Magnetic resonance imaging features for differentiating tuberculous from pyogenic spondylitis: a meta-analysis.

OBJECTIVE: To perform a meta-analysis comparing the MRI features of tuberculous and pyogenic spondylitis, using histopathological results and/or blood culture as the standard reference. MATERIALS AND METHODS: PubMed, Embase, Web of Science, and Cochrane Library were searched for English-language studies on the MRI features of tuberculous and pyogenic spondylitis published between January 2010 and February 2023. Risk for bias and concerns regarding applicability were assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Pooled MRI features' proportions were calculated using a bivariate random-effects model. RESULTS: Thirty-two studies met the inclusion criteria: 21 for tuberculous spondylitis, three for pyogenic spondylitis, and eight for both. Of the nine informative MRI features comparing tuberculous spondylitis to pyogenic spondylitis, involvement of ≥ 2 vertebral bodies (92% vs. 88%, P = .004), epidural extension (77% vs. 25%, P < .001), paravertebral collection (91% vs. 84%, P < .001), subligamentous spread (93% vs. 24%, P < .001), thin and regular abscess wall (94% vs. 18%, P < .001), vertebral collapse (68% vs. 24%, P < .001), and kyphosis (39% vs. 3%, P < .01) were more suggestive of tuberculous spondylitis, while disc signal change (82% vs. 95%, P < .001) and disc height loss (22% vs. 59%, P < .001) were more suggestive of pyogenic spondylitis. CONCLUSION: Involvement of ≥ 2 vertebral vertebral bodies, soft tissue attribution, thin and regular abscess wall, vertebral collapse, and kyphosis were MRI features more common in tuberculous spondylitis, while disc signal change and height loss were more common in pyogenic spondylitis.

Activity induced worsening of a tuberculous process in the vertebral column of a Late Bronze Age female from Liushui, Xinjiang (China)?

The partial skeleton of a 22-24-year old female from Liushui, Southern Silk Road, Xinjiang (China) was analyzed using morphological and biochemical methods. The most striking finding in this individual of a Late Bronze Age mounted nomadic population was the complete ossification of the caudal vertebral column including parts of the ligaments of this region due to chronic tuberculosis (Pott's disease). The morphological diagnosis is definitely confirmed by the results of the proteomic analysis. The bacterial protein Ag85 and, for the first time in archaeological skeletal remains, also ESAT-6 was detected, which are typical for Mycobacterium tuberculosis. Extremely intense physical stress aggravated the pathological kyphosis primarily caused by the tuberculous process and promoted dislocation of the caudal thoracic versus the lumbar vertebrae. The fate of this young female suffering from tuberculosis and the consequences of this extreme physical stress characterize the harsh living conditions of typical prehistoric population of mounted nomadic pastoralists.

A diagnostic model for differentiating tuberculous spondylitis from pyogenic spondylitis: a retrospective case-control study.

The purpose of this study was to describe and compare the clinical data, laboratory examination and imaging examination of tuberculous spondylitis (TS) and pyogenic spondylitis (PS), and to provide ideas for diagnosis and treatment intervention. The patients with TS or PS diagnosed by pathology who first occurred in our hospital from September 2018 to November 2021 were studied retrospectively. The clinical data, laboratory results and imaging findings of the two groups were analyzed and compared. The diagnostic model was constructed by binary logistic regression. In addition, an external validation group was used to verify the effectiveness of the diagnostic model. A total of 112 patients were included, including 65 cases of TS with an average age of 49 ± 15 years, 47 cases of PS with an average of 56 ± 10 years. The PS group had a significantly older age than the TS group (P = 0.005). In laboratory examination, there were significant differences in WBC, neutrophil (N), lymphocyte (L), ESR, CRP, fibrinogen (FIB), serum albumin (A) and sodium (Na). The difference was also statistically significant in the comparison of imaging examinations at epidural abscesses, paravertebral abscesses, spinal cord compression, involvement of cervical, lumbar and thoracic vertebrae. This study constructed a diagnostic model, which was Y (value of TS > 0.5, value of PS < 0.5) = 1.251 * X1 (thoracic vertebrae involved = 1, thoracic vertebrae uninvolved = 0) + 2.021 * X2 (paravertebral abscesses = 1, no paravertebral abscess = 0) + 2.432 * X3 (spinal cord compression = 1, no spinal cord compression = 0) + 0.18 * X4 (value of serum A)-4.209 * X5 (cervical vertebrae involved = 1, cervical vertebrae uninvolved = 0)-0.02 * X6 (value of ESR)-0.806 * X7 (value of FIB)-3.36. Furthermore, the diagnostic model was validated using an external validation group, indicating a certain value in diagnosing TS and PS. This study puts forward a diagnostic model for the diagnosis of TS and PS in spinal infection for the first time, which has potential guiding value in the diagnosis of them and provides a certain reference for clinical work.

