skeletal tuberculosis: etiology, epidemiology and management

1. Tuberculosis of Spine
pradeep kumar pathak
Junior Resident
pgims rohtak
dr.pathak09@gmail.com

2. Epidemiology
• An estimated 2 million people have active Spinal TB
worldwide
India
• 1/5th of total TB Cases
• vertebral tuberculosis is commonest form of skeletal T.B.

3. Regional distribution of Spine TB
• Cervical – 12%
• Cervicodorsal – 5%
• Dorsal – 42%
• Dorsolumbar – 12%
• Lumbar – 26%
• Lumbosacral – 3%

4. Types of vertebral lesions
• 4 types:
1. Paradiscal- Arterial spread
2. Central – Venous spread
3. Anterior- Subperiosteal spread
4. Appendicular

5. Radiological Investigations
• Paradiscal lesions:
– Commonest lesions
– Spreads through arterial
supply
– Reduced disc space –
Earliest sign
– Loss of vertebral margins
– Increased pre-vertebral soft
tissue shadow.

6. Types of vertebral lesions
• 4 types:
1. Paradiscal- Arterial spread
2. Central – Venous spread
3. Anterior- Subperiosteal spread
4. Appendicular
vertebral body: areas of distruction or balooning

7. Radiological Investigations
• Central type:
– Spread through the batson’s
venous plexus/ branches of
posterior vertebral artery.
– At the end concentric
collapse resembling vertebra
plana
– Minimal Disc space reduction

8. Types of vertebral lesions
• 4 types:
1. Paradiscal- Arterial spread
2. Central – Venous spread
3. Anterior- Subperiosteal spread
4. Appendicular

9. Radiological Investigations
• Anterior type of lesion
– Starts beneath the
anterior longitudinal
ligament & periosteum
– Collapse and disc space
reduction is usually
minimal and occurs late
– Erosion is primary
mechanical

10. Types of vertebral lesions
• 4 types:
1. Paradiscal- Arterial spread
2. Central – Venous spread
3. Anterior- Subperiosteal spread
4. Appendicular

11. Radiological Investigations
• Appendicular type of
lesion
– Rare
– Isolated infections of
pedicles / lamina/
transverse processes/
Spinous process.
– Intact disc space
– Para vertebral shadows

12. Clinical Features
Active stage
Constitutional
symptoms:
• Malaise
• Loss of
weight/appetite
• Night sweats
• Evening rise of
temperature
Specific Symptoms:
• Pain/Night cries
• Stiffness
• painful Restricted ROM
• localised Deformity
• Enlarged lymph nodes
• Abscess
• Neurodeficit : motor appear first Sense of position and
vibration – last to disappear
• Spontaneous muscle twitching in lower limbs
• Clumsiness while walking
• Extensor plantar response
• Exagerrated reflexes – Sustained clonus of patella and ankle

13. Clinical Features
Healed stage
Constitutional symptoms:
• Malaise
• Loss of weight/appetite
• Night sweats
• Evening rise of temperature
Specific Symptoms:
• no pain and tenderness of spine
• Stiffness
• Deformity
• Restricted ROM
• Enlarged lymph nodes
• Abscess
• Neurodeficit
• ESR - normal

14. Neurological deficit
• 10-30% cases – Neurological deficit
• Disease below L1 vertebrae rarely causes Paraplegia
• Highest Incidence of paraplegia seen in TB of lower thoracic vertebrae

15. Classification of TB Paraplegia
Early onset paraplegia (group A)
• Appears within 2 years of onset –
during the Active phase
• Underlying pathology
– Inflammatory edema
– TB Granulation tissue
– Abscess
– Caseous tissue
– Ischaemis lesion of cord (Rare)
• Good prognosis
Late onset paraplegia (Group B)
• Appears more than 2 years of disease
in vertebral column
• Underlying pathology –due to
mechanical pressure on cord
– TB Debris
– TB Sequestra from body and disc
– Internal gibbus
– Canal stenosis / Severe deformity
• Poor prognosis

16. Staging of Neurological Deficit
Goel 1967, Tuli 1985, Kumar 1988, Jain 2002
Stage Severity Clinical Features
I Negligible Patient unaware of neurodeficit, physician detects plantar
extensors or ankle clonus
II Mild Patient aware of deficit but walks with support
III Moderate Non ambulatory due to spastic paralysis (in extension), sensory
deficit less than 50 %
IV Severe III + Flexor spasm / Paralysis in flexion / Flaccid/ Sensory deficit
more than 50 % / Sphincter Involved

17. Pathology of TB Paraplegia
Extradural mass : (mc), pus, granulation tissue. casseous material
Inflammatory edema : early cases. vascular stasis, toxins
bony disorders : sequestrum, gibbus, dislocation
meningeal changes: peridural fibrosis
infarction of spinal cord: irreversible
changes in spinal cord: myelomalacia, syringomalacia
extradural garnuloma and tuberculoma

