{"presentation":{"slides":[{"elements":[{"x":5.446623093681917,"y":6.479481641468682,"width":25.05446623093682,"height":8.639308855291576,"action":{"library":"H5P.AdvancedText 1.1","params":{"text":"

Approach to diagnosis<\/strong><\/span><\/p>\n"},"subContentId":"dfa88f57-6f34-4459-80f2-cf991ab9aa8b","metadata":{"contentType":"Text","license":"U","title":"Untitled Text"}},"alwaysDisplayComments":false,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"specified","invisible":false,"solution":""},{"x":5.443790849673203,"y":19.47781857451404,"width":89.32461873638344,"height":75.5939524838013,"action":{"library":"H5P.AdvancedText 1.1","params":{"text":"

All cases of presumptive spinal TB should undergo:<\/strong><\/span><\/p>\n\n

\n\t
Blood tests: CBC, ESR, CRP, HIV serology<\/li>\n\t
Mantoux<\/li>\n\t
Imaging<\/li>\n<\/ul>\n\n
a) X-ray of affected segment in AP and lateral views
\n b) Chest X-ray for coexisting pulmonary TB
\n c) Cross sectional imaging (CE-MRI> non contrast MRI. If not available, CECT) <\/p>\n\n
\n\t
Microbiological: Microscopy, Culture, CBNAAT<\/li>\n\t
Histopathology<\/li>\n<\/ul>\n"},"subContentId":"f80be21c-ab48-48d7-9036-026e5b5f0607","metadata":{"contentType":"Text","license":"U","title":"Untitled Text"}},"alwaysDisplayComments":false,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"specified","invisible":false,"solution":""}],"slideBackgroundSelector":{}},{"elements":[{"x":5.446623093681917,"y":6.479481641468682,"width":25.05446623093682,"height":8.639308855291576,"action":{"library":"H5P.AdvancedText 1.1","params":{"text":"
Diagnostic Approach<\/strong><\/span><\/p>\n"},"metadata":{"contentType":"Text","license":"U","title":"Untitled Text"},"subContentId":"2e9c6e18-a21c-478b-8f7e-8b589aac99a0"},"alwaysDisplayComments":false,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"specified","invisible":false,"solution":""},{"x":29.411764705882355,"y":23.758099352051836,"width":39.21568627450981,"height":63.49892008639309,"action":{"library":"H5P.Image 1.1","params":{"decorative":false,"contentName":"Image","file":{"path":"images\/file-649f1201f0ac5.png","mime":"image\/png","copyright":{"license":"U"},"width":593,"height":488}},"subContentId":"51a49b4b-a3d4-4646-8037-c1a913f7b9c8","metadata":{"contentType":"Image","license":"U","title":"Untitled Image"}},"alwaysDisplayComments":false,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"specified","invisible":false,"solution":""},{"x":33.769063180827885,"y":17.278617710583152,"width":37.03703703703704,"height":6.479481641468682,"action":{"library":"H5P.AdvancedText 1.1","params":{"text":"
Clinical suspicion including risk factors<\/span><\/p>\n"},"subContentId":"da92e5aa-0fb3-424f-888b-b834ef7b145c","metadata":{"contentType":"Text","license":"U","title":"Untitled Text"}},"alwaysDisplayComments":false,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"specified","invisible":false,"solution":""},{"x":19.607843137254903,"y":84.23326133909288,"width":9.803921568627452,"height":6.479481641468682,"action":{"library":"H5P.AdvancedText 1.1","params":{"text":"
Imaging <\/span><\/p>\n"},"metadata":{"contentType":"Text","license":"U","title":"Untitled Text"},"subContentId":"249ff00e-391a-46b6-a674-67d60075b6e6"},"alwaysDisplayComments":false,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"specified","invisible":false,"solution":""},{"x":70.80610021786492,"y":84.23326133909288,"width":14.161220043572985,"height":6.479481641468682,"action":{"library":"H5P.AdvancedText 1.1","params":{"text":"
Microbiological <\/span><\/p>\n"},"metadata":{"contentType":"Text","license":"U","title":"Untitled Text"},"subContentId":"ecf35152-69f7-4ac2-8300-3c59b2fd7eb0"},"alwaysDisplayComments":false,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"specified","invisible":false,"solution":""}],"slideBackgroundSelector":{}},{"elements":[{"x":5.443790849673203,"y":6.490734341252699,"width":59.912854030501094,"height":12.958963282937365,"action":{"library":"H5P.AdvancedText 1.1","params":{"text":"
Diagnosis should be sought prior to treatment <\/strong><\/span><\/p>\n"},"metadata":{"contentType":"Text","license":"U","title":"Untitled Text"},"subContentId":"294363a4-b74c-4d7e-9e75-5d5379ba86ed"},"alwaysDisplayComments":false,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"specified","invisible":false,"solution":""},{"x":5.446623093681917,"y":15.11879049676026,"width":88.23529411764706,"height":60.47516198704104,"action":{"library":"H5P.AdvancedText 1.1","params":{"text":"
\n\t
\n\t
Tissue diagnosis (from spinal column or cold abscess) should be confirmed in an ideal and resource-rich setting \u2013 however, due to the high burden of spinal TB, in the presence of appropriate clinical setting and suggestive MRI, patient can be diagnosed as spinal TB and treated.<\/p>\n\t<\/li>\n\t
