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Spinal tuberculosis with extensive abscess formation in a 5-year-old girl of Asian origin is reported. The role of CT in the preoperative visualisation of the different compartments of the lesion, including extra- and intraspinal extension, is discussed. At present, CT seems to be the method of choice in the preoperative study of infectious spinal and paraspinal processes.
Tuberculosis is as old as mankind. Vertebral tuberculosis is fairly common form of bone and joint tuberculosis. However, isolated sacral tuberculosis is rare. It may present as an atypical sacral lesion having epidural granuloma without destruction of sacrum on MRI and plain X-rays. This atypical presentation may lead to delay in diagnosis and treatment. This case report intends to emphasize that spinal tuberculosis should be the first and foremost differential diagnosis in the presence of atypical clinical and radiological features of a sacral lesion particularly in developing countries. Early diagnosis and treatment can prevent or minimize the neurological morbidity in such cases.
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The computed tomographic (CT) features of ten documented cases of spinal tuberculosis were analyzed. All cases showed evidence of vertebral body destruction, with paravertebral soft tissue masses. Four cases revealed extension of involvement into the neural arches. Calcification within the paraspinal soft tissue was found in only two cases. Two of four cases who received intravenous contrast medium demonstrated evidence of rim enhancement around multilocuated fluid collections. Compared to conventional roentgenography, CT better delineated the extent of bony destruction, involvement of the spinal canal and existence of paraspinal soft tissue masses.
The CT appearance of eight cases of culture-positive spinal tuberculosis is reviewed. Three patients had single level vertebral involvement, while five others showed multilevel involvement. In seven of eight cases, paraspinal soft tissue involvement was seen. In two, the process caused neurologic symptoms by extending into the epidural space. In three patients the paraspinal extension was not only local, but spread along multiple levels. The CT appearance can be highly suggestive of TB in cases where the diagnosis has not been suspected. In cases where the diagnosis is suspected by plain films, CT can display unsuspected extension of the disease and be helpful in needle localization for aspiration.
Because of alarming delays in the diagnosis and treatment of vertebral osteomyelitis we have reviewed our experience over the past 15 years. Of the 36 cases, 25 were pyogenic and 11 tuberculous. Because of late referral there was a delay from onset of symptoms to diagnosis of at least three months in 13 patients. The reason for this was the failure of the initial physician to consider osteomyelitis in the differential diagnosis of a febrile illness associated with back pain. The majority of our patients from the onset did not have intense localized pain, tenderness and a high fever which is the classical clinical picture in this condition. Seven patients with a long history required surgical exploration and debridement of the lesion in order to eradicate the infection. The remainder did well on 6 to 12 weeks of antibiotic therapy. None required spinal fusion. Ten of 11 patients with spinal tuberculosis had curettage of the lesion and spinal fusion. Patients with diabetes, malignancy, alcoholism, corticosteroid therapy and recent lower urinary tract surgery were found to be at particular risk of developing spinal osteomyelitis. Very often it was difficult to identify differences in the presentation of pyogenic and tuberculous infections.
The information content of early bone changes in computed tomography (CT) of pyogenic non-tuberculous spondylitis and spinal tuberculosis is analysed. The CT findings are compared with conventional x-ray images including tomography. In 3 of 16 patients no indications of osteomyelitis were found by conventional x-ray images, whereas CT revealed paravertebral soft tissue swelling or abscesses and osteolysis and thus established the diagnosis of spondylitis. In one patient the process caused neurologic symptoms by extending into the epidural space. The contributions of CT to the diagnosis of spondylitis are to delineate the extent of soft tissue swelling, to detect small defects in the vertebral bodies, to exclude disc involvement, and to differentiate inflammations and other destructive changes. CT can be used for fine needle localization and aspiration of tissue or pus for histological or bacteriological investigations to establish the pathological diagnosis.
A retrospective study of 23 patients with spinal tuberculosis (TB) was conducted, with special attention to the diagnosis and method of treatment. Computerised tomography (CT) was found to be the diagnostic radiological modality of choice. Triple therapy with the new anti-tuberculous drugs and posterior or posteriolateral decompression succeeded in decompressing the cord and eliminating the tuberculous lesion in all cases. The outcome was comparable to series where anterior decompression was adopted. None of the patients required spinal fusion. Erythrocyte sedimentation rate was the most consistent blood test in suggesting the diagnosis and was the best tool for evaluating a patient's response to treatment. The average hospital stay was only 17 days, which speaks favourably for the surgical management of tuberculous spondylitis.