Lumbosacral tuberculosis, a rare manifestation of Pott's disease - How identified human skeletons from the pre-antibiotic era can be used as reference cases to establish a palaeopathological diagnosis of tuberculosis.

The macromorphological examination of identified human osteological collections from the pre-antibiotic era (e.g., Terry Collection) can provide invaluable information about the skeletal manifestations of tuberculosis (TB) in individuals who did not receive pharmaceutical therapy. With analysis of such collections, new diagnostic criteria for TB can be recognised which can be used in palaeopathological interpretation. The aim of our paper is to provide a reference and aid for the identification of TB in past populations by demonstrating and discussing in detail the vertebral alterations indicative of one of its rare skeletal manifestations, lumbosacral TB. These changes were detected in two individuals from the Terry Collection (Terry No. 760 and Terry No. 1093). These two case studies furnish palaeopathologists with a stronger basis for diagnosing lumbosacral TB in skeletons which exhibit similar vertebral lesions from osteoarchaeological series. To illustrate this, an archaeological case from Hungary (KK146) is also presented, displaying vertebral alterations resembling that of the two cases from the Terry Collection. Through the demonstrated case studies, we can derive a better insight into the disease experience of people who lived in the past and suffered from TB.

A comparative study of a rabbit spinal tuberculosis model constructed by local direct infection via the posterior lateral approach.

The present study aims to establish a method of constructing a New Zealand rabbit spinal tuberculosis model by direct local infusion of M. tuberculosis H37Rv strain into the intervertebral disc space through the posterior lateral approach. Sixty-six New Zealand rabbits were pretreated with complete Freund's adjuvant and randomly divided into 4 group: the posterolateral approach model group (Group A, 25), ventral transverse process approach model group (Group B, 25), control group (Group C, 10), and blank group (Group D, 6). In Groups A and B, the bone holes were filled with gelatin sponge after drilling, and the local area was directly infused with 0.1 ml of M. tuberculosis H37Rv strain suspension. In Group C, the gelatin sponge was filled through the posterolateral approach and the local area was infused with 0.1 ml of normal saline suspension. In Group D, No specific treatment was performed. The general conditions of the experimental rabbits in each group were compared to those of a control group; the degree of vertebral body exposure, incision length, and complications of the two methods were compared; and the tuberculosis models were evaluated by imaging, histopathology, and bacterial culture. In Group A, the lateral side of the vertebral body was well exposed, the damage was mild, and no peritoneal rupture or gastrointestinal complications were observed. In Group B, the ventral side of the vertebral body and the intervertebral disc were exposed, and abdominal complications were more likely to occur. The survival rates of the experimental rabbits at 8 weeks after surgery were 92.0% in Group A, 88.00% in Group B, 90.0% in Group C, and 100% in Group D. MRI examinations showed that in Group A, the positive rate of radiographic bone findings was 86.9% at 4 weeks after surgery and 100% at 8 weeks after surgery; in Group B, the positive rate of radiographic bone findings was 78.2% at 4 weeks after surgery and 95.4% at 8 weeks after surgery. There was no significant difference between Groups A and B in the radiographic bone findings rate detected by the same imaging method at the same time point (P > 0.05). Eight weeks after surgery, bone destruction, paravertebral abscess, and caseous necrosis occurred in the vertebral bodies of surviving rabbits in Groups A and B. The BacT/ALERT 3D rapid culture system was used to culture the pus in the lesion, and the results showed that the positive rate of tuberculosis was 52.17% in Group A and 54.54% in Group B, and the difference was not statistically significant (P > 0.05). After pretreatment with complete Freund's adjuvant, direct infusion of the H37Rv strain of M. tuberculosis into the intervertebral disc space of New Zealand rabbits via the posterolateral approach and the ventral transverse process approach can successfully establish rabbit spinal tuberculosis models.

