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Tuberculosis is the commonest cause of spinal infection worldwide (9-46%). Tuberculosis spondylodiscitis causes multifocal thoracic and lumbar spinal disease, and big paraspinal and psoas abscesses. It is more frequent in people under 40 who had previous tuberculosis infection and from countries where the illness is endemic. Clinic is non-specific and sub-acute. We report the clinical case of a 29-year-old patient who suffered from pericardic tuberculosis in her childhood and who presents a bilateral retroperitoneal abscess due to tuberculosis spondylodiscitis. Her clinical debut began with left inguinal pain and an irreducible mass at this level that simulated an incarcerated inguinal hernia, which is why surgery was indicated. Due to discrepancies between intraoperative findings and the initial diagnosis, the diagnosis and treatment strategy were changed. The purpose of this case report is to emphasize the challenge that the diagnosis of this pathology represents, due to low incidence in our environment and poor clinical features, which results in late diagnosis and late management.

Idiopathic scoliosis is the most common form of spinal deformity in adolescence. However, secondary causes of scoliosis should always be considered so as to provide appropriate treatment and avoid complications. Additional explorations, such as MRI, are required in the presence of atypical signs. We report a case of spinal tuberculosis, or Pott's disease, misdiagnosed as idiopathic scoliosis, and then present a discussion to help identify the warning signs during the evaluation of scoliosis that might indicate secondary scoliosis and suggest when to perform further radiologic exploration., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

Objective: Fifty-four juvenile cases under 18 years of age with thoracic and lumbar spinal tuberculosis underwent focus debridement, deformity correction, bone graft fusion, and internal fixation. The treatment effects, complications, and reasons were analyzed retrospectively., Material and Method: There were 54 juvenile cases under 18 years of age with thoracolumbar spinal tuberculosis. The average age was 9.2 years old, and the sample comprised 38 males and 16 females. The disease types included 28 thoracic cases, 17 thoracolumbar cases, and 9 lumbar cases. Nerve function was evaluated with the Frankel classification. Thirty-six cases were performed with focus debridement and deformity correction and were supported with allograft or autograft in mesh and fixed with pedicle screws from a posterior approach. Eight cases underwent a combined anterior and posterior surgical approach. Nine cases underwent osteotomy and deformity correction, and one case received focus debridement. The treatment effects, complications, and bone fusions were tracked for an average of 52 months., Results: According to the Frankel classification, paralysis was improved from 3 cases of B, 8 cases of C, 18 cases of D, and 25 cases of E preoperatively. This improvement was found in 3 cases of C, 6 cases of D, and 45 cases of E at a final follow-up postoperatively. No nerve dysfunction was aggravated. VAS was improved from 7.8 ± 1.7 preoperatively to 3.2 ± 2.1 at final follow-up postoperatively. ODI was improved from 77.5 ± 17.3 preoperatively to 28.4 ± 15.9 at final follow-up postoperatively. Kyphosis Cobb angle improved from 62.2° ± 3.7° preoperatively to 37° ± 2.4° at final follow-up postoperatively. Both of these are significant improvements, and all bone grafts were fused. Complications related to the operation occurred in 31.5% (17/54) of cases. Six cases suffered postoperative aggravated kyphosis deformity, eight cases suffered proximal kyphosis deformity, one case suffered pedicle penetration, one case suffered failure of internal devices, and one case suffered recurrence of tuberculosis., Conclusion: As long as the treatment plan is fully prepared, the surgical option can achieve a satisfactory curative effect in treating juvenile spinal tuberculosis despite some complications.

A 75-year-old woman was referred to our hospital after a health check-up disclosed abnormal shadows in the bilateral lungs. The patient was admitted to our hospital after being diagnosed with pulmonary tuberculosis. A physical examination showed a mass in the left inguinal area. Enhanced computed tomography revealed that the tuberculosis involved several regions including the lumber vertebrae, iliopsoas muscles, and left inguinal area. A therapeutic regimen consisting of INH, RFP, EB, and PZA was begun. Neuropathy in the lower extremities and dysuria indicated a spinal lesion, and spinal surgery was considered. However, the patient's history indicated that these symptoms were likely due to an iliopsoas abscess rather than a spinal lesion. This hypothesis was confirmed when the patient's symptoms improved with no sequelae after the abscess was drained. Our case demonstrates that spinal lesions as well as iliopsoas abscesses can cause neuropathy, and underscores the importance of obtaining a patient's history to correctly diagnose the disease and determine the appropriate treatment options.

