1. Pathophysiology and Treatment of Spinal Tuberculosis
by S. Rajasekaran, Rishi Mugesh Kanna, and Ajoy Prasad Shetty
JBJS Reviews
Volume 2(9):e4
September 23, 2014
©2014 by The Journal of Bone and Joint Surgery, Inc.

2. Figs. 1A through 1D Radiographs and MRI scans for a patient with tubercular psoas abscess.
Figs. 1A through 1D Radiographs and MRI scans for a patient with tubercular psoas abscess. The extent of abscess formation does not match the severity of vertebral damage. Lumbosacral radiographs (Figs. 1A and 1C) do not show any vertebral damage. However, T2-weighted coronal (Fig. 1B) and axial (Fig. 1D) MRI scans of the lumbar spine and pelvis show multiple abscess pockets (red arrows) in the paravertebral region, the psoas muscle, the gluteal muscles on both sides, and the pelvic and iliac regions. R = right.
S. Rajasekaran et al. JBJS Reviews 2014;2:e4
©2014 by The Journal of Bone and Joint Surgery, Inc.

3. Figs. 2A through 2G Schematics and imaging studies illustrating the “spine-at-risk” radiographic signs described by Rajesakaran25.
Figs. 2A through 2G Schematics and imaging studies illustrating the “spine-at-risk” radiographic signs described by Rajesakaran25. Fig. 2A Separation of the facet joint is identified when the facet joint dislocates at the level of the apex of the curve, causing instability and loss of alignment. In severe cases, the separation can occur at two levels. Fig. 2B Posterior retropulsion is identified by drawing two lines along the posterior surfaces of the first upper and lower normal vertebrae. The diseased segments are found to be posterior to the intersection of the lines. Fig. 2C Lateral translation is confirmed when a vertical line drawn through the middle of the pedicle of the first lower normal vertebra does not touch the pedicle of the first upper normal vertebra. Fig. 2D Schematic illustrating the toppling sign. In the initial stages of collapse, a line drawn along the anterior surface of the first lower normal vertebra intersects the inferior surface of the first upper normal vertebra. “Tilt” or “toppling” occurs when the line intersects higher than the middle of the anterior surface of the first normal upper vertebra. Figs. 2E Radiograph demonstrating thoracolumbar tuberculosis in an eight-year-old girl with positive posterior retropulsion and facet separation (yellow arrow). Fig. 2F Sagittal T2-weighted MRI scan of the spine of the same patient, showing a large prevertebral and epidural abscess causing cord compression. Fig. 2G Radiograph of the spine of the same patient, made after the lesion was treated with single-stage, anterior debridement with fibular strut graft reconstruction and posterior pedicle screw stabilization through a posterior approach.
S. Rajasekaran et al. JBJS Reviews 2014;2:e4
©2014 by The Journal of Bone and Joint Surgery, Inc.

4. Figs. 3A through 3F A forty-two-year-old woman presented with a three-month history of pain in the middle part of the back and a three-day history of clumsiness during gait.
Figs. 3A through 3F A forty-two-year-old woman presented with a three-month history of pain in the middle part of the back and a three-day history of clumsiness during gait. Figs. 3A and 3B Radiographs showing T10 vertebral collapse with intact adjoining disc spaces (vertebra plana). Figs. 3C and 3D T2 axial (Fig. 3C) and sagittal (Fig. 3D) MRI scans showing paravertebral and epidural abscess formation along with collapse of single vertebra. Normal discs are uncommon in patients with spinal tuberculosis. Figs. 3E and 3F Radiographs made after treatment of the lesion with posterior stabilization and anterior reconstruction through an all-posterior approach.
S. Rajasekaran et al. JBJS Reviews 2014;2:e4
©2014 by The Journal of Bone and Joint Surgery, Inc.

