Spinal tuberculosis

   June 9, 2021  Posted in Central Nervous System, Musculoskeletal System, Spine

Case contribution: Dr Radhiana Hassan

Clinical:

  • A 60 years old lady
  • No known medical illness and no history of trauma
  • Presented with back pain for 2 weeks. No fever.
  • Clinically power and sensation is reduced.
  • Imaging was done to rule out spinal stenosis
Radiograph of thoracic spine in AP and lateral views

X-ray findings:

  • Reduced T10 vertebra body height (yellow arrows) in keeping with compression fracture.
  • Suspicious retropulsed bony segment. Pedicle is still intact.
  • The rest of the vertebra bodies height are normal.
  • No obvious soft tissue mass seen
Non-contrast MRI of spine done for further assessment
MRI of spine in axial plane T2WI through the collapsed vertebra

MRi findings:

  • There is compression fracture of T10 (white arrows) with retro pulsed fragment causing compression onto the spinal cord.
  • The cord shows high signal intensity at this place suggestive of cord edema.
  • There is a soft tissue collection around the crushed body of T10. There are subligamentous extentions of this collection.
  • It is confined by the anterior longitudinal ligament anteriorly. It extends superiorly to the level of lower end plate of T8 and inferiorly to the lower endplate of L1.
  • The visualised brain and craniocervical junction are normal.

Progress of patient:

  • MTB PCR was positive
  • Patient was started on anti-TB
  • Patient also had surgical instrumentation and stabilisation of the compression fracture

Diagnosis: Spinal tuberculosis

Discussion:

  • Thoracic spine is the most common extrapulmonary spinal site for TB.
  • 5% of all TB patients have spine involvement
  • Early infection shows metaphysis involvement with subligamentous spread to contiguous multilevel or skip noncontiguous segment (15%)
  • Paraspineal abscess formation occurs in about 50% of cases and usually anterior location (more common than in pyogenic infection)
  • Initial stage does not involve disc space (also distinguishing feature of pyogenic osteomyelitis)
  • Chronic infection can cause severe kyphosis. Risk factors for buckling collapsed include retropulsion, subluxation, lateral translation and toppling changes.
  • Pharmacological treatment with antiTB (RHZE for 2 months then RH for 9-18 months)
  • Operative approach such as anterior decompression, strut grafting with or without posterior instrumented stabilization, posterior column shortening, bone grafting, pedicle subtraction osteotomy or direct decompression /internal kyphectomy
  • Complications: kyphosis/gibbus deformity, TB arteritis/pseudoaneurysm, sinus formation and Pott’s paraplegia (spinal cord injury caused by abscess/bony sequestra or meningomyelitis

 

Author: radhianahassan