Name : Mrs. R
Age : 43 years old
Sex : male
Occupation : Unemployeed
Date of admission : April 29th 2014
Registration : 652179
Chief complain: Lump at the back
Suffered since 7 month ago.Initially as big as a marble and gradually increase in size. The consistency of the lumb is solid and hard. Patient also complained of pain in his back since more than a year ago. Accompanied by sharp pain, not radiating, continuous, increase when the patient walk and relieved if the patient rest.
History of prolonged cough (+), history of dyspneu (+), history of loose weight (+), history of high fever (-), history of sweat on night(+), history of trauma (-), history of TB treatment (-) , history of family with same disease (-), history of contact with patient with TB (+) Urination and defecation are normal.
a. General Statue:
Poor nourished/ Conscious
b. Vital Sign
Blood Pressure : 120 / 80 mmHg
Heart Rate : 78 x/mnt
Respiratory Rate : 20 x/mnt
Temperature : 36,7 ° C
Inspection : Skin colors same with vicinity, Deformity (+) , Swelling (-), Hematoma (-), Gibbus (+)
Palpation : Tenderness (-), step off (-)
Laboratorium Hasil WBC 9.3. 103/Ul HGB 12.4 g/Dl RBC 4,77. 106/uL HCT 32.6 % PLT 324 103/uL GOT 52 u/l GPT 184 u/l Ureum 48 mg/dL Creatinine 1,3 mg/dL LED 69/101
a. Thoracolumbal X-Ray
b. Chest X-Ray
c. MRI thoracolumbal
Mr. R, 43 years old, chief complain Lump at the back since 7 month ago.Initially as big as a marble and gradually increase in size. The consistency of the lumb is solid and hard. Patient also complained of pain in his back since more than a year ago. Accompanied by sharp pain, not radiating, continuous, increase when the patient walk and relieved if the patient rest.There are History of prolonged cough, history of loose weight, History of night sweat and history of contact with TB patient.
On physical exam there are deformity and gibbus.
Laboratory findings: ESR elevated
Radiological imaging: Destruction of invertebra disc CV T10-L1 due to Spondylitis TB.
ANATOMY OF SPINE
A basic understanding of the spine’s anatomy and its functions is extremely important for patients with spinal disorders. The vertebral column in an adult typically consists of 33 vertebrae arranged in five regions: 7 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 4 coccygeal.(1),(2)
Figure 1. anatomy of vertebra and their nerve
The nerve root exit spinal column via intervertebral foramen C1-7 exit from above their vertebra, C8-L5 exit below their vertebra (C7 exit above C7 vertebra and C8 exit below C7 vertebra), the end of medula spinalis at L1 (Conus Medullaris) and the Lumbar and sacral nerve form cauda equina in spinal canal before they exit.(1),(2)
Figure 2. Vascularization of vertebrae
The spinal cord vasculature has a complex and highly variable anatomy. It consist of intercostales artery, radicular arteries, spinal arteries which originated from thoracoabdominal aortae and Batson’s plexus. The left arterial intercostales form an artery of Adamkiewicz, the greatest anterior radicular artery, it supplies inferior thoracal segmental, superior lumabales, and lumbosacrales enlargement of cord. When damaged or obstructed, it can result in anterior spinal artery syndrome,with loss of urinary and fecal continence and impaired motor function of the legs; sensory function is often preserved to a degree. The Batson venous plexus (Batson veins) is a network of valveless veins in the human body that connect the deep pelvic veins and thoracic veins (draining the inferior end of the urinary bladder, breast and prostate) to the internal vertebral venous plexuses. Because of their location and lack of valves, they are believed to provide a route for the spread infection and some metastases.(1),(3)
B. SPONDYLITIS OF TUBERCULOSIS
Spondylitis tuberculosis also known as Pott disease is one of the oldest demonstrated diseases of humankind, having been documented in spinal remains from the Iron Age and in ancient mummies from Egypt and the Pacific coast of South America.(4)
Data from Los Angeles and New York show that musculoskeletal tuberculosis affects primarily African Americans, Hispanic Americans, Asian Americans, and foreign-born individuals. Approximately 1-2% of total tuberculosis cases are attributable to Pott disease. In the Netherlands, xbetween 1993 and 2001, tuberculosis of the bone and joints accounted for 3.5% of all tuberculosis cases (0.2-1.1% in patients of European origin, and 2.3-6.3% in patients of non-European origin). As with other forms of tuberculosis, the frequency of Pott Disease is related to socioeconomic factors and historical exposure to the infection. In the United States and other developed countries, Pott disease occurs primarily in adults. In countries with higher rates of Pott disease, involvement in young adults and older children predominates.(4)
Mycobacterium tuberculosis is the pathogen responsible for spinal tuberculosis. It is usually a secondary infection, with the primary extraspinal lesion usually occurring in the chest or genitourinary system. These primary sites may be quiescent.(1)
Mycobacterium tuberculosisis spread by small airborne droplets, called droplet nuclei, generated by the coughing, sneezing, talking, or singing of a person with pulmonary or laryngeal tuberculosis..
