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PubMed2006

Routine surgery in addition to chemotherapy for treating spinal tuberculosis.

BACKGROUND: Tuberculosis is generally curable with chemotherapy, but there is controversy in the literature about the need for surgical intervention in the one to two per cent of people with tuberculosis of the spine. OBJECTIVES: To compare chemotherapy plus surgery with chemotherapy alone for treating people diagnosed with active tuberculosis of the spine. SEARCH STRATEGY: We searched the Cochrane Infectious Diseases Group Specialized Register (October 2005), CENTRAL (The Cochrane Library 2005, Issue 4), MEDLINE (1966 to October 2005), EMBASE (1974 to October 2005), LILACS (1982 to October 2005), conference proceedings, and reference lists. SELECTION CRITERIA: Randomized controlled trials with at least one year follow up that compared chemotherapy plus surgery with chemotherapy alone for treating active tuberculosis of the thoracic and/or lumbar spine. DATA COLLECTION AND ANALYSIS: Two authors independently assessed trial eligibility, methodological quality, and extracted data. We analysed data using odds ratio with 95% confidence intervals. MAIN RESULTS: Two randomized controlled trials (331 participants) met the inclusion criteria. They were conducted in the 1970s and 1980s with follow-up reports available after 18 months, three years, and five years; one trial also reported 10 years follow up. Completeness of follow up varied at the different time points, with less than 80% of participants available for analysis at several time points. There was no statistically significant difference for any of the outcome measures: kyphosis angle, neurological deficit (none went on to develop this), bony fusion, absence of spinal tuberculosis, death from any cause, activity level regained, change of allocated treatment, or bone loss. Neither trial reported on pain. Of the 130 participants allocated to chemotherapy only, 12 had a neurological deficit and five needed a decompression operation. One trial suggested that an initial kyphosis angle greater than 30 degrees is likely to deteriorate, especially in children. AUTHORS' CONCLUSIONS: The two included trials had too few participants to be able to say whether routine surgery might help. Although current medication and operative techniques are now far more advanced, these results indicate that routine surgery cannot be recommended unless within the context of a large, well-conducted randomized controlled trial. Clinicians may judge that surgery may be clinically indicated in some groups of patients. Future studies need to address these topics as well as the patient's view of their disease and treatment.

Aminosalicylic Acid↗
PubMed1993

CT and MR in the management of advanced spinal tuberculosis.

In regions where tuberculosis is endemic, CT and MR are of limited use in making the initial diagnosis of spinal tuberculosis. Their optimum use is for monitoring the management of cases involving paralysis. CT best evaluates the integrity of posterior bony structures which provide spinal stability and MR best demonstrates the content and extent of the extradural mass that is causing the paralysis. Their use is illustrated by three recent cases.

Child, Preschool↗
PubMed1996

[Spinal tuberculosis. Study of clinical and radiological aspects from a series of 82 cases].

We present a retrospective study of 82 cases of spinal tuberculosis diagnosed over the last 30 years. An increasing incidence of this disease not related to HIV infection has become apparent since 1992. 24% of patients were born outside continental France. The intradermal reaction was negative in 10% of patients. Discovertebral lesions detected in 93% of patients was the most frequent radiological presentation. Spondylitis with osteolysis or bone sclerosis at single or multiple levels was seen in the others. Tuberculous lesion of the posterior arch was associated in 10% of patients. In most cases CT scan showed a fragmentary vertebral destruction which was characteristic of the disease. MRI revealed the precise extent of the lesions into the spinal canal. Morphologic features suggestive of the tuberculous nature of paravertebral abcesses could be demonstrated when slices were performed in the axial or coronal plan. Tuberculous involvement of the spine is still a frequent disease. The main clinical and radiological findings are presented.

Adolescent↗
PubMed1993

Another look at spinal tuberculosis.

The steady decline in tuberculosis rates in Canada has led to a certain lack of awareness of the disease. We describe 7 patients with culture proven spinal tuberculosis, seen in a teaching hospital over a 10-year period. Persistent spinal pain and local tenderness were the most frequent presenting findings. There was a mean delay in diagnosis of 5.2 (range 1-18) months from the time of presentation. Only 2 patients had active extraspinal tuberculous infection. Plain spinal radiographs were the initial diagnostic procedure of choice showing a destructive vertebral lesion in 5 of 7 patients. Computed tomography (CT) played an important role in delineating the discovertebral lesion and in demonstrating a paraspinal soft tissue infection in 6 (85%) of 7 patients: psoas abscess in 4 (2 with epidural extension), epidural abscess in one, and a neck abscess in one. Magnetic resonance imaging (MRI) in one patient enabled a more complete definition of the vertebral infection and its soft tissue extensions. Two patients were successfully treated with combination antituberculous chemotherapy alone, and 5 required adjuvant surgical procedures. Our study stresses the need for increased alertness to this now uncommon but treatable spinal infection, and emphasizes the diagnostic usefulness of CT and MRI in defining subtle discovertebral lesions and in detecting unsuspected paravertebral soft tissue extension.

