SPINE Volume 36, Number 6, pp 469–473

©2011, Lippincott Williams & Wilkins

CLINICAL CASE SERIES

Spinal Tuberculosis
Magnetic Resonance Imaging and Neurological Impairment

Robert Dunn, FCS(SA) Orth, MMed(Orth),* Ian Zondagh, FCS(SA) Orth, MMed(Orth),*
and Sally Candy, FCRad(SA)†

signal changes in the T2-weighted images, and neurologic deficit;

Study Design. Retrospective descriptive study.
however, none were predictive of outcome. There was no significant
Objective. To evaluate the preoperative magnetic resonance imag-
correlation found between ambulatory status and the presence of an
ing (MRI) findings in spinal tuberculosis and identify features that
epidural abscess, kyphotic angle, or vertebral body destruction.
correlate with the neurologic status and outcome.
Key words: tuberculosis, MRI, cord size, neurological status, spine.
Summary of Background Data. MRI plays an important role
Spine 2011;36:469–473
in the diagnosis of spinal tuberculosis with a high specificity and
sensitivity. It allows demonstration of bony, soft tissue and neural

T
pathology; however, the clinical correlation is not clear.
uberculosis (TB) remains a growing public health prob-
Methods. MRI scans of 82 consecutively managed spinal tubercu-
lem especially in developing countries. In South Africa,
losis patients over a 4-year period were studied. Data including age,
the World Health Organization reports the incidence
gender, human immunodeficiency virus status, neurologic status
of TB at 0.72% per year.1 Local experience suggests that
were reviewed. This was correlated with preoperative MRI findings
this under reports the disease. This has been attributed to a
including level of involvement, percentage of vertebral body de-
failure in detection of TB, lack of adequate primary health
struction, kyphotic angle, soft tissue involvement, cord size, and
care facilities, poor sanitation, malnutrition, the presence of
cord signal changes.
drug-resistant strains of mycobacterium tuberculosis, and the
Results. Fifty-two percent of patients presented in a nonambulatory
effects of human immunodeficiency virus. Bone and joint in-
state, 21% mild neurologic deficit, and 27% were intact. Of those
volvement develops in approximately 0.5% to 1% of patients
with neurologic deficit, significant recovery occurred in 92%, with
with TB, and half of these affected patients will have TB of
74% improving from nonambulatory to ambulatory status. The pa-
the spine.1
tients ambulant at presentation had a larger cord dimension than
The incidence of neurologic involvement in spinal TB is
those who were not ambulatory. Cerebrospinal fluid persisting an-
10% to 47%.2 The spinal cord and cauda equina withstand
terior to the cord at the apex of the deformity showed a trend to
the slow building pressure as occurs in TB epidural abcess.
residual neurologic function. There was no significant correlation
Compression of up to 76% of cord diameter can be tolerated
found between ambulatory status and the presence of an epidural
with no neural deficit.3 However, when vascular or mechani-
abscess, kyphotic angle, or vertebral body destruction. There was no
cal instability is present, paraplegia can be produced at lesser
evidence of myelomalacia on the MRI scans, but cord signal changes
canal compromise.4
on T2 images were present in 94% of patients presenting with neu-
Magnetic resonance imaging (MRI) has proven to be the
rologic deficit.
most accurate radiologic investigation to diagnose and clas-
Conclusion. There is correlation between residual cord size, ce-
sify spinal tuberculous,5 identifying early spinal cord changes.
rebrospinal fluid remaining anterior to the cord, presence of cord
The aim of this study is to correlate MRI findings with
that of neurologic status and outcome in a cohort of TB spine
From the *Division of Orthopaedic Surgery, Groote Schuur Hospital, Univer- patients undergoing surgical intervention.
sity of Cape Town, Cape Town, South Africa; and †Department of Radiology,
Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa.
MATERIALS AND METHODS
Acknowledgment date: May 4, 2009. Revision date: November 14, 2009.
Acceptance date: December 24, 2009. This retrospective descriptive study reviewed 82 consecutive
The manuscript submitted does not contain information about medical patients with spinal tuberculous spondylitis that were man-
device(s)/drug(s). aged in the spinal surgery unit between January 2002 and
No funds were received in support of this work. No benefits in any form have January 2006. All these patients underwent surgical inter-
been or will be received from a commercial party related directly or indirectly vention of some sort. In addition, patients were treated with
to the subject of this manuscript.
4 drug antituberculosis agents for a minimum of 9 months
Address correspondence and reprint requests to Robert Dunn, FCS(SA) Orth,
MMed(Orth), Division of Orthopaedic Surgery, Groote Schuur Hospital, PO Box using the combination agent Rifafour, which contains Ri-
30086, Tokai, 7966 Cape Town, South Africa; E-mail: info@spinesurgery.co.za fampicin, Isoniasid, Ethambutol, and Pyrazinamide. Clini-
DOI: 10.1097/BRS.0b013e3181d265c0 cal response, normal ESR, and signs of radiographic healing
Spine www.spinejournal.com 469
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 CLINICAL CASE SERIES Spinal Tuberculosis • Dunn et al

