Pitfalls in Spondylitis TB

Muhammad Faris, M.D., Ph.D.; Eko Agus Subagio, M.D., Ph.D.; Prof. Abdul Hafid Bajamal, M.D., Ph.D.

Neurospine Division, Department of Neurosurgery, Faculty of Medicine, Universitas Airlangga

Surabaya, Indonesia.
 Diagnostic

• Clinical
• Radiological
• Microbiological
Pitfalls
Treatment

• Medical Therapy
• Surgery
Diagnostic Pitfalls
 Clinical Diagnosis
• Spondylitis TB is a clinical diagnostic, confirmed with
several other additional examination
• Insidious onset
Pitfall: prolonged diagnosis  mean 6.5 (3–12) months
from clinical presentation
• Late diagnosis
Pitfall: worse overall prognosis
Morphological & functional changes in skeletal system are
often irreversible once established

Fuentes Ferrer M, Gutierrez Torres L, Ayala Ramirez O, et al. Tuberculosis of the spine. A systematic review of case series. Int Orthop 2012;36(2):221-31
 Radiologic Diagnosis
• MRI of the spine  best imaging for: TB
• Anatomical abnormalities of the spine and
surrounding structures
• Determine the level of spinal damage
• Follow-up a disease
• Changes in medullary bone
• Infection detection (including spinal TB)

• Pitfall: differentiating in TB vs Pyogenic Pyogenic

(gold standard  histology; invasive)

Yueniwati, Y., & Christina, E. (2017). The challenges in differentiating tuberculous from pyogenic spondylitis using magnetic resonance
imaging. Reports in Medical Imaging, Volume 10, 37–43.
 Radiologic Diagnosis
Tuberculosis
• Abnormal signal in the vertebral body and paravertebral soft
tissue with clear margin
• Paravertebral abscess with regular and thin walls
• Involvement of ≥3 vertebral bodies
• Spreading abscess through the anterior and posterior
subligament
• Location of the lesion on thoracic and lumbar spine
• Normal intervertebral disc
• Absence of contrast enhancement on the soft tissues around
the facet joint.

Yueniwati, Y., & Christina, E. (2017). The challenges in differentiating tuberculous from pyogenic spondylitis using magnetic resonance imaging. Reports in Medical Imaging, Volume 10, 37–43.
 Radiologic Diagnosis
Pyogenic
• Abnormal signal in the vertebral body and
paravertebral soft tissue with unclear margin
• Paravertebral abscess with irregular and thick
walls
• Involvement of ≤2 vertebral bodies
• Location of the lesion on lumbar and cervical
spine
• Abnormal enhancement on intervertebral disc
and soft tissues around the facet joint

Yueniwati, Y., & Christina, E. (2017). The challenges in differentiating tuberculous from pyogenic spondylitis using magnetic resonance imaging. Reports in Medical Imaging, Volume 10, 37–43.
 DIfferential Diagnosis

Pandita, A., Madhuripan, N., Pandita, S., & Hurtado, R. M. (2020). Challenges and Controversies in the Treatment of Spinal Tuberculosis. Journal of Clinical Tuberculosis and Other Mycobacterial Diseases, 100151.
 Microbial Diagnosis
• Modalities  Ziehr-Nielsen staining, microscopic analysis
• Microbial variability hinders accurate diagnosis
• Tuberculous infection of the spine behaves differently from pulmonary TB
• Multiple mycobacterial population:
• Different growth kinetics
• Different growth characteristics
• Osseus area  paucibacillary with more dormant population
Pitfall: harder to kill and retain viability despite chemotherapy

Pandita, A., Madhuripan, N., Pandita, S., & Hurtado, R. M. (2020). Challenges and Controversies in the Treatment of Spinal Tuberculosis. Journal of Clinical Tuberculosis and Other Mycobacterial Diseases, 100151.
 Microbial Diagnosis
• Molecular assays like Xpert MTB/ RIF  rapid detection of TB  less than 2 hours.
• WHO identified diagnostic areas of highest need  Besides rapid sputum test,
DST(drug susceptibility testing), and triage test  a non sputum biomarker was
identified to be of priority
• In extrapulmonary, including spondylitis TB, sputum diagnostics have little utility
unless there is concurrent pulmonary involvement.
• Pitfall: The detection of mycobacteria from samples collected by bone biopsy.

Pandita, A., Madhuripan, N., Pandita, S., & Hurtado, R. M. (2020). Challenges and Controversies in the Treatment of Spinal Tuberculosis. Journal of Clinical Tuberculosis and Other Mycobacterial Diseases, 100151.
Treatment Pitfalls
 Treatment of Spondylitis TB
• Neurologically intact without significant bone destruction are generally treated:
• Biopsy, anti-tuberculous medications, and external bracing.
• Based on present guidelines, it is recommended that anti-tuberculous, consisting of
at least two phases, be administered for a period of at least 12 months.
• Surgical intervention may be indicated for:
• Diagnostic biopsy
• Drainage of a large paraspinal abscess
• Decompression of neural elements
• Correction of spinal deformity
• Stabilization of the spine.

