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Initial axial computed tomography at the level of T11(A) and 3D reconstruction (B) images of the thoracic vertebrae reveal multiple destructive lesions of the T9, T10 and T11 vertebral bodies and spinous process of T12.
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Objective
Spinal tuberculosis-associated symptoms are not so unique as to immediately indicate the proper diagnosis in most cases. Distinguishing spinal tuberculosis (Pott's disease) from pyogenic spondylitis is often difficult, and lesions metastatic from systemic malignancy are the other major entity from which spinal tuberculosis must be disting...
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Purpose
Spinal tuberculosis (TB) and metastatic tumor (MT) are common diseases with similar manifestations. Although pathological evaluation is the gold standard to confirm diagnosis, performing biopsies in all patients is not feasible. This study is aimed to create a scoring system to facilitate the differential diagnosis of spinal TB and MT befor...
Citations
... Atypical spinal TB is mainly represented by involvement of the posterior elements of the vertebrae, no intervertebral disc involvement, and extradural spinal cord compression without bony involvement. 16 Vertebral involvement without disc destruction is the most commonly reported atypical form of spinal TB. 17 Momjian and George, in their review of the literature, summarized the MRI presentation as signal abnormalities in the vertebral body with a preserved disc. 18 They added that it is difficult to differentiate the lesion from lymphoma or metastases. ...
Spinal tuberculosis usually presents as destroyed contiguous vertebral bodies associated with intervertebral discs and paravertebral or psoas abscesses. Atypical forms are uncommonly reported. Vertebral involvement without disk destruction is a rare form that improves satisfactorily after appropriate medical management. We report the case of a 36-year-old male who had spine tuberculosis without disk involvement, associated with intercurrent active pulmonary location with good clinical improvement after treatment and follow-up imaging showing spectacular regression of bone lesions. By reporting this case, we also review the literature on this rare form of tuberculosis.
... The posterior spinal approach, which is the workhorse of any spine surgeon, is not feasible in the upper thoracic region because of various anatomical reasons in addition to the presence of a scapula and strong shoulder muscles [2]. Pathologies commonly affecting the upper thoracic spine include fractures, tubercular osteomyelitis, ossification of the posterior longitudinal ligament (OPLL), and disk herniations [3][4][5][6]. While tubercular osteomyelitis is very commonly seen in the southern Asian subcontinent, the incidence of OPLL is high in East Asian populations [7][8][9]. ...
This retrospective case series of prospective data aims to describe the transaxillary approach for the treatment of upper thoracic spine pathology. Various surgical techniques and approaches have been reported across the literature to address upper thoracic spine pathology, including the cervicothoracic approach, anterior transsternal approach, posterolateral approach, supraclavicular approach, and lateral parascapular approaches. These techniques are invasive. A minimally invasive, less morbid, and direct access approach to the pathology of the upper thoracic spine has not been reported in the literature. Patients with pathology affecting the first thoracic vertebra up to the sixth thoracic vertebra were classified into the upper thoracic spine group. Patients with pathology below the sixth thoracic vertebra were excluded. Patients not having a minimum follow-up of 12 months were also excluded. The study analyzed 18 patients. The mean preoperative modified Japanese Orthopedic Association score was 7.2±1.44, which improved to 10.16±1.2 (p<0.05). The majority (14/18) of the patients had an excellent outcome. Three patients had good outcomes, and one patient had a fair outcome. Five cases of intraoperative dural leak were recorded, and one patient had postoperative neurological deficit. The transaxillary approach is a safe, viable, muscle-sparing, and minimally invasive approach for ventral pathologies of the upper thoracic spine.
... 22 Paravertebral TB abscesses tend to extend beyond osseous involvement with intervertebral discs sparing, demonstrated as T1W hypointensity and T2W hyperintensity with a thin contrast-enhancing wall on MRI; in contrast, pyogenic spondylitis usually forms abscesses with thick and irregularly enhancing walls, early herniation and disc destruction. 23 In a review of 26 spinal TB cases, only one had non-contiguous thoracic and lumbar involvement. 24 Notably, abscesses were present in 15 patients, 12 of which had an abscess at the initial presentation, and in the other 3, abscesses developed during treatment, highlighting the importance of following patients to detect abscess. ...
