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Spinal Tuberculosis

Disease Pott

Spinal tuberculosis or Pott's disease is an infection of the vertebral column caused by Mycobacterium tuberculosis. This condition is of great diagnostic importance due to its link to neurologic deficits and painful spinal deformities.


Presentation

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]
  • A statistically significant relationship was found between spinal tuberculosis and spinal pain, fever, gradually progressive lower limb weakness, contrast-enhancing epidural paravertebral lesions, continuous levels affected, spinal deformity, and raised[ncbi.nlm.nih.gov]
  • The patient originally presented with progressive quadriparesis, fever, night sweats and weight loss.[ncbi.nlm.nih.gov]
  • We describe a young, immunocompetent patient who presented with fever, cough, headache, diplopia and paraparesis.[ncbi.nlm.nih.gov]
  • In addition, the patient presented with low back pain, progressive fever, night sweats, and weight loss.[ncbi.nlm.nih.gov]
Acute Abdomen
  • Three patients who came to the surgical outpatient department of 'Postgraduate Institute of Medical Education and Research', Chandigarh, India with features suggestive of acute abdomen are presented.[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]
  • CASE REPORT A 59-year-old female was admitted to the hospital for back pain, which was assessed as a 9 on the visual analogue scale (VAS); the patient reported tiredness and night sweats.[ncbi.nlm.nih.gov]
  • 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]
  • We report 3 cases of spinal TB in Chinese recipients of orthotopic liver transplant whose first complaint was back pain. These 3 cases were diagnosed by magnetic resonance imaging and percutaneous biopsy.[ncbi.nlm.nih.gov]
  • Back pain disappeared, and erythrocyte sedimentation and body temperature returned to normal. We should highly suspect spinal tuberculosis if notalgia and night sweats are present after organ transplantation.[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]
  • In addition, the patient presented with low back pain, progressive fever, night sweats, and weight loss.[ncbi.nlm.nih.gov]
  • A visual analog scale was used to assess low back pain. Bone graft fusion and instrumentation failure were monitored by radiography, and tuberculosis activity was monitored by erythrocyte sedimentation rate (ESR) and C-reactive protein testing.[ncbi.nlm.nih.gov]
  • 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]
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]
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]
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]
  • We should highly suspect spinal tuberculosis if notalgia and night sweats are present after organ transplantation. Anti-tuberculosis therapy is an effective treatment for spinal tuberculosis after organ transplantation.[ncbi.nlm.nih.gov]
  • The patient originally presented with progressive quadriparesis, fever, night sweats and weight loss.[ncbi.nlm.nih.gov]
  • CASE REPORT A 59-year-old female was admitted to the hospital for back pain, which was assessed as a 9 on the visual analogue scale (VAS); the patient reported tiredness and night sweats.[ncbi.nlm.nih.gov]
  • In addition, the patient presented with low back pain, progressive fever, night sweats, and weight loss.[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]
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]
Kernig's Sign
  • On examination, the patient had positive Kernig's sign, right third cranial nerve palsy and bilateral sixth cranial nerve palsy, bilateral lower limb weakness and crepititions on lung auscultation bilaterally.[ncbi.nlm.nih.gov]

Workup

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]

Treatment

  • To help clarify the treatment over spinal TB patients without absolute surgical indications, we characterized a subtype spinal TB and then analyzed the treatment outcomes of standard chemotherapy alone.[ncbi.nlm.nih.gov]
  • Early surgical treatment of the cases with large abscesses and systemic tuberculosis may provide early improvement, and must probably be the first treatment modality after general support to the patient.[ncbi.nlm.nih.gov]
  • CT-guided percutaneous focal catheter infusion was effective for the treatment of spinal tuberculosis and induced little trauma; this treatment could also relieve the symptoms and improve the quality of life of elderly patients with poor general conditions[ncbi.nlm.nih.gov]
  • It was concluded that one-stage surgical treatment via a posterior-only approach is effective and feasible for the treatment of spinal tuberculosis.[ncbi.nlm.nih.gov]
  • Forty of those patients (experimental group) received Halo- pelvic ring traction before surgery and the rest (control group) received surgical treatment directly.[ncbi.nlm.nih.gov]

