Spinal Hydatid disease in Iraq "endemic area. Adel H. Al-hindawi. Ibrahim H. Witwit. Esam A. Al-sudany

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1 Spina Hydatid disas in Iraq "ndmic ara Ad H. A-hindawi Ibrahim H. Witwit Esam A. A-sudany A-Hia Taching Gnra Hospita, Babyon Univrsity/ Mdica Cog, Dpartmnt of Orthopdics & Nurosurgry M J B Abstract: spina hydatid disas is rar, vn in ndmic aras that considrd hydatid disas a significant probm. Twv cass of spina hydatid wr prsntd, and thir managmnt discussd. Th authors rviwd most of th rcnt itraturs and proposd a simp cassification for hydatid sions in th spin. Th study strssd on considration of this disas in th diffrntia diagnosis of backach and spina cord comprssion in ndmic aras bfor surgica intrvntion so that masurs can b takn to dcras compications and rat of rcurrnc. الخلاصة: مرض الا كیاس الماي یة في العمود الفقري نادر حتى في المناطق المستوطنة و التي تعتبر ھذا المرض مشكلة مھمة. اثنا عشر حالة أكیاس ماي یة فقریة قدمت في ھذه الدراسة مع مناقشة طریقة علاجھا. أجریت مراجعة لمعظم البحوث الحدیثة حول ھذا الموضوع وتم تقدیم نظام تصنیف بسیط لھذا المرض في العمود الفقري. ھذه الدراسة اقترحت بان یكون ھذا المرض في مناطق الاستیطان ضمن خیارات التشخیص المحتملة لحالات آلام العمود الفقري وحالات الضغط على الحبل الشوكي قبل إجراء أي تداخل جراحي لغرض اتخاذ الا جراءات التي تقلل من المضاعفات ونسبة رجوع المرض. Introduction H ydatid ( Grk- watry) disas is vry ancint, it has bn mntiond in th Tamod and rcognizd by Hippocrat, and by th Arabian physician, A-Rhazi who rfrrd to hydatid ivr in 900 AD. Churrir in 1807 dscribd spina invovmnt, and th first surgica intrvntion rportd was by Rydt in 1819(1,2). Hydatid disas is rar but significant parasitic disas in ndmic aras: Mditrranan, astrn Europan, ast Africa, cntra Asia and south Amrica, Austraia and nw Zaand(2,3,4). 335

2 Pathognsis: Hydatid disas is causd by th tapworm Echinococcus, which rsids in th bow of dogs or othr carnivor as a dfinitiv host, sgmnts of worm and ova pass out in th fcs and atr ingstd by on of th intrmdiat hosts usuay shp or catt or man. Hr th arva ar carrid via th porta circuation to th ivr, and occasionay byond to othr organs, whr thy produc s containing numrous scoics. Infstd mat is thn atn by dogs giving ris to a nw gnration of tapworm. Scoics carrid in th bood stram usuay stt in th ivr and somtims in th ung but occasionay in th bon producing hydatid s that sowy narg with itt rspct for cortica boundaris. Th bons most commony affctd ar th vrtbra, pvis, fmur and ribs. Th consist of an outr fibrous ayr and an innr grmina ayr containing scoics (4,5,6,7,8,9,10). In contrast to viscra disas, bon invovmnt is rar accounting for ss than 3% of organs invovd, haf of thm occurring in th spin: 50% in th thoracic rgion, 25% in umbar, and 25% crvica and sacra (2,3,7,911,12,13). In 90% of hydatid spin, th s ar confind to th bon and pidura spacs, whi intradura s occur in 9% ony which ar ithr primary or scondary to prvious surgry with dura tar (6,8,11,14,15,16,17,18,19,20). In ndmic aras, hydatid disas of th spin constitut a significant prcntag btwn causs of spina cord comprssion: 1.1% in Austraia, 3.8% in Turky, and 14% in Tunsia (3,8,9,12,15,21,22,23,24). Cinica faturs: In 20% thr is a history of trauma. Usuay a ong history of backach &/or signs of spina cord comprssion. Ths ar gradua in onst ik paraparsis and cauda quin syndrom, whi rapid onst may indicat vascuar compromis with ss chanc of rcovry (6,9,13,16,20,23,25). Diffrntia diagnosis: drmoid, ipoma, pyognic and tubrcuous infctions, arachnoid, mningoco. Bony sions: fibrous dyspasia, nchondroma, mtastatic maignancy, mutip myoma, and giant c tumor(1,5,7,13,24,26). Diagnosis: Bood tsts: Eosinophia in th priphra bood in 20% of cass. 9,16,19 Srodiagnosis: unik abdomina hydatid, in which ELISA (90%) and casoni (70%) tsts ar usfu in th diagnosis, thy ar not in spina hydatid bcaus of ss spcificity and snsitivity(9,10,16,19,23). Fin nd aspiration: shoud b avoidd bcaus of th risk of anaphyaxis and spiag of contnts if it rupturd(7,9,14,19,23,26). Imaging: Pain x-ray: ossous hydatid usuay appars as ytic sions surroundd by variab scrosis, vrtbra body comprssion fractur may b sn, paravrtbra soft tissu cacification is caimd to b mor suggstiv of th disas. Non-ossous hydatid may rod th pdics or narby bony surfacs(4,6,16,21,23,25). 336

