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PubMed2001

Spinal tuberculosis (Pott's disease): its clinical presentation, surgical management, and outcome. A survey study on 694 patients.

Tuberculosis (TB) of the spine (Pott's disease) is both the most common and most dangerous form of TB infection. Delay in establishing diagnosis and management cause spinal cord compression and spinal deformity. This study investigated the data on all cases of Pott's disease reported in Turkey from 1985 to 1996. A total of 694 cases were included. Out of the patients evaluated, 19% were reported in the first half of the period (1985-1990) and 81% in the second half (1991-1996). Tuberculosis affecting the spine was commonly localized in the thoracic region and involved the vertebral body. The presenting symptoms were leg weakness (69%), gibbus (46%), pain (21%), and palpable mass (10%). Decompressive surgery plus anti-TB chemotherapy remains the best mode of therapy for Pott's disease. Follow-up information was available in 414 of the 694 patients and there were ten deaths (2%), one occurring intraoperatively and the other nine postoperatively. This meta-analysis demonstrates that in Turkey Pott's disease remains a serious problem, causing paraplegia. It should be considered when patients present with neurological findings suggesting spinal cord compression and spinal deformity. In the present study, it was concluded that the neurological involvement due to Pott's disease is relatively benign if urgent decompression is performed at the onset of the disease.

Adult↗
PubMed1994

Surgical management of spinal tuberculosis in adults. Hong Kong operation compared with debridement surgery for short and long term outcome of deformity.

Of 112 patients who were subjects of the Medical Research Council's prospective study, 105 (94%) were involved in a longitudinal study follow-up for a mean of 15.3 years postoperatively. Seventy-one patients had radical resection of the tuberculous lesion and bone grafting, and the remaining 34 were treated with debridement surgery at a mean age of 36.7 and 35.3 years, respectively. All these patients were aged 18 years or older at the time of surgery. The kyphosis and deformity angles were measured on lateral spinal radiographs using an electronic digitizer. The results can be summarized as follows: (1) Neurologic recovery in both radical and debridement surgical groups were equally good and no patient had pain two years after surgery. There was no incidence of reactivation or recurrence of tuberculosis in either surgical group. (2) At the six-month postoperative evaluation, patients who had radical surgery showed marginal correction in deformity, whereas those who were treated with debridement showed deterioration in both kyphosis and deformity angles. There was a statistically significant difference between the two surgical groups for the mean changes in kyphosis and deformity angles at the six-month postoperative evaluation compared with their preoperative evaluation. (3) The mean difference for kyphosis and deformity angles at final follow-up evaluation from the patients' six-month postoperative measurements were not statistically significantly different between the two surgical groups. (4) Forty percent of patients showed an improvement in deformity angle by 5 degrees or more after radical surgery at the six-months postoperative evaluation, whereas 53% of patients showed deterioration after debridement surgery. (5) All patients with tuberculosis of the lumbar spine treated with radical surgery had normal lordosis in the lumbar spine at final follow-up evaluation, compared with only 63% of patients after debridement surgery. Correction achieved after surgery at the six-month evaluation was practically maintained up to final follow-up evaluation. Radical resection and bone grafting provided better correction of deformity than did debridement surgery.

Adolescent↗
PubMed1996

Duration of antituberculosis chemotherapy in conjunction with radical surgery in the management of spinal tuberculosis.

