Spinal tuberculosis: Clinicoradiological findings in 274 patients

Abstract

Background

Mycobacterium tuberculosis is a major cause of myelopathy and radiculopathy in high TB/HIV prevalent settings. However, a paucity of publications exists on the spectrum of neurological and magnetic resonance imaging (MRI) findings of spinal tuberculosis in these populations.

Methods

A retrospective study of adults with spinal tuberculosis conducted at a referral center for patients with spinal disease without bony involvement on plain film radiography in South Africa. We report their clinical, laboratory and spinal MRI findings, compare HIV-infected and -uninfected patients and correlate clinical and cerebrospinal fluid (CSF) findings with that of MRI.

Results

Of 274 patients, 209 (76%) were HIV-infected and 49 (18%) were HIV-uninfected. Radiculomyelitis occurred in 76% (n=210), whilst 39% (n=106) had spondylitis. Subdural abscess (n=42) and intramedullary tuberculoma (n=33) were common. In 24% of HIV-infected and 14% of HIV-uninfected patients spinal disease manifested as a paradoxical TB reaction, frequently following tuberculous meningitis (TBM). The triad of neurological deficit, fever and back pain was similar between patients with spondylitis (24%), epi/subdural abscess without bony disease (14%), meningoradiculitis (17%) and isolated myelitis (17%). Higher CSF neutrophil concentrations were observed in subdural abscess (median[IQR]= 38[4-202] cells x10⁶/L) compared to epidural collection and isolated myelitis (0[0-0] cells x 10⁶/L, both groups) and meningoradiculitis (2[0-16] cells x10⁶/L); p=0.0026 –<0.0001.

Conclusions

Radiculomyelitis is a common manifestation of spinal tuberculosis in high TB/HIV prevalence settings, often presenting as a paradoxical reaction. We describe a high frequency of rarely reported spinal tuberculosis manifestations, suggesting these are more common than what the literature implies.