2. SPINAL TUBERCULOSIS
:ROLE OF SURGERY
KHALED ABDEEN,AHMED AZAB* ,HISHAM
ABORAHMA*
ALEXANDRIA UNIVERSITY
* ALMONEFIA UNIVERSITY-EGYPT

3. Epidemiology
• 8.8 million new cases of TB/year .
• Developing counteries account for nearly 75% of
all case of TB .
• TB spine accounts for 2% of all cases .
• 50% of skeletal TB .
• Thorcic and thoracolumbar regions mostly
affected .
• Cervical TB accounts 3-9 % .
• Skip lesions 7-10 % .

4. TWO Groups
• Radical surgery patients :
• Progressive neurological deficits .
• Abscess .
• Kyphosis .
• Interactable pain .
• ATT alone patients .

5. • 52 TB spine patients treated surgically .
• 2001-2012.
• Age: 12-70 years .
• 32 male:20 females
• Follow up between 1-10 years .
• All patients received anti tuberculous treatment .
• Plain x ray , MRI , ESR .

8. Group A. The lesion was limited to the anterior column, with
no abnormal signals on MRI at, or posterior to, the pedicles.
No deformity was present. The lesion was either paradiscal or
central body in type

9. Group B.
The lesions involved the anterior and posterior columns at
the same levels and were unstable with an associated
kyphosis .

11. Isolated posterior lesion

12. J. S. Mehta, MS Orth, D Orth, MCh Orth, Orthopaedic Specialist
Registrar JBJS VOL. 83-B, NO. 6, AUGUST 2001

13. • Objective : to evaluate different surgical modalities in the
treatment of spinal tuberculosis and its outcome as regard
neurological improvement ,bony fusion ,and spinal
stability .
• This study included 25 patients with spinal tuberculosis [10
of them with cervical affection ,and 15 with dorsolumbar
tuberculosis] ,their mean age 38.5 ys [average 28 –56 ys ]
with an average follow up period of 15 months [12- 36
months ].This study included two groups ,the cervical
group[C3-7] included 10 patients and the dorsolumbar
group included 15 patients .All of our patients presented
with neurologic deficits for short period with average 2-6
months.All patients received antituberculous medications
for 9-12 months.

14. Diagnosis
• Culture , antigen demonstration, serology
tests ,and polymerasechain reaction are of
high priority .
• The polymerase chain reaction has
facilitated the diagnosis and treatment .

15. Treatment
• Effective chemotherapy for spinal
tuberculosis is the gold standard and
mainstay of treatment and all other methods
of treatment are regarded as
supplementary .
• Triple chemotherapy should be given for 12
months [ rifampicin, isoniazide , and
pyazinamide ]

16. RESULTS
• Microbiological and histopathological studies of the
operative specimen revealed specific, granulomatous
infection consistent with tuberculosis. All patients had an
increased erythrocyte sedimentation rate before anti-
tuberculous medication returnedto normal within 6 months
after medication .
• Neurological outcome:
Neurological deficits were improved at final up
examination as defined by the scoring system of Frankel .
two patients of grade B before surgery , had improvement
to grade C and grade D , of the 12 with grade C , 8 had
complete recovery to grade E , and 4 had improvement to
grade D , 5patients with grade D had complete recovery to
grade E .

17. RESULTS
• Radiological evaluation: x-ray showed the destruction of contiguous
vertebral bodies with involvement of the disc space between them in
23 patients(paradiscal type , collapsed C4 vertebral body (central type)
in two patients and the presence of widened prevertebral space was
evident in all patients . CT delineated bone involvement and
paravertebral abscess extension . MRI was performed in all cases to
show the epidural abscess and degree of spinal cord compression . (fi.
• Bony Fusion:
Clinical and radiological evidence of stable fusion observed in all
patients, with one segment fusion was obtained at average of 4 months
and 2 segments fusion was obtained at average of 5 months (3.5 to 6
months) .
• Angle of kyphosis:In the dorsolumbar groupThe average of pre-
operative Kyphosis angle was 36 degrees (range 32-48 degrees)and
the average angle of kyphosis in last follow-up was 17 degrees (range
13-19 degrees) while in the cervical group, there was bone destruction
but no significant kyphotic deformity

