Surgical treatment for spinal tuberculosis is necessary in particular cases that a large amount of necrotic tissue is encountered and there is spinal cord compression. A spinal shortening osteotomy procedure has previously been described for the correction of the sagittal balance in a late kyphotic deformity, but there have been no reports on this as a surgical treatment in the acute stage. Thus, the aim of this report is to present the surgical techniques and clinical results of 3 patients who were treated with this procedure. Three patients with tuberculous spondylitis at the thoracic spine were surgically treated with this procedure. All the patients presented with severe progressive back pain, kyphotic deformity and neurological deficit. The patients recovered uneventfully from surgery without further neurological deterioration. Their pain was improved and the patients remained free of pain during the follow-up period. In conclusion, posterior spinal shortening osteotomy is an alternative method for the management of tuberculous spondylitis.
Tuberculosis; TB spine; Shortening osteotomy; Surgical treatment
Spinal hydatid cyst with thoracic vertebra involvement is rare but serious condition. We present a 63-year old woman with spinal hydatid disease mimicking tuberculous spondylitis. A case study with Computerised Tomography and Magnetic Resonance Imaging diagnostic findings and surgical treatment is reported in this article. Primary spinal hydatid disease should be considered in the differential diagnosis of tuberculous spondylitis in endemic area. Familiarity with typical imaging appearances of spinal hydatid disease may be helpful in making a correct diagnosis and treatment.
This is a retrospective study.
We wanted to evaluate the treatment outcomes of performing simultaneous anterior and posterior surgery for patients with tuberculous spondylitis and psoas abscess.
Overview of Literature
Although various treatment options have been used for spinal tuberculosis, there are only a few reports on the treatment of tuberculous spondylitis with psoas abscess.
Between March 1997 and February 2006, we performed operations on 14 cases of tuberculous spondylitis with psoas abscess. All the cases underwent anterior debridement with an interbody bone graft and posterior fusion with using pedicle screws.
Under the Frankel classification, 1 case improved by two grades, 10 cases improved by 1 grade and 3 cases demonstrated no change. The Kirkaldy-Willis functional outcomes were classified as excellent in 10 cases and good in 4. One year after surgery, bony union was confirmed in all 14 cases. The mean kyphotic angle of the spinal lesion was 12.4° and the mean lordotic angle at the final follow-up was 6.4°. Postoperative complications (superficial wound infections) were encountered in 2 cases.
Our results demonstrate that anterior debridement with interbody bone grafting and posterior instrumented fusion can provide satisfactory results for treating tuberculous spondylitis with psoas abscess in patients with neurological deficits.
Tuberculous spondylitis; Psoas abscess; Neurological deficit; Anterior and posterior surgery
Ankylosing spondylitis (AS) may lead to a severe fixed thoracolumbar kyphotic deformity (TLKD) of the spine. In a few patients, the TLKD is so extreme that a corrective osteotomy of the spine may be considered. Several authors have reported the results of patients treated by a lumbar osteotomy, but there is no consensus on the level of the osteotomy and on the exact degree of correction required. This can be explained by the lack of quantification of the sagittal plane deformity, since compensation mechanisms of the lower extremities have to be reckoned with for the assessment of spinal sagittal balance in AS. Therefore, there is a need for a method of deformity planning for sagittal plane corrective osteotomies of the spine in AS. In this study, a biomechanical analysis and a newly developed planning procedure are presented and illustrated with two cases of AS. Sagittal balance of the spine was defined in relation to the physiologic sacral end plate angle using trigonometric terms. Nomograms were constructed to show the relationship between the correction angle, horizontal position of the C7 plumb line and the level of the spinal osteotomy. The surgical results of two patients were retrospectively analyzed with our method. It showed that the effect of a spinal osteotomy on the horizontal position of the C7 plumb line depends on the combination of correction angle and the level of osteotomy. In one patient, the achieved correction of the deformity proved to correct the sagittal spinal balance and the pelvic sacral endplate angle. In the other patient, the achieved correction was not sufficient. It is concluded that adequate deformity planning for sagittal plane corrective osteotomies of the spine in AS is essential for reliable prediction of the effect of a lumbar osteotomy on the correction of the spine.
