Spinal tuberculosis: with reference to the children of northern India.

BACKGROUND

Tuberculosis is a necrotizing bacterial infection with protean manifestation and wide distribution. There has been a great fall in the prevalence of tuberculosis in the United States since 1990, although the impact of acquired immunodeficiency syndrome (AIDS) has increased the resurgence of tuberculosis (TB). Spinal tuberculosis is the commonest form of skeletal tuberculosis. In this article, an overview of spinal tuberculosis and the personal experience of 19 children with spinal tuberculosis are presented. All the children required surgical intervention, because they manifested neurological deficit. PATHOGENESIS AND CLINICAL FEATURES: The spinal tuberculosis is a result of hematogenous dissemination from primary focus in the lungs or the lymph nodes. The central type of vertebral tuberculosis spreads along with Batson's plexus of veins, while paradiscal infection spreads through the arteries. The anterior type of vertebral body tuberculosis results from the extension of the abscess beneath the anterior longitudinal ligament and periosteum. Two types of bone and joint tuberculosis are recognized: the caseous, exudative type with abscess formation, which is more common in children, and the granular type is frequent in adults. Only 7 of the 19 children had an abscess, while 10 manifested mainly granulation tissue. Although spinal tuberculosis is an extradural disease, 2 children had intramedullary granulomas and presented a tumor-like syndrome as rare manifestations. It was interesting to encounter intradural granulation and organized intradural granuloma causing cord compression in 2 children. A frank abscess with clumping of nerve roots was encountered in the cauda of another child without vertebral involvement. There is a controversy regarding the age predilection of the disease; it is documented that it is a disease of adults in affluent countries, and a disease of the first three decades in other regions.

DIAGNOSIS

Magnetic resonance imaging is extremely useful in diagnosing the difficult and rare sites of disease like the craniovertebral junction. It detects the marrow changes, exudative and granulation types, extra- and intradural disease, and radiological response to treatment in the early follow-up period around 6-8 weeks.

TREATMENT

Opinion varies regarding the operative indication for Pott's spine. A large group of surgeons perform debridement and decompression in all cases, irrespective of neurological involvement. Others perform operative decompression only in those patients who do not respond to chemotherapy. We did surgical interventions in children with moderate to severe neurological deficits manifesting radiological compression of their neuraxis. Depending on the site of involvement and type of disease the surgical approach was decided in individual cases. Two children with healed Pott's spine also required surgery because of their spinal deformations, which caused gradual neurological deficits and pain in both. Prognosis depends on many factors; the magnitude of cord compression, duration of neural complication, age and general condition of patient. Fifteen of our children made a remarkable recovery. Children with paraplegia also made an excellent recovery of their strength and sensations.