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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 14  |  Issue : 1  |  Page : 94-97

Posterolateral migration of complete vertebral body in neglected tuberculosis of the spine


1 Baba Saheb Ambedkar Medical College, Rohini, New Delhi, India
2 Department of Orthopaedic Surgery, Paraplegia and Rehabilitation, Pt. B.D. Sharma PGIMS, Rohtak, Haryana, India

Date of Submission30-Aug-2021
Date of Acceptance29-Nov-2021
Date of Web Publication15-Jun-2022

Correspondence Address:
Dr. Roop Singh
52/9-J, Medical Enclave, PGIMS, Rohtak - 124 001, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jotr.jotr_79_21

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  Abstract 


The most common presentation of tuberculosis (TB) of the spine is paradiscal lesion secondarily involving adjacent disc and vertebral bodies. If not diagnosed early, it can lead to extensive destruction and atypical features. We report a patient who presented late with posterolateral migration of the vertebral body and multifocal spinal involvement. A 30-year-old female presented with back pain, progressive spinal deformity, and paraparesis. Plain X-rays, computed tomography scans, and magnetic resonance imaging revealed multifocal extensive TB of the spine with posterolateral migration of the first lumbar vertebra. The vertebral body showed erosions. Posterior elements involvements with pars interarticularis defects of 12th dorsal to 2nd lumbar vertebra were observed. The patient was planned for stabilization of the spine along with excision of the migrated vertebra along with antituberculous treatment, but she refused surgery. The authors discuss the pathogenesis of such a rare event and stress the early detection of this complication.

Keywords: Migration, posterior elements, spinal tuberculosis, vertebra


How to cite this article:
Kaur S, Singh R, More H, Khanna M. Posterolateral migration of complete vertebral body in neglected tuberculosis of the spine. J Orthop Traumatol Rehabil 2022;14:94-7

How to cite this URL:
Kaur S, Singh R, More H, Khanna M. Posterolateral migration of complete vertebral body in neglected tuberculosis of the spine. J Orthop Traumatol Rehabil [serial online] 2022 [cited 2022 Jun 27];14:94-7. Available from: https://www.jotr.in/text.asp?2022/14/1/94/347375




  Introduction Top


Tuberculosis (TB) of the spine demineralizes and destroys the vertebral body, causing pain and deformity (kyphosis) and sometimes spinal cord compression (Pott's paraplegia).[1] Focal areas of erosion and osseous destruction in the anterior corners of the vertebral body are typical plain film findings for tuberculous spondylitis. Involvement of the adjacent intervertebral disk or vertebral body results from penetration through the disk itself or spread of infection beneath the anterior longitudinal or posterior longitudinal ligament.[2] The most common type of involvement seen in tuberculous spondylitis is paradiscal type.[3],[4] However, with advancing disease, the vertebral body is inevitably involved with fragmentation and osseous destruction, collapse, and sequestra formation.[3],[4] Complete migration of an intact vertebral body in TB spine is a rare entity and has so far been reported only twice in the literature. We report one such case in neglected spinal TB and discuss the pathogenesis of such a rare event.


  Case Report Top


A 30-year-old woman presented to the Outpatient Department with complaints of intermittent low-grade fever and pain in the mid-to-lower back and difficulty in walking. She correlated the onset of pain to a trivial trauma due to a fall while walking 1 years back. The pain gradually increased in intensity over a few months. Around the same time, she also reported a deformity in mid-to-lower back that also gradually increasing in size. She did not seek any medical advice for it except taking self-medication of pain killers. On examination, she was anemic and malnourished. Neurological examination revealed Grade 4 power, reflexes exaggerated, with intact sensations in lower limbs. There was a mild hesitancy during micturition. She was admitted and put through investigations.

Laboratory investigations revealed mild anemia, an increased erythrocyte sedimentation rate (90 mm 1st h), and a positive Mantoux test. She was HIV-negative.

