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Introduction: Spinal tuberculosis is a serious form of extra pulmonary tuberculosis which if left untreated can be fatal; neurologic dysfunctions in association with active tuberculosis of spine can be prevented by early diagnosis and prompt treatment. Prompt treatment can reverse paralysis and minimize the potential disability resulting from Pott’s paraplegia. A significant dilemma exists as to which line of management a patient needs to be subjected once diagnosed to have spinal tuberculosis. Objective: Assess the functional and neurological outcome of patients treated with different modalities of treatment and attempts to ascertain the best practise for effective management of a case of spinal tuberculosis. Materials And Methods: 22 adult patients diagnosed with spinal TB and treated with either conservative line of management or CT/USG guided pigtail catheter drainage with chemotherapy or surgery combined with chemotherapy, were considered. Patients were followed up until completion of anti-TB treatment. Clinical outcomes were assessed using Visual analogue scale, Oswestry Disability Index and modified McCormick grade. Results: Patients having milder form were treated conservatively using anti-tubercular drugs alone (n=13). Patients with well-established abscess and without instability were treated using CT/USG guided pigtail catheter drainage along with antitubercular drugs (n=6). Patients with severe neurological compromise were treated with surgical debridement with fusion techniques (n=3). Patients in all three groups responded well to the treatment they were subjected to. It was observed that various stages of spinal tuberculosis demanded different modalities of treatment. Conclusion: Early surgical intervention or pigtail catheter drainage along with antitubercular treatment when used judiciously allows early mobilisation of patients preventing complications
Tuberculosis (TB) is one of the oldest diseases known to mankind and it continues to be one the leading causes of mortality and morbidity worldwide. (1) TB is broadly classified into Pulmonary and Extra-Pulmonary TB. Although Bone and Joint TB constitutes around 10 % of extrapulmonary tuberculosis, (2) spinal TB accounts for 50% all musculoskeletal TB. (3)
Sir Percival Pott first described the disease in 1779.(3) The term “Pott’s disease” is synonymously used for tuberculosis infection of spine whereas “Pott’s paraplegia” is used to describe paraplegia resulting from Pott’s disease. Spinal TB also remains as one the most common cause of non-traumatic paraplegia in most parts of the world.
Spinal tuberculosis is a paucibacillary disease with slow growing bacilli, if not treated adequately, may cause serious complications like bone destruction, permanent neurological deficits and spinal deformities. These complications have a grave prognosis, poor quality of life and lower life expectancy. Early diagnosis and prompt treatment are the keys to prevent these complications associated with spinal TB. Despite modern diagnostic methods, potent anti-tubercular drugs and advances in
surgical management of spinal TB, issues regarding appropriate treatment remains controversial. Proposed treatment modalities include antitubercular chemotherapy alone or surgical intervention combined with chemotherapy. However, both the modalities come with various advantages, risks and limitations.
Since management of patient with spinal tuberculosis remains a matter of debate in terms of optimal treatment strategy one needs to consider, this study was conducted at a tertiary teaching hospital to evaluate patients undergoing conservative treatment, USG/CT guided aspiration with chemotherapy and surgical combined with chemotherapy treatment modalities.
The present study evaluates the relative clinical effectiveness between the above mentioned three types of management in a case of spinal TB. This study aimed to determine the role of different treatment method in managing a case of spinal tuberculosis.
After approval of institutional ethical committee this prospective study was carried out in Department of Orthopaedic Surgery in a tertiary care hospital in Mangalore, Karnataka. 22 patients aged more than 18 years suffering from cervical/thoracic/lumbar/sacral infective Spondylodiscitis who were biopsy proven with either PCR positive, GeneXpert positive or culture proven with mycobacterium tuberculosis were enrolled in the study. Patients having milder form of disease with minimal paravertebral collection were categorised as “Group A” and treated conservatively using anti-tubercular drugs alone (n=13). Patients with well-established abscess and without spinal instability were categorised into “Group B” and
treated using CT/USG guided pigtail catheter drainage along with antitubercular drugs (n=6). Patients with severe neurological compromise were categorised into “Group C” and treated with surgical debridement with fusion techniques (n=3). Upon following up with patients until the completion of anti-TB treatment functional and neurological outcomes were assessed using Visual analogue scale, Oswestry Disability Index(4) and modified McCormick grade(5).
A sample size of 22 patients diagnosed with spinal TB who met the above-mentioned inclusion criteria, were included in the study after obtaining written informed consent.
13 patients who presented with a milder form of the disease were managed with anti-Tuberculosis treatment alone. Remaining 7 patients needed intervention either in the form of USG/CT guided pigtail drainage of the paravertebral collection or a surgical debridement and fusion technique along with anti-TB treatment.
In our study, majority of patients were males [15 (68.2%) patients] and rest 7 (31.8%) were females. Both conservative group A and pigtail group B showed male predominance with 76.9% and 66.7% respectively . However, surgical group C showed female predominance with 66.7% patients being female. The mean age of this study group was 39.05±13.247 years (range 19-60 years). Among 22 patients, 11 (50%) patients had history of other forms of tuberculosis, majorly pulmonary tuberculosis. The duration of symptoms ranged from 15 days to 12 months with a mean duration of 2.32months.
