Tuberculosis affects all systems of the

human body. Approximately 15% of patients

with active tuberculosis have an extra

pulmonary form of the disease1. The most

common sites for extra pulmonary

tuberculosis are the highly vascular areas

such as the kidney, meninges, lymph nodes,

spine and the growing end of long bones

Ramachandran, R

NIRT Institutional Repository

DIAGNOSIS AND MANAGEMENT OFTUBERCULOSIS OF THE SPINETuberculosis affects all systems of thehuman body. Approximately 15% of patientswith active tuberculosis have an extrapulmonary form of the disease1. The mostcommon sites for extra pulmonarytuberculosis are the highly vascular areassuch as the kidney, meninges, lymph nodes,spine and the growing end of long bones2.Historical: The classical paper byPercival Pott3 has led to paraplegia oftuberculous origin being named as Pott’sparaplegia and also to the currentunderstanding of the tuberculosis of spineand the accompanying neurological lesions .Incidence:  Among a l l  forms oftuberculosis, nearly one to 3 percent ofpatients have involvement of the bone andjoints. Among them, tuberculosis of thevertebral column (caries spine) accounts forabout 50% of skeletal tuberculosis4,5,6,7,8,9,10,11.The neurological involvement in TB spine hasbeen reported to vary from 10 to 30%12.Pathological changes observed in thespine: Three kinds of pathological changesare observed in the spine, viz.,Dr. Rajeswari Ramachandran*(a) Central type of vertebral bodyinvolvement.(b) Para-discal lesion(c) Anterior type of involvement of vertebralbodies.The lesions may be of “Caseousexudative type” or “granuloma” type.Loracca13 describes a central type oflesion, which extends centrifugally to involvethe whole body resulting in hyperaemia andosteoporosis. The body gets softened, leadingto compression, collapse and bony deformity.Arterial occlusion due to thrombo-embolicphenomenon results in endarteritis andperiarteritis; necrosis takes place resulting ininfarction of segments of bones14. Ischaemicnecrosis is described as a contributing factorresponsible for osseous and vertebralcollapse. Caseation and necrosis is almostdiagnostic of tuberculous pathology.The para-discal lesion begins in thevertebral metaphysis, erodes the cartilageplate and destroys the disc. The cartilaginousend plate is a sort of barrier for spread intothe adjacent tissue but once invaded,* Deputy Director, TRC, Chennaidestruction of the disc rapidly occurs becauseof its relative avascularity and the infectionspreads to adjacent vertebrae. The earlyresorption of the disc leads to narrowing ofdisc space. Sometimes the space may bewidened due to accumulation of debris.Tuberculosis of the Neural arch:Tuberculosis of vertebral arches wasconsidered to be very rare and of the 2202cases of vertebral tuberculosis treated byNovak, only 8 (0.4%) had involvement of thearch15. According to Kumar16, only 5% ofspinal tuberculosis were confined toposterior elements. However based on MRIand CT findings, Hoffman17 reported 50%involvement of posterior elements of spine.He states that the tuberculous involvementof arch is not as rare as observed by earlierworkers.Pathology in Pott’s paraplegia: Tuli18reported that among patients withparaplegia, tuberculous pathologycontributed in nearly 50% of cases.Paraplegia may result from active or healeddisease of spine.Diagnosis: The diagnosis of caries spineis based on clinical findings, imaging of thespine, bacteriological and histopathologicalexamination of the biopsy specimens/operated specimens and immuno-diagnosticmethods.Clinical presentation: The clinicalpicture has 3 components(a) The systemic illness(b) The osseous lesion(c) Neurological complications.As with tuberculosis elsewhere in thebody, there may be malaise, pyrexia, loss ofappetite and weight loss. Back pain is apredominant clinical feature19. The spinebecomes stiff and painful on movement, withspasm of the paravertebral muscles.Progressive backache is so often seen thatmany authors are of the opinion that TB mustbe considered in its differential diagnosiswhen the patient belongs to an endemicregion20. A soft tissue swelling is oftenobvious and in late cases a draining sinusmay be seen in some cases. Sinuses werereported in 10 to 50% of patients with TBspine21,22,23,24. Angulation of the spine in theform of kyphosis is diagnostic and it wasreported in 95% of cases seen by Tuli and in84% (including 40% with more than 30°) of260 patients