### Date : 2024-06-19 19:08 ### Topic : Spinal TB (Pott's disease) #medicine #pulmonology #orthopedic ---- ### Spinal Tuberculosis (TB) Overview **Spinal tuberculosis**, also known as **Pott's disease** or **tuberculous spondylitis**, is a form of extrapulmonary tuberculosis that affects the spine. It is caused by the spread of Mycobacterium tuberculosis to the vertebrae, leading to the destruction of spinal tissues, which can result in severe complications if not treated promptly. ### Pathophysiology Spinal TB typically starts in the vertebral body and then spreads to adjacent vertebrae and intervertebral discs. It can lead to: - **Granuloma Formation:** Clusters of immune cells attempting to contain the infection. - **Caseation Necrosis:** A cheese-like, softening of tissue caused by the breakdown of cells. - **Bone Destruction:** Progressive destruction of the vertebrae, leading to instability and deformities. - **Cold Abscess Formation:** Accumulation of pus without the typical signs of acute inflammation. - **Spinal Deformity and Neurological Complications:** Including kyphosis (forward curvature of the spine) and potential spinal cord compression. ### Clinical Features **Early Symptoms:** - **Back Pain:** Persistent and severe pain localized to the affected area, typically worsening at night. - **Fever and Night Sweats:** Low-grade fever and profuse sweating at night. - **Weight Loss and Fatigue:** General malaise and significant weight loss. **Progressive Symptoms:** - **Localized Tenderness:** Painful and tender vertebrae upon palpation. - **Spinal Deformity:** Kyphosis or gibbus deformity due to vertebral collapse. - **Neurological Deficits:** Weakness, numbness, or paralysis resulting from spinal cord compression or nerve root involvement. - **Cold Abscesses:** Abscesses that may track along tissue planes and present as a mass, sometimes seen in the psoas muscle or paraspinal region. ### Diagnosis Diagnosis involves a combination of clinical evaluation, imaging studies, and microbiological tests: 1. **Clinical Evaluation:** - Detailed medical history and physical examination focusing on symptoms and spinal abnormalities. 2. **Imaging Studies:** - **X-rays:** Initial imaging to identify vertebral damage, disc space narrowing, and kyphosis. - **MRI:** Preferred for detailed imaging of soft tissues, spinal cord, and extent of infection. - **CT Scan:** Useful for assessing bony destruction and abscess formation. 3. **Microbiological Tests:** - **Sputum or Abscess Aspiration:** Samples for acid-fast bacilli (AFB) smear and culture. - **Biopsy:** Needle biopsy of the affected vertebrae for histopathological examination and culture. - **PCR Tests:** To detect Mycobacterium tuberculosis DNA. 4. **Laboratory Tests:** - **Tuberculin Skin Test (TST) or IGRA:** To support diagnosis but not definitive. - **Blood Tests:** Elevated ESR (erythrocyte sedimentation rate) and CRP (C-reactive protein) indicating inflammation. ### Example Case Study **Patient Profile:** - **Name:** Jee Hoon Ju - **Age:** 42 - **Occupation:** Farmer **Medical History:** - **Symptoms:** Persistent lower back pain for several months, night sweats, weight loss, and a mild fever. Recently, he developed a noticeable hump on his back and some weakness in his legs. **Clinical Evaluation:** - **Physical Examination:** Tenderness over the lower thoracic and upper lumbar spine, a visible kyphotic deformity, and reduced strength in the lower extremities. **Imaging:** - **X-ray:** Shows destruction of the T10-L1 vertebrae with a kyphotic deformity. - **MRI:** Reveals extensive vertebral destruction, disc involvement, paraspinal abscesses, and spinal cord compression. **Microbiological Tests:** - **Biopsy:** Vertebral biopsy confirms the presence of Mycobacterium tuberculosis. **Diagnosis:** Based on clinical features, imaging findings, and microbiological confirmation, Jee Hoon Ju is diagnosed with spinal tuberculosis. ### Management 1. **Medical Treatment:** - **Antituberculous Therapy:** A combination of first-line anti-TB drugs for at least 6-12 months. - **Initial Phase (2 months):** Isoniazid (INH), rifampicin (RIF), pyrazinamide (PZA), and ethambutol (EMB). - **Continuation Phase (4-10 months):** Isoniazid and rifampicin. - **Monitoring for Drug Resistance:** Adjust treatment based on sensitivity testing if drug-resistant TB is suspected. 2. **Surgical Treatment:** - **Indications:** Severe spinal instability, neurological deficits, large abscesses, or lack of response to medical therapy. - **Procedures:** Debridement, abscess drainage, spinal fusion, and stabilization. 3. **Supportive Care:** - **Pain Management:** NSAIDs or other analgesics for pain relief. - **Bracing:** Spinal braces to support and immobilize the spine during healing. - **Physiotherapy:** To maintain mobility and muscle strength, and to assist in recovery post-surgery. 4. **Nutritional Support:** - Ensuring adequate nutrition to support overall health and healing. ### Prognosis - **Early Diagnosis and Treatment:** Lead to better outcomes and prevention of severe complications. - **Delayed Treatment:** Can result in significant morbidity due to spinal deformities and neurological impairments. - **Regular Follow-Up:** Essential to monitor response to treatment, manage side effects, and prevent recurrence. ### Conclusion Spinal tuberculosis is a serious form of TB that affects the vertebral column, potentially leading to severe complications if not treated promptly. Early diagnosis through clinical evaluation, imaging, and microbiological tests, followed by appropriate medical and possibly surgical treatment, is crucial for effective management and improved patient outcomes. Regular follow-up and supportive care are essential components of comprehensive management.