Tuberculous Spondylitis

Overview

Incidence and prevalence

TB remains a major public health problem. There are 40 million active cases with 8-10 million cases per year. 5 -15 % of the estimated 2-3 billion people infected with TB will develop the disease during their lives.  Out of these figures, 10% will have incidence skeletal involvement and a 50% involvement with Spine

Effects of TB

Economic Impact on developing nations

Tuberculosis remains endemic in most developing countries and affects patients of all ages. Delay in diagnosis and management causes spinal cord compression and spinal deformity. A common result is back pain and loss time from work

Patient and Environmental risk factors

Mortality rates are highest in Africa and Southeast Asia and least in Europe and North America

In Africa, areas of civil unrest, strife and refugee camps with poor hygiene, poor neighborhoods with cramped quarters producing very young, old and immunocompromised patients with a high risk of HIV, Drug abuse, Malnutrition. FOCOS Cases from Sierra Leone and Ethiopia have advanced stages of spinal deformities with varying levels of neurologic compromise

TB of the Spine – (POTTS Disease)

This is the oldest disease with evidence found in Egyptian mummies (4000BC) and was first described by English surgeon Percival Pott. 1-2% of overall TB cases affect the spine, 10% of all skeletal involvement and 50% involves the spine with a breakdown of:

• Cervical (12%);
• Dorsal (42%);
• Lumbar (26%);
• Junctional disease (20%)

Diagnosis

Symptoms of spinal TB—Back pain, weakness, weight loss fever fatigue and malaise

Symptoms of Craniocervical junction TB – Severe neck pain, restricted neck movements and myelopathy

TB Pathophysiology:

• Peridiscal – 50%
• Metaphyseal, eroding thru endplate, extending around disc to infect adjacent vertebra

Early Intervention

1. Early initiation of appropriate medical regimen can reduce need for surgery and neurologic complications
2. Should be combined with proper counseling of patient and family members

Radiographic studies

• Palin X-rays; CT scan; MRI and Bone scan
• Blood cultures rarely yield positive results (33%)

Medical management

Vast majority can be managed with excellent results

• Four drug regimen
  1. INH, rifampin, Ethambutol, pyrazinamide (PZA)
  2. Ethambutol can be discontinued once CX show susceptibility to other drugs
  3. PZA usually discontinued after 8 week
  4. Treat for minimum of 6 months up to 12 months
  5. Supplement with external immobilization
• A standardized multi-Drug- Resistant (MDR) regimen of 9 months (excluding pregnant women) with pulmonary MDR /RR-TB
• Bedaquiline and/or Delamanid for the treatment of M/XDR–TB as part of expanded access, with reasonable results

2. Medical Review:
   • In a 15-year Prospective Study of 61 Children Treated with Ambulatory Chemotherapy, one study’s authors reported that notable morphological changes occurred in both the kyphosis fusion mass and the uninvolved levels above and below the lesion in children with healed spinal tuberculosis.
   • These changes occurred during growth, after complete healing of the disease was achieved, and were responsible for the variability in progression of the deformity during growth seen in these children.
   • Results imply that all children with spinal tuberculosis must be followed up regularly till the entire growth potential is completed.
3. Surgical Indications
   • Elective surgery for progressive deformity or instability
   • Semi Urgent-Early- impending neurologic deficits
   • Urgent-Immediate-Now – Rapid neurologic deterioration under observation or at initial presentation
4. Spinal Deformity
   • Kyphosis is the most common deformity as the disease is mainly anterior although scoliosis is also seen
   • Thoracic spine in involved in the majority of cases
   • Deformity with active wet lesions have mobile apex more likely to collapse into a Kyphosis
   • Deformity with healed dry lesions present with a rigid apex and slow progression
5. Use of metal implants in Spinal TB treatment: Current Concepts
   • Posterior instrumentation is a useful adjunct for correction of deformities and protection of large structural bone grafts from dislodging and collapse
   • Anterior instrumentation in the presence of infection is not contraindicated and helps in bone graft stability and healing
   • Allografts and cages can be used effectively
   • Patients treated by anterior fusion alone showed the worst results with respect to the kyphotic angle. This was especially true when the lesion was located in the thoracic spine and several segments were involved.
6. Surgical Techniques

