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
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 (
). 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 (
). The results of laboratory tests were normal, including the white
blood-cell count (6.390 × 10
/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 (
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
/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 ×
/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
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
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
. 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.
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.
and Upadhyay et al.
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
The mortality rate associated with tuberculous meningitis in adults
remains high, in the vicinity of 27% (7% to 45% )
. 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
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
Note: The authors thank Dr. Miguel Ferrer Torrelles for his valuable