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www.krspine.org Multifocal Extensive Spinal Tuberculosis Accompanying Isolated Involvement of Posterior Elements - A Case Report - Dong-Eun Shin, M.D., Sang-June Lee, M.D., Young Woo Kwon, M.D., Tae-Keun Ahn, M.D. J Korean Soc Spine Surg 2016 Sep;23(3):183-187. Originally published online September 30, 2016; http://dx.doi.org/10.4184/jkss.2016.23.3.183 Korean Society of Spine Surgery Department of Orthopedic Surgery, Gangnam Severance Spine Hospital, Yonsei University College of Medicine, 211 Eunju-ro, Gangnam-gu, Seoul, 06273, Korea Tel: 82-2-2019-3413 Fax: 82-2-573-5393 ©Copyright 2016 Korean Society of Spine Surgery pISSN 2093-4378 eISSN 2093-4386 The online version of this article, along with updated information and services, is located on the World Wide Web at: http://www.krspine.org/DOIx.php?id=10.4184/jkss.2016.23.3.183 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Journal of Korean Society of Spine Surgery

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Page 1: Journal of Korean Society of Spine Surgery · 2016-09-28 · Journal of Korean Society of Spine Surgery. ... 53-year-old woman who had spinal tuberculosis in her cervical, thoracic

www.krspine.org

Multifocal Extensive Spinal Tuberculosis Accompanying Isolated Involvement of Posterior Elements

- A Case Report -Dong-Eun Shin, M.D., Sang-June Lee, M.D., Young Woo Kwon, M.D., Tae-Keun Ahn, M.D.

J Korean Soc Spine Surg 2016 Sep;23(3):183-187.

Originally published online September 30, 2016;

http://dx.doi.org/10.4184/jkss.2016.23.3.183

Korean Society of Spine SurgeryDepartment of Orthopedic Surgery, Gangnam Severance Spine Hospital, Yonsei University College of Medicine,

211 Eunju-ro, Gangnam-gu, Seoul, 06273, Korea Tel: 82-2-2019-3413 Fax: 82-2-573-5393

©Copyright 2016 Korean Society of Spine Surgery

pISSN 2093-4378 eISSN 2093-4386

The online version of this article, along with updated information and services, islocated on the World Wide Web at:

http://www.krspine.org/DOIx.php?id=10.4184/jkss.2016.23.3.183

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Journal of Korean Society of

Spine Surgery

Page 2: Journal of Korean Society of Spine Surgery · 2016-09-28 · Journal of Korean Society of Spine Surgery. ... 53-year-old woman who had spinal tuberculosis in her cervical, thoracic

© Copyright 2016 Korean Society of Spine Surgery Journal of Korean Society of Spine Surgery. www.krspine.org. pISSN 2093-4378 eISSN 2093-4386 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

183

J Korean Soc Spine Surg. 2016 Sep;23(3):183-187. http://dx.doi.org/10.4184/jkss.2016.23.3.183Case Report

Here, we present a patient with multifocal extensive spinal

tuberculosis from the cervical to sacral spine with isolated

involvement of posterior element of thoracic spine.

Case Report

A sedentary worker, 39-year old male, presented with

Multifocal Extensive Spinal Tuberculosis Accompanying Isolated Involvement of Posterior Elements - A Case Report -Dong-Eun Shin, M.D., Sang-June Lee, M.D., Young Woo Kwon, M.D., Tae-Keun Ahn, M.D.Department of Orthopedic Surgery, CHA Bundang Medical Center, CHA University, Korea

Study Design: A case report.Objectives: To report a rare case of atypical spinal tuberculosis. Summary of Literature Review: In spinal tuberculosis, non-contiguous multifocal involvement and isolated involvement of posterior elements of the spine have been considered atypical features. There have been a few reports of each of these atypical features but no reports have described spinal tuberculosis with both of these atypical features.Materials and Methods: A 39-year-old man presented with back pain and progressive weakness of both lower extremities. He was diagnosed with spinal tuberculosis from the cervical to sacral spine, showing multifocal non-contiguous involvement with multiple abscesses on magnetic resonance imaging. Notably, in the thoracic spine area, isolated involvement of posterior elements was found with an epidural abscess compressing the spinal cord. He underwent a total laminectomy of the thoracic spine and multiple abscesses were drained with pigtail catheter insertions into the cervical, thoracic, and lumbar spine.Results: At the 8-month follow-up, the patient’s neurologic status had improved to Frankel Grade D, and the patient was able to walk with the support of a walker. At the 3-year follow-up, the patient had recovered completely without any neurologic deficit. Conclusions: Since atypical spinal tuberculosis may show various patterns, examination of the entire spine is important for early diagnosis. Treatment should be provided properly from minimally invasive procedures to open surgery depending on the extent of structural instability and neurologic deficit.

