Management of Tuberculous Infection of the Spine

Abstract

Spinal tuberculosis accounts for nearly half of all cases of musculoskeletal tuberculosis. It is primarily a medical disease and treatment consists of a multidrug regimen for 9-12 months. Surgery is reserved for select cases of progressive deformity or where neurological deficit is not improved by anti-tubercular treatment. Technology refinements and improved surgical expertise have improved the operative treatment of spinal tuberculosis. The infected spine can be approached anteriorly or posteriorly, in a minimally invasive way. We review the various surgical techniques used in the management of spinal tuberculosis with focus on their indications and contraindications.

Keywords: Anterior instrumentation; Minimal invasive spine surgery; Posterior instrumentation; Posterior only vertebral column resection; Spinal tuberculosis.

Fig. 1. Preoperative X-rays from a 26 year female with tuberculosis spine D8–10 with paraplegia. (A) Anterior-posterior. (B) Lateral. Preoperative magnetic resonance imaging. (C) T1-weighted saggital. (D) T1-weighted coronal. (E) T2-weighted axial. Intraoperative pictures (F, G). Postoperative X-rays. (H) Antero-posterior. (I) Lateral, following anterior decompression and anterior Instrumentation. Computed tomography scan during follow-up showing good decompression (yellow arrow) (J) and fusion (K, L).

Fig. 2. A case of a 40 year female with active tubercular spondylitis T12–L2 with thoracolumbar kyphosis. Preoperative X-rays. (A) Lateral view (B) Anterior-posterior view. Preoperative magnetic resonance imaging. (C) Short tau inversion recovery. (D) T1-weighted images showing active disease. Postoperative X-rays (E) Lateral view, (F) Anterior-posterior view following pedicle screw instrumentation, posterolateral decompression and reconstruction with a polyether ether ketone cage.

Fig. 3. Healed tuberculosis with fixed thoracolumbar kyphosis in a 25-year-old male. Preoperative X-rays. (A) Anterior-posterior view and (B) Lateral view. Preoperative computed tomography scan with three-dimensional reconstruction. (C) Postoperative X-rays. (D) Anterior-posterior view and (E) Lat view following posterior only vertebral column resection.

Fig. 4. Multilevel spinal tuberculosis in a 30-year-old male. Preoperative X-rays. (A) Anterio-posterior view and (B) Lateral view. Preoperative magnetic resonance imaging. (C) T2-weighted sagittal. (D) T2-weighted axial and (E) T1-weighted Axial sections showing cord compression at the T9–10 level.

Fig. 5. Multilevel spinal tuberculosis in a 30-year-old male. Preoperative X-rays. (A) Anterior-posterior view and (B) Lateral view. Postoperative X-rays. (C) Anterior-posterior view and (D) lateral view following percutanous pedicle screws and posterolateral decompression at T9–10 level using retractor system.

Fig. 6. Tubercular spondylitis L2–L4, with complete destruction of L3 vertebra in a 30-year-old female. Preoperative X-rays. (A) Anterior-posterior view and (B) lateral view. Percutanous pedicle screws fixation in prone position followed by decompression, interbody fusion using DLIF (Medtronics Inc.). Postoperative X rays. (C) Anterior-posterior view and (D) lateral view.

Fig. 7. Tubercular spondylitis L2–L4, with complete destruction of L3 vertebra in a 30-year-old female. Intra operative photographs of DLIF. Lateral position (A) with bolster below the flank region. Five centimeter incision on the lateral aspect (B). Insertion of neuromonitoring probe (C). Serial dilators were inserted (D) followed by a retractor device (E, F).