were used to determine when to stop medical treatment. The

indications for surgery were to establish diagnosis, neurologic
compromise, and axial instability. Surgery ranged from costo-
transversectomy to anterior debridement and reconstructions
with allograft. This was decided on a case by case basis. All
our patients had histopathologic and/or culture confirmation
of tuberculous spinal infection.
A prospective database of demographics, neurologic sta-
tus, laboratory findings, and surgical interventions is main-
tained. This was reviewed along with case notes, radiographs, Figure 1. Graphic representation of patient’s neurologic status.
and MRI findings. Specific clinical data evaluated included
age, gender, human immunodeficiency virus status, duration kyphotic angle, percentage of vertebral destruction, soft
of neurologic deficit, ambulatory status, motor and sensory tissue extension, and presence of epidural pus were noted.
neurologic status. The preoperative neurologic deficit was The anterior-posterior cord dimensions were recorded at
compared with the postoperative neurologic outcome, using the apex on the midsagittal cut. An expected size was deter-
the Frankel grading system.6 mined by calculating an average of normal cord 1 cm above
At presentation, 43 patients (52%) were nonambulatory and below the compressed area (Figure 2). A ratio was then
and 22 patients (27%) had normal neurologic status, with derived, measured/expected. This was done to allow com-
the remaining 17 patients (21%) having mild neurologic parison across patients of different sizes and ages. Cord
deficit. The neurologic status before and after treatment signal change was noted on both T1- and T2-weighted im-
was recorded using the Frankel grading system (Table 1). ages. These data were then compared to neurologic status
Of those with neurologic deficit, recovery occurred in 92%, and outcome.
with 74% improving from nonambulatory to ambulatory Our study population had an average age of 32 years
status. Only 8% showed no recovery at all. The Frankel (1.5–73 ⫾ 21.1). There were 36 (44%) males and 46 (56%)
A group went from 27 (33%) to only 3 (4%), whereas the females.
Frankel E group changed from 23 (28%) to 62 (76%) after All our patients presented with active disease. The dura-
treatment (Figure 1). No patients were recorded as Frankel B, tion of the neurologic deficit varied between 1 and 28 weeks.
i.e., no motor but some sensation intact. Some of these Continuous data (cord size) were confirmed to be paramet-
may well be in the A group. As most of the patients are ric and analyzed with the Student t test, while the categorical
rural, and there are language and cultural difficulties when data were nonparametric and the Fisher exact test employed
assessing subtle residual sensation, it is possible it could by means of Statistica 7 software.
be missed. To allow for this possibility, analysis was done
between ambulatory and nonambulatory, i.e., Frankel A,
B, C versus D, E.
MRI was performed in all of our patients using a Siemens
Symphony System (Magnetom) operated at 1.5 T in a supine
position using spine surface coils, neck array coils, and head
coils as needed. Contiguous 4-mm slices were obtained in the
sagittal plane in T1 sequences (TR ⫾ 500–650, TE ⫾ 15), and
T2 sequences (TR ⫾ 4200, TE ⫾ 110) and in the axial plane
using T2 sequences (TR ⫾ 4400, TE ⫾ 90–100). Contrast
was not used in any of the patients.
Only the sagittal MRI films were used for the purposes
of the study as these are most useful in the clinical scenario
in terms of decision making. The level of involvement,

TABLE 1. Frankel Grading Outcomes

Frankel Grade Before Treatment After Treatment
A 27 patients (33%) 3 patients (4%)
B 0 patients 0 patients
C 16 patients (19.6%) 8 patients (10%)
D 17 patients (20.4%) 9 patients (11%) Figure 2. Mid-sagittal T2 MRI sequence indicating how the cord size
and average cord size (using measurements above and below) was
E 22 patients (27%) 62 patients (76%) measured.
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 CLINICAL CASE SERIES Spinal Tuberculosis • Dunn et al

