Epidemiology

• Leading cause of morbidity and mortality (10.4 million/years)1

• According to the World Health Organization, tuberculosis causes 1.81
million deaths in Asia each year
• India, Indonesia, China  >4.7 million cases in 20161,2
• 10% patients with extra pulmonary TB have musculoskeletal
involvement  Spine being the most commonly affected site (50%)3

1. World Health Organization. Global tuberculosis report 2017. 2017. http://www. who.int/tb/publications/global_report/en/. Accessed 2017 Dec 14.
2. Public Health England. Tuberculosis in England 2017 report (presenting data to end of 2016). 2017. https://www.gov.uk/government/ uploads/system/uploads/attachment_data/
file/654152/TB_Annual_Report_2017.pdf. Ac- cessed 2017 Dec 14.
3. Gautam MP, Karki P, Rijal S, Singh R. Pott’s spine and paraplegia. JNMA J Nepal Med Assoc. 2005 Jul-Sep;44(159):106-15.
 Pathogenesis
• Mycobacterium tuberculosis  latent and active infection
• Latent : no clinical, bacterial, or radiographic evidence of disease
• Active : result from primary infection/reactivation

• Arises from hematogenous spread from primary infection site to

cancellous bone.
• Usually occur in thoracic and lumbar spine  destruction of vertebral
bodies and intervertebral disc spaces  deformity, mechanical
instability, and neurological deficit4

4. Garg RK, Somvanshi DS. Spinal tuberculosis: a review. J Spinal Cord Med. 2011;34(5):440-54.
Pathophysiology (arterial route) Paradiscal
destruction

Paradiscal Central
Reach the
arteries split subchondral destruction
Intervertebral disc is an
avascular structure on either region of the
side of the upper and lower Anterior
disc end- plates
destruction

Posterior
destruction
 Pathophysiology (venous route)
• Batson’s paravertebral venous
plexus in the vertebra is a valve-less
system

• Allows free flow of blood in both

directions

• Spread of the infection via the

intraosseous venous central vertebral
body lesions
three patterns of spinal involvement
associated with tuberculosis
• Peridiscal  most common form, occurs adjacent to the vertebral
endplate and spreads around a single intervertebral disc as the
abscess material tracks beneath the anterior longitudinal ligament.
The intervertebral disc is usually spared
• Central  occurs in the middle of the vertebral body and eventually
leads to vertebral collapse and kyphotic deformity
• Anterior  infections begin beneath the anterior longitudinal
ligament, causing scalloping of the anterior vertebral bodies, and
extend over multiple levels
HIV in TB spine
• In HIV-negative patients, ONLY 3% to 5% of tuberculosis is skeletal
• Whereas in HIV-positive patients, about 60% of the cases involves
the bone.
• The emergence of AIDs has also significantly increased the incidence
of disseminated Mycobacterium avium complex (MAC) infection
HIV in TB spine
Clinical presentation
• Insidious in onset and progresses at a slow
pace

• Duration of the illness varies from few

months to few years, with average disease
duration ranging from 4 to 11 months

• The manifestation depends on :

- Severity and duration
- Site of the disease
- Presence of complications (abscess,
sinuses, deformity, and neurological deficit)
Clinical presentation
Constitutional symptoms are present in approximately 20–30% of cases
of osteoarticular tuberculosis. The classical constitutional features of
tuberculosis indicating presence of an active disease :
- Malaise
- Loss of weight and appetite
- Night sweats
- Evening rise in temperature
- Generalized body aches
- Fatigue
- night-cries during sleep, as the relaxation of muscle spasms allows for
movement between the inflamed surfaces
 Cold abcess
Stiffness Gibbus

Local Spinal
tenderness deformity

Local pain
Spinal Neurologica
tuberculosis l deficit
Clinical presentation – Back pain
• Back pain - most frequent symptom.

• Varies from constant mild dull aching to severe disabling.

• Pain is typically most common in the thoracic region.

• The pain may be aggravated by spinal motion, coughing, and weight
bearing
Clinical presentation – Neurological Deficit
• Neurologic deficits are common in thoracic and cervical regions.

• Can occur during the early active disease or in the late healed stage.

• Left untreated  complete paraplegia or tetraplegia.

• Paraplegia may occur at any time and during any stage

Pott’s Paraplegia
The three main causes of Pott’s paraplegia are:
• 1) cord compression by abscess and granulation tissue;
• 2) cord compression by sequestrums and the posterior bony edge of
the vertebral body at the level of the kyphosis; and
• 3) bony canal stenosis of the deformed spine above the level of the
kyphosis
 Neurological Deficit
• The incidence of neurological deficit in spinal tuberculosis varies from
23 to 76%
• 10 – 20 % in highly developed nations
• 20 – 41 % in underdeveloped countries, particularly if thoracic spine is
involved.

