Candidate Biomarkers to Distinguish Spinal Tuberculosis From Mechanical Back Pain in a Tuberculosis Endemic Setting.

Background: Spinal tuberculosis (TB) may have a variable, non-specific presentation including back pain with- or without- constitutional symptoms. Further tools are needed to aid early diagnosis of this potentially severe form of TB and immunological biomarkers may show potential in this regard. The aim of this study was to investigate the utility of host serum biomarkers to distinguish spinal TB from mechanical back pain. Methods: Patients with suspected spinal TB or suspected mechanical back pain were recruited from a tertiary hospital in the Western Cape, South Africa, and provided a blood sample for biomarker analysis. Diagnosis was subsequently confirmed using bacteriological testing, advanced imaging and/or clinical evaluation, as appropriate. The concentrations of 19 host biomarkers were evaluated in serum samples using the Luminex platform. Receiver Operating Characteristic (ROC) curves and General Discriminant Analysis were used to identify biomarkers with the potential to distinguish spinal TB from mechanical back pain. Results: Twenty-six patients with spinal TB and 17 with mechanical back pain were recruited. Seven out of 19 biomarkers were significantly different between groups, of which Fibrinogen, CRP, IFN-γ and NCAM were the individual markers with the highest discrimination utility (Area Under Curve ROC plot 0.88-0.99). A five-marker biosignature (CRP, NCAM, Ferritin, CXCL8 and GDF-15) correctly classified all study participants after leave-one-out cross-validation. Conclusion: This study identified host serum biomarkers with the potential to diagnose spinal TB, including a five-marker biosignature. These preliminary findings require validation in larger studies.

Midterm surgical results of the lamina with spinous process in treating one-level thoracic or lumbar tuberculosis: a retrospective study.

A retrospective study investigated the results of the lamina with spinous process (LSP) as a bone graft in one-level thoracic or lumbar spinal tuberculosis with the one-stage posterior approach of debridement, fusion and internal instrumentation. Data from 35 patients from January 2013 to December 2015 were analysed. Surgery time, blood loss, hospitalization time, drainage volume, and follow-up (FU) duration were recorded. The visual analogue scale (VAS), Oswestry Disability Index (ODI), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), American Spinal Injury Association (ASIA) grade, segmental angle, and bone fusion were compared between preoperative and final FU. All of the patients were followed up for a mean 43.90 ± 10.39 months. The mean age, surgery time, blood loss, hospitalization time, hospital cost and drainage volume were 33.65 ± 11.06 years, 182.40 ± 23.82 min, 280.80 ± 76.82 mL, 14.05 ± 3.58 days, 74,382.00 ± 11,938.00 yuan, and 340.00 ± 167.20 mL, respectively. VAS and ODI were significantly improved at the final FU. The ESR and CRP recovered to normal. The mean angle of 24.35 ± 5.74°preoperatively showed a significant difference between 1 week, postoperatively and final FU. Although there were the loss of angle at final FU comparing with the 1 week postoperatively, it still maintain the good alignment and the segmental stability. All patients achieved bony fusion with a mean time of 12.90 ± 3.91 months. In conclusion, the LSP as a structural bone graft is reliable, safe and effective for segmental stability reconstruction, which could be one choice for surgical management of thoracic or lumbar spinal TB.

Comparison of the Clinical Efficacy of 3 Surgical Methods for Treating Spinal Tuberculosis in Children.

BACKGROUND This study aimed to investigate the safety and clinical efficacy of 3 different surgical methods for treating spinal tuberculosis (ST) in children. MATERIAL AND METHODS We reviewed the cases of 62 children with ST who were treated in our hospital from January 2010 to December 2014. In this study, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) level, Frankel classification of neurological function, pain visual analog scale (VAS) score, and kyphosis Cobb (k-Cobb) angle were dynamically monitored to evaluate the efficacy of different surgical methods. Complications in the patients were evaluated at 3 time points: before surgery (T1), after surgery (T2), and during final follow-up (T3). The average follow-up was 27.4 months. Twenty-two patients underwent simple anterior debridement alone or combined with internal fixation (Method A), 13 patients underwent posterior debridement alone (Method B), and 27 patients received anteroposterior debridement and bone graft fusion together with internal fixation (Method C). RESULTS In all 3 groups after surgery, ESR, CRP levels, VAS scores, and k-Cobb angles significantly decreased. However, compared with patients who received Methods B and C, patients who received Method A had a significant rebound in k-Cobb angle and a higher incidence of complications at the T3 time point. The overall reoperation rate during follow-up was 37.10%. Fourteen patients (22.58%) had kyphosis, 2 patients (3.23%) had tuberculosis recurrence combined with kyphosis, and other complications were reported in 5 patients (8.06%). CONCLUSIONS Considering the incidence of complications and level of postoperative biochemical indicators, we concluded that caution should be exercised in using an anterior approach to treat pediatric ST.

