Spinal tuberculosis is a form of bone tuberculosis caused by Koch’s rods and affecting various parts of the spinal column. The first symptoms of the disease may appear both after a short time and after several years from the moment of infection. Multiple lesions are often observed. Pathology is manifested by pain, restriction of movements and gait disorders. In advanced cases, spinal deformity may develop. The diagnosis is made on the basis of tuberculin samples and radiography data. Treatment is usually conservative: prolonged immobilization, correction of diet, stimulation of immunity.
ICD 10
M49.0 Tuberculosis of the spine (A18.0+)
Meaning
Tuberculosis of the spine is a tuberculous lesion of one or more vertebrae. It is the most common form of osteoarticular tuberculosis. There is a slight predominance of male patients. In 60% of cases, the thoracic region is affected, in 30% of cases – the lumbar region, 5% each accounts for tuberculosis of the cervical and sacral regions.
One vertebra may suffer, but multiple lesions are more often detected. In 70% of cases, two vertebrae are involved in the process, in 20% of cases – three or more vertebrae. Extensive lesions are more common in the thoracic and transitional (thoracolumbar) spine. In recent years, there has been an increase in the number of cases of tuberculosis of the spine in combination with other forms of tuberculosis (lungs, eyes, kidneys).
Causes
The disease is provoked by acid-resistant strains of tuberculous Mycobacteria (Koch’s sticks). The pathogen is able to persist for a long time in the external environment and become active when it enters favorable conditions. Infection occurs by airborne droplets, dust, less often by household contact and transplacental method.
Classification
Taking into account the prevalence, there are:
- Local (limited) lesion – tuberculous ostitis. A single focus is detected that does not go beyond the vertebral body, or a lesion of one vertebral-motor segment.
- A common lesion is a process involving two or more adjacent vertebral–motor segments.
- Multiple lesion – tuberculosis of two or more non-adjacent vertebral-motor segments.
- The combined form is a lesion of two or more organs (for example, the spine and lungs).
There are the following stages of spinal tuberculosis:
- 1 – the development of primary tuberculous ostitis.
- 2a – signs of progressive spondyloarthritis while maintaining the function of the spine.
- 2b – signs of progressive spondyloarthritis with impaired spinal function.
- 3 – development of chronic destructive spondylitis, complete loss of function of the affected segment.
- 4 – post-tuberculosis spondyloarthrosis.
Symptoms of spinal tuberculosis
The manifestations of the disease can vary greatly depending on the number of affected vertebrae, localization and stage of the process. The most constant symptom is pain. At the same time, there are two types of pain syndrome. The first occurs when bone structures are destroyed, it is characterized by pain in the depth of the spine, which increases with stress and is accompanied by the formation of a zone of hyperesthesia of the skin over the lesion.
The cause of the development of pain of the second type is the compression of nerve roots by fragments of vertebrae. Irradiation in the trunk and limbs is possible, pain is accompanied by restriction of movements and tension of the back muscles. Pain irradiation is observed when all levels are affected. With tuberculosis of the cervical region, pain can be given to the interscapular, occipital or parietal region, with tuberculosis of the thoracic region – to the chest, abdomen or groin (depending on the localization of the tuberculous focus), with tuberculosis of the lumbar region – to the legs.
When the cervical spine is affected, the patient reluctantly bends and turns his head, tries to unload the damaged section, supporting the chin or head with his hands. Tuberculosis of the thoracic region is manifested by stiffness of gait and fixation of the body. The patient turns to the side with his whole body, and, lifting something from the floor, bends his knees, but keeps his back straight. When the lumbar region is affected, gait stiffness is also observed, characterized by increased lumbar lordosis and abdominal protrusion.
Complications
In the absence of treatment, the formation of leaky abscesses caused by caseification and melting of tissues with subsequent accumulation of pus under the ligaments of the spine is possible. Ulcers can compress the spinal cord and cause paraplegia. Often, pus spreads along the course of the muscle fascia and forms distant lumps. When the cervical region is affected, pharyngeal abscesses and abscesses behind the nodding muscle may occur, when the process is localized in the thoracic region, abscesses in the intercostal spaces, when the lumbar region is affected, abscesses in the groin area and along the inner surface of the thigh, less often (when pus passes through the locking hole) – in the hip joint.
