Percutaneous biopsy remains an important tool to diagnose and manage spinal TB. The yield of transpedicular biopsies in this study was comparable with international figures. Specimen decontamination prior to culture had a direct negative influence on biopsy culture yield, as did prior TB treatment.

Background: Spinal pathology in the Western Cape is managed at three tertiary level hospitals, including Tygerberg Hospital. The Tygerberg Hospital Orthopaedic Spinal Unit is responsible for the management of spinal pathology for the 3.4 million people in the hospital's catchment area. However, the unit's overall burden of disease and associated resource use is currently unclear. Aim: The first aim was to investigate the overall burden and clinical profile of spinal pathology presenting to the Tygerberg Hospital Spinal Unit over a one-year period. The second aim was to determine resource use associated with spine pathology admissions. Methods: Overall burden was investigated by performing a retrospective review of all patients admitted to the Spine Unit between 1 October 2016 and 30 September 2017. Demographic and clinical data was collected, and patients were assigned to one of five spinal pathology subgroups. Resource use was determined by length of hospital stay, waiting times, advanced imaging and theatre usage. Results: Overall burden comprised 349 individual patients and 376 admissions, including readmissions. Trauma (51%) and infection (24%) accounted for the majority of admitted pathology with degenerative (10%), deformity (7%) and malignancy (7%) representing fewer admissions. Motor vehicle accidents were the primary mechanism of injury, accounting for 48% of spine trauma. Tuberculosis was the causative organism in 87% of spinal infections with 44% HIV co-infection. Hospital resource use was considerable with 92% of spine patients requiring advanced imaging, a median operating time of 3 h 36 min and a median hospital stay of 19 days. Infection and malignancy subgroups had the longest waiting times for advanced imaging and theatre with a median wait of 14-16 days, accounting for approximately 62% of the typical total hospital stay. Conclusions: The Spine Unit experienced a substantial patient burden requiring significant hospital resources. Reduced in-patient waiting times and upskilling of orthopaedic services at secondary hospitals represent key areas for health system strengthening. However, multi-sectoral strategies would be required to effectively address our high burden of largely preventable spinal pathology.

The aim of this retrospective review was to assess the overall burden and trend in spinal tuberculosis (TB) at tertiary hospitals in the Western Cape Province of South Africa. All spinal TB cases seen at the province's three tertiary hospitals between 2012 and 2015 were identified and clinical records of each case assessed. Cases were subsequently classified as bacteriologically confirmed or clinically diagnosed and reported with accompanying clinical and demographic information. Odds ratios (OR) for severe spinal disease and corrective surgery in child vs. adult cases were calculated. A total of 393 cases were identified (319 adults, 74 children), of which 283 (72%) were bacteriologically confirmed. Adult cases decreased year-on-year (P = 0.04), however there was no clear trend in child cases. Kyphosis was present in 60/74 (81%) children and 243/315 (77%) adults with available imaging. Corrective spinal surgery was performed in 35/74 (47%) children and 80/319 (25%) adults (OR 2.7, 95% confidence interval 1.6–4.5, P = 0.0003). These findings suggest that Western Cape tertiary hospitals have experienced a substantial burden of spinal TB cases in recent years with a high proportion of severe presentation, particularly among children. Spinal TB remains a public health concern with increased vigilance required for earlier diagnosis, especially of child cases.

BackgroundSpinal tuberculosis (TB) may have a variable, non-specific presentation including back pain with- or without- constitutional symptoms. Further tools are needed to aid early diagnosis of this potentially severe form of TB and immunological biomarkers may show potential in this regard. The aim of this study was to investigate the utility of host serum biomarkers to distinguish spinal TB from mechanical back pain.MethodsPatients with suspected spinal TB or suspected mechanical back pain were recruited from a tertiary hospital in the Western Cape, South Africa, and provided a blood sample for biomarker analysis. Diagnosis was subsequently confirmed using bacteriological testing, advanced imaging and/or clinical evaluation, as appropriate. The concentrations of 19 host biomarkers were evaluated in serum samples using the Luminex platform. Receiver Operating Characteristic (ROC) curves and General Discriminant Analysis were used to identify biomarkers with the potential to distinguish spinal TB from mechanical back pain.ResultsTwenty-six patients with spinal TB and 17 with mechanical back pain were recruited. Seven out of 19 biomarkers were significantly different between groups, of which Fibrinogen, CRP, IFN-γ and NCAM were the individual markers with the highest discrimination utility (Area Under Curve ROC plot 0.88-0.99). A five-marker biosignature (CRP, NCAM, Ferritin, CXCL8 and GDF-15) correctly classified all study participants after leave-one-out cross-validation.ConclusionThis study identified host serum biomarkers with the potential to diagnose spinal TB, including a five-marker biosignature. These preliminary findings require validation in larger studies.

