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 Pains & Aches

May 2010
Spine Tuberculosis
Dr Abrar Ahmed
 
Sheetal* put up with her back pain for nearly two years before it got really worse. Pain killers, muscle spasm ointments, exercise, she tried them all. Her back pain was not relieved even by rest, and in fact worsened, especially during night. She felt her legs weaken and her limbs stiffen. The 32-year-old had difficulty in walking and also reported loss of sensation of her limbs.

It was an orthopaedician specialising in spine surgery who told her that these are the first few symptoms of spinal tuberculosis. Spinal tuberculosis, if not diagnosed early or intervened at an early stage, could cause partial or complete paralysis.

Paralysis
One out of every three spinal TB victims develops some problems related to compression on the spinal cord or nerve roots. Paralysis thus caused can be divided into two types.

Within two years: The first type of weakness of limbs (due to swelling) is caused by active spinal disease. The infected tissue grows around the spinal cord or the nerves, resulting in the pus material or pieces of infected and dead bone pressing on the spinal cord. Majority of the patients in this stage show complete improvement with surgical treatment.

After two years:
Here, the disease would have already healed but the spine would be retaining a prominent bend called kyphotic deformity of the back. The spinal cord would be stretched over the bent spinal bones and mostly have an inside projection from the bent spinal bone. It is the apex of this bend that presses on the spinal cord, leading to gradual onset of the paralysis. This can further lead to permanent damage inside the spinal cord. Results of treatment in this stage are not as good as in the earlier case.

Diagnosis & Treatment
Sheetal underwent clinical examinations, which included tests for muscle power of legs, test for sensations of the limbs, presence of muscle stiffness and analysis of the gait. She also underwent blood examination and radiological investigations, which included x-rays, ultrasound, CT scan and MRI. An X-ray revealed destruction of Sheetal’s twelfth thoracic and first lumber spine bones and outlined pus cavity surrounding the damaged bones. An MRI detected pus and necrotic tissue, at the infected level. There was a marked compression of the spinal cords by the pus, dead tissues and damaged bones. The pressure on the spinal cord had lead to weakness of the legs, difficulty in walking and stiffness of the leg muscles.

Sheetal was advised bed rest and prescribed a protein-rich diet. As she was in the early stage without having any bowel and urinary dysfunction, she was prescribed anti TB drugs along with chest physiotherapy and general exercise for legs. She was also advised to get back to the hospital after three weeks.

Apart from periodic rest, good nutritious diet and anti TB drugs constitute treatment of spine disease. Normally, patients require more than one year of treatment. In majority of the cases, the disease is completely cured if the patient takes regular medications. TB after all, was eliminated from the Western world not by medications, but by improvement in the living condition of the population.

The Surgery
A week later, Sheetal suddenly noticed increased weakness in her legs. The hospital advised her to undergo surgery since she was developing progressive weakness of her legs. The surgery removed her infected spinal bones and all the infected materials around it. In the gap formed because of removal of the above bones, a titanium cylinder filled with her own rib bone was placed like a pillar. With in a week of surgery, Sheetal made substantial recovery. She regained almost full power in her lower limbs. With a brace for her back, Sheetal could walk with the help of the walking aid. She was also put on physiotherapy that helped her improve very fast. Three months later, she could walk independently. After a year of the surgery, her final X-ray and blood result revealed that she had had complete healing.

Prevention
Like any other infectious disease, TB can be prevented by increasing the disease fighting ability of your body. Your immune system can be strengthened by maintaining a healthy lifestyle, well balanced nutritious diet, regular exercises, avoiding alcohol and smoking, and good control of blood sugar.

Prevention
India accounts for approximately 20 percent the world’s TB patients. Ten percent of six million who suffer from this disease have bony infections – and spine is the most common bone affected.

Spinal tuberculosis, like any other form of TB, is more common up to 30 years of age, though babies as small as one year of age and elderly people of 80 to 85 years of age have also been reported to have tuberculosis of spine. The disease is equally prevalent in both men and women.

Spine TB is usually not contagious - in majority of the cases, within seven to 10 days of starting the anti TB drugs, the patient becomes non-contagious. Spine TB is a curable condition and all complications can be prevented, provided the disease is diagnosed at an early stage and the patient takes regular supervised course of medications. If required, surgical intervention is necessary to prevent or treat the complications at the earliest stage.

10 Symptoms of Spinal TB
In majority of the cases, spinal TB has a slow onset. The initial symptoms are common to all types of tuberculosis: tiredness, lack of interest in work, loss of weight and appetite, night sweats and shooting up of temperature in the evening. Symptoms particular to spine TB are:
  1. Stiffness of the back
  2. Pain over the infected spine bones which become worse in the night and does not get relieved even with bed rest
  3. A small bend in the back, over the affected spinal bone
  4. Varying degrees of weakness of arms and/or legs
  5. Twitching of leg or arm muscles
  6. Loss of sensation of leg/arm muscles
  7. Problems in passing urine or stool
  8. Swellings in the spine bone, which may or may not be painful
  9. Respiratory difficulties (for TB of the neck bone)
  10. Pus discharge from skin caused by bursting of pus containing sac, in patients who have not taken proper treatment
Dr. Abrar Ahmed is Consultant - Spine Surgery at Apollo Gleneagles Hospitals, Kolkata

    
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