Treatment of Spinal Tuberculosis of GATA Type III: Primary Posterior Debridement Combined with Osteotomy Parallel to the Endplates for Reconstruction.

To evaluate the curative effect of one-stage posterior debridement and osteotomy parallel to the endplates for reconstruction, deformity correction, and tuberculosis control on treating the spinal tuberculosis of graded GATA III. From July of 2012 to December of 2017, there were 36 cases from the Second Hospital of Shanxi Medical University with thoracic and lumbar tuberculosis graded GATA III, in which we used osteotomy parallel to the endplates and reconstruction for treatment,16 for males and 20 for females. The local Cobb angles of kyphosis of all patients are greater than or equal to 20.The age varied from 28 months to 72 years with an average of 38.8 years. There were 15 cases of thoracic segment, 12 cases of thoracolumbar segment (T11 -L2 ), 9 cases of lumbar segment. Preoperative results of ASIA were 3 cases of grade C,5 cases of grade D and 28 cases of grade E with an average kyphosis Cobb angle of 37.21 ± 3.28. The visual analogue scale(VAS) scores preoperatively were 0-8 points (averaged 5.58 ± 1.66 points). All the patients had paraspinal abscesses. After completing the preoperative examinations and evaluations, the osteotomy parallel to the endplates and reconstruction were executed. We made a statistical analysis of the Cobb angles, visual analogue scale(VAS) scores, erythrocyte sedimentation rate (ESR), C-reaction protein(CRP), and ASIA grades before and after the surgery. The following-up time varied from 12 to 24 months, with an average of 18 months. The VAS score improved from 5.58 ± 1.66 before the surgery to 3.25 ± 0.92 one month after the surgery and 2.12 ± 0.73 at the last follow-up. The Cobb angles decreased from 37.21° ± 3.28° before the surgery to 5.72°± 2.66° one month later and 5.99° ± 1.92° at the last follow-up. The ESR decreased from 55.34 ± 1.72 mm/1 h before the surgery to 28.22 ± 3.76 mm/1 h one month later and 11.54 ± 0.46 mm/1 h at the last follow-up. The CRP decreased from 35.22 ± 2.46 mg/L before to 12.67 ± 2.82 mg/L and 4.50 ± 2.11 mg/L at the last follow-up. The results of the last ASIA grades were 1 case of grade D and 35 cases of grade E. The one-stage posterior debridement and osteotomy parallel to the endplates for patients with spinal tuberculosis of graded GATA III are not only beneficial to spinal reconstruction, but also obtain ideal reconstuction effects.

Mal de pott en la provincia del Chaco / Pott’s disease in the province of Chaco

Introducción: la tuberculosis es la séptima causa de muerte mundial. Menos del 1% de los pacientes tiene compromiso raquídeo. El objetivo del estudio fue investigar la frecuencia del mal de Pott en la provincia e identificar pautas para regiones similares. Materiales y Métodos: Rastreo de pacientes internados por tuberculosis entre 1996 y 2014, en Hospitales provinciales de cabecera. Revisión de historias de casos raquídeos. Clasificaciones de Frankel y del GATA. Datos de censos nacionales. Revisión bibliográfica. Resultados: Catorce casos: 8 varones/6 mujeres. Edad promedio: 35.4 años (rango 3.8-63). Seguimiento: 2.8 años (1 mes-15 años); un óbito posoperatorio inmediato. Siete pacientes provenían de Departamentos con baja carga de morbilidad de tuberculosis. Síntomas iniciales: déficit neurológico (9 casos), dolor axial o radicular puro (4 casos) y deformidad vertebral pura (1 caso). Frankel al ingreso: E (5 casos), D (2), C (2) y A (5). Localizaciones: torácica, 5; toracolumbar, 6; lumbar, 1; múltiple 2 pacientes. Distribución étnica: 5 caucásicos, 5 aborígenes, 3 criollos, 1 mestizo. Según la Clasificación del GATA: 1 lesión de tipo IB; 4 de tipo II; 8 de tipo III; 1 caso inclasificable. Los pacientes de etnia originaria tuvieron cuadros neurológicos y lesiones GATA más graves. Doce fueron operados; 5 presentaron deformidad secuelar, sin diferencias entre doble instrumentación, instrumentación posterior aislada o sin instrumentación. Al seguimiento: 8 pacientes asintomáticos, 4 fallecidos y 2 con síntomas moderados; no hubo deterioros neurológicos y solo 5 mejorías. Conclusiones: En pacientes de etnia originaria son más frecuentes las formas graves, las presentaciones avanzadas y de tratamiento quirúrgico habitual. La mortalidad es alta.

