Spinal tuberculosis (TB) can cause compression of peripheral nerves leading to loss of sensation and motor functions. There are two types of this affliction:

1. Spondylodiscitis;
2. Atypical form or spondylitis without disc involvement.

Lesions of tuberculosis affecting the vertebrae are characterized with spreading to adjacent spinal structures, provocating osteomyelitis, and arthritis in numerous vertebrae [1]. TB can cause the destruction of the bone tissue that leads to the development of kyphotic or kyphoscoliotic disfigurement and possible compression of root nerves with the collapse of the vertebrae [2]. Spinal canal can narrow due to the protrusion of granulations, lesions like cold abscesses developed in the course of the TB infection or direct infiltration. Cold abscesses are known to spread in subligamentous fashion, considering the bacteria cannot exert a lytic effect in these tissues [1] [2].

Patients with spinal TB present with local symptoms such as pain in the affected area, reduced amplitude of movement due to compression, and loss of function. Non-specific complaints are fever, night sweats, signs of wasting like reduction of weight, loss of appetite, and fatigue [3] [4] [5].

Neurological assessment can be made using the American Spinal Injury Association (ASIA) impairment scale which classifies neurologic deficit into grades. Although alternative methods are available, ASIA classification is used more frequently due to the correlation with findings from the magnetic resonance imaging scans [2].

Spasticity, progressive loss of sensory and either partial or complete motor function is expected if the tuberculosis lesions are not treated [6].

• Fever

  Spinal tuberculosis commonly presents with back pain, fever and night sweats. In this report, we present a case of spinal tuberculosis complicated by bilateral large psoas abscesses. [ncbi.nlm.nih.gov]

• Gangrene

  2016 2017 2018 2019 Billable/Specific Code tuberculous A18.01 Lordosis M40.50 ICD-10-CM Diagnosis Code M40.50 Lordosis, unspecified, site unspecified 2016 2017 2018 2019 Billable/Specific Code tuberculous A18.01 Necrosis, necrotic (ischemic) - see also Gangrene [icd10data.com]

• Night Sweats

  Spinal tuberculosis commonly presents with back pain, fever and night sweats. In this report, we present a case of spinal tuberculosis complicated by bilateral large psoas abscesses. [ncbi.nlm.nih.gov]

• Back Pain

  The patient presented with bilateral flank pain and swellings rather than the classic presentation of back pain. [ncbi.nlm.nih.gov]

• Low Back Pain

  After 3 month history of low back pain and 2 weeks radiated pain of right lower extremity, an operation was performed and the total intra-spinal mass was resected. Histological examination revealed a granulomatous necrosis with caseum. [ncbi.nlm.nih.gov]

  Disc prolapse has been implicated as one of the important causes of low back pain radiating to limbs. Apart from conservative therapy all other forms of treatment aim at decompressing the nerve roots. [indiamart.com]

  Most common symptom was low back pain. Most common sign was local tenderness. Spinal cord compression was seen in 16 cases (26.6%). MRI scan of spine showed narrowing/ destruction of disc space in 95% of cases. Wedge collapse of body in 30%. [pjms.com.pk]

• Paravertebral Muscle Spasm

  Physical examination of the spine reveals localised tenderness and paravertebral muscle spasm. A kyphotic deformity due to prominence of spinous process may be evident due to collapse and anterior wedging of vertebral bodies. [rxpgonline.com]

• Spine Pain

  In the second patient, aged 35 years, during intravesical BCG immunotherapy for carcinoma of the bladder, girdle thoracic spine pain was observed. The MRI and CT of the spine showed visible lesions characteristic of tuberculosis. [ncbi.nlm.nih.gov]

• Bilateral Flank Pain

  The patient presented with bilateral flank pain and swellings rather than the classic presentation of back pain. [ncbi.nlm.nih.gov]

• Neglect

  Differential diagnosis of the obscure spinal lesion should include tuberculosis, specifically the atypical forms; especially because complete cure is possible with early treatment and neurologic morbidity is high in neglected cases. [ncbi.nlm.nih.gov]

  But people are not aware about it and neglect the symptoms associated with it. [thehindu.com]

  In neglected cases, patient may develop angular deformity due to destruction of vertebral bodies called as kyphosis. Blood test, x-rays, MRI scan and biopsy aid diagnosis. Treatment includes taking anti-tuberculosis medication religiously. [timesofindia.indiatimes.com]

