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Computed tomography in spinal tuberculosis
0895-6111191 53.lm + .oo copyright 0 1991 Pergamon Fess plc
Computeridmrdicd ha& and Gmphics, Vol. IS, No. 6, pp. 379-388, 1991 Ftinted in the USA. All rights -cd.
COMPUTED TOMOGRAPHY IN SPINAL TUBERCULOSIS TarvinderB. S. Buxi*, ShyamS. Dada*, RakeshK. Mathur*, Prithipal S. Mainif, Virender K. Nijhawan?, ShantikumarSoganil, Har Narain AgarwalS,Vijay S. Madan* and Shristi P. Byotras *Delhi Scan ResearchCentre, Departments of tGrthopedic Surgery, *Neurosurgery and 6Intemal Medicine, Sir Ganga Ram Hospital, New Delhi, 110 060, India (Received
3 January
1991)
Abstract-Exhaustive clhkoradioiogic and computed tomographic (CT) analysis of 114 casesof spinal tuberculosis seen between January 1983 and January 1989 is presented. The mechanisms of the spinal involvement are reviewed. CT helped to diagnose cases of spinal tuberculosis in their initial stages. Inaccessible fiied areas of spine were seen with ease on axial sections of CT. The extent and anatomic depiction of soft-tissue involvement as depicted on CT helps surgeons choose the appropriate surgical approach, which may affect future spinal stability. Key Words: Spine, Tuberculosis, Computed tomography
(Table 1). The records of these patients were reviewed with particular reference to age, sex and clinical presentation. Plain X-rays, CT features and myelographic findings were available. The surgical approach was questioned before CT was done and appropriate suggestions made following CT for desired surgical intervention. CT findings were correlated with surgical findings or follow-up CT scans after conservative and surgical management at appropriate intervals. Scans were performed on a Hitachi third-generation body scanner with a scan time of 4.5 set and matrix size of 320 x 320. Most of the studies were performed with 5-mm collimation and 5-mm incrementations. An intravenous bolus of 80 to 100 mL of 60% iodinated contrast medium was used routinely to acquire enhanced sections. Intrathecal metrizamide was used when necessary. The scans were first reviewed by three radiologists independently, folowed by a consensus of final opinion. The treating clinicians were closely questioned regarding their therapeutic approach in individual cases.
INTRODUCTION Percival Pott described tuberculosis of the spine more than two centuries ago. Although antitubercular chemotherapy brought about a revolution in the treatment of tuberculosis, at times the diagnosis is still an enigma. Its presentation may no longer be typical and it seems the behavior of this disease has changed over the years. CT has helped in diagnosis of such cases with atypical or equivocal presentation. CT was found to be especially useful to depict disease in the posterior appendages and fixed inaccessible areas of the spine, such as sacrum, sacroiliac joints and craniovertibral junction. The exact surgical approach to ensure future stabilization of the spine is determined with preoperative CT. Although we have seen many cases of spinal tuberculosis during the last 6 years, this data has been obtained from medical records of the admitted cases at Sir Ganga Ram Hospital, New Delhi, India. MATERIAL
AND METHODS
RESULTS
A retrospective review of the cases of spinal infection yielded 84 cases of spinal tuberculosis at our center between January 1983 and January 1989. During the time of review, 30 cases were encountered prospectively. These 114 cases form the basis for this report
A total of 114 patients are included in this study. There were 63 males and 51 females, ranging in age from 14 to 62 years. The largest group (44.7%) was of young adults between 20 and 30 years of age; however, a significant number of patients were in older age groups, as shown in Table 1. All 114 patients presented with back pain, while 51 (44.7%) of them had mild-to-moderate fever with evening rise. Neurological examination was positive in 33 (28.9%) cases ranging
Address all correspondence to Dr. T. B. S. Buxi, Director, Delhi Scan Research Centre, Sir Ganga Ram Hospital, New Delhi, 110 060, India. 379
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Fig. 1. A 20-year-old female presented with neck pain of 1 year duration and weaknessin both upper and lower limbs of 1 week duration. She had a normal X-ray of the cervical spine in May 1984. By February 1985 X-rays showed an increase in retropharyngeal space. (a) CT demonstrates prespinai and intraspinal pus collection with Cl-C2 dislocation. (b) Post-antikochs.After 8 months of conservativetreatment, resolution of abscessis complete; however, Cl-C2 dislocation continues.
from multiple radiculopathies to spastic paraplegia. At least nine cases were referred with a strong clinical suspicion of disk prolapse. Duration of symptomatology ranged from 11 days to 13 months. Ninety-nine patients had abnormal plain film findings, compared with positive findings on CT in all cases. Most lesions were noted in dorsal and lumbar regions, whereas nine cases had involvement of the upper two cervical vertebrae as shown in Table 2 (Fig. 1). Twelve cases revealed lesions in the lumbro-sacral region, with three cases having minimal lesion of the sacral promontory (Fig. 2) and another 3 with early destruction of the ilium (Fig. 3). Three cases showed involvement of the sacroileitis @I) joint (Fig. 4) with destruction of sacral ala. Three cases had calcified lesions involving two regions, as shown in Table 3 (Fig. 5).
Small or large intraspinal extension of the granulation tissue or the abscess was demonstrated in 78 (68.4%) cases. Myelography was done in three cases and met&amide CT in 12 cases (Fig. 6). In the remaining cases it was possible to discriminate intraspind granulation tissue and abscess on an enhanced CT with a bolus of IV contrast. Seventy-two cases (63.1%) showed destruction of the anterior part of the vertebral body, with 42 of these also showing involvement of posterior part of the vertebral body (Fig. 7). There were 15 cases (13.2%) with involvement of the posterior part of the vertebral body (Fig. 8) and another 15 cases with involvement of both the posterior part of the vertebral body and posterior elements. There were six cases in which selective involvement of the lamina (Fig. 9) was present. Three cases (2.6%) showed involvement of the transverse Table 2. Distribution of casesaccording to site of involvement.
Table 1. Age and sex distribution for 114 patients with spinal tuberculosis. Age (YeW
No. of Cases
1 l-20 21-30 31-40 41-50 51-60 61-70 Males
6 51 18 21 3 15 Females=51
= 63 (55.3%)
Percentage of total 5.3 44.1
15.8 18.4 2.6 13.2
Site Cranio-cervical Cervical Cervico-dorsal Dorsal Dorso-lumbar Lumbar Lumbo-sacral SZtCGd Total
No. of cases 3 6 12 48 18 18 9 3 117
& Ilium
(44.7%) (Three
cases had two levels
of involvement.)
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Fig. 2. Erosive destruction of sacral promontory with granulation tissues.
process. Adjacent rib destruction was seen in nine cases (7.9%). Paravertebral soft tissue was seen in 42 cases (36.8%) on plain films, as compared to 99 cases (86.9%) on CT (Fig. 10). The majority of cases having no paravertebral shadow in plain films had small paravertebral components on CT. The fluid density representing abscess was seen in 63 cases (55.3%) on CT. In three cases the abscesses were bilateral and extended from the dorsolumbar region to the knees on both sides (Fig. 11). Compared with 33 cases (28.9%) demonstrating calcification on CT, only six cases (5.3%) showed the same on plain films (Fig. 12). Active tuberculosis was seen on chest X-ray of six patients (5.3%), whereas calcified primary lesion could be identified in 33 cases (29.0%). A purified protein derivative (PPD) test was positive in all 42 cases in which it was done.