Positivity rates of mycobacterial culture in patients with tuberculous spondylitis according to methods and sites of biopsies: An analysis of 206 cases.

OBJECTIVES: We aimed to evaluate the mycobacterial culture positivity rates according to biopsy methods and sites in patients with tuberculous spondylitis (TS) and identify which tissues are the best sites for the diagnosis of TS. METHODS: We retrospectively identified and reviewed medical records of all patients with TS in three university-affiliated hospitals in the Republic of Korea from January 2003 to December 2020. TS was diagnosed by culture or histopathologic examination of vertebral bodies or paraspinal tissues and characteristic clinical and radiologic features. Patients with TS who received a needle biopsy or underwent surgical biopsy were investigated. The sites of needle biopsy were classified as vertebral bodies or paraspinal tissues. RESULTS: During the study period, 206 tissues from 200 patients with TS were included in the analysis. The culture positivity rates of vertebral bodies obtained by needle biopsy, paraspinal tissues obtained by needle biopsy, and tissues obtained by surgery were 69.0%, 85.3%, and 83.2%, respectively. Multivariate logistic regression identified that paraspinal tissues as biopsy sites were independently associated with mycobacterial culture positivity in TS undergoing needle biopsy (adjusted odds ratio, 3.68; 95% confidence interval: 1.13-11.99, P = 0.030). CONCLUSIONS: We demonstrated that the positivity rates of mycobacterial culture in TS were 69.0-85.3%. Paraspinal tissues as biopsy sites were significantly associated with culture positivity in needle biopsy, suggesting that targeting paraspinal tissues during needle biopsy may be the best method for diagnosing TS.

Analysis of Clinical Characteristics of 556 Spinal Tuberculosis Patients in Two Tertiary Teaching Hospitals in Guangxi Province.

Spinal tuberculosis (STB), which accounts for half of musculoskeletal tuberculosis, is among the leading causes of extrapulmonary tuberculosis. Guangxi Province, located in southern China, is among the most severely affected provinces in China. In this study, we collected and analyzed data from 2 Class-A tertiary teaching hospitals in Nanning City, Guangxi Province, from 2011 to 2019, with the aim of providing reference points for the prevention, diagnosis, treatment, and prognosis analysis of STB, using the epidemiological characteristics of 556 STB cases. Our results revealed that males had a slightly higher incidence (50.17%) compared to females (49.83%), with 64.93% of cases falling between the ages of 18 and 45 years. Cases from rural communities accounted for 63.49% of the reviewed cases. The average time between onset of symptoms and hospitalization was 18.0 months (range: 1 day-220 months). The most commonly reported symptoms were lower back pain (78.60%), radicular pain (51.98%), and systemic toxemia (43.53%). Additionally, 53.98% of the reviewed cases had varying degrees of neurological impairment. The main pathological lesion locations were the lumbar spine (43.53%) and thoracic spine (32.55%). Among them, 72.66% of cases involved at least 2 vertebral segments, and 62.77% of cases presented with paravertebral abscesses. Among the cases reviewed, 90.65% underwent antituberculosis chemotherapy prior to surgery. Following treatment, the cure rate was 78.41%, while 3.78% of patients had postoperative relapse. There were cases of concomitant illnesses among the cases reviewed, 40.65% of patients also had pulmonary tuberculosis, 15.29% had hepatitis B, 13.30% had diabetes, and 7.91% had hypertension. Our results still demonstrate that spinal tuberculosis remains a serious public health problem in Guangxi Province. Thus, preventive measures should be directed towards rural residents with comorbidities such as the elderly and diabetic.

The efficacy of single posterior debridement, bone grafting and instrumentation for the treatment of thoracic spinal tuberculosis.

