tuberculosis of the spine. TB Spine Pott's disease management of TB Spine management of Tuberculosis of the Spine

1. Discuss Pathology and
Management of Tuberculosis of
the Spine
Dr Shindang PJ
Orthopedic department, NHA

2. Outline
• Introduction
• Epidemiology
• Pathology
• Classification
• Management
• Follow up
• Prognosis
• Prevention
• Future trends
• Complications
• Conclusion
• References

3. Introduction
• TB spine is an infection of the spine caused by M. tuberculosis resulting in
spondylodiscitis, abscess formation, and mechanical instability of the spine.
• Pott’s paraplegia – paraplegia resulting from tuberculosis of the spine
• Oldest disease Known to man yet still of public health importance
• Frequently encountered extrapulmonary form of tuberculosis.
• Early diagnosis and prompt treatment are necessary to prevent permanent neurological
disability and to minimize spinal deformity.

4. Introduction
• Found in Egyptian mummies dating back to 3400 BC
• Percival Pott in 1779 presented the classic description of spinal
tuberculosis.
• Robert Koch 1882 discovered Mycobacterium tuberculosis

5. Epidemiology
• Global TB burden
• 8-10 million new cases per year worldwide
• Over one million deaths annually
• The highest incidence occurs in Sub-Saharan Africa and south-east
Asia
• The highest prevalence is in the Indian sub-continent
• In endemic countries TB Spine
• Common in children and young adults
• Common cause of nontraumatic paraplegia
• Equally affects males and females

6. Epidemiology
• 10% of Extra Pulmonary TB have skeletal involvement
• TB spine accounts for 50% of TB of the MSS
• 1-2% of all cases of TB

7. Risk factors
• Immune-deficiency states
• Overcrowding
• low socioeconomic status
• Significant exposure to active TB patients
• High risk occupations such as healthcare workers

8. Relevant
Anatomy

9. Relevant
Anatomy

10. PATHOLOGY
• A secondary form of TB
• AETIOLOGY; Caused mainly by M. tuberculosis and occasionally by M. bovis,
M. africanum, M. microti
• M. Tb is an acid-fast bacillus, non-flagellated obligate aerobe.
• Weakly Gram +ve.
• Stained with Zehl-Neilson stain, cultured on Lowenstein-Jensen medium.
• No toxin or biofilm
• Caseous granuloma
• Spread is chiefly hematogenous
• Blood supply favors bony involvement on each side of the bone sparing the
disc in adults

11. Pathology
Focus of infection (primary site) lungs, Lymph node
Route of infection: hematogenous spread (paravertebral venous
plexus of Bateson).
Infection begins in the metaphysis of vertebral body
Advances and destroys the cortex, intervertebral disc and
adjacent vertebrae
Infectious exudate may spread beneath the anterior longitudinal
ligament to neighboring vertebrae

12. Pathology
• Tissue necrosis and breakdown of inflammatory cells result in a paraspinal
abscess.
• The pus may be localized, or it may track along tissue planes.
• Progressive necrosis of bone leads to a kyphotic deformity.
• Typically, the infection begins in the anterior aspect of the vertebral body adjacent
to the disk.
• The infection then spreads to the adjacent vertebral bodies under the longitudinal
ligaments.
• Noncontiguous (skip) lesions are also seen occasionally

13. Regional distribution.
• CERVICAL 12%
• CERVICODORSAL 5%
• DORSAL(THORACIC) 42%
• LUMBAR 26%
• DORSOLUMBAR 12%
• LUMBOSACRAL 3%

14. Types of Lesion
1. Paradiscal (commonest)
2. Central
3. Anterior
4. Appendicular
5. Articular(synovial)

15. Lesion
• Paradiscal
• Commonest
• Spread is via arteries
• Adjacent to intervertebral disc space
• Subsequent destruction of
subchondral bone
• Disc space is reduced
• Central type
• Spread is via Batson plexus of veins
• The lesion is in the central portion of
the body and extends centrifugally to
involve the whole body of the
vertebrae
• Body yields under gravity and muscle
action to compression and collapse
• Disc space intact