@I Fig. 3. (a) Young girl with low backache. CT was done from L2 to L5s 1. A destructive lesion is shown in the right iliac bone with surrounding areas showing inflammatory tissues and edema. Note extension of tissuesinto the right nerve root canal, obliterating
lateral
recess fat. CT-guided
aspiration
confirmed tubercular pathology. (b) Follow-up CT reveals resolution of inflammatoq pathology with marked improveTable 3. Distribution
ment on antikochs.
of cases according to their location within a vertebra
Involved part 1. Only anterior part of vertebral body 2. Only posterior part of vertebral body 3. Both anterior and posterior parts of vertebral body 4. Anterior and posterior part of vertebral body + posterior elements 5. Posterior part + posterior elements only 6. Lanka only 7. Transverse process only 8. Odontoid process with atlas and axis vertebra 9. Vertebral destruction with adjacent rib involvement
No. of cases Percentage 12 15 33
10.6 13.2 28.9
9
7.9
18 6 3 6
15.9 5.3 2.6 5.3
9
7.9
Forty-two cases were subjected to surgery and 30
cases underwent needle aspiration with CT guidance. All cases were followed up clinically and radiologically. A follow-up CT scan was done in 42 cases. DI!XUS!SION
Spinal tuberculosis accounts for approximately 50% of all cases of skeletal tuberculosis in adults (1). In one series, the incidence has been reported to be 58.7% (2).
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Fig. 4. Tubercular
sacroileitis left side.
Considerable variation has been reported in age incidence by various authors from different parts of the world. Hodgson, in a series of 300 patients, reported 70% of cases occurred in patients younger than 10 years of age (3). Goldblatt et al. reported over 50% of cases under 11 years of age (4). In another series, the majority of 140 Nigerian patients were below 20 years of age (5). In a series from Poland, spinal tuberculosis was stated to affect predominantly people older than 60 years (6). Most western authors report the highest incidence in young adults 20 to 30 years old (7). The age of the patients tends to be young in those countries where skeletal tuberculosis is common (4, 8).
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Table 1 shows the age incidence in the present study. The most cases, that is, 44.7%, were seen in the 20- to 30-years age group. However, a significant number of cases were also seen in older age groups. A male predominance has been reported by some authors (7, 9); however, no sex predilection was noted by others (10, 11). Whereas we had a slight male predominance in our series (see Table l), we feel that spinal tuberculosis does not have any specific predilection for males. Most cases of spinal tuberculosis present with backache. A low-grade fever with evening rise, and history of night sweats is present in a large number of cases. Varying degrees of neurological impairment accompanies a smaller percentage; the reported incidence varies from 10.5 to 41.6% (7, 9, 12-14). In our series, 33 cases (28.9%) had positive neurological examination, although intraspinal extension was noted in 78 cases (68.4%). Spinal tuberculosis is almost always a result of hematogenous spread. A direct extension from involved nodes or lungs has also been suggested (15). The hematogenous spread is presumed to be from a pulmonary focus, although evidence of active pulmonary disease is present in less than 30% of cases (4). We had only six cases with active lung parenchymal lesions (5.3%). Lower thoracic and upper lumbar regions are the most frequent sites of involvement. The incidence gradually diminishes toward both sides with cervical and sacral regions being least affected sites. The site distribution of our cases indicates that tuberculosis mav
Fig. 5. Densely calcified tubercular lesions at Dl l-D12
and L5-S 1.
CT in spinaltuberculosis 0 T. B. S. Burr et al.
Fig. 6. Metrizamide CT demonstratesthe circumferential encompassmentof the spinal cord with prespinal and paraspinal pus collection, bilateral pleural thickening. Surgical decompression was done from the right side.
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Fig. 8. Posterior half of vertebral body destruction with minimal granulation tissue.
involve any part of the vertebral column, as seen in Table 2. At least nine cases had the involvement of upper two cervical vertebrae with six cases showing partial destruction of odontoid process (Fig. 1). Cases having exclusive destruction of one sacral ala or sacral promontory are also being documented in CT literature (Fig. 2). Radiologically, the lesion most commonly affects the anterior part of the vertebral body near the intervertebral disk where it produces a localized area of rarefaction. Slowly, it passes through the stages of erosion to destruction. In early stages of the disease, there are of-
ten no changes seen on plain X-rays, and occasionally the vertebral body may be extensively involved and still present a normal roentgenographic picture (Fig. 13). CT was done because of a high index of clinical suspicion. CT helped to diagnose tuberculosis of the spine in early stages even when the plain X-rays were normal. With progression of lesion, the intervertebral disk and contiguous part of adjacent vertebral body get involved. The intervertebral disk is not affected as early as in pyogenic infection because tuberculosis does not lead to the production of proteoltic enzymes (17). The infection may also spread up and down the vertebral column underneath the paraspinal ligaments (18). Two, three or more vertebral bodies may be involved. In the initial stage, the destructive process is associ-
Fig. 7. Destruction of left anterolateral and posterior margins of dorsal vertebra with intraspinal and paraspinal granulation tissuesand no fluid pus formation.
Fig. 9. Destruction of right lamina with multiloculated pus collection and granulation tissuesin both intraspinal and posterior paraspinal muscles.
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Fig. 10. Left paravertebral and minimal enhancing intraspinal granulation tissues not seen on plain X-rays.
Fig. 12. Calcification in the right posterior spinal muscles in a resolving tubercular abscess.
ated with formation of necrotic tissue and gaseous material in the pre- and paravertebral regions. These abscesses may be bilateral and extend along fascial planes for long distances in the dorsolumbar region, and rarely into the pelvis, thigh and even to the knee and great toe (Fig. 11). In the cervical region, a retropharyngeal abscess may result. We agree with Wheelan et al. (19) that tubercular abscesses are generally large, multiloculated and show thick, irregular rim enhancement. Tubercular abscesses destroy all ligamentous barriers and thus creep into and invade the meninges (Fig. 1). Here the infective pathology has destroyed the various binding ligaments, resulting in dislocation of the Cl with respect to the occiput and C2 with respect to Cl. Evidence of cord compression is seen. In such a case, traction would perhaps result in further deterioration and early
decompression through the oral route is recommended. Further, it is to be emphasized that fixed spinal areas like the sacrum and sacroiliac and iliac bones may not show disease pathology in the initial stages (Fig. 14). Most cases of spinal tuberculosis are associated with paravertebral granulation tissue or abscess. It was only in 42 (36.8%) cases in our series that a paravertebral shadow could be seen on plain films, compared with CT demonstration of an abscess or granulation tissue mass in 99 cases (86.9%). In our experience, small paravertebral soft-tissue components are inavariably associated with spinal tuberculosis and may be easily missed on plain films (Fig. 10). A variable degree of calcification occurs in the paraspinal soft tissue component of the disease process, even without specific treatment, and indicates chronic lesion (19). CT is ideally suited to demonstrate small amounts of calcification which is not visible on plain X-rays (Fig. 12). We consider the presence of calcification in the paraspinal soft tissue component a very important fmding and is quite specific in the appropriate clinical setting. In,contrast to six (5.3%) cases showing calcification on plain X-rays, CT could pick up the same finding in 33 (29%) cases in our series. The minimum duration of symptoms was 3 months and the maximum 13 months in cases with calciticaction in our series. Isolated involvement of vertebral arch and its processes occurs in less than 2% of cases of tuberculosis spondylitis (1). The intervertebral disk is spared in such cases, but adjacent rib may be destroyed. These cases may present with posterior soft-tissue mass (15). Rahman also reported five cases of neural arch tuberculosis with complete sparing of vertebral body and disk (20).