Extreme lateral interbody fusion and percutaneous pedicle screw fixation in the minimally invasive treatment of thoracic tuberculosis.

OBJECTIVE: As a minimally invasive intervertebral fusion technique popularized in recent years, extreme lateral interbody fusion (XLIF) has various advantages. In this study, we describe the application and efficacy of XLIF for the treatment of thoracic tuberculosis (TB), as this may be an emerging treatment option for thoracic TB in the future. METHODS: We present the case of a 75-year-old man who had suffered from chest and back pain for 1 month. Imaging studies showed destruction of the T12 and L1 vertebral bodies and the T12-L1 intervertebral disc, accompanied by formation of a paravertebral abscess. After 2 weeks of standard anti-TB treatment, the patient underwent debridement of the lesions, XLIF, and percutaneous pedicle screw fixation. RESULTS: The patient's chest and back pain were significantly alleviated after the operation. The patient recovered well, and as of the most recent follow-up had no obvious limitation in thoracolumbar spine function. CONCLUSIONS: XLIF combined with percutaneous pedicle screw fixation for the treatment of thoracic TB can allow for TB lesion debridement, discectomy, and interbody fusion under direct visualization, and can effectively improve patient prognosis.

Spinal tuberculosis: proposed spinal infection multidisciplinary management project (SIMP) flow chart revision.

OBJECTIVE: We propose a revised flow chart of spinal infection multidisciplinary management project (SIMP) aimed to standardize the diagnostic process and management of spinal tuberculosis (TB). MATERIALS AND METHODS: We reviewed data from all TB cases with osteoarticular involvement treated at a large tertiary teaching hospital in Bologna, Northern Italy, from January 2013 to December 2017. We cross-linked notified osteoarticular TB cases with SIMP database and we analysed clinical, diagnostic, and treatment data of all cases managed by SIMP. RESULTS: Osteoarticular TB accounted for the 7.8% (n=40) of all TB cases notified between 2013 and 2017 (N=513). Among the identified cases, 52% (n=21/40) had spine involvement: all were enrolled and evaluated by SIMP multidisciplinary group. Females accounted for 57% (12/21) of patients, the median age was 52 years (range 24-82). In the 67% (n=14/21) of cases, the major clinical symptom of spinal TB was back pain reported for a median of 4.5 months (range 1-12 months) before hospital admission. The interferon gamma release assay was positive in 75% (n=16/21) of patients. All patients performed MRI with gadolinium, which indicated spondylodiscitis in 90%. 18F-FDG-PET/CT revealed average maximum standardized uptake value (SUV max) of 12.54 (range 5.3-22) in 17/19 (89.5%). Bacteriological confirmation of TB was obtained in 86% of cases (n=18/21). One-third of patients (7/21) underwent surgery and 95% successfully completed the anti-TB treatment. CONCLUSIONS: Our data reveal that a multidisciplinary approach to spine tuberculosis facilitates early and accurate diagnosis and can improve medical and surgical management of this disease.

Prognostic factors for unfavourable outcomes of patients with spinal tuberculosis in a country with an intermediate tuberculosis burden: a multicentre cohort study.