3 Myography: usuay avoidd bcaus of th risk of anaphyaxis and intradura dissmination foowing ruptur(7,9,18,19). C T scan: is th bst imaging mthod for ossous sions(9,13,16). M R I: is th bst imaging mthod for non-ossous sions: sphrica or sausag-ik with tow doms, containing no spta or dbris insid, and showing no nhancmnt on contrast injction. Post-oprativ MRI is usfu to dtct missd s. Scanning of had, chst and abdomn may show xtra-spina s(3,6,13,16,22). Tratmnt: Surgry: is indicatd to confirm th diagnosis, to rif nura comprssion, and to maintain spin stabiity. In nonossous xtradura or intradura sion, surgica rmova of a s without ruptur shoud rsut in cur(4,8,24). Ossous sions ar th major chang bcaus spiag of scoics is unavoidab and tota s rmova is unachivab,thus rcurrnc is th ru. Th scond probm is that vrtbra body sion may rquir xtnsiv bony rsction that ncssitat grafting and stabiization usuay through imitd surgica fid(5,9,17,19,23,25,26,27). Compications: intraoprativ dath, incrasing nuroogica dficit, misdiagnosis and ruptur causing spiag, anaphyaxis, CSF fistua, scondary infction, rcurrnc, th mortaity rat: 0-3 % incrasing to 15% with subsqunt oprations(4,9,11,15,19,20,22,23). Scoicida agnts: th safst is 3% hyprtonic sain, povidon iodin can aso b usd. Othr agnts, usd in abdomina s, ar harmfu in spina sions ik chorhxidin, 80% acoho, 0.5% sivr nitrat, and 10% formain(1,2,6,24,25,26). Prognosis: thorticay, ony nonossous sions if compty rmovd without spiag is curativ, othrwis rcurrnc is th ro. Up to 40% is th rat of symptoms rcurrnc within 2 yars of initia opration, with furthr dtrioration of nuroogica status and spin stabiity. Parapgia is rportd to occur in 45% of patints with rcurrnc(3,7,10,14,17,22). Drug thrapy: abndazo or bttr mbndazo (both ar drivativs of bnzimidazo) is usd for 6 months in a dos of 400 mg 2 tims daiy. Though thy ar not curativ, but may dcras rat of rcurrnc(5,8,9,11,14,21). Matria and Mthods: A-Hia taching gnra hospita is th ony surgica hospita in A-Hia provinc that das with spin surgica disass, it aso rcivs cass from 7 hospitas in rura aras and somtims cass rfrrd from narby provincs. A coopration btwn orthopdic and nurosurgica dpartmnts startd th study by coction of spina hydatid cass in a priod of about 9 yars from Octobr 1999-Dcmbr History, physica xamination, aboratory invstigations and radiographic xaminations and CT &/or MRI wr don for vry patint prsntd with faturs of spina cord comprssion. Th diagnosis was unxpctd in haf of th cass (6/12) and prdictab in 6/12 cass: 3/6 wr rcurrnt cass, and 2 /6 wr having MRI faturs suggstiv of hydatid and 337

