TUBERCULOSIS OF SPINE

CASE SUMMARY
Name

:Rushanita Ahmad

R/N

:172943

Mrs Rushanita is a 35 years old Malay lady who presented in early

September 1999 with the complaint of progressive left sided body
weakness and backache. It was associated with occasional headache and
progressive loss of appetite and weight. She was diagnosed by National
Tuberculosis Centre (NTBC) as widespread tuberculosis with:a.

Loculated right psoas abscess; surgical drainage was done

b.

Pulmonary TB with right lung upper zone cystic lesion

c.

Extensive spinal tuberculosis from T4 to T12

d.

Tuberculosis meningitis with brainstem tuberculoma;

Ventriculo-peritoneal shunt was done by Neurosurgical team.

She was treated initially with anti-TB drugs and body cast. Earlier,
surgical intervention was delayed because of patients reluctance. She
was presently admitted for anterior debridement and strut bone allograft
with possibility of posterior instrumentation.

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On examination, she was pink and not cachexic. Her vital signs were
normal. She had left hemiparesis with power of 4/5 for both her upper
and lower limbs. There was decreased sensation from C4 to S2 on her left
side and affected side limb reflexes were reduced. Her right upper and
lower limbs were normal. No cranial nerves signs noted and there was no
other neurological deficit.

Proper spinal examination was not done as she was on body cast.
Examination of other systems revealed normal findings.

Radiograph of her spine showed extensive vertebral bodies destructions

of T7 to T12 with posterior column involvement including the transverse
process. Parts of the intervertebral disc spaces were also reduced but
there was no obvious kyphosis noted.

Surgical Procedure
Patient was put on right lateral position for left thoraco-abdominal
approach of her spine. Seventh rib identified by palpation prior to
surgical incision and marked. Based on the seventh rib, a curved

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incision is made extending forward towards infra-mammary crease and

backward at the level between the thoracic spines and medial border of
the scapula.

Lattisimus dorsi and serratus anterior muscles identified and were

divided along the skin incision down to the ribs. The seventh rib was
then stripped off the periosteum and resected. A rib spreader was then
placed between the adjacent ribs for better exposure.

The diaphragm was released along its peripheral border to expose the
affected vertebrae. Two intercostal vessels that pass through it were
ligated. The right lung was deflated for better exposure. The affected
vertebral body was marked with a K-wire and checked under image
intensifier.

Intraoperatively, there was complete destruction of T7 to T12 vertebral

bodies with sequestum and pus formation; caseous in nature. The
affected discs were also destroyed. All the necrotic tissues were debrided
resulting with a massive bony defect at anterior column of the affected

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vertebrae. The strut humeral shaft allograft was used to stabilize the
defect.

The allograft was prepared and cut according to the size of the defect.
Seventh rib and cancellous bone graft, which was taken from patients
iliac crest, were packed within the medullary cavity of the humeral
allograft. The prepared allograft was then carefully inserted into the
defect area. The right lung was re-inflated and chest tube was inserted.
Peripheral cut margins of the diaphragm were carefully closed.

Wound was then closed in the layers and was dressed with povidonesoaked gauzes. Post-operatively, patient was monitored in Intensive Care
Unit and body cast was then applied on day 14 of operation. Posterior
instrumentation is not done in this patient due to financial constraints.

INTRODUCTION
The incidence of spinal TB varies throughout the world and usually
proportionate to the quality of the public health services. Increasing
incidence of drug abuse, acquired immunodeficiency diseases, free flow
of migrants and development of drug-resistant strains contributed to the

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increasing TB cases. Bone and joint involvement occur in 10 % of

patients with tuberculosis and half of these affected patients were
tuberculosis of spine. Neurological deficit present in 10 to 47 % of those
with tuberculosis spondylitis and can be early or late in the course of the
disease (1). Sir Percival Pott was the first person noted association
between the thoracic spine deformity with paralysis that is often seen
with this disease in 1779 (2). The occurrences of TB in children are more
malignant in the extent and degree of abscess formation but less
associated paraplegia and the reverse is usually the case in adult type
(3).

Mycobacterium tuberculosis is the pathogen responsible for spinal

tuberculosis. It is usually a secondary infection, with the primary
extraspinal lesion in the chest or genitourinary system. These primary
sites may be quiescent.