Pandita, A., Madhuripan, N., Pandita, S., & Hurtado, R. M. (2020). Challenges and Controversies in the Treatment of Spinal Tuberculosis. Journal of Clinical Tuberculosis and Other Mycobacterial Diseases, 100151.
 Treatment of Spondylitis TB
• Conventional regiment  HRZE (isoniazid, rifampin, pyrazinamide, ethambutol)
based on determined frequency
Pitfall: penetration of antimicrobial agents
Sclerotic bone may block drug entry  less efficacious

• WHO recommended treatment regimen for extrapulmonary TB patient  Initial

phase (2HRZE) daily or three times weekly  Continuation phase (4HR or 6HE daily)
daily or three times weekly.
Pitfall: close monitoring of patients for development of adverse reactions is necessary 

Pandita, A., Madhuripan, N., Pandita, S., & Hurtado, R. M. (2020). Challenges and Controversies in the Treatment of Spinal Tuberculosis. Journal of Clinical Tuberculosis and Other Mycobacterial Diseases, 100151.
 Surgery
• The indications for surgery in Spondylitis TB:
• Cases with neurologic deficit
• Huge paravertebral abscess and compressing the neural structure
• Spine instability due to kyphotic deformity (kyphotic angles of 50O to 60O or more which is likely to
progress)
• Resistance to the current antituberculosis drugs (association with the presence of HIV infection)
• To prevent or treat complications such as late-onset paraplegia
• Pitfall: delayed surgery can cause severe kyphosis, leading to respiratory system dysfunction,
painful costo-pelvic impingement, and paraplegia.
Recommendation: to perform early surgical intervention to prevent significant spinal instability and
neurologic deficit

Rasouli MR, Mirkoohi M, Vaccaro AR, Yarandi KK, Rahimi-Movaghar V. Spinal tuberculosis: diagnosis and management.  Asian Spine J. 2012;6(4):294-308.
 Surgery
• The following techniques are currently used for the treatment of Spondylitis TB:
1. Posterior decompression and fusion with bone autografts
2. Anterior debridement/decompression and fusion with bone autografts
3. Anterior debridement/decompression and fusion, followed by simultaneous or sequential posterior fusion
with instrumentation
4. Posterior fusion with instrumentation, followed by simultaneous or sequential anterior
debridement/decompression and fusion

• Types of approach:
• Single stage anterior only (AO)
• Single stage posterior only (PO)
• Combined anterior and posterior (AP)
Rasouli MR, Mirkoohi M, Vaccaro AR, Yarandi KK, Rahimi-Movaghar V. Spinal tuberculosis: diagnosis and management.  Asian Spine J. 2012;6(4):294-308.
 Surgery
Paraspinal & epidural abscess
• May resolve with drugs alone
• However, some still need surgery
• Challenge: when to operate?
early? watchful waiting with drugs?
• Pitfall
• Later surgery, worse outcome
• Drug-resistance  no significant clinical improvement after adequate therapy for at
least 2–3 months or persistent growth of MTB at other sites beyond 2 months of
therapy.
• Failure to estimate timing of surgery

• Surgical drainage is therefore reserved for worsening abscess or

mechanical pressure related symptoms owing to their size or location
Stratton A, Gustafson K, Thomas K, James MT. Incidence and risk factors for failed medical management of spinal epidural
abscess: a systematic review and meta- analysis. J Neurosurg Spine 2017;26:81–9.
Surgery
 Surgery
• The posterolateral or transpedicular approach has been
used extensively for the management of spinal TB.
• This approach is a viable and importantly a safe surgical
option for ventral decompression in thoracic spine TB
when followed by anti-tuberculosis treatment for 18
months and immobilization for 3 months.
• Pedicle screw fixation has also been advocated

Rasouli MR, Mirkoohi M, Vaccaro AR, Yarandi KK, Rahimi-Movaghar V. Spinal tuberculosis: diagnosis and management. Asian Spine J. 2012;6(4):294-308.
 Surgery
• The anterolateral approach is feasible and safe and provides 360O exposure for lesions located in
the spine from the second thoracic vertebra down to the fifth lumbar vertebra.
• Using this approach, anterior debridement, decompression, bone grafting (anterior or posteriorly),
posterior implant fixation, and kyphosis correction are all options.
Pitfall: anterior instrumentation in the presence of active disease can be dangerous and may fail
or be associated with additional complications.
Recommendation: instrumented stabilization in a tubercular infected bed seems to be safe if
meticulous debridement is performed.