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Background. Patients diagnosed with spinal tuberculosis (TB) at a major tertiary hospital in Western Cape Province, South Africa, are required to attend regular follow-up at the hospital's outpatient spine clinic and to remain on TB treatment for at least 9 months. This followup and lengthy treatment is intended to allow for specialist monitoring of TB treatment response and early identification of secondary complications, and to reduce the risk of recurrence. However, little is known about adherence to these recommendations. Objectives. The main objectives were to describe (i) loss to spine clinic follow-up (LTFU), and (ii) TB treatment duration among patients diagnosed with spinal TB at the hospital. Secondary objectives were to investigate (i) the association between LTFU and treatment duration, and (ii) factors associated with LTFU. Methods. This retrospective cohort study included 173 adults diagnosed with spinal TB between 2012 and 2015 and investigated follow-up within 2 years from diagnosis. Clinical, demographic and appointment data were obtained from hospital records and a dataset provided by the provincial Department of Health. LTFU was presented as frequency (%) and as a survival analysis. TB treatment duration was reported as frequency <9 months or ≥9 months, and the association between LTFU and <9 months of treatment was investigated using relative risk (RR) with 95% confidence intervals (CIs). Univariate associations between explanatory variables and LTFU were investigated using simple logistic regression analysis. Results. Patients had a median (interquartile range) age of 36 (29-48) years and included 98 females (57%) and 151 individuals (87%) residing <50 km from the hospital. Primary outcomes were that 129 patients (75%) were LTFU within 2 years of diagnosis and 45 (30%) completed <9 months of treatment. The RR of <9 months of treatment was 1.62 (95% CI 1.39-1.88) among those LTFU compared with those retained in follow-up. LTFU was not associated with any of the clinical or demographic variables investigated. Conclusions. Three-quarters of the patients did not complete follow-up at the tertiary hospital spine clinic, and almost one in three received <9 months of TB treatment. Remaining in spine clinic follow-up was significantly associated with receiving at least the minimum duration of TB treatment. However, LTFU could not be predicted from routine clinical and demographic information and is likely to be related to factors not accounted for in the current analysis.

The urgency of closed reduction of acute low-velocity cervical facet dislocations has recently been highlighted by the Constitutional Court of South Africa (SA), following a permanent spinal cord injury that a young rugby player sustained during a club-level match. The court found that if emergency care of the complainant had resulted in rapid closed reduction of his cervical spine injury, he might not have suffered permanent neurological damage. [1] The findings of the court were based on research by Newton et al., [2] who specifically looked at the timing of reduction of low-velocity cervical facet dislocation sustained by rugby players. In their cohort, reduction of facet dislocation within 4 hours after injury was associated with improved neurological outcomes. By performing an early closed reduction of the cervical spine, pressure is relieved from the spinal cord, preventing secondary ischaemic trauma and thus improving the possibility of neurological recovery. [3-5] It is important to note that this cohort of patients sustained low-velocity injuries. These may include sports-related injuries, falls from a standing height and blunt object assault. The severity of spinal cord trauma, or the viscous response of spinal cord tissue, is a product of the severity of compression, duration of compression and rate at which compression is applied, [6] which can also be referred to as the velocity of trauma. When compression is applied at a lower velocity, the spinal cord is more likely to show recovery and can withstand higher loads of compression than when subjected to the same compressive load applied at a higher velocity. Animal studies demonstrated this threshold to be 3 m/s, which equates to a fall from a standing height. [7] The current dispensation in SA demands that injuries of this nature be treated in specialised orthopaedic or neurosurgical units, or by qualified surgeons, with limited, if any, attempts at a closed reduction prior to arrival at a dedicated unit or service. The question of feasibility of mandatory closed reduction of cervical facet dislocations within 4 hours is therefore raised. This study reviews the time delays, delaying factors and success rate of closed reductions of cervical facet dislocations in an orthopaedic department at a tertiary-level training hospital over a period of 8 years. Methods A retrospective review of case notes and imaging screens of patients >18 years of age with cervical facet-joint dislocations presenting to a tertiary-level academic hospital in Western Cape Province of SA was performed. The university-affiliated hospital has a capacity of 1 899 beds and provides advanced trauma and This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.

Culture remains the gold standard to diagnose spinal tuberculosis (STB) despite the paucibacillary nature of the disease. Current methods can take up to 42 days to yield a result, delaying the ability to rapidly detect drug resistance. Studies have demonstrated the use of supplementation with culture filtrate (CF) from an axenic culture of Mycobacterium tuberculosis (Mtb) as a source of growth factors to improve culture rates. Our objective was to test a modified culture assay, utilizing CF supplemented media (CFSM), to improve culture positivity rates for suspected STB. Twelve patients with suspected STB were assessed by conventional culture (BACTEC™ MGIT 960), GeneXpert™ and standard histopathological examination. Spinal biopsies were taken from areas of diseased vertebral tissue or abscess, predetermined from MRI. Additional biopsies were obtained to assess CFSM for improved detection and faster culture of Mtb. All cases were diagnosed as STB and treated empirically for tuberculosis based on either bacteriological evidence (GeneXpert™, MGIT and/or CFSM positive), or based on clinical presentation. 5 specimens (45.45%) were positive for Mtb DNA as detected by GeneXpert™ and 1 specimen (8.33%) was cultured using MGIT (time to detection; 18 days). CFSM was able to culture 7 specimens (58.3%), with all CFSM positive specimens yielding a culture within 14 days. Two samples were positive only using the CFSM assay pointing to additional yield for diagnostic workup. Modification of standard culture can improve detection of Mtb and reduce time to positivity in individuals with STB where culture material is a requirement.