Copyright 1985 by The Journal ofBone and Joint Surgery.

incorporated

Tuberculous Spondylitis in Adults*

BY ROBERT M. LIFESO, M.D., F.R.C.S.(C)t, PHILIP WEAVER, M.D.t, AND

EDWARD H. HARDER, M.D. , F.R.C.P.(C)t, RIYADH, KINGDOM OF SAUDI ARABIA

From the King Faisal Specialist Hospital and Research Centre, Riyadh

ABSTRACT: We treated 107 adults with spinal tu- gical procedures still play a role. Radical d#{233}bridement and
berculosis. The average age was 41.8 years (range, six- anterior fusion has been advocated by some authors7-, while
teen to seventy-five years). Diagnosis was difficult: bone others have claimed excellent results with the use of chemo-
scans were negative in 35 per cent; gallium scans, neg- therapy alone .12 During the past eighteen years, the Mcd-
ative in 70 per cent; and results of tuberculin skin tests, ical Research Council of England has been carrying out
negative in 14 per cent. Five neurologically impaired multicenter prospective studies of spinal tuberculosis in Af-
patients had no discernible bone lesions when they were rica and Asia. These studies showed that 82 to 88 per cent
first seen but were found to have either intradural or of all patients receiving chemotherapy alone will achieve a
extradural tuberculomas or tuberculous arachnoiditis. favorable result over a three-year period3-5520.
Our indications for a spinal operation were neu- We are reporting our results of treatment of spinal
rological impairment, spinal instability, or failure of tuberculosis in 107 adults. We used the regimen of isoniazid,
medical management, and an operation was required in rifampin, and ethambutol for all patients, with adjuvant
fifty-three of the 107 patients. Anterior decompression surgical procedures (other than biopsy) in fifty-three patients
and fusion was the surgical procedure of choice. Ninety- for specific indications that will be discussed.
four per cent of neurologically impaired patients re-
covered normal neurological function after anterior de- Materials and Methods
compression; 79 per cent, after non-surgical treatment; One hundred and twenty-four patients with tuberculosis
and 55 per cent, after laminectomy. Neurological re- of the spine were referred to one of us (R. M. L.) at the
covery and relief of pain occurred more rapidly in the King Faisal Specialist Hospital and Research Centre be-
surgically treated group. Kyphosis did not worsen in any tween June 1978 and June 198 1 . Seventeen patients were
patient, whether treated medically or surgically. There excluded from this study: six patients had had surgery per-
were no organisms that were resistant to isoniazid, ri- formed elsewhere, seven were lost to follow-up, two were
fampin, or ethambutol, and there was neither progres- children, and two died within forty-eight hours after ad-
sion nor reactivation of disease after twelve months of mission to the hospital, before initiation of either medical
adequate chemotherapy. or surgical treatment. Death was caused by massive pul-
monary embolism in one patient and by gross instability at
Spinal tuberculosis has existed for at least 5000 years. the level of the first and second cervical vertebrae and res-
Mummified remains from northern Egypt that have been piratory arrest in the second patient. Neither patient had
dated to 3400 B .C. have provided unequivocal evidence of been operated on or had received chemotherapy before
its presence9. The first description of tuberculous spondylitis death.
occurred in medical records of the Indo-Aryan peoples, There were 107 patients, sixty-one male and forty-six
written in Sanskrit between 1500 and 700 BC.926. Sir Per- female, in the study. The average age at referral was 41.8
cival Poll (1779) was the first to associate spinal deformity years (range, sixteen to seventy-five years). All patients
with the paralysis that is often seen with this disease2 . At were skeletally mature.
the beginning of the twentieth century, tuberculosis was the Five patients were seen with neurological impairment
leading cause of death in western society3. but without radiographic bone lesions. Four patients had
With the advent ofeffective combination chemotherapy cord compression with long-tract signs and the fifth had
in the early 1950s, the mortality rate among patients with severe dysesthesia and radiculopathy but no long-tract signs.
spinal tuberculosis decreased from approximately 10 per All five patients demonstrated myelographic evidence of
cent to 3 per cent. However, the rate ofparaparesis remained cord or root obstruction, and on laminectomy all were found
constant at approximately 20 per cent of all patients with to have either tuberculous granulomas or severe tuberculous
spinal tuberculosis4. Although chemotherapy remains the arachnoiditis.
mainstay in the treatment of tuberculous spondylitis, sur- The average duration of symptoms before referral was
twenty months (range, one month to twenty years). The
S This article was accepted for publication prior to July 1. 1985. No average length of follow-up was four years (range, three to
conflict-of-interest statement was requested from the authors.
t King Faisal Specialist Hospital and Research Centre, Riyadh 1 12 1 1,
six years), including a twelve-month course of chemother-
Kingdom of Saudi Arabia. apy. No patient required further medical or surgical treat-

