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Spinal Tuberculosis in a Patient with Low Back Pain

Spinal Tuberculosis in a Patient with Low Back Pain. Dr Chee Yong Choo Dept of Anaesthesia, CGH Singapore. Contents. Introduction History and Physical Examination Diagnosis and Intervention Discussion Conclusion. History. Mdm L - 74 year old Chinese lady

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Spinal Tuberculosis in a Patient with Low Back Pain

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  1. Spinal Tuberculosis in a Patient with Low Back Pain Dr Chee Yong Choo Dept of Anaesthesia, CGH Singapore

  2. Contents • Introduction • History and Physical Examination • Diagnosis and Intervention • Discussion • Conclusion

  3. History Mdm L - 74 year old Chinese lady Independent in terms of activities of daily living Past medical history Bilateral total hip replacements Right total knee replacement Cataracts surgery Non ulcer dyspepsia Hypertension Lichen amyloidosis

  4. History Admitted in March 2010 Low back pain of 3 months duration Radiated to the right hip Not much relief with oral analgesics Loss of appetite Occasional night pain No other systemic complaints

  5. Psychosocial history No history of psychiatric disorders Stayed with her daughter (only child) and her family but relations were strained Devoted her free time to mainly church activities No recent travel history

  6. Physical Examination Afebrile Kyphoscoliotic Spinal tenderness at L1 upon palpation No other focal neurological deficits Able to weight-bear briefly with assistance

  7. Investigations - X rays of the thoracolumbar spine

  8. Investigations WBC 6.5 x 103 /uL ESR 60 CRP 34.3 mg/L BMD - osteoporosis Coagulation, Liver and Renal Function Tests normal

  9. Subsequent clinical history Pain thought to be due to osteoporotic compression fracture Declined further imaging this admission Responded poorly to analgesics Discussion with patient and surgical team In view of lumbar radicular pain → trial of ESI

  10. ESI performed 26 Mar 2010

  11. Subsequent clinical history Had improvement in pain symptoms Underwent physiotherapy Discharged from hospital 1 week later Meds Paracetamol 1gm qds Gabapentin 300mg tds Nortriptyline 10mg nocte

  12. Re-presentation Seen in the Pain Clinic 2 months later Complained of right sided paraumbilical pain Significant loss of appetite and weight, constipated Unable to sleep at night, very depressed No abdominal masses on examination Patient counselled for further imaging to rule out malignancy – agreed somewhat reluctantly

  13. CT Abdomen/Pelvis showed evidence of perivertebral thickening but no malignancy

  14. MRI Thoracolumbar Spine showed likely perivertebral abscess T12/L1…

  15. CT guided Biopsy T12/L1 No fluid was aspirated Multiple core biopsies performed and sent for histopathology and microbiologies

  16. Histology – TB??? Granuloma with caseating necrosis Aggregates of epithelioid histiocytes with giant cell formation amidst a collagenous background with a few scattered lymphocytes and neutrophils Further staining with Ziehl-Neelsen, GMS and PAS/PASD stains did not reveal any AFB or fungi Specimen sent for TB PCR

  17. More tests… Referral to ID Physician: AFB smear for sputum – positive AFB smear for urine – positive TB serology quantiferon – positive CT Thorax – patchy consolidation of the right lower lobe with post obstructive mucus plugging likely suggestive of PTB Diagnosed with disseminated TB

  18. Treatment Empirical TB treatment started: Isoniazid 200mg mane, Rifampicin 450mg mane, Ethambutol 800mg mane, Pyridoxine 20mg mane Analgesics: Paracetamol 1gm qds Pregabalin 75mg bd → 150mg bd Nortriptyline 10mg nocte Oxycontin 20mg bd, OxyNorm 5mg 4h/prn

  19. Interdisciplinary Management Infectious diseases physician Pain medicine specialist Orthopaedic surgeon Psychiatrist Rehabilitation physician Medical Social Worker Physiotherapist Pharmacist

  20. Low Back Pain was still a problem Underwent T9 to L4 decompression laminectomy, stabilisation, correction of kyphosis with bone grafting on 29/7/2010 Postop: Referral to rehab team Had thrombosis of the deep vein of the soleus muscle

  21. Back surgery

  22. Discharge and follow up Finally discharged after 74 days of hosp stay Discharge meds: Anti TB drugs Paracetamol, Pregabalin, OxyNorm Enoxaparin Fluvoxamine, Zolpidem Amlodipine

  23. Discussion Red flags in Low Back Pain Role of ESI High index of suspicion for TB infection Natural history of TB spine Role of surgery Multidisciplinary management

