with mean age of 27.9 years. 11 patients with mean SDI of 2.72 ± 1.1 showed normal lung function. 36 patients showed a restrictive pattern of which 12 showed mild, 14 moderate and 10 showed severe pattern. Only 3 cases showed an Obstructive pattern. 36 patients had Thoracic affection, 13 patients had a thoracolumbar affection while 1 patient had a purely Lumbar affection. As the apex of the curve shifted proximally, the FVC% reduced and the decrement was statistically significant. Increase in the SDI value was associated with a fall in the vital capacity and FEV1. Increase in the kyphotic angle was associated with a deleterious effect on PFT results. SDI showed significant difference between Normal & restrictive pattern groups. Interpretations: Careful preservation of pulmonary function along with restoration of neurological function should be the aim of management of TB spine. Usually shortening procedures are better tolerated by spinal cord as compared to distraction. However, pulmonary dysfunction resulting from vertebral body height loss due to kyphosis is neglected. This risk stratification will further emphasize the need for early detection of this disease before the deformity sets in & need for long term observation for possible deterioration in lung function. Funding Statement: The authors hereby declare that they have not received any funding for this manuscript. Declaration of Interests: Each author certifies that he or she has no commercial associations (e.g. consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article. Ethics Approval Statement: Approval from the IRB was taken prior to commencement.

Brucellar Spondylitis in Kermanshah as an Endemic Area in West of Iran

Background: Spondylitis is an important osteoarticular manifestation of brucellosis that leads to serious complications. Objectives: We aimed to investigate various aspects of spondylitis in brucellosis patients in Kermanshah, a highly endemic area in the West of Iran. Methods: This retrospective, single-center, cross-sectional study investigated 289 brucellosis patients among whom, 32 patients were confirmed to have brucellar spondylitis. The diagnosis of brucellosis was made by Wright or Coombs Wright tests (titers ≥ 1/80) or 2ME test (titer ≥ 1/40). Brucellar spondylitis was confirmed by vertebral MRI or whole-body bone scan. All analyses were done using SPSS 21 software. The chi-square or Fisher exact test was used for assessing associations. P values of 40 years, admission duration > 10 days, and ESR > 40 mm/h but not to sex, fever, anemia, and Wright titer. The lumbar disc involvement was the most common involvement (90.6%) in brucellar spondylitis patients. Vertebral body involvement, abnormal marrow signal, and bone marrow edema were observed in all 31 patients diagnosed with MRI. Conclusions: Brucellar spondylitis should be considered in patients with lower back pain and fever in endemic areas. Positive Wright serology, vertebral body involvement in MRI, and elevated ESR greatly favor the diagnosis of this complication.

Total vertebral involvement by benign fibrous histiocytoma: A case report and literature review

BackgroundBenign fibrous histiocytoma (BFH) is extremely rare in the spine. MethodsWe present a 52-year-old patient diagnosed with BFH in the thoracic spine and treated with total en bloc spondylectomy. The related literature was also reviewed. ResultsA total of 19 spinal BFHs have been reported, all involving the posterior elements of spine. Here we present the first BFH with total vertebral involvement. ConclusionsTo our knowledge, this is the first case of total vertebral BFH. Spinal BFH is a considered a non-aggressive benign lesion. Surgical intervention is usually sufficient for managing BFH with both recurrence and metastasis uncommon.

Does mesh cage subsidence have any effect on functional outcome in spinal tuberculosis?

