Spinal tuberculosis.

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Postgrad Med J 1997; 73: 525
(' The Fellowship of Postgraduate Medicine, 1997
Letters to the Editor
Spinal tuberculosis
Sir,
With reference to the article by Scullion and
Al-Kutoubi,
on
spinal
experience with a large number of cases has
been different with respect to the 'distinguish-
ing features'
in non-Caucasions.
more, our experience is supported by other
authors. Ganguli2 made an extensive study in
an Indian population and did not find poster-
ior arch involvement to be common. Hodgson
et al3 from Hong Kong reported that "tuber-
culosis infection rarely involves the transverse
process, the pedicle,
spinous process but it may do so in an isolated
case". Bell et al' reported a few cases of
posterior arch involvement in some Nigerians
and did not consider that 'the description of
this form of tuberculosis in West Indians and
Nigerians provides a ground for suggesting a
racial role in its etiology'.
In
a
five-yearstudy
conducted by the Medical Research Council
in Korea,5 only one patient had tuberculosis
confined to a single vertebra. The rest had
involvement of two or more vertebrae and of
the intervening disc spaces.
Allen et al' described a greater incidence of
sclerosis in the vertebrae of coloured patients
compared to that in white patients, while a
study by Jacobs7
carried out in UK has
described more atypical and multiple sites of
tuberculosis involvement in coloured immi-
grants from Pakistan and India. More re-
cently, Tuli,' who has studied tuberculosis of
spine for over 20 years in India reported that
98% of lesions were the typical paradiscal
type. According to him, the active lesion is
characterised by osteoporosis and osteolysis,
whereas osteosclerosis indicates healing of the
lesion. Moreover no standard textbook on
radiology or orthopaedics describes differ-
ences in the presentation of tuberculosis of
spine based on race or colour of the skin.
tuberculosis,'
our
Further-
the lamina and the
of 350
patients
RAVI MITTAL
S BHAN
Department of Orthopaedics,
All India Institute ofMedical Sciences,
New Dehli-110029, India
Accepted 10 February 1997
1 Scullion D, Al-Kutoubi A. Weight loss. Postgrad
MedJ 1996; 72: 373-5.
2 Ganguli PK. In: Middlemiss H, ed. Tropical
radiology. London: W Heinmann, 1961.
3 Hodgson AR, Wough W,
appearance of tuberculosis of spine. Springfield,
Ill: Thomas, 1969.
4 Bell D, Cockshott WP. Tuberculosis of the
vertebral pedicles. Radiology 1971; 99: 43-8.
5 Fifth report on the Medical Research Council
Working party on tuberculosis of the spine
(1976). A five year assessment of controlled
trials of inpatient and outpatient treatment and
of plaster of paris jackets for tuberculosis of the
spine in children on standard chemotherapy. _7
Bone Joint Surg 1976; 58B: 399-411.
6 Allen EH, Cosgrove DD, Millard FJC. The
radiological changes in infections of the spine
and their diagnostic value. Clin Radiol 1978; 29:
31 -40.
YauA.
X-Ray
7 Jacobs P. Osteoarticular tuberculosis in coloured
immigrants - a radiological study. Clin Radiol
1964; 15: 59-69.
8 Tuli SM. Tuberculosis of the skeletal system. Delhi:
Jaypee Brothers Medical Publishers, 1991.
This letter was shown to the authors, who responded
as follows:
Sir,
We thank Drs Bahn and Mittal for their
interest in our case report and feel sure that
their experience of patients with bony tuber-
culosis
indeed
extensive.
'distinguishing
features'
appear in our article, however, and box
serves merely to illustrate the various mani-
festations of spinal tuberculosis
occur in Caucasians and non-Caucasians.
There
of course
between racial groups and, given the protean
manifestations of this disease, an attempt to
divide patients into racial groups based on
radiological
features
unwise.
Moreover,
excluding
infection merely on the presence or absence
of particular radiological features may be
detrimental to patient care.
We agree that involvement of a single
vertebral body is uncommon. Our discussion
does not suggest otherwise. In addition we
concur that vertebral sclerosis is more com-
monly seen in coloured patients. This
referred to in box 1. Posterior arch involve-
ment is indeed uncommon, especially when it
occurs in isolation, but when seen it is more
likely to be in non-Caucasians, hence
position in box 1. This perhaps could have
been made clearer in the text.
