Tuberculosis of the Spine

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Overview

Tuberculosis (TB) is a contagious bacterial infection caused by Mycobacterium tuberculosis. While TB commonly affects the lungs, it can also target other parts of the body, including the spine. When TB infects the spine, it can lead to a condition known as Pott’s disease or Pott’s spine. Understanding the causes, symptoms, diagnosis, and treatment of tuberculosis of the spine is crucial for effective management and prevention of complications.

 

Causes and Risk Factors:

Tuberculosis of the spine is primarily caused by the spread of Mycobacterium tuberculosis bacteria through the bloodstream or lymphatic system. The bacteria typically enter the body through the inhalation of respiratory droplets expelled by someone with active TB. Once inside the body, the bacteria can travel to the spine and infect the bones and tissues, leading to Pott’s disease.

Several factors can increase the risk of developing tuberculosis of the spine:

Immune System Weakness: Individuals with weakened immune systems, such as those living with HIV/AIDS or undergoing immunosuppressive therapy, are at higher risk of developing TB.

Close Contact with Infected Individuals: Close and prolonged contact with someone who has active TB increases the likelihood of transmission.

Poor Living Conditions: Overcrowded and poorly ventilated living spaces facilitate the spread of TB bacteria.

Malnutrition: Poor nutrition can weaken the immune system, making individuals more susceptible to TB infection.

 

Symptoms and Clinical Presentation:

The symptoms of tuberculosis of the spine can vary depending on the severity and location of the infection. Common clinical manifestations include:

Back Pain: Persistent and worsening pain in the back, often localized to the affected area of the spine.

Stiffness: Difficulty in bending or moving the spine, especially in the morning or after prolonged periods of inactivity.

Neurological Symptoms: As the infection progresses, it can compress the spinal cord or nerve roots, leading to neurological deficits such as weakness, numbness, or tingling sensations in the limbs.

Deformity: Severe cases of Pott’s disease can result in spinal deformities, visible changes in posture, or the formation of abscesses around the spine.

 

Diagnosis

Diagnosing tuberculosis of the spine typically involves a combination of clinical evaluation, imaging studies, and laboratory tests. Healthcare providers may perform the following diagnostic procedures:

Medical History and Physical Examination: Healthcare providers will inquire about the patient’s symptoms, medical history, and potential exposure to TB. A thorough physical examination may reveal signs of spinal tenderness, deformity, or neurological deficits.

Imaging Studies: X-rays, MRI scans, or CT scans are commonly used to visualize the affected area of the spine and assess the extent of bone destruction, spinal cord compression, or abscess formation.

Laboratory Tests: Laboratory tests, such as sputum culture, PCR (polymerase chain reaction), or biopsy, may be performed to confirm the presence of Mycobacterium tuberculosis bacteria in the spinal tissues.

 

Orthopedic treatment 

Literature has shown studies that aim to determine the timing and reasons for surgery in spinal tuberculosis and to evaluate the efficacy of different surgical approaches in addressing kyphosis and neural outcomes. In instances of spinal tuberculosis, surgery is advised to tackle the difficulties in diagnosis, the neurological effects, and to halt the advancement of kyphosis.

The spinal cord can tolerate a canal’s encroachment of up to 76% in a typical neurologic condition since it can endure compression that increases gradually.

Nonoperative therapy has shown positive results in patients who have edema/myelitis with primarily fluid compression on MRI, but whose cord size remains largely intact.

However, individuals with cord edema/myelitis or myelomalacia, as well as extradural compression caused by granulation tissue with minimal fluid component, require early surgical decompression.

Two common procedures for decompression of the spine are extrapleural anterolateral decompression and transthoracic transpleural anterior decompression, with comparable outcomes in the dorsal spine. When post-debridement deficiencies exceed two disc gaps, instrumented stabilization may be necessary to prevent graft-related problems in short-segment illness.

However, even with instrumented stabilization, progression of kyphosis can still occur, especially in long-segment illness, so it is essential to closely monitor the situation. Correcting severe kyphosis after healing requires multiple surgical steps and is a risky procedure. Therefore, prospective studies are necessary to define the surgical approach, stages, issues, and challenges of kyphosis correction in spinal TB.