Introduction:Occurrence of mesh cage subsidence in patients undergoing anterior column reconstruction following Tuberculosis spine is frequent radiological finding as bone quality of affected vertebrae is poor. This study aims at determining effect of mesh cage subsidence on functional outcome.Methods:Retrospective demographics of 30 patients of consecutive series in age range 4-60 year were collected with Clinical outcome evaluation using VAS, ODI and ASIA scale. 30 patient having Dorsolumbar tuberculosis with vertebral involvement ranging from 1-6 with mean vertebral level involvement of 2.71, underwent anterior column reconstruction through posterior only approach between 2011-15 were reviewed. Patients were followed at regular intervals of 6 weeks, 12 weeks, 6 months & thereafter on yearly basis. They were evaluated for interbody height loss with subsidence, fusion & segmental angle.Results:Clinical parameters i.e. VAS & ODI showed improvement in postoperative period which continued to remain same even after subsidence (P < 0.05). Subsidence was categorized as combined anterior + posterior < 5mm; 5 -10mm; >10mm. ODI at follow up was 8.5 ±4.62, 9 ± 2 and 9 ± 4.2 (P = 0.961) respectively & VAS score in above group was 1.3 ± 0.51, 1.5 ± 1.2 & 1.5 ± 0.7 (P = 0.975) respectively. Subsidence was age, spinal level nonspecific.Conclusion:Study indicates that though Cage subsidence occurs to varying severity due to weakened vertebral bodies, it did not have significant impact on functional outcome in terms of VAS, ODI or radiological evidence of fusion following reconstruction in Spinal tuberculosis.

Lumbar vertebral osteomyelitis and psoas abscess caused by Actinomyces israelii after an operation under general anesthesia in a patient with end-stage renal disease: a case report

BackgroundActinomycosis is a chronic, slowly progressive infection caused by the Actinomyces species. Lumbar vertebral involvement of Actinomyces israelii is extremely rare; this is the first case report of lumbar vertebral osteomyelitis and psoas abscess caused by Actinomyces israelii after an operation under general anesthesia.Case presentationA 66-year-old Japanese man with end-stage renal disease was admitted to our hospital for an operation for cervical canal stenosis. After the operation under general anesthesia, during which tracheal intubation and nasogastric tube insertion were performed, he developed low back pain. During a second hospitalization, computed tomography revealed osteolysis of the lumbar endplates of L2 and L3, swelling of the intervertebral disk of L2/L3, and swelling of the left psoas major muscle. Percutaneous drainage of the intervertebral disc was performed, and the culture of the aspirate grew Actinomyces israelii. Based on the susceptibility, ampicillin was administered but his condition did not improve. We changed the antibiotics to ampicillin-sulbactam for coverage of unidentified oral commensals, and his symptoms and signs finally improved.ConclusionOur patient’s long-term end-stage renal disease had made the oral and gastrointestinal mucosal barriers very fragile. Under these conditions, even mildly invasive procedures such as tracheal intubation and nasogastric tube insertion could be the cause of infectious complication by oral commensals, including Actinomyces.

18FDG-PET is sensitive tool for detection of extracranial tuberculous foci in central nervous system tuberculosis – Preliminary observations from a tertiary care center in northern India

PurposeTo study the role of 18FDG- PET (Flourodeoxyglucose positron emission tomography) in a) determining the extent of cranial and extra-cranial disease and b) diagnosis as well as prognosis of CNS TB (central nervous system tuberculosis) including TBM (tuberculous meningitis). Patients and methodsThis prospective observational study (n = 70) was carried out at a tertiary care institute in Northern India from 1.1.2017 to 30.6.2018. Diagnosis of TBM was made according to modified Ahuja's criteria. All patients were evaluated in detail and treated as per standard guidelines. All patients underwent 18FDG-PET scanning of brain and whole body at baseline. ResultsMean age was 35.2 ± 14.8 years. There were 37 men. Majority of patients (n = 47; 67.1%) were below 40 years of age. 43 (61.4%) patients were in stage II TBM. The mean duration of illness was 77 ± 101.9 days. Majority of patients presented with fever (94.3%), headache (90%) and vomiting (84.3%). MRI was abnormal at baseline in 67 (95.7%) of patients, most common abnormalities being meningeal enhancement (68.6%) and tuberculomas (57.1%). PET was abnormal in 66 (95.7%) of patients. All these patients had either lung lesions (n = 62, 88.6%) or lymphadenopathy (n = 61; 87.1%). 18FDG-PET revealed evidence of brain lesions in 52 (74.3%) patients. It revealed vertebral involvement in 19 (27.1%) and genitourinary lesions in 9 (12.9%) patients. PET evidence of lymphadenopathy correlated significantly (p = .04) with good outcome in CNS TB.Conclusion18FDG-PET does seem to have a promising role in initial evaluation of patients with CNS TB.

