Spinal Tuberculosis (TB)
Introduction
Tuberculosis (TB) is an infectious disease caused by Mycobacterium tuberculosis. While it primarily affects the lungs, the disease can also spread to other parts of the body, including the bones. Among bones, the spine is the most commonly affected site. Spinal tuberculosis, also known as Pott’s disease, predominantly involves the thoracic spine, though the lumbar spine, cervical spine, and sacrum can also be affected.
Pathophysiology of Spinal Tuberculosis
The primary lesion in spinal tuberculosis usually originates from an infection of the intervertebral disc and adjacent vertebral bones. As the disease progresses, the vertebral bodies undergo destruction, leading to their collapse and resultant spinal deformity. In some cases, the infection may begin within the vertebral body or the posterior vertebral elements. Spinal tuberculosis can also extend to the spinal cord and its protective coverings (meninges), leading to neurological complications.
Patients with spinal TB typically present with localized pain at the site of infection. However, common systemic symptoms of tuberculosis, such as fever, night sweats, loss of appetite, and weight loss, are often absent in spinal TB.
As the disease progresses, vertebral destruction may result in a kyphotic deformity (hunchback). In advanced cases, spinal cord compression may occur, leading to severe neurological deficits, including:
- Loss of sensation and weakness in the arms and legs
- Bladder and bowel dysfunction
- Loss of dexterity and hand grip strength
- Loss of balance and spasticity in the lower limbs
Neurological symptoms arise due to spinal cord compression, which may result from:
- Displacement of bone fragments following vertebral body destruction and collapse
- Accumulation of pus and inflammatory tissue in the spinal canal
- Compression by the deformed spinal column
- Direct involvement of the spinal cord by infection
Risk Factors for Developing Spinal Tuberculosis
Several factors increase the likelihood of developing spinal TB, including:
- Close contact with a person infected with tuberculosis
- Malnutrition and poor overall health
- Living in overcrowded and unsanitary conditions
- Chronic debilitating illnesses (e.g., diabetes, chronic kidney disease)
- Immunosuppressive therapies (e.g., chemotherapy, corticosteroids)
- HIV/AIDS and other immunocompromised states
Imaging Studies
- X-ray:
- Early findings include reduced disc height due to disc involvement.
- In advanced cases, vertebral body collapse and spinal deformities become evident.
- MRI Scan:
- Considered the gold standard for detecting spinal TB.
- Helps visualize disc involvement, vertebral body destruction, spinal cord compression, and the extent of infection.
- Though MRI provides detailed imaging, it cannot definitively differentiate TB from other infections or tumors.
- CT Scan:
- Provides detailed visualization of bone destruction.
- Useful for assessing bone healing in post-operative patients or when MRI is not feasible.
Laboratory Investigations
- Biopsy:
- Essential for confirming the diagnosis.
- Differentiates TB from bacterial infections or tumors.
- The biopsy sample is examined histopathologically and subjected to culture and sensitivity tests to determine drug susceptibility.
- Biopsy techniques include:
- CT-Guided Biopsy: A needle is inserted under local anesthesia with CT guidance.
- Fluoroscopy-Guided Biopsy: Performed in an operation theater under local or general anesthesia.
- Surgical Biopsy: Used when prior biopsy attempts fail or when surgical intervention is already necessary.
- Culture and Sensitivity Tests:
- Determines whether the TB strain is drug-sensitive, multi-drug resistant (MDR-TB), or extensively drug-resistant (XDR-TB).
- Helps guide the selection of appropriate anti-TB medications.
- Other Tests:
- Chest X-ray and sputum tests to rule out pulmonary TB.
- Blood tests (e.g., ESR, CRP) to assess inflammation and monitor disease progression.
Treatment of Spinal Tuberculosis
Spinal TB is primarily managed with medical therapy, although surgery may be necessary in specific cases. The treatment plan consists of:
Medical Management
- Anti-tubercular therapy (ATT) is the mainstay of treatment.
- Treatment duration typically ranges from 12 to 24 months, depending on drug resistance and response to therapy.
- Supportive measures include:
- Adequate nutrition to support immune function.
- Pain management with analgesics and anti-inflammatory medications.
- Spinal bracing to provide stability and prevent deformity progression.
- Regular monitoring through clinical evaluation and imaging to assess response to therapy.
Surgical Management
Surgery is indicated in the following scenarios:
- Severe spinal cord compression with neurological deficits (e.g., paralysis, bowel/bladder dysfunction)
- Progressive neurological deterioration despite medical treatment
- Severe vertebral destruction causing spinal instability, deformity, or intractable pain
- Persistent severe pain unresponsive to medical therapy
- Need for biopsy when percutaneous techniques fail
Surgical Procedures
- Spinal decompression and fusion surgery is commonly performed to:
- Relieve spinal cord compression.
- Restore spinal stability and alignment.
- Prevent further deformity progression.
- Facilitate early mobilization.
- In some cases, a decompression-only procedure may be performed if there is no significant vertebral destruction.
- If the infection is confined to the spinal cord without vertebral involvement, a decompression procedure alone may suffice.
