Consultant Spine Surgeon Discusses 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
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Consultant Spine Surgeon Discusses Treatment of Spinal Tuberculosis
- 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. Spinal Tuberculosis is a MEDICAL disease
- 3. Surgery is reserved for COMPLICATIONS
- 4. 30y ♂ After 12 months of AKT
- 5. MRC trials Medical research council (UK) JBJS Br 1965-1998 Rhodesia, Hong Kong, Korea and India
- 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. Fusion @ 15y 5% of Chemotherapy alone had alarming ↑ in kyphosis 51 to 70 deg No late onset myelopathy Kyphosis @ 15y
- 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. 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. 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. 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. 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. 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. T R E A T M E N T O F S P I N A L T B
- 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. Investigations In all patients Diagnosis Type of compression (“soft” or “hard”) Status of spinal cord Extent of disease MRI + screen
- 17. ± CT scan
- 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. Core Biopsy High risk for drug resistance Previous ATT Noncompliance / incorrect ATT Atypical presentation Multifocal disease Children Immunocompromised Endemic City (Mumbai) Image guided
- 20. Core Biopsy Gene Xpert (PCR) AFB smear TB MGIT cultures HPE examination Bacterial cultures
- 21. Biopsy Gene Xpert (PCR) Sensitivity 47% (smear negative) Sensitivity 100% (smear positive) Fast turnaround time Detect Rif resistance
- 22. Biopsy MGIT (myco growth indicator tube) Sensitivity 50-60%
- 24. Biopsy Line Probe Assay (PCR)
- 25. Conservative Care Infectious disease consult Start empirical ATT after biopsy 2 HRZE + 10 HRE (daily dosing) Duration 9-12 months Nutrition Bracing
- 26. Doses are as per weight of patient Don't add Levoflox or Ofloxacin to first line ATT
- 27. Surgery is reserved for COMPLICATIONS
- 28. N E U R O L O G I C A L D E F I C I T
- 29. Causes of neurological deficit Compressive Non compressive (Vascular)
- 30. Causes of neurological deficit Compressive “Soft” Abscess Granulation tissue “Hard” Sequestra (disc / bone) Internal gibbus Translation, dislocation
- 31. Abscess
- 33. Sequestra
- 34. Retroplused disc
- 36. Internal Gibbus 54y F, nonabulatory, myelopathy
- 37. Sequestra Translation Internal Gibbus
- 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. 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. D E F O R M I T Y
- 42. Indications for Surgery Extensive destruction of column Progressive / severe kyphosis Circumferential destruction (dislocation, translation) Childhood tuberculosis (spine-at-risk signs) DEFORMITY
- 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. SW 15y ♂ 18o D9 56o +4 mo +4 mo +4 mo +4 mo ↑ Deformity Normal Neurology Progressive severe kyphosis
- 46. 18y ♂ Severe myelopathy, Frankel C 1 y PO 1 yPO D3 Circumferential destruction Translation
- 47. 4y♀ +6m +1y PO Difficulty walking due to pain Childhood Tuberculosis
- 48. Childhood Tuberculosis Spine-at-risk Failure of posterior column leads to severe deformity
- 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. P O O R R E S P O N S E
- 51. Poor response Clinical symptoms CBC, ESR Weight, appetite MRI New lesions Worsening of old lesions
- 52. May show worsening Paradoxical reaction Clinical response Early MRI scans
- 53. Indications for Surgery Resistant tuberculosis Spinal instability (persistent pain) Doubtful diagnosis POOR RESPONSE
- 54. Poor response ? Fusion Spinal instability Persistence or Worsening of Spondylodiscitis Review diagnosis Biopsy ? Debridement Inconclusive
- 57. +6 mo +2y +2y 58y ♀ T11 Drug Resistance (MDR)
- 58. Doubtful diagnosis 29y ♀ Not responding
- 60. No such thing ! Ideal Surgical Approach ?
- 61. Individualize
- 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?
- 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. Posterior Approach 37y ♀ Motor 0/5 B/B intact
- 68. Posterior Approach 35y M Motor 0/5, SILT B/B involved
- 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. T H A N K Y O U Sir HN Reliance Foundation Hospital Mumbai
Editor's Notes
- These statements are almost clichéd, but nevertheless true. It worthwhile emphasizing that Spinal TB is a medical disease
- And surgery is reserved for complications
- But Chemotherapy alone group had significantly higher kyphosis and non union. 5% had alarming increase in kyphosis to 70 deg However, no case of late onset myelopathy due to deformity was reported in the MRC trials
- The Hong Kong group however has suggested that the 15 year FU of MRC trails if probably insufficient as they are now seeing many patients who were conservatively treated during the study period, now presenting with late onset myelopathy. 65% of these patients have presented >20 years after antibiotic treatment
- This is another Classic paper that everyone should read. What was the conservative regimen applied in this study? Bed rest 6-9 months (hospitalised if unable to walk) Antibiotics for 2 years (no rifampicin at that time)
- Indications for surgery from neurological point of view were: Advanced neurological deficit with sphincter involvement Flexor spams Those that do not show progressive neurological improvement in 3-4 weeks of AKT. Recurrence of neurological deficit.
