Pott’s Disease– When & How to Operate?

Background: Pott’s disease is a rare form of extrapulmonary tuberculosis that manifests in a variety of clinical patterns. Delays in diagnosis and treatment can lead to serious complications. About 10-40% of patients with spinal tuberculosis may have a neurological deficit. Urgent measures are needed to halt the progression of the disease and deformity, especially to prevent and overcome paraplegia. In regards to management, every case is different and has a unique procedure. It includes simple medical management, simple decompression and debridement, anterior approach, and posterior approach, etc. Surgical decompression of the cord and instrumentation are needed in many cases besides chemotherapy. Although the anterior approach is used for cervical Pott’s disease but this procedure is very time-consuming and technically difficult in the lumbar and dorsal spine, especially in compromised patients and morbidity is more. The posterior approach alone is enough for achieving adequate decompression, debridement, reduction, fusion, reconstruction of the body, and maintaining sagittal alignment in the dorsal and lumbar Pott’s spine. The aim of the study was to describe the treatment modality and observe the outcome of treatment methods and incidence rate of infection sites among the patients of Potts spine. Material & Methods: This retrospective study was conducted at the Department of Neurosurgery, Bangabandhu Sheikh Mujib Medical University, Bangladesh. The study duration was 7 years, from March 2016 to January 2023. During this period, a total of 30 cases of Pott’s disease were included in the study following inclusion and exclusion criteria. Results: 53.33% had been from the youngest age group of 15-34 years, and 80 % were male. Very few participants had been female in the present study. Back pain was the primary complication for 50% of cases, while spinal infection was observed in the cervical region for 16.67% of cases, 43.33% had infections in the dorsal region, and 30 % in the lumbar region. 10.00% of the participants had been treated with non-surgical methods, with only anti-TB medication for 18 months or more. Posterior decompression was the most common treatment method, with 23.33% having only posterior decompression, and 40.00% having posterior decompression with the use of additional instruments. Conclusion: The study observed that Pott’s disease was most common among young adult males, and the most common sites of spinal infections were in the dorsal and lumbar regions in the present study population, contradictory to the general findings. Decompression treatment, with and without additional instruments, was the most common form of treatment among the present study population.

Absceso del psoas secundario a tuberculosis vertebral / Psoas abscess secondary to vertebral tuberculosis

Introducción: Presentamos el caso de un paciente masculino de 29 años con absceso del psoas bilateral secundario a tuberculosis vertebral. El absceso del psoas no suele ser frecuente en pacientes con tuberculosis extrapulmonar y principalmente con la enfermedad de Pott, pero cuando aparece suele ser subdiagnosticado debido a la inespecificidad de sus manifestaciones clínicas. Objetivos: Abordaje clínico-quirúrgico del absceso del psoas secundario a la tuberculosis vertebral, o Mal de Pott. Materiales y métodos: Búsqueda bibliográfica efectuada en pubmed. Relato de caso clínico: registro clínico y fotográfico, evolución, presentación de: resultados laboratoriales y de métodos auxiliares y tratamiento. Resultados: Síntomas presentados por un paciente de 29 años: dolor abdominal, dolor en miembro inferior, lumbalgia, expectoración sanguinolenta, dificultad en la deambulación, y cuadro respiratorio previo y síntomas constitucionales como pérdida de peso, anorexia, astenia. Con base en la anamnesis, examen físico y hallazgos en exámenes específicos, se pudo lograr el diagnóstico de absceso del psoas secundario a la tuberculosis vertebral. El tratamiento farmacológico seguido fue el propuesto por la OMS para la Tuberculosis más punción del absceso para drenaje y cultivo del mismo, con catéter multipropósito. El paciente tuvo una evolución favorable y posterior a la intervención neuroquirúrgica fue dado de alta. Conclusión: El paciente evolucionó de forma favorable, y las medidas aplicadas en el desarrollo de su enfermedad, fueron oportunas.

Introduction: We present de case of a 29 year old male patient with bilateral psoas abscess secondary to vertebral tuberculosis. Psoas abscess is not usually frequent in patient with extra-pulmonary tuberculosis and specially Pott's disease, but when it appears it is usually under diagnosed due to non-specificic clinical manifestations. Objectives: Clinical-surgical approach to psoas abscess secondary to vertebral tuberculosis, or Pott's disease. Materials and methods: Bibliographic search carried out in pubmed. Case report: clinical and photographic record, evolution and presentations of laboratory results, diagnostic auxiliary methods and treatment. Results: Symptoms presented by a 29 years old patient: abdominal pain, lower limb pain, low back pai, bloody expectoration, difficulty walking and previous respiratory and constitutional symptoms sucha as weight loss, anorexia, asthenia. Based on the clinicalhistory, physical examination and findins in specific tests, the diagnosis of psoas abscess secondary to vertebral tuberculosis could be achieved. The pharmacological treatment followed was the one proposed by WHO for tuberculosis, plus the drainage and culture of the abscess, with a multipurpose catheter. The patient had a favorable evolution and after the neurosurgical intervetntion he was discharged. Conclusion: The patient evolved favorably, and the measures applied in the development of his disease were appropriate.

