Role of diffusion tensor imaging in neurological prognostication in spinal tuberculosis - A prospective pilot study.

PURPOSE: The current study aims to explore the correlation between the Diffusion Tensor Imaging (DTI) indices and neurological status of individuals with TB spine with neurological deficit (TBSND). Further, factors affecting the rate of post-operative neurological recovery were also analysed with special emphasis on DTI indices. METHODS: The current study included 51 individuals with TBSND undergoing posterior instrumentation and posterolateral decompression. All individuals underwent DTI scanning at the site of compression and at a normal level proximal to the disease. The relationship of the DTI parameters with the pre-operative motor, sensory and total scores were analysed. All clinical and radiological parameters were further analysed on the basis of their recovery patterns after decompression surgery. RESULTS: The FA values at the compressed segment were significantly lower while the ADC values were significantly higher when compared with the non-compressed levels. Pre-operative motor and total neurological scores were found to be significantly positively correlated to FA values and ADC values. Faster neurological recovery after decompression was associated with high FA values and younger age while incomplete neurological recovery was associated with high ADC values. CONCLUSIONS: Higher FA indices along with lower age constitute independent predictors for faster neurological recovery following decompression. FA values correlate with the neurological status of individuals with TBSND and its use may be explored as an adjunct to objectively assess the cord damage and for predicting neurological recovery pattern after decompression in such individuals.

Detection of Spinal Tuberculosis by F-18 FDG PET/CT as a Cause of Unusual Referred Pain in the Right Upper Quadrant of Abdomen.

Tuberculous involvement of the spine (tuberculosis [TB] spine) can cause severe morbidity unless detected and treated early. Apart from the constitutional symptoms, it can present with back pain, kyphosis, gait abnormality, and paraplegia secondary to the bone or spinal cord involvement. There had been instances of TB spine presenting directly as abdominal pain due to psoas abscesses. Herein, we report a very rare clinical manifestation of TB spine as referred pain in the right upper abdominal quadrant due to right epidural phlegmon associated with T7 vertebra, detected by positron emission tomography.

Role of local streptomycin in prevention of surgical site infection in TB spine.

PURPOSE: Surgical site infection (SSI) continues to be one of the most common post-operative complications in most spine surgeries. Patients with tuberculosis (TB) of spine are more at risk of developing this complication due to a number of reasons. This adds to significant morbidity and economic burden on patients adversely affecting the mental status and quality of life of patients. The aim of this study was to investigate the role of local streptomycin in preventing SSI in patients undergoing surgical management of spinal TB. METHODS: In total, 56 patients who underwent surgical management for radiologically proven TB spine divided into two groups were included in the study. Group A included 30 patients with no local streptomycin administered intraoperatively, while group B included 26 patients operated in the later part of study with the use of local streptomycin intraoperatively. The two groups were compared and the outcome criteria analysed were SSI rate, length of hospital stay, duration of post-operative antibiotics and need for debridement. RESULTS: Length of hospital stay (group A: 18.4 ± 6.9 days; group B: 9.7 ± 3.9 days) and duration of post-operative antibiotics (group A: 8.1 ± 1.6 days; group B: 6.2 ± 2.1 days) were significantly higher in group A when compared with group B. SSI rate (group A: 13.34%; group B: 3.84%) and need for debridement (group A: 10%; group B: 3.84%) were higher in group A, but the difference was not statistically significant. CONCLUSION: Intraoperative administration of local streptomycin significantly reduces the length of hospital stay and duration of antibiotic administration in post-operative period in patients undergoing surgery for TB spine.

Modified Transclavicular-Transmanubrial Approach to Cervicothoracic Spine: Revisiting and Renovating the Path - Lessons Learned.

