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Spinal Tuberculosis in a Patient with Low Back Pain

Dr Chee Yong ChooDept of Anaesthesia, CGHSingapore

Contents

1. Introduction

2. History and Physical Examination

3. Diagnosis and Intervention

4. Discussion

5. Conclusion

History

Mdm L - 74 year old Chinese ladyIndependent in terms of activities of daily livingPast medical history• Bilateral total hip replacements• Right total knee replacement• Cataracts surgery• Non ulcer dyspepsia• Hypertension• Lichen amyloidosis

History

Admitted in March 2010Low back pain of 3 months durationRadiated to the right hipNot much relief with oral analgesicsLoss of appetiteOccasional night painNo other systemic complaints

Psychosocial history

No history of psychiatric disordersStayed with her daughter (only child) and her family but relations were strainedDevoted her free time to mainly church activitiesNo recent travel history

Physical Examination

AfebrileKyphoscolioticSpinal tenderness at L1 upon palpationNo other focal neurological deficitsAble to weight-bear briefly with assistance

Investigations - X rays of the thoracolumbar spine

Investigations

WBC 6.5 x 103 /uLESR 60CRP 34.3 mg/L

BMD - osteoporosis

Coagulation, Liver and Renal Function Tests normal

Subsequent clinical history

Pain thought to be due to osteoporotic compression fracture

Declined further imaging this admissionResponded poorly to analgesics

Discussion with patient and surgical teamIn view of lumbar radicular pain → trial of ESI

ESI performed 26 Mar 2010

Subsequent clinical history

Had improvement in pain symptomsUnderwent physiotherapyDischarged from hospital 1 week later

Meds• Paracetamol 1gm qds• Gabapentin 300mg tds• Nortriptyline 10mg nocte

Re-presentation

Seen in the Pain Clinic 2 months later

Complained of right sided paraumbilical painSignificant loss of appetite and weight, constipatedUnable to sleep at night, very depressedNo abdominal masses on examination

Patient counselled for further imaging to rule out malignancy – agreed somewhat reluctantly

CT Abdomen/Pelvis showed evidence of perivertebral thickening but no malignancy

MRI Thoracolumbar Spine showed likely perivertebral abscess T12/L1…

CT guided Biopsy T12/L1

No fluid was aspiratedMultiple core biopsies performed and sent for histopathology and microbiologies

Histology – TB???

Granuloma with caseating necrosisAggregates of epithelioid histiocytes with giant cell formation amidst a collagenous background with a few scattered lymphocytes and neutrophils

Further staining with Ziehl-Neelsen, GMS and PAS/PASD stains did not reveal any AFB or fungiSpecimen sent for TB PCR

More tests…

Referral to ID Physician:

AFB smear for sputum – positiveAFB smear for urine – positiveTB serology quantiferon – positiveCT Thorax – patchy consolidation of the right lower lobe with post

obstructive mucus plugging likely suggestive of PTB

Diagnosed with disseminated TB

Treatment

Empirical TB treatment started:Isoniazid 200mg mane, Rifampicin 450mg mane, Ethambutol 800mg mane, Pyridoxine 20mg mane

Analgesics:Paracetamol 1gm qdsPregabalin 75mg bd → 150mg bdNortriptyline 10mg nocteOxycontin 20mg bd, OxyNorm 5mg 4h/prn

Interdisciplinary Management

• Infectious diseases physician• Pain medicine specialist• Orthopaedic surgeon• Psychiatrist• Rehabilitation physician• Medical Social Worker• Physiotherapist• Pharmacist

Low Back Pain was still a problem

Underwent T9 to L4 decompression laminectomy, stabilisation, correction of kyphosis with bone grafting on 29/7/2010

Postop:Referral to rehab teamHad thrombosis of the deep vein of the soleus muscle

Back surgery

Discharge and follow up

Finally discharged after 74 days of hosp stay

Discharge meds:Anti TB drugsParacetamol, Pregabalin, OxyNormEnoxaparinFluvoxamine, ZolpidemAmlodipine

Discussion

1. Red flags in Low Back Pain2. Role of ESI3. High index of suspicion for TB infection4. Natural history of TB spine5. Role of surgery6. Multidisciplinary management

Red Flags in LBP

• “Red flags” are important in screening cases of low back pain

• Even during re-presentation• New Zealand Acute Low Back Pain Guide

(New Zealand Guidelines Group)www.nzgg.org.nz

Red Flags (highlighted in red for our patient)