Purpose: The purpose of this study was to evaluate the clinical and radiographic outcomes of modified pedicle subtraction osteotomy (mPSO) for thoracolumbar post-tubercular kyphosis in pediatric patients., Methods: From January 2008 to August 2012, 26 consecutive pediatric patients with thoracolumbar post-tubercular kyphosis underwent modified pedicle subtraction osteotomy (mPSO). The clinical and radiologic outcomes were analyzed preoperatively, postoperatively, and at the last follow-up., Results: Twenty-six patients with thoracolumbar post-tubercular kyphosis underwent mPSO. The average operation time was 256 min (188~314 min). The mean follow-up was 41 months (18~56 months). The mean estimated blood loss was 870 ml (620 ~ 1020 ml). The thoracolumbar kyphotic angle ranged from 51° to 79° before operation, 60.6° in average. The mean thoracolumbar kyphotic Cobb angle was 19.7° after operation, with a mean correction of 40.9°. The C7 sagittal plumb line was 3.8 cm after operation, comparing to the 10.5 cm preoperative. The mean preoperative angle of thoracic kyphosis (TK) was 9.9° ± 1.2° and increased to 11.8° ± 1.4°, postoperatively. Lumbar lordosis (LL) improved from -22.8° ± 4.9° preoperative to -17.8° ± 2.1° postoperative. Visual analogue scale (VAS) was 8.7 ± 1.1 preoperative and 1.2 ± 0.4 postoperative, respectively. The mean Oswestry Disability Index (ODI) improved from 49.2 ± 5.3 before surgery to 10.8 ± 3.3 postoperative (P < 0.01). All patients received good bone healing, no significant loss of correction angle. Most patients (24/26) considered pain and exterior was significantly improved., Conclusion: Modified pedicle subtraction osteotomy (mPSO) is effective and reliable for thoracolumbar post-tubercular kyphosis in pediatric patients.

Background and Study Aims: Minimally invasive retroperitoneoscopic surgery (MIS) for psoas abscess (PA) in patients with thoracolumbar tuberculosis is not well-illustrated and has not reached the status of being fully clinically assessed when we review the English literatures. The aim of this study is to introduce and investigate on efficacy and feasibility of MIS (retroperitoneoscopic technique) for PA in patients with thoracolumbar tuberculosis., Patients and Methods: From January 2008 to 2013, 39 consecutive patients of the diagnosis of PA with thoracolumbar tuberculosis received the debridement of abscesses and cavity walls of abscesses by the retroperitoneoscopic technique (MIS) in combination with anti-tuberculosis chemotherapy. Medical records and follow-up data were retrospectively studied. CRP and ESR of every patient preoperatively and postoperatively were analyzed, Results: Immediate relief in clinical symptoms and signs, and amelioration in imaging and laboratory examinations were obviously observed in all the patients. The follow-up had proceeded for 12-48 (mean 23) months. No complication was observed during the follow-up postoperatively., Conclusions: The retroperitoneoscopic technique for PA gain advantages in terms of shorter hospital stay, minimal invasiveness, absence of radiation, quicker recovery to daily life compared with percutaneous drainage, and anterior or posterior debridement surgery. Despite the technique not been fully clinically proved, it seems to be a recommended option as an effective diagnostic and therapeutic technique for PA, especially with massive or complicated PA.

Objective: The purpose of this study was to evaluate the outcomes of computed tomography (CT) guidance using percutaneous catheter with low-dose drainage local chemotherapy (modified PCD) and antituberculous therapy (ATT) for the treatment of spinal tuberculosis in children., Methods: Twenty-seven children suffering from spinal tuberculosis were treated with modified PCD and ATT in our institute from 2002 to 2012. We describe our treatment, which involves CT-guided percutaneous puncture and local chemotherapy (continuous low-dose (20 mL) irrigation). The patients were evaluated based on the Frankel scoring system, the kyphotic Cobb angle, and the erythrocyte sedimentation rate (ESR)., Results: All patients were followed up for an average of 31.00 ± 13.94 months. No sinus formation was detected. All patients responded well to this treatment. The ESR values were decreased to normal at last follow-up. The neurological functions show significant improvement after operation. Preoperatively, the kyphotic angle was 22.89 ± 7.06°, and it was measured as 21.19 ± 8.73° at the last visit., Conclusions: Our results showed that percutaneous intubation and low-dose irrigation under CT guidance (modified percutaneous catheter drainage (MPCD)) and ATT are easy, safe, efficient, and less invasive methods for the treatment of spinal tuberculosis in children.

Study Design: Retrospective case-control study., Objectives: To analyze the results of two surgical treatments for lower lumbar tuberculous spondylitis with neurological deficits in the aged., Methods: We studied 33 cases of lower lumbar spinal tuberculous spondylitis treated in our center from January 2006 to October 2010. The cases were divided into two groups: 16 cases (group A) underwent single- or two-stage anterior debridement, bone grafting and posterior instrumentation, and 17 cases (group B) underwent single-stage posterior debridement, decompression, interbody fusion and instrumentation. Clinical and radiographic results were analyzed and compared between the groups., Results: Patients were followed for a mean of 41.3 months (range 36-48 months). The average operative durations were 276.9±23.8 and 193.8±22.5 min in groups A and B, respectively. The average hospital stay was 18.2±3.2 days for group A and 13.4±1.6 days for group B. Average intraoperative blood loss for groups A and B was 1187.5±163.0 and 804.7±134.1 ml, respectively. Operative complications affected four patients in group A and one in group B. Solid fusion occurred at 12 months in the other 32 cases. Neurological status was significantly improved in all cases. Kyphosis was significantly corrected after surgical management, but loss of correction occurred in both groups., Conclusion: Single-stage posterior debridement, decompression, interbody fusion and instrumentation might be a better surgical treatment than combined posterior and anterior approaches for lower lumbar tuberculous spondylitis with neurological deficits in the aged, offering fewer complications and a better quality of life.