\n\t
Guided biopsy (CT guided or C arm guided) is the preferred procedure to access tissue<\/p>\n\t<\/li>\n\t
\n\t
CT or C-arm guided biopsy-> if inconclusive, may be followed by open biopsy to establish diagnosis<\/p>\n\t<\/li>\n\t
\n\t
With treatment of probable TB cases, diagnosis of metastatic disease\/ pyogenic infection may be delayed awaiting response to ATT.<\/p>\n\t<\/li>\n<\/ul>\n"},"subContentId":"559764fb-d53a-4e0a-b6a6-9d03bc049112","metadata":{"contentType":"Text","license":"U","title":"Untitled Text"}},"alwaysDisplayComments":false,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"specified","invisible":false,"solution":""}],"slideBackgroundSelector":{}},{"elements":[{"x":4.3544662309368185,"y":8.656177105831533,"width":59.912854030501094,"height":12.958963282937365,"action":{"library":"H5P.AdvancedText 1.1","params":{"text":"
A. Diagnostic Algorithm for presumptive Spinal TB<\/strong><\/span><\/p>\n"},"subContentId":"86579639-f0aa-451e-82a8-0eeb961752a1","metadata":{"contentType":"Text","license":"U","title":"Untitled Text"}},"alwaysDisplayComments":false,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"specified","invisible":false,"solution":""},{"x":15.250544662309368,"y":17.278617710583152,"width":68.51851851851852,"height":80.56155507559396,"action":{"library":"H5P.Image 1.1","params":{"decorative":false,"contentName":"Image","file":{"path":"images\/file-64a1342ad72b6.png","mime":"image\/png","copyright":{"license":"U"},"width":1530,"height":913}},"subContentId":"22834687-a687-44ce-9b8f-5952ec5570c8","metadata":{"contentType":"Image","license":"U","title":"Untitled Image"}},"alwaysDisplayComments":false,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"specified","invisible":false,"solution":""}],"slideBackgroundSelector":{}},{"elements":[{"x":9.803921568627452,"y":19.43844492440605,"width":78.43137254901961,"height":78.40172786177106,"action":{"library":"H5P.Image 1.1","params":{"decorative":false,"contentName":"Image","file":{"path":"images\/file-64a1344de99db.png","mime":"image\/png","copyright":{"license":"U"},"width":1644,"height":833}},"subContentId":"d104809d-41af-41d9-acf2-380794b46c57","metadata":{"contentType":"Image","license":"U","title":"Untitled Image"}},"alwaysDisplayComments":false,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"specified","invisible":false,"solution":""},{"x":5.446623093681917,"y":4.319654427645788,"width":90.41394335511983,"height":15.11879049676026,"action":{"library":"H5P.AdvancedText 1.1","params":{"text":"
Clinico-radiological features along with either of positive CBNAAT, culture or histopathology suggestive of TB
\n# If CBNAAT positive and sensitive to Rifampicin, or diagnosis based on ZN stain or histopathology- treat as drug sensitive TB with 2(HRZE) and 10 (HR) which may be extended. If CBNAAT resistant to Rifampicin, treat according to drug resistant TB.<\/span><\/p>\n"},"metadata":{"contentType":"Text","license":"U","title":"Untitled Text"},"subContentId":"6f9292d9-796a-41b3-a26f-46c4b3ae25b2"},"alwaysDisplayComments":false,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"specified","invisible":false,"solution":""}],"slideBackgroundSelector":{}},{"elements":[{"x":4.3544662309368185,"y":8.656177105831533,"width":59.912854030501094,"height":12.958963282937365,"action":{"library":"H5P.AdvancedText 1.1","params":{"text":"
B. Radiological Features of Spinal TB<\/strong><\/span><\/p>\n"},"subContentId":"7b0bdf72-e699-4af0-8532-aafa411e9daf","metadata":{"contentType":"Text","license":"U","title":"Untitled Text"}},"alwaysDisplayComments":false,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"specified","invisible":false,"solution":""},{"x":6.5359477124183005,"y":19.43844492440605,"width":89.32461873638344,"height":66.95464362850971,"action":{"library":"H5P.AdvancedText 1.1","params":{"text":"
\n\t
\n\t
Poor sensitivity (~15-30%)<\/p>\n\t<\/li>\n\t
\n\t
Demonstrates:
\n\ta) Destruction of affected vertebrae
\n\tb) Regional osteopenia
\n\tc) Adjoining intervertebral space reduction (less common than pyogenic spondylitis)- depends on stage of disease<\/p>\n\t<\/li>\n\t
\n\t
Paraspinal shadow (abscess)<\/p>\n\t<\/li>\n\t
\n\t
Quite useful for follow up \u2013 ease of cost, accessibility; especially in early post-operative phase<\/p>\n\t<\/li>\n\t
\n\t
If spinal TB diagnosed by MRI or CT, perform an X-ray to establish baseline for subsequent follow up visits.<\/p>\n\t<\/li>\n<\/ul>\n"},"subContentId":"afffb409-2524-4712-b815-0c0a29de6915","metadata":{"contentType":"Text","license":"U","title":"Untitled Text"}},"alwaysDisplayComments":false,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"specified","invisible":false,"solution":""},{"x":6.5359477124183005,"y":15.11879049676026,"width":7.625272331154684,"height":6.479481641468682,"action":{"library":"H5P.AdvancedText 1.1","params":{"text":"
