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TUBERCULOUS SPONDYLITIS : ‘GLOBAL LESION’
P Agarwal, P Rathi, R Verma, CG Pradhan
Dept. of Orthopaedics BHIMS, Mumbai 400 020.
Simultaneous involvement of anterior and posterior elements of vertebra in spinal tuberculosis is rare. Diagnosis of such ‘Global’ lesion has been made easier with the advent of modern investigation tools like CT scan and MRI.Global lesions in tuberculous spondylitis go unrecognized preoperatively serious consequences like neurological deficit or spinal instability may take place during anterior or posterior decompression surgery.
This is a case report of ‘Global’ tuberculous spondylitis to highlight the importance of preoperative evaluation with CT scan to prevent disastrous complications.
Osteoarticular tuberculosis is still a major problem of developing countries and spinal lesions constitute a major bulk of such lesions. Simultaneous involvement of the anterior and posterior vertebral elements in spinal tuberculosis is rare. With the advent of modern investigation facilities like MRI and CT scan it is possible to diagnose such a global lesion in the vertebra. We report a case of disseminated tuberculosis with a global lesion in spine.
CASE REPORT
A 26 year old male patient reported to the out patient department with chronic persistent backache of 6 months duration. There was no history of any weakness or radiating pain in the limbs or visceral incontinence. Patient had no constitutional symptoms. Examination revealed a thin built man with diffuse tenderness in thoracic spine. There was a mild scoliotic tilt to the right side from D4 to D9. There was no neurological deficit. There was mild tenderness over sacroiliac joints. His haemoglobin was 10 gm% and ESR was 120 mm at 1 hour. Plain roentgenogram of chest, pelvis and spine revealed extensive miliary type of lesions in lungs, erosion and osteopenia of sacroiliac joints and partial erosion of bodies of D5 and D9 with loss of height of body of D5 vertebra, disc spaces were however maintained. There was no evidence of any paravertebral shadow. X-ray skull did not show any significant abnormality (Sella turcica was of normal size). Plain and post contrast CT of dorsolumbosacral spine was performed. Multiple ill defined osteolytic areas were seen involving the bodies of D4, D9, L1 and L5 vertebra. There was also destruction of left pedicle of D4, the right transverse process of D9 and sacroiliac joints by osteolytic lesions. In 4th and 9th dorsal vertebrae there was circumferential or global destruction of anterior as well as posterior elements.
Topograms and axial scan of chest revealed diffuse miliary shadows in both lungs. With these findings diagnosis of multifocal tuberculous infection was kept.
Needle biopsy was done from right sacroiliac joint which clinched the diagnosis of osteoarticular tuberculosis. Patient was put on 4 drug anti-tubercular treatment and bed rest along with other supportive measures.
After 2 months of rest patient was ambulated with the spinal brace. At the end of one year his haemoglobin was 11.8 gm% and ESR came down to 20 mm at 1 hour. X-rays revealed good healing of lesions and the patient was asymptomatic.
DISCUSSION
Vertebral tuberculosis is the commonest form of osteoarticular tuberculosis and it contributes to about 50% of all cases of skeletal tuberculosis in various reported series (Tuli et al 1969, Martini et al 1988). There is 7% incidence of multiple level vertebral involvement. In majority of patients of tuberculous spondylitis a typical paradiscal lesion characterised by destruction of adjacent bone end plates with reduction in disc space is seen. Other uncommon varieties contribute 2-10% of spinal lesions (Schmoral 1959, Kumar 1985), which predominantly includes atypical spinal tuberculosis like one involving posterior spinal element.[2] Simultaneous anterior and posterior element involvement in a single vertebra has been rarely reported. Anderdorff et al (1987) reported 2 patients with circumferential spinal disease out of 703 cases with tuberculous spondylitis.[1] In one case the posterior element lesions went unrecognised and patient became paraplegic after anterior decompression. Similar case has been reported by J. Travlos[3]
Spinal tuberculosis is always the result of haematogenous dissemination from primary focus. The detection of primary focus or an associated visceral tuberculous lesion however depends greatly upon the amount of efforts put into investigations.
With advent of modern investigation facilities like bone scan, CT scan and MRI it is easy to diagnose disseminated lesions especially global vertebral lesions.
If global lesions go unrecognised preoperatively, serious consequences may ensue during anterior or posterior spinal decompression surgeries.[3]
CONCLUSIONS
This is a case report of global tubercular spondylitis to highlight the following features.
1. Unlike conventional teaching, simultaneous anterior and posterior elements involvement does occur in tuberculous spondylitis. The diagnosis of such “global lesions” has been made easier with the advent of modern investigation tools.
2. Preoperative diagnosis of global lesions will help to prevent post operative disastrous complications of spinal instability and neural compression.
3. Such patients with disseminated lesions can be managed conservatively.
REFERENCES
1. Andendorff JJ, Boeke EJ, Lazaruse. Potts paraplegia. S Afr Med J 1987; 71 : 427.
2. Babulkar SS, Tayde WB, Babulkar SK. Atypical spinal Tuberculosis. J Bone Joint Surg 1984; 66-B : 239.
3. Travlos J, Toit G Du. Spinal tuberculosis : Beware the posterior elements. J Bone Joint Surg 1990; 72-B : 722.
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