of Tuberculosis of spine studiedby TRC25.Associated lesions: Associatedpulmonary and other system tuberculosismay point the diagnosis towards caries spine.The incidence of associated visceral lesionsvaried between 14 to 50% in different series.In studies done in TRC, 45% of patients withPott’s paraplegia and 14% of spine TBpatients had abnormal chest x-ray suggestiveof tuberculosis.Neurological deficit: In the majority ofthe patients with spinal tuberculosis theonset of neurological symptoms is slow andprogressing, even though in a smallpercentage of cases the paraplegia may be ofsudden onset and nearly complete.The clinical picture of Pott’s disease isbroadly c l a s s i f i e d  i n t o  3  g r o u p s .(1) Paraplegia arising in a known case ofspinal tuberculosis. (2) Paraplegia as thepresenting symptom of spinal tuberculosis.(3) Paraplegia due to tuberculosis of otherposterior neural arch.Based on the clinical suspicion aprovisional diagnosis of TB spine is madeand this is confirmed by plain x-rays of thespine, magnetic resonance imaging andradio-isotope bone scans.Plain x-rays: The para-discal lesion is thecommonest lesion seen. This finding whenfound associated with the narrowing of thedisc space is the earliest radiological findingon plain X-rays.Plain films typically show a destructiveprocess of the vertebral body, narrowing ofthe disc space and spinal deformity, thedestructive process of the vertebrae can beeither in the form of vertebral body collapseor decreased height of the vertebral body orpedicular erosion or a combination of these.Spinal deformity is frequently present.CT Tomography: CT in the axial planewith bone and soft tissue windows willclearly define the extent of bony destructionand the para-spinal mass. CT scan is usefulin assessing the extent of destructive lesionsin the vertebral column. CT myelographywas the diagnostic procedure of choice ofdefining the relationship between bone,epidural soft tissue mass and adjacent neuralelements. However this procedure is largelyreplaced by non invasive MRI.Magnetic resonance Imaging: MRI is thesuperior imaging modality for theassessment of neural compression by softtissues, because of its multi planar (sagittal,axial and coronal plane) capacity andsuperior soft tissue resolution. MRI is veryuseful to alert the surgeon of impendingneurological complications, which may be ofextrinsic or intrinsic origin and to assess theextent  of decompression required.Compression of the spinal cord leading toneurological involvement is the most seriouscomplication of tuberculosis of spine.MRI is now an established technique forimaging the spine26. One of the major areasof  impact  of  MRI  has  been in  theinvestigation of the problem of acuteneurological deterioration in patients withtuberculosis of spine.Percutaneous computed Tomographyguided needle biopsy: CT guided needlebiopsy is an accurate, safe and rapidprocedure to obtain specimens of the bonyelements such as ribs, transverse process,vertebral body, posterior elements and softtissue para-spinal masses. The samplesobtained can then be subjected to bothhistopathological and bacteriologicalexaminations for M. tuberculosis. Additionalbenefits of this technique is the therapeuticdrainage of large paraspinal abscess. Thisprocedures helps to diagnose in 75% of cases.Immuno diagnostics: The sero-diagnosisprobably has decreased utility in smearnegative patients, with minimal pulmonarytuberculosis but it may have increasedpotential in some forms of extra pulmonarytuberculosis27.Currently a number of rapid diagnosticmethods such as Elisa and PCR are beingevaluated for the diagnosis of various extrapulmonary forms of TB. Immuno diagnosisof TB despite its apparent promise has notbecome established in medical practice forreasons such as lack of readily available andwell standardised reagents and thecomplexity introduced by the experienced inthe interpretation of results in terms ofpredictive values.Thus the diagnosis of skeletal TB needsan awareness and increased sense ofsuspicion for spinal TB among patients withback pain, soft tissue masses and para-spinalspasm. This is strengthened by imagingprocedures and confirmed by CT guidedbiopsy.Treatment: In the pre anti TBchemotherapy era, the traditional treatmentfor Pott’s disease was prolonged bed rest orplaster of paris casts. The belief then wasmost of the vertebral destruction wassecondary to weight bearing on weakenedvertebrae involved