XRAY<\/span><\/strong><\/span><\/p>\n"},"subContentId":"dfa0d867-d864-46e6-8412-527839bd1e9c","metadata":{"contentType":"Text","license":"U","title":"Untitled Text"}},"alwaysDisplayComments":false,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"specified","invisible":false,"solution":""}],"slideBackgroundSelector":{}},{"elements":[{"x":4.3544662309368185,"y":8.656177105831533,"width":27.233115468409586,"height":12.958963282937365,"action":{"library":"H5P.AdvancedText 1.1","params":{"text":"
Contrast Enhanced CT Scan<\/strong><\/span><\/span><\/p>\n"},"subContentId":"db56259f-98fa-4a1f-a355-ebe5c87c7cb0","metadata":{"contentType":"Text","license":"U","title":"Untitled Text"}},"alwaysDisplayComments":false,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"specified","invisible":false,"solution":""},{"x":4.3544662309368185,"y":12.981468682505398,"width":90.41394335511983,"height":84.23326133909288,"action":{"library":"H5P.AdvancedText 1.1","params":{"text":"
\n\t
\n\t
To be used if MRI is not available<\/p>\n\t<\/li>\n\t
\n\t
Features that can be seen:<\/p>\n\t<\/li>\n<\/ul>\n\n
a) Vertebral body destruction and collapse,
\n b) Disk space narrowing
\n c) Paraspinal soft tissue masses representing abscess formation
\n d) Paraspinal and intraosseous abscesses typically show a thick and irregular enhancing wall
\n on contrast-enhanced CT scans.<\/p>\n\n
\n\t
\n\t
Early stages of infection: bony erosions or osseous destruction may be subtle<\/p>\n\t<\/li>\n\t
\n\t
Chronic stages of infection: extensive osseous destruction, sequestrum formation and marked heterotopic bone formation.<\/p>\n\t<\/li>\n<\/ul>\n"},"subContentId":"7c2bdd9b-59b7-4fc4-80dc-a3fe15dab627","metadata":{"contentType":"Text","license":"U","title":"Untitled Text"}},"alwaysDisplayComments":false,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"specified","invisible":false,"solution":""}],"slideBackgroundSelector":{}},{"elements":[{"x":4.357298474945534,"y":6.479481641468682,"width":27.233115468409586,"height":12.958963282937365,"action":{"library":"H5P.AdvancedText 1.1","params":{"text":"
Contrast Enhanced MRI <\/strong><\/span><\/span><\/p>\n"},"subContentId":"8bf4cded-e6c7-4183-bec7-c60fd0435ed6","metadata":{"contentType":"Text","license":"U","title":"Untitled Text"}},"alwaysDisplayComments":false,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"specified","invisible":false,"solution":""},{"x":4.3544662309368185,"y":12.981468682505398,"width":90.41394335511983,"height":84.23326133909288,"action":{"library":"H5P.AdvancedText 1.1","params":{"text":"
\n\t
\n\t
To be used if MRI is not available<\/p>\n\t<\/li>\n\t
\n\t
Features that can be seen:<\/p>\n\t<\/li>\n<\/ul>\n\n
a) Vertebral body destruction and collapse,
\n b) Disk space narrowing
\n c) Paraspinal soft tissue masses representing abscess formation
\n d) Paraspinal and intraosseous abscesses typically show a thick and irregular enhancing wall
\n on contrast-enhanced CT scans.<\/p>\n\n
\n\t
\n\t
Early stages of infection: bony erosions or osseous destruction may be subtle<\/p>\n\t<\/li>\n\t
\n\t
Chronic stages of infection: extensive osseous destruction, sequestrum formation and marked heterotopic bone formation.<\/p>\n\t<\/li>\n<\/ul>\n"},"subContentId":"357fdc25-b7d6-4c32-857a-90d94f057dcc","metadata":{"contentType":"Text","license":"U","title":"Untitled Text"}},"alwaysDisplayComments":false,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"specified","invisible":false,"solution":""}],"slideBackgroundSelector":{}},{"elements":[{"x":4.3544662309368185,"y":6.485097192224622,"width":19.607843137254903,"height":12.958963282937365,"action":{"library":"H5P.AdvancedText 1.1","params":{"text":"
Cervical TB Imaging<\/strong><\/span><\/span><\/p>\n"},"subContentId":"e144b3f6-50ad-4240-a2ac-e135baf77d43","metadata":{"contentType":"Text","license":"U","title":"Untitled Text"}},"alwaysDisplayComments":false,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"specified","invisible":false,"solution":""},{"x":59.912854030501094,"y":28.077753779697623,"width":37.03703703703704,"height":30.23758099352052,"action":{"library":"H5P.AdvancedText 1.1","params":{"text":"