5. Figs. 4A through 4D A thirty-two-year-old man with upper thoracic tuberculosis who was managed successfully with anti-tubercular chemotherapy alone.
Figs. 4A through 4D A thirty-two-year-old man with upper thoracic tuberculosis who was managed successfully with anti-tubercular chemotherapy alone. Figs. 4A and 4B Sagittal (Fig. 4A) and axial (Fig. 4B) T2-weighted MRI scans showing single vertebral body collapse with epidural abscess but with minimal deformity and neurological deficit. Figs. 4C and 4D Sagittal (Fig. 4C) and axial (Fig. 4D) T2-weighted MRI scans made after nine months of chemotherapy, showing complete resolution of the disease and canal dimensions. (Courtesy of Dr. Shekhar Y. Bhojraj, Mumbai, India). D3 = third thoracic vertebra, D5-6 = intervertebral disc between fifth and sixth thoracic vertebrae, and D7 = seventh thoracic vertebra.
S. Rajasekaran et al. JBJS Reviews 2014;2:e4
©2014 by The Journal of Bone and Joint Surgery, Inc.

6. Figs. 5A and 5B Lateral radiograph (Fig
Figs. 5A and 5B Lateral radiograph (Fig. 5A) and sagittal T2-weighted MRI scan (Fig. 5B) showing C4 vertebral body tuberculosis (yellow arrows) with kyphosis causing cord compression.
Figs. 5A and 5B Lateral radiograph (Fig. 5A) and sagittal T2-weighted MRI scan (Fig. 5B) showing C4 vertebral body tuberculosis (yellow arrows) with kyphosis causing cord compression. Fig. 5C Radiograph made after treatment of the lesion with anterior debridement, iliac crest autograft reconstruction, and stabilization with a plate.
S. Rajasekaran et al. JBJS Reviews 2014;2:e4
©2014 by The Journal of Bone and Joint Surgery, Inc.

7. Figs. 6A through 6H A forty-five-year-old woman who underwent all-posterior global reconstruction of thoracic tubercular spondylitis.
Figs. 6A through 6H A forty-five-year-old woman who underwent all-posterior global reconstruction of thoracic tubercular spondylitis. Figs. 6A and 6B Anteroposterior (Fig. 6A) and lateral (Fig. 6B) radiographs of the thoracic spine, showing collapse of the sixth thoracic vertebral body. Figs. 6C and 6D T2-weighted sagittal (Fig. 6C) and short-tau inversion recovery (STIR) (Fig. 6D) MRI sequences showing complete destruction of the T6 vertebral body with epidural abscess and neurological deficit. Figs. 6E and 6F Anteroposterior (Fig. 6E) and lateral (Fig. 6F) radiographs of the thoracic spine, made immediately postoperatively, showing posterior stabilization, decompression, and anterior vertebral reconstruction of the T6 vertebral body with a cage. Figs. 6G and 6H T2-weighted sagittal (Fig. 6G) and T1-weighted sagittal (Fig. 6H) MRI scans, made at nine months, showing complete resolution and healing of the abscess. L = left, H = head, and F = foot.
S. Rajasekaran et al. JBJS Reviews 2014;2:e4
©2014 by The Journal of Bone and Joint Surgery, Inc.

8. Figs. 7A through 7D A thirteen-year-old boy was managed with closing-opening wedge osteotomy to correct a post-tubercular kyphotic deformity.
Figs. 7A through 7D A thirteen-year-old boy was managed with closing-opening wedge osteotomy to correct a post-tubercular kyphotic deformity. Figs. 7A and 7B Preoperative anteroposterior and lateral radiographs showing a kyphotic deformity of 118° at the thoracolumbar junction between the T9 and L3 vertebrae (corresponding with the area between the two white lines). Figs. 7C and 7D Postoperative anteroposterior and lateral radiographs showing good correction of the deformity with pedicle screw instrumentation placed at least three levels cephalad and caudad to the apex. The “opened” anterior wedge has been reconstructed with a titanium mesh cage.
S. Rajasekaran et al. JBJS Reviews 2014;2:e4
©2014 by The Journal of Bone and Joint Surgery, Inc.