Vertebromedular histoplasmosis: About a case of transverse myelitis in a young and immunocompetent adult

Systemic mycosis raging endemic, histoplasmosis has an increasing incidence with the advent of HIV-AIDS. The authors report a case of vertebra-medullar histoplasmosis mimicking tuberculous spondylodiscitis in a patient without proven immunosuppression. This was a patient who spent 3 years in a highly endemic area. He presented with signs of transverse myelitis. MRI of the lumbar spine showed a para-vertebral tumor lesion that partially infiltrated the spinal cord. The positive diagnosis of histoplasmosis was made by histomorphology, and symptoms were reduced with administration of itraconazole. These findings show the need for a proper coding of the management of patients living or having stayed in histoplasmosis endemic areas, whether they are immunocompromised or not.

The Relative Lymphocyte Count is Lower when the Etiological Agent in Pott Disease is Successfully Isolated / O número relativo de linfócitos é menor quando o agente etiológico da doença de Pott é isolado com sucesso

Abstract Objective To describe the clinico-epidemiological, laboratory, and radiological characteristics of tuberculous spondylodiscitis in the Brazilian population, and to assess whether there are differences between patients in whom the etiological agent in Pott disease was isolated or not. Methods Patients diagnosed with tuberculosis (TB) of the spine (Pott disease) underwent follow-up between 2009 and 2019 at a quaternary hospital and were divided into 2 groups: successful isolation (SI) of the etiological agent (through bacilloscopy, culture, or positive molecular rapid test) and unsuccessful isolation (UI) of the etiological agent. Results From a total of 26 patients diagnosed with TB of the spine, 21 (80.7%) were male, with a mean age of 40 ± 22.5 years. The average lymphocyte counts were higher in the UI group (25.35 ± 13.08; p= 0.025) compared to the SI group (14.18 ± 7.48). Moreover, the monocyte/lymphocyte ratio was lower in the UI group (0.39 ± 0.22; p= 0.009) than in the SI group (0.89 ± 0.65). Relative lymphocyte counts higher than or equal to 16.7 had a sensitivity of 76.9% and specificity of 62.5% in the UI group. Values higher than or equal to 0.58 for the monocyte/lymphocyte ratio showed a sensitivity of 84.6% and specificity of 75.0% in the UI group. Conclusion No differences were observed regarding the clinico-epidemiological and radiological characteristics of the two experimental groups. However, the UI group had higher lymphocyte counts and a lower monocyte/lymphocyte ratio.

Resumo Objetivo Descrever as características clínico-epidemiológicas, laboratoriais e radiológicas da espondilodiscite tuberculosa na população brasileira e avaliar se há diferenças entre pacientes em que o agente etiológico da doença de Pott foi isolado ou não. Métodos Os pacientes diagnosticados com tuberculose (TB) da coluna (doença de Pott) foram acompanhados em um hospital quaternário entre 2009 e 2019 e divididos em 2 grupos: isolamento positivo (IP) do agente etiológico (por baciloscopia, cultura ou teste rápido molecular positivo) e isolamento negativo (IN) do agente etiológico. Resultados De um total de 26 pacientes com diagnóstico de TB da coluna, 21 (80,7%) eram do sexo masculino, e a média de idade era de 40 ± 22,5 anos. As contagens médias de linfócitos foram maiores no grupo IN (25,35 ± 13,08; p= 0,025) do que no grupo IP (14,18 ± 7,48). Além disso, a relação monócito/linfócito foi menor no grupo IN (0,39 ± 0,22; p= 0,009) do que no grupo IP (0,89 ± 0,65). O número relativo de linfócitos maior ou igual a 16,7 teve sensibilidade de 76,9% e especificidade de 62,5% no grupo IN. A razão monócito/linfócito maior ou igual a 0,58 teve sensibilidade de 84,6% e especificidade de 75,0% no grupo IN. Conclusão Não observamos diferenças em relação às características clínico-epidemiológicas e radiológicas entre os dois grupos experimentais. No entanto, o grupo IN apresentou maior número de linfócitos e menor razão monócito/linfócito.

Traitement chirurgical du Mal de Pott et de ses séquelles au Centre Hospitalier de l'Ordre de Malte Dakar / Surgical treatm ent of Pott's diseaseand its sequelae at the Hospital of the Order of Malta/Daka

Introduction. Evaluer les résultats du traitement chirurgical du Mal de Pott et de ses séquelles au Centre hospitalier de l'ordre de Malte de Dakar. Patients et méthodes. Nous présentons les résultats préliminaires d'une série consécutive de 23 patients (13 hommes et 10 femmes) d'âge moyen de 32,35 ans [6 ­70 ans] présentant des Maux de Pott ou de leurs séquelles nécessitant un traitement chirurgical. L'échelle d'incapacité d'Oswestry, l'échelle visuelle analogique et le score ASIA ont été utilisés pour l'évaluation clinique. Les radiographies pré opératoires, post opératoires et au recul ont été utilisés pour les résultats anatomiques. Tous ces patients ont été opérés selon trois stratégies opératoires sur une période de 67 mois (Avril 2014- Novembre 2019). Nous avons réalisé une laminectomie arthrodèse postérieure dans 52,2% ; une laminectomie plus OTP et arthrodèse postérieure dans 43,5% ; une discectomie et hémicorporectomie avec arthrodèse antérieure par plaque vissée de Roy Camille à l'étage cervical dans 4,3%. Résultats. La symptomatologie était dominée par la douleur rachidienne, la cyphose et les troubles neurologiques. La cyphose post opératoire était significativement améliorée (la moyenne passe de 48,52° en pré opératoire à 17,09° en post opératoire). On a obtenu 100% de fusion vertébrale. On note une nette amélioration de la douleur rachidienne (avec une baisse au recul de 55,44 points pour l'OID et de 5,66 pour l'EVA) ; 78,3% des patients étaient très satisfaits, 17,4% satisfaits et 4,3% mécontents. Conclusion. Le traitement chirurgical du Mal de Pott et de ses séquelles a fortement amélioré les rachis au Centre hospitalier de l'Ordre de Malte.

