 SPECIALTY UPDATE

Spinal tuberculosis
REVIEW OF CURRENT MANAGEMENT

R. N. Dunn, Tuberculosis (TB) remains endemic in many parts of the developing world and is
M. Ben Husien increasingly seen in the developed world due to migration. A total of 1.3 million people die
annually from the disease. Spinal TB is the most common musculoskeletal manifestation,
From Groote Schuur affecting about 1 to 2% of all cases of TB. The coexistence of HIV, which is endemic in some
Hospital, Cape regions, adds to the burden and the complexity of management.
Town, South Africa This review discusses the epidemiology, clinical presentation, diagnosis, impact of HIV
and both the medical and surgical options in the management of spinal TB.
Cite this article: Bone Joint J 2018;100-B:425–31.

 R. N.Dunn, MBChB (UCT),
MMed Orth, FCS (SA) Orth,
HOD/Pieter Moll and Nuffield
Chair of Orthopaedic Surgery
 M.Ben Husien, MBChB, FC
Neurosurg (SA), MMed (UCT),
AOSpine Fellow
University of Cape Town and
Groote Schuur Hospital, Cape
Town, South Africa.
Correspondence should be sent
to R. Dunn; email:
robert.dunn@uct.ac.za
©2018 The British Editorial
Society of Bone & Joint
Surgery
doi:10.1302/0301-620X.100B4.
BJJ-2017-1040.R1 $2.00
Bone Joint J
2018;100-B:425–31.
Spinal tuberculosis (TB) is one of the oldest
diseases known to man having been identified
in Egyptian mummies dated before 3300 BC1
and often referred to as Pott’s disease. Percival
Pott described the associated paraplegia due to
destruction of the anterior spinal column and
progressive kyphosis, in 1779.2,3
Epidemiology
In 2015, there were 10.4 million new cases of
TB globally, 11% of which were in HIV
positive patients. In the same year, 1.8 million
people died from TB.4 Spinal TB is more
common in young adults and children and has
been labelled “a disease of poverty”3 due to its
higher incidence in lower income households
and poorly developed countries. Although the
incidence of TB is highest in the developing
world, particularly southern Africa, where it
approaches 1%, it is increasingly seen among
immigrants in the western world.5
Extrapulmonary TB represents 10% of
cases, of which half involve the
musculoskeletal system. The spine is the most
common musculoskeletal site representing
between 1% and 2% of cases.6
The reason for the high incidence in Africa
includes socioeconomic factors of poverty and
poor access to health facilities and its
association with HIV disease. Sub-Saharan
Africa has 25.6 million HIV positive people,
which represents 70% of the total number of
HIV positive patients in the world.4 HIV
reduces the cellular immunity required to
control TB by preferentially targeting TB-
specific CD4 cells. This increases the incidence
of TB infection, the rate of reactivation of
latent disease and of extrapulmonary disease. TB
in turn accelerates the replication of HIV infected
CD4 cells, increasing viral production.7 A genetic
predisposition to spinal TB has been seen in
Chinese patients with FokI polymorphism in the
vitamin-D receptor gene.8
Spinal TB follows the haematogenous
spread of mycobacterium tuberculosis into the
cancellous bone of the vertebral bodies from
lesions in the lungs or genitourinary system by
venous or arterial routes.9 Haematogenous
spread is facilitated by the arterial arcade that
flows through the subchondral region of each
vertebra, from posterior and anterior spinal
arteries which form a rich local vascular
plexus.10 The disease is characterized by the
paradiscal destruction of a vertebral body
leading to kyphosis with preservation of the
disc until late in the disease process (Fig. 1).
The kyphosis with epidural pus and disc and
osseous debris can lead to compression of the
spinal cord and neurological sequelae.
Occasionally, concertina collapse may occur
with compression at a single vertebral body
without intervertebral disc involvement.11
Late-onset paraplegia may occur despite
resolution of the active disease, due to severe
persistent kyphosis with attenuation of the
spinal cord over the internal gibbus. This leads
to myelomalacia, which is irreversible, and
poor neurological recovery despite subsequent
surgery. Thus, early control or correction of
kyphosis is required.12
Clinical features. The onset of spinal TB is
insidious, typically progressing over four to 11
months. This, with poor access to health
facilities in developing areas where TB is most

