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Spondylitis Tuberculosis in Neurosurgery

Department Bandung Indonesia
ARTICLE AUGUST 2015

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Farid Yudoyono

Universitas Padjadjaran

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JSM Neurosurgery and Spine

Central
Research Article

*Corresponding author
Ahmad Faried, Department of Neurosurgery, Faculty
of Medicine, Universitas PadjadjaranDr. Hasan Sadikin
Hospital, Jl. Pasteur No. 38, Bandung 40161, West Java,

Spondylitis Tuberculosis in
Neurosurgery Department
Bandung Indonesia

Submitted: 11 April 2015

Accepted: 13 July 2015
Published: 14 July 2015
Copyright

Ahmad Faried1*, Imam Hidayat2, Farid Yudoyono1, Rully Hanafi

Dahlan1 and Muhammad Zafrullah Arifin1
Department of Neurosurgery, Universitas PadjadjaranDr. Hasan Sadikin Hospital,
Indonesia
2
Department of Neurosurgery, Universitas Syiah Kuala-Dr. Zainal Abidin Hospital,
Indonesia
1

2015 Faried et al.

OPEN ACCESS

Keywords
Spondylitis tuberculosis
Weakness of lower extremity
Neurosurgery

Abstract
Spondylitis TB is an infection of Mycobacterium TB involving the spine. The course
of spondylitis TB is relatively indolent (without pain), thus early diagnosis is challenging.
This study was conducted to evaluate the clinical presentation and the goal of surgery
in twelve patients who had been operated for spondylitis tuberculosis (TB) in the
Department of Neurosurgery, Faculty of Medicine, Universitas PadjadjaranDr. Hasan
Sadikin Hospital, Bandung, Indonesia between May 20122013 were reviewed
retrospectively. This study analized the medical records of patients operated in our
center. A clinical examination, spinal X-Ray, computed tomography scans were obtained
before and after the operation is examined. Final diagnosis was based on histological
characteristics and polymerase chain reaction (PCR) result of the Mycobacterium TB
bacteria. The chief complaint of spondylitis TB patients admitted or consulted to our
center is lower limb weakness. There were 12 cases of spondylitis TB (5 women and 7
men with a ratio of 1: 1.4). The average age was 34.3 (the youngest patient was 17
years old and the oldest was 56 years) with a standard deviation 9.9. The infected
spines are: one patient in the cervical, eight patients in thoracal and three patients in
lumbar. The chief complaint of spondylitis TB patients admitted or consulted is lower
limb weakness (83.3%). Gibbus is observed in 83.3% of patients. Anterior cervical
discectomy and fusion was performed in 1 case and posterior was used in 11 cases.
A comprehensive history taking, along with correct sampling using various imaging
modalities and PCR, will certainly lead to the diagnosis of spondylitis TB. It must be
noted that neurological deficit due to spinal tuberculosis is reversible in majority of
cases, especially if decompression is achieved promptly.

INTRODUCTION
Spinal tuberculosis infection, or commonly referred as
spondylitis tuberculosis (TB) or vertebral osteomyelitis
tuberculosis or Potts disease [1], caused by the Mycobacterium
tuberculosis bacteria that attacks the corpus vertebrae, potentially
causing serious morbidity, including neurological deficits and
permanent spine deformity. The most common deformity is
kyphotic deformity, known as the gibbus. The diagnosis is usually
established at advanced stage, where severe spinal deformity
and neurological deficits such as paraplegia are evident [2,3].
Indonesia is ranked after India and China as country with most
population infected by TB [4]. Approximately 20% of pulmonary
TB infection will spread outside the lung (extrapulmonary TB)
[5]. Eleven percent of extrapulmonary TB is osteoarticular TB,
and approximately half of the patients have spinal TB infection

[6]. The management of spondylitis TB in general includes antiTB drugs, immobilization with or without surgical intervention.

This study was conducted in order to evaluate the clinical

presentation and the goal of surgery in 12 cases of patients
with spondylitis TB treated in the Department of Neurosurgery,
Faculty of Medicine, Universitas Padjadjaran (FK UNPAD)Dr.
Hasan Sadikin, Hospital (RSHS), Bandung from 2012-2013.

METHODS

This research was a retrospective cohort study examining

the medical records of spondylitis TB patients operated in the
Department of Neurosurgery, FK UNPADRSHS in May 2012
May 2013. A clinical examination, spinal X-Ray, and computed
tomography (CT) scans were obtained before and after the
operation is performed (Figure 1). Final diagnosis was achieved
based on histological characteristics and outcome of polymerase

Cite this article: Faried A, Hidayat I, Yudoyono F, Dahlan RH, Arifin MZ (2015) Spondylitis Tuberculosis in Neurosurgery Department Bandung Indonesia.
JSM Neurosurg Spine 3(3): 1059.