STUDY DESIGN: The effectiveness of duration of antituberculous chemotherapy in conjunction with radical surgery for tuberculosis of the spine is reported. One hundred fourteen patients were followed prospectively for a mean period of 14.6 years after radical resection of the tuberculous lesion and reconstruction of the resultant gap with bone graft. OBJECTIVE: To evaluate the efficacy of short-course antituberculous chemotherapy in relation to the standard 18-month chemotherapy in conjunction with radical surgery for tuberculosis of the spine. SUMMARY OF BACKGROUND DATA: One hundred fourteen patients who were subjects of the Medical Research Council's (London, UK) prospective study underwent radical resection of the lesion and anterior arthrodesis of the spine. These patients received 6, 9, and 18 months of antituberculous chemotherapy. Those who received 6- and 9-month chemotherapy received streptomycin, rifampicin, and isoniazid. Streptomycin was given for the first 3 months, and the other two drugs were continued for 6 or 9 months. Those who received 18 months of chemotherapy were given streptomycin (first 3 months), sodium para-aminosalicylic acid, and isoniazid. METHODS: These patients were followed longitudinally, and at each visit, clinical and radiologic data were collected at 1-month intervals up to 3 months postoperatively, at 3-month intervals to 30 months postoperatively, at 6-month intervals up to 5 years postoperatively, and at 12-month intervals to the conclusion of study (minimum, 10 years). For assessment of spinal deformity, the "deformity angle" was measured on lateral spinal radiographs obtained at each visit. RESULTS: Six-month, 9-month, and 18-month chemotherapeutic regimens in association with radical surgery produced similar clinical results with no recurrence or reactivation of tuberculosis. The changes in deformity angles at final follow-up evaluation compared with 6-month postoperative values were not statistically significantly different in the groups who underwent 6 months, 9 months, and 18 months of chemotherapy. CONCLUSIONS: The authors' findings show that a 6-month chemotherapeutic regimen combined with surgical excision and bone grafting is adequate for management of tuberculosis of the spine, as it produced clinical and radiologic results comparable with the 18-month chemotherapeutic regimen.

Adolescent↗
PubMed1989

[Early diagnosis of atlanto-axial tuberculosis].

Spinal tuberculosis at the atlanto-axial level is often overlooked or misdiagnosed for a considerable period of time, until when there has developed subluxation or other obvious complications. In order to make early diagnosis of this lesion, we analysed 30 such patients of our own and found that the positive X-ray film findings, such as thickening and widening of the soft tissue shadow of the retropharyngeal wall could hardly be concerned as an early sign, subluxation of the joint and destruction of bone were definitely quite a late occurrence. While long lasting pain in the upper cervical region and limitation of motions of the neck were constantly present prior to any other positive findings. Complaints of these subjective symptoms, particularly in young person, we would emphasize, are the early signals of tuberculosis and should be cared until being proved otherwise.

Adolescent↗
PubMed1996

[Spinal tuberculosis].

The cases of 32-year-old man and 42-year-old women are presented. Their history illustrates difficulties in the diagnosis of tuberculosis of the vertebral column. The patients suffered significant pains in the lumbar region lasting one year. Despite the presence of some abnormalities in lumbar vertebrae on x-rays no examinations were ever performed to establish the diagnosis. Lumbago and osteoporosis were considered as the cause of complaints. Aetiology was confirmed only when patients developed disseminated tuberculosis of the lungs. Antituberculous chemotherapy was successful and brought a fast improvement in general status of the patients.

Adult↗
PubMedDate not supplied

Pott's spine and paraplegia.

Spinal tuberculosis is usually secondary to lung or abdominal involvement and may also be the first manifestation of tuberculosis. Spinal tuberculosis (often called Pott's disease) is by definition, an advanced disease, requiring meticulous assessment and aggressive systemic therapy. Physicians should keep the diagnosis in mind, especially in a patient from a group with a high rate of tuberculosis infection. This review aims on updating the knowledge on spinal tuberculosis and its management. Skeletal involvement has been reported to occur in approximately 10% of all patents with extrapulmonary tuberculosis, and half of these patients develop infection within the spinal column. Symptoms of spinal tuberculosis are back pain, weakness, weight loss, fever, fatigue, and malaise. It is much more prone to develop neurological manifestation, paraplegia of varying degree. The palpation of spinous process in routine clinical examination is the most rewarding clinical method and is an invaluable measure for early recognition. Diagnosis of spinal tuberculosis is made on the basis of typical clinical presentation along with systemic constitutional manifestation and the evidence of past exposure to tuberculosis or concomitant visceral tuberculosis. Magnetic resonance imaging can define the extent of abscess formation and spinal cord compression. The diagnosis is confirmed through percutaneous or open biopsy of the spinal lesion. Surgery is necessary as an adjunct to antibiotic therapy if the vertebral infection produces an abscess, vertebral collapse, or neurologic compression. Some patents need aggressive supportive care owing to tuberculous meningitis or encephalopathy. Moreover, the importance of immediate commencement of appropriate treatment and its continuation for adequate duration along with the proper counseling of the patient and family members should not be underestimated for successful and desired outcome.