VOL. 100-B, No. 4, APRIL 2018 425

426 R. N. DUNN, M. BEN HUSIEN

Fig. 1a Fig. 1b
Fig. 2a
Radiographs showing typical mid-thoracic destruction of a
vertebral body and kyphosis on the lateral (a) and a
paraspinal abscess on the anteroposterior (b).

prevalent, results in delayed presentation.13 Weight loss is

the most consistent constitutional feature. The frequently
quoted fatigue, pyrexia, night sweats and generalized aches
are generic and often ascribed to other ailments. Spinal TB
usually presents with axial pain in the affected region with
surprisingly varied intensity from a dull ache to a severe
disabling pain.14 There is often an associated spinal
prominence, a gibbus, due to collapse of the anterior
column and kyphosis.15 Paraspinal abscesses may be large
at the time of presentation. In the cervical spine, they may
manifest as hoarseness, respiratory distress, or dysphagia.
In the thoracic spine, there may be fusiform paravertebral
collections, which are seldom clinically evident. In the Fig. 2b

lumbar area, abscesses form in the psoas muscle which may
cause swelling in the thigh and groin. These can extend
below the inguinal ligament into the medial compartment
of the thigh.
Neurological deficit is common and reported between
23% and 76% of cases,13 with higher prevalence when
cervical and thoracic regions are involved. It is usually
incomplete with sensory preservation and varying motor
involvement. Lumbar disease may present as weakness
with limitation of mobility but due to pain from the spine
destruction and psoas abscess rather than neurological
impairment.
Imaging
Imaging may suggest the diagnosis, however, a definitive
tissue diagnosis requires laboratory confirmation.
Radiographs are frequently used as they are readily
available in the under resourced areas where TB is most
prevalent. The soft-tissue shadows of a thoracic paraspinal
abscess may be the earliest radiographic sign. As the pus
disseminates in the psoas muscles, the abscess may not be
evident when the lumbar spine is involved. The fact that the
height of the disc is maintained until late in the disease
differentiates spinal TB from pyogenic discitis, in which
MRI of the thoracolumbar spine T2 sequence, (a, sagittal and b, axial
views) showing bilateral psoas abscesses, destruction involving the
bodies of T12 and L1with a large paraspinal collection, and elevation of
the posterior longitudinal ligament causing marked spinal stenosis and
a distal non-contiguous involvement.
there is early loss of disc height.16,17 The number of
vertebral bodies involved may be underestimated, and
careful review of the associated posterior elements is
required to identify this number which may also predict the
final thoracic kyphosis. The vertebral height may be divided
into tenths. Using the total number of vertebrae which are
involved, the thoracic kyphosis five years later may be
predicted; thus: kyphosis = total vertebral involvement ×
30.5° + 5.5°. Thus, two completely destroyed vertebrae
predicts a 65.5° kyphosis at five years.18
The use of CT scans allows earlier detection of vertebral
involvement and more detail of the destruction.19 Epidural
and central canal involvement and paraspinal abscesses
with calcification may be identified, suggesting TB as
opposed to pyogenic infection.20 Although CT has largely
been superseded by MRI, it is still relied on in less well-
resourced areas. MRI is the most sensitive and specific form
of imaging in these patients allowing visualization of cord