Fig. 11, Psoas thigh abscesses extending level into the thighs.
from L3 vertebral
CT in spinaltuberculosis 0 T. B. S. Bux~et al.
(a)
(b) Fig. 13. Young female with neck pain of 6 months duration. (a) X-ray, lateral view, of cervical spine shows straightening that is otherwise noncontributory. (b) CT reveals destruction of posterior vertebral margin with granulation tissues.
Depicting the exact areas of involvement helps to adopt a correct surgical approach. With plain X-rays it is difficult to defme the posterior appendage involvement in addition to vertebral body disease. In such cases, if anterior decompression is resorted to, it will lead to gross ‘instability of the spine since the posterior appendages are already compromised. CT reveals bone
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destruction along with the granulationtissuesand pus collection. The size, site, side and extent of bony and soft-tissue abnormalities obviously help to choose the correct approach for surgical intervention. Thus it is important to assess the exact pathology in order to choose the correct procedure of choice for future stability of the spine. The anterior part of vertebral body was involved in 90 (79%) cases, compared with the posterior part of vert&ral body which was involved in 75 (65.8%) cases. The intmspinal extension of the disease may be due to (a) granulation tissue which may encircle the dura; (b) paraspinal abscess invading the spinal canal; (c) fluid abscess in the spinal canal; (d) sequestrated bone and/or intervertebral disc; (e) dislocated vertebrae; or (f) thick transverse ridge of fibrous tissue (21). Most authors believe the commonest cause of compression is an intraspinal tubercular abscess or granulation tissue in extradural compartment (5, 21, 22) (Fig. 6). It is also true that all those cases having an intraspinal extension may not have neurological impairment. Whereas 78 (68.4%) cases in our series showed small or large intraspinal extension, only 33 (28.9%) cases had neurological findings. Although in initial stages, myelography was performed in three cases and metrizarnide CT was done in 12 cases, we discovered that a bolus of IV urographic contrast material provides an excellent display of intraspinal extension by enhancing the granulation tissue. We feel that the use of intrathecal contrast is required only in an occasional case of spinal tuberculosis and should be limited to cases where doubt exists on intravenously enhanced study. Wheelan et al. reported the spread of tubercular process through subarachnoid space in one case that had tubercular lesion in the posterior part of L3 vertebral body (19). They mentioned that subsequent brain scan revealed tubercular meningitis with calcified granulomas. We believe the possibility of subarachnoid spread is unlikely in their case, as we often see calcified granulomas in patients with unrelated symptomatology. Moreover, we had many cases in our series in which the posterior part of the vertebral body and neural arch were destroyed and none of them had a history of meningitis in the past or during the follow-up period. We feel a possibility of transdural spread from spinal lesion to subarachnoid space leading to meningitis is more likely, and that calcified granuloma is a nonspecific and incidental finding. Although dura provides a strong barrier to spread of the infection from the vertebral body and extradural space to the subdura, such an invasion happens in exceptional cases (21). Histological supportive evidence has been produced on surgery and postmortem (22, 23).
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Fig. 14. A &year-old male presented with backache. (a) Normal pelvis AP view. (b) Sacralforamina erosion with granulation tissuesin the sacral canal and right sacralforamina. (c) Large presacralabscess.
SUMMARY Computed tomography is useful in early diagnosis of cases of spinal tuberculosis where plain X-rays are normal. Computed tomography is useful in depicting tubercular lesions in fixed inacessible areas such as the sacrum, sacroiliac joints and craniovertebral junction. CT helps the physician to decide which surgical approach is required, keeping in view the future stabilization of spine. Conventional myelography is rarely required for showing extradural soft tissue abnonnalities. CT helps provide guidance for diagnostic needle aspirations, especially for cases in which there is strong clinical suspicion of spinal tuberculosis. One of the most important practical applications of CT is in planning operative procedures. It has often enabled orthopedic/neurosurgeon colleagues to decide whether to go
in anteriorly or posteriorly, from the left or right side, depending on the site of maximal involvement. This is also important for the future stability of the vertebral column.
Acknowledgmenr-We sincerely thank Mr. S. K. Sharma & Ms. Awa-Aftab for obtaining scans and Mr. V. Jayakumar for secretarial assistance.
1. Ciqper, G.R.; Aacker, J.D.; Robertson, J.H. Computedtomography in P&s disease. Ncurosurgay 10(4):!K&m, 1982. 2. Hodgson, A.R. Infeetous qlisx%se of the spine. In: Rothman, R.H.; Simeone, F.A., eds. The. Spine, Vol. 2. Philadelphia: WB se, 1975:567-598. 3. Hodgson,A.R.Re@rtontbcfindingsandresultsin3OOcases
CI in spinal tuberculosis 0 T. B. S. Buxr et al.
4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23.
of Pott’s disease treated by anterior fusion of the spine. J. West. Pacif. Orthop. Ass. 1:3; 1964. Goldblatt, M.; Cremin, B.J. Osteo-articular tuberculosis: Its presentation in coloured races. Clin. Radiol. 26669-677; 1978. Konstam, P.G.; Konstam, S.T. Spinal tuberculosis in Southern Nigeria with special reference to ambulant treatment of thoracolumbar disease. J. Bone Joint Surg. 4OB:26; 1958. Arct, W. 0pcrative:tmatment of tuberculosis of the spine in old people. J. Bone Joint Surg. 50A255; 1968. Bosworth, D.M.; Pietra, A.D.; Rahilly, G. Paraplegia resulting from tuberculosis of the spine. J. Bone Joint Surg. 35A735; 1953. Nicholson, R.A. Twenty years of bone and joint tuberculosis in Bradford. A comparison of the disease in the indigenous and Asian populations, J. Bone Joint Surg. 56:76&765; 1974. Jackson, J.W. Spinal tuberculosis. Postgrad. Med. J. 47:723; 1971. Tuli, S.M.; Srivastava, T.P.; Varma, B.P.; Sinha, G.P. Tuberculosis of spine. Acta Orthop. Stand. 38445; 1967. Chu, C.B. Treatment of spinal tuberculosis in Korea using focal debridement and interbody fusion. Clin. Orthop. 50:235; 1967. Jones, B.S. Pott’s paraplegia in the Nigerian. J. Bone Joint Surg. 4OB:16; 1958. Konstam, P. Ambulant treatment of spinal tuberculosis. Excerpta Med. (Intern. Congr. Series) 129316; 1965. Tuli, SM. Results of treatment of spinal tuberculosis by ‘Middle Path’ regime. J. Bone Joint Surg. 57B:l3; 1975. Bell, D.; Cockshott, W.P. Tuberculosis of the vertebral pedicles. Radiology 99:438; 1971. Auerbach, 0. Acute general&d military tuberculosis. Am. J. Path. 20:20-21; 1944. Forrester, D.M.; Nession, J.W. The Radiology of Joint Disease. Philadelphia: WB Saunders: 1973:410-419. Murray, R.O.; Jacobson, H.H. The Radiology of Skeletal Disorders. Edinburgh: Churchill Invingstone; 1971. Whelan, M.A.; Naidich, D.P.; Post, J.D.; Chase, N.E. Computed tomography of spinal tuberculosis. J. Comput. Assist. Tomogr. 7( 1):25-30; 1983. Rahman, N-U. Atypical forms of spinal tuberculosis. J. Bone Joint Surg. (Br) 62B:162-165; 1980. Tandon, P.N.; Pathank, S.N. Tuberculosis of the central nervous system. In: Spillane, J.D., ed. Tropical Neurology. London:Oxford University Press; 1973~37-62. Hodgson, AR.; Skinsness, O.A.; Le.ong, C.Y. The pathogenesis of Pott’s paraplegia. J. Bone Joint Surg. 49A1147; 1967. Garceau, G.J.; Brady, T.A. Pott’s paraplegia. J. Bone Joint Surg. 32A:87; 1950.