18. • The cervical group: 9 of them treated by anterior
cervical approach for decompression followed by
fixation by iliac bone graft and cervical plating
,one patient with C3 tuberculosis managed by
single stage- combined anterior decompression
and fusion by iliac bone graft followed by
posterior occipitocervical fixation by Ransford
Loop . There was an improvement in the Nurick
grade from a preoperative mean of 2.5 to mean 0.3
at the last follow up .
• The dorsolumbar group: 6 cases managed by
posterior instrumentation [4 cases segmental
fixation by transpedicular screws and 2 cases with
Hartshill rectangle with sublaminar wires] ,
anterior approach in 7 cases, and another 2 cases
circumferential fusion were done at one operative
setting.

22. C3 TUBERCULOSIS
APPROACH
COMBINED SINGLE STAGE
{ANTERIOR&POSTERIOR}

23. C3 Tuberculosis

29. RESULTS
• All patients showed improved neurological
outcome.All of them had solid fusion within
average 6 months .
• In the dorsolumbar group ,angle of
kyphosis was improved in all patients ,
average angle of kyphosis preoperative was
36 degree and at the late follow up ,it was
17 degree and no implant complications .

30. CONCULSIONS
• Early surgical intervention ,either posterior
rigid fixation ,anterior interbody fusion or
circumferential fusion plus chemotherapy
were found to help in arresting the disease
providing satisfactory stabilization ,as well
as preventing progression of kyphosis and
correcting kyphosis .there is no additional
risk related to the use of an implant even if
large quantities of pus were present

33. SPINAL TUBERCULOSIS
:ROLE OF SURGERY
KHALED ABDEEN,AHMED AZAB* ,HISHAM
ABORAHMA*
ALEXANDRIA UNIVERSITY
* ALMONEFIA UNIVERSITY-EGYPT

34. Epidemiology
• TB spine accounts for 2% of all cases .
• 50% of skeletal TB .
• Thorcic and thoracolumbar regions mostly
affected .
• Cervical TB accounts 3-9 % .
• Skip lesions 7-10 % .

35. • Objective : to evaluate different surgical modalities in the
treatment of spinal tuberculosis and its outcome as regard
neurological improvement ,bony fusion ,and spinal
stability .
• This study included 25 patients with spinal tuberculosis [10
of them with cervical affection ,and 15 with dorsolumbar
tuberculosis] ,their mean age 38.5 ys [average 28 –56 ys ]
with an average follow up period of 15 months [12- 36
months ].This study included two groups ,the cervical
group[C3-7] included 10 patients and the dorsolumbar
group included 15 patients .All of our patients presented
with neurologic deficits for short period with average 2-6
months.All patients received antituberculous medications
for 9-12 months.

40. Diagnosis
• Culture , antigen demonstration, serology
tests ,and polymerasechain reaction are of
high priority .
• The polymerase chain reaction has
facilitated the diagnosis and treatment .

41. Treatment
• Effective chemotherapy for spinal
tuberculosis is the gold standard and
mainstay of treatment and all other methods
of treatment are regarded as
supplementary .
• Triple chemotherapy should be given for 12
months [ rifampicin, isoniazide , and
pyazinamide ]

42. Antituberculous treatment
• All received antituberculous chemotherapy starting two
• weeks before surgery. Pyrazinamide was given for the first
• Three months only.
• Treatment with ethambutol, rifampicin, isonicotinic acid
hydrazide and folic acid supplement continued for a total 9
months .
• Patients with resistant atypical mycobacterial strains were
treated on the basis of microbiological advice, the reserve
drugs being kanamycin and ciprofloxacillin

43. RESULTS
• Microbiological and histopathological studies of the
operative specimen revealed specific, granulomatous
infection consistent with tuberculosis. All patients had an
increased erythrocyte sedimentation rate before anti-
tuberculous medication returnedto normal within 6 months
after medication .
• Neurological outcome:
Neurological deficits were improved at final up
examination as defined by the scoring system of Frankel .
two patients of grade B before surgery , had improvement
to grade C and grade D , of the 12 with grade C , 8 had
complete recovery to grade E , and 4 had improvement to
grade D , 5patients with grade D had complete recovery to
grade E .