• Spastic Paraplegia

  Tuberculosis of the spine is a preventable and treatable cause of spastic paraplegia. Early diagnosis and comprehensive treatment are needed to control this pubic health problem. [rxpgonline.com]

• Hyperreflexia

  This is in contrast to the hyperreflexia seen with spinal cord compression along with bladder involvement (cauda-equina syndrome). Formation of a cold abscess around the vertebral lesion is another characteristic feature of spinal tuberculosis. [ncbi.nlm.nih.gov]

• Cervical Cord Compression

  The destructive lesion of the sacrum with a rectally palpable presacral mass was thought to be a chordoma or chondrosarcoma until the patient developed upper cervical cord compression with an extradural myelographic block. [ncbi.nlm.nih.gov]

It is important to differentiate spinal TB from other causative agents that can establish lesions in the spine like fungal or pyogenic infections. Metastatic or primary tumors are also subjected to differentiation [1].

A positive skin test is an indicator of M. tuberculosis involvement, despite that, additional studies have to be performed to confirm the disease. This is particularly important in endemic regions where TB is widespread [7].

Biopsy and subsequent procedures associated with polymerase chain reaction amplification methods give rise to an accurate and fast diagnosis of the infection and the causative agent. This is due to difficulties obtaining M. tuberculosis cultures that can take a long time to cultivate and the results may be unreliable, even false negative [1].

Imaging studies are performed to determine the exact location of the tuberculosis lesions and estimate the grade of infiltration. Computed tomography (CT) scan or plain radiography are effective in visualizing the pathologies in the bone structures like the collapse of a vertebral body or bone tissue destruction. Narrowing or even absence of intervertebral space is noted as well [3]. Conversely, a phenomenon of ivory vertebra is possible. It is described as increased opacification of the vertebral body with no changes in size or contours. This renders the image to appear heterogeneous [2].

Magnetic resonance imaging (MRI) is a more accurate radiologic study that can exhibit characteristics of soft tissues and presence of abscesses [7]. Sagittal and axial planes are used. Spinal cord edema and signs of compression in addition to end-plate disruption may be seen [2]. Atypical findings of the spinal TB include lesions not associated with vertebral discs or only small-scale disc involvement, as well as no evidence of soft tissue abscesses [8].

• Granulomatous Tissue

  However, epidural granulomatous tissue or tuberculoma of the spinal cord may not be detected by these tools [ 8 ]. [ncbi.nlm.nih.gov]

1. Rasouli MR, Mirkoohi M, Vaccaro AR, Yarandi KK, Rahimi-Movaghar V. Spinal Tuberculosis: Diagnosis and Management. Asian Spine J. 2012;6(4):294-308.
2. Gupta AK, Kumar C, Kumar P, Verma AK, Nath R, Kulkarni CD. Correlation between neurological recovery and magnetic resonance imaging in Pott’s paraplegia. Indian J Orthop. 2014;48(4):366-373.
3. Cheng Z, Wang J, Zheng Q, Wu Y, Guo X. Anterolateral Radical Debridement and Interbody Bone Grafting Combined With Transpedicle Fixation in the Treatment of Thoracolumbar Spinal Tuberculosis. Chang. J, ed. Medicine (Baltimore). 2015;94(14):e721.
4. Jiang T, Zhao J, He M, Wang K, Fowdur M, Wu Y. Outcomes and Treatment of Lumbosacral Spinal Tuberculosis: A Retrospective Study of 53 Patients. Cardona P-J, ed. PLoS ONE. 2015;10(6):e0130185.
5. World Health Organization. Global Tuberculosis Report. WHO Library Cataloguing-in-Publication Data; Geneva 27, Switzerland: World Health Organization; 2012:107–1.
6. Jain AK, Dhammi IK, Jain S, Kumar J. Simultaneously anterior decompression and posterior instrumentation by extra pleural retroperitoneal approach in thoracolumbar lesions. Indian J Orthop. 2010;44:409–16.
7. Jain AK. Tuberculosis of the spine: a fresh look at an old disease. J Bone Joint Surg Br. 2010;92:905–913.
8. Sharma A, Chhabra HS, Mahajan R, Chabra T, Batra S. Magnetic Resonance Imaging and GeneXpert: A Rapid and Accurate Diagnostic Tool for the Management of Tuberculosis of the Spine. Asian Spine J. 2016;10(5):850-856.