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Spinal Tuberculosis in a
Patient with Low Back Pain
Dr Chee Yong Choo
Dept of Anaesthesia, CGH
Singapore
Contents
1. Introduction
2. History and Physical Examination
3. Diagnosis and Intervention
4. Discussion
5. Conclusion
History
Mdm L - 74 year old Chinese lady
Independent in terms of activities of daily living
Past medical history
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Bilateral total hip replacements
Right total knee replacement
Cataracts surgery
Non ulcer dyspepsia
Hypertension
Lichen amyloidosis
History
Admitted in March 2010
Low back pain of 3 months duration
Radiated to the right hip
Not much relief with oral analgesics
Loss of appetite
Occasional night pain
No other systemic complaints
Psychosocial history
No history of psychiatric disorders
Stayed with her daughter (only child) and her family
but relations were strained
Devoted her free time to mainly church activities
No recent travel history
Physical Examination
Afebrile
Kyphoscoliotic
Spinal tenderness at L1 upon palpation
No other focal neurological deficits
Able to weight-bear briefly with assistance
Investigations - X rays of the thoracolumbar spine
Investigations
WBC 6.5 x 103 /uL
ESR 60
CRP 34.3 mg/L
BMD - osteoporosis
Coagulation, Liver and Renal Function Tests normal
Subsequent clinical history
Pain thought to be due to osteoporotic compression
fracture
Declined further imaging this admission
Responded poorly to analgesics
Discussion with patient and surgical team
In view of lumbar radicular pain → trial of ESI
ESI performed 26 Mar 2010
Subsequent clinical history
Had improvement in pain symptoms
Underwent physiotherapy
Discharged from hospital 1 week later
Meds
• Paracetamol 1gm qds
• Gabapentin 300mg tds
• Nortriptyline 10mg nocte
Re-presentation
Seen in the Pain Clinic 2 months later
Complained of right sided paraumbilical pain
Significant loss of appetite and weight, constipated
Unable to sleep at night, very depressed
No abdominal masses on examination
Patient counselled for further imaging to rule out malignancy –
agreed somewhat reluctantly
CT Abdomen/Pelvis showed evidence of
perivertebral thickening but no malignancy
MRI Thoracolumbar Spine showed likely
perivertebral abscess T12/L1…
CT guided Biopsy T12/L1
No fluid was aspirated
Multiple core biopsies
performed and sent for
histopathology and
microbiologies
Histology – TB???
Granuloma with caseating necrosis
Aggregates of epithelioid histiocytes with giant cell formation amidst a
collagenous background with a few scattered lymphocytes and neutrophils
Further staining with Ziehl-Neelsen, GMS and
PAS/PASD stains did not reveal any AFB or fungi
Specimen sent for TB PCR
More tests…
Referral to ID Physician:
AFB smear for sputum – positive
AFB smear for urine – positive
TB serology quantiferon – positive
CT Thorax – patchy consolidation of the right lower lobe with post
obstructive mucus plugging likely suggestive of PTB
Diagnosed with disseminated TB
Treatment
Empirical TB treatment started:
Isoniazid 200mg mane, Rifampicin 450mg mane, Ethambutol
800mg mane, Pyridoxine 20mg mane
Analgesics:
Paracetamol 1gm qds
Pregabalin 75mg bd → 150mg bd
Nortriptyline 10mg nocte
Oxycontin 20mg bd, OxyNorm 5mg 4h/prn
Interdisciplinary Management
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Infectious diseases physician
Pain medicine specialist
Orthopaedic surgeon
Psychiatrist
Rehabilitation physician
Medical Social Worker
Physiotherapist
Pharmacist
Low Back Pain was still a problem
Underwent T9 to L4 decompression laminectomy,
stabilisation, correction of kyphosis with bone
grafting on 29/7/2010
Postop:
Referral to rehab team
Had thrombosis of the deep vein of the soleus
muscle
Back surgery
Discharge and follow up
Finally discharged after 74 days of hosp stay
Discharge meds:
Anti TB drugs
Paracetamol, Pregabalin, OxyNorm
Enoxaparin
Fluvoxamine, Zolpidem
Amlodipine
Discussion
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5.
6.