T2 weighted MR sagittal image - reduced height with altered signal in C2, C3 vertebral body and intervening disc. Collection deep to posterior longitudinal ligament causing narrowing of spinal canal and compressive myelopathy.<\/span><\/p>\n"},"subContentId":"6f349722-8f73-4e7b-af34-b2efa3820c39","metadata":{"contentType":"Text","license":"U","title":"Untitled Text"}},"alwaysDisplayComments":false,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"specified","invisible":false,"solution":""},{"x":59.912854030501094,"y":73.43412526997841,"width":37.03703703703704,"height":17.278617710583152,"action":{"library":"H5P.AdvancedText 1.1","params":{"text":"
Cervical spine lateral radiograph showing reduced height of C2-C3 inter-vertebral disc space and C 3 vertebral body. <\/span><\/p>\n"},"metadata":{"contentType":"Text","license":"U","title":"Untitled Text"},"subContentId":"05f6e026-4153-4950-ae91-3054546104f3"},"alwaysDisplayComments":false,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"specified","invisible":false,"solution":""},{"x":69.71677559912854,"y":90.71274298056156,"width":27.233115468409586,"height":6.479481641468682,"action":{"library":"H5P.AdvancedText 1.1","params":{"text":"
PC: Dr Swati Gupta, Dept of Radiology, MAMC Delhi<\/span><\/span><\/span><\/span><\/span><\/p>\n"},"subContentId":"0f7d8b76-7585-463f-8d6a-840affca4697","metadata":{"contentType":"Text","license":"U","title":"Untitled Text"}},"alwaysDisplayComments":false,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"specified","invisible":false,"solution":""},{"x":3.2679738562091503,"y":17.278617710583152,"width":25.05446623093682,"height":78.61771058315335,"action":{"library":"H5P.Image 1.1","params":{"decorative":false,"contentName":"Image","file":{"path":"images\/file-64a14c9a125e9.png","mime":"image\/png","copyright":{"license":"U"},"width":524,"height":832}},"subContentId":"39602418-5589-439f-b320-9d0ced1b66fb","metadata":{"contentType":"Image","license":"U","title":"Untitled 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Thoracolumbar TB Imaging <\/strong><\/span><\/span><\/p>\n"},"subContentId":"b2a749a3-f3b2-4937-8f57-f5e65da0f67d","metadata":{"contentType":"Text","license":"U","title":"Untitled Text"}},"alwaysDisplayComments":false,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"specified","invisible":false,"solution":""},{"x":58.82352941176471,"y":32.39740820734341,"width":38.12636165577342,"height":19.43844492440605,"action":{"library":"H5P.AdvancedText 1.1","params":{"text":"
T2 fat suppressed coronal section. Image showing paravertebral collections along both sides of mid thoracic spine. <\/span><\/p>\n"},"subContentId":"dec42019-9fcd-4c02-ab3a-4e98ca6cc7b0","metadata":{"contentType":"Text","license":"U","title":"Untitled Text"}},"alwaysDisplayComments":false,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"specified","invisible":false,"solution":""},{"x":58.82352941176471,"y":64.79481641468682,"width":38.12636165577342,"height":17.278617710583152,"action":{"library":"H5P.AdvancedText 1.1","params":{"text":"
T2 weighted sagittal image showing pre and paravertebral collection at 2 non-contiguous levels causing narrowing of spinal canal.<\/p>\n"},"metadata":{"contentType":"Text","license":"U","title":"Untitled Text"},"subContentId":"34c81a81-ec82-4574-8be1-5755dd24d8d9"},"alwaysDisplayComments":false,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"specified","invisible":false,"solution":""},{"x":69.71394335511984,"y":90.89827213822895,"width":27.233115468409586,"height":6.479481641468682,"action":{"library":"H5P.AdvancedText 1.1","params":{"text":"
PC: Dr Swati Gupta, Dept of Radiology, MAMC Delhi<\/span><\/span><\/span><\/span><\/span><\/p>\n"},"subContentId":"66c9599f-9990-48a6-af82-1d2a80b140b6","metadata":{"contentType":"Text","license":"U","title":"Untitled Text"}},"alwaysDisplayComments":false,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"specified","invisible":false,"solution":""},{"x":3.265141612200436,"y":17.312354211663067,"width":27.342047930283226,"height":53.99568034557235,"action":{"library":"H5P.Image 1.1","params":{"decorative":false,"contentName":"Image","file":{"path":"images\/file-64a150bf5c2bf.jpg","mime":"image\/jpeg","copyright":{"license":"U"},"width":458,"height":458}},"subContentId":"93b88665-e27a-4bf0-875c-8106f60a9efb","metadata":{"contentType":"Image","license":"U","title":"Untitled 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161)"},"type":"horizontal-line","shape":{"fillColor":"#ffffff","borderColor":"#000000","borderWidth":"0","borderStyle":"solid","borderRadius":"0"}},"metadata":{"contentType":"Shapes","license":"U"},"subContentId":"b66d071d-4eb7-4cf2-b57e-1b5b69d4e0cb"},"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"specified","invisible":false}],"slideBackgroundSelector":{}},{"elements":[{"x":3.265141612200436,"y":6.490734341252699,"width":25.05446623093682,"height":6.479481641468682,"action":{"library":"H5P.AdvancedText 1.1","params":{"text":"
