Departemen Neurologi Journal Reading

Fakultas Kedokteran Juli 2019

Universitas Pattimura

SPINAL TUBERCULOSIS: CURRENT CONCEPTS

Disusun Oleh:
Reylando D. Saimima
2018-84-042

Pembimbing:
dr. Semuel A. Wagiu, Sp.S, M.Ked

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 Spinal Tuberculosis:
Current Concepts Centuries including the discovery of the
causative agent, Mycobacterium
tuberculosis, development of Bacillus
• Abstract Calmette-Guerin (BCG) vaccine, invention of
• Introduction chemotherapeutic agents, advances in
diagnostics, and improvement in surgical
• Epidemiology outcomes.
• Pathophysiology of
spinal TB
• Clinical presentation of
Spinal TB
• Cold Abscess Keywords: Infection,
spondylodiscitis, MRI,
• Deformity decompression,
• Pediatric Spinal TB deformity, cervical,
thoracic,
• Neurological deficit thoracolumbar,
• Atypical spinal lumbar
tuberculosis
• Diagnosis Increasing prevalence of
TB is now an international
• Imaging concern, as it has its immunodeficient survivors
and the emergence of
• Laboratory footprints spread all over multidrug resistance (MDR)
Investigations the world due to the has resulted in resurgence
global migration of TB as a public health
• Management of spinal phenomenon. menace
TB
• Conclusion

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 Spinal Tuberculosis: The incidence of extrapulmonary TB (EPTB) is low
Current Concepts at 3%, but there has been no significant reduction
in incidence of EPTB when compared to
pulmonary TB (PTB).
• Abstract
• Introduction
• Epidemiology
• Pathophysiology of
spinal TB
• Clinical presentation of
Spinal TB
• Cold Abscess
In 2016, there was an estimated incidence of 10.4
• Deformity millionnew TB cases as per the WHO. While European
• Pediatric Spinal TB region contributed only 3%, the South East Asian Region
• Neurological deficit alone had 46.5% of the global TB burden. The deaths
related to TB remained to be one of the top 10causes of
• Atypical spinal
death worldwide, despite the decline of TB deaths by 22%
tuberculosis from 2000 to 2015.
• Diagnosis
• Imaging
Consistent efforts are being taken by the WHO, and the
• Laboratory WHO End TB Strategy for 2030 has been adopted by its
Investigations member nations, which aims at 80% reduction of TB
• Management of spinal incidence rate and 90% reduction of TB deaths
TB
• Conclusion

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 Spinal Tuberculosis:
Current Concepts
TB is caused by Mycobacterium tuberculosis
complex, which has around 60 species.
• Abstract
• Introduction
• Epidemiology
It is a slow-growing fastidious, aerobic bacillus. The primary
• Pathophysiology of site of infections can be in the lungs, lymph nodes of the
spinal TB mediastinum, mesentery, gastrointestinal tract, genitourinary
system, or any other viscera.
• Clinical presentation of
Spinal TB
• Cold Abscess Spinal infection is always secondary and is
• Deformity caused by hematogenous dissemination of the
• Pediatric Spinal TB bacillus from a primary focus.
• Neurological deficit
• Atypical spinal The other patterns of involvement are “central,”
tuberculosis resulting in vertebral body loss; “posterior,” when
• Diagnosis posterior appendicular structures are involved; and
“nonosseous abscess” formation.
• Imaging
• Laboratory
Investigations TB results in granulomatous inflammation characterized
by lymphocytic infiltration and epithelioid cells, which
• Management of spinal may merge to form the classical Langhans-type giant cells
TB and end up in caseating necrosis of affected tissues
forming cold abscess.
• Conclusion

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 Spinal Tuberculosis:
Current Concepts

• Abstract
Spinal TB usually is insidious
in onset and the disease
• Introduction
progresses at a slow pace.
• Epidemiology
The diagnostic period, since
• Pathophysiology of
spinal TB
onset of symptoms, may vary
from 2 weeks to several
• Clinical presentation of
years.
Spinal TB
• Cold Abscess
• Deformity
• Pediatric Spinal TB
• Neurological deficit The manifestation of spinal TB
• Atypical spinal depends on the severity and
tuberculosis duration of the disease, site of
• Diagnosis the disease, and the presence
• Imaging of complications such as
• Laboratory abscess, sinuses, deformity,
Investigations and neurological deficit
• Management of spinal
TB
• Conclusion