VOL. 67-A, NO. 9. DECEMBER 1985 1405

1406 R. M. L1FESO, PH1L1P WEAVER, AND E. H. HARDER

TABLE I had severe neurological deficits (Grade A or B of Frankel

NEUROLOG ICAL STA TUS W HEN THE PAT1E NTS WE RE FIRST SEEN et al.), failed to respond to medical management, or had
spinal instability, especially at the level of the first and
Grade* (No.)
Levels
second cervical vertebrae. Failure of medical management
Involved A B C D E Total
(No.) meant increasing neurological deficit, failure of a deficit to
improve after three or four weeks of supervised chemo-
CltoC2 2 1 3 6
therapy, persistent abscesses, or persistent pain related to
C3toC7 2 1 2 4 9
the spinal lesion. The presence of instability was a clinical
TltoT6 4 3 7 4 2 20
T7toTl2 1 5 11 10 13 40
judgment based on the amount and location of bone de-
LltoLS 8 19 27 struction.
Nobone 1 2 1 1 5 Myelograms and computed tomographic scans were
lesion performed in all patients with neurological impairment, and
Total 7 9 23 26 42 107 computed tomographic scans were made routinely for all
* Classification according to Frankel et al. : A - complete neurolog- patients with involvement of the upper part of the cervical
ical deficit with no sensory, motor, bowel, or bladder sparing distal to the spine. Patients with either a slight neurological deficit or
spinal lesion; B - sparing of some sensation but no motor function distal none were maintained on chemotherapy for a minimum of
to the spinal lesion; C - sparing of sensation and non-useful motor function
six months before surgery was performed for either per-
distal to the spinal lesion; D - sparing of sensation and useful motor
function distal to the spinal lesion; and E - normal neurologically. sistent abscesses or continuing severe pain.

Surgical Approaches
ment after the completion of chemotherapy. All patients had
standard laboratory tests, which included a complete blood- Lesions involving the base of the occiput and the first
cell count, erythrocyte sedimentation rate, blood chemistry and second cervical vertebrae were approached transorally
profile, and Mantoux tuberculin skin test. For all patients for decompression and biopsy, and then a posterior stabi-
radiographs of the chest, specific spinal lesions, and any lization was performed utilizing a Gallie fusion of the first
other suspected skeletal sites were made. Special studies and second cervical vertebrae (Figs . 1 -A and 1 -B) or a fusion
including technetium-99m bone scans, tomograms, myelo- from the occiput to the second or third cervical vertebra. A
grams, computed tomographic scans, and gallium scans fusion of the first and second cervical vertebrae was done
were performed as clinically indicated. All patients were when the arch of the first cervical vertebra was intact (two
treated and followed personally by us, and were classified patients), as ascertained by computed tomographic scan-
according to the schema of Frankel et al. (Table I). fling, but if the arch was totally destroyed (two patients) a
In forty-four patients the diagnosis was established by fusion from the occiput to the second or third cervical ver-
culturing acid-fast bacilli from material from the spinal le- tebra was performed.
sion. In twenty-three patients material from the spinal lesion Lesions from the second cervical to the first thoracic
was negative for acid-fast bacilli on smear and culture, but vertebra were exposed by the standard anterior approach.
caseating granulomas were demonstrated histologically. In A transthoracic approach was used for all thoracic lesions.
fifteen other patients no spinal tissue was obtained, but the For the lesions of the cervical spine and upper part of the
radiographs were considered diagnostic, the Mantoux test thoracic spine, the side of the approach depended on the
was grossly positive, brucella-antibody titers were negative, location ofthe largest abscess and the most bone destruction,
and the patients responded appropriately to treatment. as ascertained by computed tomographic scanning. Thora-
Twenty-five other patients had extraspinal lesions in addi- columbar lesions were approached from the left, turning
tion to spinal lesions, and in this group positive smears and down the diaphragm as needed. Lumbar lesions were ap-
cultures were obtained from material from non-spinal sites proached retroperitoneally from the left.
such as the ankle, knee, tibia, or wrist, or from the sputum. Bone grafts were taken from the anterior part of the
All patients were treated with the following drugs: iso- iliac crest in all but two patients, in whom rib grafts were
niazid, five to ten milligrams per kilogram per day (maxi- utilized.
mum, 300 milligrams per day); rifampin, ten to twenty Of the total of 107 patients, fifteen had tuberculosis of
milligrams per kilogram per day (maximum, 600 milligrams the cervical spine; sixty, of the thoracic spine; and twenty-
per day); ethambutol, fifteen milligrams per kilogram per seven, of the lumbar spine. Five had no discernible bone
day (maximum, 1200 milligrams per day); and vitamin B6, lesions as determined by radiographic study.
twenty-five milligrams daily. All drugs were given in one
Surgical Procedures
daily dose. Ethambutol was routinely discontinued after
three months; all other agents were discontinued after twelve Forty of the 103 patients who had lesions that were
months. The drug dosages were limited in eight patients caudad to the second cervical vertebra underwent radical
with concomitant liver or renal disease, but all other patients anterior d#{233}bridement and spine fusion (Table II). Laminec-
completed the standardized treatment regimen. tomy was carried out in nine patients, all of whom had a
Biopsy was done when necessary to establish the di- neurological deficit but minimum or no bone lesion. Five
agnosis. Definitive surgery was reserved for patients who showed a complete myelographic block without radio-