Thoracolumbar TB Imaging <\/strong><\/span><\/span><\/p>\n"},"subContentId":"831b1009-ffd7-40ec-9e3f-1ed449ecae76","metadata":{"contentType":"Text","license":"U","title":"Untitled Text"}},"alwaysDisplayComments":false,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"specified","invisible":false,"solution":""},{"x":7.625272331154684,"y":73.43412526997841,"width":38.12636165577342,"height":19.43844492440605,"action":{"library":"H5P.AdvancedText 1.1","params":{"text":"
Axial post contrast T1w MRI image showing peripherally enhancing prevertebral collection.<\/span><\/p>\n"},"subContentId":"2127ff3c-0dab-46c5-93b0-4a71d1bce699","metadata":{"contentType":"Text","license":"U","title":"Untitled Text"}},"alwaysDisplayComments":false,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"specified","invisible":false,"solution":""},{"x":53.37407407407407,"y":73.5803455723542,"width":41.394335511982575,"height":19.43844492440605,"action":{"library":"H5P.AdvancedText 1.1","params":{"text":"
Post contrast sagittal T1w MRI image showing enhancement in vertebral bodies of multiple lower dorsal and lumbar vertebrae with peripherally enhancing collections. <\/p>\n"},"metadata":{"contentType":"Text","license":"U","title":"Untitled Text"},"subContentId":"7af52e3f-d81c-45af-9ea8-1c16e1277653"},"alwaysDisplayComments":false,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"specified","invisible":false,"solution":""},{"x":34.85838779956427,"y":92.87257019438445,"width":27.233115468409586,"height":5.183585313174946,"action":{"library":"H5P.AdvancedText 1.1","params":{"text":"
PC: Dr Swati Gupta, Dept of Radiology, MAMC Delhi<\/span><\/span><\/span><\/span><\/span><\/p>\n"},"subContentId":"5d238424-59fe-498a-b59c-3dae744f3d2e","metadata":{"contentType":"Text","license":"U","title":"Untitled Text"}},"alwaysDisplayComments":false,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"specified","invisible":false,"solution":""},{"x":6.5359477124183005,"y":21.598272138228943,"width":37.79956427015251,"height":47.51619870410367,"action":{"library":"H5P.Image 1.1","params":{"decorative":false,"contentName":"Image","file":{"path":"images\/file-64a1523465f75.jpg","mime":"image\/jpeg","copyright":{"license":"U"},"width":732,"height":465}},"subContentId":"f4809f80-4a66-4f5a-9e17-10f6a8507d1b","metadata":{"contentType":"Image","license":"U","title":"Untitled Image"}},"alwaysDisplayComments":false,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"specified","invisible":false,"solution":""},{"x":56.64488017429194,"y":8.639308855291576,"width":30.718954248366014,"height":60.47516198704104,"action":{"library":"H5P.Image 1.1","params":{"decorative":false,"contentName":"Image","file":{"path":"images\/file-64a1523ff0f11.jpg","mime":"image\/jpeg","copyright":{"license":"U"},"width":443,"height":442}},"subContentId":"9f59396b-22e7-4a02-996e-bee38cece45a","metadata":{"contentType":"Image","license":"U","title":"Untitled Image"}},"alwaysDisplayComments":false,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"specified","invisible":false,"solution":""},{"x":2.178649237472767,"y":71.27429805615552,"width":4.357298474945534,"height":8.639308855291576,"action":{"library":"H5P.Image 1.1","params":{"decorative":false,"contentName":"Image","file":{"path":"images\/file-64a14ef6dd640.png","mime":"image\/png","copyright":{"license":"U"},"width":128,"height":128}},"metadata":{"contentType":"Image","license":"U","title":"Untitled Image"},"subContentId":"d7566a13-8166-4ac6-9f7b-6d3fdc1787a3"},"alwaysDisplayComments":false,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"specified","invisible":false,"solution":""},{"x":47.930283224400874,"y":73.43412526997841,"width":4.357298474945534,"height":8.639308855291576,"action":{"library":"H5P.Image 1.1","params":{"decorative":false,"contentName":"Image","file":{"path":"images\/file-64a14f294cd07.png","mime":"image\/png","copyright":{"license":"U"},"width":128,"height":128}},"metadata":{"contentType":"Image","license":"U","title":"Untitled Image"},"subContentId":"c046576c-b1a7-455a-890c-a2cf1331bcbc"},"alwaysDisplayComments":false,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"specified","invisible":false,"solution":""},{"x":7.625272331154684,"y":71.27429805615552,"width":35.947712418300654,"height":0.6479481641468683,"action":{"library":"H5P.Shape 1.0","params":{"line":{"borderWidth":"2","borderStyle":"solid","borderColor":"rgb(24, 56, 216)"},"type":"horizontal-line","shape":{"fillColor":"#ffffff","borderColor":"#000000","borderWidth":"0","borderStyle":"solid","borderRadius":"0"}},"subContentId":"37fb73b7-6f39-421f-a32f-ccbf7cc5dcbe","metadata":{"contentType":"Shapes","license":"U"}},"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"specified","invisible":false},{"x":53.37407407407407,"y":71.42051835853133,"width":39.21568627450981,"height":0.6479481641468683,"action":{"library":"H5P.Shape 