Abstract

Purpose
Describe the natural history spinal
tuberculosis, classifications and principles of
based upon the grading of the
neurological deficit.
Methods
Review of literature to provide the clinicoradiological correlation of the natural history
of spinal tuberculosis in different stages.

Abstract
Results
A five stage natural history of spinal tuberculosis :
Stage of neurological involvement divided into 4 grades:
1) Negligible
2) Mild
3) Moderate
4) severe with sensory and autonomic dysfunctions.
Suitable principles of management role of rest, braces,
chemotherapy and surgery.
Neurological deficit grading based management:
1) Grade 1 and 2 conservative treatment
2) Grade 3 gray zone
3) Grade 4 operative treatment

Abstract
Conclusion
Management of tuberculosis of spine no
different than management of soft tissue
tuberculosis.
Role of surgery very limited.
Management of tubercular paraplegia
based upon the grading of paraplegia
simple, logical, efficient and easy to
understand and remember by any orthopedic
surgeon

Introduction

Evidence of pulmonary and extra pulmonary

tuberculosis including spinal tuberculosis
been noted in the Egyptian mummies
Osteoarticular tuberculosis 12 % cases of
tuberculosis always secondary
tuberculosis seen in patients harboring
primary tuberculosis somewhere else in the
body.
In majority of cases (80 %) difficult to
detect the primary site of disease.

Introduction

Osteoarticular
tuberculosis

localized
manifestation of a systemic disease.
Mycobacterium tuberculosis lodged in the bone
and joints through hematogenous route and spine is
no exception.
In osteoarticular tuberculosis spinal involvement
(50 % of cases)
Mycobacterium tuberculosis can be lodged in the
vertebral body (anterior spinal tuberculosis) 9095
% or in the various components of posterior
vertebral arch (posterior spinal tuberculosis) 510 %

Introduction(2)

Radiological appearances of anterior spinal

tuberculosis primarily diagnosed on the
basis of plane radiographs. CT scan and
MRI are additional.
It is always not easy to get the
microbiological or histopathological proof of
the disease in every case
it is important to understand the clinical
behavior of the disease in relation to the
radiological changes

Clinical, pathological and radiological

correlation

Anterior spinal tuberculosis divided

into 5 stages. (different from grades of
paraplegia)
Stages of anterior spinal tuberculosis
depicts the extent of involvement or
condition of the bony element
Grades of paraplegia designates
severity of compression of the spinal
cord.

Classification of Potts
paraplegia
This classification of paraplegia based upon
the onset of disease unrealistic because onset
of disease begins with the implantation and
lodgement of mycobacterium tuberculosis to the
spine
Similarly classification based upon the status
of disease proposed by Butler as subgroups of
early and late onset of paraplegia :
(a) paraplegia of active disease
(b) paraplegia with apparent quiescence of
disease

Classification of Potts paraplegia

(2)

The classifications as paraplegia of early

onset (paraplegia with active disease)
usually within first 2 years.
Paraplegia of late onset (paraplegia of
healed disease) noted after 2 years of
onset of disease.
Clinical factors influencing the prognosis
of cord involvement indicates
relatively poor prognosis in cord
involvement of > 12 months duration

Classification of Potts paraplegia

(3)
Duration based classification based
upon the onset of spinal symptoms (not on
the onset of the disease)
The cutoff period 1 year as Early
phase paraplegia noted within 1 year
of onset of spinal symptoms better
prognosis
Late phase paraplegia noted after 1
year of onset of spinal symptoms
relatively poorer prognosis

Progressive Neurological Deficit In Potts

Paraplegia

motor fibers more susceptible to

pressure effect, whereas sensory fibers
are more susceptible to ischemia.
That is why in compression paraplegia,
signs and symptoms of motor loss
appear prior to the sensory loss.

Progressive Neurological Deficit In Potts

Paraplegia.....(2)
In anterior or posterior spinal tuberculosis
when compression is from the anterior or
posterior aspect of the cord
at first pressure is exerted on the
column of cerebrospinal fluid surrounding
the cord and gets transmitted to the
ligamentum denticulatum. Motor fibers in
the close vicinity, get pulled and show
early involvement.

Progressive Neurological Deficit In Potts

Paraplegia.....(3)

Secondly in compression from the

posterior aspect of the cord the cord
was displaced anteriorly and anteriorly
placed motor fibers compressed against
the anterior wall of the bony spinal canal
causing early motor fiber functional loss.
Functions return when pressure is relieved.
That is why simple drainage procedures
which relieve intraspinal pressure leads to
the motor recovery

Classification

Kumar proposed 4 grade

classification based predominantly upon
the motor weakness as determined and
collaborated by the complaints of the
patient, walking ability and progressively
increasing neurological deficits by
neurological examination

Classification

Confirmation of diagnosis

Clinical history
Examination
Radiological evaluation
Hematological, microbiological, serological,
immunological and other available diagnostic
tools should be used to clinch the
diagnosis
When in doubt, tissue biopsy (needle or
open) for bacteriological and pathological
confirmation should be obtained

Confirmation of diagnosis(2)

MRI is often positive before plane radiographs.