Key words Ankylosing spondylitis; Osteotomy; Spine; Methods
This is a retrospective series.
We wanted to analyze the safety and effectiveness of using the newer generation metallic implants (pedicle screws and/or titanium mesh) for the treatment of tuberculous spondylitis.
Overview of the Literature
There have been various efforts to prevent the development of a kyphotic deformity after the treatment of tuberculous spondylitis, including instrumentation of the spine. Pedicle screws and titanium mesh cages have become more and more popular for treating various spinal problems.
Twenty two patients who had tuberculous spondylitis were treated with anterior radical debridement and their anterior column of spine was supported with a tricortical iliac bone graft (12 patients) or by mesh (10 patients). Supplementary posterior pedicle screw instrumentation was performed in 17 of 22 patients. The combination of surgeries were anterior strut bone grafting and posterior pedicle screws in 12 patients, anterior titanium mesh and posterior pedicle screws in 5 patients and anterior mesh only without pedicle screws in 5 patients. The patients were followed up with assessing the laboratory inflammatory parameters, the serial plain radiographs and the neurological recovery.
The erythrocyte sedimentation rate and C-reactive protein levels were eventually normalized and there was no case of persistent infection or failure to control infection in spite of a mettalic implant in situ. The overall correction of kyphotic deformity was initially 8.9 degrees, and the loss of correction was 6.2 degrees. In spite of some loss of correction, this technique effectively prevented clinically significant kyphotic deformity. The preoperative Frankel grades were B for 1 patient, C for 4, D for 4 and E for 13. At the final follow-up, 7 of 9 patients recovered completely to Frankel grade E and only two patients showed a Frankel grade of D.
Stabilizing the spine with pedicle screws and/or titanium mesh in patients with tubercuous spondylitis effectively prevents the development of kyphotic deformity and this did not prevent controlling infection when this technique was combined with radical debridement and anti-tuberculous chemotherapy.
Tuberculous spondylitis; Pedicle screw; Titanium mesh
Percutaneous curettage and continuous irrigation were performed
for definitive diagnosis and treatment of tuberculous (TB) lumbar
spondylitis. Under local anaesthesia, affected lumbar discs were
curetted using a procedure of percutaneous nucleotomy, and in-tube
and the out-tube were placed for continuous irrigation. The period
of continuous irrigation was 12–16 days. Mycobacterium
tuberculosis was demonstrated in case 1 by culture and PCR,
whereas histology showed tuberculous lesion with caseous necrosis
in both cases. Postoperative MRI showed markedly reduced abscesses
after 3 months in both cases. The signal intensity in vertebral
bodies was improved. In Case 2, CT observations showed remodeling
over time in the vertebral body cavities. This method is
advantageous in that although minimally invasive, it achieves
identification of pathogenic bacteria and treatment
simultaneously. This surgical procedure is expected to prove
effective for both TB and pyogenic spondylitis.
In the last decade a significant rise in the prevalence of tuberculosis as well as in its extrapulmonary manifestations is detected worldwide. The central nervous system, the genitourinary tract, the organs of the abdomen and the skeletal system, are common sites of infection. Misdiagnosis and delay in treatment are common events. Herein, we present a case of a 78-year-old man non-smoker, with miliary tuberculosis complicated with tuberculous spondylitis. The patient presented with anemia and a left shoulder pain, accompanied by rigor and fever 37.5°C-38°C of one month duration. This entity is extremely rare, since only two similar cases have been reported in the English literature according to PubMed search.
Nowadays, endoscopic techniques are widely used in surgical procedures. Retroperitoneoscopy has been an extremely valuable tool for a wide variety of urologic disorders, whereas, it has limited use in orthopedic procedures.
We performed retroperitoneoscopic drainage (in combination with medical treatment) of complicated psoas abscess on 12 patients with tuberculous spondylitis. All the procedures were done under general anesthesia and in the lateral decubitus position. Psoas abscess was evacuated during procedure, and postoperatively, drainage was continued through a large silastic tube. The definitive diagnosis and the treatment were made based on the results of culture-antibiogram and PCR testing.
