58

TUBERCULOSIS OF THE SPINE

Abstract: Tuberculosis is a deadly disease affecting many people, more so in developing countries. Spinal tuberculosis is the most common form of articuloskeletal tuberculosis. Its prevalence is increasing with the spread of human immunedeficiency virus (HIV . !iagnosis is based on history, clinical e"amination, imaging studies and biopsy. #arly treatment with either antituberculous drugs alone or in combination with surgery is effective in most cases. $omplication includes kyphosis and paraplegia. Case Report: % &'(year(old $hinese gentleman was seen in our clinic for lower back pain for duration of ) years. His pain was associated with sciatica to the right foot .He did not give any history of chronic cough, loss of weight or appetite. He did not e"perience any low(grade fever nor complain of any weakness in his lower limbs. His bowel and bladder were normal. He did not have any contact with tuberculosis patients. *n e"amination his vital signs were stable. His gait was normal. %ll other systems including chest e"amination were normal. There was slight tenderness over the lower lumbar and sacral regions .His S+, was '- degrees bilaterally and his power of hip, knee and ankle, #H+ and .H+ were all full. There was no sensory loss. .urther e"amination did not reveal any wasting of his lower limb muscles. Investigation done reveled a /antou" of 01 mm. His erythrocyte sedimentation rate (#S, was raised at 0)&(mm2hour .His total white count and all other parameters were normal. 3lain 4(ray of the chest was normal but lumbosacral 4(ray demonstrated destruction of +1 and S0, involving the disc. The +12S0 disc space was reduced and bone

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appeared osteoporotic. The kyphotic angle was )- degrees. There was no psoas bulge but the vertebral height of +1 was reduced with evidence of sclerosis of the lower body of +1 and S0 ./,I showed destruction of +12S0 disc and vertebrae. There was a soft tissue mass anterior to +12S0 and within the spinal canal of +12S0. The thecal sac was markedly compressed. $T guided biopsy showed no malignant cells or multinucleated giant cells or granuloma. There were some neutrophil and histiocytes. The culture was negative for fungal or mycobacterium. *pen biopsy of tissue and bone was then preformed. Tissue biopsy demonstrated epitheloid granuloma with +anghan5s giant cell, caesation necrosis, lymphocytes and plasma cells. 6one biopsy revealed necrotic +anghan5s giant cell with epitheloid granuloma. 7iehl 8 9eelson and 3%S stains were negative. % diagnosis of tuberculosis osteomyelitis was made and patient was planned for decompression, debridement and posterior instrumentation. :nder general anaesthesia with the patient lying prone on a spinal frame, a midline longitudinal incision was made over the +& to S0 area after infiltrating the skin with adrenaline. The skin and subcutaneous tissue was dissected and the soft tissue displaced laterally till the lamina was e"posed. The level was checked and confirmed with image intensifier and laminectomy and debridement was preformed over the +1 and S0 vertebrae .The canal was also decompressed and the material was sent for histopathological e"amination. 3adicle screw was inserted into the +& and S0 vertebrae and a plate was placed. 6one graft taken from the right iliac crest was placed over the +& and S0 area .The graft site was closed after securing hemostasis .The lumbar fascia was closed using de"on - and the skin was closed with dafilon )2. % drain was also inserted. 3ost operatively the patient made an uneventful recovery and was discharged on a lumbosacral orthosis. %t ; months follow(up , there was evidence of sclerosis over the fusion area and the kyphotic angle was 0- degrees . He is still on follow up.

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Discussion Tuberculosis according to the <orld Health *rganisation (<H* has become the world=s most deadly infectious disease killing nearly ; million people anually. /ost deaths are from developing countries. %dults and children are affected e>ually with more than 1-? of the cases in children appearing within the first decade of life. 1 %lthough spinal involvement accounts for 0? of cases of tuberculosis, the spine is involved in 1-? of cases of articuloskeletal tuberculosis@ )1 ? in the cervical spine, )-? in the thoracic spine and )- ? in the lumbar and lumbosacral spine.
A

