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Tuberculous spondylitis: risk factors and

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of Iran

Article · December 2010

DOI: 10.1016/j.jiph.2010.09.005 · Source: PubMed

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Journal of Infection and Public Health (2010) 3, 196—200

Tuberculous spondylitis: Risk factors and

clinical/paraclinical aspects in the
south west of Iran
S.M. Alavi a,∗, M. Sharifi b

a Infectious Disease Ward, Jundishapur Infectious and Tropical Diseases Research Center, Razi Hospital of
Jundishapur University of Medical Sciences, No. 52, West 11 Avenue, Kianabad, Ahvaz, Iran
b Ahvaz Health Center, Iran

Received 16 April 2010 ; received in revised form 7 September 2010; accepted 10 September 2010

KEYWORDS Summary
Tuberculosis spondilitis; Background and objectives: Tuberculous spondylitis (TS) is both the most common
Risk factors; and the most dangerous form of TB infection. Delay in diagnosis and management
Clinical aspects; causes spinal cord compression and spinal deformity. The aim of this study was to
Paraclinic;
identify the clinical and paraclinical aspects and also to describe its risk factors in
Khuzestan, a province located in the south west of Iran.
Khuzestan
Method: In this medical record-based retrospective study 69 cases of TS registered
in Khuzestan Health Center from 1999 to 2008, were reviewed. For each TS case two
extra pulmonary TB cases (without spinal involvement) were randomly selected as
control. Related data in patients were analyzed in SPSS software (version 16, USA)
using chi square and Fishers exact test. Differences with P < 0.05 were considered
significant.
Results: The mean age of patients was 43.7 ± 18.3 years, and 60.8% were males. The
mean time of delay: for patients’ delay, doctors’ delays and from diagnosis to initi-
ation of treatment was 1.8 ± 1.1, 6.8 ± 4.3 and 1.3 ± 1.2 months, respectively. In 56
cases (81.1%), TS was diagnosed on lumbosacral radiograph, in remaining cases by
lumbosacral MRI. Twenty patients (30.4%) had a previous TB history, 30.4% had under-
lying medical disorders such as diabetes mellitus (30%), steroid use (45%), chronic
renal failure (50%). The most common clinical findings were: backache 98.5%, fever
26.1%, spinal tenderness 84.1%, paraparesis 26.1%, and kyphosis 28.9%. Labora-
tory results were: elevated sedimentation rate (ESR) 92.8% and positive CRP 86.9%.
There were statistically significant differences in age, gender, CRF, imprisonment
and previous TB infection between the two groups.

∗ Corresponding author. Tel.: +98 611 3387724; +98 9161184916.

E-mail address: alavi1329dr@yahoo.com (S.M. Alavi).

1876-0341/$ — see front matter © 2010 King Saud Bin Abdulaziz University for Health Sciences. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.jiph.2010.09.005
Tuberculous spondylitis risk factors and its clinical/paraclinical aspects in the south west of Iran 197

Conclusion: TS is therefore a diagnosis that attending doctors need to consider early.

Patients in endemic area of TB, presenting with back pain in association with con-
stitutional symptoms and elevated ESR and or positive CRP should be investigated to
exclude TS. Older age, male gender, chronic peritoneal dialysis, imprisonment and
previous TB infection may be the main risk factors of TS.
© 2010 King Saud Bin Abdulaziz University for Health Sciences. Published by Elsevier
Ltd. All rights reserved.