Spinal TB affects up to 50% of patients with musculoskeletal TB, with the anterior column being affected in 98% of these cases. Between 10% and 47% of spinal TB patients experience neural complications, and many develop varying degrees of kyphotic deformity.

The primary objectives of treating spinal tuberculosis are to eliminate the infection, prevent further worsening of angular deformities, and recover from any neurological deficits. The approach to treating spinal TB has evolved over the past 50 years, thanks to advancements in imaging, surgical techniques, and implants. The focus now is on healing the lesion while minimizing spinal deformity, as opposed to previous approaches that aimed to heal the lesion with residual deformity.

General Treatment of Spinal TB

The objectives of the treatment include verifying the diagnosis, eradicating the lesion through bacterial means, addressing spinal cord compression and its associated effects, and managing spinal deformity and its potential consequences, such as the onset of paraplegia in later stages.

Clinical and radiographic examination is a dependable approach for identifying spinal tuberculosis. In situations where the clinical or radiological evidence is not conclusive, a surgical decompression should be performed to obtain adequate tissue for histopathological evaluation and to confirm the diagnosis.

The compromised immunity in numerous HIV-positive individuals and the pathogenic organism’s resistance to therapy have resulted in a renewed outlook on the treatment of spinal TB.

Recent progress in spine reconstruction and instrumentation has provided patients with access to advanced treatment alternatives. Patients with severe neurological deficits were limited to radical resection of the tuberculosis-infected focus and bone grafting as the only available treatment options in the past.

Nevertheless, early diagnosis has become possible with the advent of modern imaging modalities such as CT and MRI. Advanced spinal TB patients in developing nations can now receive nonoperative treatment due to the availability of more powerful antituberculosis therapy regimens.

A patient with TB of the spine who receives non-operative treatment should be regarded as a nonresponder and surgery should be strongly considered if they develop a new lesion or do not exhibit an adequate clinical radiographic healing response.

When a patient with a deep-seated vertebral tubercular lesion should be classified as a nonresponder requires agreement among researchers. The surgery is necessary to make the diagnosis, lessen the disease burden, and obtain enough tissue for culture and sensitivity tests.

If a patient with spinal TB undergoes non-operative treatment but does not show adequate clinical radiographic healing or develops a new lesion, surgery should be strongly considered. However, there is a need for agreement among researchers on when to classify a patient with a deep-seated vertebral tubercular lesion as a nonresponder. Surgery is necessary to diagnose the condition, reduce the disease burden, and collect sufficient tissue for culture and sensitivity tests.

For the past 50 years, two surgical treatment strategies for spinal TB have been used: universal extirpation surgery and limited surgery with specific indications. Current antitubercular medications have made it possible to sterilize the lesion, eliminating the need for universal surgery.

A study by the British Medical Research Council found that both the Hong Kong procedure (anterior radical resection and débridement with fusion) and nonoperative treatment produced positive outcomes, but developing nations lack the resources for fusion surgery. Patients with a higher number of affected vertebrae may experience some kyphosis before the lesion heals, and before brace support is needed.

Spinal Instability

Spinal instability occurs when both columns of the spine are compromised, such as in spinal trauma or vertebral fractures. Chronic inflammation like that caused by tuberculosis may not necessarily make the spine unstable due to the healing response of the tissues. However, if an infection process and a mechanical insult occur together, the spine can become unstable.

When tuberculosis damages the facets and posterior complexes, the spine becomes unstable, resulting in a neurological deficit. These lesions should be recognized on AP radiographs, and if imaging shows destruction of both columns of the vertebral bodies, the spine should be stabilized. Patients with significant kyphosis or long-segment disease may also require stabilization.

Neurologic Involvement

Neurologic complications in the spine can be caused by cord compression, instability, intrinsic factors, and infective thrombosis/endarteritis. Pus, granulation tissue, caseous tissue, discs, or bony sequestra can compress the spinal cord, but there may not always be a correlation between cord compression and neural deficits.

Instability can be caused by pathological subluxation or dislocation due to pan vertebral illness. Intrinsic factors such as cord edema, myelomalacia, and direct affectation of the meninges and spinal cord can also lead to neural complications. Infectious thrombosis or endarteritis can also cause neural complications, but a combination of factors may result in less severe canal compromise and neural complications.

