Schlesinger, Naomi MD*; Lardizabal, Alfred MD†; Rao, Jayanti MD‡; Rao, Jyoti MD§; McDonald, Reynard MD†
From the *Department of Medicine, Rheumatology Division, University of Medicine and Dentistry of New Jersey/Robert Wood Johnson University Hospital, New Brunswick, New Jersey; the †New Jersey Medical School National Tuberculosis Center, Department of Medicine, University of Medicine and Dentistry of New Jersey, Newark, New Jersey; the ‡Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; and the §Department of Medicine, New York University, New York, New York.
Supported by grants from the CDC Tuberculosis Model Center (00-57-TB-S-2: Alfred Lardizabal, MD, and Reynard McDonald, MD) and NJDHSS 00-35-TB-S-2 (Reynard McDonald, MD).
Reprints: Naomi Schlesinger, MD, Department of Medicine, UMDNJ-Robert Wood Johnson Medical School, One Robert Wood Johnson Pl., P.O. Box 19, New Brunswick, NJ 08903-0019. E-mail: firstname.lastname@example.org.
Background: It is estimated that 10 to 15 million people are infected with Mycobacterium tuberculosis in the United States. Spinal involvement is said to occur in less than 1%.
Methods: A review of the clinic records of all patients having a diagnosis of spinal tuberculosis at the New Jersey Medical School National Tuberculosis Center from January 1994 to January 1999 was done.
Results: Twelve patients with spinal TB were identified (2.2%). Spinal tuberculosis is characteristically chronic and slowly progressive. Presenting symptoms are usually back and neck pain or pain at the site of involvement. Pain was noted in a majority (83%) of our patients. Despite proven diagnoses by culture or histology, only 41% were purified protein derivative-positive. Unlike pulmonary tuberculosis, which may present with a constellation of symptoms, including cough, weight loss, fever, and night sweats, if tuberculosis only involves bone, pain may be the only symptom. Most patients were successfully treated with surgery and anti-TB medications. Tuberculosis remains a major public health problem.
Conclusions: Before the disease can be treated, it must be recognized. Tuberculosis should be considered a diagnostic possibility when spinal osteomyelitis is seen, even in the absence of pulmonary disease or HIV infection. Back pain in a patient with tuberculosis should be evaluated. Early initiation of an appropriate treatment regimen may reduce the need for surgical intervention, but most patients require surgery.
Tuberculosis of the spine (Pott disease) has plagued humankind since ancient times. Skeletal lesions of Pott disease have been found in 5000-year-old Egyptian mummies.1 The resurgence of tuberculosis in the United States in the 1980s to the early 1990s has been attributed to the human immunodeficiency virus (HIV) epidemic, increased transmission in conjugate settings, immigration from countries with a high prevalence of tuberculosis, poor patient adherence in taking prescribed medications, and deterioration of the public health infrastructure.
It is estimated that approximately 10 to 15 million people are infected with Mycobacterium tuberculosis (M. Tbc) in the United States. In 1998, there were 18,361 active tuberculosis cases reported in the United States; 3541 (19.3%) involved extrapulmonary sites;2 377 (2%) involved bones and joints with less than 1% occurring in the spine.2 The resurgence of tuberculosis globally can be expected to be associated with a concomitant increase in the incidence of extrapulmonary tuberculosis, including Pott disease. We describe a review of spinal tuberculosis in an inner city referral center.
A review of the clinic records of all patients having a diagnosis of spinal tuberculosis at the New Jersey Medical School National Tuberculosis Center from January 1994 to January 1999 was done. This retrospective chart review of patients diagnosed with spinal tuberculosis was undertaken to better define the patient population experiencing this form of extrapulmonary tuberculosis and to review their management. A pulmonologist with long experience in tuberculosis management supervised the chart reviews that were done by 2 medical students, a rheumatologist and a pulmonologist.
A diagnosis of spinal tuberculosis for the purpose of this study was defined as the culture of M. Tbc (9 patients) or the finding of necrotizing on nonnecrotizing granulomas on histologic study of tissue biopsy specimens (3 patients) in symptomatic patients with bone lesions on computed tomography scan or magnetic resonance imaging compatible with tuberculosis (disc space narrowing, end plate erosions, vertebral collapse, cord compression, paraspinal abscess).
