Tuberculous vertebral osteomyelitis

Tuberculous vertebral osteomyelitis

Epidemiology

Tuberculosis of the central nervous system accounts for approximately 1% of all cases of tuberculosis and 50% of these involve the spine.

Spinal tuberculosis is more common in children and young adults. The incidence of spinal tuberculosis is increasing in developed nations. Genetic susceptibility to spinal tuberculosis has been demonstrated.

Vertebral granulomatous infections are found in 10–20% of TB cases in developed nations and upwards of 20–41% in undeveloped nations 1).

The most common levels involved are the lower thoracic and upper lumbar levels. Has a predilection for the vertebral body, sparing the posterior elements. Psoas abscess is common (the psoas major muscle attaches to the bodies and intervertebral discs from T12-L5). Sclerosis of the involved vertebral body may occur.

Etiology

M. tuberculosis is the most common etiology of vertebral granulomatous infection.

Immunocompromise has been found to increase the incidence of musculoskeletal lesions. While 3–5% of patients with pulmonary TB develop musculoskeletal lesions, this number substantially rises to nearly 60% in patients with HIV 2).

Clinical features

Characteristically, there is destruction of the intervertebral disk space and the adjacent vertebral bodies, collapse of the spinal elements, and anterior wedging leading to kyphosis and gibbus formation. The thoracic region of vertebral column is most frequently affected. Formation of a ‘cold’ abscess around the lesion is another characteristic feature. The incidence of multi-level noncontiguous vertebral tuberculosis occurs more frequently than previously recognized. Common clinical manifestations include constitutional symptoms, back pain, spinal tenderness, paraplegia, and spinal deformities.

Typically symptomatic for many months.

Neurologic deficit develops in 10–47% of patients 3) , and may be due to medullary and radicular artery inflammation in most cases. The infection itself rarely extends into the spinal canal 4) , however, epidural granulation tissue or fibrosis or a kyphotic bony deformity may cause cord compression 5).

Diagnosis

For the diagnosis of spinal tuberculosis magnetic resonance imaging is more sensitive imaging technique than x-ray and more specific than computed tomography. Magnetic resonance imaging frequently demonstrates involvement of the vertebral bodies on either side of the disk, disk destruction, cold abscess, vertebral collapse, and presence of vertebral column deformities.

Neuroimaging-guided needle biopsy from the affected site in the center of the vertebral body is the gold standard technique for early histopathological diagnosis.


The available gadgetry of investigations, such as AFB smear, culture of Mycobacterium tuberculosis, and Uniplex PCR, suffers from a lack of adequate sensitivity and/or a lack of rapidity. Therefore, many times a diagnosis is made either very late in the disease process or sometimes empirical therapy has to be started because a definite diagnosis could not be made. All of these are not ideal situations for a clinician.

MPCR using IS6110, protein b, and MPB64 primers has a high sensitivity and specificity in rapid diagnosis of spinal tuberculosis. This is particularly useful for paucibacillary infections like spinal tuberculosis. However, further studies using large sample sizes are needed to confirm the practical applicability of this technique 6).

Treatment

Esposito et al., highlighted the importance of suspecting this disorder in children with both aspecific systemic and neurological symptoms, in order to reach a timely diagnosis for appropriate and targeted intervention, avoiding the risk of overtreatment and malpractice claims 7).

In the context of evidence-based medicine and the rational use of antibiotics, it is clear that antibiotics should be preferred according to the culture antibiogram results in the treatment of infectious diseases 8).

Surgery may be required in selected cases, e.g. large abscess formation, severe kyphosis, an evolving neurological deficit, or lack of response to medical treatment.

The role of surgical debridement and fusion with TB is controversial, and good results may be obtained with either medical treatment or surgery. Surgery may be more appropriate when definite cord compression is documented or for complications such as abscess or sinus formation 9) or spinal instability.

Outcome

Early diagnosis and prompt treatment is necessary to prevent permanent neurological disability and to minimize spinal deformity 10) 11).