Our Goal at Complete Orthopedics

Spinal TB can cause devastating effects such as paralysis and deformity, and its prevalence is increasing worldwide, especially among immunocompromised individuals. Despite advances in understanding and treatment, the incidence of paraplegia and spinal deformity remains around 20%.

Gross kyphosis can lead to pulmonary and cardiac complications, and while chemotherapy may render the disease inactive, vertebral collapse can persist until the bone matures into a bone block indicating healing. However, significant advancements in TB chemotherapy and spinal canal decompression have improved outcomes, and with early diagnosis and treatment, excellent results can be achieved.

The goal of treating kyphosis caused by spinal TB is to achieve as close to a normal kyphosis as possible. However, since the dorsal spine naturally has a kyphosis of 10° to 20°, a correction may not always be necessary. Dorsolumbar kyphosis can cause compensatory lumbar lordosis and may only require minor correction.

In a study of 28 cases, a surgical approach involving posterolateral decompression and anterior interbody fusion was used to correct an average kyphosis of 40.2° from a preoperative mean of 64.3°. More research is needed to determine the best surgical approach, steps, stages, and challenges for correcting kyphosis of 60° or more.

You have arrived at the appropriate location if you want to learn more about Tuberculosis of the Spine.

Do you have more questions? 

How does tuberculosis of the spine differ from tuberculosis in other parts of the body?

Tuberculosis of the spine, also known as Pott’s disease, specifically affects the bones and tissues of the spine. It can lead to spinal deformity, neurological deficits, and chronic back pain. While the underlying bacteria causing the infection is the same, the manifestation and complications differ due to the unique anatomy and function of the spine.

Can tuberculosis of the spine spread to other parts of the body?

Yes, tuberculosis of the spine can lead to systemic complications if left untreated. The infection can spread to adjacent vertebrae, soft tissues, or nearby organs, causing abscess formation, spinal cord compression, or dissemination of bacteria through the bloodstream.

Is tuberculosis of the spine contagious?

Tuberculosis of the spine itself is not contagious, but the underlying Mycobacterium tuberculosis bacteria responsible for the infection can be transmitted from person to person through respiratory droplets. Close and prolonged contact with someone who has active tuberculosis increases the risk of transmission.

What are the potential complications of untreated tuberculosis of the spine?

Untreated tuberculosis of the spine can lead to severe complications, including spinal deformity, neurological deficits, paralysis, abscess formation, spinal cord compression, and disseminated tuberculosis affecting other organs of the body.

How is tuberculosis of the spine diagnosed?

Diagnosis of tuberculosis of the spine typically involves a combination of medical history, physical examination, imaging studies (X-rays, MRI scans, CT scans), and laboratory tests (sputum culture, PCR, biopsy) to confirm the presence of Mycobacterium tuberculosis bacteria in the spinal tissues.

What is the duration of antibiotic treatment for tuberculosis of the spine?

The duration of antibiotic treatment for tuberculosis of the spine varies depending on the severity of the infection and the response to therapy. Typically, patients receive a combination of antibiotics (isoniazid, rifampin, pyrazinamide, ethambutol) for six to twelve months to ensure complete eradication of the bacteria.

Are there any alternative treatments for tuberculosis of the spine besides antibiotics and surgery?

While antibiotics and surgery are the mainstays of treatment for tuberculosis of the spine, adjunctive therapies such as physical therapy, pain management, and nutritional support can help optimize patient outcomes and promote rehabilitation.

What are the potential risks and benefits of surgical intervention for tuberculosis of the spine?

Surgical intervention for tuberculosis of the spine carries risks such as infection, bleeding, nerve injury, and anesthesia complications. However, surgery can also provide significant benefits, including decompression of neural structures, stabilization of the spine, correction of deformities, and restoration of spinal function.

How long is the recovery period after surgical treatment for tuberculosis of the spine?

The recovery period after surgical treatment for tuberculosis of the spine varies depending on the extent of the surgery, the severity of the infection, and individual patient factors. Generally, patients may need several weeks to months to recover fully and regain strength and mobility.

