SPINE INFECTION - Pott's Spine

The most common infection of the spine in Asia and Africa is Tuberculosis (TB), also called Pott’s spine. This may be in isolation or as a part of generalised TB. Immuno-compromised patients (i.e. HIV patients, patients on long-term steroids etc.) are more likely to develop tuberculosis of the spine.

 Spine infection may also occur following spine surgery.

 

Pott’s Spine (Tuberculosis of the Spine)

This is the most common spinal infection, with multiple vertebral involvement, including skip lesions, para-vertebral collections and may cause spinal cord compression due to epidural pus, infected soft tissue and bone called sequestrum. The spine particularly the thoracic spine is the most common extra-pulmonary site in patients with TB. Rarely TB infection may occur within the spinal cord. There is a higher incidence of TB infection in HIV patients or patients on long-term steroids.

 

Non- tuberculous infections

These include:

  • Post op infections after spine surgery: The most serious deep-seated infections involve intervertebral disc and para-discal tissue called discitis. Treatment includes long-term antibiotics (up to 3 months) after removal of the infected tissue and subjecting it to culture and sensitivity testing.  Implant colonization may require removal of implant to control the infection. Post op infections after disc surgery should occur in less than one to two percent of cases. Most of these are superficial wound infections 

  • Other bacterial infections of the spine are rare and are generally seen in blood-borne infections (septicemia). 

  • Fungal infections of the spine are often associated with immuno-compromised patients, for example- prolonged users of steroids or HIV patients.

SYMPTOMS FOR SPINE TB
  1. Many of these patients would have had a period of fever with night sweats, weight loss and general malaise.

  2. In milliary tuberculosis there will also be symptoms related to the other diseased organs, such as a cough in cases of lung TB.

  3. There may be a long history of spine pain and tenderness, which, if ignored, may progress to weakness of the limbs and kyphosis (forward angulation) of the spine from collapse of the vertebral bodies.

  4. Neurological involvement of the limbs would depend upon the extent of spinal cord compression from the tubercular abscess and the location of the abscess in the spine.

 

INVESTIGATIONS FOR SPINE TB

  • Clinical: Diagnosis is made on clinical grounds by a combination of symptoms of weight loss, night sweats, and fever with spine pain and tenderness and other systemic symptoms. Examination by the treating doctor may detect spinal tenderness and neurological signs.

  • Blood test will show abnormality of raised ESR and CRP.

  • Plain radiograph of the chest and spine may suggest the diagnosis of TB.

  • MRI of the spine with contrast is the study of choice for diagnosis, treatment and follow-up. It will show the extent of spine involvement, the skip lesion, and spinal cord changes if present.

  • CT guided FNAC may be attempted, but may not be positive in a large proportion of cases. It may be useful if tumour is suspected or has to be ruled out.

  • C-Arm guided biopsy with cultures and AFB stain may clinch the diagnosis only in between 50% and 80% cases in various series. In our large case series, most of the cases were diagnosed by taking adequate specimen for biopsy and culture and sensitivity using a Jamshidi needle in the O.T, under a short anaesthetic. This is done at the time of making a diagnosis or at the time of open surgery to decompress and stabilize the spine. With this the diagnosis has been positive in 80% of cases. In patients who do not consent to the procedure, the diagnosis is made on clinical and radiological grounds. The patient is then started on anti- tubercular drugs and the response to treatment monitored at regular intervals.

TREATMENT OPTIONS FOR SPINE TB
  1. Medical Management - The treatment of Spine TB is anti-tubercular drugs (ATT), generally with four drugs to start with. There are various treatment regimes from 9 months to 18 months. Most of our cases receive 18 months of ATT, initially with four drugs, then gradually reduced to two. An orthosis is provided for pain relief and prevent progression of kyphosis.

  2. Surgical Management - may be required to decompress the spinal cord, obtain material for biopsy and culture, and stabilize the spine so that kyphosis (forward angulation of the spine) does not progress. Medical Management will continue after surgery. Surgery is not a substitute for anti-tubercular drugs.

    • In cervical spine TB, surgery for decompression and fusion of the spine is done anteriorly (front of spine). Further stabilisation may be opted for posteriorly.

    • Thoracic TB abscesses can be drained anteriorly or posteriorly (back of spine) and then stabilised  and fused. Anterior thoracic procedures can be done thoracoscopically or robotically and then stabilised posteriorly. 

    • Lumbar spine TB can be drained and stabilized / fused, in most cases, posteriorly.

  3. Follow up and end of treatment: Most cases will have return to normal of ESR in a few months after starting ATT. MRI with contrast will continue to show improvement with ATT, but may still show enhancement at the end of 18 months. Up to 20% of cases will show resistance to first line drugs and second line drugs will have to be used. It is therefore very important to get culture material in all cases, so that drug treatment can be modified, if required.

 
 
 

Disclaimer : The information on this site is not intended or implied to be a substitute for professional medical advice, diagnosis or treatment. All content, including text, graphics, images and information, contained on or available through this web site is for general information purposes only.

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