All 22 patients presented with pain as their predominant symptom. The next commonest presenting symptom was weight loss, which was seen in 9 patients of group A, 4 patients from group B and 3 patients from group C. This was followed by weakness in the limbs which was seen in 7 patients from group A, 2 and 3 patients from group B and group C respectively.
Among 22, 17 patients were found to have motor and sensory deficits. However, autonomic involvement in the form of bowel and bladder involvement was observed exclusively in surgical group C amounting to 66.7%.
17 patients had two level vertebral involvement, 4 patients had single vertebral involvement and one patient had multiple level involvement. However, the predominant vertebral involvement was seen in thoracic and lumbar vertebra accounting to 7 patients each, followed by cervical vertebra in 4 patients.
On MRI, all patients in surgical group C had features of cord compression, disc space narrowing, paravertebral collection, vertebral body destruction and collapse. Paravertebral collection was observed in all 6 patients of pigtail catheter group B. Vertebral body destruction was seen among 11 patients in group A and 2 patients from group B.
Due to loss of follow-up of one patient from group A, the outcomes were assessed among a total of 21 patients.
The functional and neurological outcomes were assessed using Visual analogue scale, Oswestry Disability Index(4) and modified McCormick grade(5) recorded at the time of initiation of treatment and after completion of the treatment. All patients showed good functional and neurological improvement irrespective of the treatment they were subjected to.
|
VAS scores |
|
Zero |
One |
Two |
Three |
Four |
Five |
Six |
Seven |
Eight |
Nine |
Ten |
|
Group A (Conservative) (n=12) |
Pre Rx |
0 |
0 |
0 |
0 |
4 |
1 |
4 |
0 |
3 |
0 |
0 |
|
Post Rx |
1 |
5 |
4 |
0 |
2 |
0 |
0 |
0 |
0 |
0 |
0 |
|
|
Group B (Pigtail) (n=6) |
Pre Rx |
0 |
0 |
0 |
1 |
0 |
0 |
2 |
1 |
2 |
0 |
0 |
|
Post Rx |
1 |
4 |
0 |
1 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
|
|
Group C (Surgical) (n=3) |
Pre Rx |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
3 |
|
Post Rx |
1 |
1 |
0 |
0 |
1 |
0 |
0 |
0 |
0 |
0 |
0 |
|
ODI Scores |
|
0-20% |
20-40% |
40-60% |
60-80% |
80-100% |
|
Group A (Conservative) (n=12) |
Pre Rx |
1 |
7 |
4 |
0 |
0 |
|
Post Rx |
9 |
2 |
1 |
0 |
0 |
|
|
Group B (Pigtail) (n=6) |
Pre Rx |
1 |
3 |
2 |
0 |
0 |
|
Post Rx |
5 |
1 |
0 |
0 |
0 |
|
|
Group C (Surgical) (n=3) |
Pre Rx |
0 |
0 |
0 |
2 |
1 |
|
Post Rx |
2 |
0 |
1 |
0 |
0 |
|
McCormick functional grade |
|
Grade1 |
Grade2 |
Grade3 |
Grade4 |
Grade5 |
|
||
|
Group A (Conservative) (n=12) |
Pre Rx |
3 |
4 |
4 |
1 |
0 |
|
||
|
Post Rx |
9 |
3 |
0 |
0 |
0 |
|
|||
|
Group B (Pigtail) (n=6) |
Pre Rx |
2 |
2 |
1 |
1 |
0 |
|
||
|
Post Rx |
6 |
0 |
0 |
0 |
0 |
|
|||
|
Group C (Surgical) (n=3) |
Pre Rx |
0 |
0 |
0 |
0 |
3 |
|
||
|
Post Rx |
2 |
1 |
0 |
0 |
0 |
|
|||
|
|
Group A |
p-value |
Group B |
p-value |
Group C |
p-value |
|||
|
Mean±SD N=12 |
Mean±SD N=6 |
Mean±SD N=3 |
|||||||
|
PRE |
POST |
PRE |
POST |
PRE |
POST |
||||
|
VAS |
5.75±1.603 |
1.75±1.215 |
<0.001 |
6.33±1.862 |
1.17±0.983 |
0.002 |
10.00±0.000 |
1.67±2.082 |
0.020 |
|
ODI |
17.58±6.762 |
7.33±5.314 |
<0.001 |
16.67±8.262 |
5.67±3.011 |
0.024 |
36.33±7.572 |
9.67±11.547 |
0.008 |
|
MC |
2.25±.965 |
1.25±0.452 |
<0.001 |
2.17±1.169 |
1.00±0.000 |
0.058 |
5.00±0.000 |
1.33±0.577 |
0.008 |
On evaluation of outcome assessment scales used in this study among patients of Group A, B and C, all patients had statistically significant outcome on comparing VAS score, ODI score and McCormick functional grades. (p<0.05) with an exception of Group B not showing significant difference(p=0.058) on McCormick functional grade pre- and post-treatment.
(c) CT guided biopsy of the same patient
d,e,f) post treatment imaging of the same patient showing resolution of disease with anti-tubercular treatment alone.
(g,h,I,j)Pre-treatment imaging of a surgically treated patient showing destruction of vertebral body
