Spinal

Orthopaedic Infections

Spinal Tuberculosis

Epidemiology

  • Most common form of skeletal TB ( ~ 50 %)
  • Skeletal = 3 % of all cases of TB
  • ~ 1 / 100,000 population per year
  • Common in HIV +ve

Manifestations

  • Anterior vertebral body
    • collapse
    • kyphosis
  • Neurological sequelae due to
    • Deformity
    • Epidural abscess
    • Meningitis
    • Intradural tuberculoma
  • Delay in diagnosis common
    • avg 3 – 4 months because of low index suspicion, mimicker, atrypical presentation

Presentation

  • Back pain 95 %
  • Weight loss 50 %
  • Neurological abnormality 50 %
  • Fevers 30 %
  • Night sweats 20 %
  • Weakness / Lethargy
  • Cold abscess

Investigations

  • Laboratory
    • ESR mildly up (15 % not)
    • Mild anaemia
    • WCC usually normal
    • Tuberculin test
      • may be –ve in eldrly & immunosuppressed
  • Xrays
    • CXR +ve in only ~ 50 %
    • Spine Xray
      • Imaging usually normal early
      • Later imaging
        • Decrease disc height, localised osteopaenia, collapse, kyphosis
  • MRI
    • extent of disease, bone & extraosseous
  • CT
    • define extent of bone destruction, guide biopsy, plan surgery
  • Bone scan
    • negative in ~ 10 %
    • look for multifocal disease
  • Biopsy
    • Cover with Abs to prevent dissemination
    • Open vs II guided Craig needle
    • CT guided FNA
    • AFB’s on smear in ~ 50 %, +ve culture in ~ 80 %, Cytology ~ 70 %

Natural Hitory

  • Progressive bone destruction
  • Complications
    • neurology, abscess / sinus, disseminated disease, fistulae

Treatment

Principles

  • Control infection
  • Prevent or correct deformity
  • Prevent or treat neuro complication

Surgery

  • Absolute indications
    • marked neuro deficit
      • paraplegia, paresis
    • Progressive neuro deficit
    • Failure of chemoRx to control
    • Severe kyphosis + active disease
    • Progressive kyphosis
    • Large abscess
    • Instability
  • Relative indications
    • Obtain specimen for culture
    • Pain
    • Minor neuro signs
    • Children – prevent kyphosis
  • Kyphosis
    • Minimal deformity
      • Abs + brace
    • Progressive deformity & failed conservative
      • surgery
    • > 30°
      • surgery