0
Case Reports   |    
Tuberculous Meningitis Following Correction of Kyphosis by Spinal Osteotomy A Case Report
Luis Alvarez, MD; Emilio Calvo, MD
View Disclosures and Other Information
Investigation performed at Fundaci�n Jim�nez D�az, Madrid, Spain

Luis Alvarez, MD
Emilio Calvo, MD
Department of Orthopedics, Fundaci�n Jim�nez D�az, Avda. Reyes Cat�licos, 2, 28040 Madrid, Spain. E-mail for L. Alvarez: lalvarez@fjd.es.
Please address reprint requests to Dr. Alvarez.

No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

JBJS Case Connector, 2002 Jun 01;84(6):1022-1024
5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case
Tuberculous spondylitis (Pott disease) involves at least two adjacent vertebrae with destruction of the intervening intervertebral disc. In one report, tuberculous meningitis occurred in conjunction with four (6%) of seventy cases of Pott disease 1 . We present an unusual case of tuberculous meningitis that occurred after a spinal osteotomy with anterior and posterior lumbar arthrodesis in a patient with a residual kyphosis related to Pott disease, which had been treated twenty-five years previously.
 
Anchor for JumpAnchor for Jump
+Fig. 1:Preoperative lateral radiograph showing complete destruction of the second through the fifth lumbar vertebrae and a residual lumbar kyphosis of 15°.
 
Anchor for JumpAnchor for Jump
+Fig. 2:Preoperative magnetic resonance imaging scans showing massive destruction of the vertebral bodies of the second through the fifth lumbar vertebrae, with a patent spinal canal.
 