Case series

Fifty-nine adult patients with thoracic and thoracolumbar spinal tuberculosis underwent single-stage transpedicular debridement, posterior instrumentation and fusion. These patients were followed for a minimum of 5 years. Patients were assigned to one of two groups according to the infected anatomic segment. In the thoracic spinal tuberculosis group, there were 28 cases (17 males, 11 females) with a mean age of 38.9 years; in the thoracolumbar spinal tuberculosis group, there were 31 cases (19 males, 12 females) with a mean age of 40.3 years. All cases were evaluated clinically using the visual analog scale (VAS), Kirkaldy Willis criteria and the ASIA impairment scale (ASIA). Radiographs were performed for measuring the angle of kyphosis and scoliosis. Complications related to surgery were recorded.

All patients successfully resolved their infections, experienced one or more ASIA grades of improvement, and improved in their VAS pain scores at final follow-up. In both groups, patient-reported outcomes reached over 90% excellent or good results using Kirkaldy-Willis criteria. The loss of kyphotic angle correction was 2.6° in the thoracic spinal tuberculosis group and 3.2° in the thoracolumbar spinal tuberculosis group. No scoliosis was observed in either group. Fifty-eight (98.3%) cases achieved solid bony fusion. In the thoracolumbar spinal tuberculosis group, one patient experienced screw loosening, and another patient with nonunion and rod breakage underwent revision surgery.

The technique of single-stage transpedicular debridement, posterior instrumentation and fusion is an effective method for the treatment of thoracic and thoracolumbar spinal tuberculosis in adults. Long-term postoperative clinical and radiological outcomes were satisfactory 12).


Kim et al., performed a retrospective review of the medical records of patients with culture negative pyogenic spondylitis (CNPS) and tuberculous spondylitis (TS). They compared the characteristics of 71 patients with CNPS with those of 94 patients with TS.

Patients with TS had more previous histories of tuberculosis (9.9 vs 22.3 %, p = 0.034), simultaneous tuberculosis other than of the spine (0 vs 47.9 %, p < 0.001), and positive results in the interferon-gamma release assay (27.6 vs 79.2 %, p < 0.001). Fever (15.5 vs. 31.8 %, p = 0.018), psoas abscesses (15.5 vs 33.0 %, p = 0.011), and paravertebral abscesses (49.3 vs. 74.5 %, p = 0.011) were also more prevalent in TS than CNPS.

Different from or contrary to the previous comparisons between CPPS and TS, fever, psoas abscesses, and paravertebral abscesses are more common in patients with TS than in those with CNPS 13).


Many previous studies in Korea usually reported that tuberculous spondylitis is the predominant infection. However, in the study of Jeong et al., the number of pyogenic infection was 3 times greater than that of tuberculous spinal disease. Etiological agents were identified in a half of all infectious spinal disease. For better outcomes, we should try to identify the causative microorganism before antibiotic therapy and make every effort to improve the result of culture and biopsy 14).

Case reports

References

1)

Wu M, Su J, Yan F, Cai L, Deng Z. Skipped multifocal extensive spinal tuberculosis involving the whole spine: A case report and literature review. Medicine (Baltimore). 2018 Jan;97(3):e9692. doi: 10.1097/MD.0000000000009692. Review. PubMed PMID: 29505022; PubMed Central PMCID: PMC5779791.
2)

Rajasekaran S, Khandelwal G. Drug therapy in spinal tuberculosis. Eur Spine J. 2013 Jun;22 Suppl 4:587-93. doi: 10.1007/s00586-012-2337-5. Epub 2012 May 12. Review. PubMed PMID: 22581190; PubMed Central PMCID: PMC3691408.
3) , 5)

Rothman RH, Simeone FA. The Spine. Philadelphia
4)

Kinnier WSA. In: Tuberculosis of the Skull and Spine. Neurology. London: Edward Arnold; 1940:575–583
6)

