Spinal tuberculosis


Step 1: View clinicals

A 35-year-old man presents with upper back pain for two weeks, which is constant and dull in nature, without radiation. Both weight-bearing and movement aggravate the pain. There is no weakness or numbness of the upper or lower limbs. Further questioning reveals an intermittent nonproductive cough for one and a half years, associated with anorexia and fatigue, and a total weight loss of ~10 kg. There is no history of trauma, exposure to tuberculosis, animal contact, or foreign travel within or immediately before that period. He has been healthy until now and is not on any medications. His family history is only significant for a myocardial infarction in his father, at the age of 62 years. He has smoked for 15 years and continues to do so, consuming around two to three cigarettes per day. He only drinks socially and denies using recreational drugs. A complete blood count is significant for a Hb of 9.5 g/dL (normal: 11-18), with a MCV of 85 fL (normal: 75-95). His ESR and CRP are 82 mm/1h (normal: <10) and 24 mg/L (normal: <6) respectively. Chest x-rays reveal a heterogeneous opacity in the left upper lobe.

Step 2: Order all relevant investigations

MRI spine

T1-weighted images show collapse of the T10-T12 vertebrae. The T10-T11 and T11-T12 disc spaces are destroyed. A kyphotic angulation of 15° is seen over T10-T12 due to the vertebral collapse. Multiple rim-enhancing lesions can be seen in the left paravertebral and sub-ligamental spaces at the level of T10-T12, suggestive of abscesses. The spinal cord is unaffected.

CT-guided percutaneous spine biopsy

Microscopy of the biopsy samples reveals epithelioid cell granulomas against a granular necrotic background, with dense lymphocytic infiltration. Ziehl-Neelsen staining reveals acid-fast bacilli. Polymerase chain reaction (PCR) confirms the presence of Mycobacterium tuberculosis.

Sputum induction for AFB

Multiple sputum samples are collected following nebulization with hypertonic saline. Ziehl-Neelsen staining is positive for acid-fast bacilli, while polymerase chain reaction (PCR) confirms the presence of M. tuberculosis.

HIV serology

HIV serology is positive.

Step 3: Select appropriate management

Start anti-tuberculous therapy first
Start anti-retroviral treatment first
Brace immobilization
Spinal stabilization surgery

Score: ★★☆