THE JOURNAL OF BONE AND JOINT SURGERY

 TUBER(ULOUS SPONDYLITIS IN ADULTS I 407

graphic evidence of vertebral tuberculosis. These patients than 10,000 per cubic millimeter. The average hemoglobin
had a laminectorny because of a suspected extradural or was 13.3 grams per deciliter. The hematological and bio-
intradural tumor. The remaining four patients who had a chemical profiles yielded no data of importance that were
laminectomy had a stable spine with minimum destruction related to the differential diagnosis of the tuberculous spinal
of bone but widespread cord compression as determined by lesions. The Mantoux tuberculin test was positive in 86 per
myelography and computed tomographic scanning. All were cent and negative in 14 per cent of the eighty patients who
approached posteriorly for biopsy and drainage of the ab- were adequately tested.
scess. Fifty-four patients had no therapeutic surgery. The radiographic evaluations included bone-scanning
Four patients with disease at the cervical-occipital junc- with technetium-99m pyrophosphate in fifty-six patients.
tion who were treated surgically wore a halo jacket after Twenty (35 per cent) had a completely normal bone scan,
spine fusion. No other patients in this series were immo- showing no area of increased activity in the spine, in spite
bilized in a cast and all patients were permitted as full a of radiographically demonstrable lesions. In five of these
program of activity as they could tolerate. No patient was patients the scan was positive for other non-spinal skeletal
maintained on bed rest. foci oftuberculosis. Thirty-five (64 percent) showed uptake
Postoperatively all patients were evaluated carefully. at the site of the spinal lesion. One patient had a negative
specifically for progression of kyphosis: degree of vertebral (cold) scan at the site of a surgically proved, active lesion.
subluxation, either laterally or anteriorly; and increasing Gallium-67 has a known affinity for tuberculosis22, and such
destruction of the vertebral body. Radiographs were made scans were performed in ten patients: seven were normal
weekly while the patient was in the hospital and then and three showed increased activity at the site of the ver-
monthly until the spinal column stabilized. All patients were tebral lesion.
then followed at three-month intervals for two years and at Forty-one patients were found to have tuberculosis in
six-month intervals thereafter. an extravertebral site: the lung in sixteen patients, other
viscera in nine, and other skeletal sites in sixteen.
Results All patients were evaluated for encroachment on the
When the patients were first seen, the average eryth- subarachnoid space, measured as a per cent of subluxation
rocyte-sedimentation rate (Westergren method) was forty- of one vertebral body on the next. Forty-one patients (38
four millimeters per hour (range, six to eighty-eight milli- per cent) had some measurable degree of encroachment on
meters per hour). Six patients had an erythrocyte sedimen- the subarachnoid space, but the degree ofencroachment did
tation rate of less than ten millimeters per hour and five had not correlate with the neurological impairment.
a rate between ten and twenty millimeters per hour. The Thirty-one patients underwent fine-needle aspiration of
average white blood-cell count was 6.5 x l0 per cubic a spinal abscess under radiographic control and local anes-
millimeter (range. 3.6 to I 1 .0 x l0 per cubic millimeter). thesia. Twelve of the thirty-one had a negative culture and
Only four patients had a white blood-cell count of more a negative smear for tuberculosis. Three of the twelve had

..

