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Tuberculosis of the Posterior


Vertebral Elements:
A Rare Cause of Compression
of the Cauda Equina
A CASE REPORT
BY SUDHIR K. KAPOOR, MS, VISHAL GARG, MS, B.K. DHAON, MS, AND MOHIT JINDAL, MS
Investigation performed at the Department of Orthopaedics, Maulana Azad Medical College and Associated Hospitals, New Delhi, India

T
uberculosis is a major public health problem in devel- drome)2. These unusual presentations are likely to cause a
oping countries. The human immunodeficiency virus delay in the diagnosis and management. Atypical spinal tuber-
has triggered a resurgence of tuberculosis in parts of culosis may present with signs and symptoms of compression
the world where the disease was sporadic or unknown in the of the spinal cord or the cauda equina3. We report the rare case
recent past1. of a patient with tuberculosis of the lumbosacral spine involv-
The spine is a common site of involvement for extrapul- ing the posterior elements and presenting with an acute cauda
monary tuberculosis. The classic picture of paradiscal involve- equina syndrome. Our patient was informed that data con-
ment of two adjacent vertebrae is readily recognized and cerning the case would be submitted for publication.
routinely managed in countries where the disease is endemic.
Atypical presentations include involvement of the central part Case Report
of the vertebral body (central type), involvement of the poste- thirty-year-old man presented with a one-month history of
rior elements, and neurological complications without any
radiographic evidence of tuberculosis (spinal tumor syn-
A pain in the lumbar region, difficulty walking for one week,
and urinary hesitancy for two days. There was weakness of the

Fig. 1
Anteroposterior and lateral radiographs of the lumbosacral spine, showing no apparent abnormal-
ity except for a loss of sharpness of the margins of the laminae of the fourth lumbar vertebra.

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Fig. 2
Sagittal T2-weighted magnetic resonance images showing compression of the cauda equina by
an epidural fluid collection lying posterior to the third, fourth, and fifth lumbar vertebrae.

ankle plantar flexors (grade-2 of 5 strength) and dorsiflexors lumbar to the first sacral vertebra and in the posterior portions
(grade-2 of 5 strength), and both ankle reflexes were absent. Hy- of the fourth and fifth lumbar vertebral bodies, with a large
poesthesia in the fourth lumbar to fifth sacral dermatomes (the multiloculated fluid collection in the right paraspinal region.
right side was greater than the left) was noted. There was no de- This epidural fluid collection caused marked extradural com-
formity, but tenderness was elicited over the spinous processes of pression of the thecal sac and the cauda equina from the third
the third and fourth lumbar vertebrae. Radiographs of the lum- lumbar to the first sacral vertebra and was suggestive of the
bosacral spine revealed a loss of sharpness of the margins of the diagnosis of tuberculosis. Antitubercular drug therapy (iso-
laminae of the fourth lumbar vertebra (Fig. 1). niazid, rifampin, pyrazinamide, and ethambutol) was started,
Magnetic resonance imaging of the lumbosacral spine and surgical exploration of the lumbosacral spine (the second
(Figs. 2 and 3) showed altered signal intensity (a hyperintense lumbar to first sacral vertebrae) through a posterior midline
signal in the T2-weighted image and a hypointense signal in approach was done. The laminae of the third and fourth lum-
the T1-weighted image) in the posterior elements of the third bar vertebrae had roughened surfaces. Portions of these lami-

Fig. 3
Transverse T2-weighted magnetic resonance images showing hyperintensity of the posterior ele-
ments of the fourth lumbar vertebra and an epidural fluid collection compressing the thecal sac
and cauda equina.

