Noncontiguous spinal tuberculosis: incidence and management

Abstract

Tuberculosis (TB) has a worthy reputation as one of the great mimickers in medicine with a multitude of clinical pictures and variations. Noncontiguous spinal TB is described as atypical and case reports are published as rarities in the mainstream academic journals. The aim of the study was to asses the incidence and review of the management of non-contiguous spinal TB. We identified 16 cases of noncontiguous spinal TB from a single surgeon series of 98 patients, who were managed surgically between 2001 and 2006. These were diagnosed on whole spine MRI. This represents the largest series reported in literature to date and is higher than the expected incidence. Case notes and imaging were retrospectively reviewed in an attempt to ascertain if there were any parameters to differentiate this group from the rest of the TB spine population. Our incidence of noncontiguous spinal TB is 16.3%. There was a higher incidence of neurology in the noncontiguous group (75%) compared to the rest of our group (58.5%). Non-contiguous TB was not found to be a manifestation of HIV, MDR TB or of chronicity in our series. Most noncontiguous lesions were evident on plain radiology. Noncontiguous spinal TB is common in areas of high prevalence such as South Africa. Despite being frequently missed initially, noncontiguous involvement is evident on plain radiography and simply requires a higher index of suspicion. When investigating spine TB patients, simple radiology of the entire spine is mandatory. If available, a full spine sagittal MRI is extremely useful in identifying noncontiguous lesions. Treatment of noncontiguous tuberculosis is as for standard spinal TB cases in our unit with similar outcomes, but care needs to be taken in surgical planning as patients may have multiple areas of neurological compromise.

Fig. 1

Diagnostic testing indicating that histology gave the highest yield with 11 positive, 3 suggestive (granuloma 0 and only 2 negative). When combined with other modalities, 13 were confirmed positive and 2 suggestive

Fig. 2

Distribution of involved vertebral bodies. Noncontiguous in blue and single focus in red

Fig. 3

A 16-year-old girl who presented complaining only of persistent vague neck pain after a fall. Apart from a clinical neck deformity, she was systemically asymptomatic, completely neurologically intact and HIV negative. On MRI, atlanto-axial, subaxial, thoracic and lumbar TB were identified. She was managed by means of anterior cervical surgery and medical management

Fig. 4

A 16-year-old girl who presented complaining only of persistent vague neck pain after a fall. Apart from a clinical neck deformity, she was systemically asymptomatic, completely neurologically intact and HIV negative. On MRI, atlanto-axial, subaxial, thoracic and lumbar TB were identified. She was managed by means of anterior cervical surgery and medical management. Cevical MRI of patient in Fig. 3 demonstrating atlanto-axial and sub-axial involvement

Fig. 5

A 16-year-old girl who presented complaining only of persistent vague neck pain after a fall. Apart from a clinical neck deformity, she was systemically asymptomatic, completely neurologically intact and HIV negative. On MRI, atlanto-axial, subaxial, thoracic and lumbar TB were identified. She was managed by means of anterior cervical surgery and medical management. MRI of case in Fig. 3 depicting thoracic and lumbar involvement