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Spinal Tuberculosis

(Potts Disease)

Epidemiology
Incidence
increasing incidence of TBin 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 will have extrapulmonary
involvement
the spine, and specifically, the thoracic spine is the
most common extrapulmonary site
5% of all TB patients have spine involvement

Pathoanatomy
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)

Spinal Tuberculosis
MRI-Saital-Gadolinium

Chronic Infection
Severekyphosis
mean deformity in nonoperative cases is 15
in 5% of patients, deformity is >60
infection is often diagnosed late, there is often much more
severe kyphosis ingranulomatousspinal infections compared to
pyogenic infections
in adults
kyphosis stays static after healing of disease
in children
kyphosis progresses in 40% of cases because of growth spurt
classification of progression (Rajasekaran)
Type-I, increase in deformity until cessation of growth
should be treated with surgery
Type-II, decreasing progression with growth
Type-III, minimal change during either active / healed
phases.

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 boney destruction and
deformity.

Physical exam
kyphotic deformity
neurologic deficits (present in 10-47% of patients with Pott's
Disease)
mechanisms
mechanical pressure on cord by abscess, granulation tissue, tubercular debris,
caseous tissue
mechanical instability from subluxation/dislocation
paraplegia from healed disease can occur with severe deformity
stenosis from ossification of ligamentum flavum adjacent to severe kyphosis

Imaging
CXR66% will have an abnormal CXR
should be ordered for any patients in which TB is
a possibility

Spine radiographs
early infection
shows
involvement
of
anterior
vertebral
body
withsparing of the disc space(this finding can
differentiate from pyogenic infection)

late infection
shows disk space destruction, lucency and compression
of adjacent vertebral bodies, and development of severe
kyphosis
risk factors for buckling collapse ("spine at risk signs")
retropulsion
subluxation
lateral translation
toppling

Buckling
collapse

Xray-Thoracic-Lateral
Shows collapse of vertebral body

MRI with gadolinium


contrast
Indications
Remains preferred imaging study for
diagnosis and treatment
Diagnose adjacent levels ; multiple levels
involved in 16-70%

Findings
low signal on T1-weighted images, bright
signal on T2-weighted images
presence of a septate pre-/ paravertebral /
intra-osseous smooth walled abscess with a
subligamentous extension and breaching of
the epidural space

MRI Findings
end-plate disruption
sensitivity 100%, specificity 81%

paravertebral soft tissue shadow


sensitivity 97%, specificity 85%

high signal intensity of the disc on the T2-weighted


image
sensitivity 81%, specificity 82%

spinal cord

edema
myelomalacia
atrophy
syringomyelia

CT
indications
demonstrates lesions <1.5cm better than radiographs
inaccurate for defining epidural extension

findings
types of destruction

fragmentary
osteolytic
subperiosteal
sclerotic

Nuclear medicine studies


obtain with combination of technetium and
gallium
shown to have highest sensitivity for detecting
infection

Studies
CBC
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 foracid-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%

DDx
Other etiologies of granulomatous infection may have
similar clinical picture as TB and includeatypical
bacteria
Actinomyces israelii
Nocardia asteroids
Brucella

fungi

Coccidioides immitis
Blastomyces dermatitidis
Cryptococcus neoformans
Aspergillosis

spirochetes
Treponema pallidum

Treatment
Nonoperativepharmacologic treatment +/- spinal
orthosis
indications
no neurological deficit
drugs are the mainstay of treatment in most cases

pharmacologic
agents
isoniazid (H), rifampin (R), ethambutol (E) and pyrazanamide
(Z)therapy

regimen
RHZE for 2 months, then RH for 9 to 18 months

spinal orthosis
indications
may be used for pain control and prevention of deformity

Operative
Anterior decompression/corpectomy,
strut grafting posterior instrumented
stabilization posterior column
shortening neurological deficit
Halo traction, anterior decompression,
bone grafting, anterior plating
Pedicle subtraction osteotomy
Direct decompression / internal
kyphectomy

Complications
Deformity(kyphosis/gibbus)
highest risk
after anterior decompression and grafting alone
slippage and breakage of graft (especially if 2 levels)

lowest risk
after both anterior and posterior fusion

Retropharyngeal abscessaffects swallowing/hoarseness


TB arteritis and pseudoaneurysm
Respiratory compromise if there is costopelvic
impingement
Sinusformation
Pott's paraplegia
spinal cord injury can be caused by abscess/bony sequestra or
meningomyelitis
abscess/bony sequestra has a better prognosis than
meningomyelitis as the cause of spinal cord injury

Atypical Spinal
Tuberculosis
definition

compressive myelopathy without visible spinal


deformity, without typical radiological appearance

etiology
intraspinal granuloma, neural arch involvement,
concertina collapse of vertebra body , sclerotic
vertebra with bridging of vertebral body

treatment
laminectomy
indications
extradural extraosseous granuloma
subdural granuloma

decompression and myelotomy


indications
intramedullary granuloma