Introduction. To evaluate the results of the surgical treatment of Pott's disease and its sequelae at the Hospital Center of the Order of Malta in Dakar. Patients and methods. We present the preliminary results of a consecutive series of 23 patients (13 men and 10 women) with an average age of 32.35 years [6-70 years] presenting with Pott's disease or its sequelae requiring treatment. surgical treatment. Oswestry Disability Scale, Visual Analogue Scale and ASIA score were used for clinical assessment. Preoperative, postoperative and followup radiographs were used for anatomical results. All these patients were operated according to three operating strategies over a period of 67 months (April 2014- November 2019). We performed posterior laminectomy-arthrodesis in 52.2%; laminectomy plus OTP and posterior arthrodesis in 43.5%; discectomy and hemicorpectomy with anterior arthrodesis by Roy Camille screwed plate at the cervical level in 4.3%. Results. The symptomatology was dominated by spinal pain, kyphosis and neurological disorders. Postoperative kyphosis was significantly improved (the average goes from 48.52° preoperatively to 17.09° postoperatively). We got 100% spinal fusion. There is a clear improvement in spinal pain (with a drop at follow-up of 55.44 points for the OID and 5.66 for the EVA); 78.3% of patients were very satisfied, 17.4% satisfied and 4.3% dissatisfied. Conclusion. The surgical treatment of Pott's disease and its sequelae greatly improved the spines at the Hospital Center of the Order of Malta.

Notification of 6442 cases of bone tuberculosis in Brazil: epidemiological profile from 2009 to 2018 / Notificação de 6442 casos de tuberculose óssea no Brasil: perfil epidemiológico de 2009 a 2018 / Notificación de 6442 casos de tuberculosis ósea en Brasil: perfil epidemiológico de 2009 a 2018

ABSTRACT Objective: To analyze the occurrence of notified cases of bone tuberculosis in Brazil during the period from 2009 to 2018. Methods: Quantitative, descriptive and retrospective study. The data consisted of cases reported to the Notifiable Diseases Information System (SINAN) of DATASUS. To analyze the results, the non-parametric statistical Chi-squared and G tests, capable of expressing statistical associations, were used. Results: 6,442 cases of bone tuberculosis were reported in Brazil, with an average of 644.2 cases per year. The Southeast was responsible for 41.5% of the cases (n = 2676). The extrapulmonary form accounted for 87.9% (5661). There was a predominance in males (66.1%, n = 4258), Whites (41.6%, n = 2678) and in the above 35 years of age group (73.9%, n = 4757). In the data collected, the risk factor data was not correctly filled out, making reliable statistical associations impossible in this study, mainly between alcoholism, tobacco use, AIDS, diabetes, mental illness, illicit drug use and homelessness. Conclusion: There was greater notification of cases of bone tuberculosis in the Southeast and Northeast regions of Brazil, which predominantly affected young, economically productive men. Tuberculosis has a correlation with diabetes, HIV / AIDS, smoking and alcohol and drug use, according to the results of this study. Level of evidence II; Retrospective, analytical, quantitative and descriptive study.

RESUMO Objetivo: Analisar a ocorrência de casos de tuberculose óssea notificados no Brasil entre o período de 2009 a 2018. Métodos: Estudo quantitativo, descritivo e retrospectivo. Os dados consistiram em casos notificados no Sistema de Informação de Agravos de Notificação (SINAN) do DATASUS. Para análise dos resultados, foram usados testes estatísticos não paramétricos, Qui-quadrado e teste G, capazes de expressar associação estatística. Resultados: Foram notificados 6.442 casos de tuberculose óssea no Brasil, com média de 644,2 casos por ano. O Sudeste foi responsável por 41,5% dos casos (n = 2676). A forma extrapulmonar correspondeu a 87,9% (5.661). Houve predomínio no sexo masculino (66,1%, n = 4258), em brancos (41,6%, n = 2678) e maiores de 35 anos (73,9%, n = 4757). Os dados coletados não tinham preenchimento correto dos fatores de risco, o que impossibilitou a associação estatística confiável neste estudo, principalmente entre alcoolismo, tabagismo, AIDS, diabetes, doença mental, uso de drogas ilícitas e moradores de rua. Conclusões: Houve maior notificação de casos de tuberculose óssea no Sudeste e no Nordeste do Brasil, que afetou predominantemente homens jovens e em plena atividade econômica. A tuberculose tem correlação com diabetes, HIV/AIDS, tabagismo e uso de álcool e drogas ilícitas, conforme os resultados deste estudo. Nível de evidência II; Estudo retrospectivo, analítico, quantitativo e descritivo.