Anterior procedures:

1. Mostly in the presence of epidural extension of abscess with neurologic compromise
2. Thoracotomy or thoracoabdominal approach may be utilized to access the lesion
3. Retroperitoneal approach is indicated for evacuation of Psoas abscess

Posterior approaches

1. Most common and feasible and familiar
2. Allows canal decompression and stabilization
3. When combined with vertebrectomy or vertebral column resection enable both column exposure and stabilization with structural grafts and segmental instrumentation

Combined anterior posterior procedures

1. Indicated for spinal instability of all 3 columns with associated deformity
2. When posterior stabilization is needed in addition to anterior evacuation of psoas abscess.

3. FOCOS Reviews

   • A retrospective review of 166 patients aged between 2 to 30 years at the FOCOS hospital in Ghana including 26 Ghanaians, 36 Ethiopians and 104 Sierra Leones. Average preoperative local kyphosis of 108 degrees was corrected to 60⁰ Major Complications occurred in 16 patients and included Post Operation Infection in 5patients, neurologic deficit in 3 patients, implant failure in 5 patients and 3 deaths. Of the eleven patients with preoperative gait disturbances, four improved to normal gait, five remained the same and two showed deteriorations of their walking ability to non-ambulating level

Conclusion

1. Tuberculosis continues to ravage underserved and underdeveloped nations of the world with significant medical morbidity and disability
2. The era of modern medical management has improved patient outcomes using the 4 drug regimen.

• Surgical treatment is reserved for patients with progressive neurologic deficits, severe spinal deformity or instability and in young children with progressive Kyphosis

1. For the most part posterior procedures will stabilize the deformity and even afford decompression of neural elements. Anterior procedures are best for epidural and anterior abscess evacuation.
2. Segmental instrumentation is not contraindicated in these infections and has been shown in various studies including the FOCOS reviews to be efficacious and safe in the management of these conditions with associated deformities with favorable outcome

References:

Late treatment of tuberculosis-associated kyphosis: literature review and experience from a SRS–GOP site. Boachie-Adjei O, Papadopoulos EC, Pellisé F, et al: Eur Spine J. 2013 Jun;22 Suppl 4:641-6. doi: 10.1007/s00586-012-2338-4. Epub 2012 May 25. Review.

Morphological Changes During Growth in Healed Childhood Spinal Tuberculosis A 15-year Prospective Study of 61 Children Treated With Ambulatory Chemotherapy. Rajasekaran S, J Pediatr Orthop. 2006 Nov-Dec;26(6):716-24.Growth changes of solidly fused kyphotic bloc after surgery for tuberculosis. Comparison of four procedures.
Schulitz KP, Spine. 1997 May 15;22(10):1150-5. 
Department of Orthopaedics, Heinrich-Heine-University, Dusseldorf, Germany.

Cochrane Database Syst Rev. 2006 Jan
Routine surgery in addition to chemotherapy for treating spinal tuberculosis

J Pediatr Orthop. 2006 Nov-Dec;26(6):716-24. Rajasekaran S,
Morphological Changes During Growth in Healed Childhood Spinal Tuberculosis A 15-year Prospective Study of 61 Children Treated With Ambulatory Chemotherapy.

The natural history of post-tubercular kyphosis in children. Radiological signs which predict late increase in deformity.
 Tuberculosis Research Centre, Chennai and Ganga Medical Centre, Coimbatore, India. Rajasekaran S.
J Bone Joint Surg Br. 2001 Sep;83(7):954-

Author

Prof. Oheneba Boachie-Adjei

CEO, FOCOS Orthopedic Hospital

Orthopedic Surgeon, FOCOS Orthopedic Hospital