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Treatment of spinal tuberculosis

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Treatment of spinal tuberculosis - presented at the Postgraduate teaching course held at KEM Hospital, Mumbai in March 2016.
The talk highlights steps in diagnostic workup and treatment algorithm for management of spinal tuberculosis.
Please see notes attached to clinical slides. They contain details about clinical presentation and treatment approach chosen for the case presented

Published in: Health & Medicine
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Treatment of spinal tuberculosis

  1. 1. Dr. Kshitij Chaudhary, MS, DNB Consultant Spine Surgeon Sir HN Reliance Foundation Hospital Mumbai T R E A T M E N T O F S P I N A L T U B E R C U L O S I S
  2. 2. Spinal Tuberculosis is a MEDICAL disease
  3. 3. Surgery is reserved for COMPLICATIONS
  4. 4. 30y ♂ After 12 months of AKT
  5. 5. MRC trials Medical research council (UK) JBJS Br 1965-1998 Rhodesia, Hong Kong, Korea and India
  6. 6. • Thoracic and Lumbar TB (MILD DISEASE) • Excluded • Severe deficit, “could not walk across the room” • Significant extra-spinal infection • > 3 levels VB destruction • Antibiotics for >1year • Random Allocation • Chemotherapy alone • Debridement + No fusion • Radical Surgery + Reconstruction (Hong Kong Op) • FU 15 years • Similar outcome - 87% favorable outcome MRC trials Favorable outcome no evidence of CNS involvement, No sinus No clinically evident abscess no radiological evidence (Xrays) of disease activity no restriction of normal physical activity SPINAL DEFORMITY NOT INCLUDED
  7. 7. Fusion @ 15y 5% of Chemotherapy alone had alarming ↑ in kyphosis 51 to 70 deg No late onset myelopathy Kyphosis @ 15y
  8. 8. Is 15y-follow-up enough? Review of 60 patients conservatively Rx 25 patients - late onset paraplegia 65% - presenting more than 20 years later
  9. 9. Conservative Regime Bed Rest for 6-9 months, (prolonged hospitalization if unable to walk) Antibiotics: SM, PAS, INH for 24 months Supervision: 3-6mo X-rays (kyphosis), ESR Resumption of activity: with brace JBJS Br 1975
  10. 10. Surgery Advanced neurological deficit with sphincter involvement Flexor spasms Do not show progressive neurological improvement in 3-4 weeks Worsening of neurological deficit JBJS Br 1975
  11. 11. 200 cases with neurological deficit 76 (38%) improved with antibiotics and bed rest (baseline deficits??) 6 died 118 surgery 14 (12%) died → meningitis, urinary infections, renal failure, bedsores 81 (69%) recovered fully 13 (11%) walking with support 10 (8%) no improvement JBJS Br 1975
  12. 12. 104 lesions (conservatively treated) Follow up of at least 1 year NOT ENOUGH Follow up No real conclusions can be drawn JBJS Br 1975
  13. 13. Middle Path regime Rationale Endemic countries / resource poor Morbidity of surgery Limited expertise available for surgery Does not apply to Severe deficits Severe column destruction (anticipation of severe deformity)
  14. 14. T R E A T M E N T O F S P I N A L T B
  15. 15. Investigations Take time to see the X-rays, count levels, think Describe the pathology first A - Alignment (kyphosis, translation, dislocations) B - Bone destruction C - Cartilage (Disc) D - Density (osteopenia) E - Environment (paraspinal abscess) Radiographs
  16. 16. Investigations In all patients Diagnosis Type of compression (“soft” or “hard”) Status of spinal cord Extent of disease MRI + screen
  17. 17. ± CT scan
  18. 18. Other investigations CBC ESR, CRP LFT and Renal function ± Total protein, albumin ± HIV Xray Chest (15% Pulm TB) Mantoux Serological test (IgG, IgM) TB gold
  19. 19. Core Biopsy High risk for drug resistance Previous ATT Noncompliance / incorrect ATT Atypical presentation Multifocal disease Children Immunocompromised Endemic City (Mumbai) Image guided
  20. 20. Core Biopsy Gene Xpert (PCR) AFB smear TB MGIT cultures HPE examination Bacterial cultures
  21. 21. Biopsy Gene Xpert (PCR) Sensitivity 47% (smear negative) Sensitivity 100% (smear positive) Fast turnaround time Detect Rif resistance
  22. 22. Biopsy MGIT (myco growth indicator tube) Sensitivity 50-60%
  23. 23. Histopathological Examination Sensitivity 72-97%
  24. 24. Biopsy Line Probe Assay (PCR)