Abscess↗
PubMed1993

Imaging in children with spinal tuberculosis. A comparison of radiography, computed tomography and magnetic resonance imaging.

We compared the usefulness of radiography, CT and MRI in 25 children with spinal tuberculosis. Radiography provided most of the information necessary for diagnosis and treatment. Axial CT was the most accurate method for visualising the posterior bony elements. Sagittal MRI best showed the severity and content of extradural compression and helped to differentiate between an abscess and fibrous tissue. The main value of CT and MRI is in the preoperative evaluation of the small proportion of patients who require surgical treatment for paraplegia.

Anti-Bacterial Agents↗
PubMed1994

Spinal tuberculosis with circumferential involvement of two noncontiguous isolated vertebral levels: case report.

We present a case of a 16-year-old boy with an atypical form of spinal tuberculosis, which circumferentially involved two noncontiguous vertebral levels without destruction of the adjacent vertebral bodies and intervertebral discs. The lesions caused paraplegia and loss of sphincter control, and they were confined to a single vertebra at each site; the findings more closely mimicked spinal malignancies. There was no evidence of pulmonary or other extrapulmonary tuberculous disease. The patient was successfully treated both surgically and medically using posterior decompression and a stabilizing procedure in combination with postoperative antituberculous therapy. Magnetic resonance imaging played a major role in determining the extent of the disease and the type of surgical procedure and in monitoring adequate medical treatment.

Adolescent↗
PubMed2006

The role of posterior instrumentation and fusion after anterior radical debridement and fusion in the surgical treatment of spinal tuberculosis: experience of 127 cases.

Long periods of immobilization, progressive kyphosis and graft failure are the major postoperative problems encountered after anterior radical surgical treatment for tuberculosis of the spine. Posterior fusion and instrumentation can be an effective solution for these problems. Effectiveness of posterior fusion and instrumentation was investigated in this study on the basis of the cases with anterior procedure only, and with combined anterior-posterior procedures. One hundred twenty-seven cases of tuberculosis of the spine were surgically treated between 1987 and 1995. All had either 1 or more of conditions such as spinal cord compression and neurological deficit, vertebral body collapse and kyphosis, or wide paravertebral abscess unresponsive to medical treatment. Of these, 57 had only anterior radical procedure between the years 1987 and 1993. Seventy cases had posterior instrumentation and fusion after the anterior procedure between the years 1991 and 1995. In about two third of the patients (81) autogenous iliac strut graft and in one third of them (40) autogenous fibular strut graft (cases with more than 2 level involvement) was used along with rib grafts after debridement. Twenty-one of the 57 patients who had only anterior procedure demonstrated a postoperative increase of kyphosis of more than 10 degrees. Increased kyphosis was due to graft slippage in 3, resorption in 2 and subsidence in 16 patients. No such increase or graft failure was noted in cases of combined anterior-posterior procedure. The difference in terms of kyphosis was found to be statistically significant (P=0.047). Anterior radical debridement and strut graft is the golden standard in the surgical treatment of spinal tuberculosis, but it should always be accompanied by posterior instrumentation and fusion to shorten the immobilization period and hospital stay, obtain good and long lasting correction of kyphosis, and prevent further collapse and graft failure.

Adolescent↗
PubMed1993

[Indicators of systemic and local immunity in patients with spinal tuberculosis].

The examination of 33 patients with tuberculous spondylitis and its sequelae revealed inhibition of T-cell immunity in 40% of the examinees, antituberculous antibodies in the blood of 73% of patients. An enzyme immunoassay detected antituberculous antibodies in cerebrospinal fluid of 70% seropositive sufferers with spinal tuberculosis. Positive results of this test serve a direct indication to spinal decompression and intensive pre- and postoperative antituberculosis treatment.

Adult↗
PubMed1999

Value of radiologically guided fine needle aspiration cytology (FNAC) in the diagnosis of spinal tuberculosis: a study of 29 cases.

FNAC is a simple diagnostic tool for the initial evaluation of various deep seated pathological lesions. This study describes the applicability and practical aspects of the technique in establishing the diagnosis of spinal tuberculosis (TB) with the aid of radiographic guidance. The study was conducted in a major teaching hospital in Kuwait between the years 1985 and 1994. Twenty-nine patients (M:F = 18:11 and age range 8-72 years) with clinically and/or radiologically suspected spinal TB were seen in the Department of Cytology, Mubarak Al Kabeer Hospital. The patients were re-examined by either computed tomography (CT) scanning (n = 19) or fluoroscopy (n = 10) to localize the lesion for FNAC. FNAC smears were routinely stained with Papanicolaou and Diff Quik stains and one smear of each case was stained with Ziehl-Neelsen (Z-N) stain for acid-fast bacilli (AFB). Aspirated purulent material or syringe washings of dry aspirates were also submitted for microbiological cultures including AFB. Radiological and cytological findings were recorded in each case. Radiological findings included: bony rarefaction and destruction (93.1%), narrowed disc space (89.7%), soft tissue calcification (65.5%) and para-vertebral abscess formation (51.7%). Cytological findings included: epithelioid cell granulomas (89.7%), granular necrotic background (82.8%) and lymphocytic infiltration (75.9%). Smears were positive for AFB in 51.7% of cases. A positive AFB culture was obtained in 82.8% of cases, including all cases with positive AFB on smear by Z-N stain. Radiologically guided FNAC with AFB culture is a simple, reliable and practical approach to diagnosing spinal TB lesions. With a high diagnostic yield, it allows immediate initiation of specific treatment, helps to avoid invasive diagnostic procedures, and decreases hospitalization time.

