TEN YEAR EXPERIENCE OF TREATMENT OF SPINAL TUBERCULOSIS IN EAST LONDON, UK

Abstract

Introduction: Tuberculosis (TB) continues to cause a significant burden of disease in the United Kingdom (UK). A total of 8113 cases were diagnosed in England, Wales and Northern Ireland in 2005, demonstrating a 28% increase since 2000. The incidence of TB in London is four times greater than the national average, with 43% of cases of TB in 2005 being identified in the capital (n= 3,479). 47% of TB cases in the UK have extra pulmonary involvement and 2–3% of all cases of TB involve the spine (n= 107)

Methods: We reviewed 109 patients treated for spinal TB in East London, UK, between 1997–2006. 59 were male and 50 were female. Their mean age was 39 (range 4–89). 63 patients were Asian (3 UK born), 30 African, 8 UK born Caucasian, 4 Caribbean (1 UK born), 3 patients from Eastern Europe and 1 from the Middle East. Of those patients born outside the UK, the mean time they had been in the country pre diagnosis was 9.6 years (range 0–50 years). They were followed up for a minimum of 1 year post completion of treatment (range 14 to 48 months).

95% of patients presented with back pain, with or without neurological compromise.

All patients were imaged with MRI or CT. 90 (86%) patients had microbiological and/or histological confirmation of TB. The majority of patients (52%) had two vertebral levels affected. The Thorocolumbar junction was the area most commonly affected. 4% of patients had paravertebral abscesses with no bony involvement seen on imaging. 29 patients (26%) had associated psoas abscess.

Combination chemotherapy, according to NICE guidelines, was the main modality of treatment. 67 (61%) patients were managed with combination chemotherapy alone. Surgery was performed for certain indications: deteriorating neurology, instability and post tubercular kyphosis. 42(39%) of patients required surgery.

Results: There were no deaths related to TB or our intervention. Most patients had a full neurological recovery but 21 patients (19%) suffered permanent neurological deficit. (4%) suffered permanent paraplegia or paraparesis severe enough to prevent walking.(out of this anybody had surgery and if so how delayed was that) There was a high incidence of persistent chronic back pain (62%) in our group of patients and was not related to any deformity.

Conclusion: Medical management is the mainstay of treatment for spinal TB, but there are certain instances where surgical intervention will be required.

Because of the high incidence of spinal TB in East London and in order to standardise treatment of these patients we set up dedicated multidisciplinary spinal TB clinic and are managed jointly by respiratory and orthopaedic teams.