Tuberculosis of Spine

Presenter: Dr. Harshavardhan U. Chandane

Guide: Dr. J.B.Panse
 Epidemiology
 Tuberculosis of the spine is one of the oldest
demonstrated diseases of humankind.
 Evidences of spinal tuberculosis have been found in
Egyptian mummies dating back to 3,400 BC.
 The descriptions in the Rigveda, Atharvaveda, and
Charak Samhita are the oldest known texts in the world
literature relating to this disease.
 Hippocrates described the clinical condition of spinal
infection believed to be tuberculosis.
 1779, Percival Pott gave the first complete report of
tuberculosis infection of the spine.
 Skeletal tuberculosis accounts for 2- 20% of all
extrapulmonary cases in various studies
 Vertebral TB constitutes 50% of skeletal TB.
 30 million people infected and 2.5 million death
annually.
 Infects a third of population worldwide.
 88% chronic infections of spine accounts for tubercular
infection.
 Incidence in Indian sub continental origin > whites.
Since the advent of ATT and improved public health
measures, spinal tuberculosis has become rare in
industrialised countries; although it is still a significant
cause of disease in developing countries.
Tuberculous involvement of the spine has the potential
for serious morbidity, including permanent neurologic
deficits and severe deformity.
Medical treatment alone, or combined medical and
surgical strategies, can control the disease in most
patients.
Spinal tuberculosis is predominantly a disease of the
young, the usual age of presentation being the first
three decades of life, while reports from developed
countries indicate a much older patient population.
 Incidence of skipped lesions is around 7% and
incidence of involvement of other bones and joints is
around 12%.
The prevalence of spinal tuberculosis is likely to rise
as the numbers of those infected with HIV rises in the
population.
 Risk factors

Children>young adult, but no age bar.

Male=Female.
Primary infection < 1 yrs.
Family history of tuberculosis.
Close contact with smear positive.
Chest x-ray – evidence of healed TB.
Immuno -compromised - HIV ,steroid, DM, CRF,
Malnutrition.
Malignancy-lymphoma, leukemia.
 Mode of spread of Infection :
Paradiscal/metaphyseal type: Commonest,
paradiscal margin of vertebra, spreads through
arteries.
 Central type: Body of vertebra , spreads along with
batson’s plexus of veins – is diffuse osteomyelitis.
 Anterior type: results from the extension of the
abscess beneath the anterior longitudinal ligament
and periosteum.
 Posterior type: Rare, involvement of vertebral arch.
 Sometimes pure tuberculous arthritis of occipito-
atlanto-axial joints can occur.
Pathological Types :
• Caseous exudative- increase destruction and
exudation and abscess formation, symptoms &
signs of TB more marked.
• Granular- less destructive, rare abscess
formation.
 Two distinct patterns are identified, the classic
SPONDYLODISCITIS, and an increasingly common
atypical form SPONDYLITIS without disc
involvement.
 The basic lesion is a combination of osteomyelitis
and arthritis.
Initial insult is of tuberculous endartertitis leading to
necrosis and granuloma formation (hallmark)
This increases in size and results in destruction of
lamellar structure of verterbral body.
Increased fragility leads to deformities, compression,
collapse.
 Presentation
Common during 1st three decades.
 Occurrence: Thoracic(42%) >
lumbar(26)>thoraco-
lumbar(12%)>cervical(12%)>cervico-
thoracic(5%)sacrum(3%).
Presentation depends upon the stage of the
disease, site of the disease, and presence of
complications such as neurologic deficit,
abscesses, or sinus tracts.
Active stage:
Localized painful movement (tender on palpation) or
referred pain depending upon the nerve root
involvement.
 Cold abscess.
Constitutional symptoms.
Evidences of associated extra-skeletal tuberculosis
like cough, expectoration, lymphadenopathy,
diarrhoea, and abdominal distension.
95% cases commonly have kyphotic deformity.
• Back pain (spinal or radicular) is the earliest and
most common symptom .This pain may worsen
with activity.
• Relaxation of muscles during sleep permits
movements which are very painful and wake-up
the patient (night cries).
• As the infection progresses, pain increases, and
paraspinal muscle spasm occurs.
• Muscle spasm obliterates the normal spinal
curves, and all spinal movements become
restricted and painful.
• Neurological deficits may occur early or late.
Early- epidural extension of an abscess.
Late- significant kyphosis, vertebral collapse with
retropulsion of bone and debris, or late abscess
formation.
• Neurological symptoms become more frequent at
higher spinal levels.
• Clumsiness in walking, and spontaneous twitching
of muscles are early signs of neurological
involvement which can progress to a single nerve
palsy, to hemiplegia, or paraplegia with spasticity,
sensory impairment, bladder/bowel involvement.
• Paraplegia is very rarely a presenting
manifestation.
Healed Stage:
• All signs and symptoms subsides except the
deformity that occurs in active stage persists.
• Radiologically signs of bone healing.
• However patient rarely presents with neurological
deficits initially.
 Cold abscess
 Cold abscess is formed by collection of
liquefied products and reactive exudates,
consists of serum, leucocytes, caseous material,
bone debris and tubercle bacilli.
 Present far away from vertebral column along
fascial plane or course of neurovascular bundles.
 Anterior and posterior cervical triangles,
paraspinal region at back, along brachial plexus
in axilla, intercostal space in chest wall,
dorsolumbar abscess along psoas sheath to be
palpable in iliac fossa, in upper part of thigh or
even downward up to knee.
 APPROACH TO DIAGNOSIS

