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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 3  |  Issue : 1  |  Page : 11-12

Incidence of lumbosacral tuberculosis: A pilot study in a tertiary center


1 Department of Orthopaedics, PGIMER, Chandigarh, Punjab, India
2 Department of Orthopaedics, Baba Farid University of Health Science, Faridkot, Punjab, India

Date of Submission10-Jan-2020
Date of Decision01-Apr-2020
Date of Acceptance02-Apr-2020
Date of Web Publication30-Apr-2020

Correspondence Address:
Saurabh Agarwal
Department of Orthopaedics, PGIMER, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JODP.JODP_1_20

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  Abstract 


Introduction: Spinal tuberculosis is a destructive form of tuberculosis. It accounts for approximately half of all musculoskeletal tuberculosis, affecting mostly the young population in their productive years of life. Characteristically, there is destruction of intervertebral disc and adjacent vertebral bodies radiologically, leading to deformities and neurological symptoms. Common clinical manifestations include constitutional symptoms, back pain, spinal tenderness and neurological symptoms. Patients with tuberculosis affecting the lumbar and sacral region may be confused with benign conditions such as prolapsed intervertebral disc until late due to absent neurological symptoms. Magnetic Resonance Imaging is the most sensitive investigation for diagnosis of spinal tuberculosis. Material and Methods: From July 2014 to September 2014, all the patients presenting to the orthopaedic outpatient department with nontraumatic back pain were evaluated. Results: Out of 16 patients diagnosed as spinal tuberculosis 11 had lumbar and Lumbosacral, 3 had dorsal, 2 had dorsolumbar region involvement. Conclusion: MRI is most sensitive investigation to diagnose undefined back pain. These back pain are due to spinal tuberculosis. Lumbosacral tuberculosis is more common than dorsolumbar region.

Keywords: Antituberculous treatment, kyphosis, Pott's disease, spinal tuberculosis


How to cite this article:
Kumar V, Agarwal S, Dhatt SS, Bahadur R. Incidence of lumbosacral tuberculosis: A pilot study in a tertiary center. J Orthop Dis Traumatol 2020;3:11-2

How to cite this URL:
Kumar V, Agarwal S, Dhatt SS, Bahadur R. Incidence of lumbosacral tuberculosis: A pilot study in a tertiary center. J Orthop Dis Traumatol [serial online] 2020 [cited 2020 Oct 26];3:11-2. Available from: https://www.jodt.org/text.asp?2020/3/1/11/283674




  Introduction Top


Percival Pott was the first person to present the classic description of spinal tuberculosis (TB) in 1779; hence, spinal TB was called “Pott's disease.”[1] Spinal TB is a frequently encountered extrapulmonary form of the disease. Spinal TB is a destructive form of TB and is more common in children and young adults. The exact incidence and prevalence of spinal TB in most parts of the world are not yet known. In countries with a high burden of pulmonary TB, the incidence is expected to be proportionately high. Approximately 10% of patients with extrapulmonary TB have skeletal involvement. The spine is the most common skeletal site affected, followed by the hip and knee. Spinal TB accounts for almost 50% of cases of skeletal TB.[2] Very little has been documented about the distribution pattern of this disease in India, though TB in this country is highly endemic. Few studies on clinical presentation and complications of the disease are published.[3],[4],[5] It is considered that spinal TB most commonly involves the dorsal and dorsolumbar region of the spine,[3],[6] but most of the studies done in this regard were done in premagnetic resonance imaging (MRI) era; so many of the occult cases of TB could potentially have been missed obscuring the real picture of the disease incidence. MRI has been found to be extremely useful in the diagnosis of tubercular affection of difficult and rare sites such as craniovertebral, cervicodorsal, and lumbosacral regions.[7],[8] Moreover, with the recent advances in interventional radiology, for example, computed tomography (CT)-guided biopsy, the diagnosis rate of doubtful cases [9] has even increased.


  Materials and Methods Top


This was a hospital-based observational study of incidence of TB affection of the spine in the patients. The study includes all the cases presenting to the orthopedic outpatient department (OPD) with nontraumatic low back pain and clinical features suggestive of tubercular infection over a period from July 2014 to September 2014. The diagnosis was made on the basis of clinical examination, radiological investigations and any associated complications. All the patients with clinicoradiological suspicion of TB of the spine were started on antitubercular treatment and were followed up after 8 weeks to look for any response to treatment.

The management of patients was according to standard published protocol and guidelines and specific for individual patients. The patient information was collected by personal interviews, specific examination and investigations, and evaluation. The data were recorded in the pro forma, with a specific focus on etiology, mode of infection, age, and demographic details.


  Results Top


From July 2014 to September 2014, all the patients presenting to the orthopedic OPD with nontraumatic low back pain were evaluated, of which 16 patients were clinicoradiologically found to be suffering from spinal TB. Of these 16 patients, eight were male and eight were female; all the patients were started on antitubercular drugs according to standard protocol and guidelines and were followed up for 8 weeks to look for response to the treatment. Of these 16 patients, one patient presented with increasing neurological deficit and did undergo surgical decompression. The remaining 15 patients showed a good response to treatment in the form of clinical improvement.

