McVeigh Luke G, Zaazoue Mohamed A, Lane Brandon C, Voorhies Jason M, Bradbury Jamie
J Neurosurg Spine. 2022 Oct 21;38(2):281-292. doi: 10.3171/2022.7.SPINE22534. Print 2023 Feb 1.
In 2021, several patients across the United States received bone allograft contaminated with Mycobacterium tuberculosis (TB). TB is typically a pulmonary infection with many possible extrapulmonary manifestations, including skeletal tuberculosis. However, TB is a rare causative organism of postoperative surgical site infection. Iatrogenic skeletal TB infections are not widely reported in the medical literature; therefore, treatment and associated outcomes are relatively unknown. In this series, the authors report 6 cases of patients who received a mesenchymal stem cell-enhanced bone graft infected with TB at their institution, including the clinical courses, imaging findings, management plans, and outcomes at 1 year postoperatively.
A retrospective review was performed of 6 consecutive patients who underwent spinal fusion surgery at the authors' institution and received bone graft from a lot contaminated with TB. Collected data included patient demographic characteristics, indications for surgery, surgical procedures performed, timing of contamination discovery, medical treatment, and follow-up information including reoperation, healing progress, and imaging findings.
Five of 6 patients (83.3%) eventually tested positive for TB via interferon-gamma release assay or wound culture. They experienced significant complications, including surgical site infections with neck swelling, pain, dysphagia, and wound dehiscence. Extensive soft-tissue infection was common; however, significant bony involvement was not observed. Surgical wound debridement was required in 4 patients, and all patients received medical management with standard RIPE (rifampin, isoniazid pyrazinamide, pyridoxine, and ethambutol) therapy for 8 weeks with extension of rifampin and isoniazid for scheduled 12 months. All patients (excluding 1 patient who died of COVID-19) showed signs of improvement with adequately healing wounds at the most recent follow-up at a median (range) of 12 (6-13) months postoperatively. To date, no patients have developed pulmonary TB.
Direct inoculation with TB via contaminated bone grafts resulted in a high rate of severe soft-tissue infection, although extensive skeletal and pulmonary involvement has not been observed at 1 year postoperatively; this review includes the longest reported follow-up period for this TB outbreak. Medical management remains the mainstay of therapy for these patients, with most patients showing recovery with oral antibiotic therapy. The severity of these infections arising from mesenchymal stem cell-containing bone allografts that undergo an alternative sterilization process than standard allografts raises concerns regarding the added risks of infection, which should be weighed against the expected benefits of these grafts.
2021年，美国有几名患者接受了被结核分枝杆菌（TB）污染的骨移植。结核病通常是一种肺部感染，有许多可能的肺外表现，包括骨结核。然而，结核病是术后手术部位感染的罕见病原体。医源性骨结核感染在医学文献中报道较少；因此，治疗方法及相关结果相对未知。在本系列研究中，作者报告了6例在其机构接受感染结核的间充质干细胞增强骨移植的患者，包括临床病程、影像学表现、治疗方案以及术后1年的结果。
对在作者所在机构接受脊柱融合手术并接受了一批被结核污染的骨移植的6例连续患者进行回顾性研究。收集的数据包括患者人口统计学特征、手术指征、所实施的手术操作、污染发现时间、药物治疗以及随访信息，包括再次手术、愈合进展和影像学表现。
6例患者中有5例（83.3%）最终通过干扰素-γ释放试验或伤口培养检测出结核阳性。他们出现了严重并发症，包括手术部位感染伴颈部肿胀、疼痛、吞咽困难和伤口裂开。广泛的软组织感染很常见；然而，未观察到明显的骨质受累。4例患者需要进行手术伤口清创，所有患者均接受了标准的RIPE（利福平、异烟肼、吡嗪酰胺、吡哆醇和乙胺丁醇）治疗8周，并将利福平和异烟肼延长使用12个月。所有患者（不包括1例死于COVID-19的患者）在术后中位（范围）12（6 - 13）个月的最近一次随访中显示伤口愈合良好，症状改善。迄今为止，没有患者发展为肺结核。
通过受污染的骨移植直接接种结核杆菌导致了较高的严重软组织感染率，尽管术后1年未观察到广泛的骨骼和肺部受累；本综述包括了此次结核爆发报道中最长的随访期。药物治疗仍然是这些患者的主要治疗方法，大多数患者通过口服抗生素治疗得以康复。与标准同种异体移植物相比，经过替代灭菌过程的含间充质干细胞的同种异体骨移植引发的这些感染的严重性引发了对感染额外风险的担忧，应权衡这些移植物的预期益处。