with tuberculousinfection. The mortality rate was high in therange of 20-30% and relapses were also high(20-30% in the pre chemotherapeutic era).Chemotherapy: Short course regimensconsisting of sterilising drugs such asRifampicin (R) and Pyrazinamide (Z) are nowuniversal in the treatment of extra Pulmonarytuberculosis. In the past 20 years a largenumber of highly effective regimens withdifferent drug combinations for treatingpulmonary and extra-pulmonary forms oftuberculosis have been evolved throughcontrolled clinical trials.Similarly studies done at the TuberculosisResearch Centre, Madras on TB spine withor without Pott’s paraplegia25,26 have shownthat regimens containing Rifampicin,Isoniazid and Pyrazinamide for 6 to 9 monthshave been effective. Revised NationalTuberculosis Control Programmerecommends Ri fampicin ,  INH andPyrazinamide three times a week for 2months in the first phase followed byRifampicin and INH for 4 months in thefollow-up phase. In severe cases Ethambutolwill be added in the first phase. If initial drugresistance is suspected, or the disease issevere, the chemotherapy may be changed tosecond line of drugs such as Kanamycin/Amikacin, Ofloxacin depending on, thesensitivity test results, and chemotherapymay be extended for 12 months.In HIV infected patients with suspectedmycobacterial disease, treatment of TB isgenerally more urgent. The first phase shouldinclude INH, Rifampicin, Pyrazinamide andEthambutol. After 2 months of therapy,Rifampicin and INH should be continued forat least 7 months. Agents that are effectiveagainst M. avium complex are Clofazamine,Rifabutin, Ciprofloxacin and Clarithromycin.Surgical treatment in tuberculosis of thespine: Many operative treatments have beendescribed and developed, includinglaminectomy by Macewen in 1888, costo-transversectomy by Michaud in 1900, spinalfusion by Albec in 1911, lateral rhachotomy byCapener in 1933, anterolateral decompressionby Alexander in 1946, costo-transversectomyand curettage of the vertebral body byWilkinson in 1952 and anterior trans-thoracicdecompression by Hodgson in 1956. Themain principle of operative treatment is todrain the abscess and remove diseased tissue(debridement) as early and as thoroughly aspossible. The aims of these operations wereto shorten the period of immobilisation inbed and to provide permanent internalstability. The operation of radical resectionof the lesion with anterior spinal fusion whenundertaken by the Hong Kong group didhave some advantages over simpledebridement in terms of less further vertebraldestruction and deformity and more rapidhealing by bony fusion. With the introductionof antituberculous drugs, the indications forsurgery became more selective such as (a) forprevention and correction of deformities andcomplications and (b) for improving thestrength of the involved joints (Tuli 1985).The results of the Madras (ICMR 1989)study on short course chemotherapy intuberculosis of the spine and the Koreanstudy (BMRC 1993) indicate the success ofchemotherapy alone, and has reduced therole of the surgery to a mere diagnostic one.Management of complications mayoccasionally require surgery, but anti-tuberculous treatment has been establishedas the essential basis of treatment.The recent concepts in the management ofspinal TB was evolved based on number ofcontrolled clinical trials done by BMRC andTRC. The salient findings of these trials are:(1) Ambulatory out-patient chemotherapywith no splinting or surgery gives about96% success rate in the treatment ofspinal TB. Immobilising patients gave noadvantage and operative debridementdid not result in a better outcome.(2) Chemotherapy alone is sufficient inmajority of cases and surgery can beadvised in a select few cases who haveassociated neurological complicationsabscesses/more than three vertebrallesions.(3) A radical spinal surgery29 by usinganterior approach to the spine withdecompression of neural elements andautologous bone grafting documented94% success rate.REFERENCES1.2.3.4.5.6.7.Mehta JB, Dutt A, Harvill L, et al.Epidemiology of extra-pulmonarytuberculosis. Chest 1991.99: 1 134-l 138.Bloom BR and Murray CJR: Tuberculosis:Commentary on a re-emergent killer.Science. 1992. 257: 1055-1064.Pott P. Remarks on that kind of palsy ofthe lower limb which is frequently foundto accompany a curvature of the spineand is supposed to be caused by it,together with its method of cure. London1779.Wilkinson MC. Tuberculosis of the spinetreated by chemotherapy and operativedebridement - long term follow-up study.J. Bone Joint. Surg. (Am) 1969, 5 l-A,1331-1342.M u k h o p a d h y a y a  B ,  M i s r a  I - 7 .Tuberculosis of the spine. Indian J. Surg.1957. 