Key words: Spine, Atypical tuberculosis, Decompression

Received: March 17, 2016 Revised: April 1, 2016 Accepted: September 12, 2016 Published Online: September 30, 2016 Corresponding author: Tae-Keun Ahn, M.D. Department of Orthopedic Surgery, CHA Bundang Medical Center, CHA University, 59 Yatap-ro, Bundang-gu, Seongnam, Gyeonggi, 13496, KoreaTEL: +82-10-3218-6614, FAX: +82-31-708-3578E-mail: [email protected]

Introduction

Typically, in spinal tuberculosis, there is paradiscal involvement

of anterior parts of the adjacent vertebral bodies. This classic

spinal tuberculosis has been well-described and readily

diagnosed.1) However, because atypical spinal tuberculosis

shows various patterns of spinal involvement without the typical

radiologic lesion, it is often misdiagnosed and mistreated.2)

Atypical features of spinal tuberculosis include the following:

involvement of single isolated vertebral body, circumferential or

pan-vertebral involvement, extradural cord compression without

radiologic evidence of bony involvement, sacral tuberculosis,

involvement of the posterior elements (neural arch) of the spinal

column without involvement of the anterior elements, multifocal

spinal involvement which may be discontinuity or non-

contiguous.3-6)

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Dong-Eun Shin et al Volume 23 • Number 3 • September 2016

www.krspine.org184

Based on the multiple signal changes on scout images of

cervical and thoracic spine, a cervical and thoracic spinal MRI

was obtained. In the cervical spine, high signal intensities were

found in the C4 vertebral body and posterior osteoligamentous

structures of the C3-C5 levels. On an enhanced sagittal T1-

weighted image with fat suppression and an axial T2-weighted

image, right paravertebral abscess formation was discovered

from C3 level to the C5 level with right posterior epidural

compression (Fig. 2).

Thoracic sagittal T1-weighted MRI images with fat

suppression revealed isolated abscess formations of posterior

element at the T2 and T4-T6 levels. The abscess at T2 had no

epidural compression. However, the abscess extending from T4

to T6 caused severe epidural compression. At the T9-T11 levels,

a paravertebral abscess with intensity changes of vertebral body

and lamina was seen on the left side (Fig. 2).

A total laminectomy at the T2-T6 levels was carried out

to decompress the spinal cord and remove abscesses. The

intraoperative specimens were harvested for biopsy. Fusion was

not performed because there was no structural instability or

kyphotic deformity. Paraspinal abscesses in cervical, thoracic

and lumbosacral spine were drained using fluoroscopic-

guided pigtail catheters (Fig. 3).7) The patient was treated with

a four drugs regimen for tuberculosis (pyrazinamide, isoniazid,

rifampin, ethambutol) for 12 months. The final diagnosis of

tuberculosis was confirmed by histopathology examination

showing caseation necrosis and granuloma. Moreover, on a skin

persistent back pain associated with progressive radiating

pain. At his hospital visit, the patient could not sustain normal

gait and required wheelchair assistance. Physical examination

showed Frankel Grade C neurologic deficits in both lower

extremities. Ankle clonus and hyperactive knee reflex were

also identified. He had a 20×20 cm sized skin lesion on his left

posterior thigh which was suspected to be skin dermatitis. On

spinal radiographs, no distinct radiographic changes or collapsed

vertebrae were found.

Laboratory tests showed an erythrocyte sedimentation rate

(ESR) of 91 mm/h, and C-reactive protein (CRP) of 13.88

mg/dL. Chest radiographs revealed no evidence of past or

presenting signs of tuberculosis. The patient’s serologic test was

negative for HIV markers and was also negative for tumor and

other hematologic malignancies. It was determined to proceed

with magnetic resonance imaging (MRI) based on the clinical

symptoms and laboratory results.

Initially, a lumbar spine MRI including scout images of the

entire spine was obtained. Enhanced sagittal and axial T1-

weighted images with fat suppression revealed high signal

intensity in the T11 vertebral body, marrow enhancement

with small intraosseous abscesses on L1 and L2 vertebral

bodies, and high signal intensity on and around the L4 vertebra

with abscesses in the psoas muscle, vertebral body, lamina

and posterior muscle. Enhanced vertebral bodies and tissues

around S1-S2 levels were also found with abscesses in S1 body

extending to the presacral space (Fig. 1).