Complete clinical and radiologic remission was observed in all patients in 3–6 months. The complication was not observed in any case postoperatively.
Retroperitoneoscopic drainage of psoas abscesses gains advantages in terms of rapid recovery, minimal invasiveness, absence of radiation, and shorter hospital stay. This procedure can be used not only for cold abscesses but also for other pathologies of lumbar vertebral area.
Retroperitoneoscopy; Tuberculous spondylitis; Psoas abscess
A 21 year old oriental male presented with a one month history of neck pain associated with neck stiffness and dysphagia. A five week course of chiropractic treatment relieved most of his symptoms. Due to persistent tenderness in the suboccipital region and substantial weight loss, he was subsequently hospitalized. Further investigations revealed tuberculous osteomyelitis affecting the left lateral mass of C1 and likely the C2 vertebra. Tuberculous spondylitis accounts for more than 50% of all cases of skeletal tuberculosis and is the most common cause of vertebral infection, particularly in young people.
Tuberculosis; spine; infection; chiropractic
We present a case of tuberculous spondylitis in which diagnosis was masked by a concomitant pyogenic infection. The patient had undergone percutaneous needle aspiration of an abscess in the cavity of the psoas muscle. Early results from the culture regimen showed isolation of methicillin-resistant Staphylococcus aureus. After eight weeks, mycobacterium tuberculosis was grown at regimen which was cultured at the same site. Initial isolation of pyogenic bacteria, considered to be highly virulent organisms, led to delayed diagnosis and treatment of the tuberculosis.
Tuberculous spondylitis; Pyogenic spondylitis; Concomitant infection
Surgery in late stage ankylosing spondylitis (AS) most often tends to correct the sagittal balance with an extension osteotomy of the spine. In the literature, extension osteotomy was first described as an open wedge osteotomy but recently closed wedge osteotomy resecting the pedicles and posterior elements have become more popular. Only a limited number of cases have been reported in the literature and with limited focus on outcome of this major surgery. In this study, we reported the results of a large series of extension osteotomy in a population of patients with AS focusing on the technical aspects, complication rates, correction obtained and outcome evaluation using newer spine outcome measuring instruments. In the period from 1995 to 2005, 36 consecutive patients fulfilled the criteria where the files, radiographs and patients were available for further studies. The following data were recorded: Age, sex, comorbidity, indication, operation time and blood loss, level of osteotomy and estimated Correction. Furthermore, perioperative complications and all late complications were registered. The average follow-up was 50 months (3–128). Twenty-one patients also filled out questionnaires (SF36 and Oswestry Disability Index) preoperatively. At the end of the period all patients were contacted and filled out the same questionnaires. Fifteen of the patients had two pedicular resection osteotomies performed, 21 had one, and two had polysegmental osteotomies. Mean operation time was 180 min, bleeding was mean 2,450 ml, stay at the hospital was 13 days. One patient had partial paresis of the lower extremities all other complications were minor. The median correction was 45°. The median Oswestry score improved significantly from 54 (range 20–94) preoperatively to 38 (range 2–94) postoperatively. The SF-36 score significantly increased, when evaluated on the major components Physical Component Summary (PCS) and Mental Component Summary (MCS). The thoracolumbar closed wedge pedicular resection osteotomy used in this series was a safe method for correction of incapacitating kyphosis in AS. There was an acceptable rate of perioperative complications and no mortality. The correction obtained was in average 45°. All of the patients except one maintained their good correction and restored function. Outcome analysis showed a significant improvement in SF-36 and Oswestry Disability Index, and the mental component of the SF-36 showed improvement to values near the normative population. It is concluded that corrective osteotomy of the thoracolumbar spine in AS is an effective and safe treatment with improvements in quality of life.