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 SPINAL TUBERCULOSIS
Fig. 3a
a) MRI showing a large collection of pus and minimal deformity, typical of HIV disease
where costotransversectomy (b) can be used to drain the pus. Based on likelihood of
progressive kyphosis, instrumentation may be added.
compression by pus and debris, intrinsic cord signal, bone
marrow changes and disc destruction.21 A full sagittal
sequence of the spine allows detection of non-contiguous
lesions, which occur in up to 16% of patients (Fig. 2).16
Positron emission tomography (PET) may allow
identification of sites of active disease and monitoring of
the response to treatment, predicting possible drug
resistance, and identifying appropriate sites for biopsy, but
is not specific.22 Availability is usually a problem in areas
where TB is endemic.
Diagnosis
Routine blood tests may be used to monitor and possibly
exclude but not confirm the diagnosis. The ESR is markedly
raised in spinal TB with an average in the 70s. The WBC
count is usually normal.23 The level of platelets is raised
and the differential count may show a lymphocytosis.24
Biopsy of the pathology is mandatory to acquire tissue or
pus to differentiate the lesion from tumour and other
infections. Tissue has a higher diagnostic yield than pus.25
Culture of mycobacterium tuberculosis remains the
benchmark for the definitive diagnosis and allows
sensitivity to antibiotics to be established. Unfortunately,
culture takes up to six weeks to yield a result despite using
accelerated culture systems such as BACTEC (BACTEC
MGIT 960, BD Diagnostic Systems, Sparks MD, Franklin
Lakes, New Jersey). As spinal TB is paucibacterial, acid fast
bacilli (AFBs) are not always seen on microscopy. We have
reported a 38% yield.26 Histological features assist if they
show the typical features of caseating granuloma, giant
cells, and occasional AFBs. In endemic areas, these features
are often regarded as diagnostic but occasionally other
conditions such as sarcoidoisis and cat scratch disease cause
similar granuloma. Histology will confirm spinal TB in
60% of cases.27
VOL. 100-B, No. 4, APRIL 2018
427
Fig. 3b
Polymerase chain reaction (PCR) technology identifies
the presence of genetic material of mycobacterium
tuberculosis with specificities between 80% and 90%, and
sensitivities of 95% with minimal delay. This technology is
now available where it is needed most due to the recent
development of GeneXpert cartridge-operated, hospital-
based machines (Xpert MTB/RIF, Cepheid, Sunnyvale,
California) and can provide a diagnosis within two days. It
also allows the recognition of antibiotic resistance.28,29
Further exciting developments include the use of
interferon-gamma measurements in the blood using
QuantiFERON-TB Gold (Cellestis Ltd, Victoria,
Australia), with reported sensitivities and specificities of
84% and 95%.30 Unfortunately, they are not useful in areas
with a high incidence of TB due to the populations
exposure with asymptomatic latent (inactive) disease rather
than active disease.
Treatment
Medical management is the mainstay of treatment of spinal
TB, with surgery indicated for specific situations. Anti-
tuberculous therapy should begin as early as possible. In
poorly resourced, high-burden areas, it may be initiated
empirically based on clinical findings while the diagnostic
process continues, in order to avoid the inevitable delays in
waiting for these investigations.
The relief of pain and resolution of a neurological deficit
follows anti-tuberculous therapy in most patients.31 The
World Health Organization has recommended treatment in
two phases, an intensive phase and a continuation phase. The
intensive phase of two months includes four drugs, isoniazid
(H), rifampicin (R), ethambutol (E), and pyrazinamide (Z).
This is reduced to two drugs, isoniazid, and rifampicin in the
continuation phase. They recommend a total duration of
nine months for patients with TB of the musculoskeletal
428 R. N. DUNN, M. BEN HUSIEN
Fig. 4a Fig. 4b
MRI scan (a) and radiograph (b) of a four-year-old child
with myelopathy showing compression of the cord and
kyphosis, in whom a posterior based decompression
and corrective fusion was undertaken with full recovery.
system.32 The American Thoracic Society recommends six
months of treatment in adults and 12 months in children.33
This is in contrast to the practice in countries with a high
burden of TB. Recent guidelines from India recommend
two months of intensive four-drug therapy (RHZE) and
three drugs (RHE) for a continuation phase of between ten
and 16 months.34
As our patients are malnourished and frequently have
HIV coinfection, and due to concerns about the antibiotic
penetration of large abscesses or granulomas, when
managed non-operatively, we use four drugs, a
combination preparation Rifafour (Aventis Pharma Ltd,
Johannesburg, South Africa) consisting of RHZE, for a
minimum of nine months. This may be extended according
to the clinical response, particularly the relief of pain and