1.0","params":{"line":{"borderWidth":"2","borderStyle":"solid","borderColor":"rgb(107, 149, 161)"},"type":"horizontal-line","shape":{"fillColor":"#ffffff","borderColor":"#000000","borderWidth":"0","borderStyle":"solid","borderRadius":"0"}},"metadata":{"contentType":"Shapes","license":"U"},"subContentId":"d7badba0-efd9-4929-902c-d8c28be1df47"},"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"specified","invisible":false}],"slideBackgroundSelector":{}},{"elements":[{"x":3.260882352941177,"y":6.507602591792656,"width":42.48366013071895,"height":10.799136069114471,"action":{"library":"H5P.AdvancedText 1.1","params":{"text":"
C. Microbiological Diagnosis of Spinal TB <\/strong><\/span><\/span><\/p>\n"},"subContentId":"c83d4e6b-c987-4717-ae2c-e1acc949a38f","metadata":{"contentType":"Text","license":"U","title":"Untitled Text"}},"alwaysDisplayComments":false,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"specified","invisible":false,"solution":""},{"x":44.66230936819172,"y":88.55291576673866,"width":53.37690631808279,"height":8.639308855291576,"action":{"library":"H5P.AdvancedText 1.1","params":{"text":"
Joo E-J et al. Diagnostic yield of computed tomography-guided bone biopsy and clinical outcomes of tuberculous and pyogenic spondylitis. Korean J Intern Med. 2016 <\/span><\/span><\/span><\/span><\/span><\/p>\n"},"subContentId":"a811e8ea-03fc-4670-9f4a-070c61ba37a2","metadata":{"contentType":"Text","license":"U","title":"Untitled Text"}},"alwaysDisplayComments":false,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"specified","invisible":false,"solution":""},{"x":4.357298474945534,"y":17.278617710583152,"width":91.50326797385621,"height":69.11447084233261,"action":{"library":"H5P.AdvancedText 1.1","params":{"text":"
Sample Collection <\/strong><\/span><\/p>\n\n
\n\t
\n\t
Percutaneous biopsy under CT guidance reduces the need for open biopsy, but this may still be required in some cases, particularly where imaging results are atypical for spinal TB and the diagnosis is uncertain. <\/p>\n\t<\/li>\n\t
\n\t
For CT guided biopsy: Diagnostic yields of TB spondylitis (61%) is higher than pyogenic spondylitis. (33%)<\/p>\n\t<\/li>\n\t
\n\t
Pus from cold para-spinal\/psoas and other abscess can be drained under ultrasound or CT guidance for diagnostic evaluation.<\/p>\n\t<\/li>\n\t
\n\t
If clinical and radiological features are highly compatible with the diagnosis of TB and if the site is not easily accessible, sampling may be avoided<\/p>\n\t<\/li>\n\t
\n\t
Clinico-radiological discordance: tissue sampling must be attempted<\/p>\n\t<\/li>\n<\/ul>\n"},"subContentId":"e8f58657-e564-473b-9e34-eec0b21f7863","metadata":{"contentType":"Text","license":"U","title":"Untitled Text"}},"alwaysDisplayComments":false,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"specified","invisible":false,"solution":""}],"slideBackgroundSelector":{}},{"elements":[{"x":4.3544662309368185,"y":6.490734341252699,"width":90.41394335511983,"height":8.639308855291576,"action":{"library":"H5P.AdvancedText 1.1","params":{"text":"
NAAT testing <\/strong><\/span><\/p>\n\n
<\/p>\n"},"subContentId":"3c7dbd9c-dd01-431d-9882-e05328328770","metadata":{"contentType":"Text","license":"U","title":"Untitled Text"}},"alwaysDisplayComments":false,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"specified","invisible":false,"solution":""},{"x":6.5359477124183005,"y":15.11879049676026,"width":88.23529411764706,"height":79.91360691144709,"action":{"library":"H5P.Table 1.1","params":{"text":"
\n\t\n\t\t\n\t\t\t
\n\t\t\t\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t<\/tbody>\n<\/table>\n"},"subContentId":"23cbaf20-cf93-43bc-8fba-48cd7ccffa2f","metadata":{"contentType":"Table","license":"U","title":"Untitled Table"}},"alwaysDisplayComments":false,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"specified","invisible":false,"solution":""}],"slideBackgroundSelector":{}},{"elements":[{"x":4.355882352941177,"y":6.501987041036717,"width":90.41394335511983,"height":84.23326133909288,"action":{"library":"H5P.AdvancedText 1.1","params":{"text":"
NAAT testing <\/strong><\/span><\/p>\n\n
\n\t
\n\t
Much faster compared to culture (2 days vs ~35 days)<\/p>\n\t<\/li>\n\t
\n\t
Slightly more sensitive than histopathology (~92-95% vs 88%)<\/p>\n\t<\/li>\n\t
\n\t
More sensitive than culture(~92-95% vs 55%) in few studies<\/p>\n\t<\/li>\n\t
\n\t
High specificity, PPV and NPV (>95%)<\/p>\n\t<\/li>\n\t
\n\t
Can detect drug resistance<\/p>\n\t<\/li>\n\t
\n\t
Must NOT be used for follow-up.<\/p>\n\t<\/li>\n<\/ul>\n\n
Still, it\u2019s role remains to be ascertained<\/p>\n\n