The aim of this study was to investigate the clinical efficacy of single posterior debridement, bone grafting and instrumentation for the treatment of thoracic spinal tuberculosis in adult patients. A retrospective analysis was conducted between June 2013 and September 2017of 88 adult patients with thoracic spinal tuberculosis. All patients were treated with single posterior debridement, bone grafting and instrumentation. The clinical manifestations and laboratory and imageological results were subsequently analysed. All patients were followed for 40.6 ± 4.1 months (range, 36-48 m). Bony fusion was achieved in all bone grafts of thoracic vertebrae. The visual analogue scale scores, erythrocyte sedimentation rate and C-reactive protein levels 6 weeks after surgery and at the final follow up were significantly lower than the preoperative levels (P < 0.05). The postoperative and final follow up kyphosis angles were both significantly smaller than the preoperative kyphosis angles (P < 0.05). The postoperative angle correction rate reached 81.5% and the postoperative angle loss reached only 4.1%. At the last follow up, American Spinal Injury Association improvement was significant, compared with the preoperative levels (P < 0.05). The single posterior approach can achieve satisfactory clinical outcomes in the treatment of thoracic spinal tuberculosis.

Magnetic resonance imaging evaluation of posterior spinal tuberculosis: a cross-sectional study.

BACKGROUND: Isolated posterior spinal (element) tuberculosis (TB) is uncommon compared to classical anterior spinal or para-discal TB. Here, we report magnetic resonance imaging (MRI) findings of posterior spinal TB in 19 patients without involvement of the vertebral body and intervertebral disc. PURPOSE: To evaluate the MRI findings in isolated posterior spinal (element) TB. MATERIAL AND METHODS: Clinical and MRI data of 19 patients of isolated posterior spinal TB were retrospectively evaluated. RESULTS: Of the 19 patients, group A comprised 4 (21%) patients with rapid onset lower limb weakness and pyramidal signs while group B comprised 15 (79%) patients without any neurological deficit. Lumbar vertebrae commonly affected 9 (47.4%) patients followed by dorsal vertebrae in 8 (42.1%) patients and cervical vertebrae in 2 (10.5%) patients. The pedicle was most commonly involved in 12 (63.2%) patients followed by the lamina in 11 (58%) patients, and spinous process and facet joint in 6 (31.6%) patients each. Extra-spinal inflammation/pyomyositis/paraspinal abscess was found in 13 (68.4%) patients followed by epidural abscess 3 (15.8%) patients and both extra spinal inflammation and epidural abscess in 3 (15.8%) patients (15.8%). Compressive cord myelopathy was observed in 4 (21%) patients, where three patients underwent emergency decompression laminectomy and the remaining 16 patients were treated conservatively with anti-tubercular therapy. CONCLUSION: Initial diagnosis of isolated posterior element TB is challenging and requires a high index of suspicion. Early diagnosis of isolated posterior spinal TB is important as early treatment may be beneficial and decreases patient morbidity.

Tubercular longitudinally extensive transverse myelitis with lower motor neuron paralysis.

Transverse myelitis typically extends two or less spinal segments, whereas longitudinal extensive transverse myelitis (LETM) extends three or more spinal segments in length and may occasionally span all the segments of the spinal cord. We present a case of spinal tuberculosis presenting with LETM with true lower motor neuron-type flaccid paraplegia.

Proteomic analysis reveals critical molecular mechanisms involved in the macrophage anti-spinal tuberculosis process.

Tuberculosis infection activates the autoimmune system. However, the role of host-pathogen interactions involved in Mycobacterium tuberculosis infection is unclear. In this study, we analyzed 6 spinal tuberculosis tissues and 6 herniated disc tissues by using liquid chromatography-tandem mass spectrometry coupled with tandem mass spectrometry, and immunohistochemical staining was performed for validating the results. We identified 42 differential immune-related proteins and 3 hub genes that are primarily localised in the tertiary granule and involved in biological processes such as cellular response to the presence of cadmium ions, regulation of ion transmembrane transport, transmembrane transport, and inflammatory responses. Genes encoding cytochrome B-245 beta chain (CYBB), matrix metallopeptidase 9 (MMP9), and C-X-C motif chemokine ligand 10 (CXCL10) were identified as the hub genes that exhibited anti-tuberculosis activity and were responsible for macrophage resistance against M. tuberculosis. In conclusion, CYBB, MMP9, and CXCL10 resist M. tuberculosis infection through chemotaxis and macrophage activation. Our results indicate that CYBB, MMP9, and CXCL10 could be considered as molecular targets for spinal tuberculosis treatment, which may significantly improve patients' quality of life and prognosis.

