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WScJ 1: 8-14,
2015

Spinal TB Infections
Mohsin Qadeer1, Salman Sharif2
1

Fellow Spine Surgery, Liaquat National Hospital & Medical College, Karachi, Pakistan
Head of Neurosurgical Unit, Liaquat National Hospital & Medical College, Karachi, Pakistan

2

ABSTRAcT
Spinal TB is still a catastrophic problem in the developing world and the developed world in immuno
compromised patients. The prompt diagnosis and treatment can help prevent increased morbidity in
terms of deformity and neurological deficits .The correct treatment and appropriate duration is necessary to
achieve cure. The new classification systems help us in guiding surgical therapy.
KEY wORDS: Post operative, spine, TB abscess, tuberculosis, tuberculosis
infection

INTRODucTION

S

pinal tuberculosis infections (TB) have been
reported as early as the time of Egyptian mummies, and
en- compass almost 1 % of the tuberculosis cases. It may
have wide range of presentations that not only affect the
spinal cord and its covering but also the adjacent bony and
soft tis- sue elements. The need for accurate and prompt
diagnosis and treatment has improved the outcome in
terms of both
deformity and neurology (24).
Spinal TB infections today occur in endemic areas with
increasing frequency in all age groups. In young adults,
the disease appears to have increased in recent decades
because of immunodeficiency syndromes and intravenous
(IV) drug abuse, especially in the developing countries.

pRESENTATION OF SpINAL INFEcTION
It may present as the classic form or spondylodiscitis,
and an increasingly common atypical form which is
spondylitis without disc involvement (16). In adults it
usually involves the end plates while in children, it can
attack the discs directly as the disks are more vascular.
The infection may involve the adjacent structures, and
form large collections or cold abscesses, and cause
symptoms by bony destruction, deformity, and pressure,
by epidural abscess, or granulation tissue (5). Neurologic
deficits may result from neural compression.
8

The patient commonly presents with back pain, along
with deformity and neurological symptoms, depending
upon the level. The disorder may be accompanied with
other constitutional symptoms, like fever, weight loss, and
night sweats, etc.
The disease is endemic in developing and
underdeveloped countries, and may be the first differential
in most of the cases. The classic clinical presentation of
spinal tuberculosis (Triad of pott) includes Gibbus, spinal
abscess and paraparesis.

RISK FAcTORS
Other than living in an endemic area, a compromised
immune status was identified with certain risks factors in
over 50% of such patients. These include chronic renal
fail- ure, diabetes mellitus, alcoholism, IV drug abuse,
malig- nancy, recurrent UTI, Pott’s disease and positivity
for HIV. Chronic steroid use, recent spinal procedure
and trauma (such as gunshot wound, etc.) are also risk
factors.

LABORATORY wORK up
No single laboratory study is pathognomonic of this
condition. CBC shows leukocytosis. The Mantoux test is
not very helpful in endemic areas. ESR is usually elevated
>30. CRP may also be raised. PCR may be helpful once the
samples have been taken by needle biopsy for culture and
World Spinal Column Journal, Volume 6 / No: 1 / January
2015

histopathology, although the yield of cultures ranges
from

9

WScJ 1: 8-14,
2015

World Spinal Column Journal, Volume 6 / No: 1 / January
2015

45-95 % in different studies. Nowadays, serum and CSF
cytokines, and matrix metalloproteinases and monocytes
are being experimented with and may have a role in the
diagnosis (15).

RADIOGRApHIc DIAGNOSIS
Plain X-ray films usually show bony destruction and
kyphosis, and some times with large psoas abscesses may
also be seen. Osteomyelitis of adjacent vertebral bodies is
seen more commonly in infections anterior to dura. There
is evidence of lytic lesions, demineralization, and
scalloping of end plates that may take about 4 to 6 weeks
after onset of infection.
CT scan is better in defining these subtle osseous
changes, more than one level may be seen involved with a
predilection for the vertebral body and disc space (sparing
posterior elements), with sclerosis of the involved
vertebral body endplates. It is important to remember that
disc space is most often involved in TB osteomyelitis,
where as it is spared in primary or metastatic tumors.
(Nucleus pulposus is avascular providing a haven for the
mycobacterium).
“A bad disc is a good sign whereas a good disc is a
bad sign”
MRI is the imaging study of choice. It not only helps
in excluding other differentials (such as herniated disc,
hematoma, neoplasm, and transverse myelitis) but also
provides better anatomical details including its rostrocaudal extension. There is a decrease in signal intensity of
the involved bone and soft tissues on T2-weighted images
and the increase in intensity of a uniform thin rim
enhancement is a pathognomonic finding suggesting
either caseation necrosis or a cold abscess in tuberculosis.
It is also helpful to check for the response to the treatment
(1,3,7,8, 15). PET Computed Tomography may play a role
in early detection and in cases where we have atypical
multiple lesions.

cLASSIFIcATION
Throughout history multiple classification systems
have been used to quantify the degree of deformity and
anterior and posterior involvement along with neurological
involvement to plan for the best treatment option. Kumar
introduced a 4-point classification system based on stage
of disease and site of involvement in 1985. Mehta and
Bhojraj in 2001 gave a classification system based on MRI
findings and classified in 4 groups, but it lacked to address
areas other

than dorsal spine. Orguz et al classified TB spine as
follows: (6) 1) Type I, one-level disc involvement and
soft tissue infiltration without abscess, collapse and
neurologic deficit.
2) Type I-A, lesions only limited to vertebra and therefore,
manageable with fine needle biopsy and medical therapy.
3) Type I-B, abscess formation exceeds the vertebra and
the treatment is debridement using an anterior, posterior
or endoscopic approach. 4) Type II, one- or two-level
disc degeneration, abscess formation and mild kyphosis
correctable with an anterior surgery (14, 18).