INTRODUCTION: A thorough knowledge of the vital structures adds to the safety in approaching the cervicothoracic spine junction. The best described method to reach the spine is via viscero-neurovascular space. We present our experience of 10 cases operated at our institute using the modified transclavicular transmanubrial approach to the cervicothoracic spine pathology.As we gained experience we have used various corridors to the operating field and used a new space to approach the lower cervicothoracic junction spine. METHODS: Between February 2011 to August 2015, 10 patients with disease in upper thoracic vertebral body were admitted and evaluated clinically and radiologically. Neurological status in all cases was graded according to Frankel grading system.Patients were followed up with Histopathological reports and treated accordingly. RESULTS: All patients(except metastasis) improved by 1 or 2 grade in post op period. Metastasis patients remained in same grade. CONCLUSION: Anterior approach with its modifications are the better suited biomechanically for exploring the pathology of cervicothoracic spine,its decompression and stabilization. Also it preserves the stability of shoulder girdle with good neurological and cosmetic outcome.

Evaluation of Healed Status in Tuberculosis of Spine by Fluorodeoxyglucose-positron Emission Tomography/Computed Tomography and Contrast Magnetic Resonance Imaging.

BACKGROUND: The healed status (end-point of treatment) in tuberculosis (TB) spine is not defined; hence optimum antitubercular therapy (ATT) duration is unresolved. We, for the first time, prospectively evaluated the healed status in TB spine by fluorodeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT) and contrast magnetic resonance imaging (MRI) with the objective to define end-point of treatment in TB spine. MATERIALS AND METHODS: Thirty seven patients of TB spine diagnosed on clinicoradio imaging/cytology/histologically/molecular methods were enrolled, treated and were evaluated radiologically, by contrast MRI and FDG-PET/CT at 9 months. ATT was stopped on contrast MRI-based healing or absence of FDG uptake on PET-CT. ATT was continued in active/resolving lesion. Repeat evaluation was done at 12, 18, 24, and 30 months till healing is demonstrated. In this research work, we got contrast MRI and FDG-PET/CT done for the patients from government institution free of cost, so patients did not have to bear the burden of cost of these investigations. RESULTS: Twenty-eight patients achieved healed status out of which 11 demonstrated healed status on contrast MRI and FDG-PET/CT both, 6 were MRI active (contrast enhancement) but FDG-PET/CT healed, 2 were MRI healed but FDG-PET/CT active (soft-tissue standardized uptake value <2.0), 9 patients were MRI incompatible due to stainless steel implants (n = 6), and in 3 patients MRI could not be done due to financial constraints and were declared healed on FDG-PET/CT. FDG-PET/CT showed healed bone lesion in 28/28 (100%) and on MRI 13/19 (68.42%), respectively. We had 6 patients whose spine was stabilized with stainless steel implants where MRI could not be performed, MRI was useful in 13/25 cases (52%) to demonstrate healed lesion. 7, 6, 6, 5, 1, 2, and 1 cases achieved healed status at 9, 12, 18, 24, 30, 36, and 48 months of ATT intake, respectively. CONCLUSIONS: FDG-PET/CT is more useful to demonstrate the healed status than MRI and is the only imaging to demonstrate healed status when MRI could not be performed due to metallic implants. All patients achieved healed status at variable length of ATT intake; hence TB spine should be treated by ATT till healed status (end-point of treatment) is demonstrated by FDG-PET/CT (absence of FDG uptake) or contrast MRI.

[Feasibility study of preoperative percutaneous catheter drainage in the treatment of lumbar tuberculosis with psoas abscess].