 Anemia, lymphocytosis, raised ESR.

 Mantoux Test may be positive but not diagnostic.
 It demonstrates a positive finding in 84 - 95% of
patients who are non-HIV-positive 1 to 3 months after
infection.
 Coexistent infection by HIV and other immune
deficiency conditions can give a false negative skin test.
 ELISA for antibody to mycobacterial antigen-6 showed
sensitivity of 94% and specificity 100% (stroebel et al.
1982).
 Chest X-ray and sputum for AFB Stain & c/s.
 PCR -100% specificity, is not readily available.
 X ray imaging
 Important diagnostic test, first line of imaging.
Early-
narrow disc space,
osteopenia ,
indistinct paradiscal margin.
Late-
ant. wedge compression,
concertina collapse ,
destruction of post. element.
Knuckle, angular kyphosis, round kyphosis.
Paravertebral abscess-
 In thoracic spine - fusiform or globular
radiodense shadow called the bird nest
appearance.
 Tracheal shadow > 8 mm and/or change in
normalcontour in C7 to T4 area.
 Long standing abscesses may produce
concave erosions around the anterior
margins of the vertebral bodies producing
scalloped appearance called aneurysmal
phenomenon.
Difficult in diagnosing early lesion. Lesion less
than 1.5 cm not demonstrable in conventional x
ray. Must have 30-40% of calcium removed from
particular area to show radiolucent region on x-
ray.
Average vertebra involved at diagnosis – 3(in
children) and 2.5 (adult).
7% may show skipped lesions in vertebral
column.
Radiological sites of Tuberculosis involvement:
Paradiscal, Central, Anterior, Appendicial.
• Paradiscal
 commonest variety.
 narrowing of disc space at earliest findings.
 Any reduction in disc space associated with a loss of
definition of paradiscal margin must invite suspicion.
• Central
 Infection starts from the centre of vertebral body.
 Diseased vertebra ballooned out like a tumor.
 Later stage-vertebra shows concentric collapse
resembling vertebral plana.
 Minimal diminution of disc space and Paravertebral
shadow .
• Anterior Type
 Lesion starts beneath anterior longitudinal ligament and
periosteum.
 Peripheral portion of vertebral body in front and side
shows erosions
 Collapse of vertebral body and diminution of disc space
is minimal and occurs late.
 More common in thoracic region and children.
 Appendicial Uncommon type
 Isolated infection of lamina, spine, pedicle, transverse
process.
 Shows erosive lesion, paravertebral shadow and intact
disc space.
 30% of typical paradiscal type show concomitant
involvement of posterior element.
Ultra sonography :
diagnose the presence of TB abscess in lumbar region
and abscess composition and quantity.
 CT scanning
 For a radiolucent lesion to be seen on a plain radiograph, 30% of
mineral loss must be there. CT and MRI detect lesions at an
earlier stage.
 CT scanning provides much better bony detail of irregular lytic
lesions, sclerosis, disc collapse, and disruption of bone
circumference.
 Specially helpful in detecting posterior spinal disease,
craniovertebral and cervicodorsal region , SI joints and of sacrum.
 More effective for defining the shape and calcification of soft
tissue abscesses.
 Useful in assessing bone destruction, but is less accurate in
defining the epidural extension of the disease, and therefore, its
effect on neural structures.
 MRI
Gold standard for evaluating disc space infection and
osteomyelitis of the spine.
 It effective for demonstrating the extension of disease
into soft tissues and the spread of tuberculous debris
