Spinal tuberculosis and neurological deficit: A 10-year study in rural tertiary care center of central India
Rohan R Patil, Girish Balasaheb Mote, Aniket Kanhaiyalal Wankhede, Kiran N Wandile, Chandrashekhar M Badole
Department of Orthopaedics, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Maharashtra, India
|Date of Submission||21-Apr-2021|
|Date of Acceptance||03-Apr-2022|
|Date of Web Publication||15-Jun-2022|
Dr. Girish Balasaheb Mote
Department of Orthopaedics, Mahatma Gandhi Institute of Medical Sciences, Sevagram – 442 102, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: India is a home for 27% of the world’s tuberculosis (TB) cases. When compared, extrapulmonary TB (EPTB) cases have a lower incidence than pulmonary TB (PTB), but there is no significant reduction in the incidence of EPTB than PTB. Spinal TB is most common of skeletal TB. Aims: We aimed to study and to identify the clinical-radiological features in spinal TB and the incidence of neurological involvement along with factors associated with it. Settings and Design: This was a retrospective study in a tertiary care center of Central India. Subjects and Methods: A total of 114 cases with spinal TB were included in the study. Data collected retrospectively from January 2008 to December 2018 using a picture archiving and picture archiving and communication system of the hospital. Radiographs, magnetic resonance imaging scan, computed tomography, and ultrasound findings were studied. History and clinical examination findings were thoroughly analyzed. Statistical Analysis Used: Data were analyzed using Epi Info Software. Results: There were 74 (64.9%) male cases and 40 (35.1%) female cases. Most of the cases belong to rural 85 (74.5%) than urban 29 (24.5%) area. After neurological evaluation, paraparesis/paraplegia was observed in 52 (45.6%) cases and tetraplegia in 2 (1.7%) cases. Sensory deficit was observed in 10 (10.5%) cases. Bowel/bladder involvement was present in 5 (4.4% cases). Most of the cases with neurodeficit had dorsal vertebral involvement 30 (61.1%). Conclusions: The pattern of spinal TB is varied and is difficult to get diagnosed. We observed a high proportion of cases with neurodeficit. Most of them were with late-onset TB. This highlights that early diagnosis and complete treatment are very important in the treatment of TB of the spine.
Keywords: Extrapulmonary tuberculosis, Pott’s spine, spinal tuberculosis, tuberculosis
|How to cite this article:
Patil RR, Mote GB, Wankhede AK, Wandile KN, Badole CM. Spinal tuberculosis and neurological deficit: A 10-year study in rural tertiary care center of central India. J Orthop Traumatol Rehabil 2022;14:55-8
|How to cite this URL:
Patil RR, Mote GB, Wankhede AK, Wandile KN, Badole CM. Spinal tuberculosis and neurological deficit: A 10-year study in rural tertiary care center of central India. J Orthop Traumatol Rehabil [serial online] 2022 [cited 2022 Jul 1];14:55-8. Available from: https://www.jotr.in/text.asp?2022/14/1/55/347361
India is a home to 27% of the world’s 10.4 million new tuberculosis (TB) cases, and 29% of the 1.8 million TB deaths globally. Figures get upmost importance when India plans to eliminate TB by 2025. Although the incidence of extrapulmonary TB (EPTB) is low at 3%; however, there has been no significant reduction in the incidence of EPTB when compared to pulmonary TB (PTB). Skeletal TB (STB) contributes to around 10% of EPTB, and spinal TB has been the most common site of STB, amounting to around half of the skeletal EPTB. Moreover, drug-resistant spinal TB poses a unique set of challenges vis-à -vis drug-resistant PTB.
The morphologic and pathophysiologic changes encountered in spinal TB are most severe and most varied among infective spondylitis. Early diagnosis and complete treatment are necessary for full recovery and healing in case of spinal TB.
