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spinal_tuberculosis

Spinal tuberculosis

Spinal tuberculosis is a destructive form of tuberculosis.

Early diagnosis and prompt treatment is necessary to prevent permanent neurological disability and to minimize spinal deformity 1) 2).

see also spinal intramedullary tuberculosis.

Epidemiology

Tuberculosis of the central nervous system accounts for approximately 1% of all cases of tuberculosis and 50% of these involve the spine.

Spinal tuberculosis is more common in children and young adults. The incidence of spinal tuberculosis is increasing in developed nations. Genetic susceptibility to spinal tuberculosis has been demonstrated.


Characteristically, there is destruction of the intervertebral disk space and the adjacent vertebral bodies, collapse of the spinal elements, and anterior wedging leading to kyphosis and gibbus formation. The thoracic region of vertebral column is most frequently affected. Formation of a ‘cold’ abscess around the lesion is another characteristic feature. The incidence of multi-level noncontiguous vertebral tuberculosis occurs more frequently than previously recognized. Common clinical manifestations include constitutional symptoms, back pain, spinal tenderness, paraplegia, and spinal deformities.

Diagnosis

For the diagnosis of spinal tuberculosis magnetic resonance imaging is more sensitive imaging technique than x-ray and more specific than computed tomography. Magnetic resonance imaging frequently demonstrates involvement of the vertebral bodies on either side of the disk, disk destruction, cold abscess, vertebral collapse, and presence of vertebral column deformities.

Neuroimaging-guided needle biopsy from the affected site in the center of the vertebral body is the gold standard technique for early histopathological diagnosis.


The available gadgetry of investigations, such as AFB smear, culture of Mycobacterium tuberculosis, and Uniplex PCR, suffers from a lack of adequate sensitivity and/or a lack of rapidity. Therefore, many times a diagnosis is made either very late in the disease process or sometimes empirical therapy has to be started because a definite diagnosis could not be made. All of these are not ideal situations for a clinician.

MPCR using IS6110, protein b, and MPB64 primers has a high sensitivity and specificity in rapid diagnosis of spinal tuberculosis. This is particularly useful for paucibacillary infections like spinal tuberculosis. However, further studies using large sample sizes are needed to confirm the practical applicability of this technique 3).

Treatment

Antituberculous treatment remains the cornerstone of treatment. Surgery may be required in selected cases, e.g. large abscess formation, severe kyphosis, an evolving neurological deficit, or lack of response to medical treatment. With early diagnosis and early treatment, prognosis is generally good.

Case series

2016

Fifty-nine adult patients with thoracic and thoracolumbar spinal tuberculosis underwent single-stage transpedicular debridement, posterior instrumentation and fusion. These patients were followed for a minimum of 5 years. Patients were assigned to one of two groups according to the infected anatomic segment. In the thoracic spinal tuberculosis group, there were 28 cases (17 males, 11 females) with a mean age of 38.9 years; in the thoracolumbar spinal tuberculosis group, there were 31 cases (19 males, 12 females) with a mean age of 40.3 years. All cases were evaluated clinically using the visual analog scale (VAS), Kirkaldy Willis criteria and the ASIA impairment scale (ASIA). Radiographs were performed for measuring the angle of kyphosis and scoliosis. Complications related to surgery were recorded.

All patients successfully resolved their infections, experienced one or more ASIA grades of improvement, and improved in their VAS pain scores at final follow-up. In both groups, patient-reported outcomes reached over 90% excellent or good results using Kirkaldy-Willis criteria. The loss of kyphotic angle correction was 2.6° in the thoracic spinal tuberculosis group and 3.2° in the thoracolumbar spinal tuberculosis group. No scoliosis was observed in either group. Fifty-eight (98.3%) cases achieved solid bony fusion. In the thoracolumbar spinal tuberculosis group, one patient experienced screw loosening, and another patient with nonunion and rod breakage underwent revision surgery.

The technique of single-stage transpedicular debridement, posterior instrumentation and fusion is an effective method for the treatment of thoracic and thoracolumbar spinal tuberculosis in adults. Long-term postoperative clinical and radiological outcomes were satisfactory 4).

1)
Jain AK. Tuberculosis of the spine: a fresh look at an old disease. J Bone Joint Surg Br 2010;92(7):905–13
2)
Jain AK, Dhammi IK. Tuberculosis of the spine: a review. Clin Orthop Relat Res 2007;460(July):39–49
3)
Sharma K, Meena RK, Aggarwal A, Chhabra R. Multiplex PCR as a novel method in the diagnosis of spinal tuberculosis-a pilot study. Acta Neurochir (Wien). 2017 Jan 21. doi: 10.1007/s00701-016-3065-0. [Epub ahead of print] PubMed PMID: 28110400.
4)
Zhang P, Peng W, Wang X, Luo C, Xu Z, Zeng H, Liu Z, Zhang Y, Ge L. Minimum 5-year follow-up outcomes for single-stage transpedicular debridement, posterior instrumentation and fusion in the management of thoracic and thoracolumbar spinal tuberculosis in adults. Br J Neurosurg. 2016 Jul 8:1-6. [Epub ahead of print] PubMed PMID: 27387195.
spinal_tuberculosis.txt · Last modified: 2017/08/22 18:52 by administrador