Broekx Senne, Buelens Eveleen
Departement of Neurosurgery, Ziekenhuis Oost-Limburg, 3600 Genk Belgium.
Clin Neurol Neurosurg. 2020 Jul;194:105944. doi: 10.1016/j.clineuro.2020.105944. Epub 2020 May 21.
Tuberculous spondylitis (TS), also known as Pott's disease (PD), is a form of tuberculosis in which the vertebral column is affected. Since the first description by Katz et al. in 1992, it became clear that Bacillus Calmette-Guérin (BCG) instillations in the treatment of superficial transitional cell carcinoma (TCC) form a plausible way in which PD is introduced. Nowadays, BCG forms the most effective treatment modality for superficial TCC. The incidence of other than minor complications have been estimated under five per cent. Here we report a case of TS after BCG-instillation in the treatment of TCC. Furthermore, all available literature concerning this topic was gathered into a systematic review. The primary objective was to create an overview of all available literature concerning TS after intravesical BCG-instillations, with an emphasis on the neurosurgical approach of these patients, forming a scaffold at which future case reports can be compared. As a secondary objective, we tried to raise the awareness concerning this very rare complication of intravesical BCG-instillation as a possible cause of low back pain (LBP).
We performed a systematic review, in which patients who developed TS after intravesical BCG-therapy in the treatment of TCC, were examined. A total of twenty-three articles (twenty-four cases) obtained from MEDLINE were included. Search terms included: "tuberculous spondylitis", "Pott's disease", "vertebral osteomyelitis", "intravesical", "Bacillus Calmette-Guérin" and "transitional cell carcinoma". Additional studies were identified by checking reference lists. Furthermore, we present a case concerning one of our own patients who consulted our Neurosurgical department with a similar clinical presentation. This systematic review is in conformity with the PRISMA-guidelines. The case report is in accordance with the CARE statement guidelines.
Results are based on twenty-five cases (twenty-four cases extracted from previous literature and our case report). All included articles are case reports written in English. Publication year and recruitment time varies from 1992 to 2018. Mean age at clinical presentation varies from 35 to 94 years old (mean 74). All patients were male. Surgery was performed in 17 out of 25 cases (68%). A posterior approach was performed in seven cases (41%), zero anterior approaches (0%), a combined approach in five cases (29%) and not specified in five cases (29%). All patients received intravesical BCG-instillation in the treatment of TCC, ranging from one month to twelve years before clinical presentation (mean 26). Radiographic abnormalities were seen in thoracic vertebral segments in thirteen cases (52%), eleven cases in lumbar segments (44%), one at the thoracolumbar transition level (4%) and not in cervical vertebral segments.
Although very rare, TS should be part of the differential diagnosis in patients with LBP, even years after BCG-instillation for TCC. It mostly affects elderly men and involves the thoracolumbar spine through hematogenous spread via Batson's plexus. Antitubercular therapy remains the mainstay in the treatment of TS. A posterior surgical approach, with debridement and stabilization, should be preferred when surgical intervention seems necessary. To our knowledge, this systematic review forms one of the first comprehensive reviews evaluating neurosurgical intervention for PD following intravesical BCG-therapy in the treatment of TCC.
结核性脊柱炎（TS），也称为波特氏病（PD），是一种结核菌感染脊柱的疾病。自1992年卡茨等人首次描述以来，已明确卡介苗（BCG）灌注治疗浅表性移行细胞癌（TCC）是引发PD的一种可能途径。如今，卡介苗是浅表性TCC最有效的治疗方式。除轻微并发症外，其他并发症的发生率估计低于5%。在此，我们报告1例TCC患者在卡介苗灌注治疗后发生TS的病例。此外，我们收集了有关该主题的所有可用文献进行系统综述。主要目的是全面概述所有关于膀胱内卡介苗灌注后发生TS的可用文献，重点关注这些患者的神经外科治疗方法，为未来病例报告的比较搭建框架。次要目的是提高对膀胱内卡介苗灌注这种非常罕见的并发症可能导致腰痛（LBP）的认识。
我们进行了一项系统综述，研究了TCC患者在膀胱内卡介苗治疗后发生TS的情况。从MEDLINE数据库中总共纳入了23篇文章（24个病例）。检索词包括：“结核性脊柱炎”、“波特氏病”、“椎体骨髓炎”、“膀胱内”、“卡介苗”和“移行细胞癌”。通过查阅参考文献列表确定了其他研究。此外，我们报告了1例有类似临床表现并咨询过我们神经外科的患者病例。本系统综述符合PRISMA指南。病例报告符合CARE声明指南。
结果基于25个病例（24个病例来自既往文献，1个为我们的病例报告）。所有纳入文章均为英文撰写的病例报告。发表年份和招募时间从1992年至2018年不等。临床表现时的平均年龄从35岁至94岁不等（平均74岁）。所有患者均为男性。25例中有17例（68%）接受了手术。7例（41%）采用后路手术，前路手术0例（0%），5例（29%）采用联合手术，5例（29%）未明确手术方式。所有患者在TCC治疗中均接受了膀胱内卡介苗灌注，从临床表现前1个月至12年不等（平均26年）。影像学异常在胸椎节段有13例（52%），腰椎节段有11例（44%），胸腰段移行水平有1例（4%），颈椎节段未见异常。
尽管非常罕见，但TS应纳入LBP患者的鉴别诊断范围，即使是在TCC卡介苗灌注多年后。它主要影响老年男性，通过Batson静脉丛经血液传播累及胸腰椎脊柱。抗结核治疗仍然是TS治疗的主要方法。当似乎有必要进行手术干预时，应首选后路手术，包括清创和固定。据我们所知，本系统综述是首批全面评估膀胱内卡介苗治疗TCC后针对PD进行神经外科干预的综述之一。
