Spinal tuberculosis, primarily caused by extraspinal infections, is most prevalent in India's spine and commonly affects the lower thoracic and lumbar regions. It leads to vertebral degeneration, which can result in severe complications such as paraplegia and spinal deformities if left untreated. Treatment includes a combination of anti-tubercular medication, surgical interventions, and a structured rehabilitation program focused on restoring patient mobility and function.

1. SPINAL
TUBERCULOSIS
By: Dr. Mumux Mirani

3. Introduction
 Tuberculosis of the spine is the most common condition
of the spine in India.
 The cause is always extraspinal.
 The primary focus may be active or latent foci, either in
the lungs or in the lymph glands of the mediastinum,
mesentry or cervical region, or kidney or other viscera.
 Alternatively, tuberculous bacilli may travel from the lung
to the spine by Batson's paravertebral venous plexus or
by lymphatic drainage to the para-aortic lymph nodes. In
most otherwise healthy individuals, the cellular immune
response is able to contain the bacilli present in these
sites, but not eradicate them.
 The most common site for bony tuerculosis is the spine
followed by weight bearing joints like the hip and knee.

4.  The predilection for spinal disease may be explained
by the fact that the vertebrae are extremely well
vascularized, even in adulthood.
 Spinal disease is most frequently located in the
lower thoracic and lumbar spine, with thoracic
disease being more common in children and
adolescents, whereas lumbar disease is found more
commonly in adults.

5. Pathophysiology
 It affects the vertebral body and spreads to the disc. In children since
the disc is more vascularized, that gets affected first.
 The lessions in the vertebrae can be of the following types :-
1. Paradiscal – contagious areas of two adjacent vertebrae along with
intervening disc are affected.
2. Central – body of a single vertebrae is affected. Leads to early
collapse of the vertebrae.
3. Anterior – localised to the anterior part of the vertebral body.
4. Posterior –
localised to the posterior
complex of the vertebrae-
pedical, lamina, spinous
process and transverse
process.

6.  Spinal tuberculosis typically involves the
initial destruction of the anteroinferior
part of the vertebrae.
 Bacilli may then spread beneath the
anterior spinal ligament and involve the
anterosuperior aspect of the adjacent
inferior vertebra, giving rise to the typical
“wedge-shaped” deformity.

7.  Also due to the criss crossing of trabaculae system, 2
areas of maximum resistance and one triangular area
of minimum resistance is formed, explaining the reason
for wedge or compression fractures.
 Further spread may result in adjacent abscesses.
 The infection may spread up and down, stripping the
anterior and posterior longitudinal ligaments and the
periosteum from the front and the sides of the vertebral

8.  Studies have found that following the infection,
marked hyperemia and severe osteoporosis take
place.
 Osseous destruction takes place by lysis of bone,
which is thus softened and easily yields under the
effect of gravity and muscle action, leading to
compression, collapse or deformation of the bones.
 Researchers have also found necrosis to take place
due to ischemic infraction of segments of bones.
 Ischemic necrosis has also been recognized as a
contributing factor responsible for osseous and

9.  As a result of ischemic changes,
sometimes, sequestration takes place,
usually appearing as “coarse sand,”
and rarely forming a definite
radiologically visible sequestrum.
 It is seen that due to loss of nutrition,
the adjacent articular cartilage or the
intervening disc gets degenerated and
may also become separated as
sequestra.
 The early involvement of paradiscal
regions of the vertebrae by the

10. Symptoms and signs
 Malaise, loss of weight, loss of appetite, night sweats
and evening rise of temperature.
 The spine is stiff and painful on movement, with
localized kyphotic deformity that would be tender on
percussion.
 There is a persistent paraspinal muscle spasm around
the involved vertebral bodies, which relaxes during
sleep, permitting movement between the inflamed
surfaces, resulting in typical night cries.
 A cold abscess may be present. Careful examination
may reveal a small knuckle kyphosis (gibbus formation)
on palpation of the spinous process.
 If neglected the spinal canal can be compromised and
lead to paraplegia. Most commonly seen in thoracic
regions since their spinal canal is the narrowest.

12. Complications
 Vertebral collapse leading to kyphosis or gibbus
deformity
 Spinal cord compression
 Nerve root compression
 Sinus formation
 Paraplegia
 Disc herniation
 Psoas abscess
 Cauda equina syndrome

13. Treatment
 Care of spine – rest and guarded mobilisation. As
the patient improves he is allowed to sit and walk
while the spine can be supported in a brace.
 Anti-tubercular chemotherapy
 Treatment of cold abscess – Aspiration and
evacuation, calve’s operation.