  24. Red Flags in LBP “Red flags” are important in screening cases of low back pain Even during re-presentation New Zealand Acute Low Back Pain Guide (New Zealand Guidelines Group) www.nzgg.org.nz

  25. Red Flags (highlighted in red for our patient) Red Flags help identify potentially serious conditions: Features of Cauda Equina Syndrome Severe worsening pain, especially at night Significant trauma Weight loss, history of cancer, fever Use of intravenous drugs or steroids Age over 50 years old

  26. Evidence for ESI Useful for lumbar radicular pain Level II - III evidence NNT for short term relief up to 2 months is 7.3 NNT for long-term relief from 3 months to 1 year is 13 Lack of well designed, placebo-controlled studies to conclusively define specific indications and techniques FPM Professional Documents PM3 2010

  27. Evidence for ESI Transforaminal approach seems slightly better and safer than interlaminar, but is more difficult to perform in our patient Schaufele MK et al.Interlaminar versus transforaminal epidural injections for the treatment of symptomatic lumbar intervertebral disc herniations.Pain Physician 2006 Oct; 9(4):361-6 Parr et al. Lumbar interlaminar epidural injections in managing chronic low back and lower extremity pain: a systematic review. Pain Physician. 2009 Jan-Feb; 12(1):163-88 McGrath JM et al. Incidence and Characteristics of Complications from Epidural Steroid Injections. Pain Med. 2011 Mar 10 [Epub ahead of print]

  28. ESI not without risks! It can lead to discitis and abscess formation Knight JW et al. Epidural abscess following epidural steroid and local anaesthetic injection. Anaesthesia 1997, 52(6): 576-8 Hooten WM et al. Discitis after lumbar epidural corticosteroid injection. Pain Med 2006, 7(1): 46-51 Simopoulos TT et al. Vertebral osteomyelitis: a potentially catastrophic outcome after lumbar epidural steroid injection. Pain Physician 2008, 11(5): 693-7 It may have potentially worsened the TB spine infection in our patient Onal SA & Ozer B. Pott disease in the differential diagnosis of low back pain. Agri 2004 16(1): 55-7 (Article in Turkish)

  29. High index of suspicion for TB Spine Rare, only a few case reports so far. Onal SA & Ozer B. Pott’s disease in the differential diagnosis of low back pain. Agri 2004 16(1): 55-7 (Article in Turkish) Rajab TK & Barre LJ. Back pain from spinal tuberculosis. J Am Coll Surg 2008 207(3): 453 Maron et al. Two cases of Pott’s disease associated with bilateral psoas abscesses. Spine 2006, 31(16): E561-4 The wrong diagnosis can be fatal… Ringshausen at el. A fatal case of spinal tuberculosis mistaken for metastatic lung cancer: recalling ancient Pott’s disease. Ann Clin Microbiol Antimicrob 2009 20(8): 32

  30. Spinal tuberculosis Insidious onset, variable presentation, slow development of radiological features, non specific constitutional symptoms Back pain resistant to medical therapy Early diagnosis improves outcomes Kotevoglu N & Tasbasi I. Diagnosing tuberculous spondylitis: patients with back pain referred to a rheumatology outpatient department. Rheumatol Int 2004, 24(1):9-13 Le Page L et al. Spinal tuberculosis: a longtitudinal study with clinical, laboratory and imaging outcomes. Semin Arthritis Rheum 2006 36(2):124-9

  31. Radiological Features Spinal TB is probably the most important extrapulmonary form of the disease Haematogenous spread, direct implantation, spread from contiguous focus MRI is better than CT in demonstrating the extent of soft tissue disease esp epidural abscess Findings include bone destruction, intervertebral disc destruction, paravertebral mass/abscess Jevtic V. Vertebral infection. Eur Radiol 2004 14 Supp 3: E43-52 Sinan T et al. Spinal tuberculosis: CT and MRI features. Ann Saudi Med 2004 24(6): 437-41

  32. Surgical Intervention Is rarely needed May be indicated in patients with persistent instability (like our patient), radiculopathy or neurological compromise Nene A. Results of nonsurgical treatment of thoracic spinal tuberculosis in adults. Spine J 2005 5(1): 79-84 Kotil K et al. Medical management of Pott disease in the thoracic and lumbar spine: a prospective clinical study. J Neurosurg Spine 2007 6(3): 222-8

  33. Multidisciplinary Intervention Multidisciplinary management was essential for a good outcome She continued to function well after surgery Relatively pain free 6 months post discharge

  34. Conclusion Rare but important disease Early diagnosis is likely to improve the clinical outcome The vigilant pain medicine specialist can make a difference!

  35. Thank youAny Questions?

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