Introduction ferent countries are reported [5—18]. Since data

Tuberculous spondylitis (TS) or spinal tuberculosis is
usually secondary to pulmonary or intestinal tuber-
culosis and may also be the first manifestation of
tuberculosis (TB). Spinal TB (often called Pott’s
disease) is by definition, an advanced disease,
requiring meticulous assessment and aggressive
systemic therapy [1]. In addition to systemic ther-
apy of TS, surgical intervention may be indicated.
Surgery is indicated for diagnostic dilemma, neu-
rological complication and prevention of kyphosis
progression [2].
TS is both common and most dangerous form of
TB infection. Delay in establishing diagnosis and
management causes spinal cord compression and
spinal deformity [3].
Physicians should keep the diagnosis in mind,
especially in a patient from a group with a high
rate of tuberculosis infection. In endemic countries
TS usually occurs in young adults, but in developed
countries it has become a disease of older persons
[4,5].
Symptoms of spinal tuberculosis are back pain,
weakness, weight loss, fever, fatigue, and malaise
[6—8]. Paraspinal cold abscesses develop in 80% or
more [6]. It is much more prone to develop neuro-
logical manifestation, paraplegia of varying degrees
[9].
The palpation of spinous process in routine clin-
ical examination is the most rewarding clinical
method and is an invaluable measure for early
recognition [1,4]. Diagnosis of TS is made by typical
sign and symptoms along with the evidence of past
exposure to tuberculosis or concomitant visceral
tuberculosis, imaging showing abscess formation
and spinal cord compression and by appropriate
clinical response to anti-TB treatment.
The diagnosis is confirmed by microbiological
and histopathological examination [1,4,6]. Microbi-
ological examination should comprise microscopy,
culture and PCR analysis for rapid detection of TS
[10]. Various and dissimilar data about epidemio-
logical, clinical, laboratory results, diagnosis and
treatment outcome from various hospitals and dif-
on TS from Iran is scanty despite the endemicity of
disease, we conducted this study aiming to identify
the clinical and paraclinical aspects of TS and also
to describe probable risk factors of the disease in
Khuzestan, a province located in the south west of
Iran.
Methods and patients
This was a medical record-based retrospective
study in which patients’ files with the diagnosis
of TS were reviewed. All cases of TS registered in
Khuzestan Health Center (KHC) affiliated to Ahvaz
Jundishapur University of Medical Sciences over the
10-year period from 1999 to 2008, were reviewed.
According to Iranian Health System, TB is an obliga-
tory reportable disease and all TB cases around the
country, in villages (Khane-e-Behdasht) and cities
(hospitals) should be reported to health centers
(provinces, medical universities) under National
TB Program. By tracing the TB epidemiological
forms in KHC we listed the hospitals where the
patients were diagnosed as TS by neurosurgeons or
infectious disease subspecialist. All medical charts
of TB patients with spinal involvement in above-
mentioned hospitals were reviewed. Only those
with histological or microbiological confirmation
or those who responded to antituberculosis ther-
apy were included [6]. For each TS case two
extra pulmonary TB cases (without spinal involve-
ment) randomly selected as control. The following
information was obtained: age, sex, symptoms
and ‘signs at presentation, imaging techniques,
mycobacterium cultures and smear, histopathology
study, treatment and clinical outcome. Additional
data about addiction, imprisonment, underlying
diseases (e.g. diabetes, renal or liver disease, and
HIV/AIDS), drug side effects and duration between
disease occurrence and initiation of treatment also
were recorded.
Data were analyzed in SPSS software (version
16, USA) using chi square and Fishers exact test.
198 S.M. Alavi, M. Sharifi