Radiographs of the thoracic and lumbosacral spine showed the body of the first lumbar (L1) vertebra extruded out along with a collapse and subluxation of D12 and L2 vertebral bodies and kyphotic spine at this level along with slight wedging of the L5 vertebra [Figure 1].
Figure 1: Plain lateral X-rays of the thoracic spine (a) and lumbosacral spine (b) showing vertebral body destruction of D12-L2 vertebrae and migration of L1 vertebra with slight wedging of L5

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A computed tomography (CT) scan with 3-D reconstruction revealed a left side posterolaterally displaced L1 vertebral body along with multiple fracture lines through the body and posterior elements of D12, L1 and, L2 vertebrae and small bony fragments lying adjacent to the transverse process of D12-L1 vertebrae. The posterior elements of the L1 vertebra were not visualized. There was pars interarticularis defect at the D12-L1 level and displacement of facet joints at D12-L1-L2 level [Figure 2].
Figure 2: Computed tomography scan with three-dimensional reconstruction (a-c) shows left side posterolateral migration of the L1 vertebra (white arrow) with the destruction of adjacent vertebrae (d-g). Posterior elements of L1 are not visualized (d-e)

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Magnetic resonance imaging showed multifocal spinal lesions with extensive skeletal involvement. Altered intensity signals from D8 to L2, L5, sacral vertebrae, iliac bones, and bilateral sacroiliac joints were observed. There were intraosseous abscesses at several levels, right-sided anterior epidural collection at L5, bilateral psoas collections, cord compression and canal stenosis at D12-L1 and L5 levels. Contrast enhancement of soft tissue and intraosseous abscess was seen [Figure 3].
Figure 3: Contrast magnetic resonance imaging T1-weighted images (sagittal a-c, coronal d-f, and axial g-j) show multiple focal spinal tuberculosis, vertebral body destruction, intraosseous abscesses, bilateral psoas abscesses, and migrated L1 vertebral body in the posterolateral gutter

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A clinicoradiologic diagnosis of the multifocal TB of the spine with paraparesis and migration of 1st lumbar vertebral body was made. The patient was advised CT-guided spinal biopsy and followed by surgical stabilization of the spine along with the removal of the migrated vertebral body. The patient refused any surgical intervention. She was put on four drug antituberculous treatment (ATT) and complete nonambulation. She was discharged on request after 1 month of hospitalization. With ATT, she started responding with diminishing neurological signs and improved general condition at her first follow-up at 3 months, but she did not turn up for subsequent follow-ups.


  Discussion Top


The morphologic and pathophysiologic changes encountered in spinal TB are the most severe and most varied among infective spondylitis.[3],[4],[5],[6] The diagnosis of TB of the spine is primarily a clinicoradiological one and confirmed by biopsy. Back pain, paraspinal muscle spam and a persistent or growing deformity in the spinal region, in an area known to be tubercular-endemic, is to be considered spinal TB unless investigations rule out the diagnosis. Early diagnosis and prompt treatment are essential to prevent permanent neurological deficit and/or spinal deformity.[3],[5],[6]

Paradiscal lesions are the most common pattern of spinal TB.[3],[4],[7] TB of the posterior element is considered rare. Kumar suggested that nearly 5% of spinal TB could be located in the posterior element.[7] Simultaneous involvement of the anterior and posterior elements leads to spinal instability. Kyphosis and spinal deformity are uncommon in posterior spinal disease as spinal stability is not grossly affected. High degree of spinal instability and serious neurological deficit occurs when there is a complex and bilateral involvement of the joints and of the middle column.[8],[9]

In the present case, the clinical signs were classical of spinal TB. Radiologically, the intact L1 vertebral body has migrated posterolaterally. On imaging, there was evidence of collapse in the displaced L1 body. Gandhi et al. reported a case of spinal TB with lateral migration of the L4 vertebral body. The posterior elements of the L4 vertebra were identified in their normal location, but there was destruction of bilateral pedicles. There is no comment on the condition of the body or its endplates.[10] Sridhar and Krishnan have described the migration of the L2 vertebral body posteriorly into the spinal canal. The vertebral body in this case was described as intact including the cortical margins but with absent bilateral pedicles.[8]

