orthopedic paper II
Transpedicular tuberculosis complicated with paraplegia
A Case Report
Abstract: Spinal appendage tuberculosis accounts for only 1% of spinal tuberculosis. It is prone to paraplegia in the thoracic section and is easily misdiagnosed. We encountered a case misdiagnosed as spinal cord tumor preoperatively but confirmed as vertebral arch tuberculosis after surgery. After a three-year follow-up, the patient has now fully recovered. Reports on this type of case are rare in China, and we now present our findings.
Case Description
Vertebral appendage tuberculosis accounts for only 1% of spinal tuberculosis and is prone to cause paraplegia in the thoracic segment, easily leading to misdiagnosis [1]. Our hospital encountered one such case, initially misdiagnosed as spinal tumor preoperatively. The postoperative pathology confirmed it to be vertebral arch tuberculosis. After a three-year follow-up, the patient has now recovered completely. Such case reports are rare domestically, and we present it as follows:
The patient, Wu XX, is a 36-year-old married male farmer from Nanling. Medical Record Number: 1928.
He had lumbar back pain for three years, unstable walking for one year, paraplegia for three months, and difficulty with bowel and bladder functions. Admitted to the hospital on April 27, 1976. Examination: Both lower limbs exhibited spastic paraplegia, muscle atrophy, 0-grade muscle strength, and numbness at the T10 level. Knee reflexes were hyperactive, and ankle clonus was present. The paraplegia index was 5 (sensory 2, motor 2, sphincter 1). There was no postural deformity of the thoracic vertebrae, but T4-T10 were tender upon percussion. Queckenstedt's test indicated partial obstruction. The cerebrospinal fluid was yellow, and the protein level was elevated (Pandy's test+). Spinal angiography on May 3rd showed an irregular filling defect on the right side of T11, and a small amount of contrast medium ascended through the narrow passage. Thoracolumbar spine X-ray did not show any specific positive signs. Clinical impression: Extramedullary spinal tumor around T10. Under endotracheal ether anesthesia, exploratory surgery of the spinal cord was performed on May 5, 1976. The posterior midline approach was used, and the lamina of T7-T12 were completely removed without affecting the facet joints. During the operation, Queckenstedt's test still indicated obstruction. Therefore, the dura mater was incised to explore the spinal cord, but no lesion was found. However, granulation tissue was found compressing the spinal cord near the facet joint of the T7 lamina on the right side, which was then scraped off. A thin catheter was used to explore the subarachnoid space, confirming it to be unobstructed. The spinal cord resumed pulsation at this time. During the operation, some adhesions of the arachnoid membrane were seen, but no definitive bone destruction of the vertebral arch was observed. The pathological report confirmed "tuberculosis". Pathology number: 2476 (PLA 127 Hospital). Forty-eight hours postoperatively, the lower limbs had voluntary movement, muscle strength was at level 3, ankle clonus disappeared, sensory function partially recovered, and subsequently gradually improved. The incision healed on time, and the patient could urinate and defecate on his own 20 days postoperatively. He was discharged on May 28 for recuperation and continued anti-tuberculosis treatment, staying in the hospital for 31 days.
Follow-up: Four months postoperatively, the patient started walking with a crutch, abandoned it five months later, and began working a year later. He can now work at 90% efficiency and can walk 20-30 miles. His general condition is normal. Examination: There is partial stiffness of the surgical segment of the spine, so bending and lifting are slightly affected. Re-examination of the X-ray on August 14, 1979, showed no bone destruction or other mutations. Residual contrast medium and absence of lower thoracic spinous processes and lamina were observed.
Discussion:
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For cases with spastic paraplegia, clinicians naturally consider space-occupying compression of the spinal cord. However, the diagnosis is often difficult for rare conditions like vertebral arch tuberculosis.
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Compared to the vertebral body, the vertebral arch has a richer blood supply and is surrounded by more muscles. If paralysis occurs, surgery is essential. This case report demonstrated good prognosis after the operation.
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If surgical exploration and total laminectomy do not damage the articular processes, there is no need to worry about spinal stability.
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Iodine contrast imaging is often misleading due to various factors such as membrane adhesions and vascular abnormalities. This case also shows that the iodine contrast agent can remain in the body for years after the operation without causing nerve pain.
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This disease is sometimes difficult to differentiate from intraspinal tuberculosis. Both can cause obstruction in the subarachnoid space leading to paraplegia. However, the latter usually has more severe symptoms, often accompanied by other foci of tuberculosis (e.g., pulmonary tuberculosis, pleuritis), and the prognosis is generally more serious.
Conclusion
This paper reports a clinical case of thoracic vertebral arch tuberculosis complicated by paraplegia, along with diagnosis, treatment, and prognosis. In light of the existing literature, we conclude the following:
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Vertebral arch tuberculosis has a low incidence rate but a high rate of misdiagnosis.
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When located in the thoracic section, the rate of complicating paraplegia is high.
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Surgical treatment yields good results.
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Issues related to myelography and the stability of the spine after extensive laminectomy are discussed.
References
[1] Tianjin Orthopedic Hospital, Clinical Orthopedics Tuberculosis Edition, P253, People's Health Publishing House, 1974
[2] Wang Guisheng et al, Surgical Treatment of Spinal Tuberculosis Complicated by Paraplegia, Chinese Journal of Surgery, 10:365, 1962
[3] Zeng Guangyi et al, Spinal Tumors, Chinese Journal of Surgery, 10: (6)374, 1962
[4] Yang Weiming et al, Intraspinal Tuberculosis, Chinese Journal of Surgery, 14: (3)165, 1966
南陵县医院外科 李名杰原载省骨科年会交流后《芜湖医药》1980；7:47
This article was originally presented at the Provincial Orthopedic Annual Meeting, later published in "Wuhu Medicine," 1980; 7:47 Nanling Hospital, Department of Surgery, Li Mingjie
from 椎弓结核并发截瘫手术一例报告