Adult↗
PubMed1996

Imaging of tuberculosis. IV. Spinal manifestations in 63 patients.

PURPOSE: To describe the radiologic findings in patients with spinal tuberculosis (TB). MATERIAL AND METHODS: Out of a total of 503 patients with TB, 63 (13%) had involvement of the spine. RESULTS: In 40 patients, the spine was the only location; 20 patients had concomitant chest TB. Conventional radiographs gave a good overview, CT visualized the disko-vertebral lesions and the paravertebral abscesses, while MR imaging was useful to determine the spread of disease to the soft tissues and the spinal canal. The typical findings were destroyed vertebrae with associated paraspinal soft-tissue mass, with or without abscess formation, sometimes also involving the epidural space together with adjoining disk lesion and focal gibbus formation. Involvement of a single vertebra was a relatively common finding. Large psoas abscesses could occur without any signs of bone involvement. The TB process could sometimes be indistinguishable from malignant processes, and in 3 patients, with multiple lesions in the spine, it mimicked metastatic disease. CONCLUSION: It is stressed that TB should always be considered in the differential diagnosis when radiologic findings suggest spinal infections or primary or secondary spinal tumors.

Adult↗
PubMed2003

[Pott's disease and different clinical presentations Pott's disease and different clinical presentations].

Skeletal tuberculosis remains a potentially crippling disease in the developing world; particularly as it usually affects children and young adults. The spine is involved approximately 50% of bone and joint tuberculosis cases. The features of four spinal tuberculosis cases were looked over this article. Their ages were between 18 and 76 years. All of them were male and immunocompetent. Pain was the major complaint. There was no life-threatening neurological sign. Among them, a case who was admitted to the hospital with painful torticollis had upper cervical-lower thoracic spinal tuberculosis with psoas abscesses and peritoneal tuberculosis, but no pulmonary involvement. The other cases had thoracolumbal spinal tuberculosis with psoas abscesses and pulmonary tuberculosis of which miliary, chronic and new pulmonary tuberculosis. The whole diagnosis of spinal tuberculosis was made by radiographically-MRI and CT-. Specific antituberculous therapy with supportive care was begun and remarkable responses without surgical intervention were seen on them except miliary pulmonary tuberculosis case. The aim of this presentation was to emphasize the importance of early diagnosis so that adequate pharmacological treatment can be initiated to avoid serious complication.

Adolescent↗
PubMed1997

Tuberculosis of the spine. Controversies and a new challenge.

Tuberculosis is a deadly disease affecting many people in the world. The prevalence of spinal tuberculosis is likely to rise as the numbers of those infected with human immunodeficiency virus rises. This presentation summarizes present knowledge of spinal tuberculosis and its management. It describes and updates material the author has previously published on this subject. The scientific basis for the clinical management of spinal tuberculosis has been well established by the British Medical Research Council group and Hong Kong surgeons. It is believed, however, that well-controlled basic and clinical studies are required if the incidence of the three unwanted complications of spinal tuberculosis is to be reduced further. Antituberculosis agents are the mainstay of management, with chemotherapy for 12 months preferred to shorter courses. The standard is a combination of isoniazid, rifampin, and pyrazinamide, with or without ethambutol. Anterior surgery consisting of radical focal debridement without fusion does not prevent vertebral collapse. The major advantage of anterior arthrodesis is the decreased tendency for progression of the deformity. Patients who present late with deformity are candidates for anterior debridement and stabilization with corrective instrumentation. Posterior stabilization with instrumentation has been found to help arrest the disease and to bring about early fusion. Posterior instrumented stabilization to prevent kyphosis in early spinal tuberculosis is indicated, however, only when anterior and posterior elements of the spine are involved, particularly in children. With early detection, institution of chemotherapy, and improved surgical techniques, patients with kyphosis rarely are seen today, particularly in urban centers that have an effective medical system. For these same reasons, patients with spinal tuberculosis who present with paraplegia and no deformity usually respond well to treatment. It is concluded that spinal tuberculosis without unsightly kyphosis and neurologic symptoms is a medical, rather than a surgical, condition. Surgery should be reserved for those patients who have advanced tuberculosis with unacceptable complications such as paraplegia and/or deformity.