Figure 3. Patomechanism Schematic of Tuberculosis
Once inhaled, the infectious droplets settle throughout the airways. Introduction of M tuberculosisinto the lungs leads to infection of the respiratory system. Lesions in persons with an adequate immune system generally undergo fibrosis and calcification, successfully controlling the infection so that the bacilli are contained in the dormant, healed lesions. For less immunocompetent persons, granuloma formation is initiated yet ultimately is unsuccessful in containing the bacilli; however, the organisms can spread to other organs, such as the lymphatics, pleura, bones/joints, or meninges, and cause extrapulmonary tuberculosis.
Generally, TB spine is a secondary infection. The primary disease may be in the lung (Ghon’s focus), the alimentary tract, the tonsil, or the genitournay tract. Bone and joint involvement develop in approximately 10% of patients with TB and half of them have TB of the spine. Half of TB spine occurs in the thorax, up to 40% in the lumber and another 10% in the cervical region, though the figures may vary. (Watts & Lifeso 1996; Moon, 1997). Neurological deficit may develop in up to half of the patients. (Moon 1997).
The disease begins in the anteroinferior portion of the vertebral body and tends to spread beneath the anterior longitudinal ligament to involve adjacent vertebral bodies. Narrowing of the disc space occurs as a late phenomenon when destruction of the cancellous bone on the both sides of a disc allows the disc to herniate into the affected vertebral body or bodies infarct and osteonecrosis may lead to a decrease in vertebral height and may be accompanied by paravertebral and possibly epidural formation of an abscess. In adults, disk disease is secondary to the spread of infection from the vertebral body. In children, the disk, because it is vascularized, can be the primary site. Progressive bone destruction leads to vertebral collapse and kyphosis.
The spinal canal can be narrowed by abscesses, granulation tissue, or direct dural invasion, leading to spinal cord compression and neurologic deficits. The kyphotic deformity is caused by collapse in the anterior spine. Lesions in the thoracic spine are more likely to lead to kyphosis than those in the lumbar spine. A cold abscess can occur if the infection extends to adjacent ligaments and soft tissues.
Potential constitutional symptoms of Pott disease include fever and weight loss. The reported average duration of symptoms at diagnosis is 4 months but can be considerably longer. This is due to the nonspecific presentation of chronic back pain. Back pain is the earliest and most common symptom of Pott disease, with patients usually experiencing this problem for weeks before seeking treatment. The pain caused by Pott disease can be spinal or radicular. The pain is usually of insidious onset and may be mechanical in nature during the initial stages of disease. Weight loss, fever and malaise may be associated with the chronic illness that precedes identification of the spinal lesion.
The physical findings include local tenderness, muscle spasm, and restricted motion. Neurologic abnormalities can occur in of 50% cases those with tuberculosis spondylitis and can include spinal cord compression with paraplegia, paresis, impaired sensation, nerve root pain, and/or cauda equina syndrome. A neurological deficit will develop in 10 to 47 percent.
The diagnosis is usually made with high index of suspicion in endemic areas in the presence of pain and appropriate clinical symptoms and signs of a systemic chronic infection. If the diagnosis cannot be established by clinical manifestation, radiographic charges, CT and MRI, cultures of blood and/or percutaneous vertebral aspirates, then bone biopsy, either by an open or percutaneous procedure is recommended.
Diagnostic procedures such as culture, antigen demonstration, serology tests and polymerase chain reactions are high priority. Polymerase chain reactions has opened up another exciting era in the diagnosis and management of tuberculosis. Through the polymerase chain reaction test, it was found that drug resistance of mycobacterium tuberculosis in many cases has been associated with discrete genetic mutation.