Introduction: tuberculosis is the seventh leading cause of death. Spinal involvement represents <1% of cases. The objective was to investigate the frequency of Pott´s disease in our province, to typify its profile and to identify guidelines for similar regions. Methods: Identification of all tuberculosis admissions from 1996 to 2014 in the main referral hospitals of our province. Medical records review of all cases with spinal involvement. Frankel and GATA classifications. Data from last national census. Literature review. Results: Fourteen cases: 8 males/6 females. Average age: 35.4 years (range 3.8-63). Follow-up: 2.8 years (range 1 month-15 years); one immediate postoperative death. Seven patients came from low tuberculosis burden Departments. Initial symptoms: neurological impairment (9 cases), pure axial and/or radicular pain (4 cases) and pure spine deformity (1 patient). Initial Frankel: E, 5 cases; D, 2; C, 2; and A, 5 patients. Localization: thoracic, 5; thoraco-lumbar, 6; lumbar, 1; multiple 2 patients. Ethnic distribution: 5 caucasians, 5 natives, 3 creoles, 1 mestizo. According to GATA classification: 1 type IB lesion; 4 type II; 8 type III; one unclassifiable case. Native patients had more severe neurological and GATA lesions. Twelve patients were operated on; 5 had residual deformities without differences among double instrumentation, isolated posterior instrumentation and no instrumentation. At follow-up: 8 asymptomatic cases, 4 deceased and 2 patients with moderate symptoms. No neurological worsening was observed; only 5 patients improved. Conclusions: Severe forms, and advanced and common surgical presentations are more frequent in native patients. Mortality is high.

[Comparison of inter- and intra-observer reliability between GATA and SMU classification systems for spinal tuberculosis].

OBJECTIVE: To compare the inter- and intra-observer reliability of the GATA and SMU classification systems for spinal tuberculosis and assess the clinical value of SMU classification. METHODS: One hundred patients with spinal tuberculosis treated in our hospital from January 2004 to December 2011 were randomly selected for analysis, including 54 males and 46 females with a mean age of 45 years (range, 16-68 years). All the patients had X-ray, CT and MRI examinations. Five observers experienced in spinal tuberculosis independently assigned the classification using the GATA and SMU classification systems, and the assignment was repeated 3 months later to test its reproducibility. Kappa value was used to determine the intra- and inter-observer reliability. RESULTS: For GATA and SMU classification systems, the inter-observer percentage of agreement averaged (59.9∓4.84)% (κ=0.412∓0.058) and (81.6∓6.06)% (κ=0.753∓0.068), and the intra-observer percentage of agreement was (75.6∓5.27)% (κ=0.624∓0.078) and (89.8∓2.28)% (κ=0.862∓0.037), respectively. CONCLUSION: The SMU classification system of spinal tuberculosis has a higher inter-observer and intra-observer reliability than the GATA classification system, but its clinical value needs to be further tested in future clinical trials.

MR findings in spinal tuberculosis in an endemic country.

INTRODUCTION: Spinal tuberculosis (TB) accounts for 50% or more of skeletal tuberculosis. MRI is a helpful tool for spinal TB. MR findings in spinal TB however, may have several different patterns. METHODS: The MRI features of spinal TB and classification as usual and unusual findings are reported. The MR images in 52 proven spinal TB patients in Srinagarind Hospital from 1996 to 2005 were retrospectively reviewed. RESULTS: There were five characteristics of unusual manifestations, including multiple skip lesions, vertebral body involvement, lamina and spinous process involvement, single vertebral collapse, and intramedullary tuberculoma. The skip lesion of spinal TB was the only distribution pattern significantly identified as being an unusual characteristic by multiple logistic regression. CONCLUSION: The most common unusual pattern of spinal TB is skip lesions (11.5%). The distribution of this pattern is statistically significant as an important MRI feature for defining unusual spinal TB.