Ankylosing spondylitis; Closed wedge osteotomy; Bechterew; Spine; Outcome analysis
There are four major challenges in the assessment of outcomes in patients with ankylosing spondylitis (AS) that are particularly relevant to the evaluation of new therapies. Firstly, measures of symptoms and impairment in AS are not specific for inflammatory processes, they also capture mechanical symptoms and fixed limitations. The non‐specific nature of these measures may cause them to be less responsive and therefore less useful in determining treatment efficacy. Secondly, acute phase reactants have limited value as measures of AS activity and other surrogate markers have not yet been established. Thirdly, the assessment of the disease modifying potential of new therapies is hampered by the slow rate of spinal fusion. Fourthly, work disability has not be studied as an endpoint in clinical trials in AS, despite the fact that work disability is an important outcome in patients with AS. Research into ways to overcome these challenges in outcome measurement will help identify useful therapies and define the range of outcomes that they influence.
ankylosing spondylitis; work disability; spinal disease; surrogate marker
Tuberculous spondylitis is a very rare disease, but it can result in bone destruction, kyphotic deformity, spinal instability, and neurologic complications unless early diagnosis and proper management are done. Because the most common symptom of tuberculous spondylitis is back pain, it can often be misdiagnosed. Atypical tuberculous spondylitis can be presented as a metastatic cancer or a primary vertebral tumor. We must make a differential diagnosis through adequate biopsy. A 30-year-old man visited our clinic due to back and chest pain after a recent traffic accident. About 1 year ago, he had successfully recovered from tuberculous pleurisy after taking anti-tuberculosis medication. We performed epidural and intercostal blocks but the pain was not relieved. For the further evaluation, several imaging and laboratory tests were done. Finally, we confirmed tuberculous spondylitis diagnosis with the biopsy results.
back pain; biopsy; differential diagnosis; tuberculous spondylitis
A closing wedge osteotomy of the lumbar spine may be considered to correct posture and spinal balance in progressive thoracolumbar kyphotic deformity caused by ankylosing spondylitis (AS). Adequate deformity planning is essential for reliable prediction of the effect of surgical correction of the spine on the sagittal balance and horizontal gaze of the patient. The effect of a spinal osteotomy on the horizontal gaze is equal to the osteotomy angle. However, the effect of a spinal osteotomy on the sagittal balance depends on both the correction angle and the level of osteotomy simultaneously. The relation between the correction angle, the level of osteotomy and the sagittal balance of the spine can be expressed by a mathematical equation. However, this mathematical equation is not easily used in daily practice. We present the computer program ASKyphoplan that analyses and visualizes the planning procedure for sagittal plane corrective osteotomies of the spine in AS. The relationship between the planned correction angle, level of osteotomy and sagittal balance are coupled into the program. The steps taken during an ASKyphoplan run are outlined, and the clinical application is discussed. The application of the program is illustrated by the analysis of the data from a patient recently treated by a lumbar osteotomy in AS. The software can be used free of charge on the internet at http://www.stega.nl under the heading “research” in the menu.
Ankylosing spondylitis; Osteotomy; Spine; Computer program; Deformity planning
Postoperative infections following spine surgery are usually attributable to bacterial organisms. Staphylococcus aureus is known to be the most common single pathogen leading to this infection, and the number of infections caused by methicillin-resistant Staphylococcus aureus is increasing. However, there is a paucity of literature addressing postoperative infection with Mycobacterium tuberculosis. We encountered a case of tuberculous spondylitis after spine surgery. A man had fever with low back pain three weeks after posterior interbody fusion with instrumentation for a herniated intervertebral disc at the L4-L5 level. He had been treated with antibiotics for an extended period of time under the impression that he had a bacterial infection, but his symptoms and laboratory data had not improved. Polymerase chain reaction for Mycobacterium tuberculosis turned out to be positive. The patient's symptoms finally improved when he was treated with antituberculosis medication.
Spine; Postoperative infection; Tuberculous spondylitis
An accepted comprehensive clinical approach to the deformed spine with tuberculous infection is still lacking. We aimed to determine the usage of a staged algorithm in the treatment of kyphotic spine with tuberculous infection and to present the clinical results of the patients treated with the help of this protocol.
Materials and Methods:
54 patients (28 females, 26 males) with a mean age of 39.2 (22-76) years. Preoperative, early postoperative, and followup clinical and radiologic results were evaluated retrospectively. The patients were classified into Kaplan A (kyphotic deformity <30°), Kaplan B (kyphotic deformity 30°-60°) and Kaplan C (kyphotic deformity >60°). They were operated by posterior instrument with anterior debridment (Kaplan A), debridment with anterior bone grafting (Kaplan B) and anterior column resection and bone grafting in Kaplan C.