16. Lesion
• Anterior
• Destruction of the cortical bone
with spread to the subperiosteal
and sub-ligamentous plane
• Stripping of periosteum with
Subsequent ischemia with
resultant vertebral body collapse
• Appendicular(uncommon)
• The pedicle and lamina of the
vertebrae are primarily affected
• Spread is via the posterior external
venous plexus
• Involves posterior arch without
the involvement of vertebral body

17. Pathological sequelae.
• Paravertebral abscesses e.g. cold abscess in the neck,Psoas,lumbar
abscesses
• Gibbus , kyphosis
• Paraplegia: the most serious complication
• Tuberculous meningitis-rupture of abscess into dura-pachymeningitis;
arachnoiditis= paralysis

18. PRINCIPLES OF MANAGEMENT
• Resuscitation
• Multidisciplinary Team
• Prompt diagnosis
• History and examination
• Investigations
• Effective treatment
• Medical
• Surgical
• Prevention
• Complications

19. Resuscitation
• Correct Anemia
• Treat dehydration
• Nutritional rehabilitation
• Sepsis
• UTI
• Bed sores

20. History
• Prolong periods of ill heath
• Back pain; Vague initially, later becomes progressively severe
• Constitutional symptoms 20-30% of patients (fever, malaise, loss of
weight and appetite).
• Night cries
• Weakness/Heaviness of limbs
• Fecal/Urinary incontinence

21. Examination findings
• Features of chronic illness
• Alderman’s gait
• Deformity
• Gibbus
• Kyphosis
• Kyphoscoliosis
• Pigeon chest
• Neurologic examination
• +/- Features of UMNL
• Lumps: Abscess
• Sinuses
• pressure sores

22. GIBBUS SCOLIOSIS

23. INVESTIGATIONS FOR T.B SPINE
AIMS
• To confirm the diagnosis
• To rule out differentials
• To monitor response to treatment
• To prepare patient for surgery

24. Radiologic Investigations
• X-RAY
• Commonest investigation
• Readily available
• Features are seen after about 6 months
• The whole spine should be evaluated
• For diagnosis
• Monitoring during treatment

25. X-ray features
• Narrowing of disc space
• Local osteoporosis
• Kissing lesions
• Wedged collapse
• Vertebra plana
• Vertebra destruction
• Scalloping
• Para-spinal soft tissue shadows
• Kyphosis , scoliosis,
• Skip lesions (7%)

26. ANT. WEDGE COMPRESSION

27. RADIOLOGICAL
CLASSIFICATION
OF T.B SPINE BY
Lagundoye et al
• Type I - Disc space narrowing only
• Type ii -kissing lesions
• Type iii -Wedge collapse of vertebra
• Type iv -Vertebra plana
• Type v -Lesion localized in the body/or its
appendages
• Type vi - Paraspinal abscess
• Type vii -Complete body destruction

28. Clinico radiologic classification of TB Spine

29. MAGNETIC RESONANCE IMAGING
• Most preferred imaging
• Sensitivity (97%) and specificity (78.6%)
• With/without gadolinium-enhanced
• Shows disc/vertebra changes
• Shows skip lesions
• Shows spinal cord affectation, compression, edema, cavitations
• Para spinal abscesses

30. THORACOLUMBAR MRI

31. LUMBOSACRAL MRI

32. CT SCAN
• Sensitivity of 90.9% and specificity
of 94.6%
• Shows pattern of bony
destruction(osteolytic, sclerotic,
fragmentary)
• Calcification within abscess
• Outlines hidden areas of the spine
e.g. posterior elements
• CT guided biopsy

