'Need of the Hour': Early Diagnosis and Management of Multidrug Resistant Tuberculosis of the Spine: An Analysis of 30 Patients from a "High Multidrug Resistant Tuberculosis Burden" Country

Abstract

Study design: Retrospective study.

Purpose: To report the prevalence of patients with multidrug-resistant (MDR) tubercular spondylodiscitis and their outcomes. Additionally, to assess the role of Xpert MTB/RIF assay in early detection of MDR tuberculosis.

Overview of literature: MDR tuberculosis is increasing globally. The World Health Organization (WHO) has strongly recommended Xpert MTB/RIF assay for early detection of tuberculosis.

Methods: From 2006 to 2015, a retrospective study was conducted on patients treated for MDR tuberculosis of the spine. Only patients whose diagnosis was confirmed using either culture and/or the Xpert MTB/RIF assay were included. Diagnostic method, treatment regimen, time taken to initiate second-line antituberculosis treatment (ATT), drug-related complications, and cost of medications were analyzed. All patients with MDR were treated according to the WHO recommendations for 2 years. The outcome parameters analyzed included clinical, biochemical, and radiological criteria to assess healing status.

Results: From 2006 to 2015, a total of 730 patients were treated for tubercular spondylodiscitis. Of those, 36 had MDR tubercular spondylitis (prevalence, 4.9%), and three had extremely drug resistant tubercular spondylitis (prevalence, 0.4%). In this study, 30 patients, with a mean age of 29 years and a mean post-treatment follow-up of 24 months, were enrolled. The majority (77%) had secondary MDR, 17 (56%) underwent surgery, and 26 (87%) completed treatment for 2 years and were healed. Drug-related complications (33%) included ototoxicity, hypothyroidism, and hyperpigmentation of the skin. The average time taken for initiation of second line ATT for MDR patients with Xpert MTB/RIF assay as the diagnostic tool was 18 days, when compared to patients for whom the assay was not available which was 243 days.

Conclusions: The prevalence of MDR tubercular spondylodiscitis was 4.9%. In total, 87% of patients were healed with adequate treatment. The sensitivity and specificity of the Xpert MTB/RIF assay to detect MDR was 100% and 92.3%, respectively.

Keywords: Diagnosis; Multi drug resistance; Treatment; Tuberculosis.

Fig. 1.

Details of the study population.

Fig. 2.

(A) Plain radiography shows erosion in the upper end plate of the L3 vertebra with reduction in the L2/3 disk space. The L5 vertebra was sacralized. (B) MRI revealed an intraosseous abscess at the L2/3 vertebrae involving the L1/2 and L2/3 disc spaces with a psoas abscess. (C) Plain radiography shows sclerosis of the involved vertebrae. Bony fusion occurred at L2/3. MRI, magnetic resonance imaging; TB, tuberculosis; ASIA, American Spinal Injury Association.

Fig. 3.

(A) Plain radiography reveals near complete destruction of the D11 and D12 vertebrae with a 69.9° kyphosis. (B) T2-weighted sagittal MRI shows complete destruction of the D11 and D12 vertebrae, as well as erosion of the D10 vertebra. An intraosseous abscess extending into the canal causes significant impingement of the spinal cord. (C) Plain radiography shows the anterior column reconstructed with cage and bone graft, sclerosis of the vertebra, healing of the disease, and deformity corrected to 4.9° kyphosis. (D) T2-weighted sagittal MRI reveals an almost complete resolution of the abscess. MRI, magnetic resonance imaging; ASIA, American Spinal Injury Association.