1/231. hypoglossal nerve injury as a complication of anterior surgery to the upper cervical spine. Injury to the hypoglossal nerve is a recognised complication after soft tissue surgery in the upper part of the anterior aspect of the neck, e.g. branchial cyst or carotid body tumour excision. However, this complication has been rarely reported following surgery of the upper cervical spine. We report the case of a 35-year-old woman with tuberculosis of C2-3. She underwent corpectomy and fusion from C2 to C5 using iliac crest bone graft, through a left anterior oblique incision. She developed hypoglossal nerve palsy in the immediate postoperative period, with dysphagia and dysarthria. It was thought to be due to traction neurapraxia with possible spontaneous recovery. At 18 months' follow-up, she had a solid fusion and tuberculosis was controlled. The hypoglossal palsy persisted, although with minimal functional disability. The only other reported case of hypoglossal lesion after anterior cervical spine surgery in the literature also failed to recover. It is concluded that hypoglossal nerve palsy following anterior cervical spine surgery is unlikely to recover spontaneously and it should be carefully identified. ( info) |
| We report a case of mycobacterium bovis BCG vertebral osteomyelitis in a 79-year-old man 2.5 years after intravesical BCG therapy for bladder cancer. The recovered isolate resembled M. tuberculosis biochemically, but resistance to pyrazinamide (PZA) rendered that diagnosis suspect. High-pressure liquid chromatographic studies confirmed the diagnosis of M. bovis BCG infection. The patient was originally started on a four-drug antituberculous regimen of isoniazid, rifampin, ethambutol, and PZA. When susceptibility studies were reported, the regimen was changed to isoniazid and rifampin for 12 months. Subsequently, the patient was transferred to a skilled nursing facility for 3 months, where he underwent intensive physical therapy. Although extravesical adverse reactions are rare, clinicians and clinical microbiologists need to be aware of the possibility of disseminated infection by M. bovis BCG in the appropriate setting of clinical history, physical examination, and laboratory investigation. ( info) |
3/231. Atypical forms of spinal tuberculosis: case report and review of the literature. OBJECTIVE: The object of this report is to highlight some of the less known atypical features of spinal tuberculosis (TB) in the hope of facilitating early diagnosis. Pure neural arch and sacral TB is rare and the co-existence of these two as widely separated skip lesions in the same patient is even rarer. CLINICAL PRESENTATION: An unusual case of tuberculous process affecting the sacrum as well as the neural arches of upper cervical vertebrae is presented. Neither the clinical features nor the imaging techniques, including radiography, bone scintigraphy, computed tomography, and magnetic resonance imaging, were helpful in establishing the diagnosis. The destructive lesion of the sacrum with a rectally palpable presacral mass was thought to be a chordoma or chondrosarcoma until the patient developed upper cervical cord compression with an extradural myelographic block. Development of this second destructive lesion involving the posterior spinal elements (the neural arch) led to a diagnosis of malignant spinal metastasis. The true diagnosis was only revealed by the histology of the solid tumor-like extradural mass in the upper cervical region and demonstration of acid-fast bacilli (AFB) in the lesion. Anti-TB chemotherapy resulted in complete resolution of sacral and cervical lesions as well as the neurologic deficits. CONCLUSION: Differential diagnosis of the obscure spinal lesion should include tuberculosis, specifically the atypical forms; especially because complete cure is possible with early treatment and neurologic morbidity is high in neglected cases. ( info) |
| Intramedullary spinal tuberculosis infection remains an extremely rare disease entity. In the most recent reviews only 148 cases have been reported in the world literature, although numerous recent reports from developing countries and on human immunodeficiency virus (hiv)-positive patients have increased this number. The authors present an unusual case of intramedullary tuberculoma in an hiv-negative patient from the southern united states who demonstrated no other signs or symptoms of tuberculosis infection. The authors believe that this is the first case of its kind to be presented in recent literature. The presentation of miliary disease via an isolated intramedullary spinal mass in a patient with no evident risk factors for tuberculosis infection emphasizes the importance of including tuberculosis in the differential diagnosis of spinal cord masses. ( info) |
5/231. Pott's disease with unstable cervical spine, retropharyngeal cold abscess and progressive airway obstruction. PURPOSE: retropharyngeal abscess formation has the potential for acute respiratory compromise from obstruction or secondarily from rupture. The initial attempt to secure the airway is of paramount importance. We describe a patient with an unstable cervical spine secondary to Pott's disease who developed progressively obstructing retropharyngeal cold abscess. CLINICAL FEATURES: A 33-yr-old man with an unstable C-spine in halo traction presented with progressive airway obstruction secondary to retropharyngeal abscess extending from the cervical to the mid-thoracic vertebrae. After review of computerized tomography (CT) and magnetic resonance (MR) studies, preparations were made to secure the airway through fibreoptic assisted intubation. A conservative approach was chosen to secure the airway before surgical airway control as a first line approach. Following local and topical anesthesia, awake endoscopy was performed to assess the extent of obstruction and possibility of intubation without abscess rupture. A narrow tract along the lateral pharynx was identified to continue inferiorly to the epiglottis, from which point the cords were visualized. Extensive edema and abscess formation otherwise distorted the normal anatomy and prevented visualization from other directions. The airway was successfully secured without trauma with a well-lubricated 7.0 mm ID endotracheal tube. CONCLUSION: This report suggests that selected cases of tense obstructing retropharyngeal abscesses can be effectively managed with fibreoptic endoscopy for assessment and subsequent intubation before requiring surgical airway control as a first line strategy. ( info) |
