Review of Surgical Management of Spinal TB

2. Surgical Treatment of Spinal TB
Dr. Manish Shrestha
Orthopaedic Surgery

3. Introduction
• Spinal tuberculosis constitutes 1/3 to ½ of all bone
and joint tuberculosis. It results from
hematogenous dissemination from primary focus in
the lungs, lymphnodes, etc.
• Its ability to cause bone destruction, deformity and
paraplegia makes it most dangerous pattern of bone
and joint tuberculosis. (Jin D. Eur Spine J 2004)

4. History
• One of the oldest diseases with evidence from
different time periods
▫ 4000 BC Egyptian mummies noted with typical
features.
▫ DNA from vertebral lesion in 12 year old from
1000 AD identified M.tuberculosis.
▫ Classic description first in 1779 by Percival Pott,
an English Surgeon.

7. Pott’ Paraplegia
• Paraplegia with active disease (Early Onset)
▫ External pressure on the cord
▫ Penetration of the dura by infection
• Paraplegia with healed disease (Late Onset)
▫ Transection of the cord by a bony ridge
▫ Constriction of the cord by granulation and fibrous tissue
• Hodgson et al. which recommended early surgery to prevent the
deveopment of dural invasion by the infection, which results in
irreversible paralysis.

8. Staging of Neural deficit
Stage Neural deficit
Stage 1 Unaware of neural deficit, clinician detects presence of Plantar
extensor and/or ankle clonus
Stage 2 Spasticity with motor deficit but is a walker
Stage 3 Bedridden spastic patient. Sensory scoring is the same as stage II
Stage 4 Bedridden with severe sensory loss, and/or pressure sore.
Impairment of both lateral and posterior column sensations
Stage 5 Same as stage 4 and/or bladder and bowel involvement, and/or flexor
spasms/flaccid tetraplegia/paraplegia
•Classification suggested by Tuli and modified by Jain
•Jain AK et all 2005

9. Investigations:
• Laboratory:
▫ Mantoux/Tuberculin test
▫ ESR (neither specific nor reliable)
▫ QuantiFERON-TB Gold assay (Sensitivity – 80%
and specificity 95%) – (Kumar et al, 2010)
▫ PCR (60-90% sesitivity and 80-90% specificity) –
early and rapid diagnosis

10. • Microbiological studies: to confirm
diagnosis
▫ Ziehl-Neelsen staining
▫ Culture and sensitivity – 6-8 weeks
• Solid media – LJ media – 3-6 weeks
• Commercially available Broth
culture system
▫ BACTEC, MGIT, VersaTREK,
MBBACT
▫ Growth – 4-14 days
Clusters of colourless M.tuberculosis

11. Ultrasonography
• To find out primary TB in abdomen
• Detect cold abscess
• Guided aspiration

12. Radiographic Imaging
• Early stage of infection(1-3
weeks) radiography may be
normal
• First signs are discrete
radiolucency localised within the
subchondral region, frequently
anteriorly
• Followed by loss of definition of
the end plate and narrowing of
the intervertebral disc

13. Radiological diagnosis:
• Plain Radiograph
• CT scan
• MRI spine – early involvement can be visualized
before the bone destruction .
• Bone scan
• The classic roentgen triad in spinal tuberculosis is –
Primary vertebral lesion, disc space narrowing and
paravertebral abscess

14. • Neuroimaging guided-needle biopsy from
affected site is the gold standard for the early
histopathological diagnosis of spinal
tuberculosis

15. Extradural Involvement
• Patterns of involvement:
▫ Paradiscal (Commonest)
▫ Central
▫ Anterior
▫ Posterior
▫ Synovial
▫ Skipped lesions

16. Type of
Involvement
Mechanism of involvement Radiological appearance
Paradiscal
(most common)
Spread of disease via the arteries Adjacent margins of two consecutive
vertebrae. The intervening disc space
is reduced
Central Spread of infection along Baston’s plexus
of veins
Involves central portion of a vertebra;
proximal and distal disc spaces intact
Anterior marginal Abscess extension beneath the anterior
longitudinal ligament and the
periosteum
Begins as destrictive lesion in one of
the anterior margins of the body of a
vertebra, minimally involving the disc
space but sparing the vertebrae on
either side.

