Cermin Dunia Kedokteran

TINJAUAN KEPUSTAKAAN

Medical Treatment

of Spinal Tuberculosis

Zuljasri Albar

Rheumatology Division, Department of Internal Medicine, Faculty of Medicine, University of Indonesia

Cipto Mangunkusumo Hospital, Jakarta

Indonesia

INTRODUCTION

Tuberculosis is still a major health problem in developing

countries. Indonesia is the third largest TB population in the

world, after China and India. Extra-pulmonary TB accounts for

17.9% - 19.4% of all tuberculosis cases. About 11% of

extra-pulmonary TB showed osteoarticular involvement; spinal

lesions constitute a major bulk among this osteoarticular TB; it

is the commonest form of osteoarticular tuberculosis and

contributes to about 50% (25-60%) of all cases of skeletal

tuberculosis in various reported series (Tuli et al 1969, Martini

et al 1988) (from Agarwal et al

(2)

; spinal tuberculosis is

relatively an uncommon form of tuberculous infection

occurring in about 1% of patients with tuberculosis.

(3)

Bone and joint TB was found more often in certain

racial/ethnic groups, HIV positive group, immigrants from

countries with high TB prevalence, elderly, children under 15

years of age and other immunocompromised conditions. In

HIV patients, the incidence of tuberculosis is 500 times higher

than that of general population. On the other hand,about

25-50% of new cases of tuberculosis in USA were HIV

positive

(1)

DIAGNOSIS

About 80% of tuberculosis infections are caused by

activation of dormant bacteria. Bacteria living in scars left by

the initial infection - usually in the top of one or both lungs -

may begin to multiply. Activation of dormant bacteria can

occur when the person's immune system becomes impaired, for

example from AIDS, the use of corticosteroids or in very

advanced age. Spinal tuberculosis is often the result of

haematogenous dissemination from primary focus, usually in

the lungs. The detection of primary focus or an associated

visceral tuberculous lesion however depends greatly upon the

amount of efforts put into investigations

(1)

The disease begins in the anteroinferior portion of the

vertebral body and tends to spread beneath the anterior

longitudinal ligament to involve adjacent vertebral bodies.

Because the anterior portion of a vertebral body is much more

likely involved than the posterior portion, a sharp kyphosis may

occurs. Simultaneous involvement of anterior and posterior

elements of vertebra in spinal tuberculosis is rare. Even with

the resolution of acute infectious process, the kyphosis may

continue to cause anterior compression of the cord and late

neurological sequelae. Multiple sites in affected. Other

investigators found thoracal vertebra is more often affected, and

cervical vertebra is the least often affected. In Cipto

Mangunkusumo Hospital, Jakarta, thoracal vertebra was

involved in about 71% spinal tuberculosis cases. There is

5%-7% incidence of multiple level vertebral involvement,

mostly between 1 to 5 vertebral body with an average 2.51.

Narrowing of the disc space occurs as a late phenomenon. In a

majority of spinal tuberculosis patients, a typical paradiscal

lesion characterised by destruction of adjacent bone end plates

with reduction in disc space is seen. Extension of the infection

into the adjacent paraspinal soft tissues, with abscess formation,

particularly beneath the fascia of the psoas muscle is frequent.

Subligamentous spread and posterior extension into the

epidural space occur less commonly.

Tuberculous spondylitis can have myriad, variable clinical

presentations. Classically, the typical complaint is spine pain

and manifestations of chronic illness including weight loss,

malaise, fever, and/or night sweats.

Physical examination may demonstrate deformity (gibbus),

local tenderness, muscle spasm, restricted motion, a mass in the

groin, thigh or flank and neurologic deficit

(3)

. Neurologic injury

may be caused by pressure on the spinal cord from a paraspinal

abscess, inflammatory vasculitis with thrombosis of spinal

vessels, cord transection from vertebral collapse or spinal root

compression from arachnoiditis or abscess. This situation occur

in 12 to 50 % of cases

(8)

. The most serious complication of

spinal tuberculosis is paraplegia (Pott's paraplegia) which may

occur either early or late in the course of the disease. Butler and

Seddon, working independently, agreed with Sorrel-Dejerine to

divide Pott's paraplegia into two types : 1). Paraplegia of early

onset, coming on during the florid phase of the spinal disease

usually within the first 2 years, and 2). Paraplegia of late onset,

Cermin Dunia Kedokteran No. 137, 2002 29

appearing even many years after the disease has become

quiescent and sometimes without evidence of reactivation

(8)

The pathology of Pott's paraplegia was described elsewhere in

the literatures.