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Fig. 4
Photomicrograph of the specimen obtained at surgery revealing typical tubercular granuloma
with Langhans giant cells, epithelioid cells, and round cells (400).

nae were soft to the touch; however, no discontinuity was terior spinous processes is rare, and the prevalence has var-
found. The diseased laminae of the third and fourth lumbar ied; however, it represented <2% of the 600 patients de-
vertebrae were removed, and greenish-yellow pus was drained. scribed by Tuli 2, 0.2% of the >2000 patients reported on by
The cauda equina was found ensheathed in what appeared to Adendorff et al.5, and 10% of the 228 patients in the study by
be an inflammatory membrane. Following careful removal of Babhulkar et al.3. Since tuberculosis of the posterior verte-
this membrane, the dural sheath was found to be intact and bral elements (the pedicles, transverse processes, laminae,
dural pulsations were present. A culture of the pus was sterile, and spinous process) alone is rare, there is often a delay in
and a biopsy specimen from the inflammatory membrane and the diagnosis and irreversible neurological sequelae may oc-
resected osseous tissue showed a typical tubercular granuloma cur. However, with magnetic resonance imaging, the disease
(Fig. 4) with Langhans giant cells, epithelioid cells, and round process can be seen in the very early stage of reactive bone-
cells, confirming the diagnosis of tuberculosis. marrow edema, before osseous destruction has occurred,
The patient was continued on the four-drug antitubercu- and the diagnosis can be established along with the clinical
lar therapy (isoniazid, rifampin, pyrazinamide, and ethambu- findings. Treatment started during this stage may prevent
tol) and bed rest. The surgical decompression and multidrug morbidity, spinal deformity, or even cord compression due
therapy resulted in rapid improvement in the neurological signs to vertebral collapse. Anterior or anterolateral decompres-
and a satisfactory recovery. Within twelve weeks, the patient sion is the appropriate surgical approach for operative man-
had no motor weakness, sensory deficit, or bladder or bowel agement of the classic paradiscal form of tuberculosis3,
symptoms. The medical therapy was changed to two drugs (iso- whereas we believe that laminectomy is required in such
niazid and rifampin) at three months and was continued for a atypical cases of neural arch tuberculosis3,6.
total of eighteen months. The patient was able to walk without Extrapulmonary tuberculosis is spread hematogenously.
any support six months after surgery. Normal alignment of the The typical paradiscal involvement in tuberculosis is explained
lumbosacral spine was maintained, and the patient was free of by arterial spread2. The uncommon involvement of the poste-
symptoms at the last follow-up examination at twenty-four rior element is better explained by venous spread. The posterior
months after surgery. external venous plexus of vertebral veins is located on the poste-
rior surfaces of the laminae and around the spinous, transverse,
Discussion and articular processes7. They anastomose freely with the other
uberculosis of the lumbosacral spine is uncommon, repre- vertebral venous plexuses and constitute the final pathway for
T senting 3% of the cases in a series of 600 patients with spi-
nal tuberculosis2. Pain in the lumbosacral region is the most
the infection to reach the neural arch6.
Such uncommon presentations are diagnosed on clini-
frequent symptom, and neurological involvement in this region cal suspicion, and appropriate diagnostic studies need to be
of the spine is rare, as the vertebral canal is relatively large and obtained early. Once the diagnosis of tuberculosis of the pos-
contains the cauda equina rather than the spinal cord4. terior vertebral elements was established in our patient, the
Isolated involvement of vertebral laminae and/or pos- functional results following treatment were dramatic. 

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Sudhir K. Kapoor, MS of their research or preparation of this manuscript. They did not
Vishal Garg, MS receive payments or other benefits or a commitment or agreement
B.K. Dhaon, MS to provide such benefits from a commercial entity. No commercial
Mohit Jindal, MS entity paid or directed, or agreed to pay or direct, any benefits to any
Department of Orthopaedics, Maulana Azad Medical College research fund, foundation, educational institution, or other charita-
and Associated Hospitals, C-610, Saraswati Vihar, Pitampura, ble or nonprofit organization with which the authors are affiliated or
New Delhi 110034, India. E-mail address for S.K. Kapoor: associated.
sumasudhir2003@yahoo.co.in

The authors did not receive grants or outside funding in support doi:10.2106/JBJS.2928pp

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