14. Surgical Procedure
1. Laminectmy and laminotomy
2. Costo-transversectomy
3. Antero-lateral decompression
4. Posterior decompression
5. Radical debridement and arthrodesis

15. Physiotherapy Management
 Studies have shown that in the acute phase rest
and pain management is of utmost importance for
maintenance of stability. (5)
 The resting period in cases without neurologic
deficits should be kept minimal (24-72 h); however,
it may be prolonged depending on general status,
pain severity, and stability in cases with neurologic
deficits. (6)
 Prolonged immobilization will lead to weakness in
the trunk and lower extremity muscles and will
contribute to the development of complications.
Prolonged immobilization may also induce
generation of secondary complications. (7,8)

16.  Later on strengthening the back and
abdominal muscles (abdominal capsule/core)
for rehabilitation is very important.
 The rehabilitation program is applied on the
basis of the neurological symptoms of the
patient.
 The presence of instability and the type of
surgical procedure are important for the
implementation of rehabilitation program

17. Acute stage
 Patients physical capacity should be determined.
 Bed positioning
 Passive, active-assisted, active exercises of all joints have
been proven to help maintain the functional capacity of the
msucles.
 If thoracic region is involved, respiratory exercises should
also begin. (5)
 Studies have shown that Isometrics have helped when
done pre operatively and early post operatively. (9,10)
 Isometric exercises are performed in cervical, thoracic, and
sacro-spinal muscle groups and all lower extremity
muscles; patient in the supine position continues to elevate
head and shoulder until the toes are visible. Gluteal
muscles are contracted and relaxed bilaterally and

18. Sub-acute
 Out of bed ambulation period.
 Depending on the infection the patient can be
mobilized with assistive devices.
 Dynamic quadriceps and other muscle setting
exercises have proved to be important in the out of
bed mobilization.
 Correct techniques of standing and weight bearing
should be taught.
 Balance exercises and strategies are taught.
 Mobilizaton 3-4 times a day has been proven to be
helpful.
(8)

19. Chronic stage
 Return back to previous life and maximum independence.
 Lying down, sitting and standing exercises should include active
and resistive exercise.
 The balance and gait exercises assets should be studied in parallel
bars.
 Climbing stairs, squat, sit on the ground activities like lifting should
be done.
 The patients are assisted to walk by using crutches or orthotics
during the chronic stage.
 Patients who achieve trunk and pelvic stabilization are taken to the
parallel bar by wearing corset for standing exercises.
 In standing position, forward, backward and sideways stepping
exercises, as well as neutral position exercises such as forward
flexion, are performed.
 Cat-camel stretching exercises and strengthening exercises are
performed to strengthen abdominal and dorsal muscles. These
exercises may also be performed in bed without wearing corset.

20. Home exercise program
 The home evaluation is an important aspect of the
rehabilitation process, to allow the patients to return home.
The main areas of concern in the home evaluation include
the entrances, bedroom, bathroom, kitchen, and general
safety issues.
 The maximum ergonomic changes should be made as
possibly in the patient’s home environment (toilet, bathroom,
bedroom, hallway, etc.) in order to ensure the patient’s
independency.
 In addition to the exercises performed during the subacute
and chronic stages, hand and wrist joint exercises, full
abduction, extension and flexion exercises for abdominal,
sacrospinal, iliopsoas, gluteus maximus, gluteus minimus,
hamstring, and quadriceps muscles, and resistive exercises
for oblique abdominal muscles are recommended to be
performed at home.

21. References
1. Viswanathan VK, Subramanian S. Pott Disease (Tuberculous Spondylitis).
2. Ansari S, Amanullah MF, Ahmad K, Rauniyar RK. Pott's spine: Diagnostic imaging modalities
and technology advancements. North American journal of medical sciences. 2013
Jul;5(7):404.
3. Onuminya JE, Morgan E, Shobode MA. Spinal tuberculosis-Current management approach.
Nigerian Journal of Orthopaedics and Trauma. 2019 Jul 1;18(2):35.
4. Rajasekaran S, Soundararajan DC, Shetty AP, Kanna RM. Spinal tuberculosis: current
concepts. Global spine journal. 2018 Dec;8(4_suppl):96S-108S.
5. Nas K, Karakoç M, Aydın A, Öneş K. Rehabilitation in spinal infection diseases. World journal
of orthopedics. 2015 Jan 18;6(1):1.
6. Chelsom J, Solberg CO. Vertebral osteomyelitis at a Norwegian university hospital 1987-97:
clinical features, laboratory findings and outcome. Scand J Infect Dis. 1998;30:147–151.
7. Bal A, Gürçay E, Ekşioglu E, Edgüder T, Tuncay R, Çakcı A. Evli birçifte eş zamanlı brucella
spondiliti (Brucella spondylits in a married couple) Romatizma. 2003;18:165–170.
8. Kıtar E. Omurganın brucella enfeksiyonu (Brucella infections of spine) In: Omurga
enfeksiyonları (Spine infections), editor. Benli T, editor. Ankara: Rekmay yayıncılık; 2006. pp.
531–546.
9. Nas K, Kemaloğlu MS, Cevik R, Ceviz A, Necmioğlu S, Bükte Y, Cosut A, Senyiğit A, Gür A,
Saraç AJ, et al. The results of rehabilitation on motor and functional improvement of the spinal
tuberculosis. Joint Bone Spine. 2004;71:312–316.
10. Nas K, Gür A, Kemaloğlu MS, Geyik MF, Cevik R, Büke Y, Ceviz A, Saraç AJ, Aksu Y.
Management of spinal brucellosis and outcome of rehabilitation. Spinal Cord. 2001;39:223–
227.

22. Thank you!