AIMS: Spinal tuberculosis (TB) remains an important concern. Although spinal TB often has sequelae such as myelopathy after treatment, the predictive factors affecting such unfavourable outcomes are not yet established. We investigated the clinical manifestations and predictors of unfavourable treatment outcomes in patients with spinal TB. PATIENTS AND METHODS: We performed a multicentre retrospective cohort study of patients with spinal TB. Unfavourable outcome was defined according to previous studies. The prognostic factors for unfavourable outcomes as the primary outcome were determined using multivariable logistic regression analysis and a linear mixed model was used to compare time course of inflammatory markers during treatment. A total of 185 patients were included, of whom 59 patients had unfavourable outcomes. RESULTS: In multivariate regression analysis, the factors associated with unfavourable outcome were old age (odds ratio (OR) 2.51; 95% confidence interval (CI) 1.07 to 5.86; p = 0.034), acid-fast bacilli (AFB) smear positivity in specimens obtained through biopsy (OR 3.05; 95% CI 1.06 to 8.80; p = 0.039), and elevated erythrocyte sedimentation rate (ESR) at the end of treatment (OR 3.85; 95% CI 1.62 to 9.13; p = 0.002). Patients with unfavourable outcomes had a significant trend toward higher ESR during treatment compared with patients with favourable outcome (p = 0.009). Duration of anti-TB and surgical treatment did not affect prognosis. CONCLUSION: Elevated ESR at the end of treatment could be used as a marker to identify spinal TB patients with a poor prognosis. Patients whose ESR is not normalized during treatment, as well as those with old age and AFB smear positivity, should be aware of unfavourable outcomes. Cite this article: Bone Joint J 2019;101-B:1542-1549.

Relationship Between IL-10 Gene Polymorphism and Spinal Tuberculosis.

BACKGROUND To investigate the relation between interleukin-10 (IL-10) gene rs1800871 (A/G) polymorphism and spinal tuberculosis. MATERIAL AND METHODS A total of 129 patients with spinal tuberculosis (spinal tuberculosis group) and 106 healthy subjects receiving physical examination (control group) were enrolled in this study. The general data of these subjects were collected, and the C-reactive protein, erythrocyte sedimentation rate (ESR) and baseline hematologic function were examined. The rs1800871 (A/G) polymorphism in IL-10 gene was detected by TaqMan-MGB probe method. RESULTS The C-reactive protein, ESR, white blood cell count, absolute neutrophil count and relative neutrophil count in spinal tuberculosis group were higher than those in control group, while the absolute lymphocyte count and relative lymphocyte count were lower than those in control group (p<0.05). Compared with AA genotype, GG and AG+GG genotypes showed statistically significant difference in distribution frequency (p<0.05), but no significant difference was detected between AG genotype and AA genotype (p>0.05). In spinal tuberculosis group, the frequency of G allele was higher than that of A allele (p<0.01). The C-reactive protein, ESR, white blood cell count and relative neutrophil count in GG genotype were increased compared with those in AG+GG genotype (p<0.05). CONCLUSIONS The rs1800871 (A/G) polymorphism in IL-10 gene is related to the susceptibility to spinal tuberculosis. Moreover, carrying G allele increases the risk of spinal tuberculosis.

The outcome of intervertebral surgery in the treatment of lumbar tuberculosis in children: A case series and long-term follow-up.

During the operation of treating lumbar tuberculosis in children, a long-segment or short-segment fixation, and fusion method were usually applied, which would adversely affect the function of normal motion unit. And so, we have been focusing on how we can shorten the range of fixation and fusion using intervertebral surgery. The objective of this retrospective study is to investigate the clinical outcome of intervertebral surgery, in the treatment of lumbar tuberculosis in children.From June 2003 to June 2013, 18 children with lumbar tuberculosis underwent intervertebral surgery, using a combined posterior and anterior approach, in our hospital. The surgical treatments included posterior pedicle screw fixation of affected vertebrae and posterolateral bone grafting, anterior debridement, compression, and strut bone grafting. Indicators such as preoperative and postoperative erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) levels, neurological function, visual analog scale (VAS) score, kyphotic Cobb angle, complications, healing of lesions, bone graft healing, and recurrence were statistically analyzed.The mean follow-up time was 86.5 months (range, 62-120 months). Three months after the operation, all patients' ESR and CRP levels decreased to normal, and both the American Spinal Injury Association neurological function scores and VAS scores improved. Successful bone graft healing was achieved, with lesions completely healed at 6 months after surgery, and no recurrence occurred. The preoperative kyphotic was 24.00°â€Š±â€Š13.15° (range -10°-39°), which decreased to -4.61°â€Š±â€Š7.31° (range -19°-10°) postoperative (Z = -4.34, P < .01); the mean deformity correction angle was 28.61°â€Š±â€Š8.43° (range 9°-43°). There was no significant difference between the kyphotic angle measured immediately after surgery at (-4.61°â€Š±â€Š7.31°) and the kyphotic angle measured at 5-year follow-up at (-3.11°â€Š±â€Š7.56°). The mean loss of correction was 1.50°â€Š±â€Š0.90°.Intervertebral surgery using a combined posterior and anterior approach is an effective and safe method for the treatment of lumbar tuberculosis in children. It can also preserve the function of normal motor segments to the maximum extent.