  25. 25. Conservative Care Infectious disease consult Start empirical ATT after biopsy 2 HRZE + 10 HRE (daily dosing) Duration 9-12 months Nutrition Bracing
  26. 26. Doses are as per weight of patient Don't add Levoflox or Ofloxacin to first line ATT
  27. 27. Surgery is reserved for COMPLICATIONS
  28. 28. N E U R O L O G I C A L D E F I C I T
  29. 29. Causes of neurological deficit Compressive Non compressive (Vascular)
  30. 30. Causes of neurological deficit Compressive “Soft” Abscess Granulation tissue “Hard” Sequestra (disc / bone) Internal gibbus Translation, dislocation
  31. 31. Abscess
  32. 32. Granulation tissue
  33. 33. Sequestra
  34. 34. Retroplused disc
  35. 35. Translation / Dislocation
  36. 36. Internal Gibbus 54y F, nonabulatory, myelopathy
  37. 37. Sequestra Translation Internal Gibbus
  38. 38. Spinal tumor syndrome
  39. 39. Indications for Surgery Severe neurological deficit Neurological worsening on treatment Mild deficit but not responding to antibiotics Neurological deficits due to “hard” lesions Spinal tumor syndrome NEUROLOGICAL DEFICIT
  40. 40. Neurological Deficit Surgery Mild deficit Biopsy Conservative care (ATT) Severe deficit (cannot stand/walk) No improvement Worsening Deficits due “hard lesions” Spinal tumor syndrome
  41. 41. D E F O R M I T Y
  42. 42. Indications for Surgery Extensive destruction of column Progressive / severe kyphosis Circumferential destruction (dislocation, translation) Childhood tuberculosis (spine-at-risk signs) DEFORMITY
  43. 43. Extensive destruction of column Reserved for Complications Severe destruction - Anticipation of significant deformity/instability 25y ♀ Normal Neurology, Back pain 12 mo 3y PO3y PO >1 Thoracic or >1.5 Lumbar VB destroyed
  44. 44. SW 15y ♂ 18o D9 56o +4 mo +4 mo +4 mo +4 mo ↑ Deformity Normal Neurology Progressive severe kyphosis
  45. 45. 14o 56o Progressive severe kyphosis
  46. 46. 18y ♂ Severe myelopathy, Frankel C 1 y PO 1 yPO D3 Circumferential destruction Translation
  47. 47. 4y♀ +6m +1y PO Difficulty walking due to pain Childhood Tuberculosis
  48. 48. Childhood Tuberculosis Spine-at-risk Failure of posterior column leads to severe deformity
  49. 49. 85o 8o SK 14y ♀ past h/o spinal TB @4y 14 ♀ 14 ♀ 15o 0o 15+5 ♀ 15+5 ♀ Normal Neurology Low back pain Healed Deformity - difficult to Rx
  50. 50. P O O R R E S P O N S E
  51. 51. Poor response Clinical symptoms CBC, ESR Weight, appetite MRI New lesions Worsening of old lesions
  52. 52. May show worsening Paradoxical reaction Clinical response Early MRI scans
  53. 53. Indications for Surgery Resistant tuberculosis Spinal instability (persistent pain) Doubtful diagnosis POOR RESPONSE
  54. 54. Poor response ? Fusion Spinal instability Persistence or Worsening of Spondylodiscitis Review diagnosis Biopsy ? Debridement Inconclusive
  55. 55. Spinal Instability ExtensionFlexion
  56. 56. Spinal Instability
  57. 57. +6 mo +2y +2y 58y ♀ T11 Drug Resistance (MDR)
  58. 58. Doubtful diagnosis 29y ♀ Not responding
  59. 59. Doubtful diagnosis Non Hodgkin’s Lymphoma
  60. 60. No such thing ! Ideal Surgical Approach ?
  61. 61. Individualize
  62. 62. Spinal Reconstruction Posterior ElementsAnterior Coumn Body Weight Tuberculosis
  63. 63. Questions? What is the goal of treatment? Site / Direction of Compression? Number of levels? Posterior column integrity? Alignment? Deformity? Osteoporosis? Medical Co-morbidities? Pulmonary? SURGICAL EXPERTISE / COMFORT? Facilities / Infrastructure?
  64. 64. Surgical Principles Exposure Decompression Reconstruction Instrumentation
  65. 65. Anterior Approach
  66. 66. Standalone Anterior T/L Inability to obtain secure fixation Posterior element disruption Severe kyphosis Extensive column destruction Lower lumbar levels CT / TL junction (relative) Surgeon not comfortable / trained Contraindications
  67. 67. Posterior Approach 37y ♀ Motor 0/5 B/B intact
  68. 68. Posterior Approach 35y M Motor 0/5, SILT B/B involved
  69. 69. Anterior and posterior
  70. 70. Surgery Avoid a half-hearted attempt Best possible decompression. Best possible reconstruction. Cage / Graft from good bone to good bone ± Instrumentation → early mobilization Keep Safety of patient in mind.
  71. 71. T H A N K Y O U Sir HN Reliance Foundation Hospital Mumbai

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