About the Author-TARVINDER Bra SINGHBuxt received his M.B.B.S. from Nagpur University in India in 1977, following junior residency in Paediatrics &. General Medicine at Holy Family Hospital, New Delhi. He served as Medical Officer in the Libyan Armed Forces Medical Services for 2 years. Dr. Buxi received his M.D. in Radiodiagnosis in 1983 from Punjabi University, Patiala and wrote a thesis on “Small Bowel Enema.” During 1984 Dr. Buxi trained in Body CT at the University of Cambridge England and Aachen University in Germany. Dr. Buxi has been working on Whole Body CT since 1983. Presently Dr. Buxi is Chief Radiologist at Delhi Scan Research Centre, Sir Ganga Ram Hospital, New Delhi, India. Dr. Buxi is a corresponding member of Radiological Society of North America. About the Author-SHYAM S. DODA received his M.D.in Radio-diagnosis from Rajasthan University, Jaipur, India in 1981. Thereafter he did his senior residency at Dr. R.M.L. Hospital, New Delhi. He received his training in Computed Tomography from St. Bartholomew’s Hospital, London and Newcastle General Hospital, Newcasde-upon-Tyne in England. Dr. Doda worked as Radilogist & Associate Director Delhi Scan Research Centrc, Sir Ganga Ram Hospital
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New Delhi, India from 1983 to 1987. Presently Dr. Doda is working as Consultant Radiologist at Diwan Chand Agganval X-ray Clinic & Imaging Centm, Dr. B.L. Kapoor Memorial Hospital, New Delhi. Dr. Doda also heads his Ultrasound Scan Centre in New Delhi Delhi, India. Dr. Doda is a member of Indian Radiological & Imaging Association. About the AU~~O~-RAKESH K. MA~HURreceived his M.D. from the Armed Forces Medical College University of Pune in 1973. He completed his residency training in Radiology at Dr. R.M.L. Hospital affiliated with the University of Delhi. He completed an M.D. in Radio-diagnosis from the same Institution in 1979. Dr. Mathur was appointed as Senior Resident in the Department of Radiology at Dr. R.M.L. Hospital. Dr. Mathur received his training in Body Computed Tomography at the Tsukuba Memorial Hospital and Institute of Clinical Medicine Tsukuba Universitv.. . Jaoan . in 1982. Dr. Mathur worked as Radiologist & Director at Delhi Scan Research Centre, Sir Ganga Ram Hospital, New Delhi, India from 1983 to 1987. Presently Dr. Mathur is Chief of Department of Radiodiagnosis and Imaging, at Batra Hospital, New Delhi, India. About the Author-F’RITHIPAL S. MAINI received his M.B.B.S. from Punjab University, India. He did his Masters at the same university. Subsequently, Dr. Maim joined as an Assistant Professor of Orthopedics at Medical College, Rohtak, India. He worked in this capacity from 1962 to 1968. Dr. Maim remained Professor of Orthopedics from 1968 to 1982. He has been actively involved in training and teaching of undergraduates and postgraduates. Dr. Maini has well known research work on Osteoporosis and bone grafts, in addition to numerous publications. Hip surgery & spine surgery are his special fields of interest. Presently Dr. Maim is Chief of Orthopedics at Sir Ganga Ram Hospital, New Delhi & visiting Emeritus Professor Orthopedics of University of Rohtak, India. About the Author-VIRENDER K. NIJHAWAN received his M.B.B.S. from Medical College Rohtak, Haryana, India. He obtained his M.S. Orthopedics in 1979 from the same institution. Dr. Nijhawan wrote a thesis on “Comparative study of various operative techniques in prolapsed lumbar intervertebral discs.” Presently he is working as Jr. Consultant in the Department of Orthopedics, Sir Ganga Ram Hospital, New Delhi, India, since September, 1985, About the Author--SH.ammm SOGANIreceived his M.B.B.S. from Jiwaji University, Gwalior, India in 1975. He did his M.S. General Surgery from the same university in 1980. Dr. Sogani obtained his M.Ch from All Indian Institute of Medical Sciences, New Delhi, India in 1983. Dr. Sogani worked as Demonstrator in Department of Surgery in G.R. Medical College, Gwalior for 2 years. Subsequently he worked as Sr. Resident in the Department of Neurosurgery of All India Institute of Medical Sciences. Presently Dr. Sogani is working as Associate Consultant in the Department of Neurosurgery, Sir Ganga Ram Hospital, New Delhi, India. About the Author-H.m NARAINAGAR~HALreceived his M.B.B.S. from King George Medical College, Lucknow, India in 1967. Dr. Agarwal did his internship, Junior & Senior Residency from the same college. He completed his MS. in General Surgery in 1971, and his MCh in Neurosurgery from the All India Institute of Medical Sciences, New Delhi, India in 1974. Dr. Agatwal was Pool Officer Specialist Neurosurgery in Safdarjung Hospital, New Delhi, India from 1974 to 1975. Further he worked in Iran with the Red Cross Red Lion & Sun Society from 1975 to 1981. Dr. Agarwal has worked as Sr. Consultant Neurosurgeon in St. Stephe& Hospital, Tkath Ram Shah Ho&al & Moo1 Chand Ho&al. New Delhi. India. Presently Dr. Agarwal is Sr. Consultant~Ne&osurgeon at Sir Ganga Ram Hospital, & Batra Hospital 8r Medical Research Centre, New Delhi, India. About tbe Author-Vmr S. MADAN was born on 19.02.1938. He passed M.B.B.S. in 1962 from King George Medical College, Luck-
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now, India. He obtained MS. in General Surgery in 1965 and M.Ch in Neurosurgery 1972. Dr. Madan wrote his thesis on “Renal angiography as a diagnostic measure.” Dr. Madan served in Army Medical Corps as Neurosurgeon from 1966 to 1988. He received Vishisht Sewa Medal for distinguished services in 1985. Dr. Madan received training in Micro-neurosurgery 8r Stereotactic surgery for 2 years at Department of Surgical Neurology University of Edinburg Scotland. Presently Dr. Madan is Senior Consultant Neurosurgeon at Sir Ganga Ram Hospital, New Delhi, India.
November-December/l991, Volume 15, Number 6 Ahout the Author-Swum P. BYOTRA received his M.B.B.S. from Jammu & Kashmir University in 1971. He obtained M.D. in General Medicine from Delhi University in 1975. Dr. Byotra worked as Senior resident in Medicine from 1975 to 1976 and Senior resident in Cardiology at G.B. Pant Hospital, New Delhi, India. Dr. Byotra worked as Consultant Physician for the Ministry of Health in Libya from 1979 to 1982. Presently Dr. Byotra is working as Associate Consultant in Medicine at Sir Ganga Ram Hospital, New Delhi, India.