RESUMEN Objetivo: Analizar la ocurrencia de casos de tuberculosis ósea notificados en Brasil en el período de 2009 a 2018. Métodos: Estudio cuantitativo, descriptivo y retrospectivo. Los datos consistieron en casos notificados en el Sistema de Información de Enfermedades de Notificación (SINAN) del DATASUS. Para análisis de los resultados, fueron usados tests estadísticos no paramétricos, Chi-cuadrado y test G, capaces de expresar asociación estadística. Resultados: Fueron notificados 6.442 casos de tuberculosis ósea en Brasil, con promedio de 644,2 casos por año. El sudeste fue responsable por 41,5% de los casos (n = 2676). La forma extrapulmonar correspondió a 87,9% (5661). Hubo predominio en el sexo masculino (66,1%, n = 4258), en blancos (41,6%, n = 2678) y mayores de 35 años (73,9%, n = 4757). Los datos colectados no tenían llenado correcto de los factores de riesgo, lo que imposibilitó la asociación estadística confiable en este estudio, principalmente entre alcoholismo, tabaquismo, SIDA, diabetes, enfermedad mental, uso de drogas ilícitas y personas sin techo. Conclusiones: Hubo mayor notificación de casos de tuberculosis ósea en el sudeste y en el noreste de Brasil, que afectó predominantemente a hombres jóvenes y en plena actividad económica. La tuberculosis tiene correlación con diabetes, VIH/SIDA, tabaquismo y uso de alcohol y drogas ilícitas, conforme a los resultados de este estudio. Nivel de evidencia II; Estudio retrospectivo, analítico, cuantitativo y descriptivo.

Tuberculosis vertebral con afectación pleural: reporte de un caso / Spinal tuberculosis with pleural involvement: a case report

Resumen La tuberculosis extrapulmonar representa hasta el 25% de todos los casos de tuberculosis. Los órganos más frecuentemente afectados son los ganglios linfáticos y la pleura. Alrededor del 10-11% de casos de tuberculosis extrapulmonar tienen afectación osteoarticular y de ellos la mitad con compromiso vertebral. La infección es causada por la diseminación hematógena del bacilo desde un foco primario al hueso esponjoso de los cuerpos vertebrales torácicos o lumbares principalmente. El síntoma característico es el dolor crónico de la columna vertebral, generalmente en el sitio afectado, sin otros síntomas o signos concomitantes. La asociación de tuberculosis vertebral con afectación pleural sin un foco pulmonar establecido es infrecuente, se ha descrito en 2.5% de pacientes e intriga acerca de su fisiopatología. En Colombia, no se encontraron reportes similares. Se describe el caso de una paciente joven con historia de dolor lumbar crónico que debutó con síntomas respiratorios persistentes asociado a síntomas constitucionales; en quien se comprobó la infección por Mycobacterium tuberculosis en vértebras toracolumbares y pleura. Este caso evidencia una historia natural atípica de la enfermedad, en la cual el mecanismo fisiopatológico parece haber sido la diseminación directa por contigüidad, y resalta la importancia de la sospecha clínica para garantizar un diagnóstico y tratamiento oportuno. MÉD.UIS.2020;33(3): 67-73

Abstract Extrapulmonary tuberculosis represents up to 25% of all cases of tuberculosis. The most frequently affected organs are lymph nodes, pleura and bone. Around 10-11% of cases of extrapulmonary tuberculosis have osteoarticular involvement and a half of them present vertebral involvement. The infection is caused by hematogenous spread of the bacillus from a primary focus to the cancellous bone of the thoracic or lumbar vertebral bodies mainly. The characteristic symptom is the chronic pain in the spine, usually in the affected site, without other concomitant symptoms or signs. The association between vertebral tuberculosis and pleural involvement without an established pulmonary focus is infrequent, it has been described in 2.5% of patients, an intrigue about its pathophysiology. Similar cases in Colombia have not been reported. This article describes a case of a young patient with a history of chronic low back pain that debuts with persistent respiratory symptoms associated with constitutional symptoms; whose Mycobacterium tuberculosis infection was proven in thoracolumbar vertebrae and pleura. This case shows an atypical natural history of the disease, in which the pathophysiological mechanism of the disease would seem to have been the direct dissemination by contiguity, and emphasizes the importance of clinical suspicion to ensure timely diagnosis and treatment. MÉD.UIS.2020;33(3): 67-73

Tratamiento quirúrgico de la espondilitis tuberculosa (enfermedad de Pott). Reporte de un caso y revisión de la literatura / Surgical treatment of tuberculous spondylitis (Pott's disease). Case report and literature review

RESUMEN La espondilitis tuberculosa (enfermedad de Pott) representa del 1-5% de los casos de tuberculosis. Se presenta un caso clínico de una paciente femenina de 14 años de edad con esta patología complicada con fractura de cuerpos vertebrales T4, T7, T8 y T9; a quien se le realizó un abordaje por vía posterior, consistente en laminectomía completa bilateral de T3, T4, T7, T8, T9 preservando las articulaciones facetarias, mas artrodesis instrumentada con ganchos sublaminares en T1-T2, colocación de alambres sublaminares T5 y T6, tornillos transpediculares en T11 y dos barras de titanio. Con excelentes resultados postoperatorios. Además, se discuten las diferentes vías de abordaje quirúrgico de esta patología.