Typical plain radiographic changes include destruction of two adjacent vertebral bodies, narrowing of the intervening disc, scalloping of the anterior vertebrae and a fusiform paravertebrae abscess shadow. Although CT demonstrates the details and soft tissue calcification better, MRI is most useful in diagnosing early or multicentric lesions before plain radiograph charges become obvious. The lesion in T1 weighted image appears hypointense and in the T2 images hyperintense, and lesions are further enhanced by intravenous gadolinium DTPA injection. MRI is also more superior in showing tuberculosis arachnoiditis and extradural or intradural spread of the abscess or granulation tissue. Techetium 99m methylene diphosphonate and gallium 67 isotope scanning have sensitivities of about 92% and 88.5%, respectively, but neither of them is specific enough for routine use as a diagnostic tool.
Tuberculosis is an excellent mimicker; neither clinical nor imaging criteria are absolutely pathognomonic. A biopsy is usually necessary to confirm the diagnosis and has become one of the indications for surgical intervention. Recent advances of CT guided biopsy and video assisted thoracoscopic surgery have enabled a less invasive way of taking a biopsy or draining an abscess which at the same time obtaining a high cytologic yield of about 88.5%. Acid fast bacilli is not seen in 50% of the histologic sections due to its low count in a spinal focus. The presence of Langhans multinucleated giant cells, typical epitheliod granuloms and caseation are already sufficient to make the diagnosis
The aims of treatment in spinal tuberculosis are eradication of the infection, preservation or restoration of neurological integrity and prevention or correction of spinal deformity. Since the introduction of anti-tuberculosis antibiotics, there has been a consenses that a multiple drug combination regimen is necessary for effective treatment of the infection. The drugs have to be given over an extended period of time because most of them are bacteriostatic rather than bacteriocids.
A lot of work has been done to find the best combination and the shortest but most effective regimen so as to improve drug compliance and save resources. On the other hand, in centers where expertise was available, excellent results were reported from surgical treatment. The recommendation for therapy vary from year to year, and from region to region, depending on the prevalence of the disease and the incidence of drug resistance in mycobacterium tuberculosis.
The mainstay of treatment is antituberculosis chemotherapy. The first line of drugs currently in use include isoniazid (INH), rifampicin (RMP), pyrazinamide (PZA), streptomycin (STM), and ethambutol (EMB). A new number of second line agents that are used in special condition include ethionamide, cycloserine, kanamycin and para aminosalicyclic acid (PAS). These drugs are used in cases of poor clinical response, side effects or demonstrable resistance of bacillus to the first line drugs. INH and RMP are bactericidal against both extracellular and intracellular organism.
PZA are bactericidal only in an acidic environment and effective against intracellular organism or within caseous lesions. STM is actively only in the extracellular space and often used to complement PZA. EMB is bacteriostatic against both intra and extracellular organisms. All drugs have potential toxicity Hepatitis may be caused by both INH and RMP, and it is 4 times more common in patents receiving agent than in those receiving INH alone. INH also can cause peripheral neuritis which is dose dependent. Major toxicity of STM is vestibulocochlear nerve damage and nephrotoxicity and EMB could cause significant optic neuritis (Ho and Leong, 1994).
The recommended regimen for a newly diagnosed patient is 2 months of PZA, INH and RMP daily followed by 4 months of INH and RMP given daily. An alternative but less patent regimen is INH and RMP given daily for 9 months, with or without addition of streptomycin or ethambutol daily for the first 2months. Nine-month and more recent six-month regimes have found to be effective when INH and RMP are combined and augmented by PZA and either STM or EMB in early stages of disease (Currier, 1992).
Antimicrobial resistance may occur from the multiplication of resistant mutant under monotherapy regime. Fortunately, resistance is low with drug regimens as long as the patient is compliant. Through a series of prospective studies performed by Medical Research Council is Asia, and Africa; chemotherapy was established as an effective treatment for the majority of patients with spinal tuberculosis. 13th MRC reports 1999 have shown excellent results of chemotherapy as an outpatient basis without bed rest, splintage or surgery, in term of healing of spinal disease and bony fusion. Bed rest, splintage, operative treatment or addition of streptomycin to combination of PAS and INH did not give any significant improvement in the results.