Combinations of all the available tests (microbiology+histopathology) should be optimally utilized
\n for diagnosis of TB. <\/p>\n\n
<\/p>\n"},"subContentId":"6ec800e5-518f-42fa-a07e-d2375e0b5e2b","metadata":{"contentType":"Text","license":"U","title":"Untitled Text"}},"alwaysDisplayComments":false,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"specified","invisible":false,"solution":""}],"slideBackgroundSelector":{}},{"elements":[{"x":4.357298474945534,"y":6.479481641468682,"width":90.41394335511983,"height":45.35637149028078,"action":{"library":"H5P.AdvancedText 1.1","params":{"text":"
Culture <\/strong><\/span><\/p>\n\n
\n\t
\n\t
TB spine is proven by suggestive histopathology and\/or culture.<\/p>\n\t<\/li>\n\t
\n\t
Among conventional methods such as ZN or fluorescent staining, culture or histology, the latter has the highest sensitivity (~90%)<\/p>\n\t<\/li>\n\t
\n\t
Among histologically proven spinal TB, culture positivity rates are only ~50-55% <\/p>\n\n\t
<\/p>\n\t<\/li>\n<\/ul>\n\n
<\/p>\n"},"subContentId":"bef6fa9b-a03e-4edf-8d49-c251b73125dd","metadata":{"contentType":"Text","license":"U","title":"Untitled Text"}},"alwaysDisplayComments":false,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"specified","invisible":false,"solution":""},{"x":61.00217864923747,"y":84.23326133909288,"width":37.03703703703704,"height":12.958963282937365,"action":{"library":"H5P.AdvancedText 1.1","params":{"text":"
Jain AK, Jaggi KR, Bhayana H, Saha R. Drug-resistant Spinal Tuberculosis. Indian J Orthop. 2018;<\/span><\/p>\n"},"subContentId":"08b04bec-8f1b-49b1-9c87-3e7d201400ff","metadata":{"contentType":"Text","license":"U","title":"Untitled Text"}},"alwaysDisplayComments":false,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"specified","invisible":false,"solution":""}],"slideBackgroundSelector":{}},{"elements":[{"x":4.357298474945534,"y":6.479481641468682,"width":56.64488017429194,"height":8.639308855291576,"action":{"library":"H5P.AdvancedText 1.1","params":{"text":"
D. Summary of diagnostic investigations of Spinal TB <\/strong><\/span><\/span><\/p>\n\n
<\/p>\n"},"subContentId":"16fabfdf-be40-4900-9f10-0e4002eb489f","metadata":{"contentType":"Text","license":"U","title":"Untitled Text"}},"alwaysDisplayComments":false,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"specified","invisible":false,"solution":""},{"x":6.5359477124183005,"y":19.43844492440605,"width":39.97821350762527,"height":6.479481641468682,"action":{"library":"H5P.AdvancedText 1.1","params":{"text":"
Table is displayed on the next slide <\/em><\/p>\n"},"subContentId":"ccf13a89-e166-4fc3-803e-b272d0fc0a7c","metadata":{"contentType":"Text","license":"U","title":"Untitled Text"}},"alwaysDisplayComments":false,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"specified","invisible":false,"solution":""}],"slideBackgroundSelector":{}},{"elements":[{"x":5.446623093681917,"y":2.159827213822894,"width":90.41394335511983,"height":92.87257019438445,"action":{"library":"H5P.Table 1.1","params":{"text":"
Reference<\/span><\/td>\n\t\t\t\t\t\t n<\/span><\/td>\n\t\t\t\t\t\t Sensitivity<\/span><\/td>\n\t\t\t\t\t\t Specificity<\/span><\/td>\n\t\t\t\t\t\t Note<\/span><\/td>\n\t\t\t\t\t<\/tr>\n\t\t\t\t\t
Solanki AM et al. Sensitivity and Specificity of Gene Xpert in the Diagnosis of Spinal Tuberculosis: A Prospective Controlled Clinical Study. Global Spine Journal. 2019<\/td>\n\t\t\t\t\t\t 160 <\/td>\n\t\t\t\t\t\t 91.2%<\/td>\n\t\t\t\t\t\t 100%<\/td>\n\t\t\t\t\t\t Gene Xpert was positive in all cases in which histopathology was inconclusive and 86.21% cases in which AFB culture was negative<\/td>\n\t\t\t\t\t<\/tr>\n\t\t\t\t\t
WHO | Xpert MTB\/RIF: WHO Policy update Implementation manual 2013. <\/td>\n\t\t\t\t\t\t Review of studies <\/td>\n\t\t\t\t\t\t 81.2%<\/td>\n\t\t\t\t\t\t <\/td>\n\t\t\t\t\t\t Pooled estimate from all tissue samples except lymph node<\/td>\n\t\t\t\t\t<\/tr>\n\t\t\t\t\t
Held M et al. GeneXpert polymerase chain reaction for spinal tuberculosis: an accurate and rapid diagnostic test. Bone Joint J. 2014<\/td>\n\t\t\t\t\t\t 71<\/td>\n\t\t\t\t\t\t 95.6%<\/td>\n\t\t\t\t\t\t 97.7%<\/td>\n\t\t\t\t\t\t <\/td>\n\t\t\t\t\t<\/tr>\n\t\t\t\t<\/tbody>\n\t\t\t<\/table>\n\t\t\t<\/th>\n\t\t\t <\/th>\n\t\t<\/tr>\n\t<\/thead>\n\t
\n\t\n\t\t\n\t\t\t\n\t\t\t\n\t\t\t\n\t\t\t\n\t\t\t\n\t\t\t\n\t\t\t\n\t\t\t\n\t\t\t\n\t\t\t\n\t\t\t
S.No <\/strong><\/span><\/td>\n\t\t\t Investigation<\/strong><\/span><\/td>\n\t\t\t Sensitivity<\/strong><\/span><\/td>\n\t\t\t Specificity<\/strong><\/span><\/td>\n\t\t\t Comment<\/strong><\/span><\/td>\n\t\t<\/tr>\n\t\t
1<\/td>\n\t\t\t Plain radiography<\/td>\n\t\t\t 15%<\/td>\n\t\t\t NA<\/td>\n\t\t\t Changes prominent only after 30% of destruction<\/td>\n\t\t<\/tr>\n\t\t
