Spinal tuberculosis: A case series and a literature review.

Background: Spinal tuberculosis (TB) is a common form of extrapulmonary TB. Although the first line of the treatment is anti-TB medications, patients with severe neurological deficits, spinal instability, and/or kyphotic deformity often warrant surgery. Here, we report five cases of spinal TB requiring operative intervention at Hasan Sadikin General Hospital, Bandung, Indonesia. Case Description: We operated on five patients with spinal TB cases from 2019 to October 2021. In addition to appropriate medical management, all five patients successfully underwent laminectomy with or without posterior stabilization.
Conclusion: It is essential to establish the diagnosis and surgically manage patients with spinal TB early in the clinical course to minimize residual post-operative neurological deficits. Copyright:

INTRODUCTION

Tuberculosis (TB) is responsible for 1.3 million deaths annually.[4] In 2020, 1.5 million people died from TB (including 214,000 people with HIV). In 2020, another 10 million people have symptomatic TB worldwide.[7] Extrapulmonary TB is accounts for approximately 10% of all TB cases, 2% of which are found in the spine. Here, we appropriately diagnosed and surgically treated five patients with spinal TB and reviewed the appropriate literature.

CASE DESCRIPTION

Five patients diagnosed with spinal TB with the average age are 25.8 years old, and included two males and three females [Table 1]. Four patients presented with paraparesis and one patient presented with low back pain that radiates to both legs. MR studies showed hypointense to isointense lesion in T1-weighted images and isohyperintense and hyperintense lesion in T2-wighted images [Figures 1-5]. CT scan showed destruction of vertebral body, pathological fracture, and kyphotic deformity [Figure 6]. Intervention given includes laminectomy debridement and decompression with or without posterior stabilization. Postoperatively, two patients demonstrated partial recoveries of neurological function and three patients demonstrated full recoveries of neurological function. Postoperative MRI/CT demonstrated progressive bony healing with improvement of deformity.

Table 1:

Clinical characteristics of the patients.

Figure 1:

Thoracolumbar MRI of spinal TB in 52-year-old male; (a)T1-weighted image showed isohypointense mass at intervertebral disc L4-L5 and vertebral body of L4-5; (b)T1-weighted image showed isohypointense mass which inhomogeneously enhanced with contrast administration at intervertebral disc L4-L5; (c)T2-weighted image showed isohyperintense mass at intervertebral disc L4-L5 and vertebral body of L4-5; (d) Coronal view; (e)Axial view.

Figure 5:

MRI of spinal TB in 20-year-old female. (a) Contrast MRI showed lesion at corpus vertebrae at T2 level;(b-c) compression fracture of the corpus vertebrae at T11 and T12 level.

Figure 6:

(a-b) Thoracolumbar CT in a 22-year-old male with spinal TB showed destruction of vertebral body at T12 and L1, pathological fracture at T12 and L1, and kyphotic deformity.

(a-b) Thoracolumbar MRI in a 22-year-old male with spinal TB. T1-weighted image showed isointense mass which inhomogeneously enhanced with contrast administration at level T12-L1. T2-weighted image showed hyperintense mass at T12-L1, destruction of vertebral body, and intervertebral disc, paraspinal and retro-spinal abscess, and pathological fracture at T12 and L1.

Thoracolumbar MRI in a 21-year-old female with spinal TB. Noncontrast MRI in the lumbosacral region showed hypointense (in T1-weighted images) and hyperintense (in T2-weighted images) mass in the paravertebrae at the L1-L4 level. (a) Sagital view; (b) Coronal view; (c) Axial view.

MRI of spinal TB in a 14-year-old female. T1-weighted images showed extradural isointense lesions at T6–T8 and L1, which intensify inhomogeneously with contrast administration. Note also that there is bone destruction. T2-weighted images showed extradural isohyperintense lesion at T6–T8 and L1 with bone destruction, canal stenosis at T6-T8, and L1, and kyphotic angle 16°. (a) Axial view ; (b) Sagital view.

DISCUSSION

Medical treatment is the mainstay of the treatment for spinal TB, with surgical interventions indicated in certain circumstances.[3] Certain situations that necessitate surgical management include: failure to respond to chemotherapy or recurrence, severe weakness at presentation, and persistent or progressive neurological deficit even after starting chemotherapy, instability, incapacitating pain, and deformities.[6] The objectives of the surgical intervention are (1) abscess drainage, (2) debridement of infected material, or (3) debridement and fusion with or without stabilization. Chemotherapy alone resolves the majority of cold abscesses and drainage is only recommended in certain situations, such as respiratory distress or dysphagia caused by a large cervical paravertebral abscess, and pseudo–hip flexion deformity caused by a large psoas abscess. Debridement alone does not prevent deformity progression or improve healing rates, particularly in children, where it can cause physeal damage and rapid deformity progression.[5]

The literature describes three surgical approaches for treating spinal tuberculosis (TB): the anterior approach, the posterior approach, and the combined approach (combined anterior and posterior approach).[2,8] The anterior approach is the most convenient for debriding/reconstructing defects because it provides direct access to the infected region and a larger operational horizon than the other two approaches.[1] Initially, the posterior approach is not a routine method, but rather an alternative treatment in patients when the anterior approach is risky and cannot be performed. However, many recent studies have found that the posterior approach is superior to the anterior approach in the correction of deformity.

Yang et al. provide evidence for anterior, posterior, and combined surgical approaches for spinal TB. However, the combined approaches require significantly longer operation times and more blood loss versus anterior alone procedures. Ultimately, Yang et al. concluded that posterior approaches offered better clinical outcomes.[8] When Bian et al. evaluated the three approaches to spinal TB they found that the operative time was significantly longer in the combined surgery (i.e., with more complications) versus the other two approaches performed alone. Further, the all three approaches offered similar degrees of correction of kyphosis and similar degrees of neurological improvement.[2]

Spinal TB involving the thoracolumbar region is biomechanically challenging and the surgical options with thoracolumbar involvement are anterior debridement and reconstruction with posterior pedicle screws or a posterior- only approach.[3] In our patient, the affected segment is in the thoracolumbar segment. We performed laminectomy with or without posterior stabilization (posterior approach in all five patients based on the location of the pathology), with drainage, and debridement and it resulted in excellent outcomes.

CONCLUSION

Spinal TB should optimally be quickly diagnosed and appropriately surgically managed (where needed) to achieve the best postoperative outcomes.