Four-rod Technique Stabilization after Pedicle Subtraction Osteotomy (PSO) for the Treatment of Thoracolumbar Hyperkyphosis Secondary to Pott Disease: A Two-Year Follow-Up Case Report

Pedicle subtraction osteotomy (PSO) is a powerful tool for themanagement of sagittal misalignment. However, this procedure has a high rate of implant failure, particularly rod breakages. The four-rod technique diminishes this complication in the lumbar spine. The aim of the present study is to provide a case report regarding PSO and fourrod technique stabilization in the treatment of short-angle hyperkyphosis in the thoracolumbar (TL) junction. The authors describe the case of a patient with TL hyperkyphosis secondary to spinal tuberculosis treated with L1 PSO and fixation with a four-rod technique. There were no major surgical complications. The self-reported quality of life questionnaires (the Short-Form Health Survey 36 [SF-36] and the Oswestry disability index) and radiological parameters were assessed preoperatively, as well as 6, 12 and 24 months after surgery, and they showed considerable and sustained improvements in pain control and quality of life. No hardware failure was observed at the two-year follow-up.

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.

Abcès fessier révélateur d'un mal de Pott. A propos d'un cas

Introduction : Le mal de Pott est rare en Occident mais s'observe encore en pays en développement. Le tableau clinique associe souvent une altération de l'état général, des rachialgies, des radiculalgies et abcès du psoas ainsi que des lésions radiologiques disco-vertébrales. L'abcès fessier est un mode de révélation peu habituel. Nous rapportons ici un cas de mal de Pott lombaire révélé par un abcès fessier traînant. Observation : Un sujet masculin de 34 ans, instituteur, sans antécédent particulier, sans notion de contage tuberculeux, a été reçu pour abcès de la fesse évoluant depuis environ 5,5 mois, plusieurs fois incisé sans succès. Le pus était épais, les radiographies pulmonaires et du rachis lombo-sacré étaient normales. L'intradermoréaction à la tuberculine (IDR) et la cherche de Bacilles Acido-Alcoolo Résistants (BAAR) étaient fortement positives, la culture du pus avait isolé du Mycobacterium tuberculosis. Le pus a été drainé et le patient mis sous antibiotiques spécifiques. L'évolution a été favorable avec cicatrisation de la plaie. Discussion : Le mal de Pott reste encore d'actualité dans nos contrées. Le tableau clinique peut être trompeur, un abcès traînant doit y faire penser. L'absence de signes radiologiques disco-vertébraux ne doit pas dérouter le praticien. L'IDR et la recherche de BAAR ne sont pas toujours positives. La tomodensitométrie, l'Imagerie par Résonance Magnétique et l'examen anatomo-pathologique sont d'un grand secours lorsque leur réalisation est possible

Tuberculosis ineection might increase the risk f invasive candidiasis in an immmunocompetent patient / Tuberculose pode aumentar o risco de candidíase invasiva em paciente imunocompetente

Deep Candida infections commonly occur in immunosuppressed patients. A rare case of a multiple deep organ infection with Candida albicans and spinal tuberculosis was reported in a healthy young man. The 19-year-old man complained of month-long fever and lower back pain. He also had a history of scalded mouth syndrome. Coinfection with Mycobacterium tuberculosis and Candida albicans was diagnosed using the culture of aspirates from different regions. Symptoms improved considerably after antifungal and antituberculous therapy. This case illustrates that infection with tuberculosis might impair the host's immune system and increase the risk of invasive candidiasis in an immunocompetent patient.

As infecções profundas por Candida ocorrem geralmente em pacientes imunossuprimidos. Relatamos caso raro de infecções profundas em múltiplos órgãos por Candida albicans e neuro tuberculose em homem jovem saudável. Um jovem de 19 anos de idade queixou-se de febre e lombalgia há um mês. Relatava ainda histórico de síndrome da boca escaldada. Foi diagnosticada co-infecção por Mycobacterium tuberculosis e Candida albicans em cultura do aspirado de diferentes regiões do organismo. Os sintomas melhoraram significativamente após a terapia antifúngica e antituberculosa. Este caso é apresentado para mostrar que a tuberculose pode prejudicar o sistema imune do hospedeiro e aumentar o risco de candidíase invasiva em paciente imunocompetente.