Spinal tuberculosis is a frequent skeletal involvement in tuberculosis. We report 122 cases between 1983 and 1998 of Pott's disease explored by plain radiographies in all cases, CT-scan in 22 cases and MRI in 6 cases. The lesion involved one localization in 98 cases, two localizations in 9 cases and multiple localizations in 15 cases. The usual form associating the discal and vertebral involvement was noted in 70%. Unusual forms were seen in 30% of the cases The localizations were: posterior arch (20 cases), centrosomatic (10 cases), suboccipital (4 cases) and subligamentar (2 cases). In addition, the CT scan noted vertebral lesion with soft tissue abscess in all cases and epidural lesion in 9 cases. MRI performed in 6 cases showed epidural lesions in 4 cases: epiduritis (2 cases) and abscess (2 cases). The disco-vertebral puncture-biopsy, performed in 12 cases, confirmed the diagnosis in 7 cases. The diagnosis of Pott's disease was confirmed biologically in 30 cases. Radiographic exploration of Pott's disease is improved by the contributions of CT and MRI which can identify sequestra, perilesional sclerosis and epidural or soft tissue abscesses. Discovertebral aspiration biopsy provides the key to diagnosis.
UNLABELLED: We retrospectively reviewed 12 patients with spinal tuberculosis of the thoracic and lumbar spine who had radical débridement, anterior decompression, interbody arthrodesis with an anterior interbody titanium cage, and autologous bone grafts, combined with a standardized perioperative antituberculous regimen. Their mean age was 55.1 years and they were observed for a mean of 65.3 months. Indications for surgery included epidural abscess, structural destruction with instability, progressive kyphosis, and/or neurologic deterioration. Kyphotic deformity was corrected from a mean of 24.6 degrees (range, 15 degrees-32 degrees) to a mean of 10 degrees (range, 4 degrees-18 degrees). Tuberculous infection was controlled and bony fusion was achieved in all patients. No recurrence of infection or construct failure was recorded. All patients were safely mobilized within the first postoperative week; back pain fully resolved in eight patients and improved in the remaining four. We conclude that radical débridement followed by anterior stabilization with a titanium cage and bone grafting is a reasonable alternative for tuberculous spondylitis requiring surgical treatment. It enables accurate and lasting deformity correction and provides adequate stability to allow early mobilization. The presence of a titanium cage in an area of mycobacterial infection did not preclude infection control or lead to recurrence. LEVEL OF EVIDENCE: Therapeutic study. Level IV (case series). Please see Guidelines for Authors for a complete description of levels of evidence.
We treated 107 adults with spinal tuberculosis. The average age was 41.8 years (range, sixteen to seventy-five years). Diagnosis was difficult: bone scans were negative in 35 per cent; gallium scans, negative in 70 per cent; and results of tuberculin skin tests, negative in 14 per cent. Five neurologically impaired patients had no discernible bone lesions when they were first seen but were found to have either intradural or extradural tuberculomas or tuberculous arachnoiditis. Our indications for a spinal operation were neurological impairment, spinal instability, or failure of medical management, and an operation was required in fifty-three of the 107 patients. Anterior decompression and fusion was the surgical procedure of choice. Ninety-four per cent of neurologically impaired patients recovered normal neurological function after anterior decompression; 79 per cent, after non-surgical treatment; and 55 per cent, after laminectomy. Neurological recovery and relief of pain occurred more rapidly in the surgically treated group. Kyphosis did not worsen in any patient, whether treated medically or surgically. There were no organisms that were resistant to isoniazid, rifampin, or ethambutol, and there was neither progression nor reactivation of disease after twelve months of adequate chemotherapy.