Sharma K, Meena RK, Aggarwal A, Chhabra R. Multiplex PCR as a novel method in the diagnosis of spinal tuberculosis-a pilot study. Acta Neurochir (Wien). 2017 Jan 21. doi: 10.1007/s00701-016-3065-0. [Epub ahead of print] PubMed PMID: 28110400.
7)

Esposito S, Moscatelli M, Schiariti MP, Viganò I, Pantaleoni C, Marucci G. Pott’s Disease: An Emerging Source of Potentially Inappropriate Treatment. Neuropediatrics. 2019 May 29. doi: 10.1055/s-0039-1691833. [Epub ahead of print] PubMed PMID: 31141827.
8)

Dogan M, Simsek AT, Yilmaz I, Karaarslan N. Evaluation of Empirical Antibiotic Treatment in Culture Negative Pyogenic Vertebral Osteomyelitis. Turk Neurosurg. 2019 Jan 2. doi: 10.5137/1019-5149.JTN.25018-18.2. [Epub ahead of print] PubMed PMID: 31049918.
9)

Medical Research Council Working Party on Tuber- culosis of the Spine. Controlled Trial of Short- Course Regimens of Chemotherapy in the Ambula- tory Treatment of Spinal Tuberculosis: Results at Three Years of a Study in Korea. J Bone Joint Surg. 1993; 75B:240–248
10)

Jain AK. Tuberculosis of the spine: a fresh look at an old disease. J Bone Joint Surg Br 2010;92(7):905–13
11)

Jain AK, Dhammi IK. Tuberculosis of the spine: a review. Clin Orthop Relat Res 2007;460(July):39–49
12)

Zhang P, Peng W, Wang X, Luo C, Xu Z, Zeng H, Liu Z, Zhang Y, Ge L. Minimum 5-year follow-up outcomes for single-stage transpedicular debridement, posterior instrumentation and fusion in the management of thoracic and thoracolumbar spinal tuberculosis in adults. Br J Neurosurg. 2016 Jul 8:1-6. [Epub ahead of print] PubMed PMID: 27387195.
13)

Kim CJ, Kim EJ, Song KH, Choe PG, Park WB, Bang JH, Kim ES, Park SW, Kim HB, Oh MD, Kim NJ. Comparison of characteristics of culture-negative pyogenic spondylitis and tuberculous spondylitis: a retrospective study. BMC Infect Dis. 2016 Oct 12;16(1):560. PubMed PMID: 27733126.
14)

Jeong SJ, Choi SW, Youm JY, Kim HW, Ha HG, Yi JS. Microbiology and epidemiology of infectious spinal disease. J Korean Neurosurg Soc. 2014 Jul;56(1):21-7. doi: 10.3340/jkns.2014.56.1.21. Epub 2014 Jul 31. PubMed PMID: 25289121; PubMed Central PMCID: PMC4185315.

Intrathecal Drug Delivery Device Infection

Intrathecal Drug Delivery Device Infection

A major complication of Intrathecal Drug Delivery Device (IDDD) implantationis infection.

Morgalla et al., assessed IDD-related complications in 51 patients who had IDD systems implanted for the treatment of chronic pain or spasticity.

Twelve patients (23.5%) presented a total of 22 complications. The main type of complication was catheter-related (50%), followed by pump failure, infection, and inappropriate refilling 1).


Device-related and surgical wound infection occurred in 12 patients (3%), and nine were regarded as severe in the series of Taira et al., 2).

Risk Factors

Patients with extremely low muscle bulk, visceral pumps may be impractical or impossible, with increased risks of dehiscence and infection 3).


Periodic refills of intrathecal implanted pumps do not seem to be a risk factor for infection if standard sterile refill procedures are performed. In a study, it was clear that comorbid infections from other parts of the body do not present as a risk for device contamination 4).

Prevention

Follett et al., concluded from the available data that the most effective antiinfection measures consist of adherence to published guidelines and recommendations that apply to surgical site infections (SSIs) in general 5).