Objective: This study aims to explore the efficacy and safety of posterior vertebral column resection (PVCR) in treating thoracolumbar spinal tuberculous angular kyphosis (TSTAK)., Methods: From January 2008 to January 2012, 17 TSTAK patients were treated surgically, including five males and 12 females, with an average age of 23.6 years, among five cases who had the kyphotic apical vertebrae located at the thoracic vertebrae, ten cases were located at the thoracolumbar segment, and two cases were located at the lumbar vertebrae. The kyphotic Cobb angle was measured in the preoperative, postoperative, and final follow-up, respectively, and the nerve function ASIA classification was assessed., Results: The mean operative time was 364 min; the average intraoperative blood loss was 2,218 ml; and the average intraoperative blood transfusion was 1,863 ml. Among the five patients with the preoperative nerve function as grade D, four of them recovered to grade E. The preoperative average Cobb angle was 81.3° ± 12.8°, while the postoperative average Cobb average was 17.3° ± 3.6°; while it was significantly improved than the preoperative (P < 0.01), the average kyphosis correction rate was 68.7% ± 6.5%; the postoperative average follow-up was 18.7 months, with an average correction loss as 3.3°., Conclusion: PVCR could be safely and effectively used in TSTAK.

A 25-year-old male state-prisoner presented with altered mental status, right neck pain, and uncontrolled hypertension., (Copyright 2015, SLACK Incorporated.)

Deep Candida infections commonly occur in immunosuppressed patients. A rare case of a multiple deep organ infection with Candida albicans and spinal tuberculosis was reported in a healthy young man. The 19-year-old man complained of month-long fever and lower back pain. He also had a history of scalded mouth syndrome. Coinfection with Mycobacterium tuberculosis and Candida albicans was diagnosed using the culture of aspirates from different regions. Symptoms improved considerably after antifungal and antituberculous therapy. This case illustrates that infection with tuberculosis might impair the host's immune system and increase the risk of invasive candidiasis in an immunocompetent patient.

Although rare in the western world; psoas abscess is a frequent finding in Indian sub continent associated with Pott's spine. Untreated Pott's spine may lead to various sequelae like destruction of vertebra, kyphosis, paraplageia etc which in modern world is amenable to anti-tubercular drugs and surgical management. We report a case of untreated Pott's spine with bilateral calcified psoas abscess with kyphosis. To the best of our knowledge no such case of complete bilateral calcified psoas abscesses has been reported earlier. We want to discuss this case with relevant literature review and its influence on treatment plan.

Spinal tuberculosis leading to paraplegia is uncommon in pregnancy and is a diagnostic and therapeutic challenge. We report a case of tubercular paraplegia presenting at 35 weeks of gestation. She was managed with Anti-tubercular drugs and did not require surgical intervention. Her neurological status improved and she was allowed to go in labour. She delivered a healthy term infant by cesarean. At three months follow-up, both mother and child are doing well.

Purpose: To evaluate the clinical and radiographic outcomes of posterior vertebral column resection (PVCR) and intraoperative manual traction to correct severe post-tubercular spinal deformity incurred during childhood., Methods: A retrospective review of 11 patients' (4 males and 7 females) charts was performed. Clinical outcome assessment was performed using Oswestry Disability Index and Visual Analog Scale for back pain. Imaging measurements and fusion status were assessed using plain radiography and computed tomography. Intraoperative and postoperative complications were recorded., Results: No perioperative mortality occurred among the patients. The average follow-up was 42.8 ± 13.1 months (range 25-60 months). Kyphosis improved from a preoperative average of 93.4° ± 10.1° to a postoperative average of 18.7° ± 6.3° for a correction of 80.1 %. The Cobb angle in the coronal plane improved from an average of 48.1° ± 18.9° to 10.3° ± 3.0° postoperatively for a correction of 76.3 %. At the last follow-up, two patients improved neurologically from ASIA grade C to grade D, and one patient improved from grade C to grade E. Only one patient with ASIA grade D deficits did not improve. Perioperative complications occurred in 4 of the 11 cases. One patient had a dural tear. Three patients had temporary degradation of intraoperative neuromonitoring, and one experienced transient paralysis of the left lower extremity postoperatively., Conclusions: PVCR and intraoperative manual traction are effective alternatives to manage severe post-tubercular spinal deformity although the procedure can be highly challenging with possible neurologic complications.