| Bone marrow transplant (BMT) recipients are prone to bacterial, viral and fungal infections. mycobacterium tuberculosis infection can occur in these patients, but the incidence is lower than that of other infections. This report describes four patients with mycobacterium tuberculosis infection identified from 641 adult patients who received a BMT over a 12-year period (prevalence 0.6%). The pre-transplant diagnosis was AML in two patients and CML in the other two. Pre-transplant conditioning consisted of BU/CY in three patients and CY/TBI in one. Graft-versus-host disease (GVHD) prophylaxis was MTX/CsA in three patients and T cell depletion of the graft in one patient. Sites of infection were lung (two), spine (one) and central nervous system (one). Onset of infection ranged from 120 days to 20 months post BMT. Two patients had co-existing CMV infection. One patient had graft failure. The two patients who received anti-tuberculous (TB) therapy recovered from the infection. Although the incidence of tuberculosis in BMT patients is not as high as in patients with solid organ transplants, late diagnosis due to the slow growth of the bacterium can lead to delay in instituting anti-TB therapy. A high index of suspicion should be maintained, particularly in endemic areas. ( info) |
7/231. Primary hydatid disease of the spine: an unusual cause of progressive paraplegia. Case report and review of the literature. Although rare, spinal hydatid disease is a manifestation of hydatid infestation. The authors present the report of a patient who presented with primary spinal hydatid disease. This disease is often misdiagnosed as tuberculous spondylitis, and thus patients may subsequently receive inappropriate treatment. The patient in this case presented, with an increasing weakness in the lower limbs, to a different clinic from an area in india where hydatid infections are endemic. The infection was misdiagnosed as tuberculous spondolytis based on evaluation of plain x-ray films, and the patient underwent antituberculous chemotherapy and a posterior surgical decompressive procedure. The patient presented to the authors' clinic with increasing paraparesis 1.5 years later. Radiographs and a magnetic resonance image of the spine were obtained, which strongly suggested hydatid disease. Examination of serum levels confirmed the diagnosis. The patient underwent a decompressive procedure of the spine in which stabilization was performed. Postoperatively her paraparesis resolved, and good control over the disease was achieved by chemotherapy. The authors conclude that primary spinal hydatid disease of the spine, although a rare manifestation, should be considered in the differential diagnosis in patients with infectious and destructive lesions of the spine in regions in which the disease is endemic. Advanced imaging studies should be performed to diagnose the disease. Early decompressive surgery with stabilization of the spine, in addition to adjuvant chemotherapy, is the treatment of choice for these patients. ( info) |
8/231. Video-assisted thoracic surgery diagnosis of thoracic spinal tuberculosis. Tuberculous spondylitis is rare in economically well-developed countries. MRI is the most sensitive radiologic method of diagnosis. CT-guided fine needle aspiration can be an appropriate method for obtaining samples for culture, with positive cultures in 25 to 89% of cases. However, it can take >6 weeks for specimens to grow, and it is essential to have adequate culture and sensitivity studies for the diagnosis and treatment of mycobacterial diseases. We propose a minimally invasive diagnostic approach that ensures that adequate surgical specimens are obtained prior to initiating treatment. ( info) |
9/231. Spinal lesions, paraplegia and the surgeon. Thirty-six patients with spinal cord lesions and varying degrees of paraplegia were seen by the surgical team at the Angau Memorial Hospital, Lae, over a thirty month period. Because the continued presence of a spinal lesion may lead to progressive cord destruction and ischaemic myelopathy, prompt treatment is advocated. The depressing results that have followed treatment of fracture dislocations of the cervical spine and secondary neoplasm with paraplegia is recorded and some suggestions are made that may improve the outlook in future cases. Early and major surgery is advocated in the treatment of spinal abscesses, tumours, Pott's paraplegia and unstable fracture dislocations of the lumbar spine. ( info) |
10/231. Craniocervical junction tuberculosis in children. A case of tuberculosis of the craniocervical junction in an eight-year-old is reported. Presenting symptoms were painful torticollis, dysphagia, and tetraparesis. Computed tomography and magnetic resonance imaging findings strongly suggested the diagnosis, which was confirmed by peroral aspiration of a retropharyngeal collection. Management was by immobilization and antituberculous agents. Surgery was not performed. After one year, the outcome was highly satisfactory. ( info) |