February, 25th 2020

SPONDYLITIS
TUBERCULOSA
YA/SI
Mod : HP
Supervisor : dr. Jainal Arifin, M.Kes, Sp.OT(K) Spine
Introduction
A spinal infection associated with tuberculosis
Characterized by a sharp angulation of the spine where
tubercle lesions are present.
Also called Pott's disease.
Etiology = Mycobacterium tuberculosis
Straight or slightly curved rods
 Pathophysiology
Spreads via:
Artery/hematogenous

Vein (batson plexus)

Percontinuitatum
Natural history of Spondylitis TB
Tuberculosis Granulomatous
inflammation
infection

Erosion of the Destroyed the

margins of intervertebral
vertebrae disc

Weakening of the
Disc
trabeculae of
degeneration
vertebral body

Collapse of the Loss its

vertebrae height

Kyphotic deformity
Tuberculous bacilli spread to the disc space from surrounding tissues (contiguous spread) or through the
vascular supply (hematogenous spread). Over time the disc may be completely digested (discitis), or the
infection may progress to involve the bone of each of the adjoining vertebral bodies (osteomyelitis). As
the vertebrae degenerate and collapse, a kyphotic deformity results (Pott’s disease).
 Affected vertebra

Vertebral
abscess Collection of pus
and tubercular
debris

Comes out

Anteriorly Posteriorly

Press neural
Form psoas absces
structures in
spinal canal
 INVOLVEMENT
1
1
1. Paradiscal/peridiscal
end plate deposition of organisms,
> 50% of cases
2. Central
usually restricted to one segment,
collapse and deformity common
2 3. Anterior
infection is localized to the anterior
part of the vertebral body,infection
spread up and down under the
anterior longitudinal ligament
3
CLINICAL
History Taking Physical Examination
 Constitutional symptoms  Spine deformity (kyphotic)
 Weakness  Localised tenderness
 Loss of appetite  Paravertebral muscle spasm
 Loss of body weight  Neurologic deficit
 Night sweat
 Back pain (spinal or
radicular), worsen with
activity
INVESTIGATION
Laboratory
Complete blood count
ESR may be markedly elevated (neither specific nor
reliable)
Mantoux test
Enzyme Linked Immunosorbent Assay (ELISA)
Polymerase Chain Reaction (PCR)
Biopsy
Culture
Ziehl-Neelsen staining
IMAGING
Plain radiograph : give good overview

CT scan : defining the extent of bony destruction,

paravertebral abscess and localization for biopsies

MRI : determined spread of the disease to soft tissue

and extend of spinal cord involvement
PLAIN X-RAY
Rarefaction of the vertebral end plates, loss of disk
height, osseous destruction, new-bone formation and
soft-tissue abscess
CT - SCAN
Greatest value in delineation of encroachment of the
spinal canal by posterior extension of inflammatory
tissue, bone or disk material, and in the CT-guided
biopsy

Presence of calcification within the abscess is

pathognomonic finding
MRI Findings may be non-specific
Findings on spinal Tuberculosis
T1W : Decreased SI of both vertebral bodies and disc
spaces
T2W : Increased SI in the vertebral disc and markedly
decreased SI in the vertebral bodies
Pathognomonic : T2W increase in intensity of a uniform
thin rim enhancement suggesting caseation necrosis
Abscess
T1W : Low SI
T2W : very high SI
T1W contrast-enhanced : central low SI with peripheral
enhancement
 Sagital T1W and Sagital
T2W

T1W : Decreased SI of both

vertebral bodies and disc
space T7-T8 with destruction
of the opposed end plates

T2W : increased SI in the

vertebral disc and areas of
markedly decreased SI in the
vertebral bodies T7 and T8.
Anterior subligamentous
abscess, epidural involvement
and extension of
inflammation in T6 with
preservation of the lower
endplate is noted
 HISTOPATHOLOGY