ABSTRACT Tuberculous spondylitis (Pott's disease) represent 1-5% of tuberculosis cases. We present a clinical case of a female patient of 14 years of age with tuberculous spondylitis (Pott's disease) complicated with vertebral body fracture T4, T7, T8 and T9, who underwent a posterior approach, bilateral complete laminectomy of T3, T4, T7, T8, T9 preserving the facet joints, more arthrodesis instrumented with sublaminar hooks in T1-T2 placement of sublaminar wires T5 and T6 placement of transpedicular screws in T11, and two titanium bars. With excellent postoperative results. In addition, the different surgical approaches to this pathology are discussed.

Bone and articular impairment in tuberculosis. An important extrapulmonary involvement: a review

This is a literature review on the pathogenesis and epidemiology of bone tuberculosis (BTB). Full-text papers from 2001 to 2017 were included. After inclusion criteria were met, 23 papers were selected for analysis. Results show that in most cases of BTB, the spine is the main site involved, regardless of the geographical regions analyzed; hip and knee involvement are also frequent. These three sites are the most prevalent, totaling approximately 70 - 80% of infections. The major forms of involvement are tuberculous spondylitis, tuberculous osteomyelitis, primarily in areas of long-bone growth, as well as cases of chronic disease leading to tuberculous arthritis, mainly in endemic areas. The results also indicated that bone involvement is still prevalent, being the fifth cause of extrapulmonary disease involvement in Brazil. This review highlights the role of tuberculosis in public health, especially in economically active groups where BTB is most prevalent

A Case of Cervical Pott's Disease Presenting as Huge Retropharyngeal Abscess / 대한이비인후과학회지

Tuberculous spondylitis, also known as Pott's disease, is a disease involving the spine with progressive destruction. It most commonly involves the thoracic and lumbosacral spine and may result in severe deformity or neurologic deficit. Although cervical spine involvement is rare, it can cause life threatening event. Recently, 70-year-old man presented with progressive dyspnea and dysphagia. Physical examination and radiologic studies showed a huge retropharyngeal abscess with bony erosion and sclerotic change at the adjacent cervical spine. After incision and drainage, it was finally confirmed as a tuberculous abscess. Herein, we report our experience with literature review.

Enfermedad de Pott: a propósito de un caso / Pott's disease. A case report

Un tercio de la población mundial está infectada por tuberculosis. Cada año en el mundo se re-portan de 8 a 10 millones de casos nuevos de tuberculosis, y cerca de 3 millones fallecen a causa de la enfermedad. Suele afectar los pulmones, pero en 33 % de los casos afecta otros órganos. La tuberculosis vertebral ocurre en menos de 1% de los pacientes, es más frecuente en niños que adultos. Los datos clínicos más comunes son: dolor, limitación funcional, y contractura muscular. En etapas avanzadas presenta una giba dorsal, y alteraciones neurológicas. Presentamos el caso de una paciente femenina de 55 años con dolor lumbar irradiado a miembro inferior izquierdo de 4 meses de evolución. Estudios imagenológicos revelan deshidratación del disco intervertebral L4-L5, acuñamiento del cuerpo vertebral de L2-L3 con desplazamiento del muro posterior en L2. Recibió tratamiento médico, se realiza biopsia por aspiración guiada por fluoroscopia y se envían muestras para histopatología y cultivo para micobacterias con adecuada respuesta clínica.

A third of the global population is infected with tuberculosis. Each year in the world are reported from 8 to 10 million new cases of tuberculosis, and about 3 million die of the disease. It usually affects the lungs, but in 33% of cases affect other organs. Spinal tuberculosis occurs in less than 1% of patients, is more common in children than adults. The most common clinical data are pain, functional limitation, and muscular contraction. In advanced stages has a dorsal hump, and neurological disorders. We report the case of a female patient of 55 years with low back pain radiating to the left leg 4 months. Imaging studies reveal dehydration L4-L5 intervertebral disc, vertebral body wedging L2-L3 of the rear wall displacement in L2. He received medical treatment, aspiration biopsy was performed guided by fluoros-copy and sent samples for histopathology and culture for mycobacteria with adequate clinical response.

Functional and Radiological Outcomes of Anterior Decompression and Posterior Stabilization via Posterior Transpedicular Approach in Thoracic and Thoracolumbar Pott's Disease: A Retrospective Study

