Tuberculosis of the spine is still quite common in the developing/underdeveloped world. Tuberculosis of the spine most commonly affects the anterior part of the dorsal-lumbar spine that is the part of the spine behind the heart/lungs or the upper part of the abdomen. Rarely, Tuberculosis of the spine rarely involves the anterior part of the cervical spine or the anterior part of the lumbo-sacral spine behind the lower abdomen. Even more rarely, Tuberculosis of the spine presents as a posterior extradural collection between the posterior bone and the dural covering of the spinal cord.
The spinal cord gets damaged progressively with time due to continued compression and progression of the disease sometimes despite medical management of tuberculosis, possibly due to sheer bulk/burden of disease which prevents medications from working optimally.
Posterior extradural collections between the posterior bone and the dural covering of the spinal cord present more acutely with fast-onset weakness in the limbs as also bowel/bladder involvement.
Spinal Tuberculosis presents initially with pain, mostly severe.
As the disease progresses and the spinal cord compression increases, patients start developing neurological symptoms.
Therefore, it is imperative that patients undergo MRI of the spine even with significant pain to pick up Spinal Tuberculosis.
Neurological symptoms will depend on location of the Spinal Tuberculosis. Only the lower limbs will be affected if the dorsal-lumbar spine is involved which is most common. Both upper and lower limbs may be affected if the cervical spine is involved which is rarer.
Subtle symptoms may include
Advanced symptoms
Posterior extradural collections between the posterior bone and the dural covering of the spinal cord present more acutely with fast-onset weakness in the limbs as also bowel/bladder involvement.
Rarely, patients may develop severe neurological symptoms including paralysis and bowel/bladder involvement without significant spinal cord compression on the MRI. This is a poor prognosis situation because the severe neurological symptoms are actually caused by tubercular arachnoiditis/vasculitis which is invasion of the spinal cord itself or its blood supply by tuberculosis. Surgery may not help in this situation at all.
MRI with contrast would diagnose correctly the severity, length and location of Spinal Tuberculosis and the extent of spinal cord compression and/or spinal cord damage with/without concomitant spinal cord compression.
Conservative with long-term anti-tuberculous medical management if MRI does not show significant spinal cord compression. Pain takes a few weeks/months to resolve.
Surgery along with long-term anti-tuberculous medical management if the MRI shows significant spinal cord compression.
The commonest location of Spinal Tuberculosis is in the anterior part of the dorso-lumbar spine that is the part of the spine behind the heart/lungs or the upper part of the abdomen. Rarely, Tuberculosis of the spine rarely involves the anterior part of the cervical spine or the anterior part of the lumbo-sacral spine behind the lower abdomen. As mentioned above, Spinal Tuberculosis requires surgery only if there is significant spinal cord compression.
Spinal Tuberculosis in the anterior part of the lumbo-sacral spine rarely requires surgery, presents mainly with low back pain radiating to the legs and pain responds well to long-term anti-tuberculous medical management.
Posterior extradural collections between the posterior bone and the dural covering of the spinal cord present more acutely with fast-onset weakness in the limbs as also bowel/bladder involvement. These require urgent decompressive surgery of the spinal cord via a posterior midline incision to maximise neurological recovery.
Rarely, patients may develop severe neurological symptoms including paralysis and bowel/bladder involvement without significant spinal cord compression on the MRI. This is a poor prognosis situation because the severe neurological symptoms are actually caused by tubercular arachnoiditis/vasculitis which is invasion of the spinal cord itself or its blood supply by tuberculosis. Surgery may not help in this situation at all.
Surgery for Spinal Tuberculosis with significant spinal cord compression in the anterior part of the dorso-lumbar spine (that is the part of the spine behind the heart/lungs or the upper part of the abdomen) is best done through the side of the chest or through the side of the abdomen. This gives direct access to the most affected part of the spine and thereby gives the best chances for clearance of maximum bulk of the tubercular disease (allowing better penetration of anti-tuberculosis drugs), gives the most adequate spinal cord decompression (and thereby maximises neurological recovery). Following removal of all the rotten bone and pus and adequate wide spinal cord decompression, the surgeon replaces the gap created in the bony spine with a Titanium expandable cage further secured by screws/rods/plates to the vertebral bodies above and below the gap. This is the Transthoracic/Transretroperitoneal approach to Spinal Tuberculosis in the anterior part of the dorso-lumbar spine.