33. BONE SCAN
Tc99 BONE SCAN
• Technetium 99,Gallium
• Not specific
• Aids to localize active disease
• Increase uptake in 60% of patients
with active T.B
• < 5mm lesion can be detected
• Avascular segments/abscess shows
cold spot
• Detects metastatic disease

34. HAEMATOLOGIC INVESTIGATIONS
FBC + DIFF
• Relative
Lymphocytosis
• Anaemia
ESR
• Raised in active
disease
• Usually >
20mm/hr
• Also used for
monitoring
Retroviral
screening

35. Investigations
PPD INJECTION
• Mantoux test
• PPD(tuberculin skin test)
• Placed in the left flexural area
• > 10mm
• >5mm( HIV infected)
• The width of induration is
measured after 72 hrs.
• Accesses evidence of exposure
• False neg /positive causes

36. Mantoux

37. • Biopsy of vertebrae/ Abscess aspirate
• Biopsy and culture is the Gold standard
• AFB staining/ histology( caseous
necrosis , epitheloid cells,) and culture
• By percutaneous CT guided or open
Solid media ( Lowestein Jensen ,
middlebrook)
Liquid broth(1-3 wks)
BACTEC MEDIA( 1-2 WKS)

38. Investigations
PCR
It detects circulating TB
DNA/RNA in the blood.
Specificity 80- 90%, sensitivity
61-90%
Distinguish Mycobacterium
tuberculosis from other types
Detect as few as 10-50 bacilli
Not readily available
ELISA
Detects Ig G against TB
Rapid Antibody –antigen test
60-80 % Sensitive
QuantiFERON TB Gold Assay
Detects t-cell-mediated gamma
interferon in the plasma
Results ready in 24 hrs.

39. GeneXpert test
• Molecular test for TB
• has a sensitivity of 95.6% and specificity of
96.2%
• Detect TB presence and test for rifampicin resistance
• Used to diagnose MDRTB
• Detects TB DNA in blood and sputum
• Uses blood, abscess aspirate, urine, csf
• Rapid- 90mins
• Detect both dead and live bacteria

40. Tests for patients with active TB
• Sputum AFB X 3
• Ziehl - Neelsen staining- pink rods
• Active pulmonary TB
• Gastric aspirate/bronchial washout/Ascitic fluid/CSF/Urine
• Results takes 3- 8 wks
• Requires > 500 bacilli for + ve result
• CHEST X-RAY
• May show evidence of active or healed lesion
• Consolidation
• Apical scaring/hilar opacities/cavitations
• Pleural effusion
• Lung collapse

41. • Liver function test-
 monitoring of treatment
Liver enzymes/protein levels
• E/ U /Cr – monitoring of renal status
• PSA
• Alkaline phospahatase
• Bence jones protein

42. DIFFERENTIAL DIAGNOSIS
PYOGENIC SPONDYLITIS - Sudden onset,high fever, severe pain, neutrophilia.
Radiologic features: rapid bone destruction, marked bone
sclerosis, loss of iv space.
common in the lumbar vert.
Heal with bony ankylosis
BRUCELLAR SPONDYLITIS - Common in patients working in animal husbandry/abbatoir.
commoner in lumbar vert.
Psoas abscess common,
disc space thining, step-like vertebra erosion and
ankylosis,no gibus.
FUNGI INFECTION (ASPERGILLOSIS,COCCIDIOMYCOSIS) -Less pain,common in immunocompromised,
increased esr,normal wbc.
lytic lesion without pus, fungi ball on chest Xray