Erythrocyte sedimentation rate is generally elevated, but is

usually nonspecific

(3)

. The raised CRP serum concentration

were strongly associated with pus formation (Hadi and

Sapardan, 1997). Tuberculin purified protein derivative (PPD)

skin test is usually positive but only indicates a history of

exposure (remote or current). Sputum specimens are positive

only if there is active pulmonary disease. The only laboratory

finding which can absolutely confirm the diagnosis is a positive

culture from a spinal lesion biopsy

(l,5,9,12)

Plain radiographs showed rarefaction of the vertebral end

plates, soft-tissue abscess, increasing loss of disc height,

variable degrees of osseous destruction and newbone

formation. In short, classic picture of spinal tuberculosis

showed narrowing of the disc space, vertebral collapse and

paraspinal abscess

(1)

. Computed tomography (CT) scan will

delineate the extent of bony destruction as well as soft tissue

changes around the spine and in the canal. It also helpful for the

guidance of biopsy and in the planning of operative procedures.

Magnetic resonance imaging (MRI) is the imaging modality of

choice because it will delineate soft-tissue masses in both the

sagittal and the coronal plane and for indicating the extent of

disease and the spread of tuberculous debris under the anterior

and posterior ligaments

(l,5,9)

Differential diagnosis is broad, including other infections

such as brucellosis or pyogenic bacterial infection, neoplasm

and sarcoidosis

(l)

Despite newer modalities of imaging of the spine and

spinal cord, diagnosis is best made by examination of biopsy

material, obtained by CT-guided or open blopsy

(l,3,5,6,8)

TREATMENT

The treatment of musculoskeletal tuberculosis is primarily

medical. Operative intervention is an adjunct to appropriate

antituberculous therapy. It is important to recognize and treat

early, before damage to the backbone causes nerve damage and

paralysis. Spinal tuberculosis can be successfully treated with

antituberculous chemotherapy alone, particularly if the

diagnosis is made early prior to gross bone destruction (Fam

and Rubenstein, 1993). With early, complete treatment the

damaged bones will usually heal and the patient may live

normally, although often somewhat hunched over. Treatment

options for spinal tuberculosis are selected based on the

presence or absence of spinal instability, neurologic deficits

and the level of surgical expertise available

(1)

. In countries

where adequate surgical facilities are lacking, an acceptable

alternative is antituberculous chemotherapy combined with a

spinal brace or cast. In Indonesia, however, the problem is not

only in the early treatment, but also in case finding. Among

40.300 estimated tuberculous patients in Central Java

(population 31 million), only 4668 cases (18%) were detected

and undergone therapy for tuberculosis

(13)

(Kompas, March 31,

2001).

The goal of treatment are to eradicate infection, and to

prevent or to treat neurological deficits and spinal deformity.

Use of antituberculosis drugs has virtually eliminated the

severe distortion of the spinal segment occuring late in the

course of the disease, which in the past often produced a

deforming gibbus or severely fixed scoliosis and pelvic

obliquity. Successful medical treatment of tuberculosis requires

the prolonged administration of a minimum of three drugs

susceptible to the organisms, and at least one of these drugs

must be bactericidal.

Isoniazid is the most potent bactericidal drug available and

is particularly effective against actively growing organisms. It

is relatively non-toxic, easily administered and inexpensive.

The usual adult dosage is 3-5 mg/kg/day. Hepatic toxicity is

major side effect. Ten milligrams of pyridoxin/day should be

given in conjunction with isoniazid to prevent peripheral

neuropathy. Rifampicin and pyrazinamide are the most

effective sterilizing drugs, and they are specifically effective

against bacilli that are dormant and undergo periodic burst of

activity. The usual adult dosage for rifampicin is 10 mg/kg/day;

for pyrazinamide, the dosage is generally 20-25 mg/kg/day.

Ethambutol is bacteriostatic. Retrobulbar neuritis is the most

frequent and serious adverse effect of this drug; the dosage is

15-25 mg/kg/day, and discontinued after 2-3 months.