I use the same approach for dorso-lumbar vertebral body fractures with gross spinal cord compression because it offers the most direct route to the fractured body and allows for good adequate spinal cord decompression (which is crucial to maximizing neurological recovery).
Unfortunately, most surgeons are a little circumspect about approaching through the side of the chest or through the side of the abdomen and thereby go from the back. By going from the back, unfortunately the unaffected normal posterior bone is removed first and thereafter the spinal cord is encountered, thus making clearance of the tuberculosis disease burden much more difficult as also good spinal cord decompression much more difficult.
An aggressive exercise/physiotherapy regimen is crucial to maximizing recovery post-operatively and needs to start from post-operative day 1.
The first purpose of surgery is to prevent further neurological deterioration.
Recovery in patients who already have neurological symptoms depends on extent of symptoms, extent of spinal cord damage on pre-operative MRI and precision of surgery. Recovery will happen slowly over many months and is maximized by an aggressive exercise/physiotherapy regimen. However, the extent and time-period of recovery is unpredictable. But it must be mentioned that most patients with Tuberculosis Spine affecting the anterior part of the dorso-lumbarspine with significant spinal cord compression exhibit miraculous improvement over a few weeks/months. And therefore, it is never too late to try. It is not uncommon to see paralysed patients get back to normal walking.
Rarely, patients may develop severe neurological symptoms including paralysis and bowel/bladder involvement without significant spinal cord compression on the MRI. This is a poor prognosis situation because the severe neurological symptoms are actually caused by tubercular arachnoiditis/vasculitis which is invasion of the spinal cord itself or its blood supply by tuberculosis. Surgery may not help in this situation at all.
Posterior extradural collections between the posterior bone and the dural covering of the spinal cord present more acutely with fast-onset weakness in the limbs as also bowel/bladder involvement. These require urgent decompressive surgery of the spinal cord via a posterior midline incision to maximise neurological recovery. Recovery will happen slowly over many months and is maximized by an aggressive exercise/physiotherapy regimen. However, the extent and time-period of recovery is unpredictable.
There are some medications for residual symptoms such as spasticity/heaviness of the legs, paraesthesias or abnormal sensations, burning sensations, nerve pain radiating along the arms or legs.
The first purpose of surgery is to decompress the spinal cord thereby preventing further spinal cord damage. Patients with no neurological symptoms are near normal immediately post-operatively.
Recovery in patients who already have symptoms of spinal cord injury depends on extent of symptoms, extent of spinal cord damage on pre-operative MRI and precision of surgery. Recovery will happen slowly over many months and is maximized by an aggressive exercise/physiotherapy regimen. However, the extent and time-period of recovery is unpredictable. But it must be mentioned that patients with some amount of preserved power in the legs prior to surgery exhibit miraculous improvement over a few months.
Severe spinal cord injury resulting in near paralysis and bowel/bladder involvement may not recover completely.
Surgery for Spinal Tuberculosis with significant spinal cord compression in the anterior part of the dorso-lumbar spine (that is the part of the spine behind the heart/lungs or the upper part of the abdomen) is best done through the side of the chest or through the side of the abdomen. This gives direct access to the most affected part of the spine and thereby gives the best chances for clearance of maximum bulk of the tubercular disease (allowing better penetration of anti-tuberculosis drugs), gives the most adequate spinal cord decompression (and thereby maximises neurological recovery).
Most patients with Tuberculosis Spine affecting the anterior part of the dorso-lumbar spine with significant spinal cord compression exhibit miraculous improvement over a few weeks/months. And therefore, it is most important to use the best surgical approach. It is not uncommon to see paralysed patients get back to normal walking after successful Transthoracic/Transperitoneal surgery.
I use the same approach for dorso-lumbar vertebral body fractures with gross spinal cord compression because it offers the most direct route to the fractured body and allows for good adequate spinal cord decompression (which is crucial to maximizing neurological recovery).
Unfortunately, most surgeons are scared about approaching through the side of the chest or through the side of the abdomen and thereby go from the back. By going from the back, unfortunately the unaffected normal posterior bone is removed first and thereafter the spinal cord is encountered, thus making clearance of the tuberculosis disease burden/fracture fragments much more difficult as also good spinal cord decompression much more difficult.
