Spinal Tuberculosis: Current Concepts

Abstract

Study design: Review article.

Objectives: A review of literature on the epidemiology, diagnosis, and management of spinal tuberculosis (TB).

Methods: A systematic computerized literature search was performed using Cochrane Database of Systematic Reviews, EMBASE, and PubMed. Studies published over the past 10 years were analyzed. The searches were performed using Medical Subject Headings terms, and the subheadings used were "spinal tuberculosis," "diagnosis," "epidemiology," "etiology," "management," "surgery," and "therapy."

Results: Tissue diagnosis remains the only foolproof investigation to confirm diagnosis. Magnetic resonance imaging and Gene Xpert help in early detection and treatment of spinal TB. Uncomplicated spinal TB has good response to appropriately dosed multimodal ambulant chemotherapy. Surgery is warranted only in cases of neurological complications, incapacitating deformity, and instability.

Conclusions: The incidence of atypical clinicoradiological presentations of spinal TB is on the rise. Improper dosing, inadequate duration of treatment, and inappropriate selection of candidates for chemotherapy has not only resulted in the resurgence of TB but also led to the most dreadful consequence of multidrug resistant strains. In addition, global migration phenomenon has resulted in worldwide spread of spinal TB. The current consensus is to diagnose and treat spinal TB early, prevent complications, promote early mobilization, and restore the patient to his or her earlier functional status.

Keywords: MRI; cervical; decompression; deformity; infection; lumbar; spondylitis; spondylodiscitis; thoracic; thoracolumbar.

Figure 1.

(A, B) Whole spine and focal T2 weighted sagittal MRI images of a 30-year-old individual showing unusually large prevertebral abscess with extensive tracking beneath the anterior longitudinal ligament. (C) Coronal image shows the abscess tracking along the psoas muscle to reach the anterior aspect of the thigh.

Figure 2.

(A, B) Plain radiography of a 52-year-old female with active cervical spinal TB and cervical kyphosis. (C, D) T2 weighted sagittal and parasagittal image showing a huge prevertebral abscess and posterior abscess spreading along and confined within posterior longitudinal ligament with cord compression. (E, F) Coronal and axial trim images demonstrating asymmetrical paravertebral abscess more toward the left side. (G, H, I) Axial, coronal, and sagittal images showing fragmentary and osteolytic lesions with near complete destruction of C4 vertebra. (J, K) One-year follow-up lateral and AP X-ray following anterior corpectomy and iliac crest autografting with posterior instrumentation showing restoration of cervical lordosis and excellent healing.

Figure 3.

The “spine at risk” signs to identify children at risk for severe deformity include: (A) separation of facet joints in lateral radiographs which indicates instability, (B) retropulsion of the posterior part of affected vertebra, (C) lateral translation of vertebrae in the antero-posterior radiograph, and (D) toppling of one vertebra over the other vertebra. Here, a line drawn from the anterior surface of the caudal normal vertebra crosses the mid-point of the anterior surface of the cranial normal vertebra.

Figure 4.

(A) Whole spine MRI screening showing multifocal lesions. (B, C) All suspected levels enhanced significantly with smooth uniform rims after contrast administration suggestive of TB. (D) Sagittal CT image with severe destruction of C1 and C2. (E, F) 1-year follow-up AP and lateral radiographs following occipitocervical stabilization. (G, H) Posterior thoracic stabilization done at the same stage.

Figure 5.

Serial radiographs and MRI images showing good progressive bony healing and complete resolution of cold abscess after receiving 9 months of ambulatory chemotherapy alone.

Figure 6.

(A, B, C) MRI images of a 40-year-old with active TB and regional kyphosis with severe canal stenosis. (D, E) 1-year follow-up after posterior column shortening and decompression along with fusion procedure employed to achieve deformity correction by posterior approach alone.

Figure 7.

(A, B) AP and lateral radiographs of thoracolumbar spine with complete collapse of T10 vertebra resembling “vertebra plana.” (C, D, E, F) Sagittal and axial T2 weighted images of spine showing contiguous involvement of T8, T9, T10, and T11 with prevertebral abscess and concentric collapse of T10 vertebra. (G, H) AP and lateral postoperative radiographs following global anterior reconstruction through posterior-only approach.