A new classification and guide for surgical treatment of spinal tuberculosis.

So far, there is no widely accepted classification system based on objective findings that can serve as a guide in selecting the treatment method for spinal tuberculosis. This retrospective study evaluates patients with spinal tuberculosis (Pott's disease) treated with different surgical procedures. Our aim was to outline a new classification of spinal tuberculosis. A retrospective review of 76 cases (55 male and 25 female patients) of spinal tuberculosis was conducted. Five of the patients were treated medically, and the others who were treated surgically were classified into three types (I, II and III) according to the new classification system for spinal tuberculosis. All 76 patients were classifiable by this new system. The most common complication observed was local kyphosis (maximum 8 degrees) in type-II patients, but none of the patients needed correction. No neurological deterioration was observed in any of the cases. This new classification system helps in differentiating the various manifestations of spinal tuberculosis and appears to correlate with the surgical treatment of spinal tuberculosis. We believe that this new classification system can be used as a practical guide in the treatment of Pott's disease.

Outcome and management of spinal tuberculosis according to the severity of disease: a retrospective study of 137 adult patients at Korean teaching hospitals.

STUDY DESIGN: A retrospective study examining the clinical features, management, and treatment outcome of patients with spinal tuberculosis (TB). OBJECTIVE: To determine the influence of disease severity and treatment modality on outcome of patients with spinal TB. SUMMARY OF BACKGROUND DATA: Although anti-TB chemotherapy is now the mainstay treatment for spinal TB, it may not be applicable to all situations, especially in patients with risk of deformity, instability, and progression of neurologic deficit. METHODS: In this retrospective study (1994-2003), medical records and radiographic findings of patients with spinal TB were reviewed at 7 teaching hospitals in South Korea. The duration of triple chemotherapy with isoniazid, rifampin, and ethambutol, disease severity, operative procedures, and outcome were analyzed. The outcome was assessed as both favorable and unfavorable according to predefined criteria. RESULTS: A total of 137 patients were diagnosed with spinal TB during the study period. Twenty-one patients were lost to follow-up and excluded from analysis. The mean age was 44.07 +/- 16.57 years. The most common vertebral area involved was the lumbar (44.8%). The mean number of vertebra involved was 2.25. The mean angle of kyphosis was 21.58 degrees. Forty-seven patients (35.1%) had severe symptoms. Radical surgery was carried out in 84 (62.2%) patients. Twenty patients were treated with short-term chemotherapy, while 96 under long-term. At the end of chemotherapy, 94 patients had achieved a favorable status and 22 an unfavorable one. Statistically, there was no significant difference between the 2 groups in terms of gender, chemotherapy duration, or the severity of spinal TB; however, age (P = 0.025; odds ratio = 0.963; 95% confidence interval 0.932-0.995) and radical surgery (P = 0.043; odds ratio = 3.047; 95% confidence interval 1.038-8.942) were significantly related to a favorable outcome by logistic analysis. CONCLUSIONS: Our results showed that a younger age and radical surgery in conjunction with anti-TB chemotherapy were significant favorable prognostic factors.

Evaluation of systems of grading of neurological deficit in tuberculosis of spine.