Hence, we planned this study to identify the clinical-radiological features in spinal TB and the incidence of neurological involvement along with factors associated with it. As per the WHO Global Report on TB 2013, India accounts for the highest burden of multidrug-resistant TB (MDR-TB) cases, i.e., 64,000 MDR-TB cases out of 300,000 cases estimated globally occur among the notified PTB cases annually. This data is taken from 2014 TB annual report of Central TB Division, Directorate General of Health Services Ministry of Health and Family Welfare, Nirman Bhavan, New Delhi.
|Subjects and Methods|
The present retrospective study was conducted in the rural tertiary care center in Central India region. All the patients with spinal TB admitted to the department of orthopedics were included in this study. Data were retrieved for the last 10 years, i.e., from January 2008 to December 2018 from hospital information system. Magnetic resonance imaging (MRI), computed tomography (CT), ultrasound, and plain radiographs findings and images for every individual case were retrieved from a picture archiving and communication system.
The diagnosis of Pott’s spine was based on the clinical findings of MRI, CT, or ultrasound-guided aspiration biopsy or serological findings such as BACTEK, Seva-TB Elisa, or Gene-Xpert. MRI records were also used to analyze the level and number of vertebra affected by disease and looked for findings of spinal TB such as paradiscal involvement, vertebral body collapse, large paravertebral abscess, endplate erosion, and any other associated deformity such as gibbus or kyphosis.
We thoroughly analyzed the history and clinical evaluation of each case. Muscle power was noted on a 0–5 Medical Research Council scale. Remarks on tone, reflex, and sensations of pinprick, joint position, and vibration were also collected. Points on clinical examination including the presence of bone deformity, tenderness, soft-tissue swelling, and extra-spinal TB were scrutinized. The findings of hematological (total blood count, erythrocyte sedimentation rate, and serum chemistry) and serological (the venereal disease research laboratory test, human immunodeficiency virus, mantoux, and tubercular antigen-antibody response) also checked. Further radiographs of the chest and spine were scrutinized.
Due ethical consideration was sought from institutional ethical committee before initiation of research.
Data were entered and analyzed using Epi Info Software. Data were checked for completeness by computing frequencies. For descriptive analysis of measures of central tendency was derived, to find out the association between dependent and independent variables Chi-square test was used with significance at P < 0.05.
The sociodemographic findings are shown in [Table 1].
Presenting complaints include back pain being the most common complaint 102 (89.5%), followed by weakness 38 (34.3%), radicular pain 26 (22.8%), fever with other constitutional 10 (8.8%), and sinus/swelling over back/abdominal pain was present in 4 (3.5%), as shown in [Figure 1].
The mean duration of symptoms till medical attention was sought 4.8 (±6.2) months whereas patients with neurological deficit sought medical attention at 4.5 (±5.4) months and 50% of patients with weakness sought treatment at 2 months.
We observed paraplegia/paraparesis associated with spinal TB in 52 (45.6%) and tetraplegia in 2 (1.7%) cases. The sensory loss was observed in 12 (10.5%) and bladder/bowel involvement was present in 5 (4.4%). Complete paraplegia was seen in 4 (2.6%) of the patients.
Most of the patients with neurological deficit had involvement in dorsal vertebral level 30 (61.1%), followed by 11 (27.5%) in lumbar, dorsolumbar, and lumbosacral each accounted for 3 (6.1%), and 2 (4.1%) in the cervical region; this difference was statistically significant (P < 0.05).
We also observed that 9 (7.8%) patients had active TB when they developed spinal TB. Concomitant active TB and neurological involvement were present in 7 (13.4%) cases and it was found to be statistically significant (P < 0.05).
Most of the patients had involvement of the vertebral body 31 (27.2%), followed by endplate erosion/discal 17 (14.9%), anterior involvement in 16 (14.1%), paravertebral 10 (8.8%), epidural 7 (6.1%), posterior 6 (5.3%), and pedicle involvement in 3 (2.6%) of cases with spinal TB, as shown in [Figure 2].
The pathology observed is shown in [Table 2].
The distribution of vertebral level involvement is shown in [Table 3]. The average number of vertebrae involvement was 2.1 (±1.1). Two vertebral level involvements were most common 76 (73.1%), followed by one vertebral involvement in 17 (16.3%), and more than three vertebral units 11 (10.6%).