Computeridmrdicd ha& and Gmphics, Vol. IS, No. 6, pp. 379-388, 1991 Ftinted in the USA. All rights -cd.
COMPUTED TOMOGRAPHY IN SPINAL TUBERCULOSIS TarvinderB. S. Buxi*, ShyamS. Dada*, RakeshK. Mathur*, Prithipal S. Mainif, Virender K. Nijhawan?, ShantikumarSoganil, Har Narain AgarwalS,Vijay S. Madan* and Shristi P. Byotras *Delhi Scan ResearchCentre, Departments of tGrthopedic Surgery, *Neurosurgery and 6Intemal Medicine, Sir Ganga Ram Hospital, New Delhi, 110 060, India (Received
3 January
1991)
Abstract-Exhaustive clhkoradioiogic and computed tomographic (CT) analysis of 114 casesof spinal tuberculosis seen between January 1983 and January 1989 is presented. The mechanisms of the spinal involvement are reviewed. CT helped to diagnose cases of spinal tuberculosis in their initial stages. Inaccessible fiied areas of spine were seen with ease on axial sections of CT. The extent and anatomic depiction of soft-tissue involvement as depicted on CT helps surgeons choose the appropriate surgical approach, which may affect future spinal stability. Key Words: Spine, Tuberculosis, Computed tomography
(Table 1). The records of these patients were reviewed with particular reference to age, sex and clinical presentation. Plain X-rays, CT features and myelographic findings were available. The surgical approach was questioned before CT was done and appropriate suggestions made following CT for desired surgical intervention. CT findings were correlated with surgical findings or follow-up CT scans after conservative and surgical management at appropriate intervals. Scans were performed on a Hitachi third-generation body scanner with a scan time of 4.5 set and matrix size of 320 x 320. Most of the studies were performed with 5-mm collimation and 5-mm incrementations. An intravenous bolus of 80 to 100 mL of 60% iodinated contrast medium was used routinely to acquire enhanced sections. Intrathecal metrizamide was used when necessary. The scans were first reviewed by three radiologists independently, folowed by a consensus of final opinion. The treating clinicians were closely questioned regarding their therapeutic approach in individual cases.
INTRODUCTION Percival Pott described tuberculosis of the spine more than two centuries ago. Although antitubercular chemotherapy brought about a revolution in the treatment of tuberculosis, at times the diagnosis is still an enigma. Its presentation may no longer be typical and it seems the behavior of this disease has changed over the years. CT has helped in diagnosis of such cases with atypical or equivocal presentation. CT was found to be especially useful to depict disease in the posterior appendages and fixed inaccessible areas of the spine, such as sacrum, sacroiliac joints and craniovertibral junction. The exact surgical approach to ensure future stabilization of the spine is determined with preoperative CT. Although we have seen many cases of spinal tuberculosis during the last 6 years, this data has been obtained from medical records of the admitted cases at Sir Ganga Ram Hospital, New Delhi, India. MATERIAL
AND METHODS
RESULTS
A retrospective review of the cases of spinal infection yielded 84 cases of spinal tuberculosis at our center between January 1983 and January 1989. During the time of review, 30 cases were encountered prospectively. These 114 cases form the basis for this report
A total of 114 patients are included in this study. There were 63 males and 51 females, ranging in age from 14 to 62 years. The largest group (44.7%) was of young adults between 20 and 30 years of age; however, a significant number of patients were in older age groups, as shown in Table 1. All 114 patients presented with back pain, while 51 (44.7%) of them had mild-to-moderate fever with evening rise. Neurological examination was positive in 33 (28.9%) cases ranging
Address all correspondence to Dr. T. B. S. Buxi, Director, Delhi Scan Research Centre, Sir Ganga Ram Hospital, New Delhi, 110 060, India. 379
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Fig. 1. A 20-year-old female presented with neck pain of 1 year duration and weaknessin both upper and lower limbs of 1 week duration. She had a normal X-ray of the cervical spine in May 1984. By February 1985 X-rays showed an increase in retropharyngeal space. (a) CT demonstrates prespinai and intraspinal pus collection with Cl-C2 dislocation. (b) Post-antikochs.After 8 months of conservativetreatment, resolution of abscessis complete; however, Cl-C2 dislocation continues.
from multiple radiculopathies to spastic paraplegia. At least nine cases were referred with a strong clinical suspicion of disk prolapse. Duration of symptomatology ranged from 11 days to 13 months. Ninety-nine patients had abnormal plain film findings, compared with positive findings on CT in all cases. Most lesions were noted in dorsal and lumbar regions, whereas nine cases had involvement of the upper two cervical vertebrae as shown in Table 2 (Fig. 1). Twelve cases revealed lesions in the lumbro-sacral region, with three cases having minimal lesion of the sacral promontory (Fig. 2) and another 3 with early destruction of the ilium (Fig. 3). Three cases showed involvement of the sacroileitis @I) joint (Fig. 4) with destruction of sacral ala. Three cases had calcified lesions involving two regions, as shown in Table 3 (Fig. 5).
Small or large intraspinal extension of the granulation tissue or the abscess was demonstrated in 78 (68.4%) cases. Myelography was done in three cases and met&amide CT in 12 cases (Fig. 6). In the remaining cases it was possible to discriminate intraspind granulation tissue and abscess on an enhanced CT with a bolus of IV contrast. Seventy-two cases (63.1%) showed destruction of the anterior part of the vertebral body, with 42 of these also showing involvement of posterior part of the vertebral body (Fig. 7). There were 15 cases (13.2%) with involvement of the posterior part of the vertebral body (Fig. 8) and another 15 cases with involvement of both the posterior part of the vertebral body and posterior elements. There were six cases in which selective involvement of the lamina (Fig. 9) was present. Three cases (2.6%) showed involvement of the transverse Table 2. Distribution of casesaccording to site of involvement.
Table 1. Age and sex distribution for 114 patients with spinal tuberculosis. Age (YeW
No. of Cases
1 l-20 21-30 31-40 41-50 51-60 61-70 Males
6 51 18 21 3 15 Females=51
= 63 (55.3%)
Percentage of total 5.3 44.1
15.8 18.4 2.6 13.2
Site Cranio-cervical Cervical Cervico-dorsal Dorsal Dorso-lumbar Lumbar Lumbo-sacral SZtCGd Total
No. of cases 3 6 12 48 18 18 9 3 117
& Ilium
(44.7%) (Three
cases had two levels
of involvement.)
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Fig. 2. Erosive destruction of sacral promontory with granulation tissues.
process. Adjacent rib destruction was seen in nine cases (7.9%). Paravertebral soft tissue was seen in 42 cases (36.8%) on plain films, as compared to 99 cases (86.9%) on CT (Fig. 10). The majority of cases having no paravertebral shadow in plain films had small paravertebral components on CT. The fluid density representing abscess was seen in 63 cases (55.3%) on CT. In three cases the abscesses were bilateral and extended from the dorsolumbar region to the knees on both sides (Fig. 11). Compared with 33 cases (28.9%) demonstrating calcification on CT, only six cases (5.3%) showed the same on plain films (Fig. 12). Active tuberculosis was seen on chest X-ray of six patients (5.3%), whereas calcified primary lesion could be identified in 33 cases (29.0%). A purified protein derivative (PPD) test was positive in all 42 cases in which it was done.