Rasouli MR, Mirkoohi M, Vaccaro AR, Yarandi KK, Rahimi-Movaghar V. Spinal tuberculosis: diagnosis and management. Asian Spine J. 2012;6(4):294-308.
 Surgery
• The combined approach may yield better outcomes and prevent future kyphosis more efficiently
• Combined approaches can be performed in two ways:
1. Anterior-posterior, anterior debridement/decompression and fusion is performed first
2. Posterior-anterior, posterior fusion with instrumentation is the first stage.
• One-stage surgical management in children with Spondylitis TB by anterior decompression and
posterior instrumentation  feasible and effective
• A biomechanical view point  anterior nor posterior approaches alone can stabilize the spinal
column as well as combined approaches in cases of Spondylitis TB.

Rasouli MR, Mirkoohi M, Vaccaro AR, Yarandi KK, Rahimi-Movaghar V. Spinal tuberculosis: diagnosis and management. Asian Spine J. 2012;6(4):294-308.
 Surgery
• Combined anterior and posterior fusion is sometimes preferred in young
cases without significant co-morbidities with either of the following
indications:
1. Both anterior and posterior involvement
2. More than three segments involved
3. Significant degree of kyphosis associated with overt destruction of one or two
vertebral bodies
4. Thoracolumbar junction involvement.

Rasouli MR, Mirkoohi M, Vaccaro AR, Yarandi KK, Rahimi-Movaghar V. Spinal tuberculosis: diagnosis and management. Asian Spine J. 2012;6(4):294-308.
 Surgery
• In adults, the progression of kyphosis after healing is rare.
• Children are at risk of severe kyphosis for they continue to have significant
changes in the growing spine even after the disease is healed.
• The risk for late onset paraplegia resulting from long standing kyphosis is
more relevant in childhood TB
• Prediction scores have been used and early surgical management may be
required in the active stage of the disease to prevent such complications

Pandita, A., Madhuripan, N., Pandita, S., & Hurtado, R. M. (2020). Challenges and Controversies in the Treatment of Spinal Tuberculosis. Journal of Clinical Tuberculosis and Other Mycobacterial Diseases, 100151.
 Surgery
• Certainly, to achieve the best results, the surgical treatment of choice for each patient should be
individualized, the following factors could be helpful in order to select the approach:
1. Patient's age
2. Presence of medical co-morbidities
3. Location of bony destruction (anterior, posterior or both)
4. Location of the compressive lesion with respect to the dura (anterior, posterior or both)
5. Density of the compressive lesion (pus or solid extradural lesion)
6. Patient's bone stock
7. Number of segments involved
8. Degree of kyphotic deformity
9. Region of involvement (craniovertebral junction, cervical, cervicothoracic junction, thoracic, thoracolumbar
junction, upper lumbar, cauda equina)
Rasouli MR, Mirkoohi M, Vaccaro AR, Yarandi KK, Rahimi-Movaghar V. Spinal tuberculosis: diagnosis and management. Asian Spine J. 2012;6(4):294-308.
 Follow up
• In 2016, Central Tuberculosis Division of India came out with a new set of
recommendations specifically pertaining to spondylitis TB:
• The standard of care is follow up serial X-rays every 3 months or so and based on
clinical response
• Repeat MRI at 6, 9, 12 and 18 months with imaging features to be interpreted in light
of clinical response
• Follow ups are suggested about every 6 months for a total of two years

Pandita, A., Madhuripan, N., Pandita, S., & Hurtado, R. M. (2020). Challenges and Controversies in the Treatment of Spinal Tuberculosis. Journal of Clinical Tuberculosis and Other Mycobacterial Diseases, 100151.
Case
• A 15-years old girl with one month history
of progressive paraplegia. She initially
complained with neck pain, gradual
weakness of the lower extremities, and
hypoesthesia in the level of below T4.

• We performed an adequate
decompression and debridement,
maintenance and reinforcement of
stability, and correcting the deformity with
single stage posterior approach only.
Case
• MR imaging of axial and sagittal sections
showed a large paravertebral abscess in the
anterior of the level vertebral C5 to T3.

• In the sagittal section, vertebral body

destruction and spinal cord compression at
the level of the Cervicothoracic Junction.
Case
• Preoperative MRI and postoperative radiograph
demonstrated decreased of the Cobb angle from
42° to 11° and the Sagittal Vertical Axis (SVA) from
5.9 cm to 1.9 cm that resulted in improved
kyphotic deformity.

• Pitfall:
 Small pedicle diameter in the patient (15 years old)
 Small lateral mass width
 Manual maneuver correction of the cervical lordotic
 Severe spinal cord compression
Case
Case

Pre-operative Post-operative
Conclusion
• Careful evaluation is necessary to identify lesions spondylitis TB that can lead to mistaken
diagnosis and treatment.
• Key aspects of the historical clinical presentation, diagnostic and provocative examination of the
patient, and anatomical understanding should be considered of primary importance in the
evaluation of spondylitis TB.
• Delays in determining diagnosis and treatment result in the higher rate of complications such as
spinal cord compression and spinal deformity.
• The indication for each surgical procedure remains unclear, the safety and the pitfall that can
occur, neurological outcomes and complication rates of surgical intervention for spondylitis TB.
Thank you