Tuberculosis Spondylitis and Treatment Pembimbing: Dr. dr. Bambang Tiksnadi, Sp.B., Sp.OT(K)., MM. Dr. dr. Ahmad Ramdan, Sp.OT(K)., MKM. dr.Abdul Kadir, Sp.OT Oleh M. Eka Putra

1. Introduction Spinal infection by tuberculosis, or commonly referred to as tuberculosis (TB) spondylitis Potential to cause serious morbidity, including a permanent neurological deficit and spinal deformity. Various studies have been conducted to evaluate the effectiveness of TB spondylitis treatment approaches with mixed results and recommendations.

2. Epidemiology In 2005, the World Health Organization (WHO) estimates that the largest number of new TB cases are found in Southeast Asia (34 percent of global TB incidents) including Indonesia. Indonesia ranks third after India and China as the country with the largest population of TB patients

Clinical presentation Presentation depends on the following: Stage of disease Site Presence of complications such as neurologic deficits, abscesses, or sinus tracts.  The reported average duration of symptoms at the time of diagnosis is 3-4 months.

Clinical presentation (cont.) The average duration of symptoms at the time of diagnosis is 3-4 months Back pain is the earliest and most common symptom. Patients have usually had back pain for weeks prior to presentation. Pain can be spinal or radicular.

Clinical presentation (cont.) Constitutional symptoms include fever and weight loss. Neurologic abnormalities occur in 50% of cases and can include spinal cord compression with paraplegia, paresis, impaired sensation, nerve root pain, or cauda equina syndrome.

Clinical presentation (cont.) Cervical spine tuberculosis is a less common presentation but is potentially more serious because severe neurologic complications are more likely. This condition is characterized by pain and stiffness. Patients with lower cervical spine disease can present with dysphagia or stridor.

Clinical presentation (cont.) Physical examination should include the following: Careful assessment of spinal alignment Inspection of skin, with attention to detection of sinuses Abdominal evaluation for subcutaneous flank mass Meticulous neurologic examination

Clinical presentation (cont.) The thoracic spine is frequently reported as the most common site of involvement followed by lumber spine The remaining cases correspond to the cervical spine. Spine deformity (kyphosis) of some degree occurs in almost every patient.

Clinical presentation (cont.) There may be large cold abscesses of paraspinal tissues or psoas muscle that protrude under the inguinal ligament. They may erode into the perineum or gluteal area.

Clinical presentation (cont.) If there is no evidence of extraspinal tuberculosis, diagnosis can be difficult. Information from imaging studies, microbiology, and anatomic pathology should help establish the diagnosis

Workup Lab studies Tuberculin skin test demonstrates a positive finding in 84-95% of patients who are non–HIV-positive. ESR may be markedly elevated (>100 mm/h).

Workup (cont.)  Microbiology studies to confirm diagnosis: Obtain bone tissue or abscess samples to stain for acid-fast bacilli (AFB), and isolate organisms for culture and susceptibility.  These study findings may be positive in only about 50% of the cases.

Workup (cont.) Imaging studies Plain radiography demonstrates the following characteristic changes of spinal tuberculosis: Lytic destruction of anterior portion of vertebral body Increased anterior wedging

Workup (cont.) Collapse of vertebral body Reactive sclerosis on a progressive lytic process Enlarged psoas shadow with or without calcification Additional findings Vertebral end plates are osteoporotic. Intervertebral disks may be shrunk or destroyed.

Workup (cont.) Fusiform paravertebral shadows suggest abscess formation. Bone lesions may occur at more than one level.

Workup (cont.) Intervertebral disks may be shrunk or destroyed. Vertebral bodies show variable degrees of destruction

Workup (cont.) CT scanning CT scanning provides much better bony detail of irregular lytic lesions, sclerosis, disk collapse, and disruption of bone circumference. Low-contrast resolution provides a better soft tissue assessment, particularly in epidural and paraspinal areas.

Workup (cont.) MRI MRI is the criterion standard for evaluating disk space infection and osteomyelitis of the spine and is most effective for demonstrating the extension of disease into soft tissues and the spread of tuberculous debris under the anterior and posterior longitudinal ligaments

Workup (cont.) MRI is most effective for demonstrating neural compression. In developed countries, MRI has nearly replaced CT myelography. Procedures: Some patients are diagnosed following an open drainage procedure (eg, following presentation with acute neurologic deterioration).

Workup (cont.) Histologic Findings: Since microbiologic studies may be nondiagnostic, anatomic pathology can be very significant. Gross pathologic findings include exudative granulation tissue with interspersed abscesses. Coalescence of abscesses results in areas of caseating necrosis.

Treatment 1. Medical treatment 2. Surgery a) Indications and Contraindications Surgery b) Selection of spinal surgical approach c) Surgical drainage of the abscess d) Surgical debridement and correction kyphosis

Treatment (cont.) d. Surgical debridement and correction kyphosis Anterior debridement and fusion without instrumentation Anterior debridement is followed by anterior or posterior instrumentation Transpedicular decompression Surgery with a posterior approach only Osteotomy and resection of the vertebral column

Treatment (cont.) e) Surgery in noncontiguous cases (skipping lesion) f) Minimally invasive surgery g) Choice of bone tart h) Surgery on Pediatric Patients i) Surgery in Elderly Patients

Conclusion Spinal infection by tuberculosis is estimated to be about one to five percent of people with tuberculosis. TB spondylitis has the potential to cause serious morbidity of great paralysis and spinal deformity.

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