Our case illustrates the commoner radi-
ological features of spinal tuberculosis and in
practice the correct diagnosis was straightfor-
ward. In the discussion less common features
are presented that, when present, may mislead
those whose experience is less extensive. It is
precisely these less common features that one
would not necessarily find referred to in
'standard texts'.
is
The
phrase
does not actually
1
that may
is
considerableoverlap
wouldbeextremely
tuberculosis
is
its
DA SCULLION
MA AL-KUTOUBI
St Mary's Hospital,
Praed Street, London W2 1NY, UK
Coital emergencies
Sir,
Banerjee' provided an excellent review of
coital emergencies but I wish to comment
on certain aspects.
Firstly, the review article failed to mention
injuries of the lower female genital
resulting from coital activity. Vaginal injury
following sexual intercourse is one ofthe most
common presentations of post-coital emer-
gencies.2-4 The majority of coital injuries
result from vigorous voluntary sexual activity
while a smaller proportion result from violent
involuntary sexual activity. The age range
spans the pre-pubertal to the post-menopau-
sal. The commonest site of injury
tract
is the
posterior vaginal fornix.2-4 Speculation as to
why this region should suffer the most trauma
abounds, including unusual sexual practices
or inadequate preparation of the woman with
the resultant increased intra-abdominal pres-
sure on her part tending to make the cul-de-
sac tense and lessening the elasticity of the
vaginal vault, especially the posterior fornix
during deep penetration. Most of the injuries
are not serious but severe injuries in this
region may lead to acute complications such
as shock from severe haemorrhage requiring
blood
transfusion,
resuscitation
gery.2'4 Late sequelae such as dyspareunia,
scarring and cicatrization of the vagina and
cervix, intractable genital infection as well as
psychological upset and emotional instability
may also occur. Misdiagnosis occurs either
because a detailed history is not taken or the
patient
does
not
volunteer
antecedent sexual activity.4
imperative that a detailed history be taken
and examination performed on women pre-
senting in the accident and emergency depart-
ment with vaginal bleeding in order to make
an accurate diagnosis.
Secondly, Banerjee states that a period of
six to eight weeks abstinence from sexual
intercourse is usually advised following myo-
cardial infarction (MI). There does not appear
to be any evidence for this advice. While a
decrease in sexual activity following MI is
often due to fear of the unknown risk of
precipitating another MI, Muller et al's recent
study in Boston shows that there are grounds
for reassurance on
this
interview of a national sample of 858 patients
with MI who were sexually active in the year
before the MI, they found that 79 (9%)
reportedsexual
activity
preceding the MI and 27 (3%) reported
sexual activity in the two hours preceding
the MI. They concluded that while there is an
increasedriskof MI
following sexual activity, the risk is about the
same for patients with and without previous
cardiac diseases. Thus, sexual activity has a
low probability of precipitating MI. However,
the question remains as to how soon after an
MI can full sexual activity be resumed.
and
sur-
a
history
is therefore
of
It
issue.5 Following
in the 24 hours
in
the
two hours
BABATUNDE A GBOLADE
Department of Obstetrics & Gynaecology and
Reproductive Health Care, Palatine Centre,
University ofManchester,
Manchester M20 3LT, UK
Accepted 10 February 1997
1 Banerjee A. Coital emergencies. Postgrad Med .7
1996; 72: 654-6.
2 Makinde 00, Gbolade BA. Traumatic injuries
of the lower female genital tract: a review of 32
cases. Trop
Obstet Gynaecol 1990; 8: 31 -3.
3 Adeleye JA. Vaginal injury during coitus in
Ibadan. A review of 50 cases. Niger Med _7
1971; 1: 234-7.
4 Sau AK, Dhar KK, Dhall GI. Non-obstetric
lower genital tract trauma. Aust NZI Obset
Gynaecol 1993; 33: 433-5.
5 Muller JE, Mittleman MA, Maclure M, Sher-
wood JB, Tofler GH. Triggering myocardial
infarction by sexual activity. Low absolute risk
and prevention by regular physical exertion.
3'AMA 1996; 275: 1405-9.
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doi: 10.1136/pgmj.73.862.525
1997 73: 525Postgrad Med J

R. Mittal and S. Bhan
Spinal tuberculosis.

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