Spinal Cord. 2017 Jan;55(1):59-63. doi: 10.1038/sc.2016.85.

Demographics of tuberculosis of spine and factors affecting neurological improvement in patients suffering from tuberculosis of spine: a retrospective analysis of 312 cases.

Sharma A1,2, Chhabra HS1, Chabra T1, Mahajan R1, Batra S1, Sangondimath G1.

1. Department of Spine Services, Indian Spinal Injuries Center, New Delhi, India.
2. Department of Orthopedic and Spine Surgery, Dr B R Ambedkar Central Railway Hospital, Mumbai, India.

 

Abstract

OBJECTIVES:

The purpose of the study was to study demographics of tuberculosis of spine and analyze factors that might affect neurological improvement in such patients.

METHODS:

Of the 638 suspected cases of spinal tuberculosis, 312 cases with confirmed diagnosis with at least 1-year follow-up were selected for retrospective analysis. Two hundred cases who presented with neurological deficit were further divided into three groups-completely improved, partially improved and no improvement according to American Spinal Injury Association impairment scale (AIS) grading. All continuous variables and categorical variables were compared across groups.

RESULTS:

A total of 209 (66.99%) patients had typical clinical presentation. A total of 264 (84.62%) had typical magnetic resonance imaging (MRI) presentation. Among 356 involved vertebrae, thoracic levels (T1-10) were most commonly affected in 163 (45.78%) followed by thoracolumbar (T11-L2) vertebrae in 98 (27.52%). In 250 patients (80.12%), disease was restricted to one or two adjoining vertebrae. At presentation, 112 (35.89%) patients were neurologically intact, whereas 97 (31%) were AIS D, 65 (20.83%) were AIS C, 8 (2.5%) were AIS B and 30 (9.61%) were AIS A. On statistical analysis, although three groups of patients with complete improvement, partial improvement and no improvement were similar in age, sex, radiological presentation, and co-morbidities and the presence of pulmonary tuberculosis, they were significantly different with regard to the levels of vertebral involvement, AIS grade at presentation, bladder and bowel involvement and its duration.

CONCLUSIONS:

In management of patients suffering from tuberculosis of spine, levels of vertebral involvement, AIS grade at presentation, bladder and bowel involvement and its duration significantly affect the final neurological improvement.

PMID: 27241442;

 

Supplements:

Tuberculosis of spine is one of the oldest and most debated disease known to us, its presence dates back to Neolithic period (New Stone Age)(1). Decades have passed since the start of modern anti- tubercular treatment yet someone in the world dies from tuberculosis every 15 seconds, and a person is newly infected with tuberculosis every second. Incidence of spinal tuberculosis has increased in the past two decades in relation with AIDS epidemics and recent migrant crisis. MRI remains the most preferred diagnostic tool for diagnosis tuberculosis of spine but in patients presenting with atypical MRI presentation further investigations like open or percutaneous biopsy is advisable (Figure 1,2). Combining MRI with GeneXpert for the biopsy sample can give a rapid and accurate diagnosis of tuberculosis in spine (3). Neurological deficit is the most morbid disability seen in cases of spinal tuberculosis. Based on the AIS grade, levels of vertebral involvement, and duration of bladder and bowel involvement at presentation patient’s final neurological prognosis can be predicted. Patients of tuberculosis of spine presenting with high grade of neurological involvement (AIS-A/B), with more then two levels of vertebral involvement and bladder and bowel involvement of more then 15 days are likely to have least neurological recovery after medical or surgical treatment.

Figure 1- MRI showing atypical presentation of tuberculosis in the form of posterior compression of upper thoracic cord without any paravertebral involvement.

 

 

Figure 2- Intraoperative picture showing thick caseous tissue over the spinal cord. Rapid and accurate diagnosis was possible by sending the caseous tissue for GeneXpert.

 

References:

1.      Taylor GM, Murphy E, Hopkins R, Rutland P, Chistov Y. First report of Mycobacterium bovis DNA in human remains from the Iron Age. Microbiology 2007;153(4):1243–9

2.      Annual Performance Plan 2012/13 – 2014/15″, Department of Health, South Africa 2012 www.tbfacts.org/App2012-2014.pdf

3.      Sharma A, Chhabra HS, Mahajan R, Chabra T, Batra S. Magnetic Resonance Imaging and GeneXpert: A Rapid and Accurate Diagnostic Tool for the Management of Tuberculosis of the Spine. Asian Spine J. 2016 Oct;10(5):850-856. Epub 2016 Oct 17.