Temporary standalone percutaneous fixation with pedicle screws for the treatment of subacute tuberculous osteomyelitis with kyphotic deformity in the lumbar spine

Abstract

Background: Tuberculous (TB) osteomyelitis is a rare, but challenging infection, that mandates antituberculosis antibiotics, and potentially surgical intervention. Per the Gulhane Askeri Tip Akademisi (GATA) classification system, corrective reconstruction is indicated in severe cases, where the kyphotic deformity is >20° (GATA Class III). Here, we describe a case of BCG vaccine-induced lumbar TB osteomyelitis at the L1-2 level in a patient presenting with mechanical pain and a focal, nonfixed kyphotic deformity of 36.1°. Surgery consisted of percutaneous fixation with pedicle screws without debridement, fusion arthrodesis, or anterior reconstruction.

Case description: A 77-year-old male presented with L1-2 TB osteomyelitis secondary to intravesical BCG application. A 36.1° focal nonfixed kyphotic deformity was evident on standing X-rays that reduced in the supine position. He underwent posterior percutaneous screw fixation with rods extending from the T12 to L3 levels, with resolution of his mechanical pain. Nine months later, the CT demonstrated reconstitution of the vertebral bodies (i.e., volume increase of 6.99 cm³ (21%) and 7.49 cm³ (27%) at L1 and L2, respectively). Standing X-rays after hardware removal demonstrated 32.7° of lumbar lordosis and a reduction of focal kyphosis to 12.9°.

Conclusion: Here, we present an exceedingly rare case of BCG vaccine-induced L1-2 spinal tuberculosis with extensive vertebral body destruction and deformity. This was effectively treated with standalone temporary pedicle fixation instead of corpectomy and reconstruction.

Keywords: BCG vaccine; GATA classification; Percutaneous fixation; Spinal tuberculosis; Tuberculous osteomyelitis.

Figure 1:

Prelaminectomy T2 MRI (a) sagittal lumbar spine, (b) axial L1-2 spine, (c) axial L3-4 spine multilevel degenerative changes are noted resulting in severe canal stenosis particularly at L2–L3 and L3–L4 and slightly less pronounced canal narrowing at L4–L5 and L1–L2. Multilevel foraminal narrowing are noted from L1 to S1.

Figure 2:

Prefixation scans: (a) standing lateral X-ray: lumbar Lordosis 15.7° and L1-2 kyphosis 36.1° (as illustrated by yellow lines), (b) CT scan: L1-2 erosion, L1 vertebral volume is 33.81 cm³, and L2 volume are 27.59 cm³, (c) T2, and (d) T1 sagittal lumbar spine MRI post contrast. There is L1 and L2 edema and destruction with L1-2 disk enhancement.

Figure 3:

Post standalone percutaneous fixation scans (a) lateral X-ray post 8 months, (b) CT scan post 9 months. Reconstitution of L1 vertebral volume is 40.80 cm³ and L2 volume is 35.08 cm³. (c) Lateral X-ray 11-month post fixation showing broken rods at L1-2.

Figure 4:

Two months post hardware removal standing X-rays. Lumbar lordosis is 32.7°, L1-2 Cobb: 12.9° (as illustrated by yellow lines).