In March 2023, a 20-year-old woman was consulted by the neurology department due to weakness in her lower extremities. Three weeks before admission, the patient complained of weakness in the lower extremities that worsened until the patient could not walk five days prior. The complaints were preceded by pain in the upper back radiating to the chest for eight months since prior. The pain worsens when the patient has an activity and improves when resting. The complaints were accompanied by tingling in the upper chest area down to both legs since three weeks ago. The patient had difficulty urinating and defecating, so he had to strain since two weeks ago. The history of trauma (-) and fever (-). Because of the complaints, she was brought to the Neurology Emergency Unit of the local hospital, hospitalized for four days by Neurologist, diagnosed with Thoracic Myeloradiculopathy, and then sent home with the complaints persisted. The patient was controlled to the local Neurology Outpatient Clinic and referred to another hospital. Underwent Cervicothoracal MRI on (Mar 4 2023), and was diagnosed with TB Spondylitis. Because the complaints worsened, she came to the Neurology Emergency Unit of Hasan Sadikin Hospital Bandung, was hospitalized for two days by a Neurologist, and then consulted the Neurosurgery Department. The patient had no history of trauma, fever, night sweats, pulmonary TB treatment, old cough, smoking, and lumps everywhere. The patient had a history of weight loss of four kilograms in one month. TB Contacts (+) of the patient’s brother are still in treatment.
On physical examination, the patient was compos mentis, vesicular sound detected, and no bronchi and wheezing sound detected in pulmo. Deformity and step-off were found in the upper thoracal region, and no tenderness was present (Figure 1a). The patient felt hypesthesia Th-2 below with weakness in the lower extremities (11111/11111) while the upper extremities motoric were normal (55555/55555) (Figure 1b). Physiological reflex (++/++), Babinski pathological reflex (+/+), perianal sensation (+), retention alvi (+), voluntary anal contraction (-), great toe extension (-), atrophy (-), clonus (-), and spastic (-). The pulse was 82/min and B.P 121/75 mmHg. Laboratory investigations showed haemoglobin 11.7gr/dL, hematocrit 37.1%, leukocyte 7.73mm3, thrombocyte 278x109/L, random blood glucose 95mmol/L, ureum 25.7mg/dL, creatinine 0.6mg/dL, sodium 138mmol/L, potassium 3.9mEq/L.
Plain X-ray of thoracal AP views revealed scoliosis thoracal with Cobb angle 14o (N<10o) (Figure 2). MRI of the cervicothoracic spine was sagittal and coronal position showed an extradural isointense and hyperintense lesion at the Th-2 until Th-4 vertebral level that is grossly inhomogeneous with contrast enhancement, which extends posteriorly to the spinal canal and causes destruction of the Th-2 and Th-3 corpuscles, ring enhancement (+) Th-1, and canal stenosis of the Th-2 (Figure 3 and 4).
The patient underwent Post Anterior Thoracic Interbody Fusion and Transmanubrio Sternotomy Surgery (Figure 5) due to Myeloradiculopathy at Vertebrae Level Th2 due to SOL Extradural at Level Vertebrae Th2-Th4 + Pathological Fracture at Thoracal Th2 et Th7 et Th10 due to Suspect Spondylitis TB DD/Non-Spesific infection + Paravertebral Abscess. The fixation and debridement technique was chosen from the anterior because the affected spine level was less than Th2. At surgery, a pocket abscess was found in the os sternum along the anterior ligament (ALL) Th2-Th3 (Figure 6). There were also pathologic fractures in Th2-Th3, discitis, necrotic tissue, and caseous. Discectomy and corpectomy were performed until a healthy end plate was reached. A tubular cage was also measured, harvesting cancellous bone from the left SIAS. The cage was placed between the Th2 and Th4 corpus (Figure 7). Morphoplate was placed, and 4 screws were fixed; furthermore, the sternum was fixed with wire by a thoracic surgery colleague. The patient has not had any treatment before for this disease. Though the late treatment from the onset of disease. The patient was started on TB treatment with four Fixed Drug Combinations (FDC) 1x3 tab PNGT, Rifampicin 1x450mg PNGT, and Acetylcysteine 3x400mg PNGT.
After surgery and medication, the patient experienced significant motor development. From the original lower extremity motor only 11111/11111, the patient can now follow the command to bend the knee with an estimated motor count of 33333/443333 (Figure 8). The patient was then discharged and continued to visit the thorax surgery clinic, medical rehabilitation clinic for physiotherapy, and neurology clinic for TB treatment evaluation.