Clinical efficacy of three types of autogenous bone grafts in treatment of single-segment thoracic tuberculosis: A retrospective cohort study.

A retrospective study investigated and compared the results of lamina with spinous process (LSP), transverse process strut (TPS) and iliac graft (IG) as bone graft in thoracic single-segment spinal tuberculosis(TB) with the one-stage posterior approach of debridement, fusion and internal instrumentation. 99 patients treated from January 2012 to December 2015 were reviewed. LSP was performed in 35 patients (group A), TPS was undertaken in 33 patients (group B), and IG was carried out in 31 patients (group C). Surgical time, blood loss, hospitalization time, drainage volume, and follow-up (FU) duration were recorded. The visual analog scale (VAS), Oswestry Disability Index (ODI), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), American Spinal Injury Association (ASIA) grade, segmental angle, intervertebral height and bone fusion time were compared between preoperative and final FU. All the patients were followed up for a mean 43.90±10.39 months in group A, 45.30±6.20 months in group B, 44.32±7.17 months in group C without difference(P>0.05). The mean age was younger, the blood loss was less, the hospitalization time and the surgical time were shorter in group A than those in group B and C (P<0.05). The drainage volume was less in group A than that in group B and group C. The CRP, ESR, VAS, and ODI were significantly decreased and there were no significant difference among the groups at the final FU. The neurological function after surgery was improved compared with preoperation among the groups. The bony fusion at a mean time 12.90±3.91 months in group A was longer than that in group B (6.75±1.55 months) and group C (5.52±1.64 months) (P<0.05). No significant difference was found at the mean segmental angle, mean intervetebral height of preoperation and final FU among the groups (P>0.05). In conclusion, the LSP and TPS as bone graft are reliable, safe, and effective for single-segment stability reconstruction for surgical management of thoracic TB and TPS could be new bone graft methods.

Is there a change in trend towards pyogenous spondylodiscitis compared to tubercular spondylodiscitis in India-A study of percutaneous biopsy evaluation in spondylodiscitis.

BACKGROUND: In Indian subcontinent where tuberculosis is endemic, the spinal infection was thought to be due to mycobacterium tuberculosis in most of the cases. Hence there is a practice of treating these patients with empirical antitubercular treatment. However, recent guidelines advice biopsy and tissue diagnosis before starting antibiotics. OBJECTIVE OF STUDY: Our retrospective study analyses the role of biopsy in establishing the microbiological diagnosis and thus identifying the incidence of pyogenic and tubercular spondylodiscitis presented to a tertiary care centre. MATERIALS AND METHODS: All patients who were diagnosed as spondylodiscitis by clinical and radiological criteria and who underwent biopsy were included in the study and data was retrieved from medical records and PACS. Criteria for tubercular spondylodiscitis included presence of mycobacterium tuberculosis either in smear/gene Xpert, or histopathological evidence of tuberculosis. Organism isolation other than MTB or absence of tubercular granuloma and response to antibiotics were considered as non-tubercular aetiology. RESULTS: Our study achieved 84% (n-63) accuracy for first biopsy and 34 patients (53.96%) were diagnosed as pyogenic spondylodiscitis. Organisms were isolated in 11 cases (32%) of pyogenic spondylodiscitis and tubercular bacilli in 17 cases (65%) of tubercular spondylodiscitis. Aspiration of pus yielded better isolation of organisms (P < 0.001) in pyogenic spondylodiscitis. 11% of cases showed drug resistant tuberculosis. CONCLUSION: We conclude that there is an increasing trend of pyogenous spondylodiscitis compared to tubercular spondylodiscitis in patients presenting to tertiary care centre, hence biopsy is essential to start antimicrobials.

Performance of conventional histopathology and GeneXpert MTB/RIF in the diagnosis of spinal tuberculosis from bone specimens: A prospective clinical study.