Analysis of Treatment and Prognosis of 863 Patients with Spinal Tuberculosis in Guizhou Province.

The objective of this study was to investigate the treatment and prognosis of patients with spinal tuberculosis in Guizhou province. A total of 863 patients with spinal tuberculosis admitted to our hospital from 2006 to 2017 were included in this study. All patients underwent standardized quadruple antituberculosis treatment. Eighty patients were lost to follow-up due to a change of their contact information or noncompliance. A total of 783 patients completed the follow-up. The average follow-up period was 20.33 ± 8.77 months (range: 6 to 38 months). Among these patients, 145 patients underwent conservative treatment, while 638 patients underwent surgical treatment. All patients in the surgery group were treated with lesion removal, bone graft fusion, and internal fixation. Preoperative and postoperative standard quadruple antituberculosis treatment was administered. The clinical efficacy was evaluated according to erythrocyte sedimentation rate (ESR), c-reactive protein (CRP), visual analogue scale (VAS), Cobb angle correction, neurological functional recovery, and interbody fusion with bone graft and tuberculosis outcome. A total of 608 patients achieved clinical cure. The symptoms, physical signs, blood tests and imaging findings were improved in 143 patients. Twenty patients showed refractory clinical symptoms, and 12 patients had local tuberculosis recurrence. Conservative and surgical treatments are the mainstream treatments for spinal tuberculosis. According to the patients' individual conditions, individualized treatments should be used to achieve good efficacy. Standardized antituberculosis treatment should be applied over the course of spinal tuberculosis.

Identification of HLA-DQA1 as a Susceptibility Gene for Spinal Tuberculosis by Exome Sequencing.

BACKGROUND Spinal tuberculosis (STB) is the main cause of bone and joint tuberculosis. This study aimed to screen and analyze the susceptibility genes for STB using whole-exome sequencing (WES). MATERIAL AND METHODS All exon regions of peripheral blood DNA from 6 STB patients were captured and sequenced using WES and the sequencing data were analyzed by modern bioinformatics methods to identify disease-causing mutations. Sanger sequencing was then used to validate the mutation sites in normal controls (207) and STB patients (193). The mRNA expression of the mutant gene and the serum levels of IL-6 and TNF-α were detected using qPCR or ELISA assay, respectively. RESULTS A nonsynonymous single-nucleotide polymorphism (SNP) in the gene HLA-DQA1 (rs796778515, c.592delCinsG, CAG to GAG, p.Q198E) was identified and further validated by Sanger sequencing. The percentage of the 3 genotypes C/C, C/G and G/G in STB patients and normal controls were 37.3%, 32.1%, and 30.6% and 47.8%, 33.8%, and 18.4%, respectively. Furthermore, the C>G mutation was significantly associated with the occurrence of STB. In addition, the levels of HLA-DQA1 mRNA were significantly lower in blood cells from STB patients compared with normal controls, while the serum levels of IL-6 and TNF-α were significantly higher. CONCLUSIONS The C>G mutation in the HLA-DQA1 gene was associated with the occurrence of STB. This variation may result in the decreased level of HLA-DQA1 mRNA and increased serum levels of IL-6 and TNF-α, which finally led the STB susceptibility.

Study on the relationship between vitamin D deficiency and susceptibility to spinal tuberculosis.

