Elsevier

The Spine Journal

Volume 11, Issue 4, April 2011, Pages 265-269
The Spine Journal

Clinical Study
Spinal tuberculosis among human immunodeficiency virus–negative patients in a Kenyan tertiary hospital: a 5-year synopsis

https://doi.org/10.1016/j.spinee.2011.01.033Get rights and content

Abstract

Background context

Spinal tuberculosis (TB) accounts for more than half of all cases of skeletal TB. Although Kenya has one of the highest burdens of TB, data on spinal TB in this country remain scarce.

Purpose

To highlight the clinical presentation and management of this condition in our setup.

Study design

Retrospective study.

Setting

Kenyatta National Hospital in Kenya.

Patient sample

One hundred twenty-nine patients.

Outcome measures

Patients' condition after intervention and duration of hospital stay.

Methods

This study involved review of patients admitted to our hospital between 2004 and 2009 with a diagnosis of spinal TB.

Results

The most common presenting complaints were back pain in 100 patients (77.5%) and limb weakness in 94 patients (72.9%), whereas the most frequent physical examination finding was gibbus deformity in 85 patients (65.8%). Most (79 patients, 61.2%) had severe motor and sensory impairment graded as either American Spinal Injury Association (ASIA) A or ASIA B. Imaging revealed multiple vertebrae disease in 90 patients (79.6%). Of these, the most common was two vertebrae disease in 77 patients (68.1%). All patients were managed using anti-TB drugs and analgesics; however, 33 (25.6%) required adjunctive operative management. Mean hospital stay was 53.3 days. Marked clinical improvement was seen in 91 patients (70.0%) within 6 months of treatment.

Conclusion

Patients with spinal TB in our setting tended to present late and with advanced disease. Therefore, a high index of suspicion should be maintained and appropriate chemotherapy started as early as possible.

Introduction

Evidence & Methods

Kenya has an exceptionally high burden of tuberculosis infection, and much of this is associated with HIV immunosuppression. While this association has been the subject of considerable research, there is little modern data available on spinal tuberculosis in HIV-negative patients.

The authors present data from a single large tertiary center from a 5-year period and note that the vast majority of patients presented with advanced disease of the spine. Three-quarters had severe back pain or weakness, and two-thirds had gross kyphosis or neurologic impairment. Most patients responded to chemotherapeutic or surgical intervention with improvement.

These data highlight that spinal tuberculosis is not limited to patients with HIV infection. Limited resources, poor nutrition, concomitant disease, and limited access to routine healthcare negatively impact patients with spinal disorders globally. These factors perpetuate the prevalence of serious spinal infections. Patients often present late in the course of their disease and with a greater likelihood of significant morbidity and mortality. Efforts to address these issues, while ongoing and admirable, are currently insufficient.

—The Editors

Tuberculosis (TB) causes 2 million to 3 million deaths annually worldwide [1], [2], [3], [4]. According to the World Health Organization's Global TB Report 2009, Kenya ranks 13th in the list of 22 high-burden TB countries in the world and has the fifth highest burden in Africa [5]. In that report, Kenya had more than 132,000 new TB cases and an incidence rate of 142 new sputum smear–positive cases per 100,000 people per year. It was also reported that the annual mortality rate associated with TB in the country was 26 per 100,000 among human immunodeficiency virus (HIV)–negative patients and 39 per 100,000 in HIV-positive individuals.

Tuberculosis usually starts in the lungs but can be disseminated hematogenously to other parts of the body, such as the musculoskeletal system [2], [3]. Spinal TB is the commonest form of skeletal TB [1], [2], [3], [4]. Spinal TB poses a great challenge to physicians owing to its nonspecific and wide spectrum of clinical presentations and thus often results in delay in diagnosis if a high index of suspicion is not maintained [6], [7]. Second, neural involvement may occur in up to 50% of patients and can cause irreversible damage if not promptly and adequately treated [1], [8], [9]. There is paucity of data regarding spinal TB in Kenya, despite the fact that the country has one of the highest TB burdens in Africa [5]. This study aimed at highlighting the clinical presentation and management of patients with spinal TB presenting at a Kenyan tertiary hospital.

Section snippets

Patients and methods

Cases of spinal TB were identified retrospectively by examining records of patients admitted to Kenyatta National Hospital, in Kenya, with a diagnosis of spinal TB between January 1, 2004, and December 31, 2009. Kenyatta National Hospital is one of the two major teaching and referral hospitals in Kenya. Approval to conduct the study was granted by the Kenyatta National Hospital Ethics Research Board. A total of 129 patient files were examined. Information retrieved included patients' biodata,

Patient data

Of the 129 patients reviewed, 68 (52.7%) were male and 61 (47.3%) were female. The youngest patient was 3 years old, whereas the oldest was 81 years old (mean, 33.5±16.2 years). Most patients were in the third and fourth decades of life. The distribution of patients according to age group is shown in the Figure. All patients studied were HIV negative.

Clinical presentation

Back pain was the most common presenting symptom as shown in Table 1. In addition to back pain, six patients had pain elsewhere. Of these

Discussion

Spinal TB, also known as Pott disease, results from an infection of the vertebrae by the Mycobacterium tuberculosis bacteria. The organism may stay dormant in the skeletal system for an extended period before the disease can be detected [2], [4]. Thus, spinal TB is a chronic and slowly progressive disease with a wide spectrum of clinical presentations. In the present study, more men than women had spinal TB. Similar and higher incidence ratios have been reported in other studies [10], [11], [12]

References (27)

  • L. Cormican et al.

    Current difficulties in the diagnosis and management of spinal tuberculosis

    Postgrad Med J

    (2006)
  • I.M. Francis et al.

    Value of radiologically guided fine needle aspiration cytology (FNAC) in the diagnosis of spinal tuberculosis

    Cytopathology

    (1999)
  • F. Khorvash et al.

    Spinal tuberculosis: a major public health hazard in Isfahan

    Pak J Biol Sci

    (2007)
  • Cited by (14)

    View all citing articles on Scopus

    FDA device/drug status: not applicable.

    Author disclosures: none.

    View full text