@I Fig. 3. (a) Young girl with low backache. CT was done from L2 to L5s 1. A destructive lesion is shown in the right iliac bone with surrounding areas showing inflammatory tissues and edema. Note extension of tissuesinto the right nerve root canal, obliterating
lateral
recess fat. CT-guided
aspiration
confirmed tubercular pathology. (b) Follow-up CT reveals resolution of inflammatoq pathology with marked improveTable 3. Distribution
ment on antikochs.
of cases according to their location within a vertebra
Involved part 1. Only anterior part of vertebral body 2. Only posterior part of vertebral body 3. Both anterior and posterior parts of vertebral body 4. Anterior and posterior part of vertebral body + posterior elements 5. Posterior part + posterior elements only 6. Lanka only 7. Transverse process only 8. Odontoid process with atlas and axis vertebra 9. Vertebral destruction with adjacent rib involvement
No. of cases Percentage 12 15 33
10.6 13.2 28.9
9
7.9
18 6 3 6
15.9 5.3 2.6 5.3
9
7.9
Forty-two cases were subjected to surgery and 30
cases underwent needle aspiration with CT guidance. All cases were followed up clinically and radiologically. A follow-up CT scan was done in 42 cases. DI!XUS!SION
Spinal tuberculosis accounts for approximately 50% of all cases of skeletal tuberculosis in adults (1). In one series, the incidence has been reported to be 58.7% (2).
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Fig. 4. Tubercular
sacroileitis left side.
Considerable variation has been reported in age incidence by various authors from different parts of the world. Hodgson, in a series of 300 patients, reported 70% of cases occurred in patients younger than 10 years of age (3). Goldblatt et al. reported over 50% of cases under 11 years of age (4). In another series, the majority of 140 Nigerian patients were below 20 years of age (5). In a series from Poland, spinal tuberculosis was stated to affect predominantly people older than 60 years (6). Most western authors report the highest incidence in young adults 20 to 30 years old (7). The age of the patients tends to be young in those countries where skeletal tuberculosis is common (4, 8).
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Table 1 shows the age incidence in the present study. The most cases, that is, 44.7%, were seen in the 20- to 30-years age group. However, a significant number of cases were also seen in older age groups. A male predominance has been reported by some authors (7, 9); however, no sex predilection was noted by others (10, 11). Whereas we had a slight male predominance in our series (see Table l), we feel that spinal tuberculosis does not have any specific predilection for males. Most cases of spinal tuberculosis present with backache. A low-grade fever with evening rise, and history of night sweats is present in a large number of cases. Varying degrees of neurological impairment accompanies a smaller percentage; the reported incidence varies from 10.5 to 41.6% (7, 9, 12-14). In our series, 33 cases (28.9%) had positive neurological examination, although intraspinal extension was noted in 78 cases (68.4%). Spinal tuberculosis is almost always a result of hematogenous spread. A direct extension from involved nodes or lungs has also been suggested (15). The hematogenous spread is presumed to be from a pulmonary focus, although evidence of active pulmonary disease is present in less than 30% of cases (4). We had only six cases with active lung parenchymal lesions (5.3%). Lower thoracic and upper lumbar regions are the most frequent sites of involvement. The incidence gradually diminishes toward both sides with cervical and sacral regions being least affected sites. The site distribution of our cases indicates that tuberculosis mav
Fig. 5. Densely calcified tubercular lesions at Dl l-D12
and L5-S 1.
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Fig. 6. Metrizamide CT demonstratesthe circumferential encompassmentof the spinal cord with prespinal and paraspinal pus collection, bilateral pleural thickening. Surgical decompression was done from the right side.
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Fig. 8. Posterior half of vertebral body destruction with minimal granulation tissue.
involve any part of the vertebral column, as seen in Table 2. At least nine cases had the involvement of upper two cervical vertebrae with six cases showing partial destruction of odontoid process (Fig. 1). Cases having exclusive destruction of one sacral ala or sacral promontory are also being documented in CT literature (Fig. 2). Radiologically, the lesion most commonly affects the anterior part of the vertebral body near the intervertebral disk where it produces a localized area of rarefaction. Slowly, it passes through the stages of erosion to destruction. In early stages of the disease, there are of-
ten no changes seen on plain X-rays, and occasionally the vertebral body may be extensively involved and still present a normal roentgenographic picture (Fig. 13). CT was done because of a high index of clinical suspicion. CT helped to diagnose tuberculosis of the spine in early stages even when the plain X-rays were normal. With progression of lesion, the intervertebral disk and contiguous part of adjacent vertebral body get involved. The intervertebral disk is not affected as early as in pyogenic infection because tuberculosis does not lead to the production of proteoltic enzymes (17). The infection may also spread up and down the vertebral column underneath the paraspinal ligaments (18). Two, three or more vertebral bodies may be involved. In the initial stage, the destructive process is associ-
Fig. 7. Destruction of left anterolateral and posterior margins of dorsal vertebra with intraspinal and paraspinal granulation tissuesand no fluid pus formation.
Fig. 9. Destruction of right lamina with multiloculated pus collection and granulation tissuesin both intraspinal and posterior paraspinal muscles.
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Fig. 10. Left paravertebral and minimal enhancing intraspinal granulation tissues not seen on plain X-rays.
Fig. 12. Calcification in the right posterior spinal muscles in a resolving tubercular abscess.
ated with formation of necrotic tissue and gaseous material in the pre- and paravertebral regions. These abscesses may be bilateral and extend along fascial planes for long distances in the dorsolumbar region, and rarely into the pelvis, thigh and even to the knee and great toe (Fig. 11). In the cervical region, a retropharyngeal abscess may result. We agree with Wheelan et al. (19) that tubercular abscesses are generally large, multiloculated and show thick, irregular rim enhancement. Tubercular abscesses destroy all ligamentous barriers and thus creep into and invade the meninges (Fig. 1). Here the infective pathology has destroyed the various binding ligaments, resulting in dislocation of the Cl with respect to the occiput and C2 with respect to Cl. Evidence of cord compression is seen. In such a case, traction would perhaps result in further deterioration and early
decompression through the oral route is recommended. Further, it is to be emphasized that fixed spinal areas like the sacrum and sacroiliac and iliac bones may not show disease pathology in the initial stages (Fig. 14). Most cases of spinal tuberculosis are associated with paravertebral granulation tissue or abscess. It was only in 42 (36.8%) cases in our series that a paravertebral shadow could be seen on plain films, compared with CT demonstration of an abscess or granulation tissue mass in 99 cases (86.9%). In our experience, small paravertebral soft-tissue components are inavariably associated with spinal tuberculosis and may be easily missed on plain films (Fig. 10). A variable degree of calcification occurs in the paraspinal soft tissue component of the disease process, even without specific treatment, and indicates chronic lesion (19). CT is ideally suited to demonstrate small amounts of calcification which is not visible on plain X-rays (Fig. 12). We consider the presence of calcification in the paraspinal soft tissue component a very important fmding and is quite specific in the appropriate clinical setting. In,contrast to six (5.3%) cases showing calcification on plain X-rays, CT could pick up the same finding in 33 (29%) cases in our series. The minimum duration of symptoms was 3 months and the maximum 13 months in cases with calciticaction in our series. Isolated involvement of vertebral arch and its processes occurs in less than 2% of cases of tuberculosis spondylitis (1). The intervertebral disk is spared in such cases, but adjacent rib may be destroyed. These cases may present with posterior soft-tissue mass (15). Rahman also reported five cases of neural arch tuberculosis with complete sparing of vertebral body and disk (20).