... 24 Notably, abscesses were present in 15 patients, 12 of which had an abscess at the initial presentation, and in the other 3, abscesses developed during treatment, highlighting the importance of following patients to detect abscess. 24 Although paravertebral masses are highly suggestive of spinal TB, non-contiguous multilevel lesions with intact intervertebral discs are usually seen in malignancies, 15,23,25 which could misdiagnose spinal TB as malignancy. 26,27 Bone metastases are the most common spinal neoplastic diseases, usually involving lower thoracic and upper lumbar and spinal TB. 25 Spinal metastases show T1W hypointensity and T2W and STIR hyperintensity, involving multiple non-contiguous vertebral bodies, particularly posterior elements with preserved intervertebral discs. ...
Spinal tuberculosis (TB) is diagnostically challenging, particularly in atypical forms. Non‐contiguous multilevel spinal TB (NMLST) is a rare presentation of spinal TB, mimicking spinal malignancies. We reported an unusual NMLST case with a paraspinal and epidural abscess in a young patient with misleading clinical and imaging presentations. Extra‐pulmonary TB can manifest with a variety of non‐specific presentations. The possibility of TB should always be kept in mind in endemic regions for prompt diagnosis and intervention to prevent severe sequels.
... Noncontiguous multi-tiered spinal involvement is very rare in the literature. 5 It is described especially among children under 7 years due to the persistence of intervertebral disc vascularization. 6 A case report of three foci spinal TB in ''British Journal Neurosurgery 2001'' was described as the first such report in English language literature. ...
The commonest site of osseous tuberculosis is the spine. Most vertebral lesions are contiguous. Current research indicates the incidence of multiple level noncontiguous vertebral tuberculosis is 1.1% to 16%1. Here, we describe a case with noncontiguous multisegmental spinal TB with no intervertebral disc involvement. Presentation of noncontiguous multisegmental spinal TB without the involvement of intervertebral disc resembles that of a neoplasm or other spinal infection. Differentiation requires the presence of a combination of general symptoms, laboratory test results, appropriate radiological results, and the physician’s experience. Bangladesh J Medicine 2022; 33: 58-61
... La TB espinal con localización en múltiples niveles es una forma atípica de presentación que afecta vértebras no contiguas, con sectores intercalados de columna no afectada. Su incidencia es muy variable según las publicaciones, desde 51% en algunas series (que toman como multinivel 2 localizaciones no contiguas), hasta reportes de casos con múltiples localizaciones no contiguas, como el que describimos, que la consideran una rara manifestación de la TB espinal [10][11][12][13] . ...
... La TB espinal con localización en múltiples niveles es una forma atípica de presentación que afecta vértebras no contiguas, con sectores intercalados de columna no afectada. Su incidencia es muy variable según las publicaciones, desde 51% en algunas series (que toman como multinivel 2 localizaciones no contiguas), hasta reportes de casos con múltiples localizaciones no contiguas, como el que describimos, que la consideran una rara manifestación de la TB espinal [10][11][12][13] . ...
A case of a 20-year-old man with multilevel non-contiguous tuberculous spondylitis (cervical, dorsal 6, dorsal 10 and lumbar) is presented. In the context of disseminated tuberculosis in an HIV-negative patient with serious compromise of his general condition and multiple locations of the disease, some of these with fistulas that secreted caseum. The acute paraplegia led, considering the sensory level at dorsal 6, to a first urgent decompression surgery via the posterior approach. A scheduled surgery was then performed, first in the cervical region via the anterior approach, with corpectomy, placement of a vertebral body replacement plus autologous graft and plate with screws. Subsequently, dislocation of dorsal level 6 was evidenced backwards, compressing the spinal cord and, given the mechanical instability, a third surgical stage was indicated by posterior approach, which included reduction, decompression and fixation, resolving the three levels by posterior approach with bars and screws. The surgical, medical and physiotherapy treatment of this rare form of Pott's disease was successful, with recovery of his mechanical stability and progressive recovery of his neurological status. The surgical, medical and physiotherapy treatment of this rare form of Pott's disease was successful, with recovery of his mechanical stability and progressive recovery of his neurological status.