Prognosis

  • In most cases, M. tuberculosis, once recognized and appropriately treated, should result in an excellent prognosis.[ncbi.nlm.nih.gov]
  • C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR) not only are useful in the diagnosis but also are reliable parameters in evaluating the response to treatment and prognosis of tuberculous spondylodiscitis.[ncbi.nlm.nih.gov]
  • Prognosis The progress is slow and lasts for months or even years. Prognosis is better if caught early and modern regimes of chemotherapy are more effective. A study from London showed that diagnosis can be difficult and is often late [ 4 ] .[patient.info]
  • PROGNOSIS: Early diagnosis with better imagings and the 2nd line of drugs has greatly improved the prognosis without necessitating surgery.[thamburaj.com]

Etiology

  • On thorough evaluation, they had bilateral psoas abscess and on detailed investigations, tuberculosis was found to be the etiological factor. They were treated conservatively with good follow-up results.[ncbi.nlm.nih.gov]
  • In developing countries, a recognized etiology of paraplegia can be tuberculous radiculomyelitis or tuberculomas, especially in patients with evidence of either active or latent tuberculosis.[ncbi.nlm.nih.gov]
  • […] 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% Differential Other etiologies[orthobullets.com]
  • ), Pott; disease (manifestation), disease (or disorder); spine or vertebra, tuberculous (etiology), disease (or disorder); spine or vertebra, tuberculous (manifestation), spine or vertebra; disorder, tuberculous (etiology), spine or vertebra; disorder[fpnotebook.com]

Epidemiology

  • We performed a retrospective observational study (1993-2014), including all cases of spinal TB diagnosed at a Barcelona hospital to assess the epidemiological changes.[ncbi.nlm.nih.gov]
  • Aim: To review the epidemiology clinical management of Spinal TB at Queen Elizabeth Hospital, London. Methods: A retrospective study was performed on spinal TB patients from 2008-2012. Results: 34 patients, mean age 43 years, 22(65%) male.[erj.ersjournals.com]
  • Epidemiology Spinal tuberculosis is rare in the UK but in developing countries it represents about 50% of musculoskeletal tuberculosis [ 2 ] .[patient.info]
  • Introduction Epidemiology incidence increasing incidence of TB in United States due to increasing immunocompromised population demographics HIV positive population ( often seen in patients with CD4 count of 50 to 200) location 15% of patients with TB[orthobullets.com]
Sex distribution
Age distribution

Pathophysiology

  • Seminars in Spine Surgery. 2015; 12 Magnetic Resonance Image findings of Spinal Tuberclosis at first presentation Arsalan Alvi,Aisha Raees,Muhammad khan Rehmani,Hafiz Aslam,Shafaq Saleem,Junaid Ashraf International Archives of Medicine. 2014; 7(1): 12 13 Pathophysiology[najms.org]
  • Medical treatment or combined medical and surgical strategies can control the disease in most patients. [4, 5 ] Pathophysiology Pott disease is usually secondary to an extraspinal source of infection.[emedicine.medscape.com]
  • Setting: Ohio, USA Methods: A review of the literature on the pathogenesis, pathophysiology, clinical presentation, diagnostic methods, treatment and prognosis of spinal TB was conducted.[nature.com]

Prevention

  • The aim of this report is to draw the attention of physicians to this uncommon presentation of spinal tuberculosis, as an early recognition of such condition may expedite diagnosis and treatment, thereby preventing future complications of the disease.[ncbi.nlm.nih.gov]
  • Early diagnosis and treatment are essential in order to prevent life-threatening complications.[ncbi.nlm.nih.gov]
  • The World Health Organization has proposed a global strategy and targets for TB prevention, care, and control after 2015.[ncbi.nlm.nih.gov]
  • It is characterized as minimum surgical trauma, good neurologic recovery, good correction of kyphosis, and prevention of progressive kyphosis.[ncbi.nlm.nih.gov]
  • The administration of the BCG vaccine is to destroy the neoplastic lesion or prevent further recurrences. The activity of the vaccine involves boosting the immune system through the stimulation of the inflammation in the bladder.[ncbi.nlm.nih.gov]

References

Article

  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.

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Last updated: 2018-06-22 03:58