MANAGEMENT GOALS
Establish diagnosis. Eradicate infection. Prevent recurrence.
Prevent or reverse neurological deficit. Relieve pain
Establish spinal stability

TREATMENT
Treatment is required after confirmation of the
diagnosis, if there is controllable pain, with no increasing
deformity, and stable neurological deficit, then a trial of
conservative management can be given and surgery is nor
necessary, in case there is increasing deformity, increasing
neurological deficit, on increasing pain, then surgical
intervention is required, with debridement
and
stabilization (1,2,4,10,
14,18).

NON-OpERATIVE TREATMENT
This involves immobilization till the pain improves or
the instability is excluded. Later mobilization is with brace
therapy. ATT is continued for a minimum of 9-18
months, depending on the extent of the infection and
organism.

MEDIcAL THERApY
Medical therapy with anti tuberculous drugs is the
corner stone in Pott’s spine. The standard drugs
consists of; Isoniazid (5 mg/kg; maximum 300 mg/day),
Rifampicin
15 mg/kg; maximum 600 mg/day, Ethambutol (15 – 25
mg/kg; maximum 2 g/day), Pyrazinamide (15 – 30 mg/
kg; maximum 2 g/day). Pyridoxine was also added to the
regimen prophylactically. This regimen is given for two
months followed by withdrawal of Pyrazinamide and
Ethambutol for the rest of the period. The period ranges
from 9-18 months (1,2,4,9,10,16,20-24, 26). In case of

MDR TB 6 drugs may be required with the duration of up
to 18 to
24
months.

Spinal TB Infections

Table 1: GATA CLASSIFICATION, E Oguz et al. Int Orthop. 2008 Feb; 32(1): 127-133

OpERATIVE TREATMENT
Surgery may be necessary in about one-eight of the
patients. The options include: radical debridement with
or without bone grafting, or radical debridement, bone
grafting along with instrumentation. Indications for
surgical intervention are to obtain diagnosis when closed
biopsy is unsafe or is unsuccessful, clinically significant
abscess with cord compression, progressive neurological
deficits, significant deformity of vertebral body, and in
medical refractory cases (i.e. high ESR, persistent pain and
progressive neurology). An increasing number of articles
indicate that instrumentation is not contraindicated in
cases where radical debridement is achieved. The
additional stability instead promotes clinical resolution of
the infection and related symptoms.

The optimal approaches are either anterior approach,
posterior approach or a combined approach. Anterior
approach is usually recommended to access for
debridement, grafting
and
stabilization
with
reconstruction of anterior column. Posterior approach
may be adequate in lumbar spine.
The correction of kyphosis is necessary as in the long
term even stable patients will progress to increasing
deformity. In children the correction is more important
because a growing skeleton causes increased deformity
(17). In types I, II, and III, progression occurs
approximately in
39%, 44%, and 17% of pediatric cases respectively,
during the growth spurt. A spinal instability score higher
than 2 seems to reliably predict patients who will have an
increase of more than 30° kyphosis and a final deformity

greater than

M Qadeer and S
Sharıf

Table 2: WHO recommended treatment regimers for different disease categories [14]

Figure 1: MRI sagittal view T2WI of cervicodorsal spine showing
tuberculous vertebral osteomyelitis with collapse and anterior cord
compression at two levels with a normal segment in between (skip
lesions).

Figure 2: Gibbus
seen
on
the
lower back of a
patient
with
Pott’s spine.

60°. the posterior approach is nor sufficient to correct
severe deformity with kyphosis and Kyphosis angle of
more than
90 deg.
New techniques like 360 deg fusion, wedge osteotomies
both anterior and posterior and pedicle subtraction
osteotomies have been done for correction of these
extreme cases with poor neurological results (11-13,17,2022,24-26).

Figure 3: MRI sagittal view T2WI of dorsolumbar spine showing
vertbral collapse at D12 with hyperintense signal intensity of the disc
space above and below, and anterior to the vertebral body, along with
compression at the conus and kyphotic deformity.

Figure 4: MRI axial contrast view showing abscess formation within
the vertebral body and para spinal region with anterior cord
compression and canal compromise.

Figure 5: MRI sagittal and axial views of lumbosacral spine showing erosion of disc at L3/4 with fragmentation at adjacent disc level. Evidence of high

signals in left para vertebral region representing an abscess. This patient had Pott’s spine and was managed conservatively on anti-tuberculous therapy.

prognosis:
With new diagnostic modalities, and proper, medical
and appropriate surgical treatment, the disease has a
favorable outcome even in the presence of deformity and
neurological deficits which are usually reversible up to
75%.

Personal series of 350 patients who underwent surgery
over 11 years, only 3 patients have remained plegic despite
25 % presenting with plegia.

Figure 6: Cervical tuberculous osteomyelitis managed surgically. Left most is X-ray cervical spine lateral view showing collapse at C4 with soft tissue
swelling anteriorly, middle one showing collapse with evidence of abscess formation anteriorly and severe cord compression. Right most X-ray showing
surgical fusion and fixation of the level involved after anterior decompression.

Figure 7: Left most showing MRI axial view of dorsal Pott’s spine. Middle and right most are intra operative pictures of evacuating pus after
performing thoracotomy and opening the wall of abscess.

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Manuscript submitted Nowember 11,
2014. Accepted December 14, 2014.
Address correspondence to: Salman Sharif, Department of Neurosurgery, Liaquat
National Hospital & Medical College, Karachi,

Pakistan email: [email protected]

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