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 Spinal Tuberculosis:
Current Concepts Spinal TB can either be complicated or
uncomplicated:
• Abstract - In complicated TB, patients present with
• Introduction deformity, instability, and neurological deficit.
• Epidemiology - Uncomplicated spinal TB is one in which
• Pathophysiology of diagnosis is made prior to development of such
spinal TB complications.
• Clinical presentation of
Spinal TB
• Cold Abscess
• Deformity
• Pediatric Spinal TB
• Neurological deficit
• Atypical spinal
tuberculosis
• Diagnosis
• Imaging
• Laboratory
Constitutional symptoms such as loss of
Investigations weight, loss of appetite, fever, and malaise
• Management of spinal are more frequently associated with PTB
TB than spinal TB
• Conclusion

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 Infeksi Mycobcterium TB pada
Vertebra

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 Spinal Tuberculosis:
Cold abscess lacks inflammatory features and initially
Current Concepts forms in the infective focus. Later, it takes the path of
least resistance along the natural fascial and
• Abstract neurovascular planes as depicted.
• Introduction
• Epidemiology
• Pathophysiology of
spinal TB
• Clinical presentation of
Spinal TB
• Cold Abscess
• Deformity
• Pediatric Spinal TB
• Neurological deficit
• Atypical spinal
tuberculosis
• Diagnosis
• Imaging
• Laboratory
Investigations
• Management of spinal
TB Figure 1. (A, B) Whole spine and focal T2 weighted sagittal MRI images of
• Conclusion a 30-year-old individual showing unusually large prevertebral abscess
with extensive tracking beneath the anterior longitudinal ligament. (C)
Coronal image shows the abscess tracking along the psoas muscle to
12/07/2019 reach the anterior aspect of the thigh.
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 Infeksi dan Abses TB pada
Vertebra

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 Spinal Tuberculosis: • Owing to the involvement of anterior column,
Current Concepts progressive destruction results in kyphotic
deformity of spine most often.
• Abstract
• The clinical appearance depends on the number
• Introduction
of vertebrae involved causing “knuckle” (1
• Epidemiology vertebra), “gibbus” (2 vertebrae), and “rounded
• Pathophysiology of kyphosis” (>3 vertebral collapse).
spinal TB
• Clinical presentation of
Spinal TB
• Cold Abscess
• Deformity
• Pediatric Spinal TB
• Neurological deficit
• Atypical spinal
tuberculosis
• Diagnosis
• Imaging
Figure 2. (A, B) Plain radiography of a 52-year-old female with active cervical
• Laboratory spinal TB and cervical kyphosis. (C, D) T2 weighted sagittal and parasagittal
Investigations image showing a huge prevertebral abscess and posterior abscess spreading
• Management of spinal along and confined within posterior longitudinal ligament with cord
compression. (E, F) Coronal and axial trim images demonstrating
TB asymmetrical paravertebral abscess more toward the left side. (G, H, I) Axial,
• Conclusion coronal, and sagittal images showing fragmentary and osteolytic lesions with
near complete destruction of C4 vertebra. (J, K) One-year follow-up lateral
and AP X-ray following anterior corpectomy and iliac crest autografting with
12/07/2019 posterior instrumentation showing restoration of cervical lordosis and
excellent healing.
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 Spinal Tuberculosis:
Current Concepts • The immaturity and flexibility of spine in children is
the reason why they are prone to rapid and severe
• Abstract deformity progression following vertebral collapseIt.
• Introduction • The 4 “spine at risk” signs were retropulsion,
• Epidemiology subluxation, lateral translation, or toppling
• Pathophysiology of
spinal TB
• Clinical presentation of
Spinal TB
• Cold Abscess
• Deformity
• Pediatric Spinal TB
• Neurological deficit
• Atypical spinal
tuberculosis
• Diagnosis
• Imaging
• Laboratory Figure 3. The “spine at risk” signs to identify children at risk for
Investigations severe deformity include: (A) separation of facet joints in lateral
• Management of spinal radiographs which indicates instability, (B) retropulsion of the
TB posterior part of affected vertebra, (C) lateral translation of vertebrae
in the antero-posterior radiograph, and (D) toppling of one vertebra
• Conclusion over the other vertebra. Here, a line drawn from the anterior surface
of the caudal normal vertebra crosses the mid-point of the anterior
12/07/2019 surface of the cranial normal vertebra.
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 Spinal Tuberculosis:
Current Concepts

• Abstract
• Introduction
• Epidemiology • Direct compression due to abscess, inflammatory
• Pathophysiology of
tissue, or sequestrum and instability are the usual
spinal TB
• Clinical presentation of
causes for neural compromise in the active stage
Spinal TB • The mechanical stretch of cord over an internalgibbus
• Cold Abscess results in delayed neurological issues even after the
• Deformity healing of TB.
• Pediatric Spinal TB • Late-onset neurological deficit due to ossification of
• Neurological deficit ligamentum flavum proximal to the kyphosis is rare,
• Atypical spinal but has been observed and believe to be due to
tuberculosis
exaggerated movements.
• Diagnosis
• Imaging
• Laboratory
Investigations
• Management of spinal
TB
• Conclusion