Absceso del psoas tuberculoso, debut en paciente inmunodeprimido: presentación de un caso / Tuberculous psoas abscess, debut in immunocompromised patient: case report

INTRODUCCIÓN: El absceso del psoas (AP) es una patología infrecuente de difícil diagnóstico. Se clasifica en primario o secundario teniendo como factor de riesgo común la inmunodeficiencia. PRESENTACIÓN DEL CASO: Paciente masculino de 40 años sin antecedentes mórbidos. Consulta por cuadro de un mes de evolución caracterizado por dolor lumbar derecho que aumenta al flexionar el muslo ipsilateral. Se asocia compromiso del estado general, dolor abdominal, sensación febril no cuantificada y bradipsiquia. La Tomografía computada (TC) de abdomen y pelvis mostró hipodensidad en relación al músculo psoas derecho diagnosticándose AP primario. El paciente evoluciona con shock séptico, siendo manejado con antibióticos de amplio espectro sin mejoría. Se realizan exámenes generales, Punción lumbar (PL) y Test de Elisa para VIH (TEVIH), resultando la PL compatible con Tuberculosis meníngea y el TE positivo. Se inició tratamiento empírico anti-tísico en espera del cultivo de Koch. Paciente evoluciona favorablemente. Se realiza una TC de control luego de dos semanas de tratamiento, que muestra imagen similar a la inicial, agregándose compromiso vertebral L4-L5, diagnosticándose Enfermedad de Pott (EP) y AP secundario. Se realiza punción y drenaje del absceso y se toma cultivo de Koch que resulta positivo. Paciente evoluciona asintomático, con buena respuesta al tratamiento. DISCUSIÓN: El AP secundario a EP es una entidad poco sospechada. Sin embargo, con métodos diagnósticos como la TC es posible realizar un diagnóstico precoz. Mycobacterium tuberculosis es una causa infrecuente de abscesos del psoas, pero debido al aumento de la población VIH positiva, es probable que aumente su incidencia.

INTRODUCTION: Psoas abscess is an uncommon disease with difficult diagnosis. It can be primary or secondary; immunodeficiency is among risk factors. CASE REPORT: 40 year-old male with no past medical history. He presented to the emergency department with right lumbar pain worsened with flexion of ipsilateral thigh. Involvement of general condition, abdominal pain, unquantified fever and bradypsychia were also present. Computed tomography (CT) scan of the abdomen and pelvis showed an hypodense lesion in the right psoas muscle. Primary psoas abscess was first diagnostic impression. Patient evolved to septic shock and was treated with broad spectrum antibiotics without improvement. General examinations were performed, lumbar puncture supported meningeal tuberculosis and HIV ELISA test was positive. Empirical quintuple therapy for tuberculosis was started before cerebrospinal fluid culture results, with favorable clinical evolution. Control CT scan was similar compared to first one but with L4 – L5 vertebrae involvement. Pott disease and secondary psoas abscess was diagnosed. Koch’s Bacillus culture from abscess puncture were positive. Patient had clinical improvement with antituberculous therapy. DISCUSSION: Psoas abscess is a rarely suspected patology, but with diagnostic methods as CT is possible to make an early diagnosis. Even though Mycobacterium tuberculosis is a rarer cause of psoas abscess, but more cases are expected due to the increased incidence of HIV – positive patients, more cases are expected eventually.

Surgical Treatment of Thoracic Outlet Syndrome Secondary to Clavicular Malunion

According to the literature, thoracic outlet syndrome (TOS) secondary to the malunion of displaced fractures of the clavicle is rare. Various surgical methods, including simple neurolysis, resection of the first rib or clavicle and corrective osteotomy, have been reported. We report a case of TOS secondary to malunion of the clavicle that was treated by an anterior and middle scalenectomy without a rib resection.