43. DIFFERENTIAL DIAGNOSIS CONT.
PRIMARY BONE TUMORS( GCT,ABC,),LYMPHOMA -Osteolytic,expansile lesions in the body , disc are
spared,spleen/liver enlargement
Multiple myeloma There is involvement of one or two vertebrae, with collapse and
eccentric destruction
ESR elevated, Anemia, Reversal od A/G ratio
Urine bence Jones protein
Confirm with myeloma cells in BM
METASTATIC TUMORS -FEATURES OF PRIMARIES,ELDERLY PTS,USUALLY INVOLVES PEDICLES
AND SPARE THE DISC
PARASITIC INFECTIONS EG.HYDATID DZX,SCHISTOSOMA -COMMON WHERE SHEEP HUSBANDARY,XRAY SHOWS
TRANSLUCENT AREA WITH SCEROTIC MARGINS
TRAUMATIC VERTEBRA FRACTURES -HX OF TRAUMA,FRACTURE LINES,INTACT DISC SPACE

44. OTHER
DIFFERENTIAL
DIAGNOSIS
• Scheuermann’s disease
• Pathologic fractures from osteoporosis
• Degenerative Disc prolapse
• Sickle cell disease
• Ankylosing spondylitis
• Sarcoidosis

45. Classification
1. Oguz et al. classification (based on the number of vertebrae involved and the presence of
complications.)
Type 1 one disc level and soft tissue infiltration without abscess, collapse and neurologic deficit
Type 2 Degeneration involving one or two disc levels with abscess formation and mild
kyphosis. Neurological deficit may be present
Type 3 Degeneration involving one or two disc levels with abscess formation, instability and
deformity that cannot be corrected without instrumentation
2. Based on location of the lesion: cervical, thoracic, thoracolumbar, lumbar or
sacral.

46. Kumar staging
Predestructive stage patient presents in <2 months of onset of disease with the straightening of
curvatures and spasm of the perivertebral muscles
Early destructive stage patient presents between 2 and 4 months of onset of disease with
decreased disc spaces and paradiscal erosion
Mild angular kyphosis stage patient presents between 4 and 9 months of onset with two to three
vertebral involvement and kyphotic angle of 10°–30°
Moderate angular kyphosis stage when patient presents between 6 and 24 months with more than 3
vertebral involvement and kyphotic angle of 30°–60°
Severe kyphosis stage patient presents after 24 months with more than 3 vertebral involvement
and kyphotic angle of more than 60°.

47. Treatment
• To eradicate the
mycobacterium
• To prevent / treat instability
• To prevent / treat deformity
• To prevent neurologic deficit
Goals

48. Middle Path Regime
• Tuli and Kumar advocated drugs as the basis of treatment and
reserves surgery for specific indications
• Operative treatment is combined with 6–12 months of bed rest,
followed by 18–24 months of spinal bracing.
• It’s the most widely accepted protocol

49. Middle Path Protocol
• Admission, bed rest
• Chemotherapy.
• X-ray and ESR once in three months.
• Gradual mobilization in the absence of neurological complications.
• Spinal braces—18 months to 2 years.
• Abscesses are aspirated or drained.
• Sinuses heal within 6–12 weeks.
• If no neural complications develop; if response is obtained within 3–4
weeks of triple-drug therapy, surgery is unnecessary.
• Operative debridement for patients who do not show arrest of
disease after 3–6 months of chemotherapy.

50. Non-Operative
management
1. MEDICAL THERAPY
Indications
• Organism Identified and antibiotic
sensitivity
• Uncomplicated TB spine
• As an adjunct to surgical therapy
• Complicated cases where surgery may
not be useful
• Therapeutic trial

51. First line drugs
• Isoniazid –5(4-6)mg/kg/day, Peripheral neuropathy
• Rifampicin –10(8-12)mg/kg/day, Hepatotoxicity
• Pyrazinamide –25(20-30)mg/kg/day, Gout
• Ethambutol-15(13-17)mg/kg/day, Optic neuritis
• or
• Streptomycin-15(12-18) mg/kg/day, Ototoxicity

52. Second line drugs
• Thiacetazone -2.5(2-3)mg/kg/day, bacteriostatic
• PAS, 10-12 g/day, bacteriostatic
• Ethionamide, 15-20mg/kg/day, bacteriostatic
• Cycloserine,0.5-1gm/day
• Kanamycin, 15-20mg/kg/day, bacteriocidal
• Capreomycin, 12-18mg/kg/day, bacteriocidal
• Ciprofloxacin, 1-1.5g/day, bacteriocidal