The optimum duration of treatment has been an issue of

considerable debate, and much of the information now

available concerns the treatment of pulmonary disease. Watts

and Lifeso recommend that treatment be continued for a

minimum of twelve months for osteoarticular involvement,

extending to perhaps eighteen months for certain problems.

Parthasarathy et al reported their experience on 235 spinal

tuberculosis patients without paraplegia treated by three

different regimens : a) radical anterior resection with bone

grafting plus six months of daily isoniazid plus rifampicin; b)

ambulant chemotherapy for six months with daily isoniazid

plus rifampicin; c) similar to b), but with chemotherapy for

nine months. Ten years from the onset of treatment, 90% of a),

94% of b) and 99% of c) had a favourable status. They

concluded that ambulant chemotherapy for a period of six

months with daily isoniazid plus rifampicin (b) was an effective

treatment for spinal tuberculosis except in patients aged less

than 15 years with an initial angle of kyphosis of more than 30°

whose kyphosis increased substantially

(15)

The Medical Research Council Committee for Research

for Tuberculosis in the Tropics concluded that the treatment of

choice for spinal tuberculosis in developing countries is

ambulatory chemotherapy for 6 or 9 months with isoniazid and

rifampicin. Surgery is reserved for biopsy, management of

myelopathy, abscesses and sinuses and for stabilization to

prevent or correct kyphotic deformity especially if there is an

associated and progressive neurologic deficits.

The recommendations for duration of TB treatment in

HIV-infected persons are the same as for persons not infected

with HIV

(5)

Surgical intervention, once the mainstay of management, is

now less frequently required. Indications include diagnostic

biopsy when needle aspiration and biopsy are unsuccessful,

drainage of a large paraspinal abscess and spinal decom-

Cermin Dunia Kedokteran No. 137, 2002

pression and fusion in patients with progressive neurologic

deficit, and in those with gross destruction and/or increasing

spinal deformity, particularly of the cervical or thoracic spine.

Another indications for operative intervention have been

proposed by several authors. Watts and Lifeso pointed out

absolute and relative indications for operative intervention.

The Merck Manual of Medical Information - Home Edition. Ch. 181.

Watts HG, Lifeso RM. Tuberculosis of bone and joints. J Bone and Joint

Surg 1996; 78A (2): 288-95.

6. Scully RE (Ed.). Case records of the Massachusetts General Hospital.

NEJM 1996; 334(12): 784-89.

7. Arnadi et al. Spinal tuberculosis profile at Cipto Mangunkusumo

Hospital, Jakarta, Indonesia during 1995-2000. Indonesian Rheumatology

Association, Annual Meeting, 2000.

8. Jones C. The great masquerader. Tuberculous spondylitis. Another

differential diagnosis in back pain.

SUMMARY

Tuberculosis infection is still a major health problem in

developing countries. Indonesia has the third largest TB

population in the world, after China and India. Spinal tuber-

culosis is found in about 1 % of tuberculous infection. Pott's

paraplegia can occur early or late in the course of the disease.

The choice of therapy depends on the condition of the patient,

the stage of the disease, availability of surgical facilities and

trained personnel.

Ytterberg SR. Mycobacterial, fungal, and parasitic arthritis. In Klippel JH

(ed.) Primer on the Rheumatic Diseases. 11

ed., Arthritis Foundation,

Atlanta, GA, 1997. p 207-11.

10. Hodgson et al. The pathogenesis of Pott's paraplegia. J Bone and Joint

Surg 1967; 49A: 1147-56.

11. Hadi SA, Sapardan S : The CRP levels in spondylitis TB. Maj Ortopedi

Indon 1997; 25(1): 21-2.

12. Lifeso RN et al. Tuberculous spondylitis in adults. J Bone and Joint Surg

1985; 67A: 1405-13.

13. Kompas, Sabtu, 31 Maret 2001.

14. Anwar IB et al. Sensitifitas dan spesifisitas infecton pada penderita

tuberkulosa tulang belakang di Rumah Sakit Hasan Sadikin Bandung Juli

1998 - Oktober 1999. Maj Ortopedi Indon, Juni 2000; 28 (1): 42-9.

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start or undergoing radical surgery. Fourteenth report of the Medical

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