Department of Neurosurgery, National Neurosciences Center, Kolkata, West Bengal, India.
Eur Spine J. 2011 Jan;20(1):1-5. doi: 10.1007/s00586-010-1524-5. Epub 2010 Aug 6.
The management of spinal tuberculosis, especially in children, is controversial. In children, vertebral destruction is more severe than adults because of the cartilaginous nature of their bone. Modern chemotherapy has significantly decreased mortality in spinal tuberculosis, but morbidity remains high. Without early surgery, patients can develop severe kyphosis leading to respiratory insufficiency, painful costopelvic impingement and paraplegia. Lumbar kyphosis results in early degenerative lumbar canal stenosis and is cosmetically unacceptable. We report a paediatric case of atypical spinal tuberculosis demonstrating the need for early surgical intervention to prevent significant spinal instability and neurologic deficit. A 12-year-old girl presented with increasing ambulatory difficulty and double incontinence 4 months after initiating treatment for pulmonary tuberculosis. There was no history of traumatic injury. Examination revealed severe lower limb neurologic deficit, with hypotonia, areflexia, marked sensory loss, and grade 0/5 power in both lower limbs. Plain radiographs and magnetic resonance imaging (MRI) demonstrated grade IV posterior listhesis of the L2 vertebral body over L3, cauda equina compression and bilateral psoas abscesses. Erosion of both the body and pedicle of L2 was observed. Both serology and pus drained from the psoas abscesses were negative for microorganisms. The patient underwent an L2 vertebrectomy via a left retroperitoneal approach. A titanium cage packed with autologous bone graft was inserted, and the spine was stabilized by fixation with screw and rods. Histopathology confirmed a diagnosis of tuberculosis. Eighteen months following the procedure, the patient has regained some power in her right leg and has completed her course of anti-tuberculous chemotherapy, but remains wheelchair-bound. To our knowledge, this is the first reported case of posterior listhesis secondary to spinal tuberculosis. Here, we discuss the possible management options in such a case, and the indications for surgery. As the global HIV/AIDS epidemic causes a resurgence in tuberculosis, increased awareness among the medical community regarding the atypical presentations of spinal tuberculosis is necessitated; both in the developing world where advanced clinical presentations are common, and in the developed world where spinal tuberculosis is an often-neglected diagnosis.
脊柱结核的治疗，尤其是儿童脊柱结核的治疗，存在争议。由于儿童骨骼的软骨性质，其骨质破坏比成人更严重。现代化学疗法显著降低了脊柱结核的死亡率，但发病率仍然很高。如果不早期手术，患者可能会出现严重的脊柱后凸畸形，导致呼吸功能不全、疼痛性胸廓出口综合征和截瘫。腰椎后凸畸形导致早期退行性腰椎管狭窄，在美容上无法接受。我们报告了一例儿童非典型脊柱结核病例，该病例需要早期手术干预，以防止严重的脊柱不稳定和神经功能缺损。一名 12 岁女孩在开始治疗肺结核 4 个月后，出现逐渐加重的步行困难和大小便失禁。她没有创伤史。检查发现下肢严重神经功能缺损，表现为肌张力低下、反射消失、感觉明显丧失，双下肢肌力 0/5 级。X 线平片和磁共振成像（MRI）显示 L2 椎体相对于 L3 的 IV 级后滑脱，马尾受压，双侧腰大肌脓肿。观察到 L2 的体部和椎弓根均有侵蚀。L2 脓肿引流物和血清学检查均未发现微生物。患者经左腹膜后入路行 L2 椎体切除术。置入钛笼，并用螺钉和棒固定脊柱以稳定脊柱。组织病理学证实为结核。手术后 18 个月，患者右腿已恢复部分力量，已完成抗结核化疗，但仍需坐轮椅。据我们所知，这是首例报告的脊柱结核继发后凸滑脱病例。在这里，我们讨论了这种情况下可能的治疗选择，以及手术的适应证。随着全球艾滋病病毒/艾滋病疫情导致结核病卷土重来，需要提高医学界对脊柱结核不典型表现的认识；不仅在发展中国家，那里常见复杂的临床表现，而且在发达国家，脊柱结核也是经常被忽视的诊断。