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Faried et al. (2015)

Central
The infected spine are: one patient in the cervical, eight patients
in thoracal and three patients in lumbar. The chief complaint
of spondylitis TB patients admitted or consulted is lower limb
weakness (83.3%). Gibbus is observed in 83.3% of patients.
ACDF was performed in 1 case and posterior was used in 11
cases (Table 1). Diagnosis is based on histological characteristic
(hematoxylin and eosin staining) and laboratory tests using PCR;
the DNA samples were amplified using primers IS6110 with
product result 123 base pairs (bp). Forward and reverse primer
IS6110 consists of:
IS6110 forward: (5 CCT GCG AGC GTA GGC GTC GG 3)

Figure 1 Clinical picture that showing gibbus. Posterior deformity of

the spine is shown in response to vertebral kypothic angulation.

chain reaction (PCR) of the Mycobacterium Tuberculosis bacteria.

SURGICAL CONSIDERATIONS

Indications for surgery in acute spondylitis TB [7,8].

1. Progressive neurologic deficit.

2. Progressive increase of spinal deformity (more than

40 of segmental kyphosis, anteroposterior or lateral
translation).

3. Conservative treatments futile including point 1 and 2

above.
4. Severe pain due to abscess or spinal instability.

5. Uncertain diagnosis: this could be an inability to obtain

microbiological diagnosis from microscopy, culture or
even via detection of mycobacterium DNA using PCR.

Patients were operated in prone position under general

anesthesia. Septic and aseptic and draping was performed, the
operation site marking was then infiltrated with 10 ml of 1%
xylocaine with adrenaline to minimize bleeding. A posterior
midline approach was commonly used. The dissection was
carried out in the subperiosteal plane to allow decent bony part
identification. In the patient with cold abscess (Figure 2), the
posterolateral extra pleural (costotransversectomy) approach
was used to decompress the cord and remove necrotic materials
within the body and disc using curettes, and paraspinal abscess
was drained. The spine was stabilized using transpedicular
screw and rod system (Figure 3), the wound was closed layer by
layer after securing haemostasis without a drain. Surrounding
muscles were injected with 20 mg of bupivacaine to reduce postoperative pain and muscle spasm. Anterior surgery (anterior
cervical discectomy and fusion; ACDF) was performed in one
case (Table 1).

Figure 2 T1-weighted and T2-weighted sagittal MRI images of

thoracic spine showing destruction due to spinal TB of thoracal 7-8
(T7-T8) with some preservation of the disc (A and B). T2-weighted
axial and coronal MRI of same patient showing paravertebral abcess
(C and D).

RESULTS

There were 12 cases of spondylitis TB in this study (five

women and seven men with a ratio of 1: 1.4). The average age of
the patients was 34.3 (the youngest patient was 17 years old and
the oldest was 56 years) with a standard deviation (SD) 9.9.
JSM Neurosurg Spine 3(3): 1059 (2015)

Figure 3 Intra-operative photograph of bilateral partial laminectomy

(A). Abcess lesion following debridement (B).

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tuberculosis (LTB) and the overall risk of opportunistic infections
[10]. Murdaca and colleagues suggested that the clinician must
have patients medical history, Mantoux test and chest x-ray
should always be done before TNFalpha inhibitor consider to
be given to the patient with chronic immune-mediated diseases
[10]. In Indonesia, TNFalpha inhibitor for chronic immunemediated diseases (such as rheumatoid arthritis, ankylosing
spondylitis, psoriatic arthritis, and other inflammatory arthritis)
is not our national protocol and will not covered by our national
insurance; therefore no LTB associated with TNFalpha inhibitor
therapy reported in our country. The message that they want to
underline is that, the clinician should be aware of TB in subjects
undergoing TNFalpha inhibitor therapy, especially in countries
with a high prevalence of TB, such us in Indonesia.
Figure 4 The final histopathological finding revealed TB infection
that shown as the accumulation of the epitheloid granulomas, datia
langhans cells, and caseous necrosis (magnifition 50x).

Figure 5 Polychain reaction (PCR) results. The IS6110 primers

amplify a fragment of MTB with a length of 123 base pair (bp).

IS6110 reverse : (5 CTC GTC CAG CGC CGC TTC GG 3)

PCR is highly accurate with a sensitivity of 80-98%, a

specificity of 98% [9] and rapid scan times (> 24 hours).