... Interestingly, the skip lesions can be defined as separate lesions in at least two vertebrae regardless of their location (Wu et al., 2018;Yalniz et al., 2000;Thammaroj et al., 2014). To date, some works of literature submitted that there are a few cases reported with noncontiguous multiple tuberculous spondylitis worldwide; where there are estimated lesions in more than 2 or 3 vertebrae levels (Wu et al., 2018;Wang et al., 2015;Kim et al., 2014;Thawani et al., 2011). ...
... Most of the reported cases have lesions only on 2 or 3 levels. However, skipped multifocal extensive spinal TB involving all spinal levels is reported as rare" (Wu et al., 2018;Wang et al., 2015;Kim et al., 2014;Thawani et al., 2001;Wang et al., 2017;Emel et al., 2006) as seen in (Table 1). ...
... However, as such lesions may not be asymptomatic and overlooked at presentations, whole-body bone scan or MRI spine may enable early detection and treatment institutions to reduce morbidity" (Wu et al., 2018;Kim et al., 2014;Khattry et al., 2007). ...
OBJECTIVE: We are reporting unanticipated noncontiguous multifocal Pott's disease involving the whole spine with quadriplegia. Therefore, the communique aimed to provide updated data on this critical atypical spinal TB and highlights the rarity and challenges of management in our environment. CASE PRESENTATION: The patient is a 62-year-old Cameroonian female farmer with recalcitrant back pain for two years until her symptom was significantly aggravated, causing her to have difficulty walking and standing. Besides, the patient presented with progressive fever, night sweats, and weight loss. Examination findings revealed gibbus at T7-11 vertebral spine. The bilateral upper and lower limbs’ findings confirmed power grade zero, hypotonia, and hypo-reflexes, the sensation was diminished (Quadriplegia). The CT myelogram showed multifocal worm-eaten and osteolytic bony destruction, appearance which suggests noncontiguous multilevel vertebral involvement in cervical, thoracic, lumbar, and sacral spine. Gene Xpert MTB/RIF test was positive. Sputum stain for acid-fast bacilli yielded Mycobacterial tuberculosis. The initial diagnosis was multiple myeloma or metastatic disease by the GP, but the final pathology confirmed skipped multifocal extensive TB involving the whole spine with quadriplegia, -an atypical form of spinal TB, which is extremely rare. Subsequently, the patient was commenced on a combination of anti-TB therapy and discharged in an improved state to continue the medication for 12 months. CONCLUSION: While assessing patients with spinal TB or Pott’s disease, clinicians must recognize skipped multifocal extensive noncontiguous Pott's disease as a potential differential diagnosis; that is rarely reported in the published literature. Interestingly, physicians have a global resolve that early diagnosis yields excellent results in Pott’s disease treatment. Finally, clinicians managing such cases should be well informed of the various limitations in such a resources-constrained environment like ours to reduce the risk of attendant morbidities and mortalities.
... [2] TB of any origin presents with weight loss, fever, night sweats, whereas severe back pain and neurological deficit direct toward spinal TB. [6] The disease progressively causes vertebral collapse, destruction, abscess formation, which trickles to adjacent pre/para/epidural spaces, subsequently causing spinal cord compression, kyphotic deformity, and neurological deficits. [7,8] Our first patient responded beautifully to early surgical decompression and showed an early complete metabolic response in PET/CT. Whereas our 2 nd patient, even though she had a responding spinal disease, developed loculated pleura effusion, which progressed in the 3 rd PET/CT. ...