under the anterior and posterior longitudinal ligaments.
 MRI is most effective for demonstrating neural
compression.
 MRI with contrast is helpful in differentiating from non-
infectious causes and delineating the extent of
disease.
Serial MRI can be used to assess the response to
treatment and regression of the disease.
 Bone scan
Bone scan with Tc-99m is considered to be highly
sensitive, but nonspecific. It may only aid to localise
the site of active disease and to detect multilevel
involvement.
Patients with active disease have an increased
uptake, whereas in avascular segments and
abscesses it may show decreased uptake
Even lesions of 5 mm size can be localized as hot
spot.
Histopathology and microbiology
Because of high prevalence, microbiological diagnosis
is not mandatory to start chemotherapy in our country.
However, a biopsy/aspiration may be needed in cases
of doubtful clinic radiological findings, lack of proper
response to drug therapy, and suspicion of drug-
resistant strains.
Biopsy study findings may be positive in only about
50% of the cases.
CT-guided needle biopsy and/ or aspiration is widely
done.
Percutaneous needle aspiration and/or biopsy is a
newer method with comparable yields as for surgical
biopsy.
 Definitive diagnosis is dependent
on culture of the organism and
requires biopsy of the lesion.
Clinicoradiological classification of typical tubercular spondylitis
Stage Clinico-radiological features Usual duration
I) pre-destructive Straightening of curvatures, spasm of < 3 mths
perivertebral muscles, bone scan would
show hyperemia, MRI shows marrow
edema
II) Early- Diminished disc space with paradiscal 2 – 4mths
destructive erosions (knuckle) MRI: marrow edema
and break of osseous margins, CT scan:
marginal erosions or cavitations
Stage III, IV ,V have vertebral bodies destruction

and collapse and appreciable kyphos

III)Mild angular 2-3 vertebrae involved (K: 10 to 300 ) 3 – 9 mths
kyphos
IV)Moderate >3vertebrae involved (K: 30 to 600 ) 6 – 24 mths
angular kyphos
V) Severe kyphos >3vertebrae involved (K: > 600 ) > 2 yrs

( humpback)
Measurement of k angle
 Angulation of spine: posterior convexity
 Forward wedge of 2 vertebral bodies- knuckle.
 Wedge collapse of 3 or more vertebra- angular.
 Wedging of large no of adjacent vertebra- round
kyphosis.

Tall vertebra-occurs only during growth period

increase in height of lumbar vertebral bodies
( up to 1\3 rd) in healed thoracic pott’s disease.
 Differential Diagnosis

Age: confused with Young child calve”s disease, congenital

defect and adults with Scheuermann”s disease.
PYOGENIC SPONDYLITIS:
 sudden onset, severe localized pain, spasm, fever.
 initially rapid bone destruction which is replaced
rapidly by bone sclerosis and new bone formation
(Radiologically after 8th wks)
 usually follows recent surgery or infection
 examination of biopsy useful
 MRI shows inflammatory changes
 heals with marked sclerosis, proliferative bone
formation, even with ankylosis.
 Tumour like conditions
 Benign
Hemangioma- most common (10.7%) . Asymptomatic usually
and found incidentally , D12 to L4 most commonly involved.
Involved vertebra radiologically shows characteristic coarsening of
vertebral trabaculations more prominent in vertical than horizontal.
GCT and ABC- typical osteoytic, expansile and usually
eccentric growth on radiological examination. disc space is not
involved in early stage. Final diagnosis made histologically.