The use of vancomycin powder in patients with implants in the series of is series of Ghobrial et al., did not reduce infection rates compared to published historical controls, and was elevated compared to institutional controls 6).


The combination of local neomycin/polymyxin with systemic antibiotic therapy can lead to a significantly lower rate of postoperative infection than when systemic antibiotics are used alone 7).


The subfascial implantation technique was associated with a reduced rate of local wound and pump infections and provided optimal cosmetic results as compared with that observed in retrospective cases 8).

Treatment

The current standard of care in the treatment of IDDD infection necessitates that the pump be explanted and the infection treated prior to implantation of a new IDDD. This process leads to long hospital stays, interruptions in optimal medical management, and a high risk for dangerous drug withdrawals.


Infections can be treated with repetitive local application of gentamicin-impregnated collagen fleece 9).


Leibold et al., describe a technique that allows for the explantation of the infected pump and implantation of a new pump concurrently, which they have named the “Turner Switch” technique in honor of its inventor.

The authors conducted a retrospective analysis of cases of infected IDDDs in which patients underwent simultaneous explantation of the infected pump and implantation of a new pump. Demographics and clinical data were collected.

Data from a total of 17 patients (11 male, 6 female) who underwent simultaneous IDDD explantation and implantation to treat infections were analyzed from a 3-year period. No patients experienced infection of the newly implanted pump or catheter. Of the 17 patients, 14 (82.4%) had baclofen pumps to treat spasticity and 3 (17.6%) had fentanyl pumps to treat chronic pain. The median hospital stay was 7 days, with 16 of 17 (94.1%) patients able to be discharged home or to a facility with a level of care similar to their preoperative care. All patients ultimately experienced complete resolution of their initial infections. Five patients (29.4%) required a return to the operating room within the next 5 months (for repair of a CSF leak in 2 cases, for treatment of infection at the old pump site in 2 cases, and for treatment of a CSF leak compounded with infection in 1 case). No patient experienced infection of the newly implanted pump or catheter.

IDDD infections represent a large portion of morbidity associated with these devices. The current standard of care for deep pump infections requires pump explantation and a course of antibiotics prior to reimplantation of the IDDD. The authors demonstrate the effectiveness of a procedure involving simultaneous explantation of an infected pump and implantation of a new pump on the contralateral side in the treatment of IDDD infections 10).


Ingale et al., suggested that consideration should be given to selective dorsal rhizotomy (SDR) as an alternative in patients previously implanted with Intrathecal Drug Delivery systems complicated by infection or nearing end of battery life 11).

Case reports

A patient with pump-site infection and Escherichia coli meningitis secondary to transcolonic perforation of an intrathecal baclofen pump catheter. While this is rare, we review the intraoperative precautions and best practices that should be taken to prevent and manage this unusual complication 12).


Intrathecal drug delivery device infection with Mycobacterium fortuitum was not been reported previously. Aliabadi et al., reported a case of an implanted baclofen pump infection and associated mycobacterium meningitis due to Mycobacterium fortuitum. The entire pump system was removed and the patient was treated successfully with a prolonged regimen of antibiotics 13).


In a case neurological complaints were pain and dysaesthesiae in the lower back and thigh, as well as paresis of the ileopsoas muscle. MRI of the lumbar spine showed an intradural-extramedullary mass at the level of L1 homogeneously enhancing with gadolinium. This mass was situated at the tip of an intrathecal catheter implanted 11 years before for a morphine trial infusion as therapy for phantom pain after amputation of the right arm. Now, removal of the catheter was performed. Cultures of lumbar CSF and the catheter tip demonstrated coagulase negative staphylococcus. Antibiotic medication with cephalosporines was given for 6 weeks. After removal of the catheter, the patient was free of pain and he progressively regained full neurological function. Although most catheter-associated granulomas reported so far were sterile in nature, bacterial infection should still be considered even years after catheter placement 14).