OBJECTIVE: To investigate the effect of preoperative percutaneous drainage in lumbar tuberculosis with psoas abscess, through compare the clinical efficacy of two different methods. METHODS: Thirty-six patients with lumbar tuberculosis complicated with psoas abscess in corresponding with the inclusion criteria were admitted in Zhejiang Province Traditional Chinese Medicine Hospital from January 2015 to January 2017. The patients were divided into group A and group B according to the different therapeutic methods. All patients were given the standard anti tuberculosis treatment, and percutaneous catheter drainage was used in group A after admission immediately for psoas abscess before operation, while group B with no special treatment. At 3 weeks after anti tuberculosis treatment, 2 patients were excluded in group B, which had to postpone operation because of no reduction in erythrocyte sedimentation rate(ESR) and C reactive protein(CRP). Finally 34 patients were enrolled in this study. There were 18 cases in group A, including 10 males and 8 females, aged from 24 to 73 years old with an average of(42.5±10.2) years. There were 16 cases in group B, including 9 males and 7 females, aged from 23 to 75 years old with an average of(42.3±9.8) years. All patients were treated with posterior pedicle screw fixation, anterior debridement and bone graft fusion. Anterior surgery bleeding volume, operation time, anterior incision length, postoperative anus exhaust time, VAS score, Cobb angle, ESR, CRP changes and postoperative sinus formation were compared between two groups. RESULTS: All patients were followed up for 6 to 21 months with an average of 13 months. At the last follow-up, no mixed infection, tuberculosis recurrence, pedicle screw loosening and nail withdrawal were found. The average operative time, anterior surgery bleeding volume and anterior incision length of group A were less than that of group B(P<0.05). Postoperative anal exhaust time of group A was lower than that of group B(P<0.05). Improvement degree of ESR, CRP at 3 weeks after anti tuberculosis and 1 week after operation, group A was better than group B(P<0.05), and there was no significant difference between two groups in 1 month and 6 months after operation(P>0.05). There was 1 case sinus formation in group A and 5 cases in group B, there was significant difference in sinus formation rate between two groups (P<0.05). VAS score and Cobb angle at 1 month after operation was obvious improved(P<0.05), but there was no significant difference between two groups (P>0.05). Spinal cord nerve injury was obvious improved after operation, but there was no significant difference between two groups. CONCLUSIONS: Preoperative percutaneous catheter drainage is a safe and feasible method for the treatment of lumbar tuberculosis with psoas abscess. It can increase the effect of anti tuberculosis before operation, reduce the surgical trauma and reduce the incidence of postoperative complications. It can be recommended in clinical application.

Feasibility study of preoperative percutaneous catheter drainage in the treatment of lumbar tuberculosis with psoas abscess / 中国骨伤

OBJECTIVE@#To investigate the effect of preoperative percutaneous drainage in lumbar tuberculosis with psoas abscess, through compare the clinical efficacy of two different methods.@*METHODS@#Thirty-six patients with lumbar tuberculosis complicated with psoas abscess in corresponding with the inclusion criteria were admitted in Zhejiang Province Traditional Chinese Medicine Hospital from January 2015 to January 2017. The patients were divided into group A and group B according to the different therapeutic methods. All patients were given the standard anti tuberculosis treatment, and percutaneous catheter drainage was used in group A after admission immediately for psoas abscess before operation, while group B with no special treatment. At 3 weeks after anti tuberculosis treatment, 2 patients were excluded in group B, which had to postpone operation because of no reduction in erythrocyte sedimentation rate(ESR) and C reactive protein(CRP). Finally 34 patients were enrolled in this study. There were 18 cases in group A, including 10 males and 8 females, aged from 24 to 73 years old with an average of(42.5±10.2) years. There were 16 cases in group B, including 9 males and 7 females, aged from 23 to 75 years old with an average of(42.3±9.8) years. All patients were treated with posterior pedicle screw fixation, anterior debridement and bone graft fusion. Anterior surgery bleeding volume, operation time, anterior incision length, postoperative anus exhaust time, VAS score, Cobb angle, ESR, CRP changes and postoperative sinus formation were compared between two groups.@*RESULTS@#All patients were followed up for 6 to 21 months with an average of 13 months. At the last follow-up, no mixed infection, tuberculosis recurrence, pedicle screw loosening and nail withdrawal were found. The average operative time, anterior surgery bleeding volume and anterior incision length of group A were less than that of group B(0.05). There was 1 case sinus formation in group A and 5 cases in group B, there was significant difference in sinus formation rate between two groups (0.05). Spinal cord nerve injury was obvious improved after operation, but there was no significant difference between two groups.@*CONCLUSIONS@#Preoperative percutaneous catheter drainage is a safe and feasible method for the treatment of lumbar tuberculosis with psoas abscess. It can increase the effect of anti tuberculosis before operation, reduce the surgical trauma and reduce the incidence of postoperative complications. It can be recommended in clinical application.