Tuberculous involvement were seen at more than one level in 40 patients and paraspinal abscess were detected in 31. Preoperative focal kyphotic deformity was reconstructed with an average of 19 (9-38) degrees. Twenty-six patients had neurologic compromise with different severities and 12 of them improved after the surgical intervention. Improvement in work ability and pain status was detected in 52% and 61% of the patients, respectively. Wound complications responding to medical care were detected in nine patients. Initial kyphotic deformity was found as an important parameter in selecting the surgical procedure.
Regarding resected amount of infected osseous material, as planned preoperatively, have resulted with better concordance between anterior and posterior column heights and better sagittal alignment. We could correct kyphosis and improve sagittal balance with staged algorithm as used by us.
Debridement; kyphosis in tuberculous spondylitis; tuberculous spondylitis
With the advancement of instrumentation and minimally access techniques in the field of spine surgery, good surgical decompression and instrumentation can be done for tuberculous spondylitis with known advantage of MIS (minimally invasive surgery). The aim of this study was to assess the outcome of the minimally invasive techniques in the surgical treatment of patients with tuberculous spondylodiscitis.
Materials and Methods:
23 patients (Group A) with a mean age 38.2 years with single-level spondylodiscitis between T4-T11 treated with video-assisted thoracoscopic surgery (VATS) involving anterior debridement and fusion and 15 patients (Group B) with a mean age of 32.5 years who underwent minimally invasive posterior pedicle screw instrumentation and mini open posterolateral debridement and fusion were included in study. The study was conducted from Mar 2003 to Dec 2009 duration. The indication of surgery was progressive neurological deficit and/or instability. The patients were evaluated for blood loss, duration of surgery, VAS scores, improvement in kyphosis, and fusion status. Improvement in neurology was documented and functional outcome was judged by oswestry disability index (ODI).
The mean blood loss in Group A (VATS category) was 780 ml (330-1180 ml) and the operative time averaged was 228 min (102-330 min). The average preoperative kyphosis in Group A was 38° which was corrected to 30°. Twenty-two patients who underwent VATS had good fusion (Grade I and Grade II) with failure of fusion in one. Complications occurred in seven patients who underwent VATS. The mean blood loss was 625 ml (350-800 ml) with an average duration of surgery of 255 min (180-345 min) in the percutaneous posterior instrumentation group (Group B). The average preoperative segmental (kyphosis) Cobb's angle of three patients with thoracic TB in Group B was 41.25° (28-48°), improved to 14.5°(11°- 21°) in the immediate postoperative period (71.8% correction). The average preoperative segmental kyphosis in another 12 patients in Group B with lumbar tuberculosis of 20.25° improved to –12.08° of lordosis with 32.33° average correction of deformity. Good fusion (Grade I and Grade II) was achieved in 14 patients and Grade III fusion in 1 patient in Group B. One patient suffered with pseudoarthrosis/doubtful fusion with screw loosening in the percutaneous group.
Good fusion rate with encouraging functional results can be obtained in caries spine with minimally invasive techniques with all the major advantages of a minimally invasive procedures including reduction in approach-related morbidity.
Minimally invasive spine surgery; tuberculous spondylodiscitis; video-assisted thoracoscopic surgery
Ankylosing spondylitis (AS) patients are most challenging. These patient present the most serious array of intubation and difficult airway imaginable, secondary to decrease or no cervical spine mobility, fixed flexion deformity of thoracolumbar spine and possible temporomandibular joint disease. Sound clinical judgment is critical for timing and selecting the method for airway intervention. The retrograde intubation technique is an important option when fiberoptic bronchoscope is not available, and other method is not applicable for gaining airway access for surgery in prone position. We report a case of AS with fixed flexion deformity of thoracic and thoracolumbar spine, fusion of posterior elements of cervical spine posted for lumbar spinal osteotomy with anticipated difficult intubation. An awake retrograde oral intubation with light sedation and local block is performed.
