Management dilemma of tuberculous paraplegia in pregnancy - A case report and review of literature.

BACKGROUND: Tuberculosis (TB)/tuberculous spondylodiscitis of the spine causing paraplegia in the 2nd trimester of pregnancy is rare and poses significant management dilemmas. Pregnancy, a relatively immunocompromised state with high hormonal levels, may prompt rapid TB destruction of a vertebral body resulting in an acute/ profound neurological deficit. Here, a pregnant paraplegic mother was diagnosed with spondylodiscitis that warranted immediate decompression/fusion to achieve neurological recovery. CASE DESCRIPTION: A 26-year-old female was 23 weeks pregnant when she presented with an acute spastic paraplegia (complete motor, sensory deficit, and sphincter loss). Operative decompression utilized a Versatile Approach along with a "Hartshill rectangle" for fusion and sublaminar wiring. This procedure accomplished simultaneous anterior and posterior fixation with a single approach without the need for intraoperative radiologic imaging. Although the pregnancy was continued with an uneventful perioperative period, intra-uterine fetal demise was documented 1 month postoperatively. Within 18 postoperative months the patient was neurologically intact, and fusion was confirmed on a computed tomography scan.
CONCLUSION: A 23-week pregnant female acutely became paraplegic due to T5 tuberculous spondylitis confirmed on an X-ray (only source of radiation), and magnetic resonance imaging. Following a decompression/ instrumented fusion performed without fluoroscopic guidance, the patient regained full neurological function. However, 1 month postoperatively, the fetus spontaneously aborted. Copyright:

INTRODUCTION

Spinal tuberculosis (TB) in pregnancy is rare, and even more infrequent is the acute onset of paraplegia when it occurs in the late second trimester. Here, we reviewed the case of a 26-year-old female, 23 months pregnant, who only underwent a preoperative X-ray along with a magnetic resonance imaging (MRI), and subsequently had decompressive spinal surgery with fusion performed without fluoroscopic guidance. The pregnancy was complicated at presentation with severe intra-uterine growth restriction (IUGR), the fetus spontaneously aborted 1 month postoperatively.

Case A 26-year-old pregnant female G2P2L1 at 23 weeks of gestation developed over a 10 days period subacute onset paraplegia (Frankel A; complete motor, sensory T10 level) with bowel bladder incontinence. Plain radiographs obtained with abdominal shielding showed a collapse of the fifth thoracic vertebral body [Figure 1] accompanied by a radio opaque shadow in the paravertebral area showing a classic appearance of spinal TB. The MRI confirmed collapse of the T5 with a prevertebral/paravertebral abscess formation contributing to cord compression [Figure 2].

Figure 1:

Preoperative X-ray showing collapse of the fifth thoracic vertebra.

Figure 2:

Preoperative magnetic resonance imaging showing collapse of the fifth thoracic vertebra with abscess.

ADMINISTRATION OF ANTI-TB THERAPY

The patient was started on four drug anti-tubercular drug therapy: isoniazid, rifampicin, pyrazinamide, and ethambutol. Tissue diagnosis was avoided as it would involve additional X-ray exposure for obtaining a specimen by fluoroscopy/computed tomography (CT)-guided biopsy. In view of the classic radiologic picture, with widespread cases of TB in our country, plus her history of cervical tubercular lymphadenitis 1 year before presentation, anti-tubercular therapy was started empirically.

OBSTETRIC EVALUATION

An obstetric consult revealed that the fetus was viable but had severe IUGR, with Doppler studies revealing reduced flow in the umbilical artery.

SURGERY

A decompressive laminectomy with instrumented fusion was performed in the thoracic spine. In the left lateral position, the surgeons utilized a “Versatile approach”[4] allowing for simultaneous anterior and posterior decompression; the fusion included a Hartshill rectangle [Figure 3] with sublaminar wiring and bone grafting. During the surgery, a senior obstetric anesthetist was present to prevent maternal hypotension, hypoxemia, and hypothermia; fetal monitoring was additionally performed by the attending obstetrician postoperatively. Successive ultrasound scans were also obtained to avoid maternal/fetal complications.

Figure 3:

Postoperative X-ray showing implant in situ.

When 3 weeks of antitubercular drug therapy resulted in no neurological recovery, a decision for operative decompression was taken.

PATHOLOGY

The pathology was consistent with necrotizing granulomatous osteomyelitis. Nucleic acid based amplification tests detected the presence of Mycobacterium tuberculosis. On culture, there was growth of M. tuberculosis which was sensitive to all four first-line antitubercular drugs.

POSTOPERATIVE COURSE

The postoperative course was uneventful. She regained partial power in the lower extremities within the 1st postoperative week. Although spasticity persisted for 14 months, motor recovery was complete at 3 postoperative months, and she additionally regained normal bowel and bladder function. At 18 months, a CT scan documented fusion [Figure 4]. Antitubercular drug therapy was stopped after radiological and serological evidence of cessation of disease process as per institutional protocols.

Figure 4:

Postoperative computed tomography scan showing fusion at 18 months.

SPONTANEOUS FOETAL ABORTION

Postoperative obstetric ultrasonography showed a single live intrauterine pregnancy with IUGR. However, the 4-week post surgery ultrasound showed reversal of end diastolic flow in the umbilical artery, and eventually confirmed intrauterine fetal demise. Despite the failure to save the fetus in this case, the authors concluded that surgical decompression/fusion for acute paraplegia due to TB of the spine remains a viable option for pregnant patients with significant TB-related neurological deficits.

DISCUSSION

A third to half of the cases of skeletal TB involves the vertebral column, and TB of the spine accounts for about 2% of all cases of TB. There are no well-defined protocols for the management of pregnancy complicated by tuberculous spondylitis with paraplegia in the second trimester of pregnancy. Pregnancy, with high serum steroid levels and a relative immunocompromised state, may enable skeletal TB to become potentially aggressive leading to rapid/profound vertebral destruction and neurological deterioration.[1,2] As ionizing radiation can be largely avoided, (e.g., by utilizing MR scans), continuing pregnancy in cases requiring decompression/fusion remains a viable option.

The first-line drugs rifampicin, isoniazid, and ethambutol are not shown to have any significant adverse maternal-fetal effects or requirement of dose adjustment during pregnancy and in the postpartum period.[3]

CONCLUSION

Neurological defecit resulting from TB of the spine has a good prognosis if early decompression and stabilization are performed under the cover of antitubercular drug therapy Here, the surgery included a “versatile” approach, which allowed for simultaneous anterior/posterior access to the vertebral column and decompression/fusion. All possible precautions were taken to prevent maternal hypotension, hypothermia, and hypoxia during surgery.

Although the pregnancy resulted in fetal demise in this case, for others maintaining the pregnancy may be a viable option in conjunction with decompression/fusion to reverse major acute neurological deficits associated with TB spondylodiscitis.