Tuberculous Spondylitis, 14 Years’ Experience of a Tertiary Care Center in Saudi Arabia

Background: Spinal Tuberculosis is the most common and dangerous form of skeletal tuberculosis. It has the potential for serious morbidity, including permanent neurologic deficits and severe deformity. The aim of this study is to review spinal Tuberculosis (TB) cases in our tertiary care center and evaluate it from different aspects, which may provide great support to the clinical decisions of this disease. Methods: The study was a retrospective charts review of all adult spinal TB patients who were evaluated at King Abdulaziz Medical City, Riyadh, from January 2001 to March 2015. The inclusion of cases will need to meet a specific case definition. Patients demography, presenting symptoms and signs, and radiological and microbiological data for all the patients were collected and reviewed. Results: A total of 61 cases screened charts were included according to the case definition. 59% were female, and the mean age was 51.3 years. The most presenting symptom was back pain (85%), followed by lower limbs weakness and lower limbs pain. The average duration of symptoms was 170 days. The average hospital stay was 41.4 days. On physical examination, about half of the patients had bilateral lower limbs weakness. Acute phase reactants like C-reactive protein (CRP) and Erythrocyte sedimentation rate (ESR) were elevated, 97% and 92% respectively, however leukocytosis was not common. Out of all the patients who had a biopsy done (59 patients), 51 patients (86%) had positive AFB culture. MTB PCR was done from spine biopsy in 16 patients, and 81% were positive. Out of 53 tissue specimens, histopathology showed 45% necrotizing granuloma, 21% non-necrotizing granuloma, and 34% non-specific inflammation. Imaging (either CT scan or MRI) was performed on the patients at the time of presentation, and the most common signs seen in both were vertebral bone destruction (95%, 80%) and perivertebral collections (70%, 84%). The thoracic and lumbar vertebrae were the most common involved locations. Thirty-one patients had both modalities done (CT and MRI), and spinal compression was seen on MRI in 68% of the cases compared to 36% on the CT scan. All the patients received the first line therapy with some individual adjustment and only 39% (27 patients) underwent surgery. Conclusion: Spinal Tuberculosis is a chronic presentation illness with a non-specific clinical picture. Interventional diagnostics is the best current modality to reach a confirmatory diagnosis. The gold standard for confirming TB diagnosis probably will remain cultures in addition to early utilization of molecular TB diagnostics. Time for diagnosis of Spinal Tuberculosis is delayed despite improvement in diagnostics tests. Medical treatment is the major solution of uncomplicated spinal TB.

Central Nervous System Tuberculosis: Clinical Characteristics and Outcome. A Saudi Tertiary Care Centre Experience

Background: Tuberculosis is an endemic problem that is of important public health concern in Saudi Arabia. Available recent prevalence of tuberculosis (pulmonary and extra-pulmonary) was estimated to be 13.7 per 100,000 people living in the Kingdom of Saudi Arabia. Methods: A retrospective chart review of all Central Nervous System tuberculosis patients (CNS-TB) treated at King Abdulaziz Medical City, Riyadh, Saudi Arabia between 1996 and 2010. CNS-TB was defined as follows: patients who had symptoms and signs of CNS-TB with radiographic, microbiologic, or histopathologic evidence of tuberculous infection and/or those with highly probable diagnosis, supported by radiographic typical features, not confirmed microbiologically but who responded to anti-TB therapy. Results: Eighty two patients (46 males) met our definition with the mean age of 50 years. Only 11 patients (13.4%) reported previous TB infection. The most common presenting symptoms were: headache (51%), fever (50%), weakness (43%), confusion (29%) and seizures (28%). The most common signs found by clinical examination were: weakness (45%) followed by sensory impairment. Positive CSF acid-fast bacilli (AFB) culture confirmed the diagnosis in 20 out of 49 tested patients (about 41%). Brain CT scan was done in 74 patients and meningeal enhancement was identified in only 6 patients (8%) but ring enhancing lesions were found in 19 patients (26%). In MRI meningeal enhancement was founded in 26 patients (37%) and ring enhanced lesions in 36 patients (51%). After receiving treatment, 45 patients (55%) had complete or good recovery and 23 patients (28%) had partial recovery. However, 15% (12 patients) had poor or no improvement. 2 patients (2%) lost their follow up. Conclusion: CNS-TB continues to be a major health issue especially in endemic areas such as Saudi Arabia. The diverse clinical presentations, lack of high yield, practical and reliable diagnosis methods and inconsistent management plans require further research and harder work in order to meet the current challenges and reach a unified case definition and evidence based management guidelines that would be a very practical step.