OBJECTIVE: Xpert MTB/RIF is recommended to detect pulmonary tuberculosis; however, there is insufficient data on its utility for bone samples. This study aimed to assess the accuracy of Xpert MTB/RIF compared with conventional histopathology in diagnosing spinal tuberculosis (STB) based on bone specimens in high burden settings. MATERIALS AND METHODS: Totally, 128 suspected STB participants were enrolled into this study. The bone specimens were obtained through puncture or operation for histological and Xpert MTB/RIF analyses, so as to compare their accuracy in diagnosing STB by the composite reference standard (CRS). RESULTS: Finally, 106 subjects with suspected STB were recruited into the analysis, including 27 confirmed and 33 clinically diagnosed STB patients. Relative to histopathology, Xpert MTB/RIF achieved a 86.7% sensitivity, and 12 out of 30 STB patients were positive, while the negative results in them were obtained upon histopathology. Based on CRS, Xpert MTB/RIF yielded a 63.3% sensitivity, which significantly elevated relative to that obtained upon histopathological test (50.0%, p < 0.001). In addition, the pooled sensitivity obtained using the above 2 approaches was as high as 95.0%, which was higher than that of any of the 2 approaches alone. The pooled specificity was 97.8%. Moreover, the area under the curve (AUC) value was 0.75 for Xpert MTB/RIF and 0.81 for histopathology, with no statistical significance. The two methods showed moderate concordance in the diagnosis of STB. CONCLUSIONS: The Xpert MTB/RIF test achieves superior specificity and fair sensitivity, which can not be recommended to replace the conventional examinations for the diagnosis of STB. The combined application of these 2 approaches can improve the pooled diagnostic sensitivity and accuracy for STB.

Management of CVJ tuberculosis: the changing paradigm.

BACKGROUND: The literature seems fractured for the management of craniovertebral junction (CVJ)-tuberculosis (TB). Presently, non-surgical management has been in vogue for neurologically intact patients. On the contrary, severely disabled cases of CVJ-TB continue to attract discussion, tilted towards surgical intervention. We present our experience with the non-surgical management of CVJ-TB tailored to their neurological status. METHODS: Authors managed 37 cases (2004-2019; age 1-57 years, mean 36 years) of CVJ-TB, of which eighteen (18/37, 48.6%) were severely disabled (Nurick grade ≥ 3) with a mean follow-up of 84 months (48-192 months). Irrespective of the clinical status and radiological findings, all patients were managed on medical management only. Needle aspiration established pathology in 23 (62.2%) cases, while 9 (24.3%) cases required drainage of an abscess. All patients received 18 months of anti-tubercular therapy (ATT). In patients with Nurick grade ≥ 3 and documented AAD, we applied halo vest for 12 months to achieve cervical immobilization. Only hard cervical collar for 3 months was prescribed in patients with no documented AAD. RESULTS: All minimally disabled cases (Nurick grade ≤ 2, n = 19) responded favorably (n = 18) to ATT, except for an infant, who succumbed to irreversible hypoxic brain damage due to the obstructed aero-digestive gateway. Of the severely disabled cases (Nurick grade ≥ 3, n = 18), 16 cases had favorable outcomes with only external orthosis (12) and 18-month ATT. One patient succumbed to multiple cerebral infarcts, while one required realignment surgery at CVJ due to fusion in malaligned position. CONCLUSION: The authors conclude that the disability grading of CVJ-TB is pertinent only for assessing the functional disability of patients at presentation, with minimal relevance in deciding its management strategy. Irrespective of neurological disability, almost all patients respond favorably to external immobilization and ATT.

Clinical Significance of M1/M2 Macrophages and Related Cytokines in Patients with Spinal Tuberculosis.

BACKGROUND: Macrophages are important immune cells involved in Mycobacterium tuberculosis (M.tb) infection. To further investigate the degree of disease development in patients with spinal tuberculosis (TB), we conducted research on macrophage polarization. METHODS: Thirty-six patients with spinal TB and twenty-five healthy controls were enrolled in this study. The specific morphology of tuberculous granuloma in spinal tissue was observed by hematoxylin-eosin (H&E) staining. The presence and distribution of bacilli were observed by Ziehl-Neelsen (ZN) staining. Macrophage-specific molecule CD68 was detected by immunohistochemistry (IHC). M1 macrophages play a proinflammatory role, including the specific molecule nitric oxide synthase (iNOS) and the related cytokine tumor necrosis factor-α (TNF-α) and interferon-γ (IFN-γ). M2 macrophages exert anti-inflammatory effects, including the specific molecule CD163 and related cytokine interleukin-10 (IL-10). The above markers were all detected by quantitative real-time PCR (RT-PCR), enzyme-linked immunosorbent assay (ELISA), and IHC. RESULTS: Typical tuberculous granuloma was observed in the HE staining of patients with spinal TB. ZN staining showed positive expression of Ag85B around the caseous necrosis tissue and Langerhans multinucleated giant cells. At the same time, IHC results indicated that CD68, iNOS, CD163, IL-10, TNF-α, and IFN-γ were expressed around the tuberculous granuloma, and their levels were obviously higher in close tissue than in the distant tissue. RT-PCR and ELISA results indicated that IL-10, TNF-α, and IFN-γ levels of TB patients were also higher than those of the healthy controls. CONCLUSION: The report here highlights that two types of macrophage polarization (M1 and M2) are present in the tissues and peripheral blood of patients with spinal TB. Macrophages also play proinflammatory and anti-inflammatory roles. Macrophage polarization is involved in spinal TB infection.