17. Paradiscal lesion
Low signal on T1 and High signal on T2 –
weighted images in the end plate with narrowing
of the disc and paraspinal and epidural abscesses

18. Anterior lesion
Sub ligamentous abscess, multiple segments

19. Central lesions

20. Type of
Involvement
Mechanism of involvement Radiological appearance
Skipped lesions Spread of infection along Batson’s plexus
of veins
Circumferentially involvement of two
noncontiguous vertebral levels without
destruction of the adjacent vertebral
bodies and intervertebral discs.
Posterior Spread via the posterior external venous
plexus of vertebral veins or direct spread
Involves posterior arch without
involvement of vertebral body
Synovial Hematogenous spread through
subsynovial vessels
Involves synovial membrane of atlanto-
axial and atlanto-occipital joints

21. Posterior lesion

22. Differential diagnosis
• Infection –
▫ pyogenic,
▫ brucella
• Neoplastic – commonly lymphoma/metastasis
The diagnosis of tuberculosis depends mostly on
histopathological evidence

23. Complications of Spine TB
• Paraplegia
• Cold abscess
• Spinal deformity –knucle, gibbus,
kyphosis, scoliosis
• Sinuses
• Secondary infection
• Amyloid disease
• Fatality

24. Priciples of Management
• Early diagnosis
• Prompt and efficient Medical Treatment
• Aggressive surgical Approach
• Prevention of deformity

25. Clinical Factors Influencing Prognosis in Cord Involvement

26. Antituberculous Treatment
• ATT shoulld be started as early as possible
• Treatment response is apparent in the form of
▫ Pain relief
▫ Decrease in neurological deficit
▫ Healing of lesion and even some correction of
spinal deformity with supportive spinal braces.

27. Therapeutic regimen
• WHO - Spinal tuberculosis falls under
Category 1 i.e, “new” EXTRAPULMONARY LESION
• Cat 1 :Two phases:
▫ Intensive phase – 2HRZE
▫ Continuation phase – 4HR
• But, WHO recommends 9 months of treatment for Bone
and joint TB
• American Thoracic Society – reccomends 12 months in children
• But many expert still believe 12-24 months or until
radiological or pathological evidence of regression of
disease occurs

28. Middle Path Regime
• Tuli in 1975 , it advocates conservative treatment with
multi-drug chemotherapy
• Surgery reserved for specific Indications
• Tuli SM, Results of spinal tuberculosis by ‘middle path’ regime.
JBJS (British) :1975:57(1):13-23

29. Spinal deformity vs Conservtive Mx
• Development of kyphosis is the rule rather than the
exception.
• Conservatively treated patients have a mean
increase in deformity of 15deg.
• Final deformity of >60deg – 3-5%
• Guven O. Severe kyphotic deformity in tuberculosis of the spine. Int
Orthop 1996:20:271
• Rajasekaran S et all; JBJS(Am), 1987;69-A:503-9

30. Early Intervention
• Majority of the cases can be treated successfully
with conservative treatment.
• But when indicated, especially when there
is neurological deficit, good
decompression and fusion should be done
promptly.

31. Indication for surgery
• Patient without neurological complications
▫ Progressive bone destruction inspite of ATT
▫ Failure to respond to conservative therapy
▫ Evacuation of paravertebral abscess
▫ Uncertainity of diagnosis, for biopsy
▫ Mechanical reasons: instability
▫ Prevention of severe kyphosis in young children
▫ Large paraspinal abscess

32. Indication for surgery
• Patient 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
▫ Neural arch disease
▫ Painful paraplegia in elderly patients
▫ Spinal tumor syndrome (epidural spinal tuberculoma
without osseous involvement)

33. Two types of Surgery
1. Debridement of the infected material without
stabilization
2. Debridement with stabilization of the spine (spinal
reconstruction)
• Reconstruction with bone grafts
• May also be done using artificial materials like steel,
carbon fiber or titanium

34. Surgical Approaches

35. Potential Benefit of surgery
• Less kyphosis
• Immeiate relief of compressed neural tissue
• Quicker relief of pain
• Higher percentage of bony fusion
• Quicker bony fusion
• Less relapse
• Earlier return to previous activities
• Less bone loss
• Prevent late neurological problems due to kyphosis and
fibrosis

36. Thank You