gain in weight with normalization of the ESR, and
radiographic features of bone healing. Pyridoxine (vitamin
B6) is added to prevent isoniazid-associated peripheral
neuropathy.
Between 5% and 11% of patients with spinal TB are
drug resistant. This may be mono or multidrug resistance.
The GeneExpert cartridge-based system detects rifampicin
resistance only, but we have not had a patient with drug
resistance which did not include resistance to rifampicin.
Following successful culture, sensitivity testing of all the
drugs is performed. Should there be resistance, infectious
diseases experts should be consulted for second-line
therapy. This usually requires the addition of a quinolone
and an aminoglycoside, necessitating prolonged daily
injections. Multiple resistance is more common in HIV
coinfection and has a poorer prognosis.
The side effects of the drugs need to be considered during
routine follow-up. These include visual deterioration from
ethambutol induced retrobulbar neuritis and hepatitis from
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HRZ. We use ESR for routine monitoring as it can be
performed in the clinic within an hour, rather than relying
on transport to a laboratory service. It will slowly return to
normal in patients with spinal TB. It is, however, less useful
in those with HIV coinfection.
The ‘directly observed treatment short-course’ (DOTS)
method improves compliance of medical management with
rates of completion of between 61% and 86%. A
financially incentivized DOTS system has further increased
completion to 91%.26
Surgery
The indications for surgery include an established or
predicted deformity, a neurological deficit, large abscesses
and diagnostic biopsy if percutaneous options are not
available.
Overall, paraplegia may recover in 40% of patients with
spinal TB with medical management alone. The use of
surgery remains controversial although it is generally
advised in selected cases.35 Surgery relieves compression of
the spinal cord, corrects kyphosis, may facilitate fusion,
and leads to faster relief of pain compared with
conservative treatment.36 Function may be improved
sooner, with less bone loss and a lower risk of late-onset
neurological deterioration.37
In many areas where TB is endemic, interventional
radiology biopsy services are not available. Thus, the
surgeon is responsible for performing the biopsy, usually in
theatre, and the opportunity may be used to drain large
abscesses due to concerns about drug penetration and in
order to expedite the resolution of symptoms. Surgical
options may be determined by what is locally available, in
terms of surgical skill and postoperative facilities. This is
also moderated by the patient’s ability to finance the care
where state-financed care is not available.38
As the thoracic spine is most commonly involved, a
costotransversectomy may be used where there is minimal
deformity with a paraspinal abscess. The pus may be
drained and anterior column debris debrided. This can be
combined with a posterior fusion (Fig. 3).
Formal debridement and reconstruction of the anterior
column is reserved for patients with severe kyphosis with
cord compression. This can be performed by an anterior-
only approach or posterior-based approaches. The T6-T11
area is easily accessed transthoracically, and the diseased
vertebrae and discs are resected and reconstructed.
Inexpensive allograft humeral shaft can be used with screw
fixation to the vertebral body above and below. This is our
preference. Some surgeons are concerned about
postoperative pulmonary risks, especially where no
intensive care facility is available.39
The anterior column can be resected from a posterior
approach after pedicle screw placement. This is achieved
using a uni or bilateral costotransversectomy, sacrifice of
one or two intercostal nerves, debridement, and the
introduction of graft and a cage (Fig. 4).40-42
THE BONE & JOINT JOURNAL
 SPINAL TUBERCULOSIS
Fig. 5a Fig. 5b
Lateral (a) and anteroposterior (b) radiographs following
decompression, humeral allograft reconstruction and
instrumented fusion.
Adequate decompression and correction of a kyphosis
can be achieved with both approaches.41 Our preference is
transthoracic, as complete debridement is easier and more
effective without sacrifice of nerve roots. Although there
may be some subsidence of the graft, the outcomes are good,
with no need for postoperative ventilation or intra-operative
single-lung ventilation as the lung is simply retracted.39
The thoracolumbar region is biomechanically more
challenging and surgery using only an anterior approach is
not advised. The options are anterior debridement and
reconstruction with posterior pedicle screws, or a posterior
only approach. Here all may be undertaken using a
posterior-based approach of pedicle screws and
costotransversectomy with anterior column debridement
and reconstruction, as it avoids intraoperative
repositioning and enables a quicker procedure.
