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Tuberculosis of Spine Overview
The tuberculosis of the spine also called as Pott’s disease is a pathological condition of the spine where a bacterial infection called tuberculosis gets lodged in the spinal vertebrae. Percivall Pott first described about the tuberculosis of the spine as a painful kyphotic deformity of the spine related to the paraplegia. Spinal tuberculosis is the most common site of the skeletal tuberculosis that accounts for about 50% of the cases.
Tuberculosis of the spine most commonly occur in the lower thoracic region, followed by the lumbar, cervical regions, upper dorsal and sacral regions. In the past, this condition used to be a disease of the early childhood, but with improved public health measure, the age incidence has changed and now this occurs most frequently in adults. It is estimated that about 1-2% of the total tuberculosis cases worldwide are attributed to Pott disease. This condition is most commonly seen in males than the females.
Types of Tuberculosis of Spine
There are two types of tuberculosis of the spine. First is a classic form of Pott disease called as spondylo-discitis and other is called spondylitis without disc involvement.
- Human type: It begins with a primary focus in the lungs and then spreads through the blood into the vertebrae.
- Bovine type: This type of tuberculosis is ingested with the milk into the intestinal canal and then absorbed into the mesenteric glands and then spreads through the blood into the spinal column.
In adults, the intervertebral disc is involved as the tuberculosis start spreading from the adjoining infected vertebrae. In children, this condition is the result of the vascularized nature of the intervertebral discs. About a 10-38% percent of cases of tuberculosis of the spine are related to the extra-skeletal tuberculosis.
Diagnosis of Tuberculosis of Spine:
Diagnosis of the tuberculosis of the spine in its early phase is extremely difficult. The doctor will perform the physical examination involving the careful assessment of the spinal alignment, abdominal evaluation for the flank mass, inspect the skin carefully to detect sinuses and detailed neurological tests. These exams will reveal the local pain associated with the affected area. Blood tests, CT and MRI scans, tuberculin skin test, bone scan, radiographs of the spine, and bone biopsy are recommended to confirm the diagnosis of Pott disease.
Initial symptoms of tuberculosis of the spine are vague and consists of weight loss, afternoon fever, fatigue, evening fever, loss of appetite and loss of desire to play outdoors (specifically seen in children). Usually, back ache is minimal, muscle spasm leads to rigid back, which can limit the motion of the spine in all directions. The first noticeable signs is a kyphus in the thoracic region, as it increases the ribs will crowd together and lead to the development of the barrel chest deformity.
In the active phase, patients suffering this condition show the following symptoms:
- Stiff and painful spine
- Weight loss
- Night sweats
- Appetite loss
- Fever during the evening hours
- Paraspinal muscle spasms
Often tenderness is present in the affected vertebral levels. Depending upon the level of lesion, fluctuant swelling may occur on the side of the neck. In case of development of the paraplegia, symptoms include varying degree of the motor weakness, a hyperactive deep tendon reflexes, disturbances of anorectal and bladder function and a spastic gait.
Treatments & Management of Tuberculosis of Spine:
At present, the systemic treatment for the tuberculosis of the antituberculosis medications is the first line of treatment. As soon as the Pott disease is suspected, the patient is placed on bed rest and chemotherapy is indicated.
There are two different treatment options: non-operative and operative.
- Non-operative treatment: It includes rifampin, isoniazid and pyrazanamide therapy for a period of 9-18 months and spinal orthosis. These treatments help to control pain and prevent the deformity. Immbolization of the spine regions using different types of collars and braces, analgesics is used for treating this condition. Physical therapy for postural education, pain relieving modalities and exercise programs may be recommended to boost the strength and flexibility of the spine.
- Operative treatment: Surgery is required to debride the entire focus of the infection and successfully reconstruct the spine so as to achieve the stability of the spine. The surgical decompression, debridement and stabilization are required in patients have neurological deficits, deformity and vertebral destruction. It includes anterior debridement with uninstrumented strut grafting. The surgical treatment decreases the sinus formation, reduces the progressive kyphosis, and helps to improve the neurologic recovery in patients with neurologic deficits.
- However, as per the results from a clinical trial that compared two different treatments for a year, including the chemotherapy with surgery and chemotherapy alone to treat patients with active tuberculosis of the spine found that surgery should not be routinely recommended. Instead the doctors should selectively moderate and then decide which patients needs operation for their condition. The thoracic spinal fusion with or without instruments is used to stabilize the spinal bone.
Management of Spinal tuberculosis is based on the two groups of lesion including the neurologic complications and without the neurological deficits. Pharmacotherapy is the first line of treatment for patients having neurologic deficits and the surgical procedures are rare in this case.