53. Standard regimen
Intensive
Phase
4drugs for 2 months
•1.Isoniazid, 5-15mg/kg-300mg
•2.Rifampicin 10—20mg/kg-600mg
•3.Ethambutol 15-25mg/kg-800mg
•4.Pyrazinamide 30-40mg/kg-1.5gm
Continuation
Phase
INH and Rifampicin

54. Duration of continuation therapy
• Isoniazid and rifampicin given for
• 10 months for the 12 months, regimen-Canadian Thoracic Society
• 7 months for the 9 months, regimen-American Thoracic Society
• 7 months for the 9 months, regimen-WHO 2010
• 16 months for the 18 months, regimen-Old school
• 4 months for the 6 months , NICE Guidlines

55. 2. Mobilization with a suitable orthotics
• Collar
• Halo vests
• Minerva jacket
3. Physiotherapy.

56. Treatment: Operative
Goals are
• to achieve adequate decompression,
• debridement,
• maintenance and reinforcement of stability,
• correction and prevention of deformity.

57. Indications
Patient without neurological
complications
• Progressive bone destruction in spite
of ATT
• Failure to respond to conservative
therapy
• Evacuation of paravertebral abscess
• For biopsy
• Mechanical reasons: instability
• Prevention of severe kyphosis in
young children
Patients with neurological
complications
• New or worsening neural
complications or lack of improvement
with conservative treatment
• Paraplegia of rapid onset or severe
paraplegia
• Late-onset paraplegia
• Painful paraplegia in elderly patients
• Spinal tumor syndrome (epidural
spinal tuberculoma without osseous
involvement)

58. Treatment: Surgery
• Surgery: Options
• Costo-transversectomy
• Anterior decompression and fusion (Hodgson and Stock)
• Hong Kong procedure
• Radical debridement, grafting and fusion
• Posterior decompression and spinal fusion
• Non-instrumentation
• Hibbs and Albee 1911
• Instrumentation
• Drainage of abscess

59. Surgical Approaches
• For spinal TB in the cervical spine, an anterior approach is most
common.
• For the thoracic spine:
• anterior and anterolateral decompression by thoracoabdominal approach
• posteriorly there is costo-transversectomy
• lumbar level spinal TB:
• Posterior
• anterior
• antero-lateral

60. Anterior approach
• Anterior approaches enable adequate exposure, debridement, and
reconstruction.
• Disadvantage
• Graft slippage - 50 - 80%
• Fracture
• Absorption, or subsidence of graft.
• Mortality 4% morbidity 18%

61. Posterior approach
• Commonly used approach
• The ability to achieve adequate exposure for circumferential
spinal cord decompression, and better deformity control through
pedicle screws
• Possibility of extension of instrumentation
• Avoidance of thoracotomy-related complications
• Transpedicular decompression and posterior instrumentation
facilitates faster recovery and also prevents deformity
progression and neurological sequelae in early disease

62. Combined approaches
Indications
• Osteoporotic bones,
• Multiple vertebral body involvement
• Severe kyphotic deformities.
• severe destructive lesions and junctional pathologies that are inherently unstable
• Posterior instrumentation with anterior decompression and fusion can be
performed in 1 or 2 stages.
• Anterior debridement removes infected foci and allows for direct neural
decompression and rigid anterior reconstruction.
• Posterior instrumentation enables better deformity correction and reduces the
stress on grafts placed anteriorly, thus helping in maintaining sagittal deformity
correction.
• it is associated with high morbidities

63. INDICATION FOR INSTRUMENTATION
• Pan vertebral disease: Instrumentation should be done to prevent
subluxation /dislocation of the spine.
• Long segment disease: Disease of 4 or more vertebral bodies.
• In the lumbar & cervical spine: There are no costotransverse &
costovertebral articulations as in the dorsal spine.
• When kyphosis correction is done
• Injunctional areas such as the CD spine and DL spine