DISCUSSION

World Health Organization (WHO) has set TB as world

emergency issues. WHO estimates that there are approximately
eight million new cases annually and two million deaths each
year. If the problem is not managed, WHO predicts that there
will be approximately 200 million people infected by TB and 35
million deaths may be encountered in 2000 to 2020 [4].
Recently, Murdaca and colleagues emerged a very serious
issue that tell us how the administration of pro-infammatory
cytokine inhibitor, such as tumor necriting factor (TNF)-alpha
inhibitor, for chronic immune-mediated diseases appears to
be responsible (adverse event) for re-activation of latentJSM Neurosurg Spine 3(3): 1059 (2015)

Clinical manifestations of spondylitis TB are relatively

indolent (without the pain) [9]. The patients usually complaint
unspecific local pain in the infected area of the vertebra. Infection
begins in the subchondral epiphyseal vertebral area then extends
to the bone ossification center that may devitalized the bone due
to TB bacilli exotoxin that may cause loss of extracellular matrix
also spread locally to the subligament longitudinal area. TB germ
induce inflammatory reaction and the formation of granulation
tissue. This granulation will start damaging and erodes the
cartilage and even bone tissue resulting in demineralization and
then spread to the disc that has a poor blood supply. This process
may lead to deformity known kyphotic gibbus (83.3% patients
are presented with gibbus in this study).
Spondylitis TB is most commonly located in thoracal areas,
as many as 71% [11]; 66.7% in this study. The main artery that
affects the spinal cord in thoracal segments is most frequently
located in the left vertebrae thorakal 8 to lumbar 3. Thrombosis
of this artery may cause paraplegia. Another factor to be taken
into account is the relatively large diameter of the spinal canal
compared with vertebral canal. Lumbar vertebrae intumesensia
begin to widen as high as vertebrae thoracal 10, where vertebral
canal in the area is relatively small. As vertebral canal in the first
lumbar vertebra is large, it provides more space to move when
there is compression on the anterior part. This may explain why
paraplegia is common in vertebral thoracal lesions.
Gulhane Askeri Tip Academics (GATA) classification
determines the best therapy for the patient. This classification
system is based on clinical and radiological criteria, including:
abscess formation, disc degeneration, vertebral collapse,
kyphosis, sagittal angulation, vertebral instability and
neurological symptoms; spondylitis TB is divided into three types
(GATA I, II, and III) [12]. Surgical intervention is performed on
patients with GATA IB-III. Meanwhile, the only contraindication
of surgery is heart and lung failure.

The management of spondylitis TB aims to: (i) eradicate TB

germs using anti-TB drugs, (ii) Improve the patients general
condition, (iii) prevent or correct deformity, using decompression
and stabilization, (iv) Prevent or treat complications such
as neurological deficit such as paraplegi [13]. Treatment of
spondylitis TB is generally divided into two parts that can be
initiated concurrently, medical and surgical. Medical treatment
is fundamental, whereas surgery and complementary medical
therapy varies among patients [14]. Although medical treatment

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is the core therapy in the management of spondylitis TB patients,
surgery play an important role in spondylitis TB cases with cold
abscess, tuberculosis lesions, paraplegia, kyphosis progressive or
bone or disc herniation in the neural canal. In this study, surgical
therapy was performed in 83.3% of patients with cold abscess.

There are several surgical approaches; including (a) Anterior

approach where abscess can be evacuated, necrotic substances
can be disposed, anterior decompression of the spinal cord
can be achieved. Tissue for histopathological examination and
culture may be obtained easily and kyphosis can be corrected or
stabilized with autogenous bone graft, (b) Posterior approach;
indicated in cases where posterior elements are involved and
posterior stabilization is needed before anterior decompression
and arthrodesis, as well as in patients with stable or minimal
spinal deformity with intramedullary tuberculoma or epidural
abscess present. In this study, surgery was conducted, using
posterior approach, due to progressive neurologic deficits and
the progressive increase of spinal deformity (91.7%).

CONCLUSION

A comprehensive history taking, along with correct sampling

using various imaging modalities and PCR, will certainly lead to
the diagnosis of spondylitis TB. It must be noted that neurological
deficit due to spinal tuberculosis is reversible in majority of cases,
especially if decompression is achieved promptly. Appropriate
fusion and stabilization may prevent pain and late deformity.

CONSENT

Informed consent was obtained from each patient on May

20122013 for publication of this study and any accompaning
images

AUTHORS CONTRIBUTIONS

AF, IH, FY, RHD and MZA had examined, treated, observed,
and followed up the subject of this research. AF, FY and
RHD performed all the operation on the patient. All authors
participated in writing the manuscript. All authors has read and
approved of the final manuscript.

ACKNOWLEDGEMENT

The authors would like to thank to Agung B. Sutiono from

Department of Neurosurgery, Faculty of Medicine, Universitas
Padjadjaran-Dr. Hasan Sadikin Hospital, Bandung, for fruitful of
discussions.

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Cite this article

Faried A, Hidayat I, Yudoyono F, Dahlan RH, Arifin MZ (2015) Spondylitis Tuberculosis in Neurosurgery Department Bandung Indonesia. JSM Neurosurg Spine
3(3): 1059.

JSM Neurosurg Spine 3(3): 1059 (2015)

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