Iatrogenic biological fracture of the cervical spine during gradual halo traction for kyphotic deformity correction: case report.

BACKGROUND: Severe kyphotic deformities carry high risk for neurological injuries as osteotomies are often required for correction. Surgeons often utilize a staged approach for dealing with these conditions starting with a period of halo traction to stretch tight soft tissues and partially correct the deformity, followed by surgery. Halo traction is a relatively safe procedure and complications are uncommon. We report a unique case of iatrogenic fracture of the cervical spine during gradual halo traction for deformity correction of a severe cervical kyphosis. CASE PRESENTATION: An 80-year-old female with previous cervical spine tuberculosis infection and C5-C6 anterior spinal fusion developed severe cervical kyphosis of 64° from C2-C6 and neck pain requiring deformity correction surgery. Gradual increase in traction weight was applied, aiming for a maximum traction weight of 45 pounds or half body weight. During the 1st stage halo-gravity traction, sudden neck pain and a loud cracking sound was witnessed during increase of the traction weight to 14 pounds. Imaging revealed a fracture through the C4 and reduction in kyphosis deformity to 11° from C2-C6. There was no neurological deficit. No further traction was applied and the patient underwent an in-situ occipital to T3 fusion without osteotomies. At 3-year follow-up, the patient was symptom-free and radiographs showed solid fusion and maintenance of alignment. CONCLUSIONS: Iatrogenic fracture may occur with halo traction. Elderly patients with osteoporotic and diseased bone should be closely monitored during the treatment. A fracture without complications was a fortunate complication as the patient was able to avoid any high-risk osteotomies for deformity correction. LEVEL OF EVIDENCE: IV.

Severe skeletal lesions, osteopenia and growth deficit in a child with pulmonary tuberculosis (mid-20th century, Portugal).

OBJECTIVE: This case-study provides a summary of skeletal lesions seen in a case of diagnosed juvenile pulmonary tuberculosis with extensive multifocal bony lesions. MATERIALS: Skeleton of a 9-year-old girl who died in the 1940s in Lisbon, Portugal. The remains of this individual are part of the Lisbon skeletal reference collection curated at the National Museum of Natural History and Science. METHODS: Lesions and paleopathological conditions were identified and documented through macroscopic, radiographic, computed tomographic, and mammographic analysis. RESULTS: The skeleton shows a variety of lytic lesions on the ribs and thoracic vertebrae including complete destruction of the bodies and fusion of the vertebral arches of four vertebrae, kyphosis, and scoliosis. Further pathological conditions were identified, including bone erosion, premature fusion of the left femoral head and greater trochanter, and abnormal size and shape changes to the lower limbs including loss of bone mass and stunting of the long bones. CONCLUSIONS: Skeletal lesions are indicative of spondylitis, Pott's disease, and prolonged bedrest. SIGNIFICANCE: This case is one of the few examples of confirmed juvenile pulmonary tuberculosis with skeletal lesions prior to the antibiotic era. As such, it provides a reference for the skeletal abnormalities which may be observed in archaeological tuberculosis cases. LIMITATIONS: Pulmonary tuberculosis was recorded as cause of death, however there is no documentation to know the length of illness period or the existence of any comorbidities. SUGGESTIONS FOR FURTHER RESEARCH: Consideration of multi-focal lesions is recommended when analyzing individuals with suspected tuberculosis.