One additional patient was diagnosed with spinal tuberculosis and was found to have a positive tuberculin skin test (TST) but did not have culture taken on histologic studies done. This patient who clinically improved and their bone lesions improved with treatment of tuberculosis (1 patient).
Review of tuberculosis surveillance data revealed that a total of 545 tuberculosis cases were seen at the New Jersey Medical School National Tuberculosis Center from January 1994 to January 1999. Of that number, we identified 12 cases as tuberculosis involving the spine. Of the 12 patients with spinal tuberculosis, a majority were male and foreign-born. Presenting symptoms included lower back pain, weakness, and numbness with a duration ranging from 2 months to 4 years (see Table 1). Fever was rare. One patient had cord compression and a neurogenic bladder.
All patients were skin tested using the Mantoux method performed by the intradermal injection of 0.1 mL of purified protein derivative tuberculin containing 5 TU (tuberculin units) into the skin of the forearm. Tuberculin skin tests of 5-mm duration in HIV-seropositive patients were read as positive and TST 10 mm were positive read as positive in HIV-seronegative patients. Only 5 of 12 (41%) were recorded with a positive tuberculin skin test. All patients underwent magnetic resonance imaging as part of the evaluation for spinal involvement. The most common findings on imaging were bone destruction, disc space narrowing, with and without the presence of cold abscesses in adjacent muscle structures and, less frequently, compression of the spinal cord or cord roots. Seven of 12 cases (58%) involved the thoracic spine; 3 of 7 (43%) involved the upper thoracic spine T2–4; 4 (57%) involved the lower thoracic spine T9–12, all of which also involved the upper lumbar spines, L1–3; 4 of 12 (33%) cases involved the lumbar sacral spine; 1 case involved the cervical spine, C4; 8 of the 12 cases (67%) developed paraspinal abscesses; more than half (7 of 12) of the cases had extraspinal involvement; 6 had concomitant pulmonary involvement and 1 case involved the breast simultaneously. The number of vertebral bodies involved per patient ranged between 1 and 5 (mean, 3.4) (see Table 2).
Almost all cases (11 of 12) underwent bone biopsy with or without biopsy of the paraspinal abscess. Six of the 11 (55%) biopsies had a positive smear, whereas 9 of 11 (82%) of biopsies had a positive culture. Histologic findings suggestive of tuberculosis involvement of the bone revealing granuloma formation, either caseating or noncaseating, were found in only 3 of the 12 biopsies. However, the 2 cases with a negative smear and culture had histologic findings suggestive of tuberculosis involvement.
Nine patients with pansensitive tuberculosis of the spine and 1 patient who was not cultured for M. Tbc were managed with standard antituberculosis therapy consisting of isoniazid, rifampin, pyrazinamide, and ethambutol during the initial 8-week intensive phase, followed by discontinuation of the pyrazinamide and ethambutol and continuation of the isoniazid and rifampin during the continuation phase of treatment. Therapy was given for an average of 12 months, and no serious complications occurred secondary to therapy.
Current guidelines for the treatment of pansensitive bone and joint tuberculosis suggest that 6- to 9-month regimens containing isoniazid and rifampin are effective. The longer duration of treatment in this review (12 months) was thought to be caused by the limited bacteriologic evaluation of spinal tuberculosis as a result of the relative inaccessibility of the sites of disease. Therefore, the response to treatment or improvement frequently had to be based on clinical and radiographic findings leading to a prolongation of therapy.3
Clofazimine, ofloxacin, clarithromycin, and kanamycin were used in the treatment of 2 patients who were infected with multidrug-resistant strains of M. Tbc (MDRTB). Treatment of these MDRTB cases was prolonged for 2 years.