Anchor for JumpAnchor for Jump
+Fig. 3:Immediate postoperative lateral radiograph showing correction of the deformity to 27° of lordosis and the anterior placement of the cylinder containing allograft.
A forty-six-year-old woman was seen because of a lumbar kyphosis. She was unable to stand or walk because of the deformity. The patient reported a history of tuberculosis of the lumbar spine, which had been treated twenty-five years previously with a posterior spinal arthrodesis from the first lumbar vertebra to the first sacral vertebra and administration of antituberculous medication; no radiographs or medical records from that time were available. After eighteen months of treatment with medication, the patient was asymptomatic and the disease was considered to have been halted. Since then, however, the patient had walked with the hips and knees flexed, until she was confined to a wheelchair five years before she presented to our institution. She had had no back pain or any evidence of neurologic involvement at the time of presentation. The patient elected to undergo surgical treatment to correct the sagittal plane deformity.
Physical examination revealed that the patient was neurologically intact. Radiographs of the spine revealed complete destruction of the second through the fifth lumbar vertebrae, with the first lumbar vertebra lying adjacent to the first sacral vertebra and with 15° of lumbar kyphosis ( Fig. 1 ). Comparison of these radiographs with a radiograph that had been made six years previously revealed that the lesion had remained stable, with no evidence of progression of either the osseous destruction or the lumbar kyphosis. Magnetic resonance imaging showed a fibrous mass occupying the space between the first lumbar vertebra and the first sacral vertebra, with no evidence of osseous union between the vertebrae, and stenosis of the lumbar canal ( Fig. 2 ). The results of laboratory tests were normal, including the white blood-cell count (6.390 × 10 9 /L), the erythrocyte sedimentation rate (0 to 15 mm/hr), and the C-reactive protein level (<1 mg/L).
Most of the inflammatory and scar tissue anterior to the spinal canal was surgically removed through a left-sided retroperitoneal approach. The dura mater was noted to be intact, and no leakage of cerebrospinal fluid was observed during the procedure. Osteotomies between the fourth and fifth lumbar vertebrae and between the fifth lumbar and first sacral vertebrae were performed through a posterior approach; the instrumentation used to close the osteotomy sites consisted of four hooks, two sacral screws, and two intrailiac screws. A titanium cylinder containing allograft was placed under moderate distraction through an anterior approach ( Fig. 3 ).
Ziehl-Neelsen and auramine-rhodamine staining did not reveal tubercle bacilli in the inflammatory tissue that had been removed at the time of surgery. After eight weeks, tissue cultures for acid-fast bacilli demonstrated no growth.
The patient was neurologically intact after the operation. Five days after surgery, with the aid of a brace, she began to stand with the hips and knees extended. She had no fever, and the white blood-cell count was 7.570 × 10 9 /L with 88.9% polymorphonuclear cells.
Ten days after the operation, however, the patient became confused and had photophobia, severe headache, fever (39°C), rigors, and marked meningism with a positive Kernig's sign. Analysis of cerebrospinal fluid revealed a white blood-cell count of 485 × 10 9 /L with 87% polymorphonuclear cells, a reduced glucose level of 0.48 mmol/L (normal, 2.8 to 4.4 mmol/L), and an elevated total serum protein level of 1.7 g/L (normal, 0.15 to 0.45 g/L). Acid-fast stained bacilli were detected in the cerebrospinal fluid. Treatment was started with rifampin, isoniazid, pyrazinamide, and ethambutol. Intrahepatic cholestasis and severe hepatic dysfunction developed two days later. Rifampin, isoniazid, and pyrazinamide were discontinued, and streptomycin was substituted. A computed tomographic scan of the head showed obstructive hydrocephalus, and an external ventriculostomy was performed. Neurologic deterioration progressed, and the patient died on the twenty-eighth postoperative day.
The prevalence of spinal tuberculosis, which had decreased notably in Western countries, has increased during the last decade because of the relatively high rate of disease that accompanies immunosuppressive disorders and because of the increased number of immigrants from countries in which tuberculosis is endemic 2 .
The dura typically provides an effective barrier to the passage of organisms; however, meningitis may occur if the dura is broached. Nevertheless, some authors have reported no direct spread of the disease after accidental opening of the dural membrane 3 .
Meningitis is a rare and often fatal complication of tuberculosis. Typically, meningitis concomitant with a spine infection develops while the disease is active and hematogenous spread of the bacilli occurs 1 . Treatment of the spinal disease with resection of the lesion and anterior grafting has not been reported to be associated with spread of the disease to the central nervous system. Bailey et al. 4 did not report a single case of meningitis in their study of 100 consecutive patients in whom spinal tuberculosis was treated with anterior arthrodesis. Similarly, Yau et al. 3 and Upadhyay et al. 5 reported no cases of meningitis in association with the treatment of residual kyphosis with radical resection and anterior arthrodesis.
In the case of our patient, even though magnetic resonance imaging showed fibrous tissue with no evidence of osseous union, which could suggest that the disease was still active, tubercle bacilli were not isolated from the inflammatory tissue. There were no signs or symptoms of active disease: laboratory test results were normal, and radiographs showed that there had been no progression of either the osseous destruction or the kyphotic angle during the previous six years. However, because of the intolerance to toxicity of most antituberculous drugs, with subsequent development of severe hepatic dysfunction, it is likely that the disease in our patient had been inadequately treated originally and thus had remained latent within the residual lumbar mass and that it may have been reactivated by the surgical procedure.
The mortality rate associated with tuberculous meningitis in adults remains high, in the vicinity of 27% (7% to 45% ) 6 . A poor prognosis has been related to increased age (with higher mortality among patients older than fifty years), increased duration of the illness, and more advanced clinical stage at the time of therapeutic intervention 7 .
In conclusion, this case illustrates that tuberculous meningitis is a dangerous complication associated with the surgical treatment of spinal tuberculosis, even when the disease is considered to have been halted.
Note: The authors thank Dr. Miguel Ferrer Torrelles for his valuable cooperation.
Smith AD. Tuberculosis of the spine. Results in 70 cases treated at the New York Orthopaedic Hospital from 1945 to 1960. Clin Orthop,1968;58: 171-6. 58171  1968  [PubMed]
 
�lvarez Galovich I, Calvo Crespo E, Aparicio Campillo G,Vallejo Galbete JC. [A long term retrospective study of Pott's disease. A clinical and radiological study of the results obtained in the Fundaci�n Jim�nez D�az since 1958]. Rev Ortop Traumatol,1997;41: 372-80. Spanish. 41372  1997 
 