Differences with P < 0.05 were considered signifi- Table 1 Frequency of clinical, laboratory and imag-
cant. ing findings among studied patients with spinal
tuberculosis.
Variables Number Percentage
Results Clinical
Fever 18 26.1
During the period of study, a total of 15,678 cases of Night sweating 12 17.4
Weight loss 10 14.5
pulmonary and extrapulmonary TB were registered
Back pain 68 98.5
in KHC, 213 patients were diagnosed as TS. We only Local tenderness 58 84.1
could find 69 medical records (having needed data Paraparesis 18 26.1
for study) of TS in our studied hospitals. Kyphosis 20 28.9
The mean age ± SD of patients was 43.7 ± 18.3 Laboratory
years, and 42 (60.8%) of the patients were male. Leukocytosis 10 14.5
The mean intervals from onset of symptoms to ESR >20 64 92.8
attend the health center or private physician Positive CRP 60 86.9
(patients’ delay), from doctor’s visit to diagnosis Imaging
(doctors’ delay) and from diagnosis to the initi- Chest X-ray 18 26.1
ation of treatment were 1.8 ± 1.1, 6.8 ± 4.3 and Spinal X-ray 56 81.1
Spinal MRI 13 18.8
1.3 ± 1.2 months, respectively. In 56 cases (81.1%),
Bone scanning 10 14.5
TS was suspected to exist after observing wedge
pattern on spinal radiograph, in remaining cases ESR: erythrocyte sedimentation rate, CRP: C-reactive
protein, MRI: magnetic resonance imaging.
spinal MRI was the initial diagnostic tool in diag-
nosis. Twenty patients (30.4%) had a previous TB
history. Cavitary lesion was observed in 12 patients
(17.4%) and the upper lobes were predominantly cases (68.1%), whereas 22 patients (31.9%) required
involved on chest radiograph. Twenty-one patients additional surgical intervention, mainly those with
(30.4%) had underlying medical disorders such as spinal cord compression, spinal deformity, or risk
diabetes mellitus in 6 (30%), steroid use in 9 (45%), of spinal instability. There was definite improve-
chronic renal failure (CRF) in 10 (50%) and liver dis- ment in 53 cases (76.8%). There was no serious
eases in 3 (15%). About 80% of these CRF patients drug side effect requiring drug discontinuation. The
were undergoing peritoneal dialysis and were reg- best outcome was in those patients diagnosed in
istered as intestinal TB. More than one underlying early phase before the occurrence of spinal defor-
diseases were detected in 7 of the patients. Fif- mity or neurological symptoms. By comparing data
teen patients (21.7%) had history of stay in prison, between patients with spinal tuberculosis (TS) and
among them 12 (80%) were intravenous drug users. patients without spinal involvement (NTS), statis-
Twelve patients (17.4%) had concurrent HIV infec- tically significant differences in age, gender, CRF,
tion. TS concurrent with TB of other sites was imprisonment and previous TB between two groups
as follows: cervical lymph node 3 (4.3%), intesti- (Table 2) were noted.
nal TB 11 (15.9%) and genitourinary TB 5 (7.2%).
As shown in Table 1 the most frequent symptoms
were backache 68 (98.5%) and fever 18 (26.1%), Discussion
and the most frequent sign was spinal tenderness
58 (84.1%). Other clinical findings were: paraparesis This study showed that TS is more prevalent in older
18 (26.1%), kyphosis 20 (28.9%). Laboratory results population than the younger population. Previous
were: elevated sedimentation rate ESR 64 (92.8%), studies have reported that in endemic TB area,
CRP 60 (86.9%), other laboratory workup was not skeletal TB complications occurred most commonly
helpful. Although spinal X-ray in some cases was in children and young adults [1,4]. Mean age of TS
helpful in diagnosis, but MRI of the spine using patients in Fennira et al. study was 48.6 years and in
contrast medium was the best diagnostic imaging García-Lechuz study was 58 years [15,16]. Our find-
tool for detecting TS. Ten patients (14.5%) had tho- ing is consistent with the results of investigations in
racic spine involvement and 33 patients (47.8%) had developed countries where the occurrence of pedi-
paraspinal abscesses. Tissue aspirates had a yield of atric TS is extremely rare [4,5]. Iran, although is an
27 (39.1%), 15 (21.7%), and 6 (8.7%) for granulomas, endemic area for TB, but we believe that mass vac-
acid-fast bacilli on smear examination, and culture, cination of Bacille—Calmette—Guerin (BCG) started
respectively. Medical therapy alone was given in 47 in 1984 and continuing through the integrated
Tuberculous spondylitis risk factors and its clinical/paraclinical aspects in the south west of Iran 199

Table 2 Comparing the risk factors for spinal tuberculosis between patients with and without spinal involvement.
Variables TS-group (n = 69) NTS-group (n = 138) P-value OR 95% CI
Age
>35 years 58(84.1) 73(52.9) <0.0001 4.7: 2.3—9.7a
<35 years 11(15.9) 65(47.1)
Sex
Male 42(60.9) 62(44.9) 0.03 1.9: 1.1—3.4a
Female 27(39.1) 76(55.1)
Diabetes mellitus 6(8.7) 9(6.5) 0.57 1.4: 0.5—4
Chronic renal failure 10(14.5) 8(5.8) 0.04 2.7: 1.1—7.3a
IVDU 12(17.4) 18(13) 0.41 1.4: 0.6—3.1
History of imprisonment 15(21.7) 12(8.7) 0.01 2.9: 1.3—6.6a
History of corticosteroid 9(13) 12(8.7) 0.33 1.6: 0.6—3.9
History of previous TB 20(28.9) 24(17.4) 0.04 1.9: 1.5—3.9a
HIV co-infection 12(17.4) 19(13.8) 0.53 1.3: 0.6—2.9
IVDU: intravenous drug user, TB: tuberculosis, HIV: human immunodeficiency syndrome.
a Risk factor for spinal tuberculosis, TS: patients with spinal tuberculosis, NTS: patients without spinal involvement.

