Spinal tuberculosis is
common in the developing countries and also seen sporadically in
well-developed countries. Lately the incidence is on the increase,
world over, with the emergence of AIDS. About 60 % of cases are
below the age of 20 years in developing countries. In developed
countries the older people are more commonly affected.
20% of the patients have multiple lesions.
Most are caused by
the human strain. The bovine type is probably responsible for less
than 5 %, especially in Europe. Isolated cases due to atypical
mycobacteria are also seen.
there is central coagulative necrosis surrounded by
epitheloid cells, Langhans giant cells(as shown by the arrow
in the picture) and an admixture of lymphocytes and plasma
cells. There may be satellite lesions and perivascular
may involve the vertebra, epidural space, dura, arachnoids,
or spinal cord.
the commonest. It is also the commonest form of skeletal
tuberculosis with an incidence of up to 50% of all skeletal
tuberculosis. In general it is a disease of the young adult in the
developing countries. In developed countries it affects more
commonly, the elderly. Due to the emergence of HIV infection the
incidence of all forms of tuberculosis is further aggravated all
over the world. Both sexes are equally effected.
spinal disease is always secondary to a primary lesion and occurs
due to hematogenous spread. The primary focus may be active or
quiescent and may be in the lungs, mediastinal lymph nodes, kidneys
and other viscera. On an average, an involvement of 3 - 4 vertebrae
at the time of presentation has been reported. As elsewhere, the
spinal tuberculosis is a granulomatous disease. Marked exudative
reaction is a common feature of spinal tuberculosis. A cold abscess
mostly comprised of serum , leucocytes, caseous material, bone
debris and bacilli, penetrates the ligaments and migrates along the
facial planes often presenting far from the site of infection.
there are four types :
discal lesion begins in the metaphysis, erodes the cartilage and
destroys the disc, resulting in narrowing of the disc space.
Central type begins in the midsection of the body which gets
softened and yields under gravity and muscle action, leading to
compression, collapse and bony deformation.
Anterior lesions lead to cortical bone destruction beneath the
anterior longitudinal ligament. Spread of the infection is in the
subperiosteal and sub ligamentous planes resulting in the loss of
periosteal blood supply to the body with resultant collapse. Other
factors such as periarteritis and endarteritis contribute to the
appendicle type, the infection settles in the pedicles, the laminae,
the articular processes or the spinous processes and causes initial
ballooning of the structure followed by destruction.
spondylitis commonly occurs in the thoracic, followed by lumbar and
cervical spines which more often occurs in the pediatrics group.
pain is a predominate (70%) feature with stiff spine and Para
vertebral muscle spasm. A soft tissue swelling or mass is often
obvious. There is 20% incidence of cold abscess and about 90%
incidence of angulations of the spine in the form of kyphosis or
Systemic symptoms may or may not be there.
most serious is the neurological involvement with overall incidence
of about 30% and the deficit depends on the site, the direction of
spread and pathological changes produced. The risk is highest in the
region of cervico-thoracic region.
The cord may be
involved in any phase, the active phase within the first 2 years or
in later years after the disease has become quiescent. The cause in
most cases is compression, which may be an abscess, granulation
tissue, sequestrated bone and disc or pathological subluxation in
In healed diseases
the deficit may be due to transverse ridge of bone anterior to the
cord, due to angulations of the spine or healing, stretching or
attrition of the cord due to spinal deformity and or fibrosis of the
In a given case more
than one factor may contribute to the pathogenesis. Non compressive
causes such as endarteritis, periarteritis or thrombosis of the
arterial supply of the cord.
earlier, cervical spine involvement is rare (1%) more often seen in
children. It is characterized by a more diffuse involvement of the
lower cervical spines the formation of retropharyhngeal abscesses,
often causing respiratory distress. The adult form is usually
confined to a single body and more commonly results in kyphosis and
TB of CV may cause
atlanto axial subluxation, upward translocation of the dens, cervico
medullary compression of tuberculous abscess or direct invasion by
the disease. The disease infiltrates the ligaments which give way.
Incidence of associated lesions vary between 40 - 50%.Simultaneous
involvement of other bones has been reported to be between 12-15%.
Suspicion is the
first step in diagnosis. No diagnostic procedure either singly or in
combination will provide an unequivocal diagnosis.
sedimentation rate is often raised. The mantoux test is generally
A negative mantoux
does not rule out a tuberculoma. ELISA (enzyme linked
immunoabsorbent assay) tests of the serum and CSF may be help.
investigations should include a search for a primary.
CT and MRI have helped
in early diagnosis and follow-up with medical management. Multiple
lesions are often seen.
Plain X-ray :
areas less than 1.5 cm in diameter are not demonstrated. At least
30-40% of calcium should be lost before it shows up as a radio
lucent area on a plain X-Ray. Narrowing of the disc space is the
earliest finding, and when associated with a loss of definition of
the paradiscal margin, the diagnosis is obvious in paradiscal type
which is the commonest type. In central type, the loss of normal
trabeculae may show areas of destruction. Occasionally body may be
ballooned out as a result of the accumulation of inflammatory debris
which expands the weakened cortical bone in the anterior type, the
infection begins beneath the anterior longitudinal ligament. The
front and the sides of the body show erosion. In appendicular type
erosion of the region involved.