Crenshaw AH (ed) (1987) Tuberculosis of spine, Campbell’s operative orthopaedics, vol 4, 7th edn. CV Mosby, St. Louis, pp 3326–3342
Clinical presentation – Cold Abscess

• Formation of a cold abscess.

• Abscess formation can grow to a very large size.

• Lack of inflammatory features. Initially forms in the

infective focus
 Clinical presentation – Cold Abscess
The site of cold abscess depends on the
region of the vertebral column affected.
• Cervical spine: Present as
retropharyngeal abscess.
• The abscess may track down to the
mediastinum to enter into the trachea,
esophagus, or the pleural cavity.
• Retropharyngeal abscess  pressure
effects  dysphagia, respiratory
distress, or hoarseness of voice.
Clinical presentation – Cold Abscess
• Thoracic spine : Fusiform paravertebral swelling, track along
intercostal vessels  swelling in the chest wall

• Lumbar spine : swelling in Petit’s triangle or groin. Track down along

the psoas  pseudo-flexion deformity.
Clinical presentation – Spinal Deformity
• Spinal deformity is a hallmark feature of spinal tuberculosis.

• Type depends on the location of the tuberculous vertebral lesion.

• Kyphosis, the most common spinal deformity, occurs with lesions

involving thoracic vertebrae.

• The severity depends on the number of vertebrae involved.

Clinical presentation – Spinal Deformity
• Progressive anterior column destruction  kyphotic deformity of
spine
• Clinical appearance :
• Knuckle (1 vertebra)
• Gibbus (2 Vertebra)
• Rounded Kyphosis (>3 vertebral collapse)
• Kyphotic deformity of > 60o increase the likelihood of developing
neurological sequele
 ABSCESS FORMATION

Cervical Region Thoracal Region Lumbar Region

Pus accumulates Cold abscess usually

presents as a fusiform Most commonly
behind prevertebral
or bulbous para- present as a
fascia to form a vertebral swellings and swelling in the groin
retropharyngeal may produce posterior and thigh
abscess mediastinal lumps
 Abscess Formation
• Batirel et al revealed that abscess formation found in 69% patients (with
the majority paravertebral at 39%)
• The thoracic and lumbar regions are the most favoured by the bacilli with
the incidence of abscess formation in spinal TB being lowest in the
cervical spine

Pertuiset E, Beaudreuil J, Liote F, et al. Spinal tuberculosis in adults. A study of 103 cases in a developed country, 1980–1994. Medicine.
1999;78:309–320.
Batirel A, Erdem H, Sengoz G, Pehlivanoglu F, Ramosaco E, Gülsün S, et al. The course of spinal tuberculosis (Pott disease): results of the
multinational, multicentre Backbone-2 study. Clin Microbiol Infect 2015;21(11):1008.e9-1008.e18.
Clinical presentation – Paediatric spinal TB
• Immaturity and flexibility of spine in children  rapid and severe
deformity progression following vertebral collapse
• In children, even after healing, deformity may progress due to the
growing nature of spine
• The 4 “spine at risk” signs  retropulsion, subluxation, lateral
translation, or toppling. He suggested that children with instability
score of 2 or more had disruption of the posterior facet and advised
surgery in such situations
 Instability

The “spine at risk” signs to identify children at risk for severe deformity include: (A) separation of facet joints
in Lateral radiographs which indicates instability, (B) retropulsion of the posterior part of affected vertebra,
(C) lateral translation of vertebrae in the antero-posterior radiograph, and (D) toppling of one vertebra over
the other vertebra. Here, a line drawn from the anterior surface of the caudal normal vertebra crosses the
mid-point of the anterior surface of the cranial normal vertebra
Clinical presentation – Paediatric spinal TB
• In children with Pott’s disease, the risk of late kyphosis depends on :
• the age (<5 years),
• level of involvement (thoracic),
• extent of the disease (>2 vertebrae),
• endplate damages and
• the pattern of involvement.
• Buckling (invaginating angulatory) collapse of the spine is unique to
childhood spinal tuberculosis at the lower dorsal and dorsolumbar
spine.
 Clinical presentation – Atypical Spinal
Tuberculosis
• Patients without the typical clinical features of axial pain, constitutional symptoms,
kyphosis, or typical radiological features (paradiscal).
• Batson’s perivertebral venous plexus plays a role in skip lesions of spinal TB and is
believed to be one cause for atypical presentations
Atypical radio- graphic patterns :
- Concentric vertebral collapse
- isolated neural arch involvement
- ivory vertebra
- circumferential vertebral involvement
- contiguous or skip vertebral lesions
- multifocal osseous involvement
 Diagnosis
• Definite diagnosis : specimen culture from
biopsy or aspiration  GOLD STANDARD