Difficult airway; ankylosing spondylitis; Retrograde intubation
Two cases with a long-standing thoracolumbar kyphosis due to ankylosing spondylitis are presented with a symptomatic localized destructive kyphotic lesion of the spine. Clinical and radiographic findings demonstrated a progressive vertebral and discovertebral kyphotic pseudarthrosis, known as an Andersson lesion, at the L1 and L1-2 level, respectively. Surgical correction and stabilization was performed by an extending transpedicular wedge resection osteotomy to restore spinal stability, to facilitate fracture healing as well as to restore the sagittal balance of the ankylosed spine. To predict the effect of a surgical correction of the Andersson lesion on the sagittal balance, deformity planning was performed preoperatively. The indication for surgery, the surgical technique and the 2 years’ clinical results are described. In addition, the difficulties experienced with preoperative deformity planning are evaluated.
Ankylosing spondylitis; Andersson lesion; Surgery; Deformity planning
Surgical treatment is mandatory for spinal pseudarthrosis in advanced ankylosing spondylitis (AS) patients with painful sagittal deformity and/or neurological deficits. However, the most effective and safe surgical procedure for AS-related symptomatic thoracolumbar pseudarthrosis is still controversial. The purpose of this study is to explore the outcomes of pedicle subtraction osteotomy (PSO) at the level of pseudarthrotic lesion combined with supplemental anterior fusion for patients suffering from kyphotic pseudarthrosis in AS.
Materials and methods
Seven AS patients with thoracolumbar pseudarthrosis and kyphotic deformity were reviewed. There were 6 males and 1 female with a mean age of 41.7 years. All patients had back pain. Imaging findings demonstrated 3-column extensive discovertebral destruction in all patients. The preoperative global kyphosis averaged 75° (range, 37°–114°) with the apex at the level of pseudarthrosis. Three patients had incomplete neurological deficits (Frankel D) preoperatively. All patients underwent PSO at the level of pseudarthrosis in the first stage followed by supplemental anterior fusion in the second stage. Radiographic and clinical outcomes were assessed with an average follow-up of 38 months (range, 24–59 months). The visual analogue scale (VAS) was compared before surgery and at the final follow-up.
All patients showed significant pain relief postoperatively and were satisfied with the kyphosis correction as well. Solid bony fusion was shown at the final follow-up. Three patients with neurological deficits had complete recovery of neurological function. The global kyphosis was corrected from 75º to 30º, with a mean correction of 45º. The VAS showed significant improvement. No surgical complication was observed.
PSO can be safely performed through the site of pseudarthrotic lesion in AS patients with pseudarthrosis and kyphotic deformity. After PSO, supplemental anterior fusion is sometimes necessary to support the anterior and middle column in a second stage if there is a bone defect in the osteotomy site.
Ankylosing spondylitis; Pseudarthrosis; Osteotomy
OBJECTIVES—Three operative techniques have been described to correct thoracolumbar kyphotic deformity (TLKD) resulting from ankylosing spondylitis (AS) at the level of the lumbar spine: opening wedge osteotomy, polysegmental wedge osteotomies, and closing wedge osteotomy. Little knowledge exists on the indication for, and outcome of these corrective lumbar osteotomies.
METHODS—A structured review of the medical literature was performed.
RESULTS—A search of the literature revealed 856 patients reported in 41 articles published between 1945 and 1998. The mean age at time of operation was 41 years, male-female ratio 7.5 to 1. In 451 patients an open wedge osteotomy was performed. Polysegmental wedge osteotomies were performed in 249 patients and a closing wedge osteotomy in 156 patients. Most of the studies primarily focus on the surgical technique. Technical outcome data were poorly reported. Sixteen reports, including 523 patients, met the inclusion criteria of this study, and could be analysed for technical outcome data. The average correction achieved with each surgical techniques ranged from 37 to 40 degrees. Loss of correction was mainly reported in patients treated by open wedge osteotomy and polysegmental wedge osteotomies. Neurological complications were reported in all three techniques. The perioperative mortality was 4%. Pulmonary, cardiac and intestinal problems were found to be the major cause of fatal complications.