FIG. I-A FIG. 1-B

Figs. I -A and I -B: A thirty-six-year-old woman with tuberculosis at the first and second cervical levels and early anterior subluxation of the first
on the second eervcal vertebra.
Fig. I-A: A soft-tissue mass is seen anterior to the body of the first cervical vertebra. The posterior arch of the first cervical vertebra is preserved.
Ftg. I -B: Radiograph tiade after Gallie fusion with restoration of normal alignment of the first cervical vertebra.

VOL. 67-A, NO. 9. I)ECEMBER 985

1408 R. M. LIFESO, PHILIP WEAVER. AND E. H. HARDER

TABLE II
TREATMENT

Surgical (No.)
Transoral
Btopsv uid
Levels Anterior Cl-C2 or 0cc.-
Involved Deconipression Laminectomy C2 Fusion Non-Surgical Total
(Ao. ) (No.)

CltoC2 4 2 6
C3toC7 6 3 9
TI toT6 II 3 6 2()
T7 to Tl2 17 2 21 4()
LI to L5 6 21 27
No bone lesion 4 I 5
Total 41) 9 4 54 lU7

a subsequent anterior decompression. Culture of the in- severe neurological impairment (Figs. 4-A and 4-B). Of the
volved tissue was positive in one and negative in two (but sixty patients with disease in the thoracic spine. thirty had
the specimens were positive histologically). All patients surgical treatment because of severe neurological impair-
with a negative culture of material that was taken at needle ment (Figs. 6-A and 6-B) and three, because of instability.
aspiration had had at least one month and as much as twelve Of the twenty-seven patients with localization of the lesion
months of chemotherapy for tuberculosis before referral to in the lumbar spine, six had surgical treatment for relief of
us. Nineteen of the thirty-one patients had a positive smear persistent pain that was related to failure of spontaneous
or culture, or both, of material taken by needle aspiration, fusion of the involved bodies or discs. No other operative
and six of these subsequently underwent anterior de- procedure had been performed in any of the six patients
compression and fusion. All six had a positive culture of with disease in the lumbar spine.
material that was obtained at surgery. All nine patients who underwent larninectomy had a
Ofthe fifteen patients with disease in the cervical spine. stable spine. Four patients without bone involvement were
ten had surgical treatment (Table II). six because of insta- found to have a tuberculoma: three extradural and one in-
bility (Figs. 2-A. 2-B, 5-A, and 5-B) and four because of tradural. Severe tuberculous arachnoiditis was found in three

FIG. 2-A FI;. 2-B

Figs. 2-A and 2-B: A forty-two-year-old woman with a purely destructive process of the anterior arch of the body of the first cervtcal vertebra.
Fig. 2-A: The entire anterior arch is deficient. A large retropharyngeal mass can he seen.
Fig. 2-B: Radiograph made six months after posterior fusion from the occiput to the third cervical vertebra.

THE JOURNAL OF BONE ANt) JOINT SURGERY

 TUBERCULOUS SPONDYLITIS IN ADULTS 1409

r-

FIG. 3-A FIG. 3-B

Fig. 3-A: This patient had a lytic lesion involving only the body of the third cervical vertebra. with slight involvement of the anterior aspect of the
second cervical vertebra. There is preservation of the posterior elements and of the posterior part of the cortex of the body of the third cervical vertebra.
Fig. 3-B: Radiograph of the same patient after anterior cervical decompression and an iliac-crest graft.

patients, and the last two had chronic tuberculous granu- and fusion. eight had a laminectomy, and one had a posterior
lation tissue without true abscess formation. All of the pa- fusion of the first and second cervical vertebrae. Twenty-
tients with a tuberculoma improved. whereas all of those four of the twenty-six patients who underwent anterior de-
with arachnoiditis did not. One of the two patients with a compression recovered normal neurological function. All
granuloma improved. No patient worsened. Two patients of these patients had been paraparetic for nine months or
with disease of the lumbar spine that was diagnosed by less. The remaining two patients. who were paraparetic for
culture of material obtained by fine-needle aspiration re- eleven and fourteen months before decompression. im-
quired subsequent surgical drainage of a persistent psoas proved postoperatively but were still not neurologically nor-
abscess, which did not resolve in spite of six months of mal (Grade D). Ofthe twenty-three paraparetic patients who
antituberculous chemotherapy. were treated with cheniotherapy alone. eighteen recovered
Five of the seven patients with total paraplegia or tet- to normal neurological function, one improved (from Grade
raplegia (Grade A of Frankel et al.) underwent anterior C to D). two remained the same (Grades C and D), and
decompression. All five recovered normal (Grade-E) neu- two worsened (from Grade C to A and from Grade D to
rological function. The average time from the onset of para- B). both eventually requiring anterior decompression. Both
plegia or tetraplegia to surgery was 3.3 months (range. six recovered normal neurological function.
weeks to five months). One patient refused operative inter- In summary. sixty-five patients had varying degrees of
vention and remained completely tetraplegic at forty neurological impairment. Twenty-nine (94 per cent) of the
months, and the seventh paraplegic patient underwent lam- thirty-one who had anterior decompression improved and
inectomy for widespread severe tuberculous arachnoiditis nineteen (79 per cent) of the twenty-four with medical treat-
but remained neurologically unchanged at thirty-six months. ment alone improved, while five (55 per cent) of nine im-
Of the remaining fifty-eight patients with a neural def- proved after laminectomy. The average time to neurological
icit (Grade B. C. or D). twenty-three were treated by chemo- recovery after anterior decompression was 5.6 months. It
therapy alone, twenty-six had an anterior decompression was 6.6 months in the non-surgically treated group.