Humans↗
PubMed1995

Tuberculosis of the spine: imaging features.

Spinal tuberculosis, the most common form of skeletal involvement, is increasing in prevalence because of the resurgence of tuberculosis during the past decade in patients with AIDS, the spread of tuberculosis among the homeless, and the expanding immigrant population. Spinal infection is usually the result of hematogenous seeding of the vertebral body, and the diagnosis often remains elusive because of the indolent nature of tuberculous infection. As a result, the radiographic findings and the signs and symptoms are typically far advanced when the diagnosis is finally established. Radiographic manifestations of tuberculous spondylitis include intraosseous and paraspinal abscess formation, subligamentous spread of infection, vertebral body destruction and collapse, and extension into the spinal epidural space. Significant instability and deformity of the spine can result, mandating prompt diagnosis and treatment to prevent permanent neurologic damage. The purpose of this essay is to illustrate the broad spectrum of imaging findings on plain radiographs, bone scans, CT scans, myelograms, and MR images of patients with spinal tuberculosis. The value of MR imaging in determining the extent of disease is demonstrated.

Adolescent↗
PubMed1999

[Pott's spinal cord compression in the child].

Spinal tuberculosis is the first etiology of spinal cord compression in our areas. We are studying the epidemiological, clinical and therapeutic aspects of Pott's disease. We have collected all children aged from 0 to 15 years admitted for Pott's disease in department of Neurology in CHU Fann SenegaIL from January 1st 1983 to December 31st 1997 spinal tuberculosis. The diagnosis was both clinical and paraclinical. 27 children aged to 2-15 years were hospitalized for Pott's disease. The sex-ratio was equal to 2 in favour of boys. 77.77% of patients were consulted more than a month after the outbreak of the paraplegia. The notion of tuberculous contagion was found in 25.92% of the cases. The main clinical signs were paralysis of the limbs, sensory symptoms and bladder sphincter dysfunction. In 96.29% anomaly of disc and vertebra were recorded, more often affecting two vertebrae. The myelography, performed in 13 patients objectivized an epidural stop in 92.30% of the cases. There was a favorable evolution in 92% of patients under antituberculous chemotherapy. Spinal tuberculosis is an affection cheating all ages and it remains the first etiology of spinal cord compression in our areas. Therefore there is a necessity of primary safety by fighting against tuberculosis what is still in our areas.

Adolescent↗
PubMed2003

[Anterior instrumentation for the treatment of tuberculotic spinal deformity].

