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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 36  |  Issue : 2  |  Page : 41-43

Solitary tuberculous lesion involving the spinous process of the cervical vertebra


1 Teerthanker Mahaveer Medical College, Moradabad, Uttar Pradesh, India
2 Teerthankar Mahaveer Medical College and Research Centre, Moradabad, Uttar Pradesh, India
3 Government Medical College, Banda, Uttar Pradesh, India

Date of Submission30-Jun-2021
Date of Acceptance14-Jul-2021
Date of Web Publication02-Aug-2021

Correspondence Address:
Najmul Huda
Department of Orthopaedic, Teerthanker Mahaveer Medical College, Moradabad, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jbjd.jbjd_7_21

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  Abstract 


The higher incidence and prevalence of tuberculosis (TB) is a common health problem particularly in developing countries like ours. The most common site of TB is the pulmonary region followed by lymph nodes and osteoarticular TB. In the spine, the dorsal spine is the most commonly affected region and the paradiscal being the most common type, posterior elements being the least involved, particularly in isolation. Of the posterior elements, the most common to be involved are the laminae. Here, we are presenting the case of the tubercular osteomyelitis involving the spinous process of the C6 vertebra in isolation. A young female presented to our outpatient department with pain and swelling on the posterior side of the neck. The swelling was nontender, without any signs of acute inflammation, cystic in consistency, and lying deep to the muscles. X-ray of the cervical spine and contrast enhanced magnetic resonance imaging (MRI) suggested the diagnosis of tubercular osteomyelitis. Pus was aspirated. Cartridge-based nucleic acid amplification test revealed Mycobacterium tuberculosis. The patient was given anti-tubercular drugs as per the index TB guidelines of the WHO and was cured. This, to the best of our knowledge, is the only case reported from India. Though the TB of the spinous process is extremely rare, still the diagnosis should be kept in mind when examining a posterior neck swelling, especially in country like ours, where the incidence of TB is high. X-ray and MRI are good tools to reach a diagnosis. Antitubercular regimen should be started for treatment.

Keywords: Case report, spine, tuberculosis


How to cite this article:
Agarwal S, Huda N, Islam MS, Agarwal S. Solitary tuberculous lesion involving the spinous process of the cervical vertebra. J Bone Joint Dis 2021;36:41-3

How to cite this URL:
Agarwal S, Huda N, Islam MS, Agarwal S. Solitary tuberculous lesion involving the spinous process of the cervical vertebra. J Bone Joint Dis [serial online] 2021 [cited 2021 Oct 28];36:41-3. Available from: http://www.jbjd.org/text.asp?2021/36/2/41/322953




  Introduction Top


Ten per cent of extra-pulmonary tuberculosis (TB) is skeletal, of which spinal TB accounts for approximately 50% of cases.[1],[2] Lower thoracic and lumbar vertebrae are the most common sites of spinal TB followed by middle thoracic and cervical vertebrae.[3],[4] Out of the total cases of TB spine, involvement of cervical spine is rare and comprises 2%–3% cases.[5] Lesions involving the posterior elements of the vertebral bodies are extremely rare, particularly in isolation.[4],[6] In areas which are not endemic the incidence of posterior spinal TB is <2% and between 5% and 10% in endemic areas.[7],[8],[9] Lesions may involve any part of the neural arch viz. lamina, pedicle, spinous, or transverse processes. According to some studies, the pedicle is the most common site of involvement,[7],[10] whereas some studies have reported lamina as the most common site.[8],[10] Here, we report a case of tubercular involvement of the spinous process of C6 vertebra in isolation. This to the best of our knowledge is the first case reported from the Indian subcontinent.