OBJECTIVE: To investigate the effect of vitamin D deficiency on susceptibility to spinal tuberculosis and its pathological development. METHODS: A case-control design was used in this study. A total of 163 treatment-naïve patients with spinal tuberculosis admitted to this institute for an operation from June 2013 to May 2016 were included in the case group, and 170 subjects who received a health examination in the same hospital were included in the control group. Control group patients were frequency-matched with the case group by age, gender, and season. Serum 25-hydroxyvitamin D levels were detected using an enzyme linked immunosorbent assay (ELISA). Pathological classification of patients in the case group was conducted according to intraoperative findings, and definite diagnosis of spinal tuberculosis was confirmed after operation. RESULTS: The serum level of vitamin D [23.99 (20.55, 29.54) nmol/L] in the case group was lower than that in the control group [42.94 (35.68, 51.04) nmol/L], and the difference was statistically significant (Z = -9.048, P < 0.05). Out of the 163 patients with spinal tuberculosis who underwent pathological classification, 107 cases of caseous necrosis and 56 cases of hyperplasia were identified. Based on the vitamin D levels of the patients in the case group, these patients were further divided into a low-level group (<25 nmol/L) and a high-level group (≥25 nmol/L). The proportion of patients with caseous necrosis in the low-level group (79.17%) was higher than that in the high-level group (46.27%), with a statistically significant difference (χ2 = 18.937, P < 0.05). CONCLUSION: Vitamin D deficiency is associated with susceptibility to spinal tuberculosis and its pathological classification, and vitamin D deficiency affects the occurrence and development of spinal tuberculosis.

25-Hydroxy Vitamin D, Vitamin D Receptor and Toll-like Receptor 2 Polymorphisms in Spinal Tuberculosis: A Case-Control Study.

Vitamin D deficiency and vitamin D receptor (VDR) gene abnormalities confer susceptibility to tuberculosis. Toll-like receptors (TLRs), such asTLR-2, are also important mediators of inflammatory response against Mycobacterium tuberculosis. We evaluated serum vitamin D, and VDR and TLR-2 gene polymorphisms in patients with spinal tuberculosis.This study comprised of 3 groups: spinal tuberculosis, pulmonary tuberculosis, and controls (each with 106 subjects). Enzyme-linked immunosorbent assay was used to measure vitamin D levels, and polymerase chain reaction-sequencing method was used to analyze VDR and TLR-2 gene polymorphisms. Patients were followed up for 6 months.Vitamin D deficiency was significantly more prevalent in patients with spinal tuberculosis (P < 0.001) and pulmonary tuberculosis (P = 0.011), versus controls. The heterozygous and mutant genotypes of VDR TaqI gene were significantly associated with spinal tuberculosis (P < 0.001; odds ratio [OR] 4.74 [2.45-9.18]) and pulmonary tuberculosis (P < 0.001; OR 3.52 [1.80-6.88]) when compared with controls. The heterozygous and mutant variants of VDR ApaI gene were significantly more common in patients with spinal tuberculosis in comparison with patients with pulmonary tuberculosis (P < 0.001; OR 2.90 [1.65-5.10]) and controls (P < 0.001; OR 6.56 [3.41-12.61]). We did not observe any significantly different results for TLR-2 gene polymorphisms. Vitamin D deficiency, VDR, and TLR-2 polymorphisms did not affect the 6-month disability.Vitamin D deficiency and VDR gene polymorphisms are significantly more prevalent in people with pulmonary and spinal tuberculosis. They may, in isolation or collectively, confer susceptibility to pulmonary and spinal tuberculosis.

Neurological Recovery Determined by C-Reactive Protein, Erythrocyte Sedimentation Rate and Two Different Posterior Decompressive Surgical Procedures: A Retrospective Clinical Study of Patients with Spinal Tuberculosis.