Complete migration of a vertebral body is possible only if it is detached from the pedicles/posterior elements before the disease process destroys the body itself. In our patient, nonvisualization of both pedicles of L1 on radiological imaging and evidence of destruction of bilateral pars interarticularis and facet joints with bone debris lying adjacent to the remnants of posterior elements indicates that the disease process in the posterior elements was far more destructive and progressed more rapidly than the body. The spread of infection anteriorly leading to laxity of the adjacent annular attachments of discs allowed the vertebral body to migrate. With progression and development of kyphosis, the force vector pushed the body posterolaterally as the anterior disc attachments would be relatively intact till then. The presence of abscess and debris around the segregated vertebral body provided a medium for the vertebra to “swim” out of the spinal column.


  Conclusion Top


Complete migration of an intact vertebral body out of the spinal column in tuberculous spine is a rare phenomenon only twice described earlier in the literature. It is probably the result of early and extensive involvement of posterior elements, bilateral pedicles, and facets along with the posterior ligaments. In this light, it becomes paramount that the progression of the disease is followed carefully with sequential imaging allowing early recognition and timely prevention of this rare process. This is only possible if the clinician recognizes the possibility and the patient seeks early treatment.

Ethical clearance and/or patient consent statement

Written patient consent was obtained for the participation and publication of the study.

The institutional review board/ethical committee

It is a case report and does not require the Institutional Review Board/Ethical Committee clearance as no new/unwarranted procedure was done.

The authors certify that all procedures performed in the study were conducted in accordance with the ethical standards given in the 1964 Declaration of Helsinki, as revised in 2013.

Patient consent was obtained for purpose of the study with due care to maintain her privacy.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that their name and initials will not be published, and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Tuli SM. Severe kyphotic deformity in tuberculosis of the spine. Int Orthop 1995;19:327-31.  Back to cited text no. 1
    
2.
Shanley DJ. Tuberculosis of the spine: Imaging features. AJR Am J Roentgenol 1995;164:659-64.  Back to cited text no. 2
    
3.
Singh R, Magu NK, Rohilla RK. Clinicoradiologic profile of involvement and healing in tuberculosis of the spine. Ann Med Health Sci Res 2016;6:311-27.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Jain AK, Sreenivasan R, Saini NS, Kumar S, Jain S, Dhammi IK. Magnetic resonance evaluation of tubercular lesion in spine. Int Orthop 2012;36:261-9.  Back to cited text no. 4
    
5.
Hoffman EB, Crosier JH, Cremin BJ. Imaging in children with spinal tuberculosis. A comparison of radiography, computed tomography and magnetic resonance imaging. J Bone Joint Surg Br 1993;75:233-9.  Back to cited text no. 5
    
6.
Agarwal S, Jain UK. Management of spinal tuberculosis-current concepts. J Indian Med Assoc 2004;102:164-7, 169.  Back to cited text no. 6
    
7.
Kumar K. A clinical study and classification of posterior spinal tuberculosis. Int Orthop 1985;9:147-52.  Back to cited text no. 7
    
8.
Sridhar K, Krishnan P. Complete posterior migration of intact vertebral body in spinal tuberculosis. Neurol India 2009;57:483-5.  Back to cited text no. 8
[PUBMED]  [Full text]  
9.
Singh R, Magu NK. Evaluation of the behavior of spinal deformities in tuberculosis of the spine in adults. Asian Spine J 2015;9:741-7.  Back to cited text no. 9
    
10.
Gandhi D, Sharma R, Kotwal PP, Hatimota P. Migrating lumbar vertebra. Lancet 2000;356:1485.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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