Tuberculosis (TB) of the spine is the most important extra pulmonary form of TB. The lytic destructive variant of spinal TB can destroy the intervertebral discs, vertebral body, collapse, kyphotic deformity, and spinal cord compression. Complicated Pott's disease if not managed early can lead to neurological deficits, so there is a need for early surgical decompression, compliant anti-tubercular therapy, and response evaluation tool. We present two cases of multilevel dorsal spinal TB diagnosed on magnetic resonance imaging spine and baseline 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) scan. They underwent early decompression with internal fixation and were followed up for 18 months with serial 18F-FDG PET/CT at 3rd and 18th month, respectively. One patient showed an early complete metabolic response and excellent functional recovery. Another patient showed progressive disease (drug-resistant status) and delayed functional recovery. 18F-FDG PET/CT has an excellent role in assessing response to therapy and thus helps to achieve therapeutic endpoint.
... The disease progressively causes vertebral collapse, adjacent tissue damage, and destruction, eventually forming a paravertebral or epidural abscess. The abscess may extend to adjacent soft tissues, subsequently causing spinal cord compression, kyphotic deformity, and further neurological complications [2,7,8]. Our patient presented with a kyphotic deformity and progressive neurological deficits; therefore, an urgent surgical evacuation was recommended. ...
Introduction:
Tuberculosis spondylitis or Pott's disease is the most common destructive form of skeletal tuberculosis. The most commonly affected site is the thoracolumbar vertebra. Once invading the adjacent structures of the vertebrae and intervertebral discs ultimately form an abscess causing spinal cord compression, vertebral collapse, and severe kyphotic deformity.
Presentation of case:
We present the first-ever case done in King Fahd Military Medical Complex in Dhahran, Saudi Arabia, of an 18-year-old male diagnosed with tuberculosis spondylitis who was complaining of progressive upper back pain and lower limb weakness. Emergent anterior decompression with expandable cage, plates, and screws were done. The patient showed a smooth and rapid recovery and was discharged with improved lower limb power and sensations.
Discussion:
Pott's disease can lead to progressive neurological deficits in which surgical decompression is indicated. Current surgical practice includes anterior or posterior decompression with or without fusion and/or instrumentation.
Conclusion:
Surgery with either anterior or posterior decompression should assure complete clearance of the lesion, correcting the kyphotic deformity that prevents disease progression.
... Following the exclusion of papers based on the relevance according to the inclusion criteria, a total number of 28 full text papers were deemed eligible for the inclusion ( Figure 2). The included studies were 10 case reports [14][15][16][17][18]20,[26][27][28][29] and six case series reporting on 18 individual patients. 19,[22][23][24][25] The search strategy is detailed in Data S1. ...
... had two signs. [15][16][17][18][22][23][24][25]27,29 On the other hand, only two cases 20,21 had a single sign while none was symptom free. ...
Rationale, aims, and objectives:
Despite research being done on spinal tuberculosis, diagnosing this condition at an early stage remains problematic due to its insidious onset and the varying symptoms being associated. Most individuals present to the health care facility with either simple back pain at an early stage or neurological complications at a later stage, when spinal compression and vertebral collapse have occurred as a result of delayed diagnosis. The prevention of secondary complications is therefore dependent on early recognition and diagnosis. The objective of this review was to identify common clinical patterns in case presentations and develop an evidence-based clinical guidance tool to assist clinicians in the early identification of spinal tuberculosis.
Method:
A comprehensive literature search was conducted for published spinal tuberculosis case studies, which yielded 28 cases after critical appraisal. Data from the studies were categorized in order to assist with a factor analysis and the development of an evidence framework for screening and diagnosing spinal tuberculosis. An evidence-based clinical guidance tool was then designed from the data obtained.
Results:
Factors associated with spinal tuberculosis and frequently reported symptoms and physical signs with which the patient could present upon assessment were identified. Options for investigations at primary, secondary, and tertiary levels were also identified.
Conclusion:
Through the use of an evidence-based clinical guidance tool, the clinician could be guided in the early suspicion and management of individuals with spinal tuberculosis and prevention of secondary complications.
