SPONDYLITIS TUBERCULOSIS

Definition
Spinal tuberculosis is one of the oldest diseases known to mankind and has
been found in Egyptian mummies dating back to 3400 BC. The disease is
popularly known as Potts spine. The classic destruction of the disk space and the
adjacent vertebral bodies, destruction of other spinal elements, severe and
progressive kyphosis subsequently became known as Potts disease. Currently, the
term Potts disease/Potts spine describes tuberculous infection of the spine. (8)
Tuberculous spondylitis (TBS) is the most common form of extrapulmonary tuberculosis. Most of TBS patients belong to poor socio-economic
status, which cannot afford costly treatment and cannot be off job for long time
for nancial reasons.(3). Most of the patients with TBS are treated conservatively;
however in some patients surgery is indicated. The most common form of TBS
involves a single motion segment of spine (two adjoining vertebrae and their
intervening disc). Sometimes TBS involves more than two adjoining vertebrae,
when it is called multilevel TBS.
In developed nations, most cases of spinal tuberculosis are seen primarily in
immigrants from endemic countries. Because the epidemic of human
immunodeficiency virus (HIV) infection caused resurgence in all forms of
tuberculosis.
Epidemiology
Tuberculosis is a disease of poverty that affects mostly young adults in their
most productive years. The risk of developing tuberculosis is estimated to be 20
37 times greater in people co-infected with HIV than among those without HIV
infection. In 2009, approximately 1.2 million new tuberculosis cases were
reported among people living with HIV; 90% of these cases were concentrated in
the African and South East Asian regions. The highest number of tuberculosisrelated deaths were in Africa. Although multidrug-resistant tuberculosis is not
common in spinal disease, there have been a few recent case reports.
Approximately 10% of patients with extrapulmonary tuberculosis have skeletal

involvement. The spine is the most common skeletal site affected, followed by the
hip and knee. Spinal tuberculosis accounts for almost 50% cases of skeletal
tuberculosis. Spinal tuberculosis is uncommon in the western world. Most of the
patients with spinal tuberculosis in developed countries are immigrants from
countries where tuberculosis is endemic.
A study evaluated the epidemiology of musculoskeletal tuberculosis in
United Kingdom and a review of data of musculoskeletal tuberculosis over a 6
year period was performed. From 1999 to 2004, there were 729 patients with
tuberculosis. Approximately 8% (61) cases had musculoskeletal involvement;
nearly 50% of these patients had spinal involvement. The majority (74%) of
patients was immigrants from the Indian subcontinent. In France, in a hospital
based survey, the overall incidence of vertebral osteomyelitis was estimated at
2.4/100 000. In 20022003, 1422 and 1425 patients were classified as definite
(64%), probable (24%), and possible (12%) vertebral osteomyelitis. The main
infectious agents reported were Staphylococcus spp. (38%) and Mycobacterium
tuberculosis (31%). In endemic countries, spinal tuberculosis is more common in
children and younger adults.
Tuberculous spondylitis has been common in developing countries, and the
number of patients with the disease has also been increasing recently in developed
countries. Tuberculosis of the spine accounts for 1% of all tuberculous infections,
and 25% to 60% of all bone and joint infections are caused by tuberculosis.(4)
Aetiology and Bacteriology
In addition the probable sources of infection are those of soft tissue and
respiratory tract among others. Most common causes of iatrogenic disc infection
are spinal surgery and invasive manipulation. Tuberculous spondylitis is most
commonly caused by Mycobacterium tuberculosis, but any species of
Mycobacterium may be responsible (4)
Diagnose
Clinical manifestations of tuberculosis of the spine: 1) afternoon fever,
fatigue, night sweats, loss of appetite, anemia; 2) accompanied by other organs of

active or old tuberculosis, tuberculosis in the lungs and kidneys as much; 3) to the
thoracic spine The most common lumbar T12L1 involvement; 4) persistent low
back pain and chest and back pain, local percussion pain, radiating pain associated
with nerve root and the corresponding muscle spasms, mostly formed paraspinal
or psoas abscess, kyphosis, sports disorder, often due to epidural abscess,
sequestrum, cheese substance, tuberculosis granulation tissue necrosis caused by
spinal disc compression and paraplegia. (9)
Clinical features
The characteristic clinical features of spinal tuberculosis include local pain,
local tenderness, stiffness and spasm of the muscles, a cold abscess, gibbus, and a
prominent spinal deformity. The cold abscess slowly develops when tuberculous
infection extends to adjacent ligaments and soft tissues. Cold abscess is
characterized by lack of pain and other signs of inflammation (Fig. 1). The
progression of spinal tuberculosis is slow and insidious. The total duration of the
illness varies from few months to few years. Usually, patients seek advice only
when there is severe pain, marked deformity, or neurological symptoms. The
classical constitutional features of tuberculosis indicating presence of an active
disease are malaise, loss of weight and appetite, night sweats, evening rise in
temperature, generalized body aches, and fatigue. Back pain is the most frequent
symptom of spinal tuberculosis. The intensity of pain varies from constant mild
dull aching to severe disabling. Pain is typically localized to the site of
involvement and is most common in the thoracic region. The pain may be
aggravated by spinal motion, coughing, and weight bearing, because of advanced
disk disruption and spinal instability, nerve root compression, or pathological
fracture. Chronic back pain as the only symptom was observed in 61% of cases of
spinal tuberculosis. The reported incidence of neurological deficit in spinal
tuberculosis varies from 23 to 76%. The level of spinal cord involvement
determines the extent of neurological manifestations. In cervical spinal
tuberculosis, patients manifest with symptoms of cord or root compression. The
earliest signs are pain, weakness, and numbness of the upper and lower
extremities, eventually progressing to tetraplegia.