STUDY DESIGN: This is a retrospective study. PURPOSE: To determine the efficacy and safety of a posterior transpedicular approach with regard to functional and radiological outcomes in people with thoracic and thoracolumbar spinal tuberculosis. OVERVIEW OF LITERATURE: Spinal tuberculosis can cause serious morbidity, including permanent neurological deficits and severe deformities. Medical treatment or a combination of medical and surgical strategies can control the disease in most patients, thereby decreasing morbidity incidence. A debate always existed regarding whether to achieve both decompression and stabilization via a combined anterior and posterior approach or a single posterior approach exists. METHODS: The study was conducted at the Indian Spinal injuries Centre and included all patients with thoracic and thoracolumbar Pott's disease who were operated via a Posterior transpedicular approach. Data regarding 60 patients were analyzed with respect to the average operation time, preoperative and postoperative, 6 months and final follow-up American Spinal Injury Association (ASIA) grading, bony fusion, implant loosening, implant failure, preoperative, postoperative, 6 months and final follow-up kyphotic angles, a loss of kyphotic correction, Oswestry disability index (ODI) score, and visual analog scale (VAS) score. Data were analyzed using either a paired t -test or a Wilcoxon Signed Rank test. RESULTS: The mean operation time was 260±30 minutes. Fifty-five patients presented with evidence of successful bony fusion within a mean period of 6±1.5 months. Preoperative dorsal and lumbar angles were significantly larger than postoperative angles, which were smaller than final follow-up angles. The mean kyphotic correction achieved was 12.11±14.8, with a mean decrease of 5.97 and 19.1 in VAS and ODI scores, respectively. CONCLUSIONS: Anterior decompression and posterior stabilization via a posterior transpedicular approach are safe and effective procedures, with less intraoperative surgical duration and significant improvements in clinical and functional status.

Absceso del psoas como presentación de tuberculosis vertebral: reporte de un caso / Psoas abscess as spinal tuberculosis presentation: case report

Introducción: El absceso del psoas es un cuadro infrecuente cuyo principal agente etiológico es el Staphyloccocus aureus, y que con baja frecuencia puede ser de etiología tuberculosa como complicación de una afección vertebral por Mycobacterium tuberculosis. Presentación del caso: Mujer de 58 años, mapuche, con antecedentes de enfermedad pulmonar obstructiva crónica y alcoholismo crónico, consultó por cuadro de dos meses de evolución de dolor lumbar, baja de peso y paresia de extremidad inferior derecha que impedía la marcha. Tomografía computada (TC) de columna evidenció espondilodiscitis y absceso del psoas derecho, iniciándose tratamiento antibiótico cubriendo Staphyloccocus aureus. Los hemocultivos y los cultivos de la colección resultaron negativos por lo que se decidió mantener tratamiento ambulatorio. Paciente consultó cuatro meses después por exacerbación de su disnea basal de dos semanas de evolución, radiografía de tórax y TC de tórax de alta resolución compatibles con tuberculosis pulmonar con diseminación miliar bilateral, por lo cual, se inició tratamiento antituberculoso, realizándose baciloscopías que resultaron negativas. Además, se solicitó identificación del bacilo de Koch mediante reacción de polimerasa en cadena que resultó positiva, con lo que se confirmó el diagnóstico de tuberculosis miliar y mal de Pott. Se decidió reevaluar con TC de columna una vez finalizado el tratamiento antituberculoso para decidir conducta quirúrgica. Discusión: Es importante la sospecha activa de etiología tuberculosa ante una espondilodiscitis y un absceso del psoas, pese a su baja frecuencia. El inicio del tratamiento en forma precoz puede modificar la progresión de una infección que puede ser invalidante e incluso mortal.

Introduction: The Psoas abscess is an infrecuent condition which main ethiology is the Staphyloccocus aureus and with less frequency can be a vertebral tuberculosis complication caused by Mycobacterium tuberculosis. Case Report: a 58 years old female, Mapuche, with Chronic Obstructive Pulmonar Disease and chronic alcoholism antecedents, was admitted in the emergency room with a two month old lumbar pain, loss of weight and right inferior extremity paresia which didn't allowed her to walk. The column's Computed Tomography (CT) showed spondylodiscitis and a right psoas abscess, the antibiotherapy, covering Staphyloccocus aureus, was started. The hemoculives and abscess' cultives were negative, so it was decided to continue with ambulatory treatment. The patient was admitted four month later because of two weeks of exacerbation of her basal dysnea. The thorax Radiography and high resolution CT were compatibles with pulmonary tuberculosis with bilateral miliar disemination. Antituberculosis treatment was started, bacilloscopies were negative, also, a Polymerase Chain Reaction identification of Koch's bacillus was performed, resulting positive, confirming the diagnosis of miliar tuberculosis and Pott's disease. Once antituberculosis treatment was finished, a new column's CT was requested to decided surgical conduct. Discussion: Is important to actively suspect of tuberculosis ethiology in presence of spondylodiscitis and psoas abscess, despite it's low frequency. The early treatment start may modify the progresion of an infección that can be invalidating and even mortal.

Mal de Pott y diagnóstico inmunológico de tuberculosis, a propósito de un caso pediátrico / Pott's disease and immunological diagnosis of tuberculosis, about a pediatric clinical case

Tuberculosis (TB) remains a major health problem in the world. The clinical forms of TB in children are variable, pulmonary involvement occurs in two thirds of cases. In the remaining third, clinical forms incluye node, meningeal and osteoarticular involvement. Case report: 7 year old boy with a history of an osteolytic lesion of the right ischial branch. Three months later he presented with spondylodiscitis at L2-L3, associated with a large abscess in the right iliac psoas muscle. Pott's disease was suspected, and tuberculin test and T-SPOT®.TB test were performed, with a positive result. Antimicrobial treatment was initiated with isoniazid, rifampicin, pyrazinamide and ethambutol. After 30 days, Mycobacterium tuberculosis was isolated from psoas abscess. We discuss methods of TB diagnosis, with special emphasis on immunological methods: tuberculin test and interferon-gamma release assays. Methods of immunological TB diagnosis are an important contribution to the diagnosis of this disease, allowing early initiation of treatment.