Fig. 11, Psoas thigh abscesses extending level into the thighs.
from L3 vertebral
CT in spinaltuberculosis 0 T. B. S. Bux~et al.
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(b) Fig. 13. Young female with neck pain of 6 months duration. (a) X-ray, lateral view, of cervical spine shows straightening that is otherwise noncontributory. (b) CT reveals destruction of posterior vertebral margin with granulation tissues.
Depicting the exact areas of involvement helps to adopt a correct surgical approach. With plain X-rays it is difficult to defme the posterior appendage involvement in addition to vertebral body disease. In such cases, if anterior decompression is resorted to, it will lead to gross ‘instability of the spine since the posterior appendages are already compromised. CT reveals bone
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destruction along with the granulationtissuesand pus collection. The size, site, side and extent of bony and soft-tissue abnormalities obviously help to choose the correct approach for surgical intervention. Thus it is important to assess the exact pathology in order to choose the correct procedure of choice for future stability of the spine. The anterior part of vertebral body was involved in 90 (79%) cases, compared with the posterior part of vert&ral body which was involved in 75 (65.8%) cases. The intmspinal extension of the disease may be due to (a) granulation tissue which may encircle the dura; (b) paraspinal abscess invading the spinal canal; (c) fluid abscess in the spinal canal; (d) sequestrated bone and/or intervertebral disc; (e) dislocated vertebrae; or (f) thick transverse ridge of fibrous tissue (21). Most authors believe the commonest cause of compression is an intraspinal tubercular abscess or granulation tissue in extradural compartment (5, 21, 22) (Fig. 6). It is also true that all those cases having an intraspinal extension may not have neurological impairment. Whereas 78 (68.4%) cases in our series showed small or large intraspinal extension, only 33 (28.9%) cases had neurological findings. Although in initial stages, myelography was performed in three cases and metrizarnide CT was done in 12 cases, we discovered that a bolus of IV urographic contrast material provides an excellent display of intraspinal extension by enhancing the granulation tissue. We feel that the use of intrathecal contrast is required only in an occasional case of spinal tuberculosis and should be limited to cases where doubt exists on intravenously enhanced study. Wheelan et al. reported the spread of tubercular process through subarachnoid space in one case that had tubercular lesion in the posterior part of L3 vertebral body (19). They mentioned that subsequent brain scan revealed tubercular meningitis with calcified granulomas. We believe the possibility of subarachnoid spread is unlikely in their case, as we often see calcified granulomas in patients with unrelated symptomatology. Moreover, we had many cases in our series in which the posterior part of the vertebral body and neural arch were destroyed and none of them had a history of meningitis in the past or during the follow-up period. We feel a possibility of transdural spread from spinal lesion to subarachnoid space leading to meningitis is more likely, and that calcified granuloma is a nonspecific and incidental finding. Although dura provides a strong barrier to spread of the infection from the vertebral body and extradural space to the subdura, such an invasion happens in exceptional cases (21). Histological supportive evidence has been produced on surgery and postmortem (22, 23).
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Fig. 14. A &year-old male presented with backache. (a) Normal pelvis AP view. (b) Sacralforamina erosion with granulation tissuesin the sacral canal and right sacralforamina. (c) Large presacralabscess.
SUMMARY Computed tomography is useful in early diagnosis of cases of spinal tuberculosis where plain X-rays are normal. Computed tomography is useful in depicting tubercular lesions in fixed inacessible areas such as the sacrum, sacroiliac joints and craniovertebral junction. CT helps the physician to decide which surgical approach is required, keeping in view the future stabilization of spine. Conventional myelography is rarely required for showing extradural soft tissue abnonnalities. CT helps provide guidance for diagnostic needle aspirations, especially for cases in which there is strong clinical suspicion of spinal tuberculosis. One of the most important practical applications of CT is in planning operative procedures. It has often enabled orthopedic/neurosurgeon colleagues to decide whether to go
in anteriorly or posteriorly, from the left or right side, depending on the site of maximal involvement. This is also important for the future stability of the vertebral column.
Acknowledgmenr-We sincerely thank Mr. S. K. Sharma & Ms. Awa-Aftab for obtaining scans and Mr. V. Jayakumar for secretarial assistance.
1. Ciqper, G.R.; Aacker, J.D.; Robertson, J.H. Computedtomography in P&s disease. Ncurosurgay 10(4):!K&m, 1982. 2. Hodgson, A.R. Infeetous qlisx%se of the spine. In: Rothman, R.H.; Simeone, F.A., eds. The. Spine, Vol. 2. Philadelphia: WB se, 1975:567-598. 3. Hodgson,A.R.Re@rtontbcfindingsandresultsin3OOcases
CI in spinal tuberculosis 0 T. B. S. Buxr et al.
4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23.
of Pott’s disease treated by anterior fusion of the spine. J. West. Pacif. Orthop. Ass. 1:3; 1964. Goldblatt, M.; Cremin, B.J. Osteo-articular tuberculosis: Its presentation in coloured races. Clin. Radiol. 26669-677; 1978. Konstam, P.G.; Konstam, S.T. Spinal tuberculosis in Southern Nigeria with special reference to ambulant treatment of thoracolumbar disease. J. Bone Joint Surg. 4OB:26; 1958. Arct, W. 0pcrative:tmatment of tuberculosis of the spine in old people. J. Bone Joint Surg. 50A255; 1968. Bosworth, D.M.; Pietra, A.D.; Rahilly, G. Paraplegia resulting from tuberculosis of the spine. J. Bone Joint Surg. 35A735; 1953. Nicholson, R.A. Twenty years of bone and joint tuberculosis in Bradford. A comparison of the disease in the indigenous and Asian populations, J. Bone Joint Surg. 56:76&765; 1974. Jackson, J.W. Spinal tuberculosis. Postgrad. Med. J. 47:723; 1971. Tuli, S.M.; Srivastava, T.P.; Varma, B.P.; Sinha, G.P. Tuberculosis of spine. Acta Orthop. Stand. 38445; 1967. Chu, C.B. Treatment of spinal tuberculosis in Korea using focal debridement and interbody fusion. Clin. Orthop. 50:235; 1967. Jones, B.S. Pott’s paraplegia in the Nigerian. J. Bone Joint Surg. 4OB:16; 1958. Konstam, P. Ambulant treatment of spinal tuberculosis. Excerpta Med. (Intern. Congr. Series) 129316; 1965. Tuli, SM. Results of treatment of spinal tuberculosis by ‘Middle Path’ regime. J. Bone Joint Surg. 57B:l3; 1975. Bell, D.; Cockshott, W.P. Tuberculosis of the vertebral pedicles. Radiology 99:438; 1971. Auerbach, 0. Acute general&d military tuberculosis. Am. J. Path. 20:20-21; 1944. Forrester, D.M.; Nession, J.W. The Radiology of Joint Disease. Philadelphia: WB Saunders: 1973:410-419. Murray, R.O.; Jacobson, H.H. The Radiology of Skeletal Disorders. Edinburgh: Churchill Invingstone; 1971. Whelan, M.A.; Naidich, D.P.; Post, J.D.; Chase, N.E. Computed tomography of spinal tuberculosis. J. Comput. Assist. Tomogr. 7( 1):25-30; 1983. Rahman, N-U. Atypical forms of spinal tuberculosis. J. Bone Joint Surg. (Br) 62B:162-165; 1980. Tandon, P.N.; Pathank, S.N. Tuberculosis of the central nervous system. In: Spillane, J.D., ed. Tropical Neurology. London:Oxford University Press; 1973~37-62. Hodgson, AR.; Skinsness, O.A.; Le.ong, C.Y. The pathogenesis of Pott’s paraplegia. J. Bone Joint Surg. 49A1147; 1967. Garceau, G.J.; Brady, T.A. Pott’s paraplegia. J. Bone Joint Surg. 32A:87; 1950.