A Case of Postoperative Tuberculous Spondylitis with a Bizarre Course

Postoperative infections following spine surgery are usually attributable to bacterial organisms. Staphylococcus aureus is known to be the most common single pathogen leading to this infection, and the number of infections caused by methicillin-resistant Staphylococcus aureus is increasing. However, there is a paucity of literature addressing postoperative infection with Mycobacterium tuberculosis. We encountered a case of tuberculous spondylitis after spine surgery. A man had fever with low back pain three weeks after posterior interbody fusion with instrumentation for a herniated intervertebral disc at the L4-L5 level. He had been treated with antibiotics for an extended period of time under the impression that he had a bacterial infection, but his symptoms and laboratory data had not improved. Polymerase chain reaction for Mycobacterium tuberculosis turned out to be positive. The patient's symptoms finally improved when he was treated with antituberculosis medication.

Mal de Pott: uma doença milenar em um novo século / Pott's disease: an ancient disease in a new century

A tuberculose espinhal, também conhecida como Mal de Pott ou Doença de Pott, caracteriza-se como a forma mais frequente de tuberculose extrapulmonar. Apresentamos aqui o caso de uma paciente encaminhada ao Serviço de Neurologia do Hospital de Clínicas de Porto Alegre com um quadro de dois meses de evolução, apresentando sintomas de compressão medular. O diagnóstico de tuberculose espinhal foi realizado por punção guiada por tomografia computadorizada e a paciente foi submetida à drenagem do abscesso. Concomitantemente, foi iniciado o tratamento com RHZ e a paciente evoluiu com melhora dos sintomas neurológicos. Esse caso ilustra que mesmo pacientes com alterações neurológicas importantes devido à tuberculose medular podem apresentar melhora significativa com tratamento.

Spinal tuberculosis, also known as Pott's disease, is the most common form of extra-pulmonary tuberculosis. We report on a patient referred to the Division of Neurology of Hospital de Clínicas de Porto Alegre presenting with spinal cord compression symptoms for two months. The diagnosis of spinal tuberculosis was rapidly done by a computerized tomography guided biopsy. The patient was submitted to abscess surgical draining and complementary RHZ treatment, with recovery of neurological symptoms. This case illustrates that even patients with severe neurological deficits due to spinal tuberculosis may have a good outcome with the appropriate treatment.

Traitement medical du mal de Pott: a propos des 18 cas

Introduction: la tuberculose vertebrale est de loin la localisation osteo-articulaire la plus frequente ; son traitement est de moins en moins chirurgical; la duree et les modalites du traitement medical restent cependant sujettes a discussion.Le but de ce travail est de proposer une attitude therapeutique standardisee pour le mal de Pott. Patients et methodes : Les acteurs rapportent une etude retrospective de 18 cas de mal de pott. Resultats : L'age moyen etait de 51 ans .Tous les malades ont beneficie d'un traitement medical ; aucune indication chirurgical n'a ete portee.l'imagerie par resonance magnetique et la biopsie sous scanner ont permis d'eviter les abords churirgicaux a visee diagnostic.La chimiotherapie consistait en une phase d'attaque comprenant quatre antituberculeux d'une duree moyenne de 5 mois ; suivi d'une phase d'entretien associant uniquement deux antituberculeux majeurs en prise quotidienne et d'une duree moyenne de 11 mois .Huit patients ont eu une immobilisation rachidienne. Apres un recul moyen de 36 mois l'evolution clinique et anatomique etait favorable pour tous les maladies. Aucune aggravation des troubles neurologiques n'a ete notee. Conclusion: traitement medical antituberculeux bien conduit est toujours efficace surtout si le diagnostic est assez precoce et permet ainsi d'eviter le recours a la chirurgie assez laborieuse et dont les resultats ne sont pas encourangeants

Tuberculosis of lower cervical spine--a prospective study.

Tuberculosis was a leading cause of mortality in the beginning of the twentieth century. Tuberculosis of the spine is one of the oldest diseases afflicting humans. A prospective study was carried out among 45 cases of tuberculosis of lower cervical spine and an attempt was made to highlight some of its features. Pain and stiffness were important and dominant complaints. Commonest level affected was C5-C6 vertebrae. The overall incidence of cord compression was 37.8 per cent. The commonest modality of treatment was antituberculous drugs, anterior excision of diseased bone and tricortical bone grafting. This regime rapidly relieves pain, compressive respiratory symptoms due to large abscess and neurological deficit.

