The Unbearable Suffering Followed by Ineffable Relief of a Good Doctor: Tuberculosis as a Malady, Still Rules the Roost
Several years ago, I remember treating an elderly doctor (around 65 years of age), referred to me by one of my teachers, being his close friend and colleague. He presented with persistent lower mid back pain. He was an ophthalmologist retired from the service but was pursuing rural charitable service. He came with full investigations. X-ray [Figure 1]a did not show anything significant. CT scan showing a large osteolytic lesion involving right D10 hemivertebrae along with involvement of the posterior elements. MRI [Figure 1]c more or less confirmed the findings of CT and did not contribute anything more. Whole-body PET [Figure 1]f and [Figure 1]g showed hypermetabolic spots over the D10 vertebra and also over the medial part of the spine of the left scapula [Figure 1]e.
The doctor was very concerned and apprehensive because of the probable diagnosis of malignancy with metastasis. All the blood investigations including ESR, were normal. We discussed various options including a biopsy. Finally, I performed an “en bloc” vertebral body excision along with a circumferential fusion (expandable cage with single-level posterior pedicle screws). We excised the scapular lesion in the same sitting. The intra-operative nature of the lesion looked very much like a neoplastic etiology. Nothing prepared me for the diagnosis.
My teacher, who was waiting anxiously outside the operating room, took the sample to the pathologist for a frozen section. We continued surgery expecting the worst. After a few minutes, the nurse requested me to speak to the pathologist on the phone, who then confirmed with a fair degree of confidence that the specimen sent was tuberculosis!
While relieved of the fact, we were still sceptical till, the final biopsy after few days again confirmed the diagnosis of tuberculosis. This was perhaps the first time in my 30 years of clinical practice that I have seen tuberculosis with a “metastatic” nodule, both the spinal and scapular lesion being hypermetabolic on whole-body PET.
It again reiterated the immense, diverse nature of tuberculosis that can exist. These facts again are brought out well by Kumaran et al. and Garg et al. in their elegant article and editorial.
The purpose of this short article is not to again repeat the facts brought by these well-written articles, but rather emphasize how this pathology can mislead even the most experienced clinicians and advanced investigations.
Currently, there have been significant changes in the management and surgery of complex spine pathologies., Instrumentation and fixation techniques have evolved significantly.
It is also possible that there may be a paradoxical increase in the size of lesions with anti-tubercular chemotherapy., The reasons may not always be drug resistance, but could also be immunogenic very similar to some situations in cranial tuberculomas.,, These situations can again throw the clinician “off track”. This is one of the important reasons, why a biopsy is important for diagnosis as it is well known that spinal tuberculosis (especially prior to the abscess stage) may mimic (or vice versa) mitotic pathologies.
In the proposal of the well-known, Tuli's criteria, the whole treatment of spinal tuberculosis was based on the assumption that the benefit of doubt should be first given to medical treatment., The “middle path regimen” was based on the premise that medical treatment should be offered as the treatment of first choice and surgery should be to the extent possible limited to decompression of the cold abscess and relief of spinal compression. In his vast experience, he had demonstrated cases with very severe cord compression and even with severe deformity with a very good outcome following medical treatment.
However, one has to admit that since the mid-1970s, the time when the “middle path” regimen was first described, a lot has changed in terms of enhanced surgical safety, development of advanced spinal instrumentation, and increased micro-neurosurgical skills especially for cord decompression.
Hence, based on his classification, we have suggested our classification based on our institution's vast experience. In our classification, we have proposed “mild”, “significant”, and “severe” categories. The significant category includes cases with potential neurological deterioration and the severe category with impending neurological deterioration. Patients with significant category underwent surgery only if the patients were in poor clinical grade (Frankel A or B). Patients in severe category underwent surgery regardless of their clinical grade. Radiological features in the significant category included vertebral body collapse, mild deformity, and abscess extending into the epidural space. In contrast, the radiological features of the severe category included severe cord compression (>50%), destruction of all three columns, severe deformity >40 degrees, and a large abscess.
There are some unique aspects of our classification:
The reader, of course, is advised to read the original article for further clarifications.
Hence, from a community standpoint of view, we found greater practicality of our classification as it is simple, effective, and can be applied both at the level of the GP and at the level of the tertiary health care.
Finally, to state last but not the least, spinal tuberculosis still is a great mimic, a chameleon, a con artist amongst various maladies.
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There are no conflicts of interest.