Red Flags help identify potentially serious conditions:

• Features of Cauda Equina Syndrome• Severe worsening pain, especially at night• Significant trauma• Weight loss, history of cancer, fever• Use of intravenous drugs or steroids• Age over 50 years old

Evidence for ESI

• Useful for lumbar radicular pain• Level II - III evidenceo NNT for short term relief up to 2 months is 7.3o NNT for long-term relief from 3 months to 1 year is 13o Lack of well designed, placebo-controlled studies to conclusively define

specific indications and techniques

FPM Professional Documents PM3 2010

Evidence for ESI

• Transforaminal approach seems slightly better and safer than interlaminar, but is more difficult to perform in our patient

Schaufele MK et al. Interlaminar versus transforaminal epidural injections for the treatment of symptomatic lumbar intervertebral disc herniations. Pain Physician 2006 Oct; 9(4):361-6

Parr et al. Lumbar interlaminar epidural injections in managing chronic low back and lower extremity pain: a systematic review. Pain Physician. 2009 Jan-Feb; 12(1):163-88

McGrath JM et al. Incidence and Characteristics of Complications from Epidural Steroid Injections. Pain Med. 2011 Mar 10 [Epub ahead of print]

ESI not without risks!

• It can lead to discitis and abscess formationKnight JW et al. Epidural abscess following epidural steroid and local anaesthetic injection.

Anaesthesia 1997, 52(6): 576-8 Hooten WM et al. Discitis after lumbar epidural corticosteroid injection. Pain Med 2006,

7(1): 46-51Simopoulos TT et al. Vertebral osteomyelitis: a potentially catastrophic outcome after lumbar

epidural steroid injection. Pain Physician 2008, 11(5): 693-7

• It may have potentially worsened the TB spine infection in our patient

Onal SA & Ozer B. Pott disease in the differential diagnosis of low back pain. Agri 2004 16(1): 55-7 (Article in Turkish)

High index of suspicion for TB Spine

• Rare, only a few case reports so far.Onal SA & Ozer B. Pott’s disease in the differential diagnosis of low back pain. Agri 2004 16(1):

55-7 (Article in Turkish)Rajab TK & Barre LJ. Back pain from spinal tuberculosis. J Am Coll Surg 2008 207(3): 453

Maron et al. Two cases of Pott’s disease associated with bilateral psoas abscesses. Spine 2006, 31(16): E561-4

• The wrong diagnosis can be fatal…Ringshausen at el. A fatal case of spinal tuberculosis mistaken for metastatic lung cancer:

recalling ancient Pott’s disease. Ann Clin Microbiol Antimicrob 2009 20(8): 32

Spinal tuberculosis

• Insidious onset, variable presentation, slow development of radiological features, non specific constitutional symptoms

• Back pain resistant to medical therapy• Early diagnosis improves outcomes

Kotevoglu N & Tasbasi I. Diagnosing tuberculous spondylitis: patients with back pain referred to a rheumatology outpatient department. Rheumatol Int 2004,

24(1):9-13Le Page L et al. Spinal tuberculosis: a longtitudinal study with clinical, laboratory and

imaging outcomes. Semin Arthritis Rheum 2006 36(2):124-9

Radiological Features

• Spinal TB is probably the most important extrapulmonary form of the disease

o Haematogenous spread, direct implantation, spread from contiguous focus

• MRI is better than CT in demonstrating the extent of soft tissue disease esp epidural abscess

o Findings include bone destruction, intervertebral disc destruction, paravertebral mass/abscess

Jevtic V. Vertebral infection. Eur Radiol 2004 14 Supp 3: E43-52Sinan T et al. Spinal tuberculosis: CT and MRI features. Ann Saudi Med 2004 24(6):

437-41

Surgical Intervention

• Is rarely needed• May be indicated in patients with persistent

instability (like our patient), radiculopathy or neurological compromise

Nene A. Results of nonsurgical treatment of thoracic spinal tuberculosis in adults. Spine J 2005 5(1): 79-84

Kotil K et al. Medical management of Pott disease in the thoracic and lumbar spine: a prospective clinical study. J Neurosurg Spine 2007 6(3): 222-8

Multidisciplinary Intervention

• Multidisciplinary management was essential for a good outcome

• She continued to function well after surgery• Relatively pain free 6 months post discharge

Conclusion

• Rare but important disease• Early diagnosis is likely to improve the clinical

outcome• The vigilant pain medicine specialist can make a

difference!

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