Positive smear of AFB ~

52%
Positive culture ~ 83%
Histologic studies ~ 60%
The most common cytological findings
Epithelioid cell granulomas (90%)
Granular necrotic background (83%)
Lymphocytic infiltration (76%).
Scattered multinucleated and Langhans' giant cells
(56%)
MYCOBACTERIAL CULTURE
Gold standard for diagnosis
Culture material from deep structures, such as
bone, abscesses, synovial fluid or synovial tissue
Culture media : Lowenstein-Jensen, Selective 7H11
and liquid-based media (Becton-Dickinson and
Co., BACTEC™ and BACTEC™ MGIT™)
Growth often be detected within 2 wks, delayed if
pretreatment with fluoroquinolone more than 2
wks
Pyogenic Spondylitis
Metastasis
MANAGEMENT
Anti TB drugs
Aims of anti TB drugs :
To cure the potent TB
To prevent death from active TB
To prevent TB relapse
To decrease TB transmision to others
Schaaf HS and Nelson LJ. Tuberculosis drug therapy in Children. In: Schaaf HS and Zumia A. Tuberculosis : A Comprehensive Clinical Reference.
Europe: Saunders Elsevier; 2009.
 Anti Tuberculosis Drugs

Kaufmann SHE, Hahn H (eds): Mycobacteria and TB. Issues Infect Dis. Basel, Karger, 2003, vol 2, pp 112–127
Surgery
Indication
 Failure of medical therapy  pain
 Neurological deficit
 Developed or worst in conservative treatment
 No recovery in 3-4 weeks of therapy
 Recurrence
 Prevertebral abscess at cervical difficult in deglutition and
respiration
 Spinal deformity with instability  Severe or progressive
kyphosis
 Advanced cases : sphincter involvement, flaccid paralysis,
severe flexor spasm
Complication
Paraplegia
Spinal Deformity
Cold Abscess
Secondary infection
 Q1
Figures 1a and 1b show the sagittal T2- and T1-weighted
MRI scans of a 25-year-old intravenous drug abuser who
has low back pain that is increasing in intensity. Laboratory
studies show a WBC count of 10,000/mm3 and an
erythrocyte sedimentation rate of 80 mm/h. Blood culture
is negative. Initial management consist of
1- CT-guided closed biopsy.
2- open surgical biopsy.
3- antibiotic coverage for Staphylococcus aureus.
4- broad-spectrum antibiotic coverage.
5- a follow-up MRI scan in 8 weeks.
The Preferred Response to Question # 1 is 1.
DISCUSSION: The MRI scans show vertebral
diskitis/osteomyelitis. The treatment of spinal infection in
adults should be organism specific; therefore, initial
management should consist of CT-guided closed biopsy
prior to administration of antibiotic coverage. An open
biopsy is indicated for a failed closed biopsy or failure of
nonsurgical management. Although Staphylococcus aureus
is the most common bacteria, a history of intravenous drug
abuse raises suspicion for other organisms, including
Pseudomonas.
 Q2
 Figures 14a through 14d are the radiographs and sagittal T1- and T2-weighted MRI
scans of an otherwise healthy 10-year-old girl who has experienced 3 weeks of
worsening pain with weight bearing and is now refusing to bear weight to either of
her lower extremities. She denies any history of injury or trauma. She has not had
any fevers or recent illnesses. She denies any numbness or parasthesias. She has
had no bowel or bladder incontinence. In the emergency department she is
afebrile and tender to palpation over the midlumbar spine. She has pain with
hyperextension and flexion of her back. Her white blood cell count is 11.4
(reference range, 4.5-11.0 x109/L), erythrocyte sedimentation rate is 40 mm/h
(reference range, 0-20 mm/h), and C-reactive protein is 2.6 mg/L (reference range,
0.08-3.1 mg/L).
 What is the most appropriate course of action at this time?
1. Admission and traction
2. Open surgical debridement of the lesion
3. Perform an open biopsy of the lesion
4. Nonsurgical treatment with antibiotics and immobilization
PREFERRED RESPONSE: 4
DISCUSSION
Childhood diskitis represents one end of a continuum of
spinal infections, from diskitis to vertebral osteomyelitis
with soft-tissue abscess. Diskitis is now generally accepted
as a bacterial infection involving the disk space and
adjacent vertebral end plates. Optimal treatment includes
the use of
antibiotics. Empiric coverage is directed against
Staphylococcus aureus because it has been the most
common organism isolated from culture-positive biopsy
specimens. Open biopsy is not necessary for
patients who exhibit all of these clinical characteristics, but
it is indicated for those whose symptoms do
not resolve rapidly with treatment or who have atypical
presentation.
THANK YOU