  Case Report Top


A 20-year-old female who presented to our hospital with complaints of pain and swelling over the posterior aspect of the neck region for the past 6 months. The swelling had been gradually increasing in size for the past 1 month. The swelling was painless, noticed by the patient's mother, not loss of weight, fever, loss of appetite, trauma, or any discharge. There was no complaint of paraesthesia or weakness of the bilateral upper and lower limbs or difficulty in walking. General physical examination, vitals, and systemic examination were unremarkable. There was no clinical evidence of disease elsewhere. Neurological examination was within the normal limits. Local examination revealed a swelling which was round, 7 cm × 6 cm in size, smooth, well defined, nontender, cystic in consistency, and lying deep to the paravertebral muscles. The skin overlying the swelling was normal, freely mobile, with no local raise of temperature [Figure 1]. Examination of the scalp, cervical and the axillary lymph nodes, and back were within the normal limits. Plain radiograph showed destruction of the spinous process of C 6 vertebrae on the lateral view, anteroposterior view showed radiolucent opacity in the paraspinal region adjoining the C 6 and C 7 vertebrae [Figure 2]. Laboratory tests revealed mild anemia (Hemoglobin-10 mg%,) lymphocytosis and raised Erythrocyte sedimentation rate (28 mm in 1st h). HIV testing was nonreactive. Contrast-enhanced magnetic resonance imaging (MRI) of the cervical spine revealed a large peripherally enhancing collection suggestive of abscess in posterior paraspinal and subcutaneous soft tissue with the erosion of spinous process of C 6 vertebral body. Depending on the clinical and radiological features, a diagnosis of tubercular osteomyelitis involving the spinous process of the C6 vertebra was made.
Figure 1: Clinical photograph of the patient showing the swelling (Cold abscess)

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Figure 2: Plain skiagram showing destruction of the spinous process of C6 vertebra

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The swelling was aspirated. The pus was sent for cartridge-based nucleic acid amplification test (CBNAAT), pus culture sensitivity for pyogenic organisms, gram staining, and Zeihl-Nelson (ZN) staining. No organism was detected on both gram and ZN staining. CBNAAT showed Mycobacterium tuberculosis without resistance to rifampicin. Antitubercular treatment was started as per the index TB guidelines laid down by the WHO. The patient was given four drugs, i.e., RHEZ (10–20 mg/kg rifampicin, 5–10 mg/kg isoniazid, 15 mg/kg ethambutol, and pyrazinamide 25–30 mg/kg) for the intensive phase of 2 months followed by 3 drugs, i.e., RHE during the continuation phase (16 months). Cervical collar was advised for the initial 6 weeks to take care of the pain and give rest to the part.


  Results Top


Patient took complete course of anti tubercular treatment for a period of 18 months. She started showing signs of improvement as early as 3 weeks after starting the treatment. The follow-up period was uneventful [Figure 3] and [Figure 4].
Figure 3: Plain Skiagram showing healing in the form of sclerotic changes over C6 spinous process upon completion of treatment

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Figure 4: Resolving of the swelling over the spinous process

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  Discussion Top


It was suggested by Batson that the infection gets lodged in the spine via the venous tracks.[11] The venous channels lie on the dorsal surface of the posterior elements of the vertebrae, as these venous plexuses are devoid of valves, backward flow of blood from the infected viscera may lead to seeding the infection to the spine.[11],[12] Tuberculous involvement of the neural arch is extremely rare.

In none of the 587 cases of TB spine reported by Hodgson, there was isolated involvement of vertebral or neural arch.[13] This, to the best of our knowledge, is the first such case report from India. Similarly of the 17 cases of neural arch TB reported by Naim-Ur-Rahman et al.,[12] only seven were of the cervical spine and none had involvement of spinous process alone.

A series of 33 patients with isolated TB of posterior elements of the spine was published by Narlawar et al.[4] Of these only 4 cases had cervical spine TB. In their series 72.7% of cases had involvement of laminae, spinous process was not involved in a single case. In 11 out of 33 patients there were other foci of TB present elsewhere in the body. The case reported by us had solitary lesion in the spinous process of the C6 vertebra.

The plain skiagram of our patient showed destruction of the spinous process, which was easily visualized on the lateral view. Radiographs are usually silent when it comes to TB of posterior elements. Babhulkar et al.[8] reported that radiographs were positive in only 10% of patients of TB of posterior elements. In the series reported by Naim-Ur-Rahman et al., all the patients with TB of the posterior element had a normal radiograph.[12] Narlawar et al.[4] demonstrated posterior element destruction in 39% of patients.