STUDY DESIGN: Prospective comparative study. OBJECTIVE: To compare the efficacy of the ASIA scoring system and Tuli's classification for assessment of neurological status in a typical case of Pott's paraplegia/tetraplegia and suggest a suitable classification. SETTING: Department of Orthopaedics of University College of Medical Sciences and GTB Hospital, Delhi, India. METHODS: A total of 33 cases of tuberculosis of the spine with paraplegia were evaluated serially for the severity of the neurological deficit by grading systems as suggested by Tuli and ASIA score, during the course of treatment. A total of 111 readings of neurological status were recorded and analysed. RESULTS: Tuli's grading was found to be sensitive for detection of early stage (grade I) of neurological deficit. The rest of the grades (grade II, III, IV) of Tuli's classification have a wide range of sensory-motor deficit and hence are insensitive to early detection of any deterioration/improvement in the neurological status. The ASIA score failed to grade all types of neurological deficit associated with the Pott's spine. The sensory-motor score obtained by the ASIA scale depends on the level of involvement of the spinal cord. The higher the level of the cord damage, the poorer is the score. CONCLUSION: Neither Tuli's grading nor the ASIA scale alone can effectively grade all stages of neurological deficit in tuberculosis of the spine. The neurological deficit in tuberculosis of the spine should be described in stages and each stage should have sensory and motor scoring. A new staging system of Pott's tetraplegia/paraplegia is suggested.

Atypical spinal tuberculosis.

Typical spinal tuberculosis is readily diagnosed and treated. Certain atypical clinical and radiologic presentations of spinal tuberculosis are described. Failure to recognize these presentations may lead to delay in diagnosis and initiation of treatment. In some atypical forms of the disease, this may have disastrous consequences. The current authors present a new classification for atypical spinal tuberculosis and describe the various presentations. The role of advanced imaging studies such as computed tomography scanning and magnetic resonance imaging and imaging-guided aspiration cytology is discussed.

Tuberculosis of the thoracic spine. A classification based on the selection of surgical strategies.

In spinal tuberculosis MRI can clearly demonstrate combinations of anterior and posterior lesions as well as pedicular involvement. We propose a classification system, using information provided by MRI, to help to plan the appropriate surgical treatment for patients with thoracic spinal tuberculosis. We describe a series of 47 patients, divided into four groups, based on the surgical protocol used in the management. Group A consisted of patients with anterior lesions which were stable with no kyphotic deformity, and were treated with anterior debridement and strut grafting. Group B comprised patients with global lesions, kyphosis and instability who were treated with posterior instrumentation using a closed-loop rectangle with sublaminar wires, and by anterior strut grafting. Group C were patients with anterior or global lesions as in the previous groups, but who were at a high risk for transthoracic surgery because of medical and possible anaesthetic complications. These patients had a global decompression of the cord posteriorly, the anterior portion of the cord being approached through a transpedicular route. Posterior instrumentation was with a closed-loop rectangle held by sublaminar wires. Group D comprised patients with isolated posterior lesions which required posterior decompression only. An understanding of the extent of vertebral destruction can be obtained from MRI studies. This information can be used to plan appropriate surgery.

Vertebral arch or posterior spinal tuberculosis.

Posterior spinal tuberculosis or arch tuberculosis is a form of skeletal tuberculosis that selectively involves the vertebral arch. It may mimic skeletal neoplasm clinically and radiographically. Although posterior spinal tuberculosis has been reported in developing countries it has rarely been found in the United States. As a result, there is limited information about this entity in the US literature. We are presenting our experience in a patient born in the United States.

[Radiology in tuberculosis]. / Radiologie der Tuberkulose.

The radiological manifestations of pulmonary tuberculosis such as primary and secondary tuberculosis, micronodular tuberculosis and tuberculous pneumonia as well as postinfectious residual scarring, are described. Simultaneously the radiology of the extrapulmonary manifestations of tuberculosis such as tuberculous pleurisy, spondylitis, different forms of abdominal tuberculosis and renal tuberculosis is discussed. Pathophysiological mechanisms are used to classify the different manifestations of tuberculosis, to explain the localizations typical of pulmonary tuberculosis as well as of extrapulmonary tuberculosis and finally to specify the most important differential diagnoses.

A clinical study and classification of posterior spinal tuberculosis.

Tuberculous involvement of the posterior elements of the spine is uncommon. Review of the literature reveals little information and there is scant mention of this subject in standard textbooks of orthopaedics. A study of 27 cases of such lesions seen over 6 years is presented, drawn from two separate centres, 21 from Central India and 6 from South Eastern Iran. The clinical presentation, investigations and treatment are analysed. A new four point classification is described based upon the site of the lesion, the stage of the lesion, associated lesions and neurological deficit.