RESULTS
The distribution of the spinal TB followed the expected
pattern with 9 (11%) cervical spine, 54 (66%) thoracic spine,
5 (6%) thoracolumbar, 11 (13%) lumbar, and 3 (4%) sacral
involvement. There were 12 patients (15%) who presented
with noncontiguous spinal involvement, i.e., 2 separate sites,
which were identified using whole spine MRI. Only 13 (16%)
of our patients had posterior element involvement.
The relationship of neurologic impairment to the cord size
was evaluated (Table 2).
In the nonambulatory groups (Frankel groups A–C), the
average Apex/Average cord size ratio was 0.68, whereas in the
ambulatory groups (Frankel D and E) it was 0.84. This was
tested with a 2-tailed unpaired Student t test after confirmation
of a normal distribution (Statistica 7), and found to be statisti-
cally significant (P ⫽ 0.005). Patients with lumbar and sacral
spine involvement alone were excluded due to the cauda equi-
Figure 3. MRI demonstrating a thin rim of CSF anterior to the cord
na and not spinal cord involvement. despite the compression.
The presence of cerebrospinal fluid (CSF) anterior to the
thecal sac cord in patients with cervical and thoracic disease
was assessed (Figures 3, 4). Preservation of anterior CSF was Signal change on the T2-weighted images, indicating cord
found in only 11 patients (13%). The remaining 57 patients edema, was present in 56 patients (80%), and absent in the
(70%) had none. The correlation of anterior CSF to ambu- remaining 12 patients (20%). The 14 patients with lumbar
latory status in cervical and thoracic involvement using the and sacral involvement were also excluded here. Correlation
Fisher exact test found a significant relationship of absent CSF of ambulatory status to cord signal changes was found to
to nonambulatory status (P ⫽ 0.0096) for preoperative sta- be significant. Of the 42 patients who were nonambulatory
tus, but no relationship to prognosis. (Frankel A–C), all (100%) had cord signal changes present on
Correlation of CSF found anterior to the cord at the apex T2 weighted (P ⫽ 0.0000). Of the 26 patients who were am-
of the deformity with our Apex/Average ratio, and neurologic bulatory (Frankel D/E), only 14 had some cord signal changes
status was made. on T2-weighted images. In the Frankel E group, 3 patients
The average of the Apex/Average Ratio for the group of had cord signal changes. These 3 patients also had the small-
patients with CSF anterior to the cord (lumbar involvement est Apex/Average cord size ratio of the whole Frankel E group
excluded) was 0.89. The group without CSF remaining was (0.57; 0.57; 0.6), which was much smaller than the average
only 0.67. We know that from the above-mentioned informa-
tion that this does correlate with neurologic status.