Red flags in Low Back Pain
Role of ESI
High index of suspicion for TB infection
Natural history of TB spine
Role of surgery
Multidisciplinary management
Red Flags in LBP
• “Red flags” are important in screening cases of low
back pain
• Even during re-presentation
• New Zealand Acute Low Back Pain Guide
(New Zealand Guidelines Group)
www.nzgg.org.nz
Red Flags (highlighted in red for our patient)
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Red Flags help identify potentially serious
conditions:
Features of Cauda Equina Syndrome
Severe worsening pain, especially at night
Significant trauma
Weight loss, history of cancer, fever
Use of intravenous drugs or steroids
Age over 50 years old
Evidence for ESI
• Useful for lumbar radicular pain
• Level II - III evidence
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NNT for short term relief up to 2 months is 7.3
NNT for long-term relief from 3 months to 1 year is 13
Lack of well designed, placebo-controlled studies to conclusively define
specific indications and techniques
FPM Professional Documents PM3 2010
Evidence for ESI
• Transforaminal approach seems slightly better and
safer than interlaminar, but is more difficult to
perform in our patient
Schaufele MK et al. Interlaminar versus transforaminal epidural injections for the treatment of
symptomatic lumbar intervertebral disc herniations. Pain Physician 2006 Oct; 9(4):361-6
Parr et al. Lumbar interlaminar epidural injections in managing chronic low back and lower
extremity pain: a systematic review. Pain Physician. 2009 Jan-Feb; 12(1):163-88
McGrath JM et al. Incidence and Characteristics of Complications from Epidural Steroid
Injections. Pain Med. 2011 Mar 10 [Epub ahead of print]
ESI not without risks!
• It can lead to discitis and abscess formation
Knight JW et al. Epidural abscess following epidural steroid and local anaesthetic injection.
Anaesthesia 1997, 52(6): 576-8
Hooten WM et al. Discitis after lumbar epidural corticosteroid injection. Pain Med 2006,
7(1): 46-51
Simopoulos TT et al. Vertebral osteomyelitis: a potentially catastrophic outcome after lumbar
epidural steroid injection. Pain Physician 2008, 11(5): 693-7
• It may have potentially worsened the TB spine
infection in our patient
Onal SA & Ozer B. Pott disease in the differential diagnosis of low back pain. Agri 2004 16(1):
55-7 (Article in Turkish)
High index of suspicion for TB Spine
• Rare, only a few case reports so far.
Onal SA & Ozer B. Pott’s disease in the differential diagnosis of low back pain. Agri 2004 16(1):
55-7 (Article in Turkish)
Rajab TK & Barre LJ. Back pain from spinal tuberculosis. J Am Coll Surg 2008 207(3): 453
Maron et al. Two cases of Pott’s disease associated with bilateral psoas abscesses. Spine 2006,
31(16): E561-4
• The wrong diagnosis can be fatal…
Ringshausen at el. A fatal case of spinal tuberculosis mistaken for metastatic lung cancer:
recalling ancient Pott’s disease. Ann Clin Microbiol Antimicrob 2009 20(8): 32
Spinal tuberculosis
• Insidious onset, variable presentation, slow
development of radiological features, non
specific constitutional symptoms
• Back pain resistant to medical therapy
• Early diagnosis improves outcomes
Kotevoglu N & Tasbasi I. Diagnosing tuberculous spondylitis: patients with back
pain referred to a rheumatology outpatient department. Rheumatol Int 2004,
24(1):9-13
Le Page L et al. Spinal tuberculosis: a longtitudinal study with clinical, laboratory and
imaging outcomes. Semin Arthritis Rheum 2006 36(2):124-9
Radiological Features
• Spinal TB is probably the most important
extrapulmonary form of the disease
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Haematogenous spread, direct implantation, spread from contiguous
focus
• MRI is better than CT in demonstrating the extent of
soft tissue disease esp epidural abscess
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Findings include bone destruction, intervertebral disc destruction,
paravertebral mass/abscess
Jevtic V. Vertebral infection. Eur Radiol 2004 14 Supp 3: E43-52
Sinan T et al. Spinal tuberculosis: CT and MRI features. Ann Saudi Med 2004 24(6):
437-41
Surgical Intervention
• Is rarely needed
• May be indicated in patients with persistent
instability (like our patient), radiculopathy or
neurological compromise
Nene A. Results of nonsurgical treatment of thoracic spinal tuberculosis in adults. Spine J 2005
5(1): 79-84
Kotil K et al. Medical management of Pott disease in the thoracic and lumbar spine: a
prospective clinical study. J Neurosurg Spine 2007 6(3): 222-8
Multidisciplinary Intervention
• Multidisciplinary management was essential for a
good outcome
• She continued to function well after surgery
• Relatively pain free 6 months post discharge
Conclusion
• Rare but important disease
• Early diagnosis is likely to improve the clinical
outcome
• The vigilant pain medicine specialist can make a
difference!
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