VOL. 67-A, NO. 9. DECEMBER 1985

1410 R. M. LIFESO, PHILIP WEAVER. AND E. H. HARDER

4
4

,- .,

FI;. 4-A FIG. 4-B

Fig. 4-A: Cervical tuberculosis with destruction of the adjacent bodies of the fturth and fifth cervical vertebrae. Sequestered hone is lying anterior
to the destroyed bodies. A large soft-tissue abscess is seen. There is preservation of the posterior elements with destruction of the anterior parts of the
vertebral bodies and the intervening disc space.
Fig. 4-B: Radiograph of the same patient. made six months after anterior decompression and fusion from the fourth to the sixth cervical vertebra.

Twelve of the forty-two patients whose neurological who received conservative medical management. Before
status was normal when they were first seen eventually treatment the average degree of kyphosis. as measured by
required operative intervention: posterior fusion of the oc- the Cobb technique. was 21 degrees (range, zero to 100
ciput to the second or third cervical vertebra in three and degrees). After anterior decompression it worsened by an
anterior decompression and fusion in nine. Seven of the average of 0.6 degree (range. 15-degree improvement to
nine anterior fusions were perhrnied to relieve pain sec- 10-degree deterioration) (Figs. 5-A and 5-B) and, under the
ondary to persistent instability after six months of adequate medical regimen. by an average of 3.2 degrees (range, zero
conservative treatment. The two remaining patients with to 15 degrees).
normal neurological findings who underwent anterior de-
compression had been treated with chemotherapy for six Complications
months, and in both an abscess in the middle area of the In the patients who were treated surgically, there was
thoracic spine did not regress. Surgery was performed pri- one non-fatal pulmonary embolism; one fracture of the graft
manly to establish the diagnosis and rule out the possibility (at seven months); and three extrusions of the graft, one
of infection either with other organisms or with drug-re- requiring repeat grafting. No deaths occurred in the sur-
sistant strains of tuberculosis. In both patients the walls of gically or medically treated patients. In the medically treated
the abscess were found to be grossly thickened. One hundred group. one patient had a reaction to isoniazid and six, to
milliliters of pus was removed from one. and in the second rifampin. These necessitated discontinuing the drugs. The
patient the abscess cavity contained only granulation tissue. reaction to isoniazid occurred four months after the initiation
No patient with neurologically normal findings worsened of therapy and the reactions to rifampin occurred between
after surgical or conservative treatment. two and four weeks after the initiation of therapy. During
The time to relief of pain after laminectomy averaged follow-up there was no recurrence of disease and no evi-
seventeen months; after medical therapy alone, 9.5 months; dence of reactivation of disease.
and after anterior decompression and posterior cervical fu- All cultures of Mvcobacterium tuberculosis from the
sion, 4.3 and three months, respectively. spine and from other non-vertebral sites were sensitive to
The average number of vertebral bodies that were ra- standard doses of isoniazid. rifampin. and ethambutol, and
diographically involved when the patients were first seen resistant strains were not encountered.
was 2. 1 (range, zero to six). Over the period of follow-up,
Discussion
that average increased by 0.3 body in the patients who
underwent anterior decompression and by 0.2 body in those Spinal tuberculosis. as seen in Saudi Arabia. is pri-

THE JOURNAL OF BONE AND JOINT SURGERY

 TUBERCULOUS SPONDYLITIS IN ADULTS 1411

FIG. 5-A FIG. 5-B

Figs. 5-A and 5-B: A ftrty-year-old woman.