Some measure of agreement and no little debate continue to surround the management of bone and joint tuberculosis. There is a consensus that the first phase of antituberculous chemotherapy should consist of three drugs (isoniazid, rifampin, and pyrazinamide) or four drugs (plus ethambutol) given for two to three months. When neither resistance nor side effects occur, isoniazid and rifampin should be continued as maintenance therapy. Patient compliance is well-recognized as requiring special attention because of its large impact on treatment outcomes. Provided strict patient selection criteria and close medical supervision are used, spinal cord compression can be treated nonsurgically with four antituberculous drugs, immobilization and, in many cases, a glucocorticoid. In spinal tuberculosis without neurological signs, immobilization is not always necessary, except when the cervical spine is involved. The optimal duration of antituberculous chemotherapy required for complete recovery of bone and joint tuberculosis is still debated. Twelve months is the duration currently recommended by most experts. Shorter durations, of six to nine months, have been advocated in adults. A critical analysis of the literature shows that proof is still lacking of the equivalence between six- to nine-month and 12- to 18-month treatments. In particular, trials conducted under the aegis of the Medical Research Council of the United Kingdom failed to resolve this issue because of methodological inadequacies regarding sample size and statistical analysis. The large sample size and long follow-up needed to obtain conclusive data would probably require a multicenter international study.
AIM OF STUDY: To study the aetiological and clinical profile of non traumatic paraparesis and radiological correlation with newer aids of diagnosis like CT scan, MRI. METHODOLOGY: Forty cases of non traumatic paraparesis admitted at Sri Sayaji General Hospital, Baroda were studied. The clinical, laboratory data and radiological features were analyzed. RESULTS: Spinal tuberculosis was commonest cause (30%) of paraparesis followed by acute transverse myelitis (20%) and then by primary spinal cord tumours (10%). Incidence of paraparesis was highest (32.5%) in third decade. Backache (75%), parasthesias (62.5%) were common symptoms accompanying paraparesis. Spasticity was present in 57.5% patients. Myelography showed block in 58.5% patients. CT scan following myelography exactly delineated the primary spinal cord tumours and confirmed diagnosis in spinal TB, arachnoid cysts and other compressive myelopathies. MRI, showed plaques of demyelination in two patients, and epidermoid cyst in one patient. CONCLUSION: Tuberculosis of the spine was the commonest cause of paraparesis followed by acute transverse myelitis. CT scan and MRI are important diagnostic aids in patients of paraparesis.
BACKGROUND: Data on tuberculosis (TB) of the spine from Nigeria is scanty despite the endemicity of the disease. OBJECTIVE: To highlight hospital data on spinal tuberculosis. DESIGN: A ten-year retrospective study of records on spinal TB from the medical records, orthopaedic and medical wards was done. The clinical notes, radiographs and haematology results of the patients were analysed. SETTING: University of Ilorin Teaching Hospital, Ilorin, Nigeria. SUBJECTS: All patients treated for spinal TB in the hospital from January 1990 to December 1999 were studied. RESULTS: Fifty patients were seen, 24 males and 26 females, age range 1.5-70 years (mean 27.1 +/- 22.8 years). Peak prevalence (30%) was in the first decade. Twenty seven patients had complete clinical data in their case notes. Twelve patients had paraplegia and three had concomitant pulmonary TB. The lumbar spine was the commonest site of involvement. Two thirds (18 patients) had positive mantoux test. Twenty three patients had chemotherapy but a third was lost to follow up within two months. Twenty one patients (77.8%) had difficulty obtaining the prescribed drugs due to financial difficulties. No patient had surgical intervention. CONCLUSION: Spinal TB is still a common disease in Nigeria with unacceptable laxity in control measures. There is need for patient health education, contact tracing, provision of free anti-TB drugs and a general improvement in the economy to reduce the prevalence of spinal TB in the country.
A retrospective analysis was performed of CT scans of 30 consecutive patients with a clinical suspicion or diagnosis of spinal tuberculosis. Four patterns of bone destruction were noted, namely, fragmentary, osteolytic, subperiosteal and well-defined lytic with sclerotic margins. The fragmentary type was most common (47%). Intervertebral disc destruction was always associated with contiguous vertebral body destruction. Associated paravertebral soft-tissue masses were seen in all patients. Epidural extension of disease was seen in 66% and showed a very good correlation with neurological signs on clinical evaluation. Bone fragments were detected in the epidural soft-tissue mass in 65% of patients with epidural extension of disease. CT appearances of bone destruction are highly suggestive of tuberculous osteomyelitis in about half the patients.