CONCLUSION—Lumbar osteotomy for correction of TLKD resulting from AS is a major surgery. The indication for these lumbar osteotomies as well as the degree of correction in the lumbar spine has not yet been established. Furthermore, there is a need for a generally accepted clinical score that encompasses accurate preoperative and postoperative assessment of the spinal deformity. The results of this review suggest that the data from the literature are not suitable for decision making with regard to surgical treatment of TLKD resulting from AS.
Spinal tuberculosis represents a challenging disease to treat, not because of the technical expertise or the time required to cure it, but more so because of the decisions involved to treat it. The Medical Research Council (MRC) Working Party on Tuberculosis of the Spine designed trials to help address several questions.
A comprehensive literature search was performed using PubMed Medline, including English articles from 1934 to 1012, which pertain to spinal tuberculosis, with special effort in tracing the 13 MRC reports. The primary focus was on disease eradication, fusion rate, and a secondary focus on both short and long-term results in terms of disease recurrence and alignment. Additional searches were made on the use of spinal implants for infection cases.
After reviewing MRC and non-MRC reports, it was evident that the “Hong Kong operation”, which involved radical debridement and strut grafting the lesion, produced better short-, medium- and long-term results in such aspects as fusion rate, spinal deformity and relapse of abscess/sinus. Subsequent work by others demonstrated the importance of prevention of progressive kyphosis, therefore the need to identify risk factors for these and pre-emptive measures such as kyphosis correction, careful graft selection, and instrumentation.
Improvement in quality of life is also accompanied by higher patient expectations. Though developing nations may lack the resources now, eventually patients will demand better functional and cosmetic results after being afflicted by this disfiguring and potentially disabling disease, and the “Hong Kong operation” represented the best outcome, provided resources were available.
Tuberculosis; Spine; Spinal fusion; Debridement; Instrumentation
The authors report a case of iliopsoas tuberculous abscess without obvious spinal column involvement. Cervical and axillary tuberculous lymphadenopathy were also presented. Despite appropriate antituberculous treatment, patient required percutaneous drainage with CT-guided catheter insertion.
Hydrocephalus is well recognised as a complication of tuberculous meningitis in childhood. This complication may occur more frequently in the acute stage in adults than has been appreciated. Three cases are described to illustrate this observation. Early recognition and prompt treatment may improve mortality and morbidity at any age.
Objective: To determine the efficacy of anakinra, an interleukin 1 receptor antagonist in active ankylosing spondylitis (AS), and to investigate the effect of anakinra treatment on spinal enthesitis/osteitis using magnetic resonance imaging (MRI).
Methods: A 3 month open label study of anakinra (100 mg subcutaneous injection daily) was carried out in nine patients with active AS who had back pain and an increased acute phase response, and who had failed to respond to at least one non-steroidal anti-inflammatory drug. Clinical assessment included the Bath AS Functional Index (BASFI), Bath AS Disease Activity Index (BASDAI), and AS Quality of Life (ASQoL) before and after treatment. Fat suppressed MRI of the spine and sacroiliac joints was performed with a 1.5 T scanner at baseline and at 3 months to determine the effect of treatment on spinal enthesitis/osteitis.
Results: Significant improvement was found in the BASFI (median baseline 5.88, 3 months 3.63, p = 0.021), BASDAI (median baseline 5.63, 3 months 3.48, p = 0.028), ASQoL (median baseline 12, 3 months 8, p = 0.011) and laboratory measures reflecting inflammation, with C reactive protein (median baseline 31 mg/l, 3 months 17 mg/l, p = 0.036) and erythrocyte sedimentation rate (median baseline 19 mm/1st h, 3 months 15 mm/1st h, p = 0.008) also showing significant improvement. Six patients (67%) achieved the Assessments in AS (ASAS) Working Group criteria of 20% improvement. Of the 38 regions of enthesitis/osteitis determined by MRI at baseline, 23 (61%) either improved or regressed completely.
Conclusions: This open label pilot study suggests that anakinra is effective in controlling the clinical manifestations of AS. The clinical response was reflected by an improvement in MRI determined spinal enthesitis/osteitis.