BACKGROUND: C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR) not only are useful in the diagnosis but also are reliable parameters in evaluating the response to treatment and prognosis of tuberculous spondylodiscitis. OBJECTIVE: To analyze the correlation between neurological recovery and declination of CRP or ESR after two different posterior spinal procedures. MATERIAL AND METHOD: The patients who had neurological deficit due to spinal tuberculosis and undergone spinal surgery between January 2009 and June 2013 were analyzed retrospectively. Posterior transforaminal decompression and interbody fusion were done in group I, whereas posterior transpedicular decompression and posterolateralfusion were performed on group II. Both groups were stabilized with pedicle screw instrumentation. Rapid recovery represented by improvement of at least one Frankel grade within 6 weeks after operation, otherwise it was slow recovery. Inflammatory markers were evaluated at initial diagnosis and at 6-week, 3-month, 6-month, and 1-year post-operation. RESULTS: There were 31 patients. Group I included 14 cases and group II consisted of 17 cases. The median CRP and ESR at diagnosis were 80.4 mg/L and 78.0 mm/hour respectively. Rapid neurological recovery significantly related to the earlier declination of CRP within the first 6 weeks (p < 0.001). Considering the type of spinal procedures especially at thoracic and thoracolumbar level, neurological recovery in group I was significantly faster than in group II (p = 0.02; relative risk, 2.67; 95% confidence interval, 1.02 to 6.91). CONCLUSION: Earlier declination of CRP within six weeks post-operation could determine rapid neurological recovery. Posterior transforaminal decompression and interbody fusion with instrumentation may be a suitable optionfor thoracic and thoracolumbar lesions.

Correlation between Serum Level of Monocyte Chemoattractant Protein-1 and Postoperative Recurrence of Spinal Tuberculosis in the Chinese Han Population.

OBJECTIVE: To correlate serum level of monocyte chemoattractant protein-1 (MCP-1) with postoperative recurrence of spinal tuberculosis in the Chinese Han population. METHODS: Patients of Han nationality with newly diagnosed spinal tuberculosis were consecutively included in this study. At different time points postoperatively, serum level of MCP-1 was determined using an enzyme linked immunosorbent assay. Recurrence of spinal tuberculosis after surgery and during the follow-up period was recorded. The correlation between serum MCP-1 level and recurrence of spinal tuberculosis was analyzed. RESULTS: A total of 169 patients with spinal tuberculosis were included in the study and followed up for an average of 2.2 ± 1.3 years (range, 1-5 years). Of these patients, 11 had postoperative recurrence of spinal tuberculosis. The patients' serum level of MCP-1 increased significantly after postoperative recurrence of spinal tuberculosis. Once the symptoms of recurrence were cured, the serum level of MCP-1 decreased significantly and it did not differ from patients without disease recurrence. CONCLUSION: Postoperative recurrence of spinal tuberculosis is likely to increase the serum level of MCP-1.

Differential diagnosis between tuberculous spondylodiscitis and pyogenic spontaneous spondylodiscitis: a multicenter descriptive and comparative study.

BACKGROUND CONTEXT: Although tuberculous and pyogenic spondylodiscitis are common causes of spinal infections, their protean manifestation complicates differential diagnosis. PURPOSE: The clinical, laboratory, and radiologic characteristics of tuberculous and pyogenic spontaneous spondylodiscitis were compared in this study. STUDY DESIGN: This multicenter retrospective study was conducted in 11 teaching hospitals in the Republic of Korea from January 2011 to December 2013. PATIENT SAMPLE: Study subjects included adult patients (≥18 years) diagnosed with tuberculous (n=60) or pyogenic (n=117) spontaneous spondylodiscitis. OUTCOME MEASURES: Risk factors for tuberculous spondylodiscitis were determined, and their predictive performance was evaluated. METHODS: Multivariate logistic regression analysis was performed to determine predictors independently associated with tuberculous spondylodiscitis. Receiver-operating characteristic curve analysis using the presence or absence of risk factors was used to generate a risk index to identify patients with increased probability of tuberculous spondylodiscitis. RESULTS: Of 177 patients, multivariate logistic regression analysis showed that patients with tuberculous spondylodiscitis (n=60) were more frequently women, with increased nonlumbar spinal involvement and associated non-spinal lesions, delayed diagnosis, higher serum albumin levels, reduced white blood cell counts, and lower C-reactive protein and procalcitonin levels. Among 117 patients with pyogenic spondylodiscitis, the most frequent causative microorganism was Staphylococcus aureus (64.1%). The mean diagnostic delay was significantly shorter, which may reflect higher clinical expression leading to earlier diagnosis. A combination of clinical data and biomarkers had better predictive value for differential diagnosis compared with biomarkers alone, with an area under the curve of 0.93, and sensitivity, specificity, and positive and negative predictive values of 95.0%, 79.5%, 70.4%, and 96.9%, respectively. CONCLUSIONS: This study provides guidance for clinicians to predict the causative organisms of spondylodiscitis in uncertain situations and before culture or pathologic examinations. Clinical data and single biomarkers combined can be useful for differential diagnoses between tuberculous and pyogenic spondylodiscitis.