Management of spinal tuberculosis - a metropolitan city based survey among orthopaedic and neurosurgeons.

OBJECTIVE: To explore the core understanding of spinal tuberculosis and its current management plans by orthopaedics and neurosurgeons. METHODS: The questionnaire-based study was conducted from July 2011 to November 2012 in Karachi and comprised consultant orthopaedics and neurosurgeons belonging to 4 private and 3 government tertiary care teaching hospitals and having a minimum five years of post-fellowship experience. A pre-designed questionnaire was used to explore the current practice in spinal tuberculosis regarding its clinical presentation, diagnosis and treatment. SPSS 15 was used for statistical analysis. RESULTS: There were 48 subjects in the study; 24(50%) orthopaedic surgeons and 24(50%) neurosurgeons. According to 44(91.70%) respondents, common age for spinal tuberculosis was second and third decades of life, and 37(77.08%)reported refractory back pain with or without neurological deficits as the commonest clinical finding. Typical magnetic resonance imaging findings was the uniform observation of all the 48(100%) respondents. Diagnosis was made by histopathological findings by 39(81.25%) respondents. Anti-tuberculosis therapy was started empirically on the basis of clinical, laboratory and radiological findings by 33(68.75%) respondents. Those in favour of giving anti-tuberculosis therapy for 18 months were 32(66.7%) respondents, and 33(68.75%) thought surgery does not expedite recovery. CONCLUSIONS: Extremely variable tools of diagnosis and diversified approaches for the treatment are alarming signs for the possible development of resistant strains and complications of spinal tuberculosis.

Diffusion tensor imaging observation in Pott's spine with or without neurological deficit.

BACKGROUND: Diffusion tensor imaging (DTI) is based upon the phenomenon of water diffusion known as "Brownian motion." DTI can detect changes in compressed spinal cord earlier than magnetic resonance imaging and is more sensitive to subtle pathological changes of the spinal cord. DTI observation in compressed and noncompressed spinal cord in tuberculosis (TB) spine is not described. This study presents observations in Pott's spine patients with or without neural deficit. MATERIALS AND METHODS: Thirty consecutive cases of TB spine with mean age of 32.1 years of either sexes with paradiscal lesion, with/without paraplegia divided into two groups: Group A: (n = 15) without paraplegia and group B: (n = 15) with paraplegia were evaluated by DTI. The average fractional anisotropy (FA) and mean diffusivity (MD) values were calculated at 3 different sites, above the lesion (SOL)/normal, at the lesion and below SOL for both groups and mean was compared. Visual impression of tractography was done to document changes in spinal tracts. RESULTS: The mean canal encroachment in group A was 39.60% and group B 44.4% (insignificant). Group A mean FA values above SOL, at the lesion and below SOL were 0.608 ± 0.09, 0.554 ± 0.14, and 0.501 ± 0.16 respectively. For group B mean FA values above SOL, at the lesion and below SOL were 0.628 ± 0.09, 0.614 ± 0.12 and 0.487 ± 0.15 respectively. There was a significant difference in mean FA above the SOL as compared to the mean FA at and below SOL. P value above versus below the SOL was statistically significant for both groups (0.04), but P value for at versus below the SOL (0.01) was statistically significant only in group B. On tractography, disruption of fiber tract at SOL was found in 14/15 (93.3%) cases of group A and 14/15 cases (93.3%) of group B (6/6 grade 4, 3/3 grade 3 and 5/6 grade 2 paraplegic cases). CONCLUSION: The FA and MD above the lesion were same as reported for healthy volunteer hence can be taken as control. FA increases, and MD decreases at SOL in severe grade of paraplegia because of epidural collection while in milder grade, both decrease. In group A (without neurological deficit), mean FA and MD in patients with and without canal encroachment was similar. On tractography, both groups A and B (with or without neurological deficit) showed disruption of fiber tract at SOL and thickness of distally traced spinal cord was appreciably less than the upper cord. FA and MD could not differentiate between various grades of paraplegia. Although the number of patients in each group are small.