Yau AC, Hsu LC, O'Brien JP,Hodgson AR. Tuberculous kyphosis: correction with spinal osteotomy, halo-pelvic distraction, and anterior and posterior fusion. J Bone Joint Surg Am,1974;56: 1419-34. 561419  1974  [PubMed]
 
Bailey HL, Gabriel M, Hodgson AR,Shin JS. Tuberculosis of the spine in children. Operative findings and results in one hundred consecutive patients treated by removal of the lesion and anterior grafting. J Bone Joint Surg Am,1972;54: 1633-57. 541633  1972  [PubMed]
 
Upadhyay SS, Saji MJ, Sell P,Yau AC. The effect of age on the change in deformity after radical resection and anterior arthrodesis for tuberculosis of the spine. J Bone Joint Surg Am,1994;76: 701-8. 76701  1994  [PubMed]
 
Garcia-Monco JC. Central nervous system tuberculosis. Neurol Clin,1999;17: 737-59. 17737  1999  [PubMed]
 
Kennedy DH,Fallon RJ. Tuberculous meningitis. JAMA,1979;241: 264-8. 241264  1979  [PubMed]
 

Submit a comment

Anchor for JumpAnchor for Jump
+Fig. 1:Preoperative lateral radiograph showing complete destruction of the second through the fifth lumbar vertebrae and a residual lumbar kyphosis of 15°.
Anchor for JumpAnchor for Jump
+Fig. 2:Preoperative magnetic resonance imaging scans showing massive destruction of the vertebral bodies of the second through the fifth lumbar vertebrae, with a patent spinal canal.
Anchor for JumpAnchor for Jump
+Fig. 3:Immediate postoperative lateral radiograph showing correction of the deformity to 27° of lordosis and the anterior placement of the cylinder containing allograft.

References

Smith AD. Tuberculosis of the spine. Results in 70 cases treated at the New York Orthopaedic Hospital from 1945 to 1960. Clin Orthop,1968;58: 171-6. 58171  1968  [PubMed]
 
�lvarez Galovich I, Calvo Crespo E, Aparicio Campillo G,Vallejo Galbete JC. [A long term retrospective study of Pott's disease. A clinical and radiological study of the results obtained in the Fundaci�n Jim�nez D�az since 1958]. Rev Ortop Traumatol,1997;41: 372-80. Spanish. 41372  1997 
 
Yau AC, Hsu LC, O'Brien JP,Hodgson AR. Tuberculous kyphosis: correction with spinal osteotomy, halo-pelvic distraction, and anterior and posterior fusion. J Bone Joint Surg Am,1974;56: 1419-34. 561419  1974  [PubMed]
 
Bailey HL, Gabriel M, Hodgson AR,Shin JS. Tuberculosis of the spine in children. Operative findings and results in one hundred consecutive patients treated by removal of the lesion and anterior grafting. J Bone Joint Surg Am,1972;54: 1633-57. 541633  1972  [PubMed]
 
Upadhyay SS, Saji MJ, Sell P,Yau AC. The effect of age on the change in deformity after radical resection and anterior arthrodesis for tuberculosis of the spine. J Bone Joint Surg Am,1994;76: 701-8. 76701  1994  [PubMed]
 
Garcia-Monco JC. Central nervous system tuberculosis. Neurol Clin,1999;17: 737-59. 17737  1999  [PubMed]
 
Kennedy DH,Fallon RJ. Tuberculous meningitis. JAMA,1979;241: 264-8. 241264  1979  [PubMed]
 
Accreditation Statement
These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
CME Activities Associated with This Article
Submit a Comment
Please read the other comments before you post yours. Contributors must reveal any conflict of interest.
Comments are moderated and will appear on the site at the discretion of JBJS editorial staff.

* = Required Field
(if multiple authors, separate names by comma)
Example: John Doe





Related Content
The Journal of Bone & Joint Surgery
JBJS Case Connector
Topic Collections
Related Audio and Videos
PubMed Articles
Clinical Trials
Readers of This Also Read...
JBJS Jobs
06/29/2012
PA - Thomas Jefferson University
05/03/2012
CA - UCLA/OH Department of Orthopaedic Surgery
12/31/2013
SC - Department of Orthopaedic Surgery Medical Univerity of South Carlonina