Adolescent↗
PubMed2004

Spinal tuberculosis due to dissemination of atypical mycobacteria.

There has been an increase in disease caused by Non Tuberculous Mycobacteria (NTM) since the early 1980s. Though ubiquitous in environment, they may act as clinically important pathogens in various conditions. More importantly they are resistant to the conventional anti-tuberculous therapy (ATT) and respond to antibiotics such as quinolones and aminoglycosides and need an aggressive surgical intervention. Missing these atypical mycobacteria may lead to unnecessary administration of ATT and hence delay in proper management of the case. We report a case of spinal tuberculosis due to a Non Tuberculous Mycobacteria, M. fortuitum (Rapid grower). Relevant literature is also reviewed.

Adult↗
PubMed1993

17-year prospective study of surgical management of spinal tuberculosis in children. Hong Kong operation compared with debridement surgery for short- and long-term outcome of deformity.

A comparative analysis of the short and long-term results of two surgical procedures, radical excision or debridement, for the management of spinal tuberculosis in children is reported. Eighty children (47 treated with radical surgery and 33 with debridement) were prospectively studied and followed to maturity (mean follow-up, 17 years postoperatively). The kyphus and deformity angles were measured from lateral spinal radiographs using an electronic digitizer. The results can be summarized as follows: 1) Long-term clinical outcome of the two surgical procedures were equally good for recovery of neurologic deficit and relief of pain. There was no incidence of reactivation and/or recurrence of tuberculous lesion in either group; 2) The mean changes in kyphus and deformity angles at the 6-month postoperative evaluation compared to their preoperative value were significantly different for the two surgical groups. There was an overall correction in these angles after radical surgery, whereas there was a deterioration after debridement surgery; 3) There were no significant differences in the changes in kyphus or deformity angles at final follow-up from their 6-month postoperative measurements between the two surgical groups; 4) The majority of children (56%) showed an improvement in deformity angle of 5 degrees or more after radical surgery at the 6-month postoperative evaluation, whereas 69% of children showed deterioration after debridement surgery; 5) At final follow-up in lumbar tuberculosis, 60% of patients in the debridement group had 10 degrees or more kyphus angle, whereas only one patient in the radical group had a kyphotic lumbar spine due to graft failure.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed2001

Spinal tuberculosis: a 15 year review at OAUTHC Ile-Ife.

A review of the hospital records over 15 years was made. The objective of the study was to describe the clinical presentation, management and outcome of spinal tuberculosis. Thirty-four patients were studied. There were 15(44.16%) males and 19 (55. 9%) females. Their age range was 2-80 years with mean (+/- SD) of 25.28 +/- 22.33 years. The occupations most commonly affected are Students (44.1%), Pre-school Children (17.6%) and Traders (14.7%). Back pain (100%), weight loss (47.1%), paraparesis (47.1%), kyphotic spinal deformity (32.4%) and night sweats (29.4%) were common features. Only 26.5% patients had active pulmonary tuberculosis. All the vertebral segments were involved. The Lumbar spine was the most involved vertebral segment in 50% patients. Using the Westergren method the mean (+/- SD) Erythrocyte Sedimentation Rate (ESR) mm/hour at the initial diagnosis was 83.58 +/- 31.11 mm/hour whereas three months after the commencement of antituberculosis chemotherapy it was 30.06 +/- 11.96 mm/hour. All the patients were given multiple antituberculosis drugs therapy and spinal traction. Spinal support was offered when the patients became ambulant. At the end of two years follow-up, 94.1% patients were alive, while 5.9% patients died during the course of treatment due to overwhelming sepsis. Among the patients that were alive, 14.7% still had persistence of their neurological deficit ie. paraparesis. Ten percent of the patients were mobilised on crutches while 5.96% were confined to wheelchair. This study shows that in tuberculosis endemic areas, symptom of back pain especially in the younger age group should be thoroughly investigated as this group constituted the largest affected population.

Adolescent↗
PubMed2006

Intradural spinal tuberculosis in the absence of vertebral or meningeal tuberculosis: a case report.

We present a patient with spinal intradural tuberculosis in the absence of both vertebral and meningeal tuberculosis. Diagnosis was made based on intra-operative findings and was confirmed by histopathology. Early surgical decompression along with a combination of steroid and antitubercular therapy resulted in a good outcome. At 26-month follow-up, the patient regained bladder control and was able to walk with support. Clinical features, magnetic resonance imaging, and intra-operative findings are described. Pathology and the relevant literature are discussed.

Adult↗