Tuberculosis extrapulmonar: mal de Pott / Extrapulmonary tuberculosis. Pott’s disease

La tuberculosis es una enfermedad de distribución mundial, que en los últimos años está reemergiendo en los países occidentales debido a la aparición de la infección por el virus de la inmunodeficiencia humana, el abandono de los programas de control, el aumento de la inmigración y las condiciones sociosanitarias que ésta conlleva, y las tasas de resistencias. La forma de presentación más habitual continúa siendo la pulmonar. Sin embargo, debemos tener un alto índice de sospecha para el diagnóstico de formas más infrecuentes, como las extrapulmonares. La enfermedad de Pott, o espondilitis tuberculosa, es una de estas manifestaciones, que cursa con sintomatología general, como pérdida de peso o decaimiento y, sobretodo, con dolor en la zona afectada. Para el diagnóstico son fundamentales las pruebas de imagen y la biopsia de la lesión para su estudio histológico y microbiológico. El tratamiento se realiza con fármacos tuberculostáticos y cirugía para la estabilización de la columna (AU)

Tuberculosis is a disease that has a worldwide distribution. Its frequency in western countries is increasing in recent years due to the emergence of human immunodeficiency syndrome, the failure to carry out control programs, the immigration phenomenon and the socioeconomic and health status of these populations, and the rates of resistance. Although the most common form is still that involving lung, we should maintain a high index of suspicion for the diagnosis of more uncommon forms like meningeal or miliary tuberculosis. Pott’s disease, or tuberculous spondylitis, is one of these infrequent forms that is associated with general symptomatology, such as weight loss or weakness, and mainly with pain in the affected area. The diagnosis is based on imaging studies and is confirmed by the positive culture of a biopsy specimen and histopathological findings compatible with the results of the culture. The treatment of patients with Pott’s disease consists of antituberculous chemotherapy and surgery for the stabilization of the spine (AU)

Non-traumatic paraplegia in Nigerian children presenting at the University College Hospital, Ibadan.

A review of the presentation, management and outcome in all children presenting with non-traumatic paraplegia managed by the paediatric neurology team at the University College Hospital Ibadan, Nigeria from June 1989 to May 2004 is presented. Of the 110 patients, there were 54 males and 56 females giving a M:F ratio of 1:1. The mean age of the group was 5.3 (SD = 3.1) years, with a range from 9 months to 11 years. Infections and infectious processes caused the paraplegia in 102 (92.7%) of the cases with poliomyelitis and tuberculosis (TB) of the spine accounting for 88 (80%) of cases. The study period was divided into three 5 year periods. While poliomyelitis was the commonest cause of paraplegia (60%) in the first 5 years: TB spine was responsible for most cases (40%) in the last 5-year period of the study. There was a significant reduction in the total number of cases seen when the initial 5-year period was compared with the last (45 and 26 respectively, P = 0.001). Overall mortality among the 110 admitted patients was 7.2% being highest (50%) in malignant disorders and none was recorded in TB spine. Prognosis for eventual ability to walk was best in cases of TB spine where 37 of the 39 patients (95%) were ambulant by discharge after 60 days of anti-TB treatment. The 2 non-ambulant patients eventually walked within 3 months of discharge while on maintenance treatment for TB. Only 2 of the 51 non-ambulant patients obtained wheelchairs at discharge. The implications of inadequate facilities for investigation and treatment as well as the lack of financial and social support for the families of affected children are discussed.

Craniocervical tuberculosis: protocol of surgical management.