4 on with primary ossous sion. surgry prformd as wid aminctomy through th postrior approach for nuroogica dcomprssion at th v of spina invovmnt. Th surrounding surgica fid was packd with mops to prvnt oca spiag. Howvr, scoicida soutions, such as hyprtonic sain, wr not usd during surgry for far of chmica damag to th cord. So many tims. w hav surprisd with hydatid xtrudd aftr aminctomy and som wr arg nough ncssitating widr xposur at mutip vs. Unfortunaty, ruptur hav occurrd in 2 cass, this dfinity wi ad to dissmination, for this rason w foowd ths instructions in subsqunt cass: 1- putting th diagnosis in mind bfor surgry. 2- Carfu dissction and atraumatic surgry. 3- Saing-off surgica fid. 4- Avoid ruptur and dura tar. Postoprativ car: abndazo 400 mg thr tims daiy, aftr histoogica confirmation of th diagnosis, continud for 6-12 months. Gradua patint mobiization using spina bracs and physiothraputic car for owr imbs. Foow up: initiay vry 6 wks in th form of nuroogica rassssmnt and imaging study, thn according to patint condition. Rsuts: ( s th schdu) Twv patints hav bn sn and tratd: 9 nw cass pus 3 rcurrnt. Most of thm ( 9/ 12) 75% wr from rura aras. Svn wr fma and 5 wr ma with fma: ma ratio of 1.4: 1. thir ag rangd from yars with an avrag of 42 yars. Th spina v invovd was: 4 cass-dorsa, 3 cass-dorsoumbar junction, 5 cassumbar. A patints prsntd with cinica faturs of spina cord comprssion: nuroogica dficit in variab grads and in diffrnt vs in th owr imbs. W hav dividd hydatid sions in th spin into: Ossous: Primary ossous on cas cass Scondary ossous 3 rcurrnt Non-ossous: Extradura 8 cass Intradura 0 cass A patints undrwnt surgry: in 9/12 w did wid fu aminctomy achiving dcomprssion and rmova ( 2 cass show spiag). For th 3 rcurrnt cass, aminctomy at anothr vs was don for two, and xcision for on. Rcurrnc hav bn sn in 6/12 cass, 3 cass wr arady rcurrnt, 2 wr thos who showd spiag inraoprativy, and on with primary ossous sion. Discussion: Hydatid disas is a rar but significant disas in ndmic aras, about haf cass of muscuoskta hydatid invovs th spin, in this study w hav 12 cass of hydatid spin and this mans that our ara(iraq) is ndmic of hydatid disas(2,3,4). Th fma: ma ratio is 1.4: 1 this fma prdiction may b du to th fact that most of farm works in Iraq is don by fma rathr than ma. 338

5 Th ag rang was 42 yars, this at onst is ratd to th vry sow arva growth in this intrmdiat stag. Th v of spina invovmnt was: dorsa in 4/12 (33%); dorsoumbar in 3/12 (25%); and umbar in 5/12(42%); this sighty diffrs from that of most rports: 50% dorsa; 25% umbar; and 25% crvica and sacra(1,3,6,9,10,11,14,18,20,25). A 12 cass ar prsntd with nuroogica symptoms of th owr imbs with various grads and svrity according to th v of invovmnt,most cass ar prsntd with back pain(80%),radicuar pain(90%),parapriss(20%) and qauda quin(12%),ths figurs ar nary simiar to that of othr studis(4,5,8,10,12,15). Hnc, th importanc of rmmbring hydatid as a possib caus of spina cord comprssion spciay in ndmic ara(3,6,9,11,23,26,27). By rviwing most of rcnt itraturs on spina hydatid, w found most of thm considrd spina hydatid as a part of bon disas 1% of hydatid disas patints hav bon sion, haf of thm affcting th spin (1,2,4,6,7,9,10,11,13,15,17,18,19, 20,23,24,25,,26,27),this statmnt was rpatd in most of ths itraturs and at th sam tim thy rportd that 90% of spina hydatid sions ar nonossous xtradura To avoid confusion, w hav cassifid spina hydatid sions into : Ossous : primary ossous---affcting bony part of spin. Scondar yossous---foow rcurrnc of nonossous sion Non-ossous: primary non-ossous--- ithr intra-dura or xtra-dura. Scondary nonossous---foow rcurrnc of primary ossous sion. Rcurrnc: In spit of 6-12 months abndazo thrapy, rcurrnc hav occurrd in 6/12 cass within th first yar of foow-up( provd by MRI), this high rat of rcurrnc indicats th inffctivnss of drug thrapy and th maignant bhavior of th disas Concusion: Spina hydatid disas shoud b considrd in th diffrntia diagnosis of spina cord comprssion syndrom in ndmic countris. Du to th rativ rarity of th ntity most diagnoss ar mad intraoprativy which incrass th risk of futur rcurrncs Extrm caution shoud b takn not to ruptur th xtradura s as compt rmova might potntiay rsut in cur. Mdica thrapy is of no vau in th tratmnt or contro of rcurrnc aftr surgica rmova with spiag of s. Th prognosis in cass of hydatid disas rcurrnc is poor in comparab to that of maignancis. Rfrncs: 1.k S t a. Spina hydatid disas. Spina Cord 1998; 36: Barnouti H. N. Human hydatid disas(ecchinococcosis). Arviw Artic, Arab Journa of Mdicin 1985:vo. 4:No. 8, P