In the late stages of spinal tuberculosis, deformities are observed due to the destruction of the vertebral bodies. At the level of the affected vertebra, an angular curvature (hump) occurs. With multiple widespread lesions, pronounced shortening of the trunk is possible.
Diagnostics
The main instrumental method of diagnosing spinal tuberculosis is X-ray examination. Etiological verification of the diagnosis is assisted by immunological reactions: in vivo – Mantoux test and Diaskintest, as well as in vitro – interferon and T-Spot test.
Chest x-ray indicates the presence of primary tuberculous foci in the intra-thoracic lymph nodes and upper lungs, while calcification is detected, confirming the significant prescription of the lesion. During radiography of the spine in the early stages, narrowing of the gaps between adjacent vertebrae or the presence of areas of bone structure disturbance in the area of the vertebral bodies is revealed.
Subsequently, the vertebral bodies fall off, an angular curvature of the spine occurs. With tuberculous abscesses within the lateral ligaments of the spine, dense fusiform cords are visible in the images, with leaky abscesses in the lumbar and thoracic regions, shadows are determined, sometimes surrounded by thin strips of calcification or containing calcified lumps. To detect leaky abscesses in tuberculosis of the spine, an MRI of the spine can also be used.
Differential diagnosis
Making a final diagnosis in most cases does not cause difficulties. In children and adolescents, it is sometimes necessary to carry out differential diagnosis of spinal tuberculosis with Sheyerman-Mau disease and Calve disease. In Sheyerman-Mau disease, there are no radiological signs of triangular deformation of the vertebral bodies, in Calve disease, a uniform formation with a lamellar structure and calcification nests is revealed in the images at the site of one of the vertebrae. In addition, spinal tuberculosis is sometimes differentiated with congenital malformations, primary malignant tumors and metastases of tumors of other localizations.
Treatment
The treatment is long-term, carried out in a hospital. The treatment plan is made taking into account the form and stage of the process, the characteristics of the reaction of the body, the age of the patient, the prescription of the disease and the condition of the internal organs. The main goals of therapy are to stimulate the body’s defenses, prevent the development of complications and restore the function of the spine. The basis for complex treatment becomes a sanitary and hygienic method, which includes the organization of a proper daily routine and proper nutrition, as well as normalization of the neuropsychological state of the patient.
Local treatment involves prolonged immobilization followed by rehabilitation measures. The most important part of the treatment is long-term chemotherapy, which allows to prevent death, minimize the likelihood of severe deformities and severe complications. The treatment regimen is made taking into account the stage of the disease, combinations of several drugs are used, and drugs are replaced during therapy. Surgical intervention is indicated only if paraplegia is preserved.
Prognosis and prevention
With early detection and adequate treatment, recovery is possible. With severe lesions, there is a high percentage of disability, a fatal outcome is not excluded. Tuberculosis is a social disease caused by the living conditions of patients. Among the measures to limit the spread of this disease are regular anti-epidemic and preventive measures. It is necessary to undergo regular fluorography and immediately consult a doctor if suspicious symptoms appear. When contacting patients with tuberculosis, the precautions recommended by the phthisiologist should be observed. During the first 30 days of life, primary prevention should be carried out for newborns.
Literature
- Spinal tuberculosis: the association between pedicle involvement and anterior column damage and kyphotic deformity. Yusof MI, Hassan E, Rahmat N, Yunus R. Spine (Phila Pa 1976). 2009 Apr 1;34(7):713-7. link
- Is spinal tuberculosis changing with changing time? Hasan Khan MN, Jamal AB, Hafeez A, Sadiq M, Rasool MU. Ann Med Surg (Lond). 2021 May 28;66:102421. link
- Spinal tuberculosis: with reference to the children of northern India. Kumar R. Childs Nerv Syst. 2005 Jan;21(1):19-26. link
- Pott’s spine and paraplegia. Gautam MP, Karki P, Rijal S, Singh R. JNMA J Nepal Med Assoc. 2005 Jul-Sep;44(159):106-15. link
- Atypical imaging features of tuberculous spondylitis: case report with literature review. Momjian R, George M. J Radiol Case Rep. 2014 Nov 30;8(11):1-14. link