Tuberculosis Of Spine : Current

Views in Diagnosis and Management

 Introduction

• Tuberculosis in human is usually a chronic

disease with weight loss, and currently the
world’s leading cause of death.
• Tuberculous spondylitis is a less common yet
the most dangerous form of skeletal
tuberculosis.
 Epidemiology
• Ninety-five percent of tuberculosis patients
are in the developing regions of the world.
According to the World Health Organization,
tuberculosis causes 1.81 million deaths in Asia
each year.
• The number of reported tuberculosis cases
has doubled or even tripled with the spread of
human immunodeficiency virus and acquired
immunodeficiency syndrome (HIV/AIDs).
 Clinical Manifestation
• At its active stage, symptoms of tuberculous spondylitis are often insidious.
Common symptoms are malaise, loss of appetite and weight, and night sweat. The
involved spine is stiff and painful on movement with a localized humpback. Back
muscle spasms are present. Occasionally, patients may have night-cries during
sleep, as the relaxation of muscle spasms allows for movement between the
inflamed surfaces. Cold abscess and/or sinus may be present. In the early stages of
disease, some of these symptoms and signs may be absent. On palpation, a small
gibbus may be detected. Rarely, neurological deficits may present as the first
symptom.
• Despite the recent advances in the diagnosis and management of spinal
tuberculosis, there remain a significant number of issues that up to now have
received little attention in spite of its significant clinical importance [5]. This paper
seeks to address these issues in diagnosis and management of spinal tuberculosis,
in particular focusing on the newer diagnostic techniques including non-culture
laboratory methods, hyperbaric oxygen therapy, immunosuppressant drug use,
surgical options for the spinal deformity and associated neural involvement,
instrumentation and implant removal time and the fate of the instrument-
immobilized joints.
 Diagnosis
• The insidious onset, lack of early constitutional symptoms and local
signs of spinal tuberculosis make early diagnosis difficult. With the
increasing incidence of all tuberculosis types across the globe,
physicians and surgeons must exercise a high index of suspicion to
achieve early diagnosis.
• Clinicians typically rely on a battery of means in diagnosing spinal
tuberculosis. These include observation and investigation of clinical
signs and symptoms and the use of various imaging techniques,
smear and/or culture, metabolic product detection (interferon-γ
[IFN-γ] test), polymerase chain reaction (PCR) and histological study.
Diagnosis may take days to weeks, and involves expensive, invasive
and complex procedures [1,2,4,5]. There is currently no single
diagnostic method that can detect all tuberculosis types and cases.
 Clinical Examination
Tuberculin Skin Test
• The tuberculin skin test (TST) has inherent limitations of sensitivity and
specificity. Even in high tuberculosis-burden areas, approximately 20% of
individuals show negative to TST throughout life, despite repeated
exposure to the tubercle bacilli. Additionally the sensitivity decreases in
immuno-compromised patients for whom accurate diagnosis of latent
tuberculosis infection is essential. In terms of specificity, TST is influenced
by Bacillus Calmette-Guérin (BCG) vaccination and non-tuberculous
mycobacterial infection [2,5].
Imaging
• Imaging techniques such as simple radiographs, bone scan, computed
tomography (CT) and magnetic resonance imaging (MRI) are useful but
not diagnostic. For example, when disc and/or end-plate destruction with
surrounding soft tissue swelling is observed on simple radiographs, spine
infection should be suspected.
• Diffusion-weighted MRI has been found to have limited usefulness for
differentiating spinal infection and malignancy.
Laboratory
Laboratory aids to diagnosis include: 1) complete
blood counts including total lymphocyte and CD4
lymphocyte (helper-inducer T-cell) counts; 2) ESR
and CRP; smear and/or culture; histology;
detection of specific antigen [22]; metabolic
products; 3) patient’s antibody response and
detection of antibody to M. tuberculosis; 4) DNA
sequence polymerase-chain reaction (PCR) of M.
tuberculosis
• treatment goals of spinal tuberculosis are primarily to eradicate the infection and to save life.
Secondly the goals are: to provide stability for the affected spine; to meet the patient’s
aesthetic demand by preventing and/or correcting spinal deformities (not only for aesthetic
purpose but also for reducing the parafusion segment disease); and to prevent or treat
paralysis. The ideal management would be one that meets all above goals.
• The management of spinal tuberculosis consists of supportive care, chemotherapy and
surgery. Surgical measures include: cold abscess drainage; focal debridement of the
tuberculous lesion and/or anterior fusion; decompression surgery including
costotransversectomy and anterior radical surgery [33]; a two-stage procedure of posterior
instrumentation [34] and anterior radical surgery [35]; a combined procedure of anterior
radical surgery and anterior instrumentation; and corrective spinal osteotomy for healed rigid
kyphosis [2,5]. However, surgery alone cannot cure the active disease, and effective
antituberculous chemotherapy is necessary. Although the final fusion of the affected
vertebral segment is an important part of the treatment, it does not necessarily accompany
the spontaneous healing process.
• Recently the current author found an important fact that spinal malalignment of the fused
segment at the time of the disease cure in adults is a contributing factor increasing the
incidence of parafusion segment disease [31]. Therefore maintenance and/or restoration of
normal spinal alignment at the time of the disease cure is strongly recommended.
• Nutritional Therapy
• Hyperalimentation may be necessary to restore patients
from a physically debilitated pre-therapy state to the pre-
morbid nutritional status. The goal should be to achieve a
serum albumin level >3 g/dL, an absolute lymphocyte
count >800/mm3 and a 24 hours urine creatinine excretion
> 10.5 mg in men and >5.8 mg in women [5,17,18].
• Chemotherapy
• When a patient presents early with minimal to moderate
bony involvement that does not seem to cause noticeable
deformity, conservative chemotherapy alone is indicated.
Chemotherapy can be given on an ambulatory basis
without bracing (Tables 1-3) [36-39]. Effective institution
 Conclusions
Spinal tuberculosis is curable with the presently
available chemo-therapeutic agents. With early
detection and institution of chemotherapy and
improved surgical techniques, patients with kyphosis
are rarely seen in daily practice currently. Selection of
the therapeutic measures to minimize the residual
kyphosis in the highly mobile spinal segments after
cure of the disease is stressed not only for aesthetic
view point but also for reduction of incidence of
parafusion segment disease. Paraplegic patients can be
well managed with minimal residuals if early diagnosis
and effective treatment are achieved.
The most common presenting symptom of spinal tuberculosis is back pain
or neck pain. Most patients seek consultation after weeks or months of
pain as the onset is usually insidious and progression is slow. Frequently it
is mistaken as benign low back pain, and treated with painkillers as the
early radiographs are often normal. Patients may experienceconstitutional
symptoms (reported incidence varies between 17-54%), however,
compared to pyogenic spondylodiscitis fever, anorexia, fatigue are less
common. Therefore, the clinician should maintain a high degree of
suspicion, especially in patients who complain of ongoing pain for more
than a month, have rest pain, or if associated constitutional symptoms are
present. In addition, as tuberculosis affects the anterior column primarily,
a knuckle deformity, i.e. prominence of a single spinous process might be
one of the early signs of tub erculous spondylodiscitis. Some patient can
also present with a cold abscess in remote locations like the posterior
triangle of the neck (cervical spine TB), along the ribs (thoracic spine TB),
or in the inguinal region (lumbar spine TB). The clinician should also
maintain a high degree of suspicion in immunocompromised patients ,
especially HIV infections, and should also be wary of patients with a
history of tuberculosis, or those who have come in contact with
tuberculosis patients.