In late cases of all
types there is frank erosion and collapse with areas of sclerosis
because and concomitant bone regeneration and fusion of the
vertebral bodies. A tense Para vertebral abscess may cause
scalloping of the vertebral bodies.
In addition to the
focal osseous changes, plain X-Ray may show kyphosis deformity and
lateral curvature when large number of adjacent vertebrae are
involved. Soft tissue shadows may suggest Para vertebral abscess or
extension of tuberculous granulation tissue.
shows body lysis and destruction at an earlier stage more
accurately. Additionally it can depict paraspinal abscess and
granulation tissue distinctly. Enhancement with contrast may aid in
better delineation. CT is also useful during aspiration of suspected
areas of infection.
cervical spine with cold abscess
dorsal spine with cold abscess
neural arch (laminae involvement)
its high resolution, direct multiplanar imaging, detection
of early lesions and also associated lesions such as
abscesses, skip lesions and epi and intradural involvement,
MRI is the obvious choice of investigation. Contrast MRI
aids in better delineation and also in differentiating the
lesion from the surrounding edema. T1 images show decreased
signal from the lesion within the 30 days and narrowing of
the disc space and also loss of signal from the nuclear
pulpous. T2 may show increased signal from the involved body
and the disc narrowing with
normal decreased or increased signal higher than normally
seen. Response to
therapy may be
seen as an increase in the signal intensity of T1 compared
to previous images.
Epidural abcess-MRI T1
therapy is advised by many. Bed rest and antitubercular
therapy alone have been found sufficient in most cases
including early cases of paraparesis. Bed rest is advised
for 4-6 weeks till the pain and spasm disappear and general
They are then allowed to get
up, but wear braces which can be discarded after 6-8 weeks.
chemotherapy is continued for 18 months.
Epidural abcess- MRI T2
is similar to intracranial tuberculosis:
diagnostic Ct guided needle biopsy is routine in well
established centers. Other indications are:
Neurological deficit which is not improving or worsening with in 4
weeks of adequate chemotherapy - Too long a delay may lead to
problems like extradural fibrosis which may be difficult to
Development of progressive neurological signs while on adequate
Rapid onset paraplegia and in patients in an advanced stage of
disease when delay is risky.
Posterior spinal disease (because it is rare).
onset paraparesis - usually the results are less satisfactory in
healed cases. Patients with active disease respond better.
Correction of kyphosis which has not responded satisfactorily to
braces and proper posturing.
Simple drainage of the cold abscess which would be sufficient in
these cases when the tension inside the abscess is the cause of cord
direct approach thro an anterior or lateral route and radical
removal of the compressing elements such as debris, sequestrae or
granulation tissue with or without bone grafting. Medical Research
Council working party on tuberculosis of spine study showed that
fusion occurred earlier and in a higher proportion in the group with
bone graft but at 5 and 10 years there was little difference between
the two. At 10 years there was a small reduction in the angle of
kyphosis in the bone grafted group and a small increase in the angle
in the non grafted series.
some centers in developed countries and in modern Neuro/Orthopedic
practice, instrumentation has a significant place with good results
and early mobilization. The main problem is the formation of a focus
of infection and of course the cost involved. The current trend is
to use instruementation.
Laminectomy is an unsatisfactory procedure except in a few cases
when the compressing element is posterior, a condition seen in
tuberculous disease of the neural arch.
the case of cranio vertebral tuberculosis, urgent skull traction to
reduce the atlanto axial subluxation is mandatory. In some such
closed reduction may not be satisfactory. They require excision of
the diseased bone granulation tissue thro a transoral route followed
by a C1 - C2 posterior Fusion either at the same sitting or at a
are secondary to vertebral lesion. Occasionally we come across a
lesion without any bony lesion. It is likely they are secondary to a
small hidden focus in the adjoining vertebra. The diagnosis is often
made post operatively, as there is nothing specific in X-Ray or in
MRI. The granuloma usually encircles the dura.
and excision followed by a complete course of ATT is the usual
Intradural intramedullary involvement :
less frequent . With absence of any indication of tuberculosis
elsewhere the diagnosis is made with histopathology.
the least common and the diagnosis made with histopathology. Only
eleven cases have been reported.
seen in patients who have had tuberculous meningitis. Treatment is
unsatisfactory. Microsurgical techniques may provide some relief. If
it is localized, intrathecal administration of hydrocortisone or
hyaluronidase have been claimed to be effective.
diagnosis with better imagings and the 2nd line of drugs has
greatly improved the prognosis without necessitating surgery.
Recurrence may be seen if the drug therapy is irregular or
discontinued after a short time, which may be the cause for the
emergence of drug resistant cases, which are on the increase lately.
A number of these cases ultimately respond to continued therapy and
to carefully worked out combinations with or without second line of