Study Design: This was a prospective study on the clinical outcomes of single-stage surgery for thoracic and lumbar spine tuberculosis patients with bilateral paraspinal or bilateral psoas abscesses., Objective: The aim of this study was to investigate the feasibility of, indications for, and clinical effects of single-stage posterior surgery for the treatment of thoracic and lumbar spinal tuberculosis with bilateral paraspinal or bilateral psoas abscesses., Summary of Background Data: An increasing number of articles have been published on the use of single-stage surgery for spinal tuberculosis; however, none of these articles have discussed the use of such surgery in patients with bilateral abscesses., Methods: Between January 2003 and January 2011, 41 patients with thoracic and lumbar spinal tuberculosis and bilateral paraspinal or bilateral psoas abscesses were treated with single-stage posterior surgery. All of the patients were treated preoperatively with 1-2 weeks of antituberculosis drugs. All patients were managed postoperatively with standard courses of chemotherapy with triple or quadruple antituberculosis drugs. The clinical symptoms, complications, and laboratory and image indicators were recorded., Results: There were no local recurrences except in one L3-L4 tuberculosis patient. Two patients presented with extraspinal tuberculosis in the third year. There were no incision complications. Bone fusion was observed 6 months after the operation. The erythrocyte sedimentation rate was normal at 3 weeks-3 months postoperatively. There were no internal fixation failures. The internal fixations in 6 young patients were removed after the spinal tuberculosis was cured., Conclusions: Single-stage posterior surgery with instrumentation results in less operative trauma and can be a suitable alternative for treating thoracic and lumbar tuberculosis with bilateral paraspinal or bilateral psoas abscesses.

Objective: Observation of post treatment kyphotic angle in patient of cervical spine tuberculosis managed non operatively., Background: The incidence of tuberculosis of cervical spine is about 6-9%. The most dreaded complications of spinal tuberculosis are neural involvement and spinal deformity. Due to destruction of the vertebra tuberculosis of spine usually leads to variable amount of kyphotic deformity., Methods: We retrospectively reviewed 13 patients with clinico-radiological diagnosis of cervical spine tuberculosis managed in our centre between 2004 to 2011. The patients were started on antitubercular therapy. Crutchfield tongs traction was applied 8 to 12 weeks followed by mobilization with four post collar. The kyphotic angles were measured by radiograph at presentation and last available follow up radiograph., Observations: The mean age of the patients was 20 years. C3-C4 vertebra was the most commonly involved area. One patient had single vertebra involvement, five patients had two vertebrae involvement, five patients had three vertebrae involvement and two patients had four vertebrae involvement. The average number of vertebrae involved was 2.6 vertebrae. 9 out of 13 patients had neural deficit at the time of initial presentation. The mean follow up was 21.23 months (12 to 42 months). All patients responded favorably and had neural recovery. At final follow up, 10 out of 13 patients had improvement in kyphotic angle, two patients had deterioration of kyphotic angle and one patient had no change in kyphotic angle. Only one patient had significant deterioration in kyphotic angle., Conclusions: Non operative treatment of cervical spine tuberculosis by initial traction and antitubercular therapy improves the pretreatment deformity irrespective of the number of vertebra involved.

Spinal tuberculosis in its typical form that shows destruction of two adjacent vertebral bodies and opposing end plates, destruction of the intervening intervertebral disc and a paravertebral or psoas abscess, is easily recognized and readily treated. Atypical tuberculous spondylitis without the above mentioned imaging features, although seen infrequently, has been well documented. We present, in this report, a case of atypical tuberculous spondylitis showing involvement of contiguous lower dorsal vertebral bodies and posterior elements with paravertebral and epidural abscess but with preserved intervertebral discs. The patient presented in advanced stage with progressive severe neurological symptoms due to spinal cord compression. Non-enhanced magnetic resonance imaging led to misdiagnosis of the lesion as a neoplastic process. It was followed by contrast enhanced computed tomography of the chest and abdomen that raised the possibility of an infectious process and, post-operatively, histopathological examination of the operative specimen confirmed tuberculosis. This case indicates the difficulty in differentiating atypical spinal tuberculosis from other diseases causing spinal cord compression. The different forms of atypical tuberculous spondylitis reported in the literature are reviewed. The role of the radiologist in tuberculous spondylitis is not only to recognize the imaging characteristics of the disease by best imaging modality, which is contrast enhanced magnetic resonance imaging, but also to be alert to the more atypical presentations to ensure early diagnosis and prompt treatment to prevent complications. However, when neither clinical examination nor magnetic resonance imaging findings are reliable in differentiating spinal infection from one another and from neoplasm, adequate biopsy, either imaging guided or surgical biopsy is essential for early diagnosis.

Background: Paraplegia associated with epidural anesthesia or caused by intramedullary spinal tuberculoma is rare but catastrophic. We present a case of paraplegia following epidural anesthesia in a patient with an undiagnosed intramedullary spinal tuberculoma., Case Presentation: A 42-year-old man developed paraplegia after an open cholecystectomy under epidural anesthesia. Spinal cord infarction, acute transverse myelitis, and intramedullary neoplasms were ruled out by histopathologic examination, and intramedullary spinal tuberculoma at the T6-T7 level was identified. Despite surgical treatment and subsequent antituberculous therapy, the patient retained some disability attributable to the delay in diagnosis., Conclusion: Physicians should be aware of coexisting disease as a cause of paraplegia following procedures using epidural anesthesia. Magnetic resonance imaging is the most sensitive diagnostic test, although it is still difficult to differentiate spinal cord infarction, myelitis, intramedullary spinal tuberculoma, and neoplasms from imaging features alone.