6 3- Rao S, Parikh S, Krr R. Echinococca infstation of th spin in North Amrica. Cin Orthop Rat Rs 1991; 271: Atinörs N, Bavbk M, Canr H, Erdoan B. Cntra nrvous systm hydatitosis in Turky: a cooprativ study and itratur survy anaysis of 458 cass. J Nurosurg 2000; 93: Baysfr A t a. Hydatid disas of th spin. Spina Cord 1996; 34: Pamir MN, Akaan N, Özgn T, Erbngi A. Spina hydatid s. Surg Nuro 1984; 21: Bttaib A, Khaid T, Bn Rhouma T, Touibi S.Th vrtbro-mduary chinococcosis. Nurosurgry: 1978; 24: Bhojraj SJ, Shtty NR. Primary hydatid disas of th spin: An unusua caus of progssiv parapgia. J Nurosurg (Spin 2) 1999; 91: Lam KS, Faraj A, Muhoand RC, Finch RG. Mdica dcomprssion of vrtbra hydatidosis. Spin 1997; 22: Sapkas GS, Stathakopuos DP, Babis GC, Tsarouchas JK. Hydatid disas of bons and joints. Acta Orthop Scand 1998; 69: Özk MM. Compications of cntra nrvous systm hydatid disas. Pdiatr Nurosurg 1994; 20: Mis TJ. Parapgia du to hydatid disas. J Bon Joint Surg 1956; 38B: Rayport M, Wisoff HS, Zaiman H. Vrtbra chinococcus. J Nurosurg 1964; 21: pikçiogu AC t a. Spina invasion of pumonary hydatidosis: Computd tomographic dmonstration. Nurosurgry 1991; 29: Baybk M, nci S, Tahta K, Brtan V. Primary mutip spina xtradura hydatid s of th itratur: Cas rport and rviw. Parapgia 1992; 30: Pandy M, Cahudhari MP. Primary hydatid of sacra spina cana: cas rport. Nurosurgry 1997; 40: Özr F, Özk MM, Pamir MN, Erzn C. Magntic rsonanc imaging in th diagnosis of spina hydatid disas. Parapgia 1993; 31: Turgut M. Hydatid disas of th spin: a survy from Turky. Infction 1997; 25: Sparks AK, Connor DH, Nafi RC. Echinococcosis. In: Binford CH, Connor DH (ds) Pathoogy of Tropica and Extraordinary Disass Vo.2, AFIP: Washington D.C., 1976, pp Lightfowrs M, Godstin B. Immunodiagnosis of Echinococcus. In: Thompson RCA, Lymbrty AJ (ds) Echinococcus and Hydatidosis Waingford: CAB intrn, 1995, pp King C. Cstods. In: Mand GL, Bnnt JE, Doin R (ds) Princips and practic of Infctious disass 4th dn Churchi & Livingston, 2000, pp Kiough KK, Lusbough WB, Harky HL. Parasitic infstations of th 340

7 spin. In: Osnbach RK, Zidman SM (ds) Infctions in Nurosurgry Lippincott & Ravn: Phiadphia, 1999, pp Gi-Grand L t a. Randomisd controd tria of fficacy of abndazo in intraabdomina hydatid diasas. Lanct 1993; 342: Tkkök H, Bni K. Primary spina xtradura hydatid disas: rport of a cas with magntic rsonanc chararctristics and pathoogica corration. Nurosurgry 1993; 33: k S, Zii M, Erahin Y. Intradura spina hydatid s. Eur Spin J 1998; 7: Sharma A, Kashyap V, Abraham J, Kurian S. Intradura hydatid s. Surg Nuro 1981; 16: Ly A, Marti A. Intramduary hydatid. J Nurosurg 1970; 33:

8 Schdu as summary of a cass 7. ma 26 urba n 8. fma 45 rura M RI +v +v Prvious history -v Opration Laminctomy, cord dcomprssion Laminctomy,xcision of th No. Sx Ag Spina v Sit 1. fma 51 rura D9- Primary ossous 2. ma 40 urba L3-4 xtradura n scondary ossous 3. ma 32 rura 4. fma 44 rura D fma 28 rura 6. fma 58 rura L3-4 xtradura +v -v Laminctomy,xcision of th xtradura -v -v Laminctomy,ruptur and sippag D9-10 xtradura -v -v Laminctomy,xcision of th D7-8 xtradura -v -v Laminctomy,xcision of th D10- +v Laminctomy,xcision of th 12-L1 xtradura scondary ossous L4-5 xtradura -v -v Laminctomy,xcision, ruptur and sippag Rcurr. 9. ma 55 urba n D12- L1-2 xtradura -v -v Laminctomy,xcision of th 10 fma 35 rura L4-5 xtradura -v -v Laminctomy,xcision of th 11 fma 48 rura D11- scondary +v Excision of th 12L1 nonossos 12 ma 40 rura L4-5 xtradura +v -v Laminctomy,xcision of th Th diffrncs btwn ossous and nonossous hydatid ar brifd hr: Primary Non-ossous Primary Ossous Incidnc Common (>90%) Rar (<10%) Nuroogica dficit Eary & svr Lat& ss svr Spin stabiity Not affctd Affctd ary Surgica approach Postrior(aminctomy)& xcision Antrior (corpctomy) & grafting & stabiization Prognosis Cur if xcisd without ruptur Rcurrnc is th ro 342