Spinal

tuberculosis is the most dangerous and common form of articuloskeletal tuberculosis is a paucibacillary disease with slow growing bacilli .In 0B'', 3ercival 3ott described the natural history of tuberculous spondylitis hence infectious involvement of the spine was called 3ott5s disease or 3ott=s paraplegia. In understanding the natural history of the disease process, the blood supply to the vertebrae plays a maCor role in the pathophysiology. The vertebra has a good blood supply. !irect sources are vertebral arteries to the cervical spine , intercostal arteries to the thoracic spine and lumbar arteries to the lumbar spine The body also gets blood supply from small arterioles that penetrate the body directly . The second source is from posterior spinal branches that enter through the intervertebral foramen. They form anastomotic network posterior to the vertebral body and supply nutrient through a foramen in the posterior wall of the vertebral body. The venous systems forms a valveless ple"iform from the dural sinuses to the sacrum in a longitudinal arrangement. It consists of ; divisionsD venous channels within the body, epidural vein surrounding the dura within the canal and venous network surrounding the vertebral column. The disc is composed of & tissues( hyaline cartilage endplates superiorly and inferiorly, annulus fibrosus, transition Eone and nucleus pulposes. The adult vasculature terminates at the annulus thus leaving the disc relatively avascular. Hence infection of the disc occurs as a direct innoculation iatrogenically or spread from

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adCacent vertebrae. %ntibiotics penetration into the nucleus occurs by diffusion and the positively charged nucleus allow better penetration of negatively charged antibiotics like aminoglycosides than positively charged onces. The organism involved in spinal tuberculosis is mycobacterium tuberculosis. The focus in the spine is usually secondary to e"traspinal source either by direct e"tension or hematogenous spread. The pattern of involvement have been described as)@ i ii iii paradiscal anterior central

The most common type in adults is the paradiscal lesion in which the primary infectious focus begin in the vertebral metapyhsis and erodes through the cartilagenous endplates resulting in disc space narrowing. %nterior lesions develop beneath the anterior longitudinal ligament and may spread to involve several vertebrae. $entral lesions involves the entire vertebral body. There may also be skip lesions. %bscesses are a common finding in spinal tuberculosis. The focus has a propensity to spread along fascial planes though e"tension posteriorly into the spinal canal can occur at any level. 9eck abscesses are more common in children and they may present as swelling or dysphagia or dyspnoea due to compression of the oesophagus or trachea. They may involve the lung and form adhesion in the thoracic region while in the lumbar and sacral region they may form soft tissue swelling in the femoral triangle or perineum and gluteal regions .It is not uncommon for patients to present with discharging sinus. 3rogressive involvement of the vertebral bodies leads to its collapse resulting in a kyphotic deformity +esion in the thoracic spine have a greater tendency towards kyphosis than in the thoracolumbar or lumbar spines. :ltimately the degree of kyphosis is proportional to the initial loss of vertebral body rather than initial radiographic measurement of kyphosis. The collapse into kyphosis may continue until

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the vertebal bodies meet interiorly or until the caesated material and granulation tissue mature into bone .The loss of one vertebrae may result in ;- to ;1 degrees kyphosis with most collapse occurring during the first 0A months after treatment. )The disc is rarely destroyed but most often gets se>uestered causing paraplegia .The posterior elements are also often involved. Infection from here can progress to involve the meninges and spinal cord directly giving rise to neurological compromise. 9eurology is rarely associated with bone destruction alone unless accompanied with dislocation or sublu"ation of the spine. 3yogenic osteomyelitis must be differentiated from tuberculous osteomyelitis. %mong the differences are@ Pyo enic Single vertebral involvement Symmetrical collapse Spread intraosseously %nterior column involvement !isc destroyed #pidural abscess more common /ore acute onset Tubercu!osis /ultisegment involvement Fyphosis Spread along fascial planes ; column involvement !isc se>uestered 3aravertebral abscess common Insidious chronic coarse

i ii iii iv v vi vii

The gross pathological findings are e"udative granulation tissue with interspersed abscesses resulting in caesation necrosis. The tissue has a yellow appearance with an opa>ue cheesy >uality. *n microscopy, there are nodular patterns with a central area of necrosis and epitheloid cells. +anghan=s giant cells with periphery arranged nucleus are common but not pathognomonic. !emonstration of acid(fast bacilli in cultures is diagnostic. The diagnosis can be made from clinical, biochemical e"amination and imaging studies. The most common presentation is pain which is usually insidious in onset. *ther symptoms include weight loss, fever and malaise. *ther organ involvement should also be assessed. $ervical involvement may present with torticollis, neck pain, stiffness and dysphagia. 9eurological involvement has been reported to occur in 0-? to G- ? of patients.