Purpose: There has been no uniform and extensive description of the use of expandable cages in the setting of thoracolumbar tuberculosis. The purpose of the study was to evaluate the results of the expandable cages and compare with autogenous strut grafting in thoracolumbar tuberculosis., Methods: From January 2003 to January 2014, a total of 28 patients with thoracolumbar tuberculosis were treated surgically in our medical center. Patients were divided into three groups. 17 patients received anterior-only surgery; consisting of autogenous iliac bone grafting only in 9 (Group 1), grafting with anterior screw-rod system instrumentation after debridement in 8 patients (Group 2). 11 patients underwent anterior surgery including debridement and distraction of the kyphosis by cages after corpectomy following posterior instrumentation (Group 3).The changes in degree of kyphotic deformity, loss of correction, intervertebral height and loss of intervertebral height were evaluated preoperatively, postoperatively and at the final follow-up., Results: Patients were followed 52 ± 10.7 months (range, 18-120 months). Mean age in the Group 1 was 42 (18-69) years, 62 (19-86) years in the Group 2 and 51 (19-71) years in the Group 3. There was no statistically significant difference (P > 0.05) in the focal kyphosis preoperatively, postoperatively and at the last follow-up between three groups. There were statistically significant differences (P < 0.05) in loss of correction, intervertebral height (preoperative, postoperative and final follow-up) and loss of intervertebral height between three groups. There was a greater loss of correction in Group 1 when compared with Group 2 and Group 3. The difference was statistically significant (p < 0.001). There was no statistically significant difference in the intervertebral height postoperatively and follow-up between Group 1 and Group 2. There was a significant increase in the intervertebral height in Group 3 when compared with Group 1 and Group 2. There was also a significant increase in the intervertebral height in Group 2 when compared with Group 1. There was a greater loss of intervertebral height in Group 1 than in Group 2 and Group 3. The difference was statistically significant (p < 0.001)., Conclusions: Expandable cages are an acceptable surgical option for the treatment of thoracolumbar tuberculosis. Sagittal alignment is better prevented with the expandable cages than anterior grafting with or without anterior instrumentation. Subsidence of the expandable cages is not uncommon and results in the loss of Cobb angle correction and intervertebral height. However, anterior vertebral column reconstruction by expandable cages provides a very high and effective rate of deformity correction and maintenance.

Purpose: The purpose of this study was to present a singular pathological process of thoracic or lumbar spinal tuberculosis contributing to listhesis at the involved site, with special focus on clinical features and management of this disorder., Methods: We retrospectively reviewed the medical records of 14 patients (5 males and 9 females, including 2 boys) admitted to our institution from April 2007 to March 2010 and were subsequently diagnosed with thoracic or lumbar spinal tuberculosis with resultant listhesis at the involved level. All patients underwent posterior instrumentation and reduction combined with single-stage anterior radical debridement and interbody fusion. Patients were followed-up clinically and radiographically., Results: The average follow-up duration was 54.6 months. All patients had a successful fusion. Complete reduction was achieved in 10 cases. Preoperative neurological injury was observed in six patients and all recovered after surgery. The average postoperative Frankel grade improvement was 1.2. The preoperative median value of the extent of listhesis was 26.2%, which fell to zero at the final follow-up (Z=-3.296, P=0.001). Pre- and postoperative median spinal stenosis rates were 45.9% and 8.4%, respectively (Z=-3.296, P=0.001). The preoperative neurologic level was positively correlated with the listhesis distance before surgery (rs=0.770, P=0.001). Postoperatively, the spinal stenosis rate was positively correlated with listhesis distance (rs=0.691, P=0.006). The correlation between neurologic level and age or spinal stenosis rate was not significant. The standardized coefficient of listhesis distance was greater than that of spinal stenosis rate in our multiple linear regression analysis model. No implant failure or recurrence of tuberculosis occurred., Conclusion: Treatment of this rare pathology aims to restore good spinal alignment, radical debridement, and permanent stability. A reasonable surgical strategy may be the combination of posterior reduction, anterior debridement, and supportive graft fusion. This strategy can safely and effectively achieve all of the therapeutic goals in one step., (Copyright © 2014 Elsevier B.V. All rights reserved.)

Study Design: A retrospective study was conducted on 148 spinal tuberculosis (TB) patients (M:F, 92:56; mean age, 39.7±12.3; range, 16-74 y) treated with anterior debridement and bone graft fusion with nail and screw internal fixation (nails+screws group); posterior pedicle screw fixation (pedicle screw group); vertebral arch pedicle internal fixation through a posterior route (posterior arch fixation group); or posterior debridement, bone graft fusion, and vertebral arch pedicle internal fixation (arch fixation group)., Objective: We investigated 4 variant surgical approaches for internal fixation of spinal TB., Summary of Background Data: The effectiveness of single-stage surgical fixation for different degrees of spinal TB is a matter of debate., Methods: Operation time and bleeding volume were recorded. Complications, American Spinal Injury Association (ASIA) score, C-reactive protein, and erythrocyte sedimentation rate were examined preoperatively and 6 months after surgery., Results: Overall, 78, 48, 16, and 6 patients underwent nails+screws, pedicle screws, arch fixation, and posterior arch fixation approaches, respectively. The mean operation times were 175.8±48.8, 308.5±76.7, 143.8±43.0, and 398.3±90.8, respectively (P<0.01). Mean blood transfusion volumes were 1227.1±988.2, 1771.7±794.7, 467.7±123.3, and 2833.3±1083.8 mL, respectively (P<0.01). Primary wound healing was achieved in 127 patients. No patients experienced spinal TB recurrence or failure of bone graft or fixation. All groups achieved significantly improved C-reactive protein and erythrocyte sedimentation rate, but significantly improved ASIA scores were only observed in the nails+screws and pedicle screw groups (P<0.01)., Conclusions: Surgical approach limitations and advantages should be considered based on the position and severity of spinal TB infection to maximize functional outcomes and minimize surgical risks.