Is tuberculosis of the spine more common in certain populations or geographic regions?

Tuberculosis of the spine can occur in people of all ages and ethnicities, but it is more prevalent in regions with high rates of tuberculosis and socio-economic disparities. Factors such as overcrowded living conditions, poor nutrition, and inadequate access to healthcare contribute to the increased risk of tuberculosis of the spine in certain populations.

Are there any dietary recommendations for individuals with tuberculosis of the spine?

Nutritional support is crucial for individuals with tuberculosis of the spine to promote healing, strengthen the immune system, and prevent complications. A balanced diet rich in protein, vitamins, and minerals can help support recovery and enhance the effectiveness of antibiotic therapy.

Can tuberculosis of the spine recur after treatment?

Yes, tuberculosis of the spine can recur after treatment, especially if antibiotic therapy is incomplete or if there is poor adherence to follow-up care. Close monitoring, regular medical evaluations, and adherence to prescribed treatment regimens are essential for preventing recurrence of tuberculosis of the spine.

Can tuberculosis of the spine cause permanent disability?

In severe cases, tuberculosis of the spine can lead to permanent disability, including spinal deformity, paralysis, and neurological deficits. However, early diagnosis, prompt treatment, and appropriate rehabilitation can minimize the risk of long-term disability and optimize functional outcomes.

How effective is the Bacille Calmette-Guérin (BCG) vaccine in preventing tuberculosis of the spine?

The Bacille Calmette-Guérin (BCG) vaccine provides partial protection against tuberculosis, including severe forms of the disease such as TB meningitis and miliary TB, in children. While the BCG vaccine can reduce the risk of certain TB complications, it does not provide complete immunity and is not routinely recommended for preventing tuberculosis of the spine in adults.

How can healthcare providers differentiate tuberculosis of the spine from other spinal conditions with similar symptoms?

Healthcare providers differentiate tuberculosis of the spine from other spinal conditions through a thorough medical history, physical examination, imaging studies, and laboratory tests. Key differentiating factors include the presence of risk factors for TB, characteristic radiographic findings, and confirmation of Mycobacterium tuberculosis infection through laboratory testing.

Are there any support groups or resources available for individuals with tuberculosis of the spine?

Yes, there are support groups, patient advocacy organizations, and online resources available for individuals with tuberculosis of the spine and their caregivers. These resources provide information, education, peer support, and practical assistance to help navigate the challenges of living with and managing tuberculosis of the spine.

What are the long-term prognosis and outcomes for individuals with tuberculosis of the spine?

The long-term prognosis and outcomes for individuals with tuberculosis of the spine depend on various factors, including the severity of the infection, the extent of spinal involvement, the timeliness of diagnosis and treatment, and individual patient factors. With early diagnosis, appropriate treatment, and comprehensive rehabilitation, many patients with tuberculosis of the spine can achieve favorable outcomes and resume normal activities.

Can tuberculosis of the spine affect children and adolescents?

Yes, tuberculosis of the spine can affect individuals of all ages, including children and adolescents. However, the clinical presentation and management of tuberculosis of the spine in pediatric patients may differ from adults, requiring specialized care and considerations for growth and development.

Is there ongoing research or clinical trials investigating new treatments for tuberculosis of the spine?

Yes, there is ongoing research and clinical trials investigating new treatments, diagnostic methods, and preventive strategies for tuberculosis of the spine. These studies aim to improve outcomes, reduce treatment duration, minimize side effects, and address challenges such as drug resistance and treatment adherence in individuals with tuberculosis of the spine.

How can individuals reduce their risk of contracting tuberculosis of the spine?

Individuals can reduce their risk of contracting tuberculosis of the spine by practicing good hygiene, avoiding close contact with individuals diagnosed with active TB, maintaining a healthy lifestyle, seeking timely medical evaluation for symptoms suggestive of TB, and adhering to recommended vaccination and preventive therapy guidelines.

I am Vedant Vaksha, Fellowship trained Spine, Sports and Arthroscopic Surgeon at Complete Orthopedics. I take care of patients with ailments of the neck, back, shoulder, knee, elbow and ankle. I personally approve this content and have written most of it myself.

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