Spinal TB is characterized by caseous necrosis and destruction of tissues. The spinal cord is susceptible to myelopathy secondary to compression from an epidural abscess and may present with specific symptoms depending on the site of cord compression. Cord compression can also result from a collapsed vertebra with dorsal fragment impinging on the cord resulting into partial and total motor loss with a gradual sensory deficit.,
We observed 114 cases with Pott’s spine for 10 years. Out of which, male 74 (64.9%) outnumbered female 40 (35.1) with ratio of 1.8:1. Similar findings were observed by Vaishnav et al. while conducting a clinical study of spinal TB presenting with neurodeficit. Most of the patients were in the age group of 19–59 years 86 (75.4%). Overall, the mean age was 43 (±16.4) years and the youngest case was of 2 years and oldest of 86 years.
This was comparable to Bodpati et al.’s findings while prospectively studying 48 patients to find out the outcome of surgical management. Wang et al. also observed a range of 2–82 years in patients of spinal TB in teaching hospital of southwest of China. About 85 (74.5%) of the patients were from rural background where poverty, poor sanitation, and low income as significant risk factors for spinal TB. Similar observations were made by Ghosh et al.
As mentioned by other studies, the present study also highlights low back pain 102 (89.5%) as major complaint followed by weakness and radicular pain. In active stage, low back pain is due to inflammation of bone, whereas the rest pain is believed to be pathognomonic and the intensity is proportional to the amount of bone destruction and instability.
Fever, weight loss, and other constitutional symptoms were seen 10 (8.8%) of the patients which are more frequently associated with PTB than spinal TB. In our study, we observed that 9 (7.8%) patients had active PTB.
Paraplegia/paraparesis associated with spinal TB was seen in 52 (45.6%) while complete paraplegia was seen in 4 (2.6%) of patients. The mean duration of presenting complaint was 4.8 (±6.2) months whereas patients with neurological deficit sought medical attention at 4.5 (±5.4) months. Moreover, the median duration was 2 months. The presence of active TB and the neurological deficit was found to be significant in our study (P < 0.05) which may be due to direct compression by abscess and inflammatory tissue.
The most common vertebral level involvement was at thoracic level 41 (39.1%), followed by 40 (38.1%), 10 (9.5%) in thoracolumbar which was similar to the Sharma et al.’s findings while Bodpati et al. found lumbar region as most susceptible to infection and cervical 5 (4.8%) region has the least proportion of infection. The present study also highlights the strong association between thoracic vertebra involvement and the presence of neurodeficit (P < 0.05).
The average number of vertebrae involvement was 2.1 (±1.1). Two vertebral level involvements were most common 76 (73.1%), followed by one vertebral involvement in 17 (16.3%), and more than three vertebral units 11 (10.6%). Similar observations were made by Wang et al. with 59.5% of cases had two vertebra involvements whereas Sharma et al. documented one level of vertebral spinal involvement as the most common type accounting to 80.4%. Here, Sharma et al. considered one level of vertebral spinal involvement as one functional unit.
Vertebral body 31 (27.2%) involvement was the most common finding of our study followed by endplate erosion/discal 17 (14.9%), this was similar to Vaishnav et al. demonstrating vertebral body wedging or collapse as the most common cause of compression.
Despite the Government of India pushing for the elimination of TB by 2025 still it remains Achilles’ heel. In the present study, we could identify cases of spinal TB in a child as young as 2 years to old age person of 85 years. Around three-fourth of the cases are from rural area and longer duration of time to seek medical attention which highlights the importance of hygiene and sanitation, risen gap between patient and health-care personnel. Moreover, pattern of spinal TB is varied which is difficult to get diagnosed at earliest. We also observed a high proportion of cases with neurodeficit; most of them were with late-onset TB. This also highlights that the importance of early diagnosis and complete treatment as various studies have shown the final outcome of spinal TB presenting with neurological deficits has improved significantly due to simultaneous medical and surgical management.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]