Spinal Tuberculosis by Dr. Monsif Iqbal

Spinal Tuberculosis

Dr. Monsif IqbalDepartment of Surgery

POF Hospital, Wah Cantt

CASE PRESENTATION

Patient Profile

• Name : Rukhsana• Age : 45 years• Sex : Female• Address : Wah Cantt• D.O.A : 26/06/2011• M.O.A : OPD

• Presenting Complaints

– Severe Backacke 5-7 days

• History of present illness

Past History

• h/o Cholecystectomy 01 month back

• Diagnosed as a case of HCV 01 month back

Drug HISTORY

• No histroy of any drug intake

PHYSICAL EXAMINATION

1. GPE:A middle aged lady, lying in bedHis vitals are;– Pulse: 85/min– B.P: 130/80 mm of Hg– Oxygen Sat: 96%– Temp: AfebrileRest of GPE unremarkable.

NEUROLOGICAL EXAMINATION

• Tenderness in the lumbar spine (L1, L2)• SLR – Right 60 degress– Left 70 degrees

• Sensory system intact• Motor system intact• Reflexes normal• Plantars downgoing

Rest of the systemic examination

• Abdomen– Cholecystectomy scar

• Chest– NAD

Investigations on the day of admission

• Blood CP• ESR• LFTs• X-ray Lumbo-sacral Spine

X-Ray Chest (PA view)

T1 weighted image

T2 weighted image

T1 weighted Slide

T2 weighted Slide

• So clinically the diagnosis of Spinal Tuberculosis was made

Spinal Tuberculosis

Introduction

• According to WHO(2010), about one third of the world’s population is infected by Mycobacterium TB, and 9 million individuals develop TB each year

• One third of total TB population is in South-East Asia.

• Three percent are suffering from skeletal TB.

• Vertebral TB is the most common form of skeletal TB and accounts for 50% of all cases of skeletal TB.

• The mortality rate is 27/100,000 of the population.

• Neurological complications are the most crippling complications of spinal TB

(Incidence : 10 to 43%).

Spinal Tuberculosis

Pathology of Spinal TB

• Spinal tuberculosis is usually a secondary infection from a primary site in the lung or genitourinary system.

• Spread to the spine is hematogenous in most instances.

• Delayed hypersensitivity immune reaction.

• The basic lesion is a combination of osteomyelitis and arthritis…. Affects the anterior part of vertebra…

• Kyphosis• Paravertebral Abscess

Clinical Presentation• Presentation depends on :

– Stage of disease,– Site– Presence of complications such as neurologic deficits, abscesses, or sinus tracts.

• Average duration of symptoms at the time of diagnosis is 3 – 4 months.

• Back pain is the earliest & most common symptom.

• Constitutional symptoms.

• Neurologic symptoms (50 % of cases).

• Cervical spine Tuberculosis

• Spinal TB in HIV patients

Spinal Tuberculosis Diagnosis

• Lab Studies– Mantoux / Tuberculin skin test ( purified protein derivative {PPD})

– ESR

– ELISA : for antibody to mycobacterial antigen-6 , sensitivity of 60 – 80%.

– PCR : sensitivity of 40% only.

– Brucella complement fixation test (useful in endemic areas as brucella can clinically mimic tuberculosis).

– IFN – Release assays (IGRAs)

Recently, two in vitro assays that measure T-cell release of IFN in response to stimulation with the highly specific tuberculosis antigens ESAT- 6 & CFP-10 have become commercially available.

• Microbiology studies– Ziehl-Neelsen staining– Cultures positive in 50 % of the cases only

Spinal Tuberculosis Diagnosis

• Radiological Diagnosis

– Plain Radiograph

– CT Scan

– MRI Spine

Plain Radiograph• Typical tubercular spondylitic features in long standing paraspinal

abscesses – produce concave erosions around the anterior margins of the vertebral bodies

producing a scalloped appearance called the Aneurysmal phenomenon. – fusiform paraspinal soft tissue shadow with calcification in few .

• Skip lesions as involvement of non contiguous vertebrae (7 – 10 % cases).

• DEFORMITIES:1. Anterior wedging2. Gibbous deformity.3. Vertebra plana = single collapsed vertebra .

wedge collapse of L1 and L2 vertebral bodies

X-ray of the spine in a child showing complete destruction of D12 and L1 vertebral bodies leaving only

the pedicles.

CT Scanning • CT scanning provides much better bony detail of irregular lytic

lesions, sclerosis, disk collapse, and disruption of bone circumference.

• Low-contrast resolution provides a better assessment of soft tissue, particularly in epidural and paraspinal areas.

• It detects early lesions and is more effective for defining the shape and calcification of soft tissue abscesses.

• In contrast to pyogenic disease, calcification is common in tuberculous lesions.

MRI Spine

• MRI is the modality of choice as delineates leptomeningeal disease better, direct evaluation of intramedullary lesions, associated osseous signal change and epidural abscesses.

• Typical (spondylo-discitis) and atypical (spondylitis without discitis) types.

• Differentiate tuberculous spondylitis from pyogenic spondylitis

• most effective for demonstrating neural compression

Patterns of Vertebral Involvement

Deformities in Spinal Tuberculosis

• Kyphotic deformity (more common in thoracic spine) occurs as a consequence of collapse in the anterior spine

• Knuckle Kyphosis : forward wedging of one or two VB causing small kyphos

• Angular Kyphosis : wedge collapse of 3 or more VB

Differential Diagnosis

• The differential diagnosis of the tuberculous spine includes:1. SPINAL INFECTIONS- pyogenic, brucella & fungal.2.NEOPLASTIC commonly lymphoma/ metastasis3.DEGENERATIVE

• No pathognomonic imaging signs allow tuberculosis to be readily distinguished from other conditions. Biopsy is definitive.

Complications of Spinal Tuberculosis

• Paraplegia• Cold abscess• Spinal deformity• Sinuses• Secondary infection• Amyloid disease• Fatality

What is Middle path regime?• Rest in bed

• Chemotherapy

• X-ray & ESR once in 3 months

• MRI/ CT at 6 months interval for 2 years

• Gradual mobilization is encouraged in absence of neural deficits with spinal braces & back extension exercises at 3 – 9 weeks.

• Abscesses – aspirate when near surface & instil 1gm Streptomycin +/- INH in solution

• Sinus heals 6-12 weeks after treatment.

• Neural complications if showing progressive recovery on ATT b/w 3-4 weeks :- surgery unnecessary

• Excisional surgery for posterior spinal disease associated with abscess / sinus formation +/- neural involvement.

• Operative debridement–if no arrest after 3-6 months of ATT / with recurrence of disease .

• Post op spinal brace→18 months-2 years

All first-line anti-tuberculous drug names have a standard three-letter and a single-letter abbreviation:

• Ethambutol is EMB or E,• isoniazid is INH or H,• Pyrazinamide is PZA or Z,• Rifampicin is RMP or R,• Streptomycin is STM or S.

Surgical Indications• No sign of neurological recovery after trial of 3-4 weeks therapy

• Neurological complications develop during conservative treatment

• Neuro deficit becoming worse on drugs & bed rest

• Recurrence of neurological complication

• Prevertebral cervical abscess with difficulty in deglutition & respiration

• Advanced cases- Sphincter involvement, flaccid paralysis or severe flexor spasms

THANKS