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 Spinal Tuberculosis:
Current Concepts
Patients without the typical clinical
• Abstract features of axial pain, constitutional
• Introduction symptoms, kyphosis, or typical radiological
• Epidemiology features (paradiscal) are considered as
• Pathophysiology of having atypical presentation
spinal TB
• Clinical presentation of
Spinal TB Batson’s perivertebral venous plexus
• Cold Abscess plays a role in skip lesions of spinal TB
• Deformity and is believed to be one cause for
• Pediatric Spinal TB atypical presentations.
• Neurological deficit
• Atypical spinal
tuberculosis
• Diagnosis
Atypical clinical presentations such as prolapsed
intervertebral disc as reported by Pande and
• Imaging
Babhulkar, isolated cold abscess without bony
• Laboratory
involvement, and intraspinal pure soft tissue
Investigations
granulomas do occur
• Management of spinal
TB
• Conclusion

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 Spinal Tuberculosis:
Current Concepts

• Abstract
Growth of Mycobacterium in culture
• Introduction specimens obtained from the infected tissue is
• Epidemiology the single most confirmatory diagnostic test of
• Pathophysiology of spinal TB and is considered the gold standard
spinal TB method.
• Clinical presentation of
Spinal TB
• Cold Abscess
• Deformity
• Pediatric Spinal TB
• Neurological deficit
• Atypical spinal
tuberculosis
• Diagnosis
However, due to its very poor sensitivity,
• Imaging histopathological studies demonstrating classical
• Laboratory granulomas and staining of smears to identify
Investigations acid fast bacilli (AFB) are considered as reference
• Management of spinal standards for all other diagnostic modalities.
TB
• Conclusion

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 Spinal Tuberculosis:
Current Concepts

• Abstract
• Introduction
• Epidemiology • Have no role in early diagnosis of spinal TB.
• Disc space narrowing and rarefaction of vertebral
• Pathophysiology of
spinal TB Plain end plates can be identified as the disease progresses
and further destruction leading to kyphosis and

• Clinical presentation of radiographs instability can be made out only in late stages.

Spinal TB
• Cold Abscess
• Deformity
• Pediatric Spinal TB
• Neurological deficit
• Atypical spinal • Demonstrates vertebral destruction
tuberculosis Computed well before plain radiographs and is
• Diagnosis tomography extremely useful n identifying extent of
bony destruction, posterior column
• Imaging (CT) involvement, junctional pathologies,
• Laboratory joint involvement, and regional stability.
Investigations
• Management of spinal
TB
• Conclusion

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 Spinal Tuberculosis:
Current Concepts

• Abstract
• Introduction
• Epidemiology • Has been the imaging modality of choice as it
• Pathophysiology of has been able to detect earliest changes.
Gadolinium-enhanced MRI further helps in
spinal TB
• Clinical presentation of
MRI differentiating TB from other causes of infective
spondylodiscitis.
Spinal TB
• Cold Abscess
• Deformity
• Pediatric Spinal TB
• Neurological deficit
• Atypical spinal • Scan helps in real-time assessment of
tuberculosis Nuclear disease activity, compared with CT and
MRI, as 18F-FDG is known to accumulate in
• Diagnosis inflammatory cells such as neutrophils and
• Imaging imaging activated macrophages at the site of
inflammation
• Laboratory
Investigations
• Management of spinal
TB
• Conclusion

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 Figure 4. (A) Whole spine MRI screening showing
multifocal lesions. (B, C) All suspected levels
enhanced significantly with smooth uniform rims
after contrast administration suggestive of TB. (D)
Sagittal CT image with severe destruction of C1 and
C2. (E, F) 1-year follow-up AP and lateral radiographs
following occipitocervical stabilization. (G, H)
Posterior thoracic stabilization done at the same
stage.
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 Spinal Tuberculosis:
Current Concepts

• Abstract
• Introduction
• Epidemiology
• Pathophysiology of
spinal TB
• Clinical presentation of Two other tests
Spinal TB used in latent TB
Serological are interferon-g
• Cold Abscess (IFN-g) release
examination of IgM
• Deformity and IgG levels, assays and whole
• Pediatric Spinal TB which are high in blood-based
active and chronic enzyme-linked
• Neurological deficit immunosorbent
C- reactive protein infective stages of
• Atypical spinal (CRP) is more assays, measuring
tuberculosis TB the amount of
specific for acute
• Diagnosis infection rather IFN-g produced in
response to
• Imaging than TB
Mycobacterium
• Laboratory tuberculosis
Investigations antigens
• Management of spinal
TB
• Conclusion

