'Need of the Hour': Early Diagnosis and Management of Multidrug Resistant Tuberculosis of the Spine: An Analysis of 30 Patients from a “High Multidrug Resistant Tuberculosis Burden” Country

다국어 초록 (Multilingual Abstract)

Study Design: Retrospective study.
Purpose: To report the prevalence of patients with multidrug-resistant (MDR) tubercular spondylodiscitis and their outcomes. Additionally, to assess the role of Xpert MTB/RIF assay in early detection of MDR tuberculosis.
Overview of Literature: MDR tuberculosis is increasing globally. The World Health Organization (WHO) has strongly recommended Xpert MTB/RIF assay for early detection of tuberculosis.
Methods: From 2006 to 2015, a retrospective study was conducted on patients treated for MDR tuberculosis of the spine. Only patients whose diagnosis was confirmed using either culture and/or the Xpert MTB/RIF assay were included. Diagnostic method, treatment regimen, time taken to initiate second-line antituberculosis treatment (ATT), drug-related complications, and cost of medications were analyzed. All patients with MDR were treated according to the WHO recommendations for 2 years. The outcome parameters analyzed included clinical, biochemical, and radiological criteria to assess healing status.
Results: From 2006 to 2015, a total of 730 patients were treated for tubercular spondylodiscitis. Of those, 36 had MDR tubercular spondylitis (prevalence, 4.9%), and three had extremely drug resistant tubercular spondylitis (prevalence, 0.4%). In this study, 30 patients, with a mean age of 29 years and a mean post-treatment follow-up of 24 months, were enrolled. The majority (77%) had secondary MDR, 17 (56%) underwent surgery, and 26 (87%) completed treatment for 2 years and were healed. Drug-related complications (33%) included ototoxicity, hypothyroidism, and hyperpigmentation of the skin. The average time taken for initiation of second line ATT for MDR patients with Xpert MTB/RIF assay as the diagnostic tool was 18 days, when compared to patients for whom the assay was not available which was 243 days.
Conclusions: The prevalence of MDR tubercular spondylodiscitis was 4.9%. In total, 87% of patients were healed with adequate treatment. The sensitivity and specificity of the Xpert MTB/RIF assay to detect MDR was 100% and 92.3%, respectively.

참고문헌 (Reference)

1 World Health Organization, "XpertMTB/RIF assay for the diagnosis of pulmonary and extrapulmonary TB in adults and children: policy update" World Health Organization 2013

2 Denkinger CM, "Xpert MTB/RIF assay for the diagnosis of extrapulmonary tuberculosis : a systematic review and meta-analysis" 44 : 435-446, 2014

3 World Health Organization, "Use of high burden country lists for TB by WHO in the post-2015 era" World Health Organization

4 Jain AK, "Tuberculosis spine : therapeutically refractory disease" 46 : 171-178, 2012

5 Jain AK, "Treatment of tuberculosis of the spine with neurologic complications" 398 : 75-84, 2002

6 Sundararaj GD, "Treatment of haematogenous pyogenic vertebral osteomyelitis by single-stage anterior debridement, grafting of the defect and posterior instrumentation" 89 : 1201-1205, 2007

7 Konstam PG, "The ambulant treatment of spinal tuberculosis" 50 : 26-38, 1962

8 Barani Rathinavelu, "The Extended Posterior Circumferential Decompression Technique in the Management of Tubercular Spondylitis with and without Paraplegia" 대한척추외과학회 8 (8): 711-719, 2014

9 Torun T, "Side effects associated with the treatment of multidrug-resistant tuberculosis" 9 : 1373-1377, 2005

10 Balaji V, "Risk factors for MDR and XDR-TB in a tertiary referral hospital in India" 5 : e9527-, 2010

11 MacNab I, "Negative disc exploration : an analysis of the causes of nerve-root involvement in sixty-eight patients" 53 : 891-903, 1971

12 Pawar UM, "Multidrug-resistant tuberculosis of the spine : is it the beginning of the end? : a study of twenty-five culture proven multidrug-resistant tuberculosis spine patients" 34 : E806-E810, 2009

13 Maynard FM Jr, "International standards for neurological and functional classification of spinal cord injury. American Spinal Injury Association" 35 : 266-274, 1997

14 World Health Organization, "Guidelines for the programmatic management of drug-resistant tuberculosis:emergency update 2008"

15 World Health Organization, "Guidelines for the programmatic management of drug-resistant tuberculosis:2011 update"

16 World Health Organization, "Global tuberculosis report 2018" World Health Organization

17 World Health Organization, "Global tuberculosis report 2015" World Health Organization

18 Held M, "GeneXpert polymerase chain reaction for spinal tuberculosis:an accurate and rapid diagnostic test" 96-B : 1366-1369, 2014

19 Boehme CC, "Feasibility, diagnostic accuracy, and effectiveness of decentralised use of the Xpert MTB/RIF test for diagnosis of tuberculosis and multidrug resistance : a multicentre implementation study" 377 : 1495-1505, 2011

20 World Health Organization, "Companion handbook to the WHO guidelines for the programmatic management of drug-resistant tuberculosis"

21 Carlsson AM, "Assessment of chronic pain: I. aspects of the reliability and validity of the visual analogue scale" 16 : 87-101, 1983