18. Investigations
• CBC:
– Hb% ↓
– Lymphocytosis
• ESR:
– Raised in active stage of disease
– Normal ESR over period of 3 months suggests patient is in stage of repair

19. Investigations
• Mantoux test
– Erythema of more than 20 mm at 72 hours – Positive
– Negative test, in general, rules out the disease

20. Investigations
• Biopsy
– In case of doubt, it is mandatory to prove the diagnosis by obtaining the diseased
tissue

21. Investigations
• Smear and culture
– Pus: Zeill- Neilson stain → Acid Fast bacilli
– Culture of pus in Lowenstein jensen media
– Bactec For faster culture of Mycobacterium
tuberculosis

22. Investigation
• Serological Investigations
– ELISPOT (Enzyme- linked immunospot)
– T-cell based assay from blood
– IgM & IgG antibodies : High sensitivity, low specificity
– PCR: more sensitive

23. Radiological Investigations
• Xray: Plain radiograph signs
– Reduced disc space
– Blurred paradiscal margins
– Destruction of bodies
– Loss of trabecular pattern
– Increased prevertebral soft tissue shadow
– Subluxation /dislocation
– Decreased lordosis/Kyphosis

24. Radiological Investigations
• Xray: Plain radiograph signs
– Reduced disc space
– Blurred paradiscal margins
– Destruction of bodies
– Loss of trabecular pattern
– Increased prevertebral soft tissue shadow
– Subluxation /dislocation
– Decreased lordosis/Kyphosis

25. Radiological Investigations
• Xray: Plain radiograph signs
– Reduced disc space
– Blurred paradiscal margins
– Destruction of bodies
– Loss of trabecular pattern
– Increased prevertebral soft tissue shadow
– Subluxation /dislocation
– Decreased lordosis/Kyphosis

26. Radiological Investigations
• Xray: Plain radiograph signs
– Reduced disc space
– Blurred paradiscal margins
– Destruction of bodies
– Loss of trabecular pattern
– Increased prevertebral soft tissue shadow
– Subluxation /dislocation
– Decreased lordosis/Kyphosis

27. Radiological Investigations
• Xray: Plain radiograph signs
– Reduced disc space
– Blurred paradiscal margins
– Destruction of bodies
– Loss of trabecular pattern
– Increased prevertebral soft tissue shadow
– Subluxation /dislocation
– Decreased lordosis/Kyphosis

28. Radiological Investigations
• Xray: Plain radiograph signs
– Reduced disc space
– Blurred paradiscal margins
– Destruction of bodies
– Loss of trabecular pattern
– Increased prevertebral soft tissue shadow
– Subluxation /dislocation
– Decreased lordosis/Kyphosis

29. Radiological Investigations
• Skipped lesions:
– More than one TB
Lesion in vertebral
column with one or
more healthy vertebrae
in between the 2 lesion.
– More frequently
detected on CT/MRI

30. Radiological Investigations
• Lateral shift and scoliosis
– More destruction of vertebrae
on one side
• Kyphotic deformity
– Due to collapse of bone
– Forward angulations

31. Radiological Investigations
• Healing is indicated by
– Decreased soft tissue
shadow
– Return of normal density
– Bony ankylosis

32. Computed tomography (CT)
• Calcifications in abscess (pathognomic for Tb)
• Regions which are difficult to visualize on plain films, like :
1. Cranio-vertebral junction (CVJ)
2. Cervico-dorsal region,
3. Sacrum
4. Sacro-iliac joints.
5. Posterior spinal tuberculosis
because lesions less than 1.5cm are usually missed due to
overlapping of shadows on x rays.

33. MRI
• Detect marrow infiltration in vertebral bodies, leading to early
diagnosis.
• Changes of diskitis
• Assessment of extradural abscesses / subligamentous
spread.
• Skip lesions
• Spinal cord involvement.
• Spinal arachanoiditis.

34. USG
- to find out primary in abdomen
- Detect cold abscess
- Guided aspiration
Radionucleotide Scan T 99m
• Increased uptake in active tuberculosis.
• Avascular segments and abscesses show a cold spot due to
decreased uptake.
• Aid to localise the site of active disease and to detect multilevel
involvement

35. Clinico-radiological classification of
Typical TB Spondylitis

36. Prognosis of recovery of cord functions
Cord involvement Better prognosis Poor prognosis
Degree Partial (Stage I & II) Complete (Stage IV)
Duration Shorter Longer(>12 months)
Type Early onset Late onset
Speed of onset Slow Rapid
Age Younger Older
General condition Good Poor
Vertebral disease Active Healed
Kyphotic deformity <60 degree >60 degree
Cord on MRI Normal Myelomalacia

37. Basic Principles Of Management
Early Diagnosis
Expeditious medical
treatment
Aggressive surgical
approach
Prevent Deformity
Expect Good
Outcome

38. Present management
Cases of
spinal TB
Conservative
treatment with
chemotherapy only
Middle path regime
Radical surgery

