Name:
FOCUS25824video14
Description:
FOCUS25824video14
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/af064079-1d90-492b-8173-a4ecf1ce1378/videoscrubberimages/Scrubber_1.jpg?sv=2019-02-02&sr=c&sig=D0LodtuaB5GIA2tZHC23gjdwYxHNGJX5toay24jWzwo%3D&st=2026-05-13T19%3A55%3A23Z&se=2026-05-14T00%3A00%3A23Z&sp=r
Duration:
T00H06M14S
Embed URL:
https://stream.cadmore.media/player/af064079-1d90-492b-8173-a4ecf1ce1378
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/af064079-1d90-492b-8173-a4ecf1ce1378/14. 25-111.mp4?sv=2019-02-02&sr=c&sig=TwRbrWckQcBcJfdCM8N6qdHfOtyXRf6n%2BBrdYwdnIhw%3D&st=2026-05-13T19%3A55%3A23Z&se=2026-05-13T22%3A00%3A23Z&sp=r
Upload Date:
2025-12-03T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
SPEAKER: This is a case of a 19-year-old man with no
SPEAKER: significant past medical history, who presented with intermittent back pain and was found to have a lytic lesion in the left L1 vertebral body. He was neurologically intact and discharged from the emergency department with referrals to neurosurgery and oncology. Unfortunately, he missed his scheduled follow-up with the outside neurosurgeon and never underwent the biopsy ordered by the oncologist.
SPEAKER: He re-presented 2 months later with subjective weakness. He was neurologically intact on exam. At that time, MRI demonstrated growth of the previously identified lesion, with compression of the thecal sac and the left-sided foraminal stenosis. Additional imaging, including CT of the chest, abdomen, and pelvis, was negative for other lesions consistent with a primary malignancy or metastasis.
SPEAKER: Given the unclear diagnosis, he was admitted to oncology for further workup. An image-guided biopsy performed the following day demonstrated granulation tissue without evidence of malignancy. This was thought to be most consistent with extrapulmonary tuberculosis. Surgical treatment was deferred given that the patient was neurologically intact. He was started on antibiotic therapy per the RIPE protocol and was discharged with close follow-up with neurosurgery and infectious disease.
SPEAKER: Six weeks later, he was called by the health department and told that his tuberculosis was resistant to RIPE therapy and that he should report back to the hospital. At that time, he reported new right-sided radiculopathy and weakness. He was only able to ambulate with the assistance of two canes and was using a wheelchair. Imaging demonstrated growth of his T12–L1 lesion. His antibiotics were changed and surgical intervention was offered given his new neurological deficit.
SPEAKER: On the left, you see sagittal and axial CT images demonstrating the lytic lesion at the L1 level. On the right, you see sagittal and axial postcontrast T1-weighted MR images showing the same lesion, highlighting the epidural extension, as well as extension out the T12–L1 foramen prior to the biopsy. On this imaging that was obtained when the patient re-presented following failure of medical therapy, you can see extension of the bony erosion to the T12 level on the CT scan on the left.
SPEAKER: On the right side, you see the MR image demonstrating extension of the lesion to the T12 level in a subligamentous manner, with relative sparing of the disc space, as well as increased epidural extension of the lesion. Due to involvement of the left L1 pedicle and the ventral location of the lesion, in order to achieve appropriate decompression of the neural elements, stabilization would also be required.
SPEAKER: T10–L3 instrumentation with a T12–L1 decompression, including a full left-sided facetectomy with debulking of the lesion, was planned. Carbon fiber instrumentation was chosen in order to limit artifact on follow-up MR images. Pedicle screw instrumentation was placed bilaterally from T10 to L3, skipping the involved L1 level.
SPEAKER: A complete L1 laminectomy with an inferior T12 laminectomy and a left-sided T12–L1 facetectomy were performed. The lesion was visualized and debulked, including a transpedicular approach for ventral decompression. Postoperatively, the patient had improvement of his right-sided radiculopathy and strength. At 1-month follow-up, he was able to ambulate with a single cane.
SPEAKER: And at 6-month follow-up, he was ambulating without an assistive device. On the left side, you can see a sagittal and axial T2-weighted MR image that demonstrates decompression of the canal, as well as regression of the prior disease seen at the L1 level. On the right, you can see lateral and AP radiographs demonstrating appropriate spinal alignment and no hardware complications 6 months following surgery.
SPEAKER: Given the unclear diagnosis at the time of the patient's presentation, surgical intervention was deferred until a diagnosis was made with hopes that the lesion may be amenable to either medical or radiation therapy, and spine surgery could be avoided in this young patient. After the initial biopsy results were suggestive of extrapulmonary tuberculosis, medical management was pursued, given that he was neurologically intact.
SPEAKER: Unfortunately, it was difficult to obtain a definitive diagnosis, and culture sensitivities took 6 weeks to result. During this time, the patient developed a new neurologic deficit with weakness and radiculopathy due to expansion of his lesion. This case highlights a few important lessons. Although it is rare, tuberculosis that is resistant to first-line therapies can be encountered within the United States.
SPEAKER: Sensitivities can take a long time to result, and prior to confirmation of medical treatment success, patients are at risk for worsening disease burden and development of neurologic deficits. These patients should be closely monitored until a response to therapy is confirmed.
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