 Malignant
Primary malignant are rare ,but Ewing's and Osteogenic
sarcoma occasionally occur. Tumors have rapid course of
disease with progressive paraplegia and radiological evidence
of bony trabecular destruction. Diagnosis confirmed by biopsy.
 Multiple myeloma
may resemble Pott’s TB with involvement of only 1 or
2 vertebra and if there is collapse and eccentric
destruction. Involvement of multiple joints ,high ESR,
anemia , Bence Jones protein, reversal of albumin
globulin ratio, electrophoresis helpful in diagnosis.
Confirmed by biopsy shows myeloma cells.

 Lymphomas-(Hodgkin’s disease, Leukaemias)

may rarely involve spine, diffuse sclerosis of bone and
trabecular destruction. Enlargement of spleen , liver, and
lymph node with characteristic haematological changes.
Secondary neoplastic deposits -largest
percentage of neoplasm of spine. onset more
acute, progress more rapidly and local sign more
widespread. Secondary deposit nearly always
involve vertebral body with no disc involvement.

Traumatic condition-usually traumatic fracture is

wedge shaped with intact disc space. There may
be marginal spurring and spondylitis changes.
Eosinophilic granuloma- self limiting. Develop in
vertebral body which undergoes an extensive degree of
concentric collapse. The disc above and below are not
involved . Usually disease occur between 6 and 12
years of age and patient complains of localized pain
without constitutional symptom.

Osteoporosis- may lead to collapse of vertebral column.

In pre-collapse stage vertical bony trabeculae are more
prominent but there is no evidence of osteolytic
destruction. Nucleus pulposus of disc expands and
attain a biconvex appearance and biconcave vertebral
bodies.
Mycotic spondylitis-. In blastomycosis, paravetebral
abscess formation and in actinomycosis sclerosis
and destruction of bone occur. Anterior and lateral
surface of several vertebral body may be involved and
may show an irregular saw tooth appearance by
periosteal new bone formation.
Syphilis-
Rare. Thoraco-lumbar and lumbar spine are common
Three types-arthralgic type, gummatous type and
charcots diseases.
. Radiological- gross disorganization and destruction
of involved vertebra along with proliferative new bone
formation.
Serological test, biopsy.
Local developmental abnormalities.
 Complications
Due to Tubercular Infection
 Potts Paraplegia
 Cold Abscess
 Sinuses
 Fatality
 Secondary infection
 Amyloid Disease.
 Neurological complications

Most dreaded and crippling complications.