Biallelic variants p.Arg1133Cys and p.Arg1379Cys in COL2A1: Further delineation of phenotypic spectrum of recessive Type 2 collagenopathies.

The phenotypic spectrum of Type 2 collagenopathies ranges from lethal achondrogenesis Type 2 to milder osteoarthritis with mild chondrodysplasia. All of them are monoallelic except for the two recent reports showing that biallelic variants in COL2A1 can cause spondyloepiphyseal dysplasia congenita in two children. Here we report two additional families with homozygous variants, c.4135C>T (p.Arg1379Cys) and c.3190C>T (p.Arg1133Cys) in COL2A1 resulting in two distinct skeletal dysplasia phenotypes of intermediate severity. Though all six patients from four families exhibit a spondylo-epimetaphyseal dysplasia, they demonstrate a wide variation in severity of short stature and involvement of epiphyses, metaphyses, and vertebrae. We hypothesize that the variants are likely to be hypomorphic, given the underlying mechanisms of disease causation for known heterozygous variants in COL2A1. With this report, we provide further evidence to the existence of autosomal recessive Type 2 collagenopathy.

Comparative clinical study on seldom segment with multiple segment intramedullary primary spinal cord tumors.

Several clinical studies were performed on multi-segment intramedullary primary spinal cord tumors. However, no clinical study focused on the relationship between different vertebral segments intramedullary tumors involvement and neurological functions, as well as prognosis of the patients. This prospective study was performed to compare clinical analysis on neurological functions and prognosis of the patients with intramedullary spinal cord primary tumors. A prospective cohort study was performed in a single medical center, Neurosurgical Department, Peking University Third Hospital. Between Jan. 1, 2010 and Dec. 30, 2015, 135 patients underwent microsurgery for intramedullary primary spinal cord tumors. The intramedullary tumor length occupying 3 or more vertebral body levels was considered as multiple segments intramedullary primary spinal cord tumor, and occupying one or two vertebral body levels considered as seldom segments. Preoperative and postoperative functions were assessed using IJOA (improved Japanese orthopaedic association) scoring system, and analyzed using the appropriate statistical tests. Among the 135 patients, 52 cases had seldom segments intramedullary primary spinal cord tumors, and 83 cases had multiple segments. In the seldom group, 32 (62%) patients presented with normal urine and stool function, 8 (15%) patients with severe dysfunction, 7 (14%) with slight dysfunction, and 5 (9%) with incontinence, and 30 (58%) patients demonstrated various degrees of limbs weakness. The preoperative IJOA scores of the patients were 16.9±2.4. The postoperative IJOA scores at the end of 3 months were 16.6±2.3. The current IJOA scores until the end of the follow-up were 17.5±4.4. In the multiple group, 37 (45%) patients presented with normal urine and stool functions, 26 (31%) patients with slight dysfunction, 11 (13%) with severe dysfunction, and 9 (11%) with incontinence, and 62 (75%) patients demonstrated various degrees of limbs weakness. The preoperative IJOA scores of the patients were 15.6±3.4. The postoperative IJOA scores at the end of 3 months were 15.5±3.8. The current IJOA scores until the end of the follow-up were 16.9±5.8. The difference of presenting urine and stool dysfunction (Z=-1.35, P=0.18) was not statistically significant between the different patient groups. However, the difference of presenting limbs weakness (Z=-2.06, P=0.04) was statistically significant between the two groups. Most patients with multiple segment intramedullary tumors suffered from various limbs weakness. The difference of the preoperative IJOA score (P=0.02) and the postoperative early IJOA score (P=0.004) of the patients was statistically significant between the seldom and multiple segments groups. Preoperative and early postoperative neurological function of the patients was better with seldom segments tumor than with multiple segments tumor. Most patients with multi-segment intramedullary tumors experienced various limbs weakness. However, the difference of long-term neurological function (P=0.12) between the seldom and multiple segments groups was not statistically significant. The neurological function of the patients with multiple segments intramedullary tumor was remarkably improved after physical therapy. Perioperative neurological function of the patients with seldom segments primary tumor was superior to that of the patients with multiple segments primary tumor, especially for limb strength. The neurological function of the patients with multiple segments intramedullary primary tumor was remarkably improved after physical therapy during long-term follow-up.

