Active tuberculosis of spine: Current updates

Abstract

Background: Spinal tuberculosis (TB) is the most common extrapulmonary form of tuberculosis. In both developing and developed countries, TB has been on the rising trend due to factors such as increasing HIV coinfection, multidrug resistance of the organism, and global migration. Spinal TB, which most often affects the lower thoracic and thoracolumbar area, accounts for 50% of all musculoskeletal tuberculosis.

Methods: Using the Cochrane Database of Systematic Reviews, EMBASE, and PubMed, a systematic computerized literature search was performed. Analyses of studies published within the past 10 years were conducted. The searches were performed using Medical Subject Headings terms, with "spinal tuberculosis," "diagnosis," "epidemiology," and "etiology","management," "surgery," and "therapy" as subheadings.

Results: Progressive collapse, kyphosis, and neurological deficiency are hallmarks of the disease because of its destructive effect on the intervertebral disc and adjacent vertebral bodies. The condition may be identified using laboratory testing and distinctive imaging features, but the gold standard for diagnosis is tissue diagnosis using cultures, histology, and polymerase chain reaction. Uncomplicated spinal TB is today a medical condition that can be adequately treated by multidrug ambulatory chemotherapy. Surgery is reserved for individuals who have instability, neurological impairment, and deformity correction. Debridement, deformity correction, and stable fusion are the cornerstones of surgical treatment.

Conclusions: Clinical results for the treatment of spinal TB are generally satisfactory when the disease is identified and treated early. However, the major health issue and the biggest obstacle in achieving the goals of the "End TB strategy" is the recent rise in the emergence of drug resistance. Hence strict vigilance and patient perseverance in the completion of the treatment is the main need of the hour.

Keywords: Antitubercular therapy; Instability score; Potts spine; Spinal tuberculosis; Spine at risk; Spondylodiscitis.

Fig. 1

(A) Radiograph of the patient with L5-S1 TB spondylodiscitis with narrowing of disc space and endplate erosion, (B) T2W MRI sagittal images showing prevertebral and epidural abscess (C, D) T2W MRI Axial images showing left psoas abscess.

Fig. 2

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 the 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.

Fig. 3

(a) A case of L4–L5 TB spondylodiscitis (A) T2 weighted, (B) T1 weighted and (C, D, E) Postcontrast images with anterior epidural abscess and endplate erosion. (b) One-year follow-up following conservative management with ATT treatment. (A, B,C, D) MRI showing complete resolution of the infection, (E) Radiograph shows completely healed L4–L5 lesion.

Fig. 4

(A) Lateral radiograph of thoracolumbar spine showing kyphosis of 34.2 degrees; (B) Mid Sagittal T2W MRI showing epidural abscess; (C) Coronal MRI showing paravertebral and psoas collection; (D) Lateral postoperative radiograph after posterior column shortening showing good deformity correction.

Fig. 5

(A) Lateral radiograph of lower thoracic spine showing involvement of T10–T11 vertebrae; (B) Mid Sagittal T2W MRI showing epidural abscess causing spinal cord compression; (C) Lateral postoperative radiograph showing posterior instrumentation with anterior column reconstruction; (D) 2 years follow-up lateral radiograph showing no significant loss of correction.

Fig. 6

(A, B) AP and Lateral radiographs showing focal kyphosis (59.4 degrees) at the upper thoracic region (Type IIA); (C–E) Sagittal Ct scan image showing only anterior column loss with intact posterior column (Type IIA). Note the presence of 2 pedicles in a single anterior fusion mass; (F) Postoperative radiograph following Disc- Bone Osteotomy with kyphosis reduced to 23.4 degrees.

Fig. 7

(A, B) AP and Lateral radiograph showing a lateral translation and focal kyphosis at the thoracolumbar region. Anterior column destruction is accompanied with functional failure of the posterior column (Type IIIB). (C) Mid Sagittal T2W MRI showing stretching of the conus at the level of T12. (D) Postoperative radiograph after closing opening wedge osteotomy (COWO) showing kyphosis correction.