OBJECTIVES: To summarize the clinical results in the treatment of spinal tuberculosis with debridement, bone grafting and anterior fixation and to evaluate the safety and the value of this procedure. METHODS: From June 1997 to May 2001, 18 patients with spinal tuberculosis were treated using anterior debridement, autograft of bone and primary internal instrumentation. They were 8 men and 10 women, aged from 25 to 59 years (mean 41 years). The degree of kyphosis before surgery was 27.0 degrees to 75.5 degrees (mean 47.5 degrees +/- 11.4 degrees ). The involved spines included cervical spine (1 patient), thoracic spine (10), thoracic-lumbar spine (2), and lumbar spine (5). Average 2.8 intervertebral bodies in each patient were afflicted with tuberculosis disease. Spinal fusions were done with iliac bone grafts. RESULTS: All patients were followed up for an average of 25 months. No deep wound infection and sinus were observed after surgery. The grafted bones were fused in all patients with an average time of 3.6 months. The degree of spine kyphosis correction was 32.7 degrees +/- 8.3 degrees, and 3.2 degrees +/- 2.8 degrees was lost on average in the late stage. CONCLUSION: Anterior instrumentation for spinal tuberculosis could stabilize the spine, correct kyphosis and fuse the grafted bone.

Adult↗
PubMed1997

Growth changes of solidly fused kyphotic bloc after surgery for tuberculosis. Comparison of four procedures.

STUDY DESIGN: A study to analyze the changes of the spinal deformity during the growth period, with regard to different operations for spinal tuberculosis in children. OBJECTIVES: To quantify the changes in the kyphotic angle and the growth ratio of the fusion bloc during spinal growth for different fusion techniques. SUMMARY OF BACKGROUND DATA: Most of the publications dealing with spinal tuberculosis in children focused on the clinical outcome with regard to different conservative and operative treatments. There is little reliable information concerning the growth of the solidly fused kyphotic bone bloc and its influence on the changes of the kyphotic deformity after different operative procedures. METHODS: The study included 117 children operated on for spinal tuberculosis at the age of 2-6 years at the Ruttonjee Sanatorium in Hong Kong during the 1950s and 1960s. Lateral radiographs obtained postoperatively and 5 and 10 years after the operation were analyzed for the growth changes of the solidly fused bone bloc. These results were compared with the different operation techniques (e.g., anterior fusion, posterior fusion, combined anterior and posterior fusion, and anterior debridement without fusion). RESULTS: The patients treated by anterior fusion showed the worst results with respect to the kyphotic angle. This was especially true when the lesion was located in the thoracic spine and several segments were involved. Regarding the growth ratio of the fusion bloc, only the combined fusion and the anterior debridement guaranteed an equal growth of the anterior and posterior height. CONCLUSIONS: Radical anterior surgery for spinal tuberculosis destroys the anterior growth and limits the capacity for spinal remodeling. Therefore, it should be avoided, if it is not absolutely necessary, for the healing of the infection or the primary correction of the tuberculous deformity.

Bone Remodeling↗
PubMed1999

Transpedicular instrumentation as an adjunct in the treatment of thoracolumbar and lumbar spine tuberculosis with early stage bone destruction.

OBJECT: Because modern imaging techniques now allow for early diagnosis of spinal tuberculosis, more conservative management options are possible. The authors evaluated the effectiveness of transpedicular instrumentation for treatment of thoracolumbar and lumbar spinal tuberculosis in patients with mild bone destruction and the main symptom of "instability catch" (a sudden painful "snap" that occurs when one extends from a forward bent to an upright position). METHODS: Eighteen patients (nine men and nine women, age range 49-71 years) with spinal tuberculosis were treated with transpedicular instrumentation that was supplemented with posterolateral fusion and chemotherapy. All patients were wheelchair dependent or bed-ridden due to severe instability catch, with a mean symptom duration of 2.5 months (range 1-6 months). Two contiguous vertebrae were involved in 17 patients, and a single vertebrae was involved in one. In five patients mild neurological deficits (Frankel Grade D) were present. During surgery, the screws were implanted into the two nonaffected pedicles nearest the lesion to stabilize the involved segments. No attempt at radical debridement or neural decompression was undertaken. The follow-up period ranged from 21 to 40 months. Postoperatively the instability catch was relieved within 10 days (excellent outcome) and within 1 month (good outcome) in seven and eight patients, respectively, and within 3 months (fair outcome) in two; in the remaining patient, the symptom did not resolve (poor outcome). A short duration of symptoms (generally < 3 months) and bone destruction of less than 50% in the involved vertebral bodies were observed in patients who made a good or excellent outcome. During the follow-up period, good maintenance of spinal alignment, stabilization of the involved segment, and resolution of the inflammatory process were shown; however, there was no strong evidence that fusion had occurred at the bony defect. Patients in whom a fair outcome was achieved experienced a longer duration of symptoms, and in each, one vertebral body with greater than 50% bone destruction was demonstrated. However, good maintenance of spinal alignment was also shown during the follow-up period. The patient whose outcome was poor had the longest history (6 months) of symptoms and the most extensive involvement of the spine (> 50% destruction of two adjacent lumbar vertebral bodies). Postoperatively, implant failure occurred and the patient developed a wound infection. CONCLUSIONS: Transpedicular instrumentation provides rapid relief of instability catch and prevents late angular deformity in patients with thoracolumbar and lumbar spinal tuberculosis in whom limited (< 50%) bone destruction of the involved vertebral bodies has been shown and whose main symptom is instability catch.