Preventive Vertebroplasty for Long-Term Consolidation of Vertebral Metastases.

To evaluate the long-term consolidation of vertebral metastases (VM) after preventive vertebroplasty (PV) and to report risk factors of pathological fracture despite PV. Files of 100 consecutives cancer patients referred for PV of VM were retrospectively analyzed. We enumerated 215 VM at the time of the PV procedure (T0): 138 VM were considered at risk of pathological fracture and had PV (treated-VM), and 77 VM were not cemented. We compared the VM characteristics using the spine instability neoplastic score (SINS) at T0 and the rate of pathologic fracture between treated-VM and untreated-VM using Kaplan-Meier method. We analyzed risk factors of pathological fracture despite PV using treated-VM characteristics and quality of cement injection criteria. Despite a lower SINS value at T0 (p < 0.001), the rate of pathological fracture was significantly higher among untreated-VM compared to the treated-VM, (log-rank, p < 0.001). Major risk factors of fracture among treated-VM were: SINS value ≥ 8 (p < 0.012), mechanical pain (p = 0.001), osteolytic lesion (p = 0.033), metastatic vertebral body involvement > 50% with no collapse (p < 0.001) and unilateral posterior involvement by the vertebral metastasis (p = 0.024), Saliou score < 9 (p = 0.008), vertebral metastasis filling with cement < 50% (p = 0.007) and the absence of cement's contact with vertebral endplates (p = 0.014). PV is long-term effective for consolidation of VM and must be discussed at the early diagnosed. Quality of cement injection matters, suggesting that techniques that improve the quantity and the quality of cement diffusion into the VM must be developed.

Classifications in Brief: The Spinal Instability Neoplastic Score.

Classifications in Brief: The Spinal Instability Neoplastic Score.

Petrous apex non-secretory plasma cell myeloma with aberrant cytokeratin expression

ABSTRACTMultiple myeloma is a monoclonal proliferation of plasma cells with common involvement of vertebrae, ribs and skull vault. However, involvement of skull base is relatively uncommon and myeloma manifesting initially as a petrous apex mass is distinctly rare. We report a rare case of non-secretory multiple myeloma in a 52-year-old Egyptian male presenting primarily as a right petrous apex mass with abducens nerve palsy. Additionally, neoplastic cells aberrantly expressed cytokeratin. Although rare, plasma cell myeloma should be considered in the differential diagnosis of petrous apex masses.

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

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

A rare case of tuberculous abscess causing airway obstruction in a paediatric patient in South-East Asia

A 6-year old girl, presented with symptoms of obstructive sleep apnoea. She was referred to our centre when she developed obstructive symptoms such as stridor and dysphagia a month later. She was found to have a right neck swelling with a posterior pharyngeal wall mass, which caused upper airway obstruction. A computerized-tomography scan of her neck showed a very narrowed upper airway with a retropharyngeal abscess without prevertebral or vertebral involvement. She had a challenging intubation and underwent an emergency intraoral incision and drainage. Pus that was drained revealed acid fast bacilli and histopathological examination showed necrotizing granulomatous inflammation, in favour of a tuberculous abscess. Post operatively, her symptoms resolved and her intraoral wound healed. She completed anti-tuberculous treatment and has remained well at 6 months follow up. Our case illustrates how a cold retropharyngeal abscess can masquerade as obstructive sleep apnoea, with a compromised airway as it increases in size.

Thoracolumbar myelopathy with diffuse vertebral involvement in a dog secondary to aleukaemic lymphocytic leukaemia

Incidence rate of lymphocytic leukaemia is unknown in canine patients; neurological manifestations and imaging findings are rarely reported. In human medicine, acute lymphocytic leukaemia is known to have a high...