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3hysical e"amination includes careful assessment of spinal alignment, inspection of skin with attention to fungal infection and sinuses, abdominal e"amination to evaluate subcutaneous flank mass and a thorough neurological e"amination which include cranial nerve e"amination. 6iochemical e"amination include raised levels of white blood cell count during acute phase and elevated #S, and a positive tuberculin skin test. %typical values are not uncommon Imaging studies include@ i ii iii iv v 3lain " rays $T scan /,I Scintigraphy /yelography

The basic radiographic e"amination consists of spine and chest views. They may demonstrate bony deformity but the earliest changes is rarefaction. !isc space narrowingD anterior vertebral scalloping or erosion, vertebral plana and kyphotic deformity may also be seen. In evaluating spinal deformity, modified Fonstam=s angle is used .It is the angle formed by ) parallel lines to the superior and inferior borders of the vertebrae pro"imal and distal to the lesion. !eformity angle is the angle formed by Coining ) lines to the superior end plate and inferior end plate of the affected vertebrae. 3araspinal abscess may also be detected on 4( ray as a fusiform soft tissue swelling or loss of psoas shadow or calcification.0Scintigraphy is not very useful in the early course of the disease as it may not show spinal tuberculosis despite the presence of active disease clinically and radiographically . +ater in the course of the disease once e"tensive osseous changes and attempted healing has taken place, it may then manifest as increase in uptake in bone scan. It is most useful in determining number of sites and skip lesions. Single photon emission $T scan is helpful in evaluating involvement of posterior element.

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*n the other hand gallium imaging is useful in the setting of chronic infection and for monitoring response to anti(T6 therapy. $T scan also shows anterior vertebral body destruction , vertebral body collapse , disc space narrowing and large paraspinal soft tissue mass ./ediastinal abscesses , pleural effusion , psoas flank abscesses may also be demonstrated. & 3araspinal and intraosseous abscesses show a thick and enhancing wall on contrast enhanced $T scan. It can also provide guidance for diagnostic and therapeutic procedures. /yelography is also a useful tool. 3lain film finding include displacement or thinning of the contrast column and partial or complete obstruction of the flow. $T myelograph can further determine the e"tent of epidural process and differentiate between epidural abscess and bony encroachment. /,I changes are believed to be diagnostic. It improves the detection of vertebral intraosseous abscess, skip lesion and subligamentous spread of the infection .In contrast to T0 weighted which shows decrease signal to the affected vertebrae, T) weighted shows increased signal within the area of osseous and soft tissue changes. It can further differentiate between abscess and granulation tissue .The presence of thick rim of enhancement around the paraspinal and intraosseous abscesses is diagnostic of T6 spondylitis which can be seen on contrast enhanced se>uences. 6ecause of its multiplanar capabilities and sensitivity in detecting osseous and soft tissue changes and lack of ioniEing radiation, /,I imaging is considered treatment of choice for imaging in spinal tuberculosis. It is also suitable for post(operative assessment and monitoring response to therapy. *ther diagnostic procedures include culture from blood, percutaneous vertebral aspirates and bone biopsy. %ntigen demonstration, serology test and polymerase chain reaction (3$, are high priority. The 3$, is a diagnostic tool if all other e"aminations are not conclusive. It has also detected drug resistance mainly to rifampin and streptomycin. !ifferential diagnosis include bacterial infection like

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actinomycosis, nocardosis, brucellosis, which present with a more indolent course, tumors and metastatic disease which is usually seen in older population, fungal infection, sarcoidosis, hydatid disease and syphilis. Treatment of spinal tuberculosis is still controversial. %mong the modalities include@ i ii iii $hemotherapy Surgery $ombination of chemotherapy and surgery.

$hemotherapy has been an established effective treatment for the maCority of patients with spinal tuberculosis through a series of G prospective studies performed by /,$ (/edical ,esearch $ouncil .) This consists of multidrug therapy taken during both induction and continuation phase. Induction phase are when agents are used to kill rapidly multiplying population and to prevent emergence of drug resistance and continuation phase are when steriliEing drugs are used to kill intermittently dividing population. %ntituberculosis drugs can have ; main activities@ bactericidal, steriliEing and prevention of drug resistance. /ost potent bactericidal drug is isoniaEid (I9H . The drugs rifampin and streptomycin have some bactericidal activity. SteriliEing drugs are semidormant bacteria, e.g. rifampin and pyraEinamide. #ffective treatment consists of ) phases, an induction phase during which bactericidal and drug resistant agents are used and continuation phase where steriliEing drugs are used.B6oth phases must contain at least ; drugs ( isoniaEid ,rifampin and pyraEinamide along with ethambutol or streptomycin if local resistant pattern to I9H is not documented or is greater than &?.%dherence to treatment is best achieved by directly observed therapy (!*T .!*T can be given daily or intermittently ) (; times a week. $ontrolled clinical trials have shown that therapeutic serum levels were maintained with intermittent regime. !uring treatment patient should be e"amined at least once monthly for evidence of active T6, adherence to treatment and adverse reaction to medication. Sputum specimen for acid fast bacilli smear and culture should be obtained when