44. RESULTS
• Radiological evaluation: x-ray showed the destruction of contiguous
vertebral bodies with involvement of the disc space between them in
23 patients(paradiscal type , collapsed C4 vertebral body (central type)
in two patients and the presence of widened prevertebral space was
evident in all patients . CT delineated bone involvement and
paravertebral abscess extension . MRI was performed in all cases to
show the epidural abscess and degree of spinal cord compression . (fi.
• Bony Fusion:
Clinical and radiological evidence of stable fusion observed in all
patients, with one segment fusion was obtained at average of 4 months
and 2 segments fusion was obtained at average of 5 months (3.5 to 6
months) .
• Angle of kyphosis:In the dorsolumbar groupThe average of pre-
operative Kyphosis angle was 36 degrees (range 32-48 degrees)and
the average angle of kyphosis in last follow-up was 17 degrees (range
13-19 degrees) while in the cervical group, there was bone destruction
but no significant kyphotic deformity

45. • The cervical group: 9 of them treated by anterior
cervical approach for decompression followed by
fixation by iliac bone graft and cervical plating
,one patient with C3 tuberculosis managed by
single stage- combined anterior decompression
and fusion by iliac bone graft followed by
posterior occipitocervical fixation by Ransford
Loop . There was an improvement in the Nurick
grade from a preoperative mean of 2.5 to mean 0.3
at the last follow up .
• The dorsolumbar group: 6 cases managed by
posterior instrumentation [4 cases segmental
fixation by transpedicular screws and 2 cases with
Hartshill rectangle with sublaminar wires] ,
anterior approach in 7 cases, and another 2 cases
circumferential fusion were done at one operative
setting.

47. C3 TUBERCULOSIS
APPROACH
COMBINED SINGLE STAGE
{ANTERIOR&POSTERIOR}

48. C3 Tuberculosis

52. RESULTS
• All patients showed improved neurological
outcome.All of them had solid fusion within
average 6 months .
• In the dorsolumbar group ,angle of
kyphosis was improved in all patients ,
average angle of kyphosis preoperative was
36 degree and at the late follow up ,it was
17 degree and no implant complications .

53. CONCULSIONS
• Early surgical intervention ,either posterior
rigid fixation ,anterior interbody fusion or
circumferential fusion plus chemotherapy
were found to help in arresting the disease
providing satisfactory stabilization ,as well
as preventing progression of kyphosis and
correcting kyphosis .there is no additional
risk related to the use of an implant even if
large quantities of pus were present

56. • When tuberculosis is suspected, a purified protein
derivative skin test will be positive in 95% of cases.
• Immunosuppressed patients may be anergic, leading to
falsenegative results.
• Recently, polymerase chain reaction testing has been used
to amplify the microbial genome for identification within
a few hours when standard culture methods fail.
• Isolation of an organism is necessary for appropriate
antibiotic treatment, especially for nonsurgical
management; however, definitive identification of the
pathogen can only be accomplished using tissue cultures
obtained directly from the site of infection.

57. • In the case of Pott disease, treatment lasts for a mean of 12
months, with variations in duration and type of chemotherapy
depending on regional resistance patterns.
Initially, isoniazid, ethambutol, rifampin, and pyrazinamide are
prescribed for the first 2 months. If no information o
sensitivities is available, isoniazid, ethambutol, and rifampin
are continued for 12 months. If sensitivities are known, two
drugs can be used. If isoniazid and rifampin are active, they
are continued for 12 months. If other combinations are used,
therapy is extended to 18 to 24 months. In
immunocompromised patients, indinavir and rifabutin are
added.