Spinal tuberculosis is the most common manifestation of extra-pulmonary tuberculosis. It is difficult to diagnose the disease due to its insidious onset and non-specific clinical presentation. A high degree of suspicion and appropriate imaging studies are necessary for its early diagnosis and treatment. The authors report a case of lumbosacral tuberculosis in an adult patient presenting with hip pain and abscesses., (2014 BMJ Publishing Group Ltd.)

Background Context: Conventional circumferential stabilization for pathologies causing instability of the thoracic spine requires a two or even a three-staged procedure. The authors present their tertiary care center experience of single-staged procedure to establish a circumferential fusion through an extended costotransversectomy approach., Objective: To demonstrate neural canal decompression, removal of the pathology, achieve circumferential fusion, and correcting the deformity through a single procedure., Study Design: Prospective and observational., Patient Sample: Forty-six patients with pan thoracic column instability due to various pathologies., Outcome Measures: Neurologic condition was evaluated using American Spinal Injury Association and Eastern Cooperative Oncology Group grading systems. Outcome was evaluated with regard to the decompression of neural canal, correction of deformity, and neurologic improvement. All patients were evaluated for neural canal compromise and degree of kyphosis preoperatively, early, and late postoperatively., Methods: All patients had severe spinal canal compromise (mean, 59%±9%) and loss of vertebral body height (mean, 55%±10%). A single-stage circumferential fusion was performed (four-level pedicle screw fixation along with a ventral cage fixation after a vertebrectomy or corpectomy) through an extended costotransversectomy approach., Results: The pathologies included trauma (21), tuberculosis (18), hemangioma (2), aneurysmal bone cyst (1), recurrent hemangioendothelioma (1), solitary metastasis (1) and plasmacytoma (1), and neurofibromatosis (1). Thirty-five of 46 patients (76%) demonstrated improvement in the performance status. The major complications included pneumonitis (3), pneumothorax (3) and neurologic deterioration (3; improved in two), deep venous thrombosis (2), and recurrent hemoptysis (1). No implant failures were noted on last radiology follow-up. There were two mortalities; one because of myocardial infarction and another because of respiratory complications., Conclusions: The following study demonstrated that extended costotrasversectomy approach is a good option for achieving single-staged circumferential fusion for correcting unstable thoracic spine due to both traumatic and nontraumatic pathologies., (Copyright © 2014 Elsevier Inc. All rights reserved.)

The aim of this study was to retrospectively evaluate the safety, feasibility and efficacy of one-stage posterior instrumentation combined anterior debridement and interbody fusion for treatment of active thoracic and lumbar spinal tuberculosis (TB) in children with kyphotic deformity. A total of 20 children (12 boys, 8 girls) were enrolled in this study from January 2006 to January 2011. All patients underwent one-stage posterior instrumentation combined anterior debridement and interbody fusion. Clinical and radiographic results were analyzed. Patients were followed up for 28.9 months on average. Improvement was shown in all patients with neurologic dysfunction according to American Spinal Injury Association Impairment Scale. The mean preoperative angle of kyphosis was 35.2° ± 6.8° (range 26°-47°), which reduced to 9.7° ± 1.8° (range 6°-13°) postoperatively. The mean angle of kyphosis at the last follow-up was 12.0° ± 1.9° (range 9°-15°). Erythrocyte sedimentation rate and C-reactive protein returned to normal in all patients within 6 months after surgery. All patients acquired bony fusion, and no major complications were observed through the final follow-up visit. One-stage posterior instrumentation combined anterior debridement and fusion were demonstrated to be a safe and effective method to achieve spinal decompression and kyphosis correction in children with thoracic and lumbar spinal TB.

Involvement of upper cervical and craniovertebral junction is rare but might lead to lethal consequences if the diagnosis is delayed. We present a case of atlantoaxial joint tuberculosis, resulting in gross instability of the joint. The patient was treated with antitubercular medication combined with posterior decompression and transarticular screw fixation. Patient improved neurologically, and clinical and radiological improvements were maintained at the latest follow-up of 2 years.