Our preference is to use allograft for reconstruction of
the anterior column usually with humerus in the thoracic
spine and femur in the lumbar spine. The fibula may be
used in smaller patients, particularly children. This is
extremely cost-effective. Our commercially available
allograft humeral and femoral shafts cost between 5% and
10% as that of cages. They also integrate over time giving a
biological solution (Fig. 5). In areas where commercial
allograft is not available, the options include: fibula
autograft, with associated morbidity and increased theatre
time, the patient’s own ribs, which are frequently too weak
and often fracture, or commercially available cages. There
is no contraindication to the use of instrumentation, pedicle
screws, or anterior cages in spinal TB as the mycobacterium
does not create a biofilm.43
The cervical spine can be managed with anterior
debridement and reconstruction. If the residual endplates
are soft from the disease, there may be subsidence due to
poor fixation and posterior instrumented augmentation
should be considered (Fig. 6).
VOL. 100-B, No. 4, APRIL 2018
429
Fig. 6a Fig. 6b
Preoperative MRI (a) and postoperative radiograph (b) of cervical
tuberculosis undergoing anterior only decompression, iliac crest graft
and plating.
Spinal TB in HIV positive patients
In many areas where TB is endemic, HIV disease is also
endemic. Not only do these diseases drive each other, as
discussed above, the coexistence complicates management.
The immune reconstitution inflammatory syndrome (IRIS)
manifests when HIV medication is initiated and the
patient’s immunity improves and reacts to the TB. There
may be an overwhelming inflammatory response, which
can result in death. It is important to prevent this syndrome
by treating the TB before the HIV. When the CD4 cell count
in the blood is < 50 per cubic mm, highly active anti-
retroviral treatment (HAART) should be deferred for two
weeks; when the CD4 count is > 50 per cubic mm, it should
be deferred for eight weeks.
There are also pharmacological interactions where anti-
TB drugs, specifically rifampicin, stimulate the cytochrome
P450 system, increasing the metabolism of HIV drugs, and
the dose may need to be increased.44-50
Prognosis
The prognosis is generally good in spinal TB, with almost
all patients having relief of pain and improved neurological
deficits.42 As opposed to trauma, even patients with no
sensory or motor function below the lesion usually improve
due to the low energy nature of the cord compression. Most
patients regain mobility following surgery. A poor
prognosis is dictated by the general health status of the
patient rather than the neurological deficit. Neurological
recovery may be expected in most patients managed for
active spinal TB and usually occurs within the first three
months.51
In conclusion, spinal TB is most prevalent in
socioeconomically deprived communities with poor access
to health care. It is, however, increasingly prevalent in the
developed world, where it had been largely eradicated, due
to population migration. With its insidious onset and vague
430 R. N. DUNN, M. BEN HUSIEN
symptomatology, a high index of suspicion needs to be
maintained. Coexistent HIV disease increases its incidence
and complicates management. Although medical treatment
is always required, surgery may expedite neurological
recovery and allow a kyphosis to be corrected. The
technique used needs to be tailored to the local skills and
facilities. The prognosis is usually good, once the diagnosis
has been made, and treatment initiated. Most patients have
relief of pain and neurological improvement within three
months of the onset of treatment.
Take home message:
- TB has its highest incidence in the developing world but with
increased population migration is increasingly present in the
developed world.
The management is further challenged by the co-existence of HIV infec-
tion
- Presentation can be insidious and a high level of suspicion needs to be
maintained
- Biopsy is mandatory to confirm diagnosis and antibiotic sensitivity
- Medical management is the mainstay but surgery is indicated for pre-
dicted or established severe kyphosis, neurological deterioration and
large abscess collection
- Medical management needs to be adapted in the presence of HIV to
avoid IRIS (immune reconstitution inflammatory syndrome)
- With optimal management, prognosis is good even with profound neu-
rological impairment
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Author contributions:
R. N. Dunn: Planned the paper, Gave insight based on our local practice, Pro-
vided some of the pertinent literature, Revised and re-wrote the paper, Pro-
vided the images
M. Ben Husien: Wrote the first draft, Collected the literature under the direc-
tion of the senior author
Funding statement:
No benefits in any form have been received or will be received from a com-
mercial party related directly or indirectly to the subject of this article.
This article was primary edited by J. Scott.