64. Treatment: Surgery
• Surgery: Abscess drainage
• Indication
• Large abscess
• Cord compression
• Septic features
• Principles
• Incision over non dependent area
• Incision is closed
• Drain not longer than 2 days

65. Treatment: Cervical
• Decompression
• Anterior approach (Southwick Robinson)
• Transoral
• Stabilization
• Instrumented + fusion
• Cages
• Cervical plate
• Cervical rods and screws

66. Treatment: Thoracic
• Abscess
• Costotransversectomy
• Transpedicular drainage
• Decompression
• Anterolateral extrapleural
approach
• Anterior transthoracic
• Costotransversectomy

67. COSTOTRANSVERSECTOMY
This approach helps in evacuating abscesses in the dorsal spine .
• Midline incision Elevate soft tissue & periosteum from spinous
process & laminae over abscess.
• Resect transverse process at its base
• Resect 5cm of contiguous rib
• Open abscess by blunt dissection
• Wash and close in layers

68. TRANS THORACIC TRANSPLEURAL
APPROACH
• Hodgson & stock described propagated for anterior clearance of
lesion & Reconstruction by bone grafting.
• Patient in lateral decubitus position with bean bag.
• Incision over corresponding involved vertebra & expose
subperiosteally.
• Disarticulate rib from transverse process
• Incise parietal pleura & reflect it off the spine.
• Pleural adhesions cleared gradually.

69. TRANS THORACIC TRANSPLEURAL
APPROACH
• It allows adequate exposure for debridement & grafting
• Identify segmental vessels & ligate.
• ICN useful guide to intervertebral foramina.
• Reflect periosteum overlying spine & expose involved vertebrae.
• Lesion is debrided & anterior decompression of spinal canal achieved

70. Treatment: Thoracic

71. Treatment: Lumbar
• Abscess
• Lumbar paravertebral abscess
• Transpedicular drainage
• Decompression
• Approach through Hypogastric
para median trans peritoneal approach.
• Retroperitoneal
• Transperitoneal

72. Advantage of surgery
• Less kyphosis
• Immediate relief of compressed neural tissue
• Quicker relief of pain
• A higher percentage of bony fusion
• Less relapse
• Earlier return to previous activities
• Less bone loss
• Prevent late neurological problems due to kyphosis and fibrosis

73. Neurologic complications of spinal TB
• Most feared complication
• Occurs in 30% of cases
• Kumar’s classification, ASIA classification
• Paraplegia of early onset will resolve with ATT
• Paraplegia of late onset usually requires surgical decompression

74. Paravertebral abscesses
PARAVERTEBRAL
ABSCESS
ACCUMULATE UNDER
ANTERIOR
LONGITUDINAL
LIGASMENT
GRAVITATE ALONG
FASCIAL PLANES
PRESENT EXTERNALLY
AT SOME DISTANCE
FROM THE SITE OF
THE ORIGINAL LESION
LUMBAR PSOAS
ABSCESS ALONG THE
SHEATH

75. Abscess formation
• Cervical spine →Posterior/ Anterior triangle
• Upper thoracic →Intercostal Spaces on the chest wall
• Lower thorax and Lumbar → Thigh and inguinal region: Psoas Abscess
• Treatment
• Anti Tubercular Drugs
• Percutaneous CT guided needle aspiration
• MIS
• Surgical Drainage

77. Kyphosis
• TB spine is a common cause of Kyphosis
• More severe curves are seen in children
• Surgery is indicated if Kyphotic Angle is ≥ 60%
• Prevention is Key
• Early treatment with ATT
• Posterior decompression and screw fixation

78. TB spine in children
• 35% of cases of TB in India
• Vertebrae is cartilagenous
• Progressive deformity occurs in
39%
• Aim of treatment
• Early eradication of TB
• Identification of children that are
likely to develop progressive