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warranted . The #S, and $,3 gives good indication to treatment progress . 4ray is done to look for sign of fusion ..irst line drugs used in treatment of tuberculosis and their side effects are listed below@

Dru a"#erse e$$ects IsoniaEid ,ifampin 3yraEinamide #thambutol Streptomycin

Dai!y Dose % &' 1 ( 0001 ( ;01 ( )1 01 ( )-

Action bactericidal 6actericidal SteriliEing SteriliEing bactericidal interferes with 6acterila protein Synthesis

Co((on hepatitis, peripheral neuropathy hepatitis, flu(like illness hepatitis, HI upset, elevated uric acid level, arthralgia optic neuritis vertigo, tinnitus, renal failure

IsoniaEid must be given with pyrido"ine to prevent peripheral neuropathy as it interferes with pyrido"ine synthesis. ,ifampin works by inhibiting ,9% transcription and it also produces a harmless red orange discolouration of the urine and other body fluids. ,ifabutin has similar properties to rifampin .It has also been used for prophyla"is of infection with mycobacterium avium. Second line medication include cyclosporin , ethionamide , kanamycin, amikacin, and fluoro>uinolones group. They are difficult to use than first line drugs. The duration of treatment is very controversial but most authors agree that it should be given for at least 0 year. 1Treatment for less than G months resulted in failure to control the infection To prevent recurrence and to eradicate slow growing bacilli , triple chemotherapy for 0A months or 0) months four drug regime(I9H,rifampin, ethambutol and pyraEinamide is appropriate. AIn addition, non(steroidal anti inflammatory drugs may be useful early in the disease for management of non specific synovial membrane inflammation and to inhibit or minimise bone resorption by prostaglandin

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Supportive measures like sanatorium care and brace immobiliEation has been since discarded as it was found to be inefficient. %lthough drug therapy is effective in eradicating infection and spontaneous arthrodesis is usually achieved, it is not effective in reversing significant spinal deformity and resultant neurological deficit. Surgery is indicated in certain conditions which includes@ i ii iii iv more than 1 degrees of kyphosis segmentally neurological compromise more than 1-? of vertebral body destruction unresponsiveness to medical therapy

Surgery can be either focal debridement, radical debridement with bone grafting or combined with posterior debridement and instrumentation. However the most efficacious surgical procedure was anterior radical debridement followed by bone grafting (HongFong procedure .It was first described by Hodgsan and Stock in 0'1G using rib and iliac crest graft. !ebridement without grafting and e"ternal support were unreliable means of preventing deformity. ) %nterior surgical surgery has ) benefits , a small decrease in the progression of kyphosis during the first 0A months of therapy and a more and rapid fusion . In a study reported by :padhyay comparing short and long term results of anterior debridement versus radical e"cision, he found that0) @ i ii iii iv recovery from neurological deficit, relief of pain and fusion rates were e>ually good in both groups correction of kyphus and deformity angles were good in radical surgery but deterioration was noted in the focal debridement group no significant difference in changes in kyphus or deformity angles at final follow(up (0B years from their G months post(operative radical surgery showed improvement of 1 degrees in deformity angle at G months post operatively He concluded that the status of deformity achieved G months after surgery is important because it is virtually maintained up to follow(up. The approach for surgery can be transthoracic or e"tra peritoneal. 9ewer techni>ue like closed laparoscopy and