A B C

Fig. 1. Enhanced T1-weighted magnetic resonance images of the lumbosacral spine with fat suppression. (A) A sagittal image showing high signals at T11, L1, L2, L4, S1, and S2 with abscesses at the L4 and S1 levels. (B) Abscesses in the anterior vertebral body, right psoas muscle, and left erector muscle at the L4 level on an axial image. (C) Abscesses in the sacrum extending to the presacral space and high signals in the sacrum and both sacral ala.

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Extensive Multifocal Spinal Tuberculosis with Isolated Posterior InvolvementJournal of Korean Society of Spine Surgery

www.krspine.org 185

element or the multifocal non-contiguous spinal tuberculosis

with intervening normal vertebrae have rarely been reported and

considered to be atypical spinal tuberculosis.8,9)

Among the multifocal non-contiguous spinal tuberculosis,

extensive involvement of whole spine is rarer and there have

only been two case reports in the literature. Turgut reported a

53-year-old woman who had spinal tuberculosis in her cervical,

thoracic and lumbar spine with psoas abscess.8) Emel et al

described a 17-year-old girl who had tuberculosis involvement

from cervical to sacral spine with paravertebral abscesses.6)

Similarly, our patient also had extensive involvement of

biopsy of the posterior thigh, the lesion was determined as the

squamous cell carcinoma.

ESR/CRP normalized after 2 months of steady medication. At

the 8 month follow-up, the patient’s neurologic status had

improved to Frankel Grade D and the patient was able to walk

under walker assistant. At the 3-year follow-up, the patient had

recovered completely without any neurologic deficit.

Discussion

In spinal tuberculosis, an isolated involvement of posterior

Fig. 2. Magnetic resonance images of the cervical and thoracic spine. (A) An enhanced sagittal T1-weighted image. In the cervical spine, the cord com-pressing the epidural abscess with high signals in the C4 vertebral body and posterior osteoligamentous structures of the C3-C5 levels was found. In the thoracic spine, two abscesses limited to the posterior elements of the T2 and T4-T6 levels were revealed. Notably, the posterior epidural abscess of the T4-T6 level was compressing the spinal cord, causing progressive neurologic deficits. (B) An axial T2-weighted image of the C4 level showing a huge right paravertebral abscess and spinal cord deviation to the right side by the right posterior epidural abscess (white arrow). (C) Severe cord compression (white arrow) by a huge posterior abscess involving the posterior epidural space and posterior elements on an axial T2-weighted image at the C5-C6 in-tervertebral disc level. (D) A left-sided anterior paravertebral abscess with involvement of the vertebral body, pedicle, and lamina at the T10 level on the axial T2-weighted image.

A B C D

Fig. 3. Plain radiographs of the cervical, thoracic, and lumbosacral spine after pigtail catheter insertions. (A) Pigtail insertion into the right paravertebral area at C3 to C4. (B) Pigtail insertion into the left paravertebral area at T8 to T11. (C) Pigtail insertion into the right paravertebral area.

A B C

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Dong-Eun Shin et al Volume 23 • Number 3 • September 2016

www.krspine.org186

REFERENCES

1. Harry N. Herkowitz, Steven R Garfin, Frank J. Eismont,

et al. Rothman-Simeone the spine: expert consult 6th ed.

Elsevier Health Sciences:2011.1535.

2. Lolge S, Maheshwari M, Shah J, et al. Isolated solitary ver-

tebral body tuberculosis—study of seven cases. Clin Radiol.

2003;58:545-50.

3. Wellons JC, Zomorodi AR, Villaviciencio AT, et al. Sacral

tuberculosis: a case report and review of the literature. Surg

Neurol. 2004;61:136-9.

4. Al-Arabi KM, Khan FA. Atypical forms of spinal tubercu-

losis. Acta Neurochir (Wien). 1987;88:26-33.

5. Sankaran-Kutty M. Atypical tuberculous spondylitis. Int

Orthop. 1992;16:69-74.

6. Emel E, Güzey FK, Güzey D, et al. Non-contiguous

multifocal spinal tuberculosis involving cervical, thoracic,

lumbar and sacral segments: a case report. Eur Spine J.

2006;15:1019-24.

7. Pieri S, Agresti P, Altieri AM, et al. Percutaneous man-

agement of complications of tuberculous spondy-

lodiscitis: short-to medium-term results. Radiol Med.

2009;114:984-95.