Aged↗
PubMed2005

Tuberculosis of the spine: experience in an inner city hospital.

BACKGROUND: It is estimated that 10 to 15 million people are infected with Mycobacterium tuberculosis in the United States. Spinal involvement is said to occur in less than 1%. METHODS: A review of the clinic records of all patients having a diagnosis of spinal tuberculosis at the New Jersey Medical School National Tuberculosis Center from January 1994 to January 1999 was done. RESULTS: Twelve patients with spinal TB were identified (2.2%). Spinal tuberculosis is characteristically chronic and slowly progressive. Presenting symptoms are usually back and neck pain or pain at the site of involvement. Pain was noted in a majority (83%) of our patients. Despite proven diagnoses by culture or histology, only 41% were purified protein derivative-positive. Unlike pulmonary tuberculosis, which may present with a constellation of symptoms, including cough, weight loss, fever, and night sweats, if tuberculosis only involves bone, pain may be the only symptom. Most patients were successfully treated with surgery and anti-TB medications. Tuberculosis remains a major public health problem. CONCLUSIONS: Before the disease can be treated, it must be recognized. Tuberculosis should be considered a diagnostic possibility when spinal osteomyelitis is seen, even in the absence of pulmonary disease or HIV infection. Back pain in a patient with tuberculosis should be evaluated. Early initiation of an appropriate treatment regimen may reduce the need for surgical intervention, but most patients require surgery.

Adult↗
PubMed1981

Pott's paraplegia: a clinical review of operative and conservative treatment in 63 adults and children.

Two hundred and twenty patients with active spinal tuberculosis were seen at the Orthopaedic Centre, Tunis, between 1965 and 1975. Fifty adults and 11 children were paraplegic, this being particularly associated with infection of the mid-thoracic spine and with marked kyphosis. The number of diseased vertebrae ranged up to 7, the average kyphosis measuring 53 degrees and the worst being 140 degrees. Patients had been paralysed for an average of 4 months before seeking treatment. Thirty seven patients were treated by chemotherapy alone and 26 with the addition of anterior decompression and grafting. The selection of treatment was arbitrary. The average follow up was nearly three years. Sixty eight percent of the medical group had complete neurological recovery and 19% partial recovery, against 38% and 31% respectively for the surgical group. Mortality in the medical group was 5% compared with 23% after surgery. Patients in either group who showed no sign of improvement within six months of the beginning of treatment failed to recover. The prognosis was better in children and in patients with partial paraplegia but was not influenced by the duration of paraplegia.

Adolescent↗
PubMed1989

Addisonian crisis induced by treatment with rifampicin.

A patient with spinal tuberculosis and subclinical adrenal tuberculosis who developed acute Addisonian crisis on starting anti-tuberculosis therapy including rifampicin is reported. The possibility that many patients with tuberculosis have adrenal involvement with limited hormonal reserve and that they may develop incipient adrenal failure on commencing treatment is discussed.

Addison Disease↗