La tuberculosis sigue siendo un importante problema en salud en el mundo. Las formas clínicas de TBC en los niños son muy variadas, presentándose en dos tercios de los casos compromiso pulmonar. En el tercio restante destacan los compromisos ganglionar, meníngeo y osteoarticular. Caso clínico: varón de 7 años que presentó una espondilodiscitis L2-L3, asociada a un absceso en músculo psoas-ilíaco derecho. Por sospecha de mal de Pott se realizó PPD y T-SPOT®.TB que resultaron positivos. Se inició tratamiento antimicrobiano asociado con isoniazida, rifampicina, pirazinamida y etambutol. Después de 30 días, se aisló Mycobacterium tuberculosis del absceso del psoas. Se discute los métodos de diagnóstico de TBC en pediatría, con especial énfasis en los métodos inmunológicos: reacción de tuberculina y test de liberación de interferón-gamma, los que son una importante contribución para el diagnóstico de esta enfermedad, permitiendo el pronto inicio de su tratamiento.

Tuberculosis sistémica en paciente inmunocompetente

Se presenta caso de mujer HIV negativa con tuberculosis diseminada con afectación cerebral, ósea y pulmonar. Durante su evolución desarrolló bacteriemia a Mycobacterium. Presentó buena evolución a tratamiento antituberculoso.

This is the case of an HIV negative woman with disseminated tuberculosis affecting her brain, bones and lungs.During the evolution, she developed bacteremia due to Mycobacterium. The patient had good evolution with anti-tuberculosis treatment.

Atypical Noncontiguous Multiple Spinal Tuberculosis: A Case Report

OBJECTIVE: Spinal tuberculosis-associated symptoms are not so unique as to immediately indicate the proper diagnosis in most cases. Distinguishing spinal tuberculosis (Pott's disease) from pyogenic spondylitis is often difficult, and lesions metastatic from systemic malignancy are the other major entity from which spinal tuberculosis must be distinguished. CLINICAL PRESENTATION: A 27-year-old male patient presented with a history of back pain after a minor trauma 1 month ago. Computed tomography and magnetic resonance imaging of the thoracic spine showed multiple osteolytic bone lesions at the bodies of T9, T10 and T11 vertebrae and the spinous processes of T12 and L1. Other noncontiguous osteolytic lesions were noted at S2 body and right sacro-iliac joint. INTERVENTION: To confirm the pathologic diagnosis, the patient underwent an open biopsy for the T12 and L1 spinous process lesions and a percutaneous transpedicular biopsy on T9, T10, T11 lesions. Frozen biopsy was reported as compatible with chronic granulomatous caseating necrosis without malignant cells. The final diagnosis was an atypical presentation of multiple spinal tuberculosis. The patient received an appropriate enteral anti-tuberculosis therapy and recovered without any complications. Follow-up MRI taken after a year of medical treatment revealed marked resolution of the lesions. CONCLUSION: Current research indicates the incidence of multi-level noncontiguous, remote vertebral tuberculosis is 1.1% to 16%. Because tuberculous spondylitis could represent variant and atypical pattern, the disease should be considered in differential diagnosis along with other diseases such as metastatic neoplasm, pyogenic spondylitis, especially when the radiologic studies are revealing multiple spinal lesions.

Spinal tuberculosis; A study of the disease pattern, diagnosis and outcome of medical management in Sri Lanka.

Background: Sri Lanka has an intermediate burden of tuberculous disease. Most patients with spinal tuberculosis (STB) are managed with medical treatment alone as advanced surgical facilities are not freely available. Objective: To describe the clinico-demographic and imaging pattern of STB and to assess the outcome of medical treatment in the local setting. Design: Descriptive case series. Methods: All patients diagnosed with definite or probable STB, had their symptomatology and investigations recorded. They were followed up with anti-TB treatment (ATT) according to standard guidelines. An initial six-week tapering course of steroid was given when there was an evidence of neural involvement. Results: Of 32 patients with STB, backache was the commonest presenting feature (92%). Nine had lower limb neurological deficits. Uni-focal upper lumbar involvement was the commonest disease pattern noted in the series. High ESR (84%) and Mantoux positivity (53%) were frequent. 72% had end-plate changes on imaging. 53% had paraspinal soft tissue components. The triad of backache, high ESR and end-plate and/or paraspinal disease on CT/MRI showed a diagnostic sensitivity of 81.2%. Response to ATT was satisfactory in 87%. Poor neurological response was seen among some with large paraspinal collections or extensive vertebral damage at diagnosis. Conclusion: This study showed that backache over one month, high ESR and specific CT/MRI features helped diagnosis of STB, in the absence of definitive evidence. Medical management alone, comprising a prolonged course of ATT with an initial steroid cover when indicated, appeared to be safe and effective in the local setting for uncomplicated STB.