A patient who experienced a prolonged course of intrathecal baclofen withdrawal syndrome after removal of an implantable baclofen pump for treatment of pump infection and meningitis. The current literature outlines management options for the acute management of this syndrome. In this report the authors discuss the long-term presentation of this syndrome and suggest a treatment strategy for management of the syndrome. A 37-year-old man who presented with a baclofen pump infection and meningitis experienced acute onset of intrathecal baclofen withdrawal syndrome 12 hours after the pump had been surgically removed. The patient’s symptoms evolved into a severe, treatment-refractory withdrawal syndrome lasting longer than 1 month. Oral baclofen replacement with adjunctive administration of parenteral gamma-aminobutyric acid agonists only served to stabilize the patient’s critical condition throughout his hospital course. Replacement of the baclofen pump and restoration of intrathecal delivery of the medication was necessary to trigger the patient’s dramatic recovery and complete reversal of the withdrawal syndrome within approximately 48 hours. These findings indicate that a more direct method of treating infected baclofen pumps than immediate surgical removal is necessary to prevent the onset of intrathecal baclofen withdrawal syndrome. Various options for preventing the onset of the syndrome while simultaneously treating the infection are discussed 15).

References

1)

Morgalla M, Fortunato M, Azam A, Tatagiba M, Lepski G. High-Resolution Three-Dimensional Computed Tomography for Assessing Complications Related to Intrathecal Drug Delivery. Pain Physician. 2016 Jul;19(5):E775-80. PubMed PMID: 27389121.
2)

Taira T, Ueta T, Katayama Y, Kimizuka M, Nemoto A, Mizusawa H, Liu M, Koito M, Hiro Y, Tanabe H. Rate of complications among the recipients of intrathecal baclofen pump in Japan: a multicenter study. Neuromodulation. 2013 May-Jun;16(3):266-72; discussion 272. doi: 10.1111/ner.12010. Epub 2012 Dec 14. PubMed PMID: 23240625.
3)

Waqar M, Ellenbogen JR, Kumar R, Sneade C, Zebian B, Williams D, Pettorini BL. Indwelling intrathecal catheter with subcutaneous abdominal reservoir: a viable baclofen delivery system in severely cachectic patients. J Neurosurg Pediatr. 2014 Oct;14(4):409-13. doi: 10.3171/2014.6.PEDS13686. Epub 2014 Aug 1. PubMed PMID: 25084089.
4)

Dario A, Scamoni C, Picano M, Fortini G, Cuffari S, Tomei G. The infection risk of intrathecal drug infusion pumps after multiple refill procedures. Neuromodulation. 2005 Jan;8(1):36-9. doi: 10.1111/j.1094-7159.2005.05218.x. PubMed PMID: 22151381.
5)

Follett KA, Boortz-Marx RL, Drake JM, DuPen S, Schneider SJ, Turner MS, Coffey RJ. Prevention and management of intrathecal drug delivery and spinal cord stimulation system infections. Anesthesiology. 2004 Jun;100(6):1582-94. Review. PubMed PMID: 15166581.
6)

Ghobrial GM, Thakkar V, Singhal S, Oppenlander ME, Maulucci CM, Harrop JS, Jallo J, Prasad S, Saulino M, Sharan AD. Efficacy of intraoperative vancomycin powder use in intrathecal baclofen pump implantation procedures: single institutional series in a high risk population. J Clin Neurosci. 2014 Oct;21(10):1786-9. doi: 10.1016/j.jocn.2014.04.007. Epub 2014 Jun 14. PubMed PMID: 24938386.
7)

Miller JP, Acar F, Burchiel KJ. Significant reduction in stereotactic and functional neurosurgical hardware infection after local neomycin/polymyxin application. J Neurosurg. 2009 Feb;110(2):247-50. PubMed PMID: 19263587.
8)

