Analysis of changing paradigms of management in 179 patients with spinal tuberculosis over a 12-year period and proposal of a new management algorithm.
OBJECTIVE
To describe management and outcome in a large cohort of patients with spinal tuberculosis (TB).


METHODS
Of 212 patients with spinal TB treated between January 1999 and June 2011, 179 patients were included in the study (≥6 months follow-up; mean age, 34.8 years; age range, 10-75 years). The cohort was divided into two groups (n = 89 and n = 90); group I was treated from 1999-2003, and group II was treated from 2004-2011.


RESULTS
The study cohort comprised 93 male patients. Mean age was 34.8 years ± 7.2 (range, 10-75 years). Mean duration of symptoms was 2.4 months. Sensorimotor deficits were present in 167 patients (93.5%; 74 patients were paraplegic), pain was present in 156 patients (87%), bladder involvement was present in 127 patients (71.7%), and extraspinal TB was present in 36 patients (22.3%). Of patients, 92% were receiving prior chemotherapy; one fifth of these patients were on second-line chemotherapy. Thoracic spine involvement was most common (n = 86; 57%), followed by cervical spine (n = 50; 29%), craniovertebral junction (n = 22; 15%), and lumbosacral spine (n = 20; 10.5%). Surgery was performed in 146 patients (68% instrumented fusions and 16% circumferential fusions). Mean follow-up was 20.2 months (range, 6-60 months). Sensorimotor deficits improved in 89% of patients, pain improved in 71%, bladder symptoms improved in 88%, and paraplegia improved in 77%. Patients in group II had a higher incidence of cord compression (P < 0.01), severe vertebral body collapse (P < 0.001), and paraplegia (P < 0.001). Group II patients underwent more instrumented surgeries (P < 0.01), especially circumferential fusions (P < 0.001). The improvement in paraplegia was better after 2004 (group II). Bladder symptoms correlated with the timing of surgery (P < 0.1).


CONCLUSIONS
Medical treatment of spinal TB is the mainstay; however, radical, instrumented surgeries should be offered when indicated. The presence of paraplegia should not preclude surgery. A practical management paradigm is also suggested.
Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India. Electronic address: saratpchandra3@gmail.com.
Sarat P
SP
Chandra
Ajit
A
Singh
Nishant
N
Goyal
Rajender K
RK
Laythalling
Manmohan
M
Singh
Sharad S
SS
Kale
Manish S
MS
Sharma
Ashish
A
Suri
Pankaj
P
Singh
Ajay
A
Garg
Chitra
C
Sarkar
Manjari
M
Tripathi
Bhawani S
BS
Sharma
Ashok K
AK
Mahapatra
D000293:Adolescent; D000328:Adult; D000368:Aged; D000465:Algorithms; D000995:Antitubercular Agents / Q000627:therapeutic use*; D019090:Case Management; D002675:Child, Preschool; D015331:Cohort Studies; D003131:Combined Modality Therapy; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D009422:Nervous System Diseases / Q000453:epidemiology / Q000209:etiology; D009460:Neurologic Examination; D019635:Neurosurgical Procedures / Q000379:methods*; D010264:Paraplegia / Q000209:etiology / Q000628:therapy; D011183:Postoperative Complications / Q000453:epidemiology; D012189:Retrospective Studies; D013117:Spinal Cord Compression / Q000209:etiology; D013131:Spine / Q000473:pathology / Q000601:surgery; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D014399:Tuberculosis, Spinal / Q000150:complications / Q000188:drug therapy* / Q000601:surgery*; D001745:Urinary Bladder Diseases / Q000209:etiology / Q000628:therapy; D055815:Young Adult
D000995:Antitubercular Agents
Antitubercular chemotherapy; CT; Computed tomography; ESR; Erythrocyte sedimentation rate; MRI; Magnetic resonance imaging; Paraplegia; Spinal deformity; Spinal tuberculosis; Surgery; TB; Tubercular spondylitis; Tuberculosis; Vertebral collapse