TABLE 2. Frankel Outcome Correlated to

Cord Size
Minimum Maximum Average
Frankel Frankel Apex/ Apex/ Apex/
Grading Grading Average Average Average
Before After Ratio Ratio Ratio
A A 0.4 0.83 0.56
A C 0.33 1 0.66
A D 0.43 0.92 0.63
A E 0.18 0.86 0.57
C C 0.8 1.2 0.93
C D 0.73 0.77 0.75
C E 0.5 0.86 0.68
D D 0.92 0.92 0.92
D E 0.43 1.17 0.76
Figure 4. MRI demonstrating complete obliteration of CSF anterior to
E E 0.57 1 0.85
the cord with associated hyperintense cord signal.
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 CLINICAL CASE SERIES
for the group (0.85). In the Frankel D group, 11 patients had
cord signal changes and 3 did not despite having a neurologic
deficit. In these, we found that the Apex/Average cord size
ratio was at least equal to but mostly larger (0.66; 0.77; 1; 1)
than the average size for the group (0.68). The morphology
or size of signal change was not noted to be different between
the different ambulatory function groups.
No MRI demonstrated a low intensity on T1-weighted
images. Therefore, no evidence of myelomalacia was found.
Of the 56 patients with cord signal changes, only 5 patients
showed no clinical recovery. There were no predictive features
found for this on MRI; however, poor general health status
was present in all these patients. Significant recovery from a
nonambulatory (Frankel A–C) to ambulatory (Frankel D/E)
status occurred in 31 of 42 (74%) patients. No patients
deteriorated in neurologic function. In the 11 of 42 (26%)
patients who remained nonambulatory, no predictive MRI
features were found.
There was no significant correlation found between
ambulatory status and the presence of an epidural ab-
scess, the kyphotic angle, or percentage of vertebral body
destruction.
DISCUSSION
The clinical outcome of TB spine patients is based on a multi-
tude of factors such as general health status, extent of disease,
etc. However, the MRI is frequently used in their assessment
as it is an excellent tool for the evaluation of the pathology in
spinal TB with neurologic complications,7 delineating pathol-
ogy, and neural structures. Yet the clinical relevance is not
always clear. This study attempts to give some insight to the
correlation of these changes in relation to the neurologic out-
come following surgical decompression.
Paraplegia in patients with active disease may be caused
by mechanical pressure on the spinal cord by tubercular ab-
scess, caseous granulation tissue, or debris. The localized
pressure caused by internal gibbus on the spinal cord or
mechanical instability caused by pathologic subluxation or
dislocation of vertebrae also may contribute to neurologic
complications. Intrinsic changes in the spinal cord such as
inflammatory edema or direct involvement of meninges and
spinal cord by the tuberculous infection may lead to para-
plegia. Infective thrombosis or endarteritis of spinal vessels
leading to infarction of the spinal cord also may produce
neurologic complications.
The spinal cord seems to have some physiologic reserve to
withstand some pressure particularly when pressure develops
slowly, as is the case with TB. Jain et al8 calculated canal en-
croachment on computed tomography scans in 15 patients
with TB of the spine without neurologic complications from
C3 to T12 and found that as much as 76% of spinal canal
encroachment is compatible with an intact neural status.
Our evaluation using MRI offers more detailed information
regarding the exact size of the cord itself. We were able to
directly visualize the cord and measure the mid sagittal di-
mension. This is a far more direct and accurate way of deter-
mining the cord compression.
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BRS203627.indd 472
Spinal Tuberculosis • Dunn et al
In the nonambulatory groups, their average Apex/Average
cord size ratio was significantly smaller (0.68) than the value
in the ambulatory groups (0.84). There were few patients,
only 10 of 82 with evidence of cord compression exceed-
ing 50% of the expected dimensions. All of these except for
1 patient presented as a complete paraplegia. This been said
though, due to the nature of the disease and favorable re-
sponse to therapy, most of these patients had some neurologic
recovery. This seems to indicate that cord compression alone
is not solely responsible for prognosis. However, these data
show that the cord is susceptible to pressure even if the disease
process is slow and that previous values given are generous in
their estimates. Our information shows us that at most, 40%
of AP midsagittal cord compression is still possible without
any neurologic implications.
We found no previous studies documenting the significance
of CSF anterior to the cord. Our study shows a direct corre-
lation with CSF anterior to the cord at the level of maximal
involvement to the amount of cord compression, as may be
expected. It is evident that those patients with CSF remain-
ing anterior to the cord presented with far greater neurologic
function and therefore a better outcome after treatment. The
average of the Apex/Average Ratio for the group of patients
with CSF anterior to the cord (lumbar involvement excluded)
was 0.89. The group without CSF remaining was only 0.67.
This correlates well with the Frankel groups as mentioned
earlier when differentiating between the ambulatory and non-
ambulatory groups.
Though the cord is known to be the target of the injury,
surgical decompression does not invariably alleviate the neu-
rologic fallout in tuberculous spondylitis. Correlation be-
tween cord signal changes and prognosis is expected, particu-
larly the implications of both cord signal changes in T1- and
T2-weighted images and their relation to neurologic prog-
nosis. T2-weighted image signal changes correlate well with
the state of neurologic involvement as all the patients with
Frankel grades A to C had significant signal changes present.
Even in those patients with mild involvement, it seems that
T2 signal changes are sensitive for neurologic complications.
Only 3 patients with mild neurologic deficit showed no evi-
dence of cord edema on T2 images and in these patients had
larger cord dimensions with CSF remaining anterior to the
cord, possibly explaining the lack of cord changes present.
T1-weighted image cord changes indicating myelomala-
cia were universally absent. Myelomalacia is a phenomenon
caused by long-standing compression and ischemia leading to
significant cord damage and axonal loss with permanent loss
of function and sometimes associated with the formation of
a syrinx. The absence of this in our study can probably be
explained but the fact that our patients were all treated in the
active stage of the disease with a relatively short history.
CONCLUSION
MRI is mandatory in the evaluation and surgical manage-
ment of spinal TB. Midsagittal cord size and CSF anterior to
the cord correlate with neurologic deficit. Most cases have a
favorable prognosis, which is understandable with the lack of
March 2011
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 CLINICAL CASE SERIES
T1 cord signal changes. No negative predictors of neurologic
improvement were identified on MRI and these appear to be
related to the general health of the patient.
➢ Key Points
‰ MRI is an excellent tool to demonstrate pathology of
TB of the spine.
‰ Residual cord size ratio, as measured on a mid-
sagittal T2, correlates with neurologic status.
‰ The persistence of residual CSF anterior to the cord
suggests preserved neurologic status.
‰ No significant correlation between ambulatory status
and the presence of an epidural abscess, kyphotic
angle, or vertebral body destruction.
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