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thoracoscopy as well as video assisted procedure using limited open incision provide an e"cellent alternative for lesions in the thoracic and lumbar regions. ' 3atient with neurologic deficit must be graded using .rankel=s classification. .rankel % or 6 lesion should undergo rapid decompression and anti( tuberculosis drugs started. 3atient with grade $ and ! can be treated e"pectantly with chemotherapy alone mindful that deterioration may be common and fre>uent monitoring is mandatory. In evaluating the recovery rate from paraplegia with surgery, it is known that paraplegia lasting more than G months is unlikely to improve. +ate paralysis with active disease and severe kyphosis with paralysis caused by vascular embarrassment ha s the worst prognosis as with atrophic spinal cord. 6ut treatment of paraplegia with advanced tuberculosis is chemotherapy combined with anterior radical surgery and bone graft because paraplegia usually resolves rapidly after ade>uate decompression. *ther methods like laminectomy, costotransversectomy and radical surgery are not used as they further destabilise the spine. Fyphosis on the other hand being an unstable lesion tends to progress until there is sound bony fusion anteriorly. 3rogression is more in the thoracic region where natural kyphosis e"ists. It has also been found that kyphosis is arrested within G months of commencement of chemotherapy and is not influenced by duration of the drug. Several methods has been used to manage kyphosis which includes posterior fusion, anterior radical surgery, one stage, two stage and three stage operation .In two stage operation, either posterior instrumentation followed by anterior radical surgery or anterior release and graft followed by posterior instrumentation has proven satisfactory.A In an attempt to attain fusion, ) type of grafts can be usedD either allograft or autograft. In a study by Hovender of &B patients using fresh froEen allograft from the humerus to stabilise the spine, he found that rib allografts are inade>uate to support anterior column if more than ) vertebrae are resected. G $ortical allografts usually evoke an intense immune response, which enhances bone resorption. *ther authors

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also support this theory that graft construct spanning more than ) disc space should be supplemented by posterior fusion.) .ailure from allograft is usually due to infection, fracture or slippage. 3osterior instrumentation can be used to correct deformity and maintain correction. 3atient with significant posterior element or ;(column involvement are suitable candidates. 3atient with significant long segment involvement of the anterior column with severe kyphosis are also suitable candidates but this should be combined with anterior debridement and strut graft. The duration of anti(tuberculosis remains controversial In a study by Shanty of 0&& patients to evaluate the efficacy of short course therapy in conCunction with radical surgery at 01 years follow(up , she concluded that G months of chemotherapy regime combined with surgical e"cision and bone grafting is ade>uate for management of tuberculosis of the spine as it produces clinical and radiological results comparable with ' and 0A months regime.00 In conclusion, chemotherapeutic agents remain the corner stone for treatment of spinal tuberculosis. !elay in diagnosis can lead to a poorer outcome. #arly intervention either by drugs or combined with surgery is still the most reliable way of achieving good results provided patients adhere to their regime religiously. Specia! consi"eration@ Tuberculosis in children. 3rogressive kyphosis from posterior element overgrowth has been associated with anterior fusion of ) vertebral levels both in adults and children. 6ahr et al (cited in %ltman, 0''G suggested that posterior element fuse ;(A months after anterior fusion. :padhyay et al however reported that following anterior fusion , early posterior fusion may prevent kyphosis by preventing posterior element overgrowth and by supporting the anterior strut graft because anterior strut graft has been reported to be weakest at G months post(operative and re>uires ) years for incoperation .

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$oncerning the time interval between anterior and posterior fusion, %ltman et al concluded from their study that surgery preformed within ; months helps prevent post(operative progression of kyphosis and in attaining solid fusion . Tuberculosis in pregnancy Treatment should not be delayed during pregnancy. #ffective therapy for T.6. is the best way to prevent infection of the fetus and the new born. 3yraEinamide and streptomycin are not given because of possible teratogenic effcet. 3yrido"ine can however be given Breast feeding and Tuberculosis Small concentration of anti tuberculosis drug in breast milk are not to"ic to the newborn. Therefore breastfeeding should not be discouraged Re$erences: 0. A!t(an )*T+ A!t(an D*T+ Fran'o#itc, -*F*: %nterior and posterior fusion for children with tuberculosis of the spine. $lin *rthop. 0''GD ;)1@ ))1();0 ). Boac,ie. A"/ei O an" S0ui!!ante R*)*@ Tuberculosis of the spine. *rthop $lin 9orth %m 0''GD )B(0 @ '1(0-; ;. Ca!"erone *R*R an" Larsen 1*%*: *verview and classification of spinal infection. *rthop. $lin 9orth %m 0''GD )B@ 0(B &. Cor"o#a + Francis+ Criner an" )erar" 1. %)1 years old man with back pain and abnormal chest radiograph. $hest 0''GD 0-'() @ 11'(1G0 1. Dee* R* 3rinciples of *rthopaediac 3ractice 0''BD )9! #dition @ 0;--(0;-0.

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Upa",yay S*S+ Sa/i %*1 an" 4au A*C*%*C* !uration of anti(tuberculosis chemotherapy in conCunction with radical surgery in the management of spinal tuberculosis. Spine 0''GD Vol )09o 0G@ 0A'A(0'-;

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