- of the 200 patients in this series with neurological deficit. 76(38%) improved with antibiotics. However, the paper is not clear on how many of these patients had severe deficits (e.g. Non ambulators). I suspect many of those recovered had milder deficits to begin with. 6 died Remaining 118 had surgery Not very good outcomes by today’s standards 12% mortality (surgical and anesthesia has advanced quite a bit since then). What is interesting is that only 69% with surgery fully recovered neurology. Was this because neurological decompression was delayed in may patient’s with the hope that antibiotics would work. We don’t know.
- Not much can be concluded from this study about the eventual deformity in conservatively treated patients.
- MRI spine in all patients. Screen entire spine (incidence of non contiguous lesions is 16-71%
- CT scan - Not as a routine. For surgical planning.
- Mantoux, serological test and TB gold test have no value and should not be done
- Ask for CT guided core biopsy before starting ATT in all patients. The incidence of MDR TB is increasing and it is important to know antibiotic sensitivity. some patient groups are at a high risk for MDR and it is absolutely must to attempt a biopsy before starting AKT.
- 5 things you will ask for in a biopsy
- PCR based test. Greater sensitivity Faster turnaround time (48hrs) Detection of resistance (Rif) - aide in starting MDR treatment early Can detect MTB in smear negative samples But in spinal TB, if Gene Xpert is negative - does not rule out tuberculosis Smear negative sensitivity is low 47% Smear positive sensitivity is high 100% Specificity is obviously is 100% (DNA PCR test)
- Culture are must for drug sensitivity testing. MGIT results available in few weeks. Sensitivity is ~50 to 60% (spinal TB is paucibacillary)
- Not routine. Only if smear positive No recommended as a routine test for extrapulmonary TB which tends to be paucibacillary. For drug resistance testing (PCR based0
- We always involve a infection disease specialist. Duration is controversial. We typically dive 9-12 months depending on clinical and radiological response
- And surgery is reserved for complications
- First complication is neurological deficit
- What is internal gibbus? Angulation of disease spine - formation of a bony ridge on the anterior wall of the spinal canal
- Extensive destruction of column and you anticipate a severe deformity Circumferential distraction with dislocation/translation Progressive kyphosis on serial imaging Childhood tuberculosis with spine at risk signs
- Surgery is indicated where there is anticipation that the destruction is severe enough to cause severe deformity or instability, potentially threatening the spinal cord. This is a 25 y old lady with severe vertebral body destruction, 5 VB are destroyed, with normal neurology. Surprisingly this patient was also ambulatory.
- 15 year old boy. D9 tuberculosis. Not much deformity. Treated with antibiotics. Progressive collapse over 4 months to 56 deg, complete collapse of D9 VB. Toppling sign. Causes of worsening of destruction despite antibiotics and bracing. Patient was compliant with antibiotics. Drug resistance? Paradoxical reaction?
- PVCR one VB. Correction from 56 deg to 14 deg
- Another patient who presented with both significant neurological deficit and severe column destruction. was operated with a P+A surgery. First...posterior...second.. High thoracotomy approach third rib bed.
- Avoid early MRI scans (3-4 months) May show radiological worsening. Paradoxical reactions. Immune reaction to dying bacilli. Go by clinical response.
- There is a nonunion with opening of the pseudo on extension film
- Fusion and column reconstruction performed
- This is a 58 yr old lady who was diagnosed with T11 tuberculosis on HPE, cultures were negative. The initial VB height loss was minimal. 6 mo later, she develop 2 VB loss, progressive kyphosis and became non ambulatory and was treated with surgery. Such progressive destruction could be because of drug resistance (which was almost non existent during the MRC trials, non compliance with antibiotics as these have to be taken for over 6 to 9 months, and a paradoxical reaction, which is typically seen in the first 3 months in 15% cases. It is also called the immune restoration syndrome which is due to exuberant inflammatory response against dying bacilli. (Especially seen in HIV patients who are on HAART and pregnancy). This patient had multi-drug resistant tuberculosis strain.
- Treated as tuberculosis, initially, worsened on treatment, neurology deteriorated. Therefore surgery was performed
- Turned out to be Non Hodgkin’s lymphoma.
- You may ask what is the ideal surgical approach?
- The key or the mantra is to INDIVIDUALIZE.
- Tuberculosis preferentially damages the anterior column and usually the spinal cord compression is from the ventral aspect of the spinal cord.
- Several advantages Ideal exposure. Direct decompression of the spinal cord. Least handling of the spinal cord. Very good reconstruction of the column is possible Avoids damaging posterior elements (which are usually intact in TB spondylodiscitis) Disadvantages Technical (requires experience with anterior approaches) Patient selection is important as all patients may not tolerate thoraotomy.
- Cervicothoracic region - anterior approach may be difficult (depend on location of the manubrium) In addition, this patient has posterior column destruction. Therefore, this was treated with a posterior approach.
- Posterior element tuberculosis. Direction of spinal cord compression was dorsal and hence posterior approach was chosen.
- Large defect may not be amenable to reconstruction via the posterior approach alone, especially in the lumbar spine where the defects are large and the lumbar roots cannot be sacrificed. Hence here A+P approach is chosen.