About the Author-TARVINDER Bra SINGHBuxt received his M.B.B.S. from Nagpur University in India in 1977, following junior residency in Paediatrics &. General Medicine at Holy Family Hospital, New Delhi. He served as Medical Officer in the Libyan Armed Forces Medical Services for 2 years. Dr. Buxi received his M.D. in Radiodiagnosis in 1983 from Punjabi University, Patiala and wrote a thesis on “Small Bowel Enema.” During 1984 Dr. Buxi trained in Body CT at the University of Cambridge England and Aachen University in Germany. Dr. Buxi has been working on Whole Body CT since 1983. Presently Dr. Buxi is Chief Radiologist at Delhi Scan Research Centre, Sir Ganga Ram Hospital, New Delhi, India. Dr. Buxi is a corresponding member of Radiological Society of North America. About the Author-SHYAM S. DODA received his M.D.in Radio-diagnosis from Rajasthan University, Jaipur, India in 1981. Thereafter he did his senior residency at Dr. R.M.L. Hospital, New Delhi. He received his training in Computed Tomography from St. Bartholomew’s Hospital, London and Newcastle General Hospital, Newcasde-upon-Tyne in England. Dr. Doda worked as Radilogist & Associate Director Delhi Scan Research Centrc, Sir Ganga Ram Hospital
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New Delhi, India from 1983 to 1987. Presently Dr. Doda is working as Consultant Radiologist at Diwan Chand Agganval X-ray Clinic & Imaging Centm, Dr. B.L. Kapoor Memorial Hospital, New Delhi. Dr. Doda also heads his Ultrasound Scan Centre in New Delhi Delhi, India. Dr. Doda is a member of Indian Radiological & Imaging Association. About the AU~~O~-RAKESH K. MA~HURreceived his M.D. from the Armed Forces Medical College University of Pune in 1973. He completed his residency training in Radiology at Dr. R.M.L. Hospital affiliated with the University of Delhi. He completed an M.D. in Radio-diagnosis from the same Institution in 1979. Dr. Mathur was appointed as Senior Resident in the Department of Radiology at Dr. R.M.L. Hospital. Dr. Mathur received his training in Body Computed Tomography at the Tsukuba Memorial Hospital and Institute of Clinical Medicine Tsukuba Universitv.. . Jaoan . in 1982. Dr. Mathur worked as Radiologist & Director at Delhi Scan Research Centre, Sir Ganga Ram Hospital, New Delhi, India from 1983 to 1987. Presently Dr. Mathur is Chief of Department of Radiodiagnosis and Imaging, at Batra Hospital, New Delhi, India. About the Author-F’RITHIPAL S. MAINI received his M.B.B.S. from Punjab University, India. He did his Masters at the same university. Subsequently, Dr. Maim joined as an Assistant Professor of Orthopedics at Medical College, Rohtak, India. He worked in this capacity from 1962 to 1968. Dr. Maim remained Professor of Orthopedics from 1968 to 1982. He has been actively involved in training and teaching of undergraduates and postgraduates. Dr. Maini has well known research work on Osteoporosis and bone grafts, in addition to numerous publications. Hip surgery & spine surgery are his special fields of interest. Presently Dr. Maim is Chief of Orthopedics at Sir Ganga Ram Hospital, New Delhi & visiting Emeritus Professor Orthopedics of University of Rohtak, India. About the Author-VIRENDER K. NIJHAWAN received his M.B.B.S. from Medical College Rohtak, Haryana, India. He obtained his M.S. Orthopedics in 1979 from the same institution. Dr. Nijhawan wrote a thesis on “Comparative study of various operative techniques in prolapsed lumbar intervertebral discs.” Presently he is working as Jr. Consultant in the Department of Orthopedics, Sir Ganga Ram Hospital, New Delhi, India, since September, 1985, About the Author--SH.ammm SOGANIreceived his M.B.B.S. from Jiwaji University, Gwalior, India in 1975. He did his M.S. General Surgery from the same university in 1980. Dr. Sogani obtained his M.Ch from All Indian Institute of Medical Sciences, New Delhi, India in 1983. Dr. Sogani worked as Demonstrator in Department of Surgery in G.R. Medical College, Gwalior for 2 years. Subsequently he worked as Sr. Resident in the Department of Neurosurgery of All India Institute of Medical Sciences. Presently Dr. Sogani is working as Associate Consultant in the Department of Neurosurgery, Sir Ganga Ram Hospital, New Delhi, India. About the Author-H.m NARAINAGAR~HALreceived his M.B.B.S. from King George Medical College, Lucknow, India in 1967. Dr. Agarwal did his internship, Junior & Senior Residency from the same college. He completed his MS. in General Surgery in 1971, and his MCh in Neurosurgery from the All India Institute of Medical Sciences, New Delhi, India in 1974. Dr. Agatwal was Pool Officer Specialist Neurosurgery in Safdarjung Hospital, New Delhi, India from 1974 to 1975. Further he worked in Iran with the Red Cross Red Lion & Sun Society from 1975 to 1981. Dr. Agarwal has worked as Sr. Consultant Neurosurgeon in St. Stephe& Hospital, Tkath Ram Shah Ho&al & Moo1 Chand Ho&al. New Delhi. India. Presently Dr. Agarwal is Sr. Consultant~Ne&osurgeon at Sir Ganga Ram Hospital, & Batra Hospital 8r Medical Research Centre, New Delhi, India. About tbe Author-Vmr S. MADAN was born on 19.02.1938. He passed M.B.B.S. in 1962 from King George Medical College, Luck-
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now, India. He obtained MS. in General Surgery in 1965 and M.Ch in Neurosurgery 1972. Dr. Madan wrote his thesis on “Renal angiography as a diagnostic measure.” Dr. Madan served in Army Medical Corps as Neurosurgeon from 1966 to 1988. He received Vishisht Sewa Medal for distinguished services in 1985. Dr. Madan received training in Micro-neurosurgery 8r Stereotactic surgery for 2 years at Department of Surgical Neurology University of Edinburg Scotland. Presently Dr. Madan is Senior Consultant Neurosurgeon at Sir Ganga Ram Hospital, New Delhi, India.
November-December/l991, Volume 15, Number 6 Ahout the Author-Swum P. BYOTRA received his M.B.B.S. from Jammu & Kashmir University in 1971. He obtained M.D. in General Medicine from Delhi University in 1975. Dr. Byotra worked as Senior resident in Medicine from 1975 to 1976 and Senior resident in Cardiology at G.B. Pant Hospital, New Delhi, India. Dr. Byotra worked as Consultant Physician for the Ministry of Health in Libya from 1979 to 1982. Presently Dr. Byotra is working as Associate Consultant in Medicine at Sir Ganga Ram Hospital, New Delhi, India.