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 Spinal Tuberculosis:
Current Concepts

• Abstract
• Introduction
• Epidemiology
• Pathophysiology of
spinal TB
• Clinical presentation of
Spinal TB
• Cold Abscess
• Deformity
• Pediatric Spinal TB
• Neurological deficit
• Atypical spinal
tuberculosis
• Diagnosis
• Imaging
Imaging
• Laboratory
Investigations
• Management of spinal
TB
• Conclusion
• Drug-resistant TB
• Surgical Management
• 12/07/2019
Conclusion
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 Spinal Tuberculosis:
Current Concepts • Chemotherapy

• Abstract • Multidrug antitubercular treatment (ATT) is the

• Introduction mainstay of treatment in both complicated and
• Epidemiology uncomplicated TB
• Pathophysiology of • In addition, multidrug ATT reduces instances of
spinal TB drug resistance
• Clinical presentation of • WHO recommends 9 months of treatment where
Spinal TB
4 drugs-isoniazid, rifampicin, pyrazinamide,
• Cold Abscess
ethambutol, or streptomycin-are administered in
• Deformity
• Pediatric Spinal TB
the “initiation” phase for 2 months, followed by
• Neurological deficit isoniazid and rifampicin for 7 months in the
• Atypical spinal “continuation” phase.
tuberculosis • The second-line ATT drugs (kanamycin, amikacin,
• Diagnosis capreomycin, levofloxacin, etc) have to be used
• Imaging judiciously as they have more side effects and are
• Laboratory expensive than the standard first-line ATT drugs
Investigations
• However, the WHO and all other TB programs
• Management of spinal
TB continue to use DOTS as an important strategy in
• Conclusion fear of drug resistance

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 Spinal Tuberculosis:
Current Concepts

• Abstract
• Introduction
• Epidemiology
• Pathophysiology of
spinal TB
• Clinical presentation of
Spinal TB
• Cold Abscess
• Deformity
• Pediatric Spinal TB
• Neurological deficit
• Atypical spinal
tuberculosis
• Diagnosis
• Imaging Figure 5. Serial radiographs and MRI images showing
• Laboratory good progressive bony healing and complete
Investigations resolution of cold abscess after receiving 9 months
• Management of spinal of ambulatory chemotherapy alone.
TB
• Conclusion

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 Spinal Tuberculosis:
Current Concepts • Chemotherapy

• Abstract • Multidrug antitubercular treatment (ATT) is the

• Introduction mainstay of treatment in both complicated and
• Epidemiology uncomplicated TB
• Pathophysiology of • In addition, multidrug ATT reduces instances of
spinal TB drug resistance
• Clinical presentation of • WHO recommends 9 months of treatment where
Spinal TB
4 drugs-isoniazid, rifampicin, pyrazinamide,
• Cold Abscess
ethambutol, or streptomycin-are administered in
• Deformity
• Pediatric Spinal TB
the “initiation” phase for 2 months, followed by
• Neurological deficit isoniazid and rifampicin for 7 months in the
• Atypical spinal “continuation” phase.
tuberculosis • The second-line ATT drugs (kanamycin, amikacin,
• Diagnosis capreomycin, levofloxacin, etc) have to be used
• Imaging judiciously as they have more side effects and are
• Laboratory expensive than the standard first-line ATT drugs
Investigations
• However, the WHO and all other TB programs
• Management of spinal
TB continue to use DOTS as an important strategy in
• Conclusion fear of drug resistance

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 Spinal Tuberculosis:
Current Concepts

• Abstract
• Introduction • Drug-Resistant TB
• Epidemiology
• Pathophysiology of • Extensively drug-resistant TB (XDR-TB) is when
spinal TB there is resistance to INH and rifampicin, along
• Clinical presentation of with resistance to any fluoroquinolone and at
Spinal TB
least one injectable second-line anti-TB drugs
• Cold Abscess
• Deformity
• 5 predictors for successful outcome in MDR-TB:
• Pediatric Spinal TB (1) progressive clinical improvement at 6 months
• Neurological deficit following chemotherapy, (2) radiographic
• Atypical spinal improvement during treatment, (3) disease with
tuberculosis strains that are resistant to less than 3 ATT drugs,
• Diagnosis (4) use of less than 4 second-line drugs in
• Imaging treatment, and (5) no changes of regimen during
• Laboratory treatment
Investigations
• Management of spinal
TB
• Conclusion