• Sputum examination and chest radiograph

should be evaluated in any extrapulmonary
TB (WHO)7

7. World Health Organization. Treatment of tuberculosis guidelines. 2010. http:// apps.who.int/iris/bitstream/10665/44165/ 1/9789241547833_eng.pdf?ua51&ua51. Accessed
2017 Dec 14.
 Imaging
• Plain radiograph have no role in early
diagnosis of spinal TB.
• MRI  first line investigation if STB is
suspected.
• detect changes early in the development of
disease.
• Higher sensitivity than x-ray and higher specificity
than CT scan6
• Bone destruction : decreased intensity on T1-
weighted image, increased intensity on T2-
weighted image

6. Rivas-Garcia A, Sarria-Estrada S, Torrents- Odin C, Casas-Gomila L, Franquet E. Imaging findings of Pott’s disease. Eur Spine J. 2013 Jun; 22(Suppl 4):567-78. Epub 2012 Jun 9.
 Tuberculous Spondylitis –
Radiological Findings

Griffith, J. Imaging of Musculoskeletal Tuberculosis: A new look at an old disease. 2002. Clinical orthopedics and related
research.
 Imaging Features that Favor
Spinal TB Rather than Neoplastic
Disease

Griffith, J. Imaging of Musculoskeletal Tuberculosis: A new look at an old disease. 2002. Clinical orthopedics and
related research.
Laboratory Investigations
• complete blood counts including total lymphocyte and CD4 lymphocyte
(helper-inducer T-cell) counts;
• ESR  sensitive marker to monitor therapeutic response
• CRP  more specific in acute infection
• smear and/or culture; histology; detection of specific antigen [22];
metabolic products;
• patient’s antibody response and detection of antibody to M. tuberculosis;
• DNA sequence polymerase-chain reaction (PCR) of M. Tuberculosis 
Gene Xpert MTB/RIF test : fully automated diagnostic test. Result in 90
minuets (95.6% sensitivity, 96.2% specificity)
 Histo - pathology

Granuloma and caseous

appearance, Consists
central zone granular
and acidophilic which is
circled by the epitheloid
cell and Langhans giant
cell with cluster of
lymphosit at the outer
margin of the
granuloma.
MANAGEMENT
• The treatment goals of spinal tuberculosis :
• are primarily to eradicate the infection and to save life.
• Secondly the goals are:
• to provide stability for the affected spine;
• to meet the patient’s aesthetic demand by preventing and/or
correcting spinal deformities (not only for aesthetic purpose
but also for reducing the parafusion segment disease); and
• to prevent or treat paralysis.
NUTRITIONAL
• The goal should be to achieve :
• a serum albumin level >3 g/dL,
• an absolute lymphocyte count >800/mm3 and
• a 24 hours urine creatinine excretion > 10.5 mg in men and >5.8 mg in women
 Chemotherapy
• Multidrug antitubercular treatment -> mainstay of teatment
• Extrapulmonary TB should be treated with use of the same regimens that
are used for pulmonary TB8
• Some specialist suggested longer duration of treatment (up to 18 months)9
• Short course regimens of isoniazid and rifampicin (6-9 mo), were as effective as an
18 mo course10
• There are no clear-cut definitions of good (or rapid) response, poor (or
slow) response and non-response.
• In non-paralytics, a 6- to-8-week assessment (maximum 3 months) is
recommended, whereas in paralytics the assessment should take 3 to 4
weeks.
8. Kandwal PGV, Jayaswal A. Management of tuberculous infection of the spine. Asian Spine J. 2016 Aug;10(4):792-800. Epub 2016 Aug 16
9. Jain AK. Tuberculosis of the spine: a fresh look at an old disease. J Bone Joint Surg Br. 2010 Jul;92(7):905-13.
10. MRC. A 15-year assessment of controlled trials of the management of tuberculosis of the spine in Korea and Hong Kong. Thirteenth Report of the Medical Research Council
Working Party on Tuberculosis of the Spine. J Bone Joint Surg Br. 1998 May;80(3):456-62.
Chemotherapy
Chemotherapy
• the WHO recommends 9 months of treatment where 4 drugs
• Isoniazid
• rifampicin,
• pyrazinamide,
• ethambutol, or streptomycin—are administered in the “initiation” phase for
2 months, followed by isoniazid and rifampicin for 7 months in the
“continuation” phase.
 Treatment

• The aim : eradicate the infection, stabilize the

vertebrae & to correct the khypose
• The combination of chemotherapy or surgical therapy
• INH ( 5-15mg/KgBW/ day ) orally
• Rifampicin ( 10-15mg/KgBW/day ) orally
• Pirazinamid ( 25-35/KgBW/day ) orally
• Ethambutol ( 15-20mg/KgBW/day ) orally
• Streptomycin ( 15-30mg/KgBW/day ) IV
 Surgical treatment