Fig. 5-A: Radiograph showing destruction ofthe bodies ofthe fifth and sixth cervical vertebrae with a 95-degree kyphosis. The patient was neurologically
normal.
Fig. 5-B: Radiograph made three months after anterior cervical decompression and fusion. showing good correction of the kyphosis and excellent
stability.

manly a disease of adults, similar in pattern to that found at the King Faisal Specialist Hospital. This is in marked
in Europe and North America423. In our series of adult contrast to other studies that have been reported from Asia
patients the average age was 4 1 . 8 years when they were and Africa. In Hong Kong 69 per cent of the patients were
first seen, and during the three years of the study only two reported to be less than ten years old5.
children were diagnosed as having tuberculous spondylitis The diagnosis of spinal tuberculosis is often simpler in

Fu;. 6-B
Fig. 6-A:A twenty-three-year-old wonian with a six-month history of complete paraplegia at the third thoracic level and destruction of the anterior
parts of the bodies of the third and fourth thoracic vertebrae.
Fig. 6-B: Radiograph made of the same patient six months after thoracotomy. anterior decompression. and strut-grafting using bone from the iliac
crest. The paravertebral abscess has resolved and the patient had a complete neurologtcal recovery.

VOL. 67-A, NO. 9. I)ECEMBER 1985

1412 R. M. LIFESO. PHILIP WEAVER. AND E. H. HARDER

children than in adults, because in children other spinal the thoracic spine (Fig. 7), and 90 per cent of the patients
diseases that might radiographically mimic tuberculosis are with lesions in the upper part of the thoracic spine had
rare. In adults, the differential diagnosis involves many neurological impairment. Lesions in the lumbar spine were
other possibilities. We did not find determinations of the less frequent. and fewer of those patients had instability or
erythrocyte sedimentation rate. hemoglobin, white blood- a neurological deficit.
cell count, or serum biochemical profile to be of value. The When they were first seen. five patients had no radio-
technetium-99m bone scan was negative in 35 per cent of graphic evidence of bone abnormality. They had marked
our patients with radiographic and clinical evidence of active intradural or extradural involvement of the spinal canal with
disease; similarly, gallium scans also were negative in most tuberculomas or arachnoiditis. This has only been reported
of the patients (seven of ten) with radiographic evidence of once2. These lesions perhaps are more common in adults
active disease. The gallium scans were usually done in the than has previously been appreciated. It also is noteworthy
early phase of the disease. in the hope of demonstrating a that six patients had severe involvement at the junction of
lesion (or lesions) at a time when other radiographic inves- the occiput and the first cervical vertebra. One patient. not
tigations might not detect it. included in the statistics, died within forty-eight hours after
Neurological impairnient was present in sixty-five of admission to the hospital due to gross atlanto-axial insta-
our 107 patients when they were first seen. a much higher bility. This localization of lesions is in contrast to a report
percentage than that reported in the literature424. We sus- from China, where only fifteen of 5.393 patients had atlanto-
pect that this was because our hospital is a tertiary care axial involvement25.
center, and was for a time the only hospital in Saudi Arabia Resistance to isoniazid, ethambutol, or rifampin was
in which major spinal surgery was performed. No statistics not demonstrated in any of the strains of Mveobacteriu,n
are yet available on the incidence of tuberculosis in our tuberculosis that were isolated from our patients. All pa-
referral population. tients. except the seven who showed drug incompatibilities.
In our series there was a predominance of lesions in were treated with triple therapy for three months and then
with isoniazid and rifampin alone for nine months. No pa-
tient has shown either reactivation or continuation of disease
after a minimum follow-up of three years.
Nearly half of our patients required surgery for stabi-
lization of the spine or decompression of the lesions. or
both. This is a higher percentage than the 20 per cent of
patients requiring surgery reported by Tuli. but it should be
realized that a large number of our patients were referred
with significant neurological impairment4.
We now recommend immediate anterior decompres-
sion and spine fusion in all patients with complete tetraplegia
or paraplegia. in all patients with a profound neurological
deficit secondary to a lesion in the cervical or upper part of
the thoracic spine. and in patients with gross destruction of
the upper cervical spine at the cervicothoracic junction or
at any site where there is marked kyphosis and active dis-
ease. Before biopsy of the spine. consideration should be
given to needle aspiration of a spinal or psoas abscess under
computed tomography guidance or to biopsy of an involved
extravertebral site.
Patients who have slight or no neurological deficit and
slight kyphosis can be safely treated with medical therapy
alone. and close observation should then be the rule. An
increase in kyphosis and in the number of affected vertebral
bodies does not appear to occur as frequently in adults as
has been previously described in children75.
Of the nine patients in our series who underwent lam-
inectomy. only three returned to completely normal neu-
rological function. These nine patients deserve special
FI;. 7
comment. Each of them had slight or no radiographically
A twenty-six-year-old woman who had seven months of complete para-
demonstrable bone involvement hut each had widespread
plegta at the stxth thoractc level. Antertor thoracotomy and decompresston
was perfortied six months before this radiograph was niade. Rib graft is intradural orextradural abscess forniation and arachnoiditis.
still well seen n the posterior aspects of the bodies of the fifth and seventh
Patients who had inflammatory damage to the cord or dura
thoracic vertebrae. whereas the antertor tltac spine that was used in the
anterior portion of the fusion mass is already incorporating. generally did not show significant postoperative recovery.