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 Spinal Tuberculosis:
Current Concepts

• Abstract
• Introduction
• Epidemiology
• Pathophysiology of
• Surgical Management
spinal TB
• Clinical presentation of • Anterior debridement and radical excision of the
Spinal TB disease foci along with ATT therapy was the
• Cold Abscess choice of treatment initially, in spite of the
• Deformity associated high morbidities
• Pediatric Spinal TB
• The fundamentals of surgical management are
• Neurological deficit
adequate decompression and debridement,
• Atypical spinal
tuberculosis maintenance and reinforcement of stability, and
• Diagnosis correcting the deformity or halting the progress of
• Imaging deformity.
• Laboratory • The surgical objectives are (1) abscess drainage,
Investigations (2) debridement of the infected material, or (3)
• Management of spinal debridement and fusion with or without
TB
stabilization
• Conclusion

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 Figure 6. (A, B, C) MRI images of a 40-year-old with active TB
and regional kyphosis with severe canal stenosis. (D, E) 1-year
follow-up after posterior column shortening and
decompression along with fusion procedure employed to
achieve deformity correction by posterior approach alone.

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 Spinal Tuberculosis:
Current Concepts • Nowadays, global reconstruction is being advocated
• Abstract through posterior approach alone
• Introduction • Several posterior and posterolateral approaches have
• Epidemiology been described in the thoracic and lumbar spine
• Pathophysiology of where the anterior and lateral column can be reached
spinal TB
safely
• Clinical presentation of
Spinal TB
• Cold Abscess
• Deformity
• Pediatric Spinal TB
• Neurological deficit
• Atypical spinal
tuberculosis
• Diagnosis
• Imaging
• Laboratory
Investigations
• Management of spinal Figure 7. (A, B) AP and lateral radiographs of thoracolumbar spine with
TB complete collapse of T10 vertebra resembling “vertebra plana.” (C, D, E,
• Global Reconstruction F) Sagittal and axial T2 weighted images of spine showing contiguous
by Posterior Alone involvement of T8, T9, T10, and T11 with prevertebral abscess and
Approach concentric collapse of T10 vertebra. (G, H) AP and lateral postoperative
• Conclusion radiographs following global anterior reconstruction through posterior-
12/07/2019 only approach. 27
 Spinal Tuberculosis:
Current Concepts
• Abstract
• Introduction
• Epidemiology
• Pathophysiology of
spinal TB
• Clinical presentation of
Spinal TB
• Cold Abscess • The MIS procedures include thoracoscopic
• Deformity
debridement, posterolateral endoscopic
• Pediatric Spinal TB
debridement, and MIS transforaminal interbody
• Neurological deficit
fusion
• Atypical spinal
tuberculosis
• Diagnosis • Successful outcomes have been reported; however,
• Imaging their role in cases with severe neurological deficits
• Laboratory and extensive osseous destruction is questionable.
Investigations
• Management of spinal
TB
• Minimally Invasive
Surgery (MIS)
• Conclusion
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 Spinal Tuberculosis:
Current Concepts
• Abstract
• Introduction
• Epidemiology
• Pathophysiology of
spinal TB
• Clinical presentation of
Spinal TB
• Cold Abscess
• Deformity
• Pediatric Spinal TB • The options for posterior deformity correction
• Neurological deficit procedures are transpedicular decancellation
• Atypical spinal procedures, pedicle subtraction osteotomy and
tuberculosis posterior closing wedge osteotomy, posterior
• Diagnosis vertebral column resection, and closing opening
• Imaging wedge osteotomy
• Laboratory
Investigations
• Management of spinal
TB
• Surgery in Healed
Tuberculosis
• Conclusion
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 Spinal Tuberculosis:
Current Concepts
• Abstract
• Introduction
• Epidemiology
• Pathophysiology of
spinal TB
• Clinical presentation of
Spinal TB • The goals of treatment in spinal TB are to eradicate
• Cold Abscess the disease and to prevent and/or correct spinal
• Deformity deformity and neurological deficits. Uncomplicated
• Pediatric Spinal TB spinal TB is purely a medical disease
• Neurological deficit
• Atypical spinal • Surgery in spinal TB is directed toward achieving
tuberculosis
adequate decompression and debridement,
• Diagnosis
maintenance, and reinforcement of stability and
• Imaging
halting the progress of deformity or finally correcting
• Laboratory
Investigations the deformity in healed disease
• Management of spinal
TB
• Surgery in Healed
Tuberculosis
• Conclusion
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 THANK YOU

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