8. Turgut M. Multifocal extensive spinal tuberculosis (Pott’s

disease) involving cervical, thoracic and lumbar vertebrae.

Br J Neurosurg. 2001;15:142-6.

9. Arora S, Sabat D, Maini L, et al. Isolated involvement of the

posterior elements in spinal tuberculosis. J Bone Joint Surg

Am. 2012;94:E151.

tuberculosis from the cervical to sacral spine as observed in the

aforementioned cases. However, in thoracic spine of our patient,

there was additionally isolated involvement of posterior element

at the T4-T6 levels with posterior epidural abscesses. Isolated

involvement of the posterior elements or neural arch is atypical

tuberculosis in the spine. This occurs rarely in less than 6% of

patients with spinal tuberculosis.9) To our knowledge, there

have been no reports which address spinal tuberculosis with

isolated posterior involvement and multifocal non-contiguous

involvement from cervical to sacral spine as presented in our

case.

The patient was treated with a total laminectomy on the

posterior epidural abscess causing progressive neurologic deficit.

Since other abscesses in cervical, thoracic and lumbosacral

spine did not cause progressive neurologic deficit or structural

instability requiring urgent surgery, percutaneous pig-tail

catheters were inserted to treat the abscesses. The percutaneous

catheterization in drainage of paravertebral tuberculous abscesses

of spine has been described as an effective and safe procedure.7)

In the current case, although the primary origin of infection

was not identified, considering the squamous cell carcinoma on

his posterior thigh, it is thought his immune system had been

compromised.

In conclusion, since atypical spinal tuberculosis may show

various patterns, examination of entire spine is important for

early diagnosis. Surgical treatment should be provided properly

from minimally invasive procedures to open surgery depending

on structural instability and neurologic deficit.

Page 6: Journal of Korean Society of Spine Surgery · 2016-09-28 · Journal of Korean Society of Spine Surgery. ... 53-year-old woman who had spinal tuberculosis in her cervical, thoracic

© Copyright 2016 Korean Society of Spine Surgery Journal of Korean Society of Spine Surgery. www.krspine.org. pISSN 2093-4378 eISSN 2093-4386 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

187

J Korean Soc Spine Surg. 2016 Sep;23(3):183-187. http://dx.doi.org/10.4184/jkss.2016.23.3.187Case Report

후방부 단독침범을 동반한 다발성 광범위 척추 결핵 - 1례 보고 - 신동은 • 이상준 • 권영우 • 안태근

차의과대학 분당차병원 정형외과학교실

연구 계획: 증례 보고

목적: 비전형 척추 결핵의 증례 보고

선행연구문헌의 요약: 척추결핵에 있어서 비연속성 다발성 침범 이나 후방부 단독 침범은 비전형적 형태이다. 이전 문헌에 있어 이와 같은 두 비전형적

형태가 동시에 나타난 경우에 대한 사례에 대한 보고가 없다.

대상 및 방법: 39세 남자가 요통과 점진적인 양측 하지의 근력약화를 보였다. 자기공명영상상 경추에서 천추까지 이르며 농양을 동반한 다발성 비연속성

척추 결핵이 확인되었다. 흉추에서는 후방부에서 단독침범하여 척수를 압박하고 있는 경막 외 농양이 확인되었다. 흉추에 대해서 척추궁 전절제술을 통

한 감압을 시행하였고 경추에서 요추에 이르는 다발성 농양에 대해서는 pigtail 도관을 이용한 배액을 시행하였다.

결과: 8개월 추시관찰에서 Frankel Grade D의 신경학적 호전을 보였고 보행기 보조 하에 보행이 가능하였다. 3년 추시관찰에서 신경학적으로 완전한 호

전을 보였다.

결론: 비전형 척추 결핵은 다양한 양상으로 나타나므로 조기 진단을 위해서 전 척추에 대한 검사가 중요하다. 치료는 척추의 구조적 안정성과 신경학적

증상을 고려하여 최소침습적인 치료부터 관혈적 수술까지 적절하게 시행되어야 한다.

색인 단어: 척추, 비전형 결핵, 감압술

약칭 제목: 후방부 단독침범을 동반한 광범위 다발성 척추결핵

접수일: 2016년 3월 17일 수정일: 2016년 4월 1일 게재확정일: 2016년 9월 12일

교신저자: 안태근

경기도 성남시 분당구 야탑로 59(야탑동) 차의과대학 분당차병원 정형외과학교실

TEL: 010-3218-6614 FAX: 031-708-3578 E-mail: [email protected]