THE JOURNAL 01: HONE ANt) JOINT SURGERY

 TUBERCULOUS SPONDYLITIS IN ADULTS 1413

The laminectomy did allow drainage of an intradural or six months of conservative treatment alone.
extradural lesion and also was of value in securing tissue Seven patients underwent anterior fusion for persistent
for biopsy. For these reasons, although laminectomy ap- pain after six months of conservative treatment. Whether
parently is a less successful treatment than anterior de- this group would have achieved relief of pain with a longer
compression, the procedure does have value in selected period of conservative care is difficult to predict. All had
patients. After limited laminectomy, an increasing kyphosis rapid relief of pain within three months after surgery.
or an increasing neurological deficit did not develop in any Patients with paraparesis (Grade C or D according to
patient. the classification of Frankel et al.) and a stable spine can
We recommend early incision and drainage of large generally be managed with conservative treatment. Only
psoas abscesses, preceded by large-bore needle aspiration two of twenty-three patients worsened with conservative
under computed tomography guidance. In our series two treatment, and both recovered completely after anterior de-
patients had a very large abscess that did not resolve with compression and fusion.

References
I. ADAMS, Z. R. : Tuberculosis of the Spine in Children. A Review of Sixty-three Cases from the Lakeville State Sanatorium. J. Bone and Joint
Surg., 22: 860-861. July 1940.
2. BERGER, S. A.; MAYER, IRA: and NELSON. STUART: Tuberculous Epidural Abscess without Osteomyelitis Iletterl. Arch. Neurol. , 35: 397. 1978.
3. EDITORIAL: Tuberculosis of the Spine. British Med. J.. 4: 613-614, 1974.
4. FRANKEL. H. L.: HANCOCK. D. 0.; HYSLOP. G.: MELZAK. J.; MICHAEI.IS. L. S.: UNGAR. G. H.; VERNON. J. D. S.; and WALSH, J. J.: The Value
of Postural Reduction in the Initial Management of Closed Injuries of the Spine with Paraplegia and Tetraplegia. Part I. Paraplegia. 7: 179-192,
I 969.

,
5. GRIFFITHS. D. L.: The Treatment of Tuberculosis of Bone and Joint. J. Trop. Med. and Hyg. . 72: 559-563. 1978.
6. GRIFFITH5. D. L.: Tuberculosis of the Spine: A Review. Adv. Tuberc. Res., 20: 92-1 10, 1980.
7. HotxsoN. A. R. and STOCK, F. E.: Anterior Spine Fusion for the Treatment of Tuberculosis of the Spine. The Operative Findings and Results
of Treatment in the First One Hundred Cases. J. Bone and Joint Surg.. 42-A: 295-310, March 1960.
8. H0DcS0N. A. R.; STOCK, F. E.: FANG, H. S. Y.: and ONG, G. B.: Anterior Spinal Fusion. The Operative Approach and Pathological Findings
in 412 Patients with Potts Disease of the Spine. British J. Surg.. 48: 172-178. 1960.
9. KEERS, R. Y. : Pulmonary Tuberculosis: A Journey down the Centuries. London. Balli#{232}rcTindall, 1978.
10. KEMP, H. B. S.: JACKSON. J. W.: JEREMIAH. J. D.: and CooK. JOSEPHINE: Anterior Fusion of the Spine for Infective Lesions in Adults. J. Bone
and Joint Surg. . 55-B(4): 715-734. 1973.
I I . KONSTAM, P. G. . and BLESOVSKY, A.: The Ambulant Treatment of Spinal Tuberculosis. British J. Surg. . 50: 26-38, 1962.
12. KONSTAM, P. G., and KONSTAM. S. T.: Spinal Tuberculosis in Southern Nigeria. With Special Reference to Ambulant Treatment of Thoraco-