19: 59-81.Falk A. A follow up study of the initialgroup of ‘cases of skeletal tuberculosistreated with  Streptomycin  andapplication of radical surgical techniquesin certain effects and complications oftuberculous lesion. J. Bone JointSurg.(Am) 1952, 34A: 267-278.Konstam PG. Spinal tuberculosis inNigeria. Ann. R. Coll. Surg. Engl. 1963,32: 99-114.8.9.10.11.12.13.14.15.Baus B. Treatment for tuberculosis ofspine. Acta Orthop, Scand. 1964. 72(Suppl.): 34-38.Grewal KS, Singh M. Tuberculosis of thespine. Indian J. Surg. 1956.18: 394 -399Tuli SM, Srivatsava TP, Verma BP, et al.Tuberculosis of spine. Acta. Orthop.Scand. 1967. 38: 445-451.Martin NS. Tuberculosis of the spine(A study of the results of treatmentduring the last twenty-five years). J. BoneJoint. Surg. (Br) 1970. 52-B: 613-628.Griffith DL, Seddon HL, Road R. Pott’sparaplegia, Oxford University Press,London (1956).Larocca H. Spinal sepsis in Rothman RHand Simeone FA (eds). :The Spine. WBSaunders Company, (2ns Ed.). 1982.2: 767-774.Cleveland M, Bosworth DM. Pathologyof tuberculosis of spine. J. Bone. Joint.Surg. (Am) 1942, 24: 527-546.Novak (Schmorl 1959) Schmorl G,Junghanns H. The human spine in healthand disease 1959, New York. Grune .16. Kumar K.A. Clinical study classificationof posterior spinal tuberculosis. Int.Orthop. 1985, 9, 147-152.17. Hoffmann EB, Crosire JH, Cremin BJ.Imaging in children with spinaltuberculos is  -  a  comparison ofradiography computed tomography andMRI. J. Bone Joint Surg. (Br.) 1993. 75B:233-239.18. Tuli SM. Judicious management oftuberculosis of bones, joints and spine.Indian J. Orthop. 1985. 19: 147-166.19. Jallah RD Kuppusamy, T. Mahayiddin AAet al. Spinal tuberculosis. A five yearreview of cases at the national TB centre.Med. J. Malasia 46: 269- 199 1 .20. Chan WH LIV JS Howng SL.  Tuberculousspondylitis: a clinical analysis. KAOHSIUNG I: Hsueh Ko Ko KSvch TSAChina 6 : 428 1990) .18 .21.22.23.24.British Medical Research Council. AControlled trial of plaster of Paris jacketsin the management of ambulant out-patient treatment of TB of spine inchildren on standard chemotherapy. Astudy in Pusan Korea. Tubercle. 1973 a.54A; 261-282.British Medical Research Council. AControlled trial of ambulant outpatienttreatment and inpatient rest in bed in themanagement of TB of spine in youngKorean, p a t i e n t s  o n standardchemotherapy. J. Bone Joint Surg. (Br.)1973b: 55b: 678-697.British Medical Research Council. Acontrolled trial of debridement andambulatory treatment in the managementof TB of spine in patients on standardchemotherapy. A study in Bulawayo,Rhodesia. J. Trop. Med. Hyg. 1974a. 72:12-92.British Medical Research Council. Acontrolled trial of anterior spinal fusionand debridements in the surgical25.26.27.28.29.30.management of TB of spine in patients onstandard chemotherapy. A study in HongKong. J. Bone Joint Surg. (Br.) 1974b. 61:853-866.Indian Council of Medical Research/British Medical Research Council. Acontrolled trial of short course regimensof chemotherapy in patients receivingambulatory treatment or undergoingradical surgery for tuberculosis of thespine. I n d i a n  J .  T u b e r c .  1 9 8 9 .36 (Suppl. ): 1-21.Sze G, Brant-Zawadski M, Mac NamaraMT, et al. Use of magnetic resonancecontrast agent gadodiamide in the centralnervous system - Results of a multicentraltrial. Invest Radiol. 1993, 28 (Suppl. 1):545- 555.Thomas M.Danikl. Immuno-diagnosis ofTB. Thomas M.Daniel. Page 223-232. TextBook - Tuberculosis. Edited by WilliamN . Rom . Start M . Garay. Little BrownCompany NewYork. 1990 .Indian Council of Medical Research/British Medial Research Council. Acontrolled trial of short course regimensof chemotherapy in patients receivingambulatory treatment or undergoingradical surgery for tuberculosis of thespine. Indian J Tuberc.  1989. 36(Suppl): 1-21.Pott’s ParaplegiaBMRC, 199331. Hodgson AR, Stock FE. Anterior spinefusion. A preliminary communication onthe radical treatment of Pott’s disease andPott’s paraplegia. Br J Surg. 1956 44:266-275.* * *

Diagnosis and management of tuberculosis of the spine

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Diagnosis and management of tuberculosis of the spine

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