Overall incidence 10 to 30 %.
More common in first 3 decades of life.
Tuberculous pathology remains commonest
pathology for paraplegia in developing countries.
 Classification of tuberculous paraplegia/tetraplegia
(predominantly based on motor weakness)
 I : negligible – pt unaware of neural deficit , physician
detects plantar extensor and /or ankle clonus.
 II : mild- pat aware of deficit but manages to walk with
support. All signs of spastic paresis present.
 III : moderate- non ambulatory because of paralysis in
extension, sensory deficit less than 50%.
 IV : severe – stage III + flexor spasms/paralysis in flexion/
flaccid / sensory deficit more than 50%/ sphincters involved.
HIGHER THE STAGE OF PARALYSIS , MORE
SEVERE IS THE CORD COMPESSION AND POORER IS
THE PROGNOSIS.
 Pathology of tuberculous paraplegia
Inflammatory edema – cause of early cases of neuro
deficits
Extradural mass – commonest mechanism
Bony disorders- sequstra, angulation of the diseased
spine, pathological dislocation leading to mechanical
instability
Meningeal changes- peridural fibrosis
Infraction of spinal cord- rare but important cause
since paralysis caused is irreparable.
 Myelography
Indications- paraplegia without evidence
radiologically, as in cases of “spinal tumor
syndrome”, or when multiple vertebrae are involved.
Also when there is no recovery after surgical
decompression to demonstrate inadequate
decompression.
 Medical treatment
 Medical treatment is in the form of ATT.
There is a lot of discordance among experts on the
duration of anti tuberculous treatment.
British Medical Research Council and US Centres
for Disease Control and Prevention indicate that
tuberculous spondylitis of the thoraco-lumbar spine
should be treated with combination chemotherapy
for 6 - 9 months.
However, British Medical Research Council studies
did not include patients with multiple vertebral
involvement (which is commoner in our country),
cervical lesions, or major neurologic involvement.
 WHO/RNTCP guidelines consider spinal tuberculosis with
neurological deficit to be severe extra pulmonary (category
1 ) and should receive treatment for 6 months.
 In relapse or treatment failure, it should be given treatment
according to category 2, i.e., for 9 months
 The currently recommended regime is four-drug therapy
include isoniazid, rifampicin, pyrazinamide, ethambutol . In
children, ethambutol is replaced by streptomycin.
 In view of multiple vertebrae involvement, extensive
disease, neurological involvement; most of the authorities in
India prefer to give ATT for 18 months – HRZE 4 + HR14 .
 Treatment protocol of HIV positive patients is same as of
HIV negative. Patients with lower CD4 counts have poor
prognosis
 Surgical treatment
 Opinion varies regarding the operative
indication for Pott’s spine.
 A large group of surgeons perform
debridement and decompression in all
cases, irrespective of neurological
involvement.
 Others perform operative decompression
only in those patients who do not respond to
chemotherapy.
Resources and experience are key factors
in the decision to use a surgical approach.
• Indications for surgery are neurologic deficit,
spinal deformity with instability, severe or
progressive kyphosis, retropulsed bone fragments
in the canal, large abscess causing respiratory
embarrassment, and no response to medical
therapy.
• Post-operatively the patient is advised absolute
bed rest for three months, and then gradually
mobilised in a spinal brace.
• A lower threshold for surgery is recommended in
case of cervical spine involvement as it is more
commonly associated with higher incidence and
severity of neurological deficits and abscess
compression.
 Middle path regime of SM Tuli
 treated on non operative basis, anti TB chemotherapy,
rest and spinal braces.
 Hospitalization for those who require surgical evacuation
of abscess or debridement of vertebral lesions or those
who agree for fusion of spine for extensive dorsal lesion in
children or for an unstable and painful spinal lesion or
paraplegics who are unable to walk.
PROTOCOLS:
I ) Rest: in hard bed or plaster of Paris bed to put the
disease part in rest.
II ) Anti-tubercular Drugs:
 intensive phase of 5 to 6 m: H-300 to 400 mg , R –
450 to 600 mg and ofloxacin – 400 to 600 mg
 continuation phase of 7 to 8 m : H and Z 1500 mg,
for 3 to 4 m followed by H and E 1200 mg for 4 to 5 m
 prophylactic phase – for 4 to 5 m: Z and E
 Pyridoxine 10mg prevent peripheral neuropathy due
to INH.
 Supportive therapy with haematinics, analgesics,
multivitamins and high protein diet.
III ) Radiographs and ESR are taken at 3 to 6 months interval for
2 years.

 90% Bony healing, 10% Fibro-osseous.

 early stage of healing shows disease foci surrounded
by sclerotic bones (ivory vertebra).
 early radiological signs of healing: sharpening of the
fuzzy paradiscal margins, & reappearance and
mineralization of bone which had earlier been
absorbed.
IV ) Gradual mobilization
is encouraged in the absence of neural deficit with
help of suitable spinal braces after the comfort at the
diseased site permits. At 8 to 9 weeks of treatment
back extension exercise. Spinal brace continued for
18 months to 2 years.