,
Lumbar Disease. J. Bone and Joint Surg.. 40-B(l): 26-32, 1958.
13. LEFF, ALAN; LESTER. T. W.: and ADDINGTON. W. W.: Tuberculosis. A Chemotherapeutic Triumph but a Persistent Socioeconomic Problem.
Arch. Intern. Med. 139: 1375-1377, 1979.
14. MARTIN, N. S.: Tuberculosis of the Spine. A Study of the Results of Treatment during the Last Twenty-five Years. J. Bone and Joint Surg.,
52-B(4): 613-628. 1970.
IS. MEDICAl. RESEARCH COUNCII. Tuberculosis and Chest Diseases Unit Report, 1973-1977. London, Journal of Tropical Medicine and Hygiene,
1977.
16. MEDICAL. RESEARCH COUNCIL WORKING PARTY ON TUBERCULOSIS OF THE SPINE - FIRST REPORT: A Controlled Trial of Ambulant Out-Patient
Treatment and In-Patient Rest in Bed in the Management of Tuberculosis of the Spine in Young Korean Patients on Standard Chemotherapy. A
Study in Masan, Korea. J. Bone and Joint Surg. . 55-B(4): 678-697. 1973.
17. MEDICAL RESEARCH COUNCIL WORKING PARTY ON TUBERCULOSIS OF THE SPINE - THIRD REPORT: A Controlled Trial of D#{233}bridement and
Ambulatory Treatment in the Management of Tuberculosis of the Spine in Patients on Standard Chemotherapy. A Study in Bulawayo, Rhodesia.
J. Trop. Med. and Hyg.. 77: 72-91, 1974.
18. MEDICAl. RESEARCH COUNCIL WORKING PARTY ON TUBERCULOSIS OF THE SPINE - FOURTH REPORT: A Controlled Trial of Anterior Spinal Fusion
and D#{233}bridement in the Surgical Management of Tuberculosis of the Spine in Patients on Standard Chemotherapy: A Study in Hong Kong. British
J. Surg. , 61: 853-866. 1974.
19. MEDICAL RESEARCH COUNCIL WORKING PARTY ON TUBERCUI.OSIS OF THE SPINE - SIXTH REPORT: Five-Year Assessments of Controlled Trials
of Ambulatory Treatment, Debridement and Anterior Spinal Fusion in the Management ofluberculosis ofthe Spine. Studies in Bulawayo (Rhodesia)
and in Hong Kong. J. Bone and Joint Surg., 60-B(2): 163-177. 1978.
20. MEDICAL RESEARCH COUNCIL WORKING PARTY ON TUBERCULOSIS OF THE SPINE - SEVENTH REPORT: A Controlled Trial of Anterior Spinal
Fusion and D#{233}bridement in the Surgical Management of Tuberculosis of the Spine in Patients on Standard Chemotherapy: A Study in Two Centres
in South Africa. Tubercle, 59: 79-105, 1978.
2 1 . POTT, PERCIVAL: Remarks Ofl That Kind of Palsy of the Lower Limb, Which Is Frequently Found to Accompany a Curvature of the Spine, and
Is Supposed To Be Caused by It. Together with Its Method of Cure. In Medical Classics. Vol. 1 . no. 4. pp. 281-297. London, 1936.
22. SARKAR, S. D.; RAVIKRISHNAN. K. P.; WOODBURY, D. H.; CARSON. J. J.: and DALEY. KENNETH: Gallium-67 Citrate Scanning - A New Adjunct
in the Detection and Follow-up of Extrapulmonary Tuberculosis: Concise Communication. J. NucI. Med. . 20: 833-836. 1979.
23. Swirl, W. E.: End Results of the Spine-Fusion Operation for Tuberculosis of the Spine. J. Bone and Joint Surg., 22: 815-823, July 1940.
24. TULI, S. M.: Results of Treatment of Spinal Tuberculosis by Middle-Path Regime. J. Bone and Joint Surg., 57-B(l): 13-23, 1975.
25. WANG, L. X.: Peroral Focal Debridement for Treatment of Tuberculosis of the Atlas and Axis. Chinese J. Orthop.. 1(4): 207-209, 1981.
26. WEBB. G. B. : Tuberculosis. pp. 20-24. New York, Hoeber. 1936.

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