Surgical Management of Spinal tuberculosis.
An operation is done aiming to drain abscess, to debride bone and disc, decompress the spinal cord or stabilize the spine to prevent or correct deformity. An absolute indication for surgery is paraplegia of active disease and operation gives rapid cord decompression and thus early and complete recovery. Other indications for surgery are:
a. patient with neurologic deficit who failed conservative treatment
b. posterior spinal lesion
c. instability after healing
d. neurological complication
There were two main types of surgeries, which were also studied by the UK Medical Research Council
1. Debridement, which entailed removal of all pus and necrotic tissue, achieving neural decompression – but with no attempt of fusion; and
2. Radical surgery, which involved complete removal of the disease focus until normal bleeding bone is reached, and fusion with autogenous bone graft.
Radical anterior excision of the diseased vertebra and strut graft fusion was developed by Hodgson in Hong Kong in 1956. The indications of surgery included severe pan from the expending abscess, tissue biopsy for diagnosis, neurologic deterioration from spinal cord compression, correction of severe kyphosis and tissue biopsy for diagnosis in doubtful cases. Tuli (1975) advised a “middle path” regimen of operating when medical management failed. Lifero et al. (1985) generally concluded that patients with mild neurological defects and kyphoisis should be treated with medical therapy and if an abscess is present to operate early.
To verify whether surgery was essential for a good outcome, the Medical Research Council multicenter trial in Hong Kong, Korea and Rhodesia to which the patients were randomly allocated drug treatment alone, limited debridement or radial surgery (Hong Kong proecedure). Hong Kong surgery produced significantly better correction of deformity, less long term deterioration better correction of kyphosis and much higher bony fusion rate. Although chemotherapy is the mainstay in the management of tuberculosis spondylitis, surgical procedures still play a major role, especially in four aspects of management which are cold abscesses, tuberculosis lesions, paraplegia and in kyphosis or other deformities.
In 1779, Pott’s advocated drainage and dressing of the abscess until the patient perfectly recovered the use of his legs. Such optimism was held for a long time and it was thought evacuation of the abscess improved the patient’s general condition with rapid recovery. However this belief is no longer recommended for all abscesses (Moon, 1997). Focal debridement can effectively clean debris and remove sequestra, but it does not prevent progression of kyphois and has no advantage over ambulant chemotherapy alone, and is therefore no longer the preferred method of treatment.
Anterior radical surgery is the treatment of choice. Prior chemotherapy for at least two weeks to anterior surgical extirpation of the tuberculosis focus, followed by its replacement by bone grafting (iliac crest, ribs or fibula) in a structurally sound position, resulting in solid arthrodesis has been advocated and there is compelling evidence of better results in terms of deformity, recurrence, development of paraplegia and resolution. (Moon, 1997) Moreover, from an anterior approach, the abscess can be evacuated, avascular material excised safe anterior decompression of the spinal cord done, tissue easily obtained for culture and sensitivity and correction of kyphosis with stabilisation of instability by autologous grafting. It is generally known that recovery rate from paraplegia is influenced by many factors: the patient’s general state, age and spinal cord condition; the level and the number of involved vertebrae; the severity of spinal deformity; the duration and severity of paraplegia; the time of initiation of treatment; the type of treatment; and drug sensitivity.
Paraplegia caused by vascular embarrassment has a worse prognosis. Patients with an atrophic spinal cord or pre-operative MRI usually do poor after decompression. In the early active stage of the disease, Pott’s paraplegia is caused by an abscess and deformity (Moon 1997). In contrast, when an operation is indicated, it is easier to do it early because abscesses dissect along tissue planes and if delayed, fibrons make the procedure technically more difficult.
Because paraplegia usually resolves rapidly after adequate decompression, many surgeons believe that is unfair to allow patients to lie paralysed for weeks to months awaiting cue through conservative means and prefer management by anterior decompression and stabilisation with bone graft. It is generally agreed that decompressive laminectomy should not be done because it destabilises the spine while offering no advantages. Currently, the only indication for laminectomy in the treatment of Pott’s paraplegia is atypical disease involving the neural arch and causing posterior spinal cord compression or in posterior epidural or intradural tuberculomas. Likewise, costotraneversectomy rarely was performed to decompress the cord in the less deformed spine because the procedure makes the spine more unstable, worsens the kyphosis and is less effective in decompression than radical surgery.