39. Middle path regime
• Rationale
– “ All Spine Tuberculosis cases do
not require surgery and all those
who do not respond to
conservative measures should be
operated”

40. Algorithm for management of pott’s paraplegia

41. Middle path regime
•
• Admission for
– paraplegics
– who require surgical evacuation of pus or debridement of vertebral lesion
– those who agreed for fusion of spine
• Chemotherapy
• X-ray & ESR once in every 3 months
• MRI/ CT at 6 months interval for 2 years for Craniovertebral ,cervicodorsal, lumbosacral& sacroiliac joints
• Gradual mobilization
– 3-9 weeks- back extention exercise 5-10 min 3-4 times
– Spinal brace--- 18 months-2 years

42. Middle path regime
phase duration drug
Intensive 5-6 months INH 300-
400mg
Rifampicin
ofloxacin400-600mg /
streptomycin
Continuatio
n
7-8 months -do 3-4mth Pyrazinamide
1500mg
4-5mth Rifampicin
Prophylactic 4-5 months -do Ethambutol 1200mg
SM TULI, TUBERCULOSIS OF SKELETAL SYSTEM. 5TH ED.

43. Middle path regime
• Abcesses – aspirate near surface
– Instille 1gm Streptomycin +/- INH in sol
– all radiologicaly visible abcesses need not be drained.
– prevertebral abcess in cervical region are drained when complicated by dificulty in deglutition and
respiration.
• Neural complications if responds 3-4 weeks :- surgery unnecssary
• Excisional surgery for posterior spinal disease a/w abcess & sinus because of danger of
2' infection of meninges if dissease does not come in control in 4 wk.
• Operative debridement for patients –
– if no arrest after 3-6 months
– recurrence of disease

44. Middle path regime
• post spinal arthrodesis - symptomatic unstable sinal lesion in which
dissease otherwise seems to be arrested.
• laminectomy has no role , except in canal stenosis, spinal tumor
syndrome, non healing post spinal dissease

45. Middle path regime
• DONT RUSH IN FOR SURGERY SO LONG AS PATIENT IS ABLE TO
WALK.
• THE MOMENT patient is unable to walk, anterior decompression/
transposition is carried out.
• preferd op. aproach
• CERVICAL : anterior aproach
• DORSAL : anterolateral / transpleural aproach
• LUMBAR : transverse vertebrotomy aproach

46. Middle path regime
• Absolute Indications of surgery
1. No progressive recovery after fair trial of conservative
treatment
2. Neurological complications develops during conservative
treatment
3. Worsening of neurological deficit during t/t
4. Recurrence of neurological complications
5. Pressure effects (deglutition/respiration)
6. Advanced cases of neurological involvement(Sphincter
disturbances, flaccid paralysis or severe flexor spasm)

47. – post op:
• hard bed and rest
– for 3-5 months if paraplegic
– for 2-4 months in abscence of paraplegia.
– then mobilised with spinal braces
– braces are discarded after 1-2 years after surgery

48. Operative Management
Surgery Indications
1 Decompression(+/- fusion) Too advanced disease, Failure to
respond to conservative therapy
2 Debridement +/-
decompression +/- fusion
Recurrence of disease or of neural
complications
3 Anterior transposition of cord
(Extrapleural anterolateral
approach)
Sever Kyphosis (>60 degree) + /
neural deficit
4 Laminectomy Extradural granuloma/ Old healed
disease presenting as secondary
canal stenosis/ Posterior spinal
disease

49. Follow up
• Patient evaluated at 3 months interval upto 2 years.
Evaluation
Clinical:
Weight gain
Pain relief
Free ROM
Resolution of abscesses
Neurological recovery
Radiological:
Decreased soft tissue shadow
Disappearance of erosions
Return of mineralization
Graft incorporation
Bony ankylosis

50. Recovery
 first objective evidence of onset of recovery - 3 wks
 Time taken for near complete recovery varies between 3-6 months
• No significant neural recovery occurs after 12-18 months

51. Results
• Definition of favorable status-
– No residual neural impairment
– No sinus/ cold abscess
– No impairment of physical activity due to spinal disease / lesion
– Presence of radiographic quiescent disease

52. Recurrence/ Relapse
• Extradural granuloma
• Severe kyphosis
• Reactivation of lesion
– Poor nutrition
– Resistant organism
– Immuno compromised status

53. Recurrence/ Relapse
• Necessary surgery
• Newer anti TB drugs
• Supportive measures

54. spinal braces
C1-C7 FOUR POST
COLLAR
D1-D3 taylor brace with
cervical collor,
SOMI
D4-L2 taylor brsce
jawette brace
(ASH)
L3-L5 goldthwait
brace
Jawette brace
Taylor brace

55. Ash Brace (Hyper Extension Brace)
Four Post Cervical Brace

56. Sternal-Occipital-Mandibular Immobilizer (SOMI)

57. Take home message
• Conservative and operative management have
their distinct advantages and disadvantages
• Judicious choice of treatment for pott’s spine
usually gives good results.

58. Thank you