Conclusion
Spinal tuberculosis is a serious but treatable condition that requires timely diagnosis and appropriate management. Early intervention with anti-tubercular drugs can prevent complications and reduce the need for surgical intervention. However, in cases with severe neurological involvement or spinal instability, surgery plays a crucial role in ensuring optimal recovery and functional outcomes. Close follow-up is essential to monitor treatment response, prevent complications, and ensure complete resolution of the infection.
FAQs
Walking with spinal tuberculosis depends on the severity of the disease and the extent of spinal damage. In early or mild cases, limited movement with spinal support (such as a brace) is usually allowed. However, in cases with significant vertebral destruction, instability, or spinal cord compression, bed rest may be necessary to prevent worsening of symptoms. Always follow your doctor’s advice regarding mobility restrictions and rehabilitation exercises.
The standard treatment for spinal TB includes a combination of anti-tubercular drugs (ATT). First-line medications include:
- Isoniazid (INH)
- Rifampicin (RIF)
- Pyrazinamide (PZA)
- Ethambutol (EMB)
For drug-resistant TB (MDR-TB or XDR-TB), second-line drugs such as fluoroquinolones (Levofloxacin, Moxifloxacin) and injectable agents (Amikacin, Capreomycin) may be required. The treatment duration can range from 12 to 24 months depending on the patient’s response and resistance pattern.
Recovery from spinal TB varies depending on the severity of infection and treatment adherence. In uncomplicated cases, patients may recover within 12 to 18 months with proper medication and supportive care. However, in cases requiring surgery or those with neurological complications, recovery may take 18 to 24 months or longer, with rehabilitation playing a crucial role in regaining mobility and strength.
Spinal tuberculosis progresses through distinct stages:
- Early Stage: Mild pain, localized stiffness, and minimal vertebral involvement.
- Progressive Stage: Destruction of vertebral bodies, kyphotic deformity, and worsening pain.
- Advanced Stage: Spinal instability, neurological deficits (weakness, loss of bladder/bowel control), and possible paralysis.
- End-Stage/Complications: Severe deformity, complete paralysis, or systemic TB spread.
Bed rest is recommended in cases where spinal instability or severe pain is present. However, prolonged immobility is discouraged as it can lead to muscle wasting and complications like deep vein thrombosis (DVT). A balanced approach involving short-term bed rest followed by guided physiotherapy is ideal for optimal recovery.
Signs of recovery from spinal tuberculosis include:
- Pain reduction at the affected site
- Improved mobility and posture
- Gradual weight gain and improved appetite
- Resolution of neurological symptoms, if present
- Normalizing inflammatory markers in blood tests (e.g., ESR, CRP levels)
- Improved findings on follow-up MRI/X-ray, showing healing of infected areas
Recovery after spinal TB surgery varies based on the complexity of the procedure and individual response. Typically:
- Hospital Stay: 7 to 14 days
- Initial Recovery: 4 to 6 weeks (with limited mobility)
- Full Recovery & Rehabilitation: 6 to 12 months Physical therapy and proper follow-up care are essential to ensure complete recovery and prevent complications.
The standard four-drug regimen for spinal tuberculosis consists of:
- Isoniazid (H)
- Rifampicin (R)
- Pyrazinamide (Z)
- Ethambutol (E) After two months of intensive therapy, treatment is continued with Isoniazid and Rifampicin for an extended duration (up to 12-24 months, depending on the severity of the disease).
Yes, back pain can persist during the early phase of TB treatment due to inflammation and healing-related changes in the spine. In some cases, spinal deformities and nerve compression may contribute to continued discomfort. Proper pain management, physical therapy, and regular medical follow-ups help alleviate symptoms.
The standard treatment duration for spinal TB ranges from 12 to 24 months. The exact duration depends on:
- Severity of the infection
- Presence of drug-resistant TB
- Response to treatment
- Presence of complications requiring surgery Regular monitoring through MRI/X-ray and blood tests helps determine the effectiveness of treatment.
A spine specialist or orthopedic surgeon specializing in spinal disorders is the ideal doctor to consult for spinal tuberculosis. Additionally, a pulmonologist or infectious disease specialist may be involved in managing the TB infection and medication regimen.
The cost of spinal TB surgery varies depending on factors such as hospital choice, surgeon expertise, location, and procedure complexity. Estimated costs:
- ₹2,00,000 – ₹8,00,000 ($2,500 – $10,000)
Costs may include hospitalization, surgical fees, medications, post-operative care, and rehabilitation.
Yes, spinal TB is completely curable with early diagnosis, appropriate anti-tubercular treatment, and, if necessary, surgical intervention. Adherence to the full course of medication is crucial to prevent complications and recurrence.
Common side effects of anti-tubercular therapy include:
- Liver toxicity (hepatitis, jaundice)
- Gastrointestinal issues (nausea, vomiting, loss of appetite)
- Peripheral neuropathy (tingling, numbness due to Isoniazid)
- Visual disturbances (Ethambutol-related optic neuritis)
- Skin rashes and hypersensitivity reactions
- Joint pain and fatigue
Regular monitoring of liver function, vision, and overall health is necessary to detect and manage these side effects early.