Tuberculous kyphosis is an unstable lesion that tends to progress at least until there is sound bony fusion anteriorly. Rapid progression is more likely in the thoracic spine, where a natural kyphosis exists. Anterior radical surgery for kyphosis in multilevel fusion anterior strut graft is necessary with posterior stabilisation and instrumentation. Posterior stabilisation has advantages including arrest of the disease early, enhancing early fusion and allowing correction of mobile deformity. This procedure is only indicated in those patients likely to develop or who have pre-existing deformity. Other indications for this procedure include a thoracic kyphosis of more than 40o, a thoracolumbar kyphosis of more than 30o and any kyphosis deformity in the lumbosacral region that disrupts the mechanical competence of the anterior spinal column.
COMPLICATION AND PROGNOSIS (5),(6)
Paraplegia is another serious complication of spinal tuberculosis. Its incidence has been reported to be between 10 to 46% and the majority occurred in those with thoracic involvement (Hodgson et al. 1960, Moon et al. 1996, Luk 2000, Jain 2002). Neurologic deficit can occur early (during the active stage of the disease) or late (after the lesion healed – may occur years after the initial disease has healed). The prognosis depends on the age and general health of the patient, the severity and duration of neurological deficit and the treatment selected.
Early paraplegia may be caused by mechanical pressure by tubercular abscess, granulation tissue, tubercular debris and caseous tissue. Neurologic involvement during the active phase of infection can also be caused by pathologic subluxation or dislocation of vertebrae, inflammation from direct affection by the disease on the meninges and the spinal cord itself, and from infective thrombosis and endarteritis of spinal vessels leading to spinal cord infarction (Luk 2000, Jain 2002).
Late-onset paraplegia can be caused by local pressure on the spinal cord by anterior bony ridge, scar tissue or through formation of interstitial gliosis (Watts et al. 1996, Luk 2000, Jain 2002). Early-onset paraplegia usually has a better prognosis for response to treatment (conservative and/or surgical) compared to late onset paraplegia (Watts et al. 1996, Moon et al. 1996, Moon 1997, Jain 2002).
Other factors that influence recovery from paraplegia are : the patient’s general state, age and preexisting spinal cord condition; the level, severity and number of vertebral involvement; the severity of spinal deformity; the duration and severity of paraplegia; the time to initiation of treatment; the type of treatment and drug sensitivity (Moon et al. 1996, Jain 2002). Moon et al. (1996) also found out that prognosis was poor in patients with paraplegia longer than 6 months, paraplegia associated with vascular embarrassment and spinal cord atrophy (on MRI), and in patients with late-onset paraplegia.
Spinal tuberculosis, with its dreaded complications, imposes challenge for surgeons and physicians to continue studying and constructing the best treatment protocol. Chemotherapy, being the mainstay of treatment, has to be supplemented in certain conditions by surgery. In the end, what we want out of these treatment regimes is an efficient, properly-timed and patient-centered management of spinal tuberculosis and its complications.
1. Raymond J. Gardocki, et all. Spine. Campbell Operative Orthopaedics 8th Edition. Mosby, An Imprint of Elsevier.
2. Thompson JC. Netter’s Concise Orthopaedic Anatomy 2nd Edition. Elsevier Saunders.
3. Moulton A. Understanding Spinal Anatomy. [Online]. [Cited 3 Februari 2014]; from URL: http://ptjournal.apta.org/content/81/6/1264.full
4. Purves D, Augustine GJ, Fitzpatrick D, et al., editors. Sunderland (MA): The Blood Supply of the Brain and Spinal Cord. Neurosciences 2nd Edition. 2001. Sinauer Associates. http://www.ncbi.nlm.nih.gov/books/NBK11042/
5. Hidalgo JA. Pott Disease Treatment & Management. [online]. [Cited 23 January 2014]; from URL: http://emedicine.medscape.com/article/226141-overview#showall
6. Millers. Reviews of Orthopaedics 4th Edition. America Saunders;2004. Chapter 7, Spine; p.445.
7. Apley, System of Orthopaedics and Fractures, 9th edition. Southampton. 2010. P. 491-493