Expanded Program of Immunization (EPI) since 1993
resulted in significant decreases in TB complications
in children and young adults.
According to the present study TS occurred
more frequently in males than in females (60.8%
vs. 39.2%). Mulleman et al. in their work have
reported female predominance [13] but in some
other reports prevalence of TS in both males and
females was equal [6—8,14]. These differences are
not clear for us; we think that in our study males
due to their life style and underlying diseases may
be at a higher risk of TB skeletal complication.
In the most endemic areas for TB, TB with its
complication is a neglected disease and there is
a considerable gap between occurrence of illness
and the time of diagnosis [7]. In our study this
gap was far away from the previous studies (8.6
months vs. 4 months). This delay is due to the negli-
gence of patients and lack of awareness of primary
physician[12]. We suppose that low level of pub-
lic awareness about TB and its complication in the
region is the main reason for these phenomena.
We believe that the reasons for delay ±1.3 months
from diagnosis to the initiation of treatment may
be as follows: (1) Patient’s delay from the time of
referral by practitioner to health center to initi-
ate anti-TB drugs. (2) Primary denial of the patient
having TB, because TB is still considered a stigma
in public thought in the region. (3) Some patients’
low opinion on health care provider comparing with
experienced aged physicians (mostly not familiar
with the health policy of TB national program). (4)
Lack of some specific anti-TB drugs in rural health
centers while the patient needs in the first visit.
It is documented that vertebral involvement is a
chronic process in TB and the chief complaints of
the patients are local manifestations such as back
pain, tenderness and paraparesis [4,6,8]. Our find-
ing regardless of their frequency is in agreement
with these studies.
In our study a history of previous TB was observed
in only 30.4%. This rate in published studies ranges
from 7.2% to 100% [6,7,9,12,13]. These differences
reflect the variation of TB prevalence among differ-
ent communities with different socioeconomic and
public health status.
We found elevated ESR in 92.8% and positive
CRP in 86.9% patients. Diwakar et al., Alothman
et al and Rodriguez-Gomez have described ele-
vated ESR in their studies in more than 90% of
their cases [6,7,12]. CRP was positive in only 26%
cases in Maeda et al’s report. We believe the dif-
ference between our result and the result of Maeda
is contributed to aged patients in Maeda’s study.
Overall, we think CRP and ESR are useful tests
in diagnosing TS in kyphotic cases in endemic TB
area.
As mentioned above, if there is any suspicion of
spinal TB, MRI of the spine using contrast medium
should be implemented as diagnostic means. After
the collection of spinal and/or paraspinal speci-
men, microbiological examination should comprise
microscopy, culture and PCR to avoid any delay to
establish the correct diagnosis and specific treat-
ment.
In this study most patients were cured by anti-TB
drugs. Neurosurgery was performed in only 31.9%
patients that is similar to the study of Rodriguez-
Gomez (32%). Operations for spinal tuberculosis are
now indicated less for the control of disease than
for complications, including nonresponding neural
deficit (nearly 40% of neural complications), pre-
vention or correction of severe kyphotic deformity,
and for tissue diagnosis [18].
 200
The present study revealed that older age, male
gender, chronic peritoneal dialysis, imprisonment
and previous TB are associated with higher risk
of TS. We believe that these mentioned variables
may be the main risk factors of TS. In published
studies, aging, intestinal TB, alcoholism, Diabetes
mellitus, corticosteroid and previous TB have been
considered as spinal TB risk factors [4,13]. Con-
sidering the history of imprisonment as risk factor
may be doubtful. Stay in prison puts patients at
a higher risk of TB infection, but progress of the
infection to spinal involvement is not clear to
us. We think further investigation is needed to
conclude the association between TS and impris-
onment.
Conclusion
Spinal tuberculosis is therefore a diagnosis that
attending doctors need to consider early. Patients
from countries with a high prevalence of tuber-
culosis, presenting with back pain in association
with constitutional symptoms and a high ery-
throcyte sedimentation rate and/or positive CRP
should be investigated to exclude tuberculo-
sis. In the context of a normal spinal x ray
and a high clinical suspicion, further imaging
such as MRI using contrast medium should be
warranted.
Study limitations
As this was a retrospective study, some of the infor-
mation required was incomplete. Sample size of 69
patients was small for calculating the appropriate
rates or comparing the variables. Future prospec-
tive study in larger scale is recommended. Case
definition of TS was dependent on the diagnosis reg-
istered in the medical file. Better result should be
found by culture confirmation.
Conflict of interest
There is no conflict of interest in this study.
Funding: This work is funded by Jundishapur
Infectious Diseases Research Center.
Ethical approval: This work is supported by eth-
ical committee of JIDRC.
Available online at www.sciencedirect.com
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S.M. Alavi, M. Sharifi
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