OBJECTIVE: Craniovertebral junction tuberculosis (CVJ-TB) is rare and occurs in only 0.3 to 1% of patients with tuberculous spondylitis. In the available literature, the treatment options offered for this entity have ranged from a purely conservative approach to radical surgery without well-defined guidelines. In this study, we attempt to establish the most effective strategy for the management of this condition. METHODS: Twenty-five patients with CVJ-TB were treated during the past 8 years. Severe neck pain, restricted neck movement, and myelopathy were the predominant symptoms. The patients were graded according to their disability as follows: Grade I (n = 7), only neck pain with no pyramidal tract involvement; Grade II (n = 8), independent with minor disability; Grade III (n = 1), partially dependent on others for assistance with activities of daily living; and Grade IV (n = 9), completely dependent on others for assistance with all activities of daily living. Nine patients in Grade IV also had severe respiratory compromise. In all patients, lateral radiographs of the CVJ in flexion and extension were used to determine the presence of atlantoaxial dislocation (AAD). Bony destruction, paraspinal abscess, and thecal compression were seen on intrathecal contrast computed tomographic scans (n = 9) and magnetic resonance imaging studies (n = 22). Under the cover of antituberculous therapy (ATT) administered for 18 months, the patients were placed under a management protocol that took into account the patient's preoperative grade, the presence of mobile or fixed AAD, bony destruction and retropharyngeal abscess formation at the CVJ, and the clinicoradiological response to ATT within 3 months. Thus, 14 patients were kept on conservative management, with their neck movements stabilized with an external orthosis; 4 patients underwent a single-stage transoral decompression and posterior fusion procedure; and 7 patients underwent direct posterior fusion. RESULTS: In a follow-up period that ranged from 6 months to 7 years (mean, 2.5 yr), the patients in Grades I and II maintained their neurological status. The single patient in Grade III improved to Grade II. Seven of the nine patients in Grade IV returned to normal, and one improved to Grade II. Neck pain improved in all patients. The only death in the series occurred as a result of aspiration pneumonitis leading to septicemia in a child in Grade IV with poor respiratory status and multilevel tuberculous involvement who had undergone transoral decompression and posterior fusion for fixed AAD. CONCLUSION: This study discusses the clinicoradiological presentation as well as the management of CVJ-TB, in which ATT is administered for 18 months. In the patients with minor deficits (Grades I and II), conservative neck stabilization is adopted; in the patients with severe deficits (Grades III and IV) due to significant cervicomedullary compression caused by fixed AAD or bone destruction and granulation, anterior decompression and posterior fusion are performed. Patients with persistent reducible AAD undergo direct posterior fusion. A significant improvement is possible even in poor-grade patients with judicious use of the surgical options and ATT.

Prevention of postoperative late kyphosis in Pott's disease by anterior decompression and intervertebral grafting.

A total of 185 patients with Pott's disease were operated on between 1973 and 1992. Anterior decompression by preserving the pleura (extrapleural approach) was the preferred method in the thoracic spine. In the lumbar spine the approach was retroperitoneal, and interbody fusion was performed in both for the thoracic and the lumbar regions. Anterior decompression and intervertebral grafting comprised the treatment. In five patients, internal fixation accompanied anterior decompression and intervertebral grafting. The aim of instrumentation was to enhance anterior spinal stability, and Alici spinal instrumentation was the preferred device. Graft destruction and a late increase in kyphosis was prevented by this means. The mean follow-up period was 7.5 years. Thirty-two of the cases were admitted to the clinic because of Pott's paraplegia: 19 of the cases recovered completely following anterior decompression; partial recovery was observed in 5 cases; but 3 cases did not recover. Various complications, including seven deaths, were observed in 42 of the cases.

A 10-year assessment of controlled trials of inpatient and outpatient treatment and of plaster-of-Paris jackets for tuberculosis of the spine in children on standard chemotherapy. Studies in Masan and Pusan, Korea. Ninth report of the Medical Research Council Working Party on Tuberculosis of the Spine.

Two hundred and eighty-three patients with tuberculosis of the thoracic and/or lumbar spine have been followed for 10 years from the start of treatment. All patients received PAS plus isoniazid daily for 18 months, either with streptomycin for the first three months (SPH) or no streptomycin (PH), by random allocation. There was also a second random allocation for all patients: in Masan to inpatient rest in bed (IP) for six months followed by outpatient treatment or to ambulatory outpatient treatment from the start (OP), and in Pusan to outpatient treatment with a plaster-of-Paris jacket (J) for nine months or to ambulatory treatment without any support (No J). A favourable status was achieved on their allocated regimen by 88% of patients at 10 years. Some of the remaining patients also attained a favourable status after additional chemotherapy and/or operation, and if these are included the proportion achieving such a status increases to 96%. There were five patients whose deaths were attributed to their spinal disease. A sinus or clinically evident abscess was present on at least one occasion in the 10-year period in 42% of the patients. Residual sinuses persisted at 10 years in two patients, at death at seven years in a third and at default in the seventh year in a fourth. Thirty-five patients had paraparesis at some time during the 10-year period, including two who died with paraplegia before five years. Complete resolution occurred in 26 patients (in six after additional chemotherapy and/or surgery). At 10 years two patients had severe paraplegia and one a moderate paraparesis.(ABSTRACT TRUNCATED AT 250 WORDS)