Un Caso Inusual de Tuberculosis de Unión Craneocervical Revelado como Dolor Cervical Postraumático / An Unusual Case of CV Junction Tuberculosis Revealed as Post-Traumatic Cervical Pain

Antecedentes: La tuberculosis es un problema de salud en todo el mundo. Las manifestaciones extrapulmonares de latuberculossis siendo el compromiso del sistema esquelético el más frecuente. La tuberculosis espinal representa el 50% de estoscasos. Caso clínico: Paciente varón de Colombia, 66 años de edad, sin ningún antecedente médico de interés, que después deuna lesión cerebral traumática desarrolló dolor cervical, y limitación de los movimientos cervicales. La Resonancia MagneticaNuclear Cervical reveló un proceso osteolítico en la apófisis odontoides, que fue sometido a biopsia por vía transoral; elanálisis hitologica demostró una lesion tipo granulomatosa crónica con necrosis caseosa, además de infiltrado linfoplasmaticoinespecífico sugestivo de origen tuberculoso. El paciente fue manejado de manera conservadora. Conclusiones: es vitalmantener un alto grado de sospecha clínica para el diagnóstico de la tuberculosis espinal Cuando la ubicación de la tuberculosisespinal es en la región cervical, y en concreto suboccipital, esto puede sospecharse cuando el paciente manifieste dolor, con lascaracterísticas mencionados. Se recomienda el tratamiento conservador y seguimiento neuroquirurgico estricto, pero cuando lossíntomas no mejoran con el tratamiento conservador, o cuando se evidencia compromiso neurologico, la cirugía está indicada...

Background: Tuberculosis (TB) is a worldwide health problem. Extrapulmonary manifestations of TB are common with skeletalsystem involvement being the most frequent. Spinal TB accounts for 50% of these cases. Case report: Colombian male patient,66-years-old, without any medical antecedent of interest, who after traumatic brain injury developed cervical pain, and cervicalmovement limitation. Cervical MRI revealed an osteolytic process in the odontoid process, which was biopsied transorally.Histological analysis showed chronic granulomatous type of inflammation with caseous necrosis in addition to nonspecificlymphoplasm infiltrate, suggestive of tuberculous origin. Patient was conservative managed. Conclusions: It is vital to maintaina high degree of clinical suspicion for diagnosis of spinal TB when the location of spinal TB is cervical, and specificallysuboccipital. This can be suspected when patient refers to pain, with the previously mentioned characteristics. Conservativemanagement and closely follow up is recommended, but when not improved with conservative therapy, or when paralysis isevident, surgery is indicated...

Pott's Disease and Cold Abscesses / General Medicine

Tuberculous spondylitis, or so-called Pott's disease, seems to be overlooked because of a lack of severe inflammation in the insidious generating process and tends to cause non-specific symptoms, such as back pain, fever, weakness, and weight loss. Diagnostic delay is common and the results can be disastrous. Discriminating between Pott's disease and other diseases, such as malignancy and pyogenic infection, is difficult. However, the inflammatory process in Pott's disease tends to spare the disk space, while that of pyogenic infection typically affects the area. Herein, we present a patient with Pott's disease who showed the characteristic clinical and radiological findings.

Espondilitis tuberculosa en adultos: revisión de una serie de casos en un hospital de tercer nivel, Lima-Perú / Tuberculous spondylitis in adults: a case series from a reference hospital in Lima, Peru

Describimos las características clínicas y demográficas en pacientes adultos con espondilitis tuberculosa así como un análisis exploratorio que buscó establecer características que contribuyeron al desarrollo de esta enfermedad, en un hospital de tercer nivel de Lima. Realizamos un estudio tipo serie de casos y describimos 33 casos recolectados entre 1999-2009. 18 pacientes (55 por ciento) fueron varones, la media de edad fue 31 años (IQ 23 a 51 años) y un tiempo de enfermedad de 3 meses (IQ 1 a 8 meses). El principal síntoma fue lumbalgia en 28 (85 por ciento). Los segmentos más comprometidos fueron el torácico en 28 (60 por ciento) casos y lumbar en 13 (28 por ciento). Tuberculosis pulmonar se encontró en 14 (42 por ciento) casos. Veinticuatro (73 por ciento) recibieron esquema I. La duración de tratamiento fue 10,5 ± 4,2 meses . Las características clínicas, diagnósticas fueron similares a series nacionales previas e internacionales.

We describe the demographic and clinical characteristics of adult patients with tuberculous spondylitis as well as an exploratory analysis that seeked to establish patient characteristics that contributed to the development of this disorder at a reference hospital in Lima. This is a case-series descriptive study where data collection from 33 medical records of patients from 1999 to 2009 was done. Eighteen (55 percent) were male. Median age was 31 years (IQR 23 to 51 years). Median time of symptoms was 3 months (IQR 1 to 8 months). The most frequent symptom was back pain in 28 (85 percent). The most frequently affected areas were the thoracic spine involved in 28 (60 percent) cases and lumbar spine in 13 (28 percent). Pulmonary tuberculosis was present in fourteen (42 percent) cases. Twenty four (73 percent) patients received first line treatment. Treatment duration was 10.5 ± 4.2 months. Clinical and diagnostic characteristics were similar to previous Peruvian case reports and current literature.