In all cases with severe back pain or neurologic deficits suggestive of epidural or canal compression, adjunctive surgical therapy was used and was required in 10 of the 12 cases. Six of the 10 cases required surgical management consisting of laminectomy, corporectomy, or anterior stabilization. All cases that required these interventions also had drainage of their cold abscesses. Three of the 10 cases with surgical intervention only had percutaneous drainage of cold abscesses performed. Two patients required a repeat drainage procedure performed for the reaccumulation of abscess fluid manifested clinically by increased intensity in back pain. No patients have further relapses or neurologic residuals; 2 patients had permanent kyphosis.
Spinal tuberculosis may be missed in patients with no evidence of pulmonary tuberculosis. In 1989, the Centers for Disease Control and Prevention reported that the median age of patients with spinal tuberculosis was 39 years. This is similar to the findings in our study.
Spinal tuberculosis is characteristically chronic and slowly progressive. Presenting symptoms are usually back and neck pain4,5 or pain at the site of involvement. Pain was noted in a majority (83%) of our patients. Neurologic deficits such as weakness, numbness, gait difficulties, and incontinence occur less frequently. Unlike pulmonary tuberculosis, which may present with a constellation of symptoms, including cough, weight loss, fever, and night sweats, if tuberculosis only involves bone pain, it may be the only symptom. Because of the nonspecific nature of the symptoms of spinal tuberculosis, a high index of suspicion is important in establishing the diagnosis of destructive spinal lesions. The presence of risk factors for tuberculosis infection in each patient should always be considered.
In spinal tuberculosis, different vertebral sites may be involved as seen in our cohort. In a study by Block et al, involvement of the thoracic spine was reported in 50%, cervical spine in 25%, and lumbar spine in 25%.6 This generally parallels our finding that most tuberculosis of the spine involves the thoracic and lumbar vertebrae. Simultaneous involvement of multiple sites in the spine was infrequent. Radiographically, the obliteration of the disc space was a common finding.
A normal chest x-ray does not exclude the diagnosis of tuberculosis. Only one third of patients presenting with tuberculosis of the bone have a history of pulmonary disease.7 In our patient population, only 50% had pulmonary tuberculosis. In evaluating a patient with a destructive spinal lesion, there should be a heightened sense of suspicion for spinal tuberculosis. This is particularly important if the patient has 1 or more risk factors.
A positive tuberculosis skin test provides supporting evidence but by itself does not confirm the diagnosis. A paraspinal abscess (seen in 8 of our patients) associated with the presence of pulmonary tuberculosis (seen in 50% of our patients) strongly suggests a diagnosis of spinal tuberculosis.8 Ultimately, a bone biopsy with or without biopsy of the paraspinal abscess confirmed the diagnosis.
All patients should be started on an appropriate treatment regimen when spinal tuberculosis is suspected. The most commonly used treatment is a 4-day regimen containing 5 mg/kg isoniazid per day, 10 mg/kg rifampin per day, 20 to 25 mg/kg pyrazinamide per day, and 15 mg/kg ethambutol per day.9 However, drug susceptibility testing should always be done, and the ultimate choice of a treatment regimen will depend on the drug sensitivity pattern of the M. Tbc strain.
Therapy should be continued for a duration of 6 to 9 months. In all cases with severe back pain or neurologic deficits suggestive of epidural or cord compression, adjunctive surgical therapy may be necessary.
Tuberculosis remains a major public health problem. Before the disease can be treated, it must be recognized. Tuberculosis should be considered a diagnostic possibility when spinal osteomyelitis is seen, even in the absence of pulmonary disease or HIV infection. Back pain in a patient with tuberculosis should be evaluated. Early initiation of an appropriate treatment regimen may reduce the need for surgical intervention.
The authors thank Dr. Lee B. Reichman, Executive Director of the NJMS National Tuberculosis Center, for his assistance in preparing this paper.
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Atlanta: US Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention; 1997.
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6. Bloch AB, Reider HL, Kelly GD, et al. The epidemiology of tuberculosis in the United States. Semin Respir Infect
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8. Watts HG, Lives RM. Current concepts review: tuberculosis of bones and joints. J Bone Joint Surg
9. American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America. Treatment of tuberculosis. Am J Respir Crit Care Med
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