V ) Sinuses
usually heals within 2 to 3 months. Few may require
excision of tract.
VI ) Abscesses
are aspirated when its near the surface and one gram
of streptomycin with or without INH instilled at each
aspiration. Sufficient to heal about 95%. 5% requires
surgery

Open drainage or suction drainage for 72 hours of

abscess is performed if aspiration fails to clear.
Clinical factors influencing prognosis of cord involvement
Cord involvement Better prognosis Relatively poor prognosis

Degree Partial – stage 1 and 2 Complete – stage 3 and 4

Duration Shorter Longer > 12 months

Type Early onset Late onset

Speed of onset Slow Rapid

Age Younger Older

GC Good poor

Vertebral disease Active Healed

Kyphotic deformity < 600 > 600

Cord on MRI Normal Myelomalacia / syrinx

Per operative Wet lesion Dry lesion

VII ) Neural complication-
 If the patient shows progressive neurological recovery
with in 3 to 4 wks surgical debridement is not
necessary.
Indication of surgical decompression
 If progressive recovery to satisfactory level after of fair
trial of conservative therapy do not start.
 Neurological complication develops during the
conservative treatment.
 Neurological complication become worse or there is
recurrence.
 Para vertebral cervical abscess with difficulty in
deglutition or respiration.
 Advance case with Motor, Sensory and Sphincter
involvement.
 Doubtful diagnosis
VIII) Operative debridement advised for cases who don’t
show arrest of the activity of the spinal lesion after 3 to 6
months of chemotherapy or the cases with recurrence.
Posterior spinal arthrodesis recommended for unstable
spinal lesions in which the disease otherwise seems to be
arrested.

IX ) Post-operative- Patient are nursed on hard bed for 2

to 3 weeks, in case of neural complications 3 to 5
months, the patient is gradually mobilized with the help of
spinal braces.
Surgical Approaches: Described by Various Authors
 C1-C2:Anterior, Transoral/ Transthyroid
 Cervical Region: Anterior, Through Anterior/ Posterior triangle.
 C7-D1:Transpleural (3rd rib), Anterior Cervical, Low Ant. Cervical.
 Dorsal: Anterolateral or Transpleural, Ant. Transpleural D5-
D12, Trans-sternal D3-D4.
 Dorso-lumbar: Anterolateral ,11th rib Extra pleural/ Extra
peritoneal or 9th rib Left Transpleural.
 Lumbar: Retroperitoneal, or Ureter or Sympathectomy
Approach, Antero-lateral, Renal Approach
 L5-S1:Transperitoneal in Trendelenburg position with
paramedian or low midline Incision, Retroperitoneal through
oblique renal or hemisection incision, Retropsoas transverse
vertebrotomy.
 Main indications for various operations
for vertebral tuberculosis
Decompression ± fusion for neurological
complications which failed to respond to
conservative treatment or are very advanced.
 Decompression ± fusion in failure of response in 3
to 6 months of non-operative treatment.
Doubtful diagnosis.
Fusion of symptomatic mechanical instability after
healing.
Debridement ± Decompression ± fusion in
recurrence of disease or of neural complications.
Prevention of severe kyphosis by debridement +
fusion by panvertebral operation in children with
extensive dorsal lesions.
Anterior transposition of cord through extrapleural
anterolateral approach for neural complications due
to severe kyphosis.
Laminectomy has no role, except for extradural
granuloma/tuberculoma presenting as spinal tumor
syndrome, or a case of healed disease presenting
with secondary canal stenosis.
• Due to efficacy of modern ATT absolute
indications for surgery are reduced to nearly 5%
of uncomplicated cases and to about 60% of
cases with neurological complications.
• All pts who recover are able to return to full
activity within 6 to 12 months of treatment.
• Active life is permitted with suitable braces which
are gradually discarded within about 2 years.
 Prognosis
Poor prognostic factors include neurological deficit of
more than one year duration, myelopathic changes
in the cord, and increased pre-treatment kyphotic
angle, poor compliance, drug resistance.
Newer techniques such as sensory and motor
evoked potentials are being studied as a prognostic
marker of outcomes of Pott’s paraplegia.
Current treatment modalities are highly effective and
if not complicated by severe deformity or established
neurologic deficit results, are usually good.