Paradiscal
In this form of involvement, the primary infection focus begins at the
vertebral metaphysis and erodes to the cartilaginous end-plate resulting
in disc space narrowing. It is the most common pattern and is commoner

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in adults. In contrast to pyogenic disciitis, the disc is usually preserved

and resistant to tuberculosis because of its avascularity. The result of
bone infarction leading to necrosis would cause decrease in vertebral
height and size, which, if significant, may cause kyphotic deformity.
Anterior
An anterior lesion occurs with bony destruction under the anterior
longitudinal ligament. With increasing accumulation in the abscess,
tension rises and strips off of the anterior longitudinal ligament and
periosteum from the anterior surface of the vertebral body. Anterior
scalloping occurs, most commonly in the thoracic spine in children.
These lesions however could affect several adjacent vertebral bodies.
There is minimal bone destruction, so kyphotic deformity is rare.
Central
This lesion, which is common in children, generally involves the whole
vertebral body. They tend to lead to vertebral collapse and therefore are
the most likely type to produce significant spinal deformity.
Tuberculosis infection of the posterior elements of the spine is rare and
the use of computed tomography scanning is helpful in making the
diagnosis of the posterior involvement.

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Diagnosis
The diagnosis is usually made with a high index of suspicion in endemic
areas in the presence of pain and appropriate clinical symptoms and
signs of a systemic chronic infection. Typical plain radiographic changes
include destruction of two adjacent vertebral bodies, narrowing of the
intervening disk, scalloping of the anterior vertebrae, and a fusiform
paravertebral

abscess

shadow.

Although

computed

tomography

demonstrates the bony details and the soft tissue calcification better, MRI
is most useful in diagnosing early or multicentric lesions before plain
radiographic changes become obvious.

The lesion in the T1-weighted images appears hypointense and in the T2images hyperintense, and lesions are further enhanced by intravenous
gadolinium DTPA injection. The enhancement is typically in the rim,
which corresponds to the inflammatory reaction in the periphery, while
sequestrum in the center remains hypointense. This finding, though
sensitive, is not specific for tuberculosis and may be mimicked by
pyogenic infection or neoplasia (4).
Furthermore, MRI is superior to CT in showing tuberculous arachnoiditis
and extradural or intradural spread of the abscess or granulation tissue.

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Technitium-99m

methylene

diphosphonate

and

gallium-67

isotope

scanning have sensitivities of about 92% and 88.5% respectively, but

neither of them is specific enough for routine use as a diagnostic tool (5).
Tuberculosis is an excellent mimicker; neither clinical nor imaging
criteria are absolutely pathognomonic.

A biopsy usually necessary to confirm the diagnosis, especially in

nonendemic areas, and has become one of the indications for surgical
intervention (6). Recent advances in CT-guided fine needle aspiration and
video-assisted thoracoscopic surgery have enabled less invasive way of
taking a biopsy or draining an abscess while at the same time obtaining
a relatively high cytologic yield of about 88.5% (7). Bacterial count in a
spinal focus is very low compared with that in pulmonary lesions,
however, the presence of the typical epitheloid granuloma, Langerhan
multinucleated giant cell, and caseation are already sufficient for making
the diagnosis. Recent advances in the polymerase chain reaction also
have it limitations in these extra pulmonary diseases (8).

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The disease occurs most frequently in thoracic spine followed by lumbar

and thoraco-lumbar junction. Paraplegia due to spinal tuberculosis has
been classified into 2 groups:
i) Paraplegia of early onset is caused by spinal cord compression from
liquid or caseous pus and inflammatory granulation tissue of the active
disease. Less commonly, pachymeningitis or myelitis can also produced
significant neural deficits, which carry a much poorer prognosis.
ii) Paraplegia of late onset or healed diease, the spinal cord is
compressed by healed bony scars, calcified caseous material, fibrosis and
increasing deformity of the internal kyphus.

The deterioration of neurology is more related to the amount of spinal

canal compromise than to the amount of kyphosis (9). Obviously, the
onset of paraplegia depends on the rapidity of increase of mechanical
cord compression, and in spinal tuberculosis the spinal cord can tolerate
50 to 76% of canal stenosis before neurologic deficit appears (10). In
general, neurologic complications are more frequent and serious in
diseases affecting the cervical spine. The other less commonly involved
but more problematic part of the spine is the lumbar and lumbosacral

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region. Preservation of the lumbar lordosis is important in this area to

prevent chronic backache later (11).

Treatment
The goals of treatment are:
i.

To eradicate infection

ii.

Preservation or restoration of neurologic integrity

iii.

Prevention or correction of spinal deformity.