9. Jain AK. Tuberculosis of the spine: a fresh look at an old disease. J Bone Joint Surg Br. 2010 Jul;92(7):905-13.
 TOTAL TX SUBROTO SAPARDAN

9. Jain AK. Tuberculosis of the spine: a fresh look at an old disease. J Bone Joint Surg Br. 2010 Jul;92(7):905-13.
 Surgical treatment
• principles guide the selection of the appropriate surgical approach
for a spinal infection :
• location of the infection,
• presence/absence of abscess,
• extent of bone destruction, and
• need for stabilization

9. Jain AK. Tuberculosis of the spine: a fresh look at an old disease. J Bone Joint Surg Br. 2010 Jul;92(7):905-13.
 Surgical treatment
• Indicated for patient who have not responded to medical therapy, or who have
spinal deformity (kyphosis), mechanical instability, neurological deficit that does
not response with therapy, and for abscess decompression.

• Kyphosis of >30o in children and > 60o in adult --> generally managed operatively9
• It is strongly advised that kyphosis of more than 45˚ not be allowed, as such puts
the posterior spinal muscles at a mechanical disadvantage, adding to the
deforming force.

• Surgical procedure : (1) anterior decompression; (2) posterior stabilization/fusion

9. Jain AK. Tuberculosis of the spine: a fresh look at an old disease. J Bone Joint Surg Br. 2010 Jul;92(7):905-13.
The Hong Kong procedure
• Anterior approach for anterior pathology
• Radical debridement (i.e., corpectomy) and removal of all necrotic
tissue
• Strut grafting or fusion using autograft or allograft, which restores the
anterior column and maintains sagittal balance; fusion rates >95%
(Dietze et al. 1997, Govender et al. 1999)
• Better results when the infection is active (versus “burnt out”)
• Laminectomy alone is contraindicated except in rare cases of isolated
posterior involvement. If done, the surgeon must consider
instrumentation and fusion
 Surgical treatment
• M. tuberculosis has little tendency to adhere to implants which can
be safely used in tuberculous lesions.
• However in HIV positive patients, the use of biomaterials in the
infected foci is inappropriate, because they are susceptible to a
variety of other opportunistic infections [5,17,18].
• Additionally bacteria adhere less to titanium than stainless steel,
because titanium has a less electrochemically active oxide surface
compared to stainless steel

9. Jain AK. Tuberculosis of the spine: a fresh look at an old disease. J Bone Joint Surg Br. 2010 Jul;92(7):905-13.
 Anterior Radical Surgery (Anterior
Debridement and Anterior Fusion)
• However, it later became clear that the only advantage of anterior
fusion is a certain extent of deformity correction and a decreased
tendency for deformity progression.
• The author’s experience suggests that, because of graft failure, the
procedure is not always successful in preventing kyphosis
progression and/or correcting pre-existing kyphosis.

11. Jain AK, Dhammi IK, Jain S, Mishra P. Kyphosis in spinal tuberculosis - prevention and correction. Indian J Orthop. 2010 Apr;44(2): 127-36.
 Surgical treatment
• Anterior decompression11
• used to remove the diseased vertebra and
decompress the neural elements.
• Can be done by a thoracotomy or
posterolateral approach
• Corpectomy cages are often used to
reconstruct the sagital alignment
• Occasionally, osteotomies are indicated

11. Jain AK, Dhammi IK, Jain S, Mishra P. Kyphosis in spinal tuberculosis - prevention and correction. Indian J Orthop. 2010 Apr;44(2): 127-36.
 Posterior Instrumentation and Anterior
Radical Surgery
• Patients presenting late with extensive, multisegment tuberculosis
involving more than two vertebral bodies and kyphosis are suitable
candidates for the two-stage procedure,
• includes posterior stabilizing and corrective instrumental surgery together
with
• anterior radical surgery, under the cover of chemotherapy.

11. Jain AK, Dhammi IK, Jain S, Mishra P. Kyphosis in spinal tuberculosis - prevention and correction. Indian J Orthop. 2010 Apr;44(2): 127-36.
 Posterior Instrumentation
• advantages of posterior spinal instrumentation include:
• Preservation of spinal alignment and restoration of spinal stability following
radical debridement
• Increased fusion rates
• Ability to correct kyphotic deformities
• Avoidance of graft collapse or dislodgement
• Rapid patient mobilization and early rehabilitation without the need for an
external orthosis

11. Jain AK, Dhammi IK, Jain S, Mishra P. Kyphosis in spinal tuberculosis - prevention and correction. Indian J Orthop. 2010 Apr;44(2): 127-36.
Thankyo
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