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1. SPINAL TUBERCULOSIS

2. Tuberculosis of the bone. Child on crutches with legs deformed by tuberculosis of the bone.
*Refugees from the Oklahoma drought in the USA, in June 1935

3. Outline
• Case discussion
• Introduction
• Pathology
• Clinical presentation
• Investigations
• Treatment

4. Case Discussion
Mr X, 40 years old malay male, NKMI, active
smoker, active IVDU
P/w :
Lower back pain x6/12
- Progressively worsening, aggravated by
active movement and lying flat, relieved
by resting in prop up position, pain score
5/10.
- Still able to ambulate slowly but limited
due to pain upon movement.
A/w :
LOA/LOW x6/12
O/w :
Denies history of trauma, no PTB contact,
no night sweat, no limb weakness or
numbness, no prolonged cough

5. On examination:
• Alert, conscious, pink
• Vital signs stable
• Back examination:
- Gibbus deformity at thoracolumbar
region
- No paraspinal spasm
- Restricted bending in view of pain
• Upper limb and lower limb
examinations
No deformity, ROM full
Power 5/5, sensation intact

6. Investigations
• Twc 9.5/hb 11.5/plt 275
• Urea 5.5/Na 133/ K 4.7/Cl 97/ Creat 86
• ALT 5/ALP 98
• Hep B/HIV /syphilis screening: non reactive
• Mantoux test positive 18mm
• ESR 26
• AFB smear x3 negative

8. Diagnosis?
Management?

9. INTRODUCTION
• The spine is the most common site of
skeletal TB and accounts for 50% of all
musculoskeletal TB
• Most common site: Thoracolumbar,
however any part of the spine can be
affected
• Spinal TB - can be associated with
neurologic deficit due to compression
of adjacent neural structures and
significant spinal deformity.

10. PATHOLOGY
Blood borne infection
settles in vertebral body
adjacent to
intervertebral disc
Bone destruction and caseation
with infection spreading to disc
space and adjacent vertebrae
Paravertebral abscess may form
and then track along muscle
planes to involve sacroiliac or
hip joint or along psoas muscle
to the thigh
As vertebral body collapse into
each other, sharp angulation
(gibbus/kyphos) developed

13. Early infection
Begins in the metaphysis of the
vertebral body
Spreads under the anterior
longitudinal ligament and leads to
contiguous multilevel involvement
skip lesion or noncontiguous
segments (15%)
paraspinal abscess formation (50%)
- usually anterior and can be quite
large (much more common in TB
than pyogenic infections)
Initially does not involve the disc
space (distinguishes from pyogenic
osteomyelitis, but can be
misdiagnosed as a neoplastic
lesion)

14. Angular kyphosis is a localized spinal deformity with a sharp
angulation. It is observed in patients with congenital kyphosis,
kyphosis associated with spina bifida, post-tuberculosis
kyphotic deformity, and kyphosis associated with skeletal
dysplasia (type 1 neurofibromatosis, Morquio syndrome or
achondroplasia

16. CLINICAL PRESENTATION
• Symptoms
• Onset of symptoms of tuberculous spondylitis is
typically more insidious than pyogenic infection
• Constitutional symptoms
• chronic illness
• malaise
• night sweats
• weight loss
• Back pain
• often a late symptom that only occurs after
significant bony destruction and deformity.
• Physical exam
• Kyphotic deformity/Gibbus deformity
• neurologic deficits (present in 10-47% of patients
with Pott's Disease)

17. Atypical features:
• Lack of deformity
• Involvement only the posterior
vertebrae elements
• Infections confined to single
vertebral body
• Involvement of multiple vertebrae
bodies and posterior
elements(especially in HIV patients)
resulting in kyphoscoliosis

19. Pott’s paraplegia
• Most feared complication of spinal TB
• Early onset paresis (within 2 years of disease
onset)
• Due to pressure by inflammatory edema,
abscess, caseous material, granulation tissue or
sequestra
• Prognosis for neurological recovery following
surgery is good
• Late onset paresis
• Due to direct cord compression from increasing
deformity or vascular insufficiency of the cord
• Recovery following decompression is poor

20. LABORATORY INVESTIGATION
• FBC
• relative lymphocytosis
• low hemoglobin
• ESR
• usually elevated but may be normal in up to 25%
• PPD (purified protein derivative of tuberculin)
• positive in ~ 80%
• Diagnosis
• CT guided biopsy with cultures and staining effective at obtaining diagnosis
• should be tested for acid-fast bacilli (AFB)
• mycobacteria (acid-fast bacilli) may take 10 weeks to grow in culture
• PCR allows for faster identification (95% sensitivity and 93% accuracy)
• smear positive in 52%
• culture positive in 83%

21. • 66% will have an abnormal CXR
• should be ordered for any patients in which TB is a possibility
CXR
• Early infection: shows involvement of anterior vertebral body
with sparing of the disc space
• Late infection: shows disk space destruction, lucency and
compression of adjacent vertebral bodies, and development of
severe kyphosis
Spine
radiographs
• preferred imaging study for diagnosis and treatment
• Diagnose adjacent level
MRI
• demonstrates lesions <1.5cm better than radiographs
CT

23. Differential diagnosis
Pyogenic and
fungal
infection
Malignant
disease
Parasitic
infestations

26. TREATMENT
Objectives
• Eradicate or at least arrest the disease
• Prevent or correct deformity
• Prevent or treat major complications

27. Non
operative
Pharmacological
Indication: no neurological deficit
Antituberculous agents: isoniazid (H), rifampin
(R), ethambutol (E) and pyrazanamide
(Z) therapy
Spinal orthosis
may be used for pain control and prevention
of deformity

28. Operative Indications:
abscess that can be readily drained
advanced disease with marked bone destruction and
threatened or actual severe kyphosis
neurological deficit
Failed medical therapy and progression of disease despite best
medical therapy
advantages of surgical treatment
less progressive kyphosis
earlier healing
decreased sinus formation
improved neurological recovery

29. HIV and spinal tuberculosis
• Spinal TB, which is extrapulmonary focus, is AIDS defining
• These patients are prone to develop opportunistic infections and
mycobacterial infections
• The tuberculous infection usually involves multiple vertebrae and results in
severe deformity. A primary epidural abscess is not uncommon
• Decompression and stabilization for neurological deficit are performed
through an extrapleural posterolateral approach with instrumentation to
minimize pulmonary complications
• Primary epidural abscess is drained through laminectomy
• Post operatively, anti TB and antiretroviral treatment are commenced.

30. Reference
• Apley’s System of Orthopaedics and Fracture, Ninth Edition
• https://www.orthobullets.com/spine/2027/spinal-tuberculosis
• https://www.sciencephoto.com/media/151248/view/tuberculosis-of-
the-bone-1935
• https://www.asianspinejournal.org/upload/pdf/asj-6-294.pdf