Serum and CSF cytokines and matrix metalloproteinases in spinal tuberculosis.

AIMS AND OBJECTIVES: Both pro-inflammatory and anti-inflammatory cytokines play key roles in the pathogenesis of various forms of tuberculosis. In this study, we evaluated the role of various cytokines and matrix metalloproteinases (MMPs) in patients with spinal tuberculosis. MATERIALS AND METHODS: In this prospective study, we enrolled 55 histopathologically/microbiologically confirmed patients with spinal tuberculosis. We also included 55 control subjects. Blood and cerebrospinal fluid (CSF) were collected both from cases and controls. Tumor necrosis factor (TNF)-α, interferon (IFN)-γ, interleukin (IL)-1ß, IL-6, IL-8, IL-10, matrix metalloproteinases MMP-2 and MMP-9 were measured by enzyme-linked immunosorbent assay (ELISA). Disability and outcome were measured by modified Barthel Index (MBI). Measured inflammatory parameters were correlated with the outcome after 6 months of follow-up. RESULTS: We observed that serum and CSF cytokines and MMPs were significantly higher in patients with spinal tuberculosis than in controls (p < 0.001). Spearman's rank order correlation test for correlation of baseline MBI (measure of disability) and cytokine/MMP levels showed that baseline MBI had significant negative correlation with serum levels of IFN-γ (r = -0.517; p < 0.001), IL-1ß (r = -0.355; p = 0.008), IL-6 (r = -0.306; p = 0.023), IL-8 (r = -0.275; p = 0.042), MMP-9 (r = -0.311; p = 0.021) and CSF levels of TNF-α (r = -0.327; p = 0.015); whereas baseline MBI had a positive correlation with the serum level of anti-inflammatory cytokine IL-10 (r = 0.327; p = 0.015). Poor outcome, after 6 months, was associated with higher serum TNF-α (p = 0.015) and IFN-γ (p = 0.021) and CSF MMP-9 (p = 0.006) and a lower serum IL-10 (p = 0.018) level. CONCLUSIONS: To conclude, in patients of spinal tuberculosis, poor outcome is associated with higher pro-inflammatory serum TNF-α and IFN-γ, and CSF MMP-9 levels, and a lower anti-inflammatory serum IL-10 level.

Computed tomography-guided percutaneous focal catheter infusion in the treatment of spinal tuberculosis.

The study aimed to investigate the efficacy of computed tomography (CT)-guided percutaneous focal catheter infusion for the treatment of spinal tuberculosis. Clinical and follow-up data from 27 spinal tuberculosis patients who underwent CT-guided intervertebral catheterized infusion chemotherapy from May 2008 to October 2011 were retrospectively analyzed; treatment included pure intervertebral infusion chemotherapy and catheter drainage for continuous abscess washing during infusion chemotherapy. All surgeries were successfully completed under CT guidance without complications. The C-reactive protein levels of most patients rebounded within the first postoperative week but significantly decreased after the second and fourth postoperative weeks. CT-guided percutaneous focal catheter infusion was effective for the treatment of spinal tuberculosis and induced little trauma; this treatment could also relieve the symptoms and improve the quality of life of elderly patients with poor general conditions.

Comparison of platelet count in tuberculosis spine to other spine pathology.

