Posterior listhesis of a lumbar vertebra in spinal tuberculosis

[摘要] A 12-year-old Bangladeshi girl with a recent history of pulmonary tuberculosis presented with a 5-day history of immobility, loss of sensation below the mid-thigh bilaterally and bowel and bladder incontinence. She was on anti-tuberculous therapy at admission—rifampicin and isoniazid—for pulmonary tuberculosis diagnosed 4 months previously. Severe lower back and anterior thigh pain had developed 1 month before admission, diagnosed at another centre as tuberculosis of the L2 vertebra; bed rest and continuation of anti-tuberculous therapy was advised at that time. There was no history of traumatic injury. Past medical history revealed a Dandy-Walker cyst, untreated due to lack of parental consent. There was no history of abnormal mental state, but performance in school was subnormal. Examination revealed macrocephaly in keeping with hydrocephalus, but normal higher functions and cranial nerves. Bilateral upper-extremity muscle tone, power, and reflexes were normal. Both lower limbs were wasted without fasciculation but demonstrated hypotonia, grade 0/5 muscle power and areflexia. Abdominal reflexes were present and plantars were down-going bilaterally, but anal reflex was absent. Sensation below the level of L3 was absent on the right and vastly reduced on the left. At the level of L2, gibbus was present with severe tenderness, as well as scoliosis with convexity to the right. Owing to the patient’s ambulatory status, gait was unable to be assessed. Routine hematological and biochemical investigations, including erythrocyte sedimentation rate (ESR), were normal. Plain radiographs of the dorso-lumbar spine (anteroposterior and lateral) revealed Meyerding’s Grade IV posterior listhesis (total intervertebral foramina occlusion) of L2 over L3, with evidence of erosion of the L2 body and pedicle (Fig. 1). MRI of the same region demonstrated cauda equina compression, hypointensity of the L2 vertebra, minor hypointense signal changes of the L1 and L3 vertebrae (Fig. 2) and bilateral psoas abscesses (Fig. 3). Cerebral MRI revealed the Dandy–Walker malformation and hydrocephalus, without peri-ventricular leukomalacia. Both serology and pus drained from the psoas abscesses failed to grow microorganisms, and no acid-fast bacilli were demonstrated on Ziehl–Neelsen staining.

[学科分类] 骨科学

[关键词] Posterior listhesis;Spinal tuberculosis;Lumbar spine;Vertebrae;Pott’s disease