2<\/td>\n\t\t\t MRI<\/td>\n\t\t\t 100%<\/td>\n\t\t\t 80%<\/td>\n\t\t\t Gold standard imaging technique<\/td>\n\t\t<\/tr>\n\t\t
3<\/td>\n\t\t\t CT<\/td>\n\t\t\t 100%<\/td>\n\t\t\t NA<\/td>\n\t\t\t <\/td>\n\t\t<\/tr>\n\t\t
4<\/td>\n\t\t\t ESR > 20mm<\/td>\n\t\t\t 60-90%<\/td>\n\t\t\t NA<\/td>\n\t\t\t Serial values show gradual drop after initiating treatment; second peak in case of reactivation<\/td>\n\t\t<\/tr>\n\t\t
5<\/td>\n\t\t\t CRP<\/td>\n\t\t\t 71%<\/td>\n\t\t\t NA<\/td>\n\t\t\t Reaches normal levels after 14 days of treatment<\/td>\n\t\t<\/tr>\n\t\t
6<\/td>\n\t\t\t Mantoux Assay<\/td>\n\t\t\t 40% to 55%<\/td>\n\t\t\t 75%<\/td>\n\t\t\t False positive results in BCG-vaccinated individuals<\/td>\n\t\t<\/tr>\n\t\t
7<\/td>\n\t\t\t Ziehl Neelsen Technique<\/td>\n\t\t\t 25% to 75%<\/td>\n\t\t\t 99%<\/td>\n\t\t\t Ziehl-Neelsen technique\u2014bright red bacilli; 104 to 105 bacilli\/mL required<\/td>\n\t\t<\/tr>\n\t\t
8<\/td>\n\t\t\t Culture <\/td>\n\t\t\t 47%<\/td>\n\t\t\t 100%<\/td>\n\t\t\t Lowenstein Jensen media, 6-8 weeks, requires 101 to 102 bacilli\/mL (live bacilli). Liquid culture 2-4 weeks<\/td>\n\t\t<\/tr>\n\t\t
9<\/td>\n\t\t\t GeneXpert MTB\/RIF <\/td>\n\t\t\t 82.9%<\/td>\n\t\t\t 98%<\/td>\n\t\t\t Results <48 hours+ rifampicin resistance detection<\/td>\n\t\t<\/tr>\n\t\t
10<\/td>\n\t\t\t Histopathology <\/td>\n\t\t\t 53% to 81%<\/td>\n\t\t\t NA<\/td>\n\t\t\t Epithelioid cell granulomas, Langhans giant cells, caseous necrosis<\/td>\n\t\t<\/tr>\n\t<\/tbody>\n<\/table>\n\n
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Rajasekaran S, Soundararajan DCR, Shetty AP, Kanna RM. Spinal Tuberculosis: Current Concepts. Global Spine Journal. 2018<\/span><\/p>\n"},"subContentId":"50302a3d-762f-4761-b2d6-f2c28ea540be","metadata":{"contentType":"Text","license":"U","title":"Untitled Text"}},"alwaysDisplayComments":false,"backgroundOpacity":0,"displayAsButton":false,"buttonSize":"big","goToSlideType":"specified","invisible":false,"solution":""}],"slideBackgroundSelector":{}}],"keywordListEnabled":true,"globalBackgroundSelector":{},"keywordListAlwaysShow":false,"keywordListAutoHide":false,"keywordListOpacity":90},"override":{"activeSurface":false,"hideSummarySlide":false,"summarySlideSolutionButton":true,"summarySlideRetryButton":true,"enablePrintButton":false,"social":{"showFacebookShare":false,"facebookShare":{"url":"@currentpageurl","quote":"I scored @score out of @maxScore on a task at @currentpageurl."},"showTwitterShare":false,"twitterShare":{"statement":"I scored @score out of @maxScore on a task at @currentpageurl.","url":"@currentpageurl","hashtags":"h5p, course"},"showGoogleShare":false,"googleShareUrl":"@currentpageurl"}},"l10n":{"slide":"Slide","score":"Score","yourScore":"Your Score","maxScore":"Max Score","total":"Total","totalScore":"Total Score","showSolutions":"Show solutions","retry":"Retry","exportAnswers":"Export text","hideKeywords":"Hide sidebar navigation menu","showKeywords":"Show sidebar navigation menu","fullscreen":"Fullscreen","exitFullscreen":"Exit fullscreen","prevSlide":"Previous slide","nextSlide":"Next slide","currentSlide":"Current slide","lastSlide":"Last slide","solutionModeTitle":"Exit solution mode","solutionModeText":"Solution Mode","summaryMultipleTaskText":"Multiple tasks","scoreMessage":"You achieved:","shareFacebook":"Share on Facebook","shareTwitter":"Share on Twitter","shareGoogle":"Share on Google+","summary":"Summary","solutionsButtonTitle":"Show comments","printTitle":"Print","printIngress":"How would you like to print this presentation?","printAllSlides":"Print all slides","printCurrentSlide":"Print current slide","noTitle":"No title","accessibilitySlideNavigationExplanation":"Use left and right arrow to change slide in that direction whenever canvas is selected.","accessibilityCanvasLabel":"Presentation canvas. Use left and right arrow to move between slides.","accessibilityProgressBarLabel":"Choose slide to display","containsNotCompleted":"@slideName contains not completed interaction","containsCompleted":"@slideName contains completed interaction","slideCount":"Slide @index of @total","containsOnlyCorrect":"@slideName only has correct answers","containsIncorrectAnswers":"@slideName has incorrect answers","shareResult":"Share Result","accessibilityTotalScore":"You got @score of @maxScore points in total","accessibilityEnteredFullscreen":"Entered fullscreen","accessibilityExitedFullscreen":"Exited fullscreen","confirmDialogHeader":"Submit your answers","confirmDialogText":"This will submit your results, do you want to continue?","confirmDialogConfirmText":"Submit and see results","slideshowNavigationLabel":"Slideshow navigation"}}

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