79. TB spine in Children
• Clinical Risk factors for Kyphosis correction
• Age less than 11 yrs
• Affectation of 3 or more vertebrae Kyphotic angle >30 at presentation
• Disease at the lower thoracic and thoracolumbar junction
• Radiologic Spine at risk (Rajasekaran et al):
• 2 or more spines at risk plus clinical risk factors is an indication for surgery

80. Complications
• Disease
• Quadriplegia
• Paraplegia
• kyphosis
• Tuberculoma
• Tuberculous meningitis,
arachnoiditis
• Secondary infection
• Amyloid disease
• Death
• Intervention
• Drugs
• Hepatitis
• Peripheral neuropathy
• Optic neuropathy

81. Complications
• Intervention
• Surgery
• Graft migration
• Fixation failure
• Cord compression/ injury
• Pneumothorax, pleural effusion
• Ileus
• Injury to surrounding structures

82. Follow up/ Monitoring
• Aim
• Response to therapy and complications
• Compliance (DOTS)
• Development of neurological deficit
• Deformity
• All patients were examined clinically and
radiologically at 3, 6, and 12 months after surgery and
then once a year.

83. Follow up/ Monitoring
• Modality
• Regular weighing
• Erythrocyte sedimentation rate (ESR)
• Full blood count
• Lymphocyte count
• Liver function tests
• Visual acuity
• Electrolyte, urea, and creatinine
• Chest X-ray and regional areas
• “Healed status”
• Clinical and radiological evidence of healing without any
recurrence after 2 years

84. Rehabilitation
• Aims to return the patient to the pre-morbid state
• Physiotherapy
• Occupational therapy
• Psychotherapy

85. Prevention
• Primary prevention
• Health Education
• BCG Immunization
• Good standard of living
• Proper Housing unit
• Secondary prevention
• Early diagnosis and treatment
• Screening of high risk individuals
• Tertiary prevention
• Rehabilitation
• Limitation of disability

86. Prognosis
• Mortality
• Very high before advent of anti TB drugs
• 70% patients with surgery
• Severity of neurological deficit
• 11% in patients with severe neurologic deformity
• Kyphosis
• Neurologic, respiratory and cardiac failure
• Associated with non operative management

87. Prognosis
• Neurology
• May improve with chemotherapy
• Better after anterior decompression 94%
• 79% after non operative
• 48% with severe neurology recovered
• Poor results
• Atrophic cord
• Pachymeningitis

88. Local experience

89. Future Trends
• Xpert MTB/RIF Ultra, as they found it, to have better detection
rates of Mycobacterium tuberculosis in specimens with low
numbers of bacilli.

90. Conclusion
• Tuberculosis of the spine is a severe
debilitating disease
• High index of suspicion is required in
patients with chronic back pain
• Mainstay of treatment is chemotherapy
• Surgery has a big role to play

91. References
• Onuminya JE, Morgan E, Shobode MA. Spinal tuberculosis - Current
management approach. Niger J Orthop Trauma 2019;18:35-43
• Mohammad R. R et al Spinal Tuberculosis: Diagnosis and Management
Asian Spine Journal Vol. 6, No. 4, pp 294~308, 2012
• Kirkman MA, Sridhar K. Posterior listhesis of a lumbar vertebra in spinal
tuberculosis. Eur Spine J 2011;20:1-5.
• Rajasekaran S. The natural history of post-tubercular kyphosis in children.
Radiological signs which predict late increase in deformity. J Bone Joint
Surg Br 2001;83:954-62.
• Neradi, D., Sengupta, D.K. (2022). Epidemiology of Tuberculosis of Spine. In:
Dhatt, S.S., Kumar, V. (eds) Tuberculosis of the Spine. Springer, Singapore.
https://doi.org/10.1007/978-981-16-9495-0_3
• Google images