Background Context: Isolated tuberculosis (TB) of posterior elements of the cervical spine is extremely rare. Only few cases are reported in literature, but none describe isolated spinous process and laminae involvement without TB in any other part of the body., Purpose: To report a case of isolated TB involvement of the spinous process and right laminae of C2 combined with atlantoaxial luxation., Study Design: A case report of isolated spinous process and right laminae TB of C2 combined with atlantoaxial luxation., Patient Sample: A 20-year-old male farmer complained about a 2-month history of aggravating neck pain, a 1-month history of a slowly growing lump at the back of the neck, and numbness and weakness of the right arm that had gradually progressed to involve all the limbs for 2 weeks before presentation., Outcome Measures: X-ray and computed tomography of cervical spine and Frankel grading of neural function are included to evaluate the therapeutic efficiency., Methods: Computed tomography scans showed flake-like bony destruction located in the spinous process and at the right laminae of C2. Magnetic resonance imaging (MRI) showed a large swelling posterior to C2 and atlantoaxial luxation-induced distinct compression of the spinal cord. The patient underwent 2 weeks of skull traction and quadruple anti-TB treatment before surgery., Results: The patient underwent surgical treatment that included posterior radical debridement, decompression, internal fixation with a screw-rod system from C1 to C4, autologous bone grafting, and fusion. The patient gained normal neural function and returned to work 1 year after surgery., Conclusions: Tuberculosis of the posterior elements of the upper cervical spine is very rare and potentially dangerous. Computed tomography and MRI are very useful and important for correct diagnosis. Prompt medical and surgical treatment may avert potential catastrophic event in these cases., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Purpose: The correction of severe post-tubercular kyphosis (PTK) is complex and has the disadvantage of being multistaged with a high morbidity. In this study, we evaluated the outcomes of children who underwent single-stage closing-opening wedge osteotomy as a surgical treatment of PTK of the thoracolumbar spine., Method: Our study group included 12 children with thoracolumbar PTK (seven boys and five girls) with an average age of 9.4 years (range 6-12 years), who were treated at our institution from January 2004 to October 2009. The American Spinal Injury Association Impairment Scale and visual analog scale score were used to classify neurologic function. All patients underwent halo-pelvic traction before surgery and were treated with single-stage closing-opening wedge osteotomy., Result: The duration of surgery averaged 99 min (range 70-150 min). Average blood loss was 782 ml (range 560-1,200 ml), and the average length of hospital stay was 12 days (range 8-16 days). The neurological function of all patients improved significantly after the procedure. The mean preoperative kyphotic angle was 83.3° (range 59-118°), which had reduced to 27.6° (range 20-38°) at the final follow-up visit. All patients had solid fusion, and no major complications were observed through the final follow-up visit., Conclusion: Single-stage closing-opening wedge osteotomy is an effective method to correct severe thoracolumbar PTK. A main advantage of the procedure is that it is a posterior-only, single-staged surgery, allowing for significant correction with minimal complications.

Tuberculosis and sarcoidosis share similar histopathological findings. An aetiological connection between these diseases has been discussed. We report a case of pulmonary sarcoidosis, which occurred shortly after an isoniazid (INH)-resistant spinal tuberculosis was diagnosed which was suspected to be a miliary tuberculosis. This report illustrates the need to sensitise clinicians to two possible important causes of lung parenchyma alterations under tuberculostatic therapy.

We present an atypical case of tuberculosis in an immunocompetent man from west Africa living in Europe. The patient entered the hospital with a painful lump of 3 cm on his right clavicule which he noticed 2 weeks before and back pain. During the examinations for further evaluation his condition deteriorated within short time. Tuberculosis was diagnosed, treatment started but he needed mechanical ventilation at the intensive care unit and had kidney failure. The further evolvement was favourable in the end but needed intensive treatment for over 4 weeks. Tuberculosis cases with such severe evolution are rather known with immunodeficient patients. Extrapulmonary tuberculosis, especially skeletal tuberculosis is seen more frequent in young immunocompetent migrants. The migrating persons seem to be more at risk to get sick than the ones staying in their origin country. We suppose the course of our patient's disease is miliary or septic, of which both are rather rare entities.

A 4-year-old Cambodian male presented to the emergency room with 2 weeks of gradually increasing leg weakness until he could no longer stand. He was also reported to have a deformity on his back, intermittent fevers and cough. His physical exam was notable for a 2 cm × 1 cm bony protrusion at his T4 vertebrae, and 2/5 strength and positive Babinski reflexes in his lower extremities. A chest x-ray showed a 3.2 cm × 2.9 cm mass in the middle mediastinum extending to the posterior mediastinum. A purified protein derivative test was positive. A computed tomography scan showed findings consistent with pulmonary tuberculosis and a paravertebral mass with amorphous calcifications, which involved destruction of the T4-T5 vertebrae and evidence of cord compression. These findings were all consistent with tuberculous spondylitis (Pott's disease).

Spinal tuberculosis (Pott's disease) is one of the common extra-pulmonary presentations of tuberculosis. Spinal tuberculosis commonly presents with back pain, fever and night sweats. In this report, we present a case of spinal tuberculosis complicated by bilateral large psoas abscesses. The patient presented with bilateral flank pain and swellings rather than the classic presentation of back pain. The aim of this report is to draw the attention of physicians to this uncommon presentation of spinal tuberculosis, as an early recognition of such condition may expedite diagnosis and treatment, thereby preventing future complications of the disease.