PURPOSE: Haematological markers currently used to investigate TB spine vary from WCC, Anaemia, ESR and CRP. Platelet count in TB spine as a marker has been inadequately investigated. METHOD: In this retrospective review, Platelet count in TB spondylitis on admission was compared to patients undergoing other elective spinal surgery (control) preoperatively. Comparisons of the platelets with ESR and the effect of HIV on platelet count in TB spine were also evaluated. RESULTS: 160 TB spine patients showed statistically significant higher platelet count when compared to 210 patients in the control group (p < 0.001). 52.5 % patients had a raised platelet count in the TB spondylitis group. Raised Platelet count had a sensitivity and specificity of 52.5 % and 86.2 %, respectively in TB spondylitis. ESR and platelet count had a Pearson correlation r = 0.31 (p < 0.001). HIV however did not statistically show any difference in the platelet count (p = 0.12). CONCLUSION: A raised platelet count in spinal pathology may be used as an inflammatory marker of TB spondylitis.

[Evaluation using QFT-2G/TBGL/LAM in the patients with osteoarticular tuberculosis of post-treatment period].

PURPOSE: To evaluate results of QFT-2G/TBGL/ LAM in patients who had been completed the antituberculosis treatment for osteoarticular tuberculosis with various periods after the completion of the treatment, MATERIALS AND METHODS: Fifty-five patients who had been completed the antituberculosis treatment for osteoarticular tuberculosis at least one year after the completion of treatment were evaluated using QFT-2G/TBGL/LAM tests. Forty patients with spinal tuberculosis and 15 patients with articular tuberculosis were included. The patients with the period after the completion of the treatment less than 4 years were classifled as short-term group (33 patients) and those with the period not less than 4 years were classified as mid-long-term group (22 patients). The results of the tests were compared between the two groups. RESULTS: The result of QFT-2G test was positive in 60.6% of the patients in short-term group while 45.5% in mid-long-term group (p=0.12). On the other hand, the result of TBGL test was positive in 75.8% of the patients in short-term group whereas 22.7% in mid-long-term group (p=0.0001) and the result of LAM test was positive in 90.9% of the patients in short-term group whereas 63.6% in mid-long-term group (p= 0.01), both of these tests showed significantly low,er positive rate in mid-long-term group. There was no significant difference in the comparisons between patient groups writh/without pulmonary tuberculosis as well as with/without surgical treatment. CONCLUSION: The patients with a history of osteoarticular tuberculosis tend to show positive results of QFT-2-G test for a prolonged period, whereas significantly less positive results of TBGL/LAM tests in mid-long-term.

Transpedicular curettage and drainage of infective lumbar spondylodiscitis: technique and clinical results.

BACKGROUND: Infective spondylodiscitis usually occurs in patients of older age, immunocompromisation, co-morbidity, and individuals suffering from an overall poor general condition unable to undergo reconstructive anterior and posterior surgeries. Therefore, an alternative, less aggressive surgical method is needed for these select cases of infective spondylodiscitis. This retrospective clinical case series reports our novel surgical technique for the treatment of infective spondylodiscitis. METHODS: Between January 2005 and July 2011, among 48 patients who were diagnosed with pyogenic lumbar spondylodiscitis or tuberculosis lumbar spondylodiscitis, 10 patients (7 males and 3 females; 68 years and 48 to 78 years, respectively) underwent transpedicular curettage and drainage. The mean postoperative follow-up period was 29 months (range, 7 to 61 months). The pedicle screws were inserted to the adjacent healthy vertebrae in the usual manner. After insertion of pedicle screws, the drainage pedicle holes were made through pedicles of infected vertebra(e) in order to prevent possible seeding of infective emboli to the healthy vertebra, as the same instruments and utensils are used for both pedicle screws and the drainage holes. A minimum of 15,000 mL of sterilized normal saline was used for continuous irrigation through the pedicular pathways until the drained fluid looked clear. RESULTS: All patients' symptoms and inflammatory markers significantly improved clinically between postoperative 2 weeks and postoperative 3 months, and they were satisfied with their clinical results. Radiologically, all patients reached the spontaneous fusion between infected vertebrae and 3 patients had the screw pulled-out but they were clinically tolerable. CONCLUSIONS: We suggest that our method of transpedicular curettage and drainage is a useful technique in regards to the treatment of infectious spondylodiscitic patients, who could not tolerate conventional combined anterior and posterior surgery due to multiple co-morbidities, multiple level infectious lesions and poor general condition.