The characteristic flake-like fragments of the bone enclosed in the posterior paraspinal soft-tissue mass with bony destruction that is localized to the vertebral arch are the distinguishing features of TB of the posterior element on computed tomography. Involvement of the soft-tissue abnormality is demonstrated better by MRI than any other technique of imaging.[14] Detection of abscess and soft-tissue mass can be well demonstrated on MRI and it also has great value in evaluating cord compression and identifying intramedullary lesions. TB of the posterior element of the spine has a better prognosis when compared to typical spinal TB.[12] Osteoblastoma, metastatic disease, pyogenic osteomyelitis, and aneurysmal bone cyst are some of the differential diagnosis in a lesion of the posterior element. For the management of such atypical TB, it is required that early diagnosis is made radiologically.[15]


  Conclusion Top


Posterior element TB is a rare condition and isolated TB of the spinous process is even rarer, but its possibility should always be considered even in the absence of disease elsewhere, especially in endemic areas like ours. Diagnosis can be easily made depending on the clinical features and radiological findings. Plain X-ray, especially the lateral view is indispensable in identifying the lesion, MRI is extremely useful in evaluating the extent of involvement. Antitubercular treatment is effective in curing the disease.

Clinical message

Although TB of the spinous process is very rare, the possibility should always be kept in the list of differential diagnoses of posterior neck swelling. Plain X rays, if analyzed thoroughly may help in clinching the diagnosis. However, MRI should be done for confirmation and to find out the extent of involvement.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Polley P, Dunn R. Noncontiguous spinal tuberculosis: Incidence and management. Eur Spine J 2009;18:1096-101.  Back to cited text no. 1
    
2.
Milburn H. Key issues in the diagnosis and management of tuberculosis. J R Soc Med 2007;100:134-41.  Back to cited text no. 2
    
3.
Yusof MI, Hassan E, Rahmat N, Yunus R. Spinal tuberculosis: The association between pedicle involvement and anterior column damage and kyphotic deformity. Spine (Phila Pa 1976) 2009;34:713-7.  Back to cited text no. 3
    
4.
Narlawar RS, Shah JR, Pimple MK, Patkar DP, Patankar T, Castillo M. Isolated tuberculosis of posterior elements of spine: Magnetic resonance imaging findings in 33 patients. Spine (Phila Pa 1976) 2002;27:275-81.  Back to cited text no. 4
    
5.
Lukhele M. Tuberculosis of the cervical spine. S Afr Med J 1996;86:553-6.  Back to cited text no. 5
    
6.
Yalniz E, Pekindil G, Aktas S. Atypical tuberculosis of the spine. Yonsei Med J 2000;41:657-61.  Back to cited text no. 6
    
7.
Kumar K. A clinical study and classification of posterior spinal tuberculosis. Int Orthop 1985;9:147-52.  Back to cited text no. 7
    
8.
Babhulkar SS, Tayade WB, Babhulkar SK. Atypical spinal tuberculosis. J Bone Joint Surg Br 1984;66:239-42.  Back to cited text no. 8
    
9.
Abdelwahab IF, Camins MB, Hermann G, Klein MJ. Vertebral arch or posterior spinal tuberculosis. Skeletal Radiol 1997;26:737-40.  Back to cited text no. 9
    
10.
Bell D, Cockshott WP. Tuberculosis of the vertebral pedicles. Radiology 1971;99:43-8.  Back to cited text no. 10
    
11.
Batson OV. The vertebral vein system. Caldwell lecture, 1956. Am J Roentgenol Radium Ther Nucl Med 1957;78:195-212.  Back to cited text no. 11
    
12.
Naim-Ur-Rahman N, Jamjoom A, Jamjoom ZA, Al-Tahan AM. Neural arch tuberculosis: Radiological features and their correlation with surgical findings. Br J Neurosurg 1997;11:32-8.  Back to cited text no. 12
    
13.
Hodgson AR. Tuberculosis of the spine. In: Rothman RH, Simone FA, editors. The Spine. Philadelphia: WB Saunders; 1975. p. 573-95.  Back to cited text no. 13
    
14.
Paushter DM, Modic MT, Masaryk TJ. Magnetic resonance imaging ofthe spine: Applications and limitations. Radiol Clin North Am 1985;23:551-62.  Back to cited text no. 14
    
15.
Shamim MS, Tahir MZ, Jooma R. Isolated tuberculosis of C2 spinous process. Spine J 2009;9:e30-2.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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