Efficacy of directly observed treatment short-course intermittent regimen in spinal tuberculosis.

BACKGROUND: Most important cause of treatment failure and emergence of drug resistance in the treatment of tuberculosis is noncompliance. Compliance can be improved by direct observation of drug intake, intermittent therapy, and short-course treatment. The efficacy of Directly Observed Treatment Short Course (DOTS) strategy advocated by World Health Organization (WHO) in spinal tuberculosis is not yet proven. We conducted a prospective clinical study on a consecutive series of patients with spinal tuberculosis treated by Category I Revised National Tuberculosis Control Programme (RNTCP) regimen based on DOTS strategy of WHO from 2004 to 2007 to evaluate the efficacy. MATERIALS AND METHODS: Forty-nine consecutive patients of spinal tuberculosis were treated with short-course intermittent chemotherapy under Category I RNTCP/DOTS strategy. Patients were followed up for a minimum period of 2 years. Surgery was done if the patient presented with significant neurologic deficit or when the drug treatment failed. Outcome was assessed by clinical, radiologic, and laboratory criteria, and graded into excellent, good, fair, and poor based on various parameters. RESULTS: 63.4% (n=26) of the patients had excellent results. 14.6% (n=6) of the patients had good and fair results. Three patients (7.3%) had poor results 48.7% (n=20) of the patients had but only one of them was severe enough to warrant change of drug. CONCLUSIONS: Efficacy of DOTS was comparable with other standard regimens. There was a significant reduction in adverse side effects when compared with daily regimens. Study showed that the outcome was better in those treated early.

Operative treatment to spinal multi-level tuberculosis / 中国康复理论与实践

@#ObjectiveTo investigate the effect of operation treating spinal multi-level tuberculosis.Methods45 patients with multi-level spine tuberculosis were treated with debridement completely and anterior or lateral-anterior intervertebrae autograft. Of them, 5 patients added to anterior instrumentation.Results45 patients had been followed up for 12 to 40 months.The back pain of 40 cases were relieved within 5 weeks after operation, erythrocyte sedimentation rate decreased 3 weeks after operation. 38 patients who involved in kyphosis decreased their kyphosis mostly and only one patient lost 3 degrees in follow-up.15 patients who involved in neurological deficits improved one or two grades (Frankel). Grafts fused in 44 patients and there were no recurrent in follow-up.Conclusions Operative treatment is efficacious to multi-level body spine tuberculosis.

APPLICATION OF INTRAVERTEBRAL PEDICLE FIXATION SYSTEM IN SURGICAL MANAGEMENT OF SPINAL TUBERCULOSIS / 解放军医学杂志

Posterior transpedicle instrumental fixation and anterior arthrodesis were performed in 34 patients with spinal tuberculosis.Antituberculous chemotherapy was qiven for nine months postoperatively, and the surgical outcomes were followed up for three to five years.All the patients were cured and there was no recurrence two years after stopping chemotherapy.Tubercular kyphosis was 24?preoperatively and 9?postoperatively, and deformity correction was maintained during the follow up period.Interbody fusion was achieved in all the patients after surgery,four months for one segment fusion, six months for two segments fusion.It is concluded that posterior instrumental stabilization and anterior interbody fusion are helpful in providing rigid stabilization,correcting or preventing progression of kyphosis, and that transpedicle instrumental fixation can accelerate interbody fusion, shorten chemotherapy course and improve its cucative ratio.

The Analysis of Spinal Tuberculosis by Imaging / 实用放射学杂志

Objective To determine the potential value of imaging for spinal tuberculosis. Methods 180 patients proved as spinal tuberculosis by operation or clinical follow who underwent X-ray film, CT and MRI were reviewed. They were classified A, B or C in term of imaging and clinical symptom. A was the normal of X- ray film and positive of CT or MRI. B was positive of X-ray film, CT and MRI. C was with the neurological symptoms. Results 40 patients ( 40/180 ) were categorized as A . They had short duration (