Contradictory to the fact published in literature and books that dorsolumbar spine is the most common site involved, it was found that in 11 patients, the most commonly involved site was the lower lumbar and lumbosacral region, with three cases having involvement purely of the dorsal spine and two cases having involvement of the dorsolumbar junction.


  Discussion Top


It has been observed that on an average every month, 4–5 new cases with clinical suspicion of spinal TB with radiological features suggestive of TB in radiographs and MRI present to the Orthopedic OPD of PGIMER. Most of the patients were young adults from the second to fourth decade of life with both the sexes affected almost equally. The most common presenting feature was pain with or without constitutional symptoms. Clinical manifestation includes constitutional symptoms such as low-grade fever with evening rise of temperature, weight loss with loss of appetite, back pain, spinal tenderness, spinal deformity, and neurological symptoms with laboratory investigation such as relative lymphocytosis in total cell count and raised erythrocyte sedimentation rate.

Plain radiograph shows irregularity and sclerosis of vertebral end plate of adjacent vertebrae. There is loss of disc space, loss of vertebral height and kyphotic deformity in advanced stages. MRI is the neuroimaging of choice for spinal TB. It is more sensitive than X-ray and more specific than CT scan in diagnosis of spinal TB. They are especially helpful in early diagnosis of affection of rare areas and skip lesion. MRI demonstrates an involvement of the vertebral bodies on either side of disk, disk destruction, cold abscess, vertebral collapse, presence of vertebral column deformity, and mechanism of neurological involvement. T1-weighted images of the spine typically show decreased signal within affected vertebral bodies, loss of disk height, and paraspinal soft-tissue masses. T2-weighted images show increased signal intensity within areas of osseous and soft-tissue affection.

All the patients after clinicoradiological confirmation of TB were started on antitubercular drugs under standard treatment guidelines published in literature with complete course of treatment over 18 months divided into early intensive phase of 2 months with daily dosage of four drugs, namely isoniazid, rifampicin, ethambutol, and pyrazinamide, followed by initial continuation phase of 7 months with daily dosage of three drugs, namely isoniazid, rifampicin, and ethambutol, and another 9 months of continuation phase with isoniazid and rifampicin only along with pyridoxine throughout the course. The dose of specific drugs is as follows: isoniazid 4–6 mg/g/day, rifampicin 8–12 mg/kg/day, ethambutol 13–17 mg/kg/day, pyrazinamide 20–40 mg/kg/day, and pyridoxine 10 mg/day. All patients responded to the treatment in the form of clinical improvement on follow-up after 8 weeks. Only one patient required surgical decompression due to increasing neurological deficit.

As most of the studies were done in the pre-MRI era, the cases of lumbosacral TB may have been missed because of the paucity of clinical symptoms and rare neurological involvement. With the increased use of MRI, these cases are being diagnosed at an early stage improving the clinical outcome of the patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Chauhan A, Gupta BB. Spinal tuberculosis. Indian Acad Clin Med 2007;8:110-4.  Back to cited text no. 1
    
2.
Davies PD, Humphries MJ, Byfield SP, Nunn AJ, Darbyshire JH, Citron KM, et al. Bone and joint tuberculosis. A survey of notifications in England and Wales. J Bone Joint Surg Br 1984;66:326-30.  Back to cited text no. 2
    
3.
Tuli SM. Tuberculosis of the Skeletal System (Bones, Joints, Spine and Bursal Sheaths). 3rd ed. New Delhi: Jaypee Brothers; 2004.  Back to cited text no. 3
    
4.
Jain AK. Tuberculosis of the spine: A fresh look at an old disease. J Bone Joint Surg Br 2010;92:905-13.  Back to cited text no. 4
    
5.
Garg RK, Somvanshi DS. Spinal tuberculosis: A review. J Spinal Cord Med 2011;34:440-54.  Back to cited text no. 5
    
6.
Ibrahim EK, Ahmed EG, Elbadawi NE, Mohammed MM. Vertebral distribution of Pott's disease of the spine among adult Sudanese patients in Khartoum, Sudan. Am J Health Res 2014;2:93-6.  Back to cited text no. 6
    
7.
Agrawal V, Patgaonkar PR, Nagariya SP. Tuberculosis of spine. J Craniovertebr Junction Spine 2010;1:74-85.  Back to cited text no. 7
    
8.
Jacqueline P, Sharon S. Potts disease: Diagnosis with magnetic resonance imaging. Radiography 2010;16:84.  Back to cited text no. 8
    
9.
Mondal A. Cytological diagnosis of vertebral tuberculosis with fine-needle aspiration biopsy. J Bone Joint Surg Am 1994;76:181-4.  Back to cited text no. 9
    




 

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