Formation of a cold abscess around the vertebral lesion is another

characteristic feature of spinal tuberculosis. Abscess formation is common and can
grow to a very large size. The site of cold abscess depends on the region of the
vertebral column affected. In the cervical region, the pus accumulates behind
prevertebral fascia to form a retropharyngeal abscess (Fig. 2). The abscess may
track down to the mediastinum to enter into the trachea, esophagus, or the pleural
cavity. Retropharyngeal abscess can produce considerable pressure effects such as
dysphagia, respiratory distress, or hoarseness of voice. In the thoracic spine, the
cold abscess usually presents as a fusiform or bulbous paravertebral swellings and
may produce posterior mediastinal lumps (Fig.3).
Spinal deformity is a hall mark feature of spinal tuberculosis. Type of spinal
deformity depends on the location of the tuberculous vertebral lesion. Kyphosis,
the most common spinal deformity, occurs with lesions involving thoracic
vertebrae. The severity of the kyphosis depends on the number of vertebrae
involved. An increase in kyphotic deformity by 10 or more may be seen in up to
20% of cases, even after the treatment. Atlanto-axial tuberculosis may present as
torticollis.
Laboratory Features
The definitive diagnosis of spinal spondylitis can only be made from
microscopic or bacteriological examination and culture of the infected tissue.
However the diagnosis must be considered in combination with corresponding
changes in clinical manifestations, radiological findings, blood and tissue cultures
and histopathological findings.
1. Laboratory evaluation
The erythrocyte sedimentation rate (ESR) and gram stain and culture are the
commonly used laboratory tests in the diagnosis of pyogenic spine infections.
C-reactive protein (CRP) has been shown to be helpful in the diagnosis of
infection and has supplanted ESR as the laboratory study of choice for
assessing the presence of infection. Koo et al described that the ESR and CRP
level were significantly higher in the patients with pyogenic spondylitis than
tuberous spondylitis. Polymerase chain reaction has been used to rapidly

identify the presence of mycobacterium in formaldehyde solution-fixed,

paraffinembedded tissue specimens.
2. Plain radiologic evaluation
The earliest and most common radiographic finding is narrowing of the disc
space in pyogenic spondylitis. It is due to the disc destruction by proteolytic
enzyme and is followed by irregularity of endplate from the bone destruction.
In progression and healing of the disease, osteolytic changes are followed by
new bone formation and osteosclerotic changes at the vertebral margins. The
findings of plain radiographs for tuberous spondylitis may vary depending on
the pathologic type and chronicity of the infection. In early tuberous
spondylitis, the disc space is preserved more than pyogenic spondylitis from
the lack of proteolytic enzyme. Radiographs may show osteoporosis of body
and irregularity of endplate, among others.
3. CT Scan: 1) bone changes spinal tuberculosis as osteolytic bone destruction,
destruction of lesion or most often involving the vertebral one. See the
destruction of multiple foci of irregular sequestrum, often involving the
destruction of the vertebral pedicle rear (Figure 7), adjacent vertebral density
generally reduced. 2) changes in the intervertebral disc: both are associated
with destruction of the adjacent vertebral disc space narrowing, disc damage,
whereas CT showed tuberculous disc damage, uneven density, there are stars
like dead bone residue dispersed therein, bone and joint destruction or
disappearance of the irregular surface (Figure 9). 3) paraspinal abscess:
paraspinal soft tissue between the vertebrae are connected to the damaged area,
irregular shape, clear boundaries, pushing the adjacent psoas muscle
tuberculosis group not only paraspinal abscess formation, and Common
calcification within the abscess, abscess often than vertebra length, forming a
single room or multiple rooms or flow injection into the spinal abscess.
4. Magnetic resonance imaging
MRI has been reported to be beneficial for early diagnosis and differential
diagnosis of the spondylitis and is being extensively used for diagnosis. As for
tuberculous spondylitis, it typically starts from the anterior cancellous bone in
the vertebral body followed by vertebral body starting to be destructed,
extending beneath anterior longitudinal ligament and creating an abscess near
the vertebral body. Many of the studies dealing with tuberculous spondylitis

have reported that abscess involves uniquely multiple vertebral bodies,

especially in gadoliniumenhanced MRIs. Chang et al has reported that
aforementioned form of contrast enhancement is completely shown in
tuberculous spondylitis. Destruction of vertebral bodies in tuberculous
spondylitis entails more of such contrast enhancement. It is assumed that
abscess is formed more and also available to be used for beneficial indices
when performing a differential diagnosis. Epidural extension and epidural
abscess formation have been reported to be observed more in tuberculous
spondylitis. As for paraspinal abscess formed in tuberculous spondylitis,
contrast enhancement is known to be more easily performed in the rim of
abscess, with the importance of a differential diagnosis. In other words,
paraspinal abscess is frequently found in pyogenic spondylitis; but welldefined paraspinal abnormal signal, thin and smooth abscess wall and presence
of paraspinal or intraspinal abscess are more suggestive of tuberculous
spondylitis than of pyogenic spondylitis. On the other hand, if the wall of
abscess is relatively thick entailing irregular contrast enhancement, it has been
reported to be implying pyogenic spondylitis. Chang et al has reported that
cases with grade 3 or above and destructed more than 50% of vertebral body
height were observed in 82% of all cases in tuberculous spondylitis.