Ultrasound has been used in the diagnosis of cold
abscess
Presently, role of myelography is extremely limited
Nuclear scintigraphy by 99mTechnitium (MDP or HDP) or
Gallium (67Ga) effective and quite sensitive but
nonspecific and may be used in localizing multifocal
lesions. often positive much before plane radiograph,
CT or MRI
Positron emission tomography scan (PETCT) highly
sensitive but expensive and nonspecific with higher
radiation.

Conservative drug therapy

Antitubercular drugs (Rifampicin, Isoniazid, Pyrazinamide and

Ethambutol {RIPE}) the key stones in the management of
tuberculosis of spine (not only treats the spinal tuberculosis but
also the primary tubercular foci existing somewhere else in the
body.)
Drug toxicity must be monitored and managed accordingly
British Medical Research Council indicates tuberculous
spondylitis of the thoracolumbar spine treated with
combination chemotherapy for 69 months.
Many experts still recommend chemotherapy for 912 months.
Tuberculosis of spine by multi drug resistant (MDR) should
preferably be treated with guidance from specialized centers
with facilities for quality-controlled drug susceptibility testing
and experience in managing such cases.
Incidence of refractory tuberculosis is growing and presently
approximately 510 %.

Rest, Braces, and Traction

Enforced and prolonged rest on hard bed or Plasterof Paris bed (6-9 months) causing dermatological,
pulmonary,
abdominal
and metabolic problems.

No study comparing and indicating patients

(particularly children) who did not follow the
instruction of rest on hard bed or plaster bed and
use of braces, showed any significantly different
results than those who didnt.

Braces pseudo satisfying devices and torture

devices
do not prevent progression of kyphotic
deformity.

Hence braces little use (most of the cases)

Rest, Braces, and

Traction.(2)

The only brace which may be useful

Trauma cervical brace (cranio-occipital)
and cervical spine tuberculosis.
Cervical traction no established role.
Halo frames stabilization. not for
traction or distraction.

Treatment of Potts
Paraplegia

Conservative Therapy

Indicate : Lower grades of paraplegia (Grade 1 and 2)

due to inflammatory compression of the cord (edema,
inflammatory cells, tubercular pus or debris and early
granulation tissue) can be removed by body
defenses mechanisms (influence of chemotherapy
respond very well and recover completely).
Also supported by logistic regression analysis of clinical,
radiological and neuroradiological findings i.e., SEP or
sensory evoked potentials and MEP or motor evoked
potentials.
Short course of steroids to potentiate neurological
recovery.

Gray Zone

Consist : Grade 3 Paraplegia

Paraplegia (Grade 3 and 4) predominantly due to
mechanical compression of the cord + preexisting
inflammatory compression (edema, inflammatory cells,
tubercular pus or debris) can be removed by body
defenses mechanisms under the influence of
chemotherapy associated with thick fibrous bands,
bony ridge, sequestered bone/cartilage tissues and
thick granulation tissue canal stenosis cannot be
phagocytized and removed by the body defenses
mechanisms.

Gray Zone.(2)

Conservative drug therapy should be

started!
Monitoring of the neurological recovery
If signs of are noted within 68 weeks of
chemotherapy then conservative
treatment should be continued
If neurological recovery/improvement
remains static or deteriorates surgical
intervention must be done

Operative Surgical
Treatment

Recommended for grade 4 paraplegia Surgical

decompression of the cord with debridement of the
lesion through anterior or antrolateral approach
under the cover of multi drug chemotherapy.
Augmented with bone grafting, correction of the
kyphotic deformity and additional instrumentation for
stabilization considered necessary
Surgical single stage anterior and posterior
stabilization, extrapleral dorsal spine anterior
stabilization and endoscopic thoracoscopic surgeries
(VATS) reduced the morbidity and mortality

Operative Surgical
Treatment.(2)

Neurological deficits compressive pathologies recover

following decompression of the cord whereas paraplegia
produced by intrinsic cord lesions (gliosis, myelomalacia,
syringomyelia, arachnoiditis and vascular compromise/
insufficiency/ infarction)

multiple
causes
(extrinsic/compressive
and
intrinsic/destructive) often exist need surgical
decompression to get some neurological recovery

Anterior transposition of cord + shaving of the internal

gibbus severe kyphotic deformities with compression of
the cord.

Spine remains stable severe kyphotic deformity +

advanced disease in most of the cases of tuberculosis of
spine

Spine unstable if both anterior and posterior elements

Conclusion

Management of tuberculosis of spine no different than

management of soft tissue tuberculosis
Role
of
Rest,
Braces,
Traction,
Chemotherapy
and Surgery has been redefined.
Need of orthopedic surgeon when there is neurological
deficit or deformity.
Indications of surgery very limited.
Barring few exceptions, the management of Potts spine
and paraplegia upon the grading of paraplegia
simple, logical, efficient and easy to remember.