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(Potts Disease)
Epidemiology
Incidence
increasing incidence of TBin United States due to
increasing immunocompromised population
demographics
HIV positive population (often seen in patients with
CD4+ count of 50 to 200)
location
15% of patients with TB will have extrapulmonary
involvement
the spine, and specifically, the thoracic spine is the
most common extrapulmonary site
5% of all TB patients have spine involvement
Pathoanatomy
early infection begins in the metaphysis of the
vertebral body
spreads under the anterior longitudinal ligament
and leads to
contiguous multilevel involvement
skip lesion or noncontiguous segments (15%)
paraspinal abscess formation (50%)
usually anterior and can be quite large (much more common
in TB than pyogenic infections)
Spinal Tuberculosis
MRI-Saital-Gadolinium
Chronic Infection
Severekyphosis
mean deformity in nonoperative cases is 15
in 5% of patients, deformity is >60
infection is often diagnosed late, there is often much more
severe kyphosis ingranulomatousspinal infections compared to
pyogenic infections
in adults
kyphosis stays static after healing of disease
in children
kyphosis progresses in 40% of cases because of growth spurt
classification of progression (Rajasekaran)
Type-I, increase in deformity until cessation of growth
should be treated with surgery
Type-II, decreasing progression with growth
Type-III, minimal change during either active / healed
phases.
Presentation
Symptoms
onset of symptoms of tuberculous spondylitis is typically more
insidious than pyogenic infection
constitutional symptoms
chronic illness
malaise
night sweats
weight loss
back pain
often a late symptom that only occurs after significant boney destruction and
deformity.
Physical exam
kyphotic deformity
neurologic deficits (present in 10-47% of patients with Pott's
Disease)
mechanisms
mechanical pressure on cord by abscess, granulation tissue, tubercular debris,
caseous tissue
mechanical instability from subluxation/dislocation
paraplegia from healed disease can occur with severe deformity
stenosis from ossification of ligamentum flavum adjacent to severe kyphosis
Imaging
CXR66% will have an abnormal CXR
should be ordered for any patients in which TB is
a possibility
Spine radiographs
early infection
shows
involvement
of
anterior
vertebral
body
withsparing of the disc space(this finding can
differentiate from pyogenic infection)
late infection
shows disk space destruction, lucency and compression
of adjacent vertebral bodies, and development of severe
kyphosis
risk factors for buckling collapse ("spine at risk signs")
retropulsion
subluxation
lateral translation
toppling
Buckling
collapse
Xray-Thoracic-Lateral
Shows collapse of vertebral body
Findings
low signal on T1-weighted images, bright
signal on T2-weighted images
presence of a septate pre-/ paravertebral /
intra-osseous smooth walled abscess with a
subligamentous extension and breaching of
the epidural space
MRI Findings
end-plate disruption
sensitivity 100%, specificity 81%
spinal cord
edema
myelomalacia
atrophy
syringomyelia
CT
indications
demonstrates lesions <1.5cm better than radiographs
inaccurate for defining epidural extension
findings
types of destruction
fragmentary
osteolytic
subperiosteal
sclerotic
Studies
CBC
relative lymphocytosis
low hemoglobin
ESR
usually elevated but may be normal in up to 25%
Diagnosis
CT guided biopsy with cultures and staining effective at
obtaining diagnosis
should be tested foracid-fast bacilli(AFB)
mycobacteria (acid-fast bacilli) may take 10 weeks to grow in culture
DDx
Other etiologies of granulomatous infection may have
similar clinical picture as TB and includeatypical
bacteria
Actinomyces israelii
Nocardia asteroids
Brucella
fungi
Coccidioides immitis
Blastomyces dermatitidis
Cryptococcus neoformans
Aspergillosis
spirochetes
Treponema pallidum
Treatment
Nonoperativepharmacologic treatment +/- spinal
orthosis
indications
no neurological deficit
drugs are the mainstay of treatment in most cases
pharmacologic
agents
isoniazid (H), rifampin (R), ethambutol (E) and pyrazanamide
(Z)therapy
regimen
RHZE for 2 months, then RH for 9 to 18 months
spinal orthosis
indications
may be used for pain control and prevention of deformity
Operative
Anterior decompression/corpectomy,
strut grafting posterior instrumented
stabilization posterior column
shortening neurological deficit
Halo traction, anterior decompression,
bone grafting, anterior plating
Pedicle subtraction osteotomy
Direct decompression / internal
kyphectomy
Complications
Deformity(kyphosis/gibbus)
highest risk
after anterior decompression and grafting alone
slippage and breakage of graft (especially if 2 levels)
lowest risk
after both anterior and posterior fusion
Atypical Spinal
Tuberculosis
definition
etiology
intraspinal granuloma, neural arch involvement,
concertina collapse of vertebra body , sclerotic
vertebra with bridging of vertebral body
treatment
laminectomy
indications
extradural extraosseous granuloma
subdural granuloma