SPINAL TUBERCULOSIS - A DIAGNOSTIC AND MANAGEMENT CHALLENGE

The authors reviewed 29 cases of spinal tuberculosis treated from 1973 to 1993 with an average follow-up time of 7.4 years. Clinical finding s included back pain, paraparesis, kyphosis, fever, sensory disturbanc e, and bowel and bladder dysfunction. Twenty-two patients (76%) presen ted with neurological deficit; 12 (41%) were initially misdiagnosed. S ixteen patients (55%) had predominant vertebral body involvement; nine had marked bone collapse with neurological compromise. Eleven individ uals (39%) had intraspinal granulomatous tissue causing neurological d ysfunction in the absence of bone destruction, and two (7%) had intram edullary tuberculomas. All patients received antituberculous medicatio ns: 13 were initially treated with bracing alone, eight underwent lami nectomy and debridement of extra- or intradural granulomatous tissue, and eight underwent anterior, posterior, or combined fusion procedures . No patient with neurological deficit recovered or stabilized with no noperative management. Thirteen patients were readmitted with progress ion of inadequately treated osteomyelitis; 12 (92%) of these required new or more radical fusion procedures. Anterior fusion failure was ass ociated with marked preoperative kyphosis and multilevel disease requi ring a graft that spanned more than mio disc spaces. Courses of antibi otic medications shorter than 6 months were invariably associated with disease recurrence. It was concluded that 1) patients should receive at least 12 months of appropriate antituberculous therapy; 2) individu als with neurological deficit should undergo surgical decompression; 3 ) laminectomy and debridement are adequate for intraspinal granulomato us tissue in the absence of significant bone destruction; 4) when vert ebral body involvement has produced wedging and kyphosis, aggressive d ebridement and fusion are indicated to prevent delayed instability and progression of disease.