Conservative treatment
The mainstay of treatment is antituberculosis chemotherapy. The first
line drugs currently in used include isoniazid (INH), rifampicin (RMP),
pyrazinamide, (PZA), streptomycin (STM), and ethambutol (EMB). A new
number of second line agents that are use in special condition include
ethionamide, cycloserine, kanamycin, and para aminosalicyclic acis
(PAS). These drugs are used in cases of poor clinical response, side
effects or demonstrable resistance of bacillus to the first line drugs.

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INH and RMP are bactericidal against both extracellular and intracellular
organisms. PZA are bacterial only in acidic environment and effective
against intracellular organism or within caseous lesions. STM is active
only in the extracellular space and often used to complement PZA. EMB
is bacteriostatic against both intra and extracellular organisms.

All drugs have potential toxicity. Hepatitis may be caused by both INH
and RMP, and it is 4 times more common in patients receiving both
agents than in those receiving INH alone. INH also can cause peripheral
neuritis which is dose dependent. Major toxicity of STM is vestibulocochlear nerve damage and nephrotoxicity and EMB could cause
significant optic neuritis.

The recommended regime for a newly diagnosed patient is 2 months of

PZA, INH and RMP daily followed by 4 months of INH and RMP; given
daily. An alternative but less patent regime is INH and RMP given daily
for 9 months, with or without addition of streptomycin or ethambutol
daily for the first 2 months. Nine months and more recent six months
regimes have found to be effective when INH and RMP are combined and
augmented by PZA and either STM or EMB in early stages of disease (1).

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Antimicrobial resistance may occur from the multiplication of resistant

mutant under monotherapy regime. Fortunately, resistance is low with
drug regimens as long as the patient is compliant.

Through a series of prospective studies performed by Medical Research

Council in Asia and Africa, chemotherapy was established as an effective
treatment for majority of patients with spinal tuberculosis. The 13 th MRC
reports 1999 have shown excellent results of chemotherapy as an
outpatient basis without bed rest, splintage or surgery, in term of healing
of spinal disease and bony fusion. Six or nine months of RMP-containing
regimens were excellent and as effective as 18 months of INH plus EMB
or PZA as shown by 14th MRC reports.

Surgical Management of Spinal Tuberculosis

The indications for surgery included severe pain from the expanding
abscess, tissue biopsy for diagnosis, neurologic deterioration from spinal
cord compression, and correction or prevention of kyphosis (12). Patient
with neurological deficit are graded using Frankel Classification as a
guide for surgical decision. Patients with Frankel A and B lesions should
go for immediate anterior decompression and fusion after localization of

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the offending pathology using MRI and immediate administration of

antituberculous chemotherapy. A 6 month trial of chemotherapy was
indicated in all other patients including those with Frankel C and D
neurological deficits. Surgery was postponed until deterioration in
neurological deficit (13).

The most efficacious surgical procedure is Hong Kong anterior radical

debridement followed by bone grafting. Debridement without grafting and
external support was proved to be unreliable to prevent spinal deformity
when compared to chemotherapy alone or with simple debridement (MRC
trial). Despite solid anterior fusion, deformity may progress in children
because of disproportionate anterior and posterior spinal growth (13).
Uphadhyay et al compared the long term changes, after a radical
operation of TB spine, in 33 children versus 71 adult patients. Kyphosis
and scoliosis deformity was measured at 6 months, 1 year and 5 years
post operatively and no significant differences detected in both groups.
Thus, they concluded that growth of the posterior portion of spine does
not contribute to the progression of deformity after a radical anterior
procedure (14).

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Although anterior strut bone grafting can achieve very high rates of
fusion, loss of correction does occur as a result of graft fracture,
resorption

or

subsidence

into

the

recipient

site.

Therefore,

instrumentation has been done to improve and maintain deformity

corrected. Supplementary posterior fusion is suggested as an adjunct to
anterior fusion in patients with destruction of two or more vertebral
bodies or if there is instability because of destruction of the posterior
elements (15). For patients who have more severe disease and kyphotic
deformity which needed anterior debridement and strut fusion, short
segment anterior instrumentation has also been found to be safe and
maintenance of the deformity correction, provided the posterior column
is intact (16).

SUMMARY

Tuberculosis remains a major health problem in most parts of the world.

Paraplegia is one of the most disabling and distressing complications.
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The mainstay of the treatment is chemotherapy. Operative treatment

involves decompresion and removal of the diseased tissues together with
stabilization of the affected spine. Age, sex and site of the lesion have no
influence on the prognosis, whereas paraplegia of longer duration,
paraplegia in flexion and poor patient compliance carries a bad
prognosis.

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