That Nagging Back Pain may be Spinal Tuberculosis

May 25, 2015

That Nagging Back Pain may be Spinal Tuberculosis

One of the oldest diseases known to mankind, Pott’s spine or spinal tuberculosis is common in occurrence and has high frequency of long term morbidity. In 2009, approximately 1.2 million new tuberculosis cases were reported in HIV positive populations and 90% of these were African and South East Asians. Spinal Tuberculosis is uncommon in the Western World. In endemic countries, it is more common in children and younger adults, while it affects the adult population in developed Western and Middle East countries.

What is Spinal Tuberculosis

In spinal tuberculosis, the intervertebral disk space and the adjacent vertebral bodies are destroyed. Initially, it affects the anterior inferior part of the vertebral body which spreads on to the central part of the body or disk later on.

The spinal elements and anterior wedging lead to the characteristic angulation and palpable deformity of the involved vertebrae. The upper lumbar and lower thoracic spine are most frequently involved. More than one vertebra and vertebral body is affected. The distortion of spinal column leads to deformities of the spine.

In younger patients, the disk is primarily involved while in older patients the disk is not primarily involved.

What are the alarming signals?

The clinical features of spinal tuberculosis are generally inclusive of:

Local pain, tenderness, stiffness and spasm of the muscles

A cold abscess or a localized collection of pus surrounded by inflamed tissue which is generally painless.

Prominent spinal deformity, kyphosis formation most commonly involves lesions of thoracic vertebrae.

Gibbus formation: a structural deformity where one or more vertebrae become wedged.

The progression of illness is slow and its duration varies from a few months to few years, with an average duration ranging from 4 to 11 months.

Back pain is the most frequent symptom of Spinaltuberculosis whose intensity varies from a persisting mild dull aching to severe disabling. Usually, patients seek advice only when there is severe pain, marked deformity or a neurological symptom. The pain is localized to the site of involvement and may be aggravated by spinal motion, coughing and weight bearing resulting from the advanced disk disruption and spinal instability, nerve root compression or pathological features such as pus formation. Almost 61% of total Spinal tuberculosis cases reported of chronic back pain. Other symptoms of active disease are malaise, loss of weight and appetite, night sweats, evening rise in temperature, generalized body aches and fatigue.

If left untreated, early neurologic involvement may progress to a complete paraplegia or tetraplegia. Spinal deformity can be passed on as a hallmark of Spinal tuberculosis. The location of the tuberculosis lesion defines the type of deformity.

What are the tests done to diagnose Spinal Tuberculosis

Screening of the whole spine should be done to detect non-infectious vertebral lesions. Magnetic resonance imaging is most sensitive imaging technique and it demonstrates involvement of the vertebral disks on either side of the disk, disk destruction, cold abscess, vertebral collapse and presence of vertebral column deformities. Neuroimaging needle biopsy is done early for histopathological diagnosis. Diagnosis depends on histological evidence. Polymerase chain reaction is also promising in early diagnosis of the disease. Erythrocyte sedimentation rate is also raised in patients of spinal tuberculosis.

Treatment of Spinal Tuberculosis

The treatment should be initiated as early as possible. The treatment protocol generally includes antituberculous treatment, supportive therapy and surgery.

Antituberculous treatment

Most of the patients respond very well to treatment. The responses to therapeutic regimen with antitubercular drugs include pain relief, decrease in neurological deficit and correction of spinal deformity. WHO recommends a category based treatment of tuberculosis. Spinal tuberculosis is included in Category I treatment.

Initial Phase I: Intensive phase for 2 months. It includes a combination of four first line drugs; isoniazid, rifampicin, streptomycin, and pyrazinamide.

Continuation Phase 2: Two drugs, isoniazid and rifampicin are given for four months,

WHO recommends 9 months of treatment for tuberculosis of bones and joints. Direct observed treatment and short course regimens are administered to take care of poor compliance.

Supportive care

Ambulatory care without prolonged recumbency. Adequate rest is suggested. Caste or brace immobilization was used initially which is inefficient and has been generally abandoned in present day treatment protocols.

Surgery

Surgery is reserved for specific indications. Surgery is beneficial in case of pan-vertebral lesions, refractory disease, severe kyphosis, a developing neurologic deficit, clinical deterioration or lack of clinical improvement. Two types of surgical procedures are performed:

Debridement of the infected material
Debridement of the infected material with stabilization of spine (Spinal reconstruction using bone grafts or artificial materials like steel, carbon fiber, titanium).

Spinal tuberculosis is usually not contagious. All complications can be prevented with strict adherence to treatment regimen and corrective surgeries. Maintain a healthy life style, well balanced nutritious diet, regular exercise; avoid alcohol and smoking and maintaining good control of blood sugar

Patients who do not show deformity or neurologic deficit show good prognosis. Almost 82 to 95% patients respond well to the medical treatment alone. Early diagnosis and rapid intervention improve the prognosis for spinal tuberculosis.

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