Background: Tuberculosis of the musculoskeletal system is not a common clinical condition; however, multifocal bone involvement is even rarer and difficult to recognize., Case: In this paper, we presented a patient who developed paraplegia 15 days before his hospital admission. He was operated by neurosurgeons due to spinal mass, but postoperative examination revealed vertebral and multifocal skeletal tuberculosis. It is difficult to diagnose this condition by conventional imaging methods. The importance of positron emission tomography (PET) in the diagnosis of skeletal tuberculosis was emphasized., Result: The importance of rehabilitation program in restoring functionality was overviewed in the light of current literature. Vertebral and osteoarticular tuberculosis should be considered in patients with vertebral and thoracic mass presenting with neurological deficits.

A 19-year-old Filipino man was admitted to our hospital because of persisting fever and back pain. He had recognized his symptoms 6 months previously, but a definite diagnosis was not made. Image testing demonstrated a compressed fracture of the thoracic vertebrae accompanied with a perivertebral abscess. A biopsy specimen revealed granuloma compatible with tuberculosis (TB). Anti-TB drugs were initiated, and his clinical symptoms steadily improved. However, he developed neuropathic symptoms due to exacerbation of the abscess two months after starting the anti-TB drugs. An immediate laminectomy was performed resulting in symptom relief; however severe kyphosis remained. Polymerase chain reaction testing of the abscess collected during the operation was positive for Mycobacterium tuberculosis, confirming the diagnosis of spinal TB. The diagnosis of spinal TB has been a challenge world-wide. Clinicians should be aware of the demographic background as well as the clinical and laboratory features of spinal tuberculosis, facilitating earlier diagnosis.

Purpose: Tuberculosis can be responsible for extensive spinal lesions. Despite the efficacy of medical treatment, surgery is indicated to avoid or correct significant deformity, treat spinal instability, prevent neurological compromise, and to eradicate an extensive tuberculous abscess. In this paper we present our experience in the surgical management of spinal tuberculosis complicated with large abscess., Patients and Methods: Fifteen patients with spinal tuberculosis complicated with extensive abscess were identified; and nine of those patients had extension of the infection into the epidural space. The average age at treatment was 34 years old. Seven patients had thoracic infection, seven patients had lumbar infection and one had thoracolumbar infection. Six patients had neurological deficit at presentation. All patients were surgically treated with abscess debridement, spinal stabilization and concurrent antituberculous chemotherapy. A single anterior surgical approach was used in three cases, a posterior approach was used in four others and a combined approach was performed in eight patients., Results: Surgical management allowed for effective abscess debridement and sspinal stabilization in this cohort. In combination with antituberculous drugs, surgical treatment resulted in infection eradication and bone fusion in all patients at 24 month average follow-up. Satisfactory neurological outcomes with improved American Spinal Injury Association (ASIA) scores were observed in 100% of patients., Conclusion: Surgical treatment for spinal tuberculosis abscess can lead to satisfactory clinical outcomes.

Tuberculous involvement of the central nervous system (CNS) and vertebral column is the most lethal and disabling form of tuberculosis (TB). Several factors contribute to poor outcome, including cerebrovascular involvement with ischemia, hydrocephalus, direct parenchymal injury and formation of abscess and inflammation in the brain and spinal cord, hyponatremia, seizures, and delayed diagnosis. Spinal spondylitis from TB and associated spinal deformity is the leading cause of paraplegia in developing countries. The evidence for supportive treatment of TB infection of the CNS is limited, leading to substantial differences in management protocols. Many of the treatment approaches used in TB infection of the CNS have been extrapolated from treatment of other acute neurological disorders such as bacterial meningitis and traumatic brain injury. We review data from the available literature and highlight questions relating to the neurological and neurosurgical care of children with TB infection of the CNS and vertebral column.

Background: Psoas abscess complicating tuberculous spondylitis is a rare morbidity in extrapulmonary tuberculosis. There are no established guidelines for evaluating the clinical response of psoas abscess. Although several studies have shown that positron emission tomography-computed tomography with 18 F-fluorodeoxyglucose can play a potential role in diagnosing multifocal tuberculosis and monitoring the clinical response of pulmonary tuberculosis, to our knowledge, this is the first report demonstrating that positron emission tomography-computed tomography is useful for evaluating local inflammation and disease activity of a tuberculous psoas abscess., Case Presentation: We report a case of multifocal bone and lymph node tuberculosis with concomitant lumbar psoas abscess in a 77-year-old man, along with a literature review. An initial positron emission tomography-computed tomography scan showed intense 18 F-fluorodeoxyglucose accumulation in the sternum, ribs, vertebrae, and lymph nodes. The patient was successfully treated with antitubercular agents and computed tomography-guided drainage therapy. A follow-up positron emission tomography-computed tomography after abscess drainage and 9 months of antitubercular drug treatment revealed that the majority of lesions improved; however, protracted inflammation surrounding the psoas abscess was still observed. These results indicate that disease activity of psoas abscess can remain, even after successful drainage and antitubercular medication regime of appropriate duration., Conclusion: We have successfully followed up the extent of skeletal tuberculosis complicated with psoas abscess by positron emission tomography-computed tomography. In this patient, positron emission tomography-computed tomography is useful for evaluating the disease activity of tuberculous psoas abscess and for assessing the appropriate duration of antitubercular drug therapy in psoas abscess.