Kopell BH, Sala D, Doyle WK, Feldman DS, Wisoff JH, Weiner HL. Subfascial implantation of intrathecal baclofen pumps in children: technical note. Neurosurgery. 2001 Sep;49(3):753-6; discussion 756-7. PubMed PMID: 11523691.
9)

Peerdeman SM, de Groot V, Feller RE. In situ treatment of an infected intrathecal baclofen pump implant with gentamicin-impregnated collagen fleece. J Neurosurg. 2010 Jun;112(6):1308-10. doi: 10.3171/2009.8.JNS081692. PubMed PMID: 19731988.
10)

Leibold AT, Weyhenmeyer J, Lee A. Simultaneous explantation and implantation of intrathecal pumps: a case series. J Neurosurg. 2019 Apr 12:1-7. doi: 10.3171/2019.1.JNS18919. [Epub ahead of print] PubMed PMID: 30978693.
11)

Ingale H, Ughratdar I, Muquit S, Moussa AA, Vloeberghs MH. Selective dorsal rhizotomy as an alternative to intrathecal baclofen pump replacement in GMFCS grades 4 and 5 children. Childs Nerv Syst. 2016 Feb;32(2):321-5. doi: 10.1007/s00381-015-2950-9. Epub 2015 Nov 9. PubMed PMID: 26552383.
12)

Devine OP, Harborne AC, Lo WB, Price R. Colonic perforation by an intrathecal baclofen pump catheter causing delayed Escherichia coli meningitis. BMJ Case Rep. 2017 Dec 20;2017. pii: bcr-2017-222539. doi: 10.1136/bcr-2017-222539. PubMed PMID: 29269368.
13)

Aliabadi H, Osenbach RK. Intrathecal Drug Delivery Device Infection and Meningitis due to Mycobacterium Fortuitum: A Case Report. Neuromodulation. 2008 Oct;11(4):311-4. do 10: i: 10.1111/j.1525-1403.2008.00181.x. PubMed PMID: 22151146.
14)

Lehmberg J, Scheiwe C, Spreer J, van Velthoven V. Late bacterial granuloma at an intrathecal drug delivery catheter. Acta Neurochir (Wien). 2006 Aug;148(8):899-901; discussion 901. Epub 2006 Jun 23. PubMed PMID: 16791432.
15)

Douglas AF, Weiner HL, Schwartz DR. Prolonged intrathecal baclofen withdrawal syndrome. Case report and discussion of current therapeutic management. J Neurosurg. 2005 Jun;102(6):1133-6. Review. PubMed PMID: 16028775.

Peripontomedullary hydatid cyst

Peripontomedullary hydatid cyst

Even when Hydatid cyst is found in the brain it presents usually in the supratentorial compartment. However this case was unique in having the Hydatid cyst within the infratentorial fossa. With multiple small cysts, causing mass effect and challenging for surgical resection.

A 44 years female presented with headachediplopia and bulbar symptoms, followed by ataxia. Full examination, proper investigations showed the peripontomedullary hydatid cysts. Surgical management is illustrated.

It is still challenging for the neurosurgeons to operate on these lesions in spite of modern technologies and fancy approaches due to its delicate nature, associated risk of allergic reaction, cyst’s material dissemination and irreversible injury of multiple neurological structure due to prolonged compression of cranial nerves crossing the cerebellopontine angle.

In this case report Alkhotani et al., from the King Faisal Specialist Hospital and Research Center, present a rare case of Multiple Hydatid cysts involving a rare location in the brain; peripontomedullary area and extending all the way down to the foramen magnum. Supported with a literature review in relation to disease etiologyepidemiology, clinical presentation and management 1).

1)

Alkhotani A, Butt B, Khalid M, Binmahfoodh M. Peripontomedullary hydatid cyst: Case report and literature review. Int J Surg Case Rep. 2019 Jan 18;55:23-27. doi: 10.1016/j.ijscr.2019.01.003. [Epub ahead of print] PubMed PMID: 30710875.
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