STUDY DESIGN: Study of magnetic resonance imaging (MRI) of tuberculosis of spine to determine the incidence and features of isolated tuberculous involvement of the posterior spinal elements. OBJECTIVE: To describe the MRI findings in patients with isolated tuberculous involvement of the posterior spinal elements. SUMMARY OF BACKGROUND DATA: Spinal tuberculosis is more common in the eastern countries than in the western world. Recently, there has been a renewed interest in tuberculosis in the west because of its re-emergence, especially in immunocompromised patients (e.g., HIV). The classic radiologic picture of "two vertebral disease with the destruction of the intervertebral disc" is easily recognized and readily treated, but its atypical forms are often misdiagnosed and mistreated. METHOD: A total of 33 patients 13-53 years of age (16 men, 17 women; mean age 28.30 years) with proven tuberculosis of posterior element of the spine were retrospectively evaluated. The clinical and imaging data were studied in all 33 patients. RESULTS: Involvement occurred from C2 to L5 vertebral levels. Most commonly, involvement was seen in the thoracic vertebrae (16 patients, 48.5%) followed by lumbar vertebrae (13 cases, 39.4%) and cervical vertebrae (4 patients, 12.1%). The laminae were most commonly involved (24 patients, 72.7%; 8 bilateral, 16 unilateral) followed by pedicles (20 patients, 60.6%; 6 bilateral, 14 unilateral), articular processes (19 patients, 57.5%; 5 bilateral, 14 unilateral), spinous processes (19 patients, 57.5%), and transverse processes (12 cases, 36.4%; 5 bilateral, 7 unilateral). Bone destruction and marrow changes were seen in all patients. Involvement of the entire posterior arch was seen in eight patients. A total of 23 patients revealed extraspinal soft tissue collections. Intraspinal extradural granulation tissue/abscess was seen in 11 patients. Spinal cord was either displaced or compressed in 15 patients, and abnormal high signal intensity intrinsic cord changes were seen in eight patients. CONCLUSION: In tuberculosis of the posterior element of the spine, MRI is extremely useful in evaluating the extent of involvement and response to therapy of isolated tuberculosis of posterior elements. Involvement of posterior elements due to tuberculosis is not so uncommon.
OBJECTIVE: To evaluate the efficacy and clinical outcome of simultaneous or sequential anterior and posterior surgical approaches in the management of spinal tuberculosis in the form of anterior extirpation of the tuberculous lesion, strut bone grafting of the defect produced and posterior instrumentation for spinal fixation. SUBJECTS AND METHODS: Twenty-two patients who had tuberculosis of the thoracic and lumbar spine with moderate to severe localized kyphosis and variable degrees of neurological deficits were treated at Al Razi Hospital (Kuwait) in the period from 1998 to 2000 by anterior debridement and autogenous strut bone grafting with simultaneous or staged posterior spinal fixation using either USS or SOCON spinal instrumentation. Appropriate antituberculosis treatment was given to all patients for 9-12 months. The postoperative follow-up period was 18 months. RESULTS: Of the 22 cases the average of preoperative kyphosis was 42 degrees. The average of immediate postoperative correction was 27 degrees. At the last follow-up the average correction was 24 degrees and the loss of correction did not exceed 3 degrees. Average fusion times were 5 months for one-segment fusions and 8 months for two-segment fusions. There was no recurrence of the disease in any of the cases. CONCLUSION: Posterior instrumental stabilization and anterior interbody fusion were found to be effective in arresting the disease, correcting kyphotic deformity and maintaining correction until solid spinal fusion.
Tuberculosis of the central nervous system is uncommon. The intramedullary localization is exceptional. We report five cases of intramedullary tuberculosis observed in four women and one man with a mean age of 43 years. Two patients had a prior history of tuberculosis. Spinal cord compression was found clinically in all cases. The spinal MRI visualized the tuberculoma in all patients; two had a double tumor. Complete removal of the tuberculoma was possible in only one patient. Outcome was stationary for four patients.