Tuberculose vertebral (doença de Pott) associada a abscesso de psoas: relato de dois casos e revisão da literatura / Spinal tuberculosis (Pott's disease) associated to psoas abscess: report of two cases and a literature review

A tuberculose é uma das principais doenças infecciosas de acometimento mundial com 3,9 milhões de casos notificados no mundo, em 2002. A forma esquelética pode corresponder a 3 por cento do número total de casos, sendo 50 por cento devido à tuberculose vertebral. O abscesso de psoas é uma entidade clínica rara com aproximadamente 12 casos relatados por ano na literatura médica e tem no Mycobacterium tuberculosis, um dos seus agentes etiológicos. O objetivo deste trabalho é relatar dois casos de tuberculose vertebral associada a abscesso de psoas atendidos em nosso serviço, bem como uma revisão da literatura.

Psoas abscess secondary to Pott's disease an unusual presentation in a young child

Psoas abscess in neonates and infants are rare. Primary psoas abscesses are said to be more common in young children. Limping, fever and abdominal pain has been described to be the way psoas abscesses usually present. The authors describe the unusual presentation and successful treatment of a young child with a unilateral psoas abscess secondary to advanced spondylodiscitis

Pregnancy complicated by paraplegia due to Pott's spine.

Pott's paraplegia associated with pregnancy is a serious problem and is difficult to treat, as not much literature is available regarding its management. Such a case, where the multidisciplinary team approach gave good neonatal and maternal outcome, is reported here.

Espondilodiscitis. Análisis de una serie de 25 casos / Spondylodiscitis. Analysis of 25 cases

BACKGROUND: Spondylodiscitis is a rare but prolonged inflammation of two adjacent vertebral bodies and the disk in between. AIM: To report the clinical features of a series of patients with spondylodiscitis. MATERIAL AND METHODS: A retrospective analysis of medical records of patients with spondylitis, identified between 1989 and 2002. RESULTS: A total of 25 cases were identified, 15 female, aged 49.8 years as a mean. Their mean evolution before admission was 4.3 months. Main complaints were back or radicular pain. Mild anemia was present in most patients. Mean erythrocyte sedimentation rate and C reactive protein values were 66 mm/h and 60 mg/L, respectively. Forty four percent of patients had neurological complications. Vertebral computed tomography and scintigraphic studies were done in 72 per cent of patients, but magnetic resonance imaging was done only in 4 (16 per cent). In 18 patients, a tissue sample for pathological and microbiological analysis, was obtained by imaging guiding or surgically. Tuberculosis, diagnosed on pathology, was the leading cause of spondylitis in nine cases (36 per cent), followed by Staphylococcus aureus infection in five (20 per cent). Other agents found were E coli and group D Streptococcus (one each). Age, symptoms, evolution time and different laboratory parameters did not differ between patients with tuberculosis and patients with other causes. A microbiological cause was not established in 36 per cent of cases. Most patients evolved satisfactorily and recovered from neurological complications (88 per cent). One patient with tuberculosis did not improve after prolonged treatment and 2 patients infected with S aureus died (8 per cent). CONCLUSIONS: Spondylodiscitis is associated to a diversity of microbial agents and in most cases has a favorable prognosis.

Cervico thoracic junction spinal tuberculosis presenting as radiculopathy.

A case of cervico thoracic junctional area spinal tuberculosis presenting as painful radiculitis of the upper extremity is reported. The predominant symptom of radicular pain and muscle weakness in the hand, along with a claw deformity, led to considerable delay in diagnosis. The presence of advanced bone destruction with severe instability was demonstrated on the MRI scan done later. Surgical management by radical anterior debridement and fusion, along with chemotherapy, led to resolution of the upper extremity symptoms. The brachial plexus radiculopathy secondary to tuberculosis has not been reported. The absence of myelopathic signs even in the presence of advanced bone destruction, thecal compression and instability is uncommon in adults.

Non traumatic paraparesis: aetiological, clinical and radiological profile.

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.