Tuberculosis of the Skeletal System SM Tuli
Chapter Notes

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1General Considerations
  • Epidemiology and Prevalence
  • Pathology and Pathogenesis
  • The Organism and Its Sensitivity
  • Evolution of Treatment of Skeletal Tuberculosis
  • Diagnosis and Investigations
  • Antitubercular Drugs
  • Principles of Management of Osteoarticular Tuberculosis2

Epidemiology and PrevalenceCHAPTER 1

Tuberculous bacilli have lived in symbiosis with mankind since time immemorial. In India, Rig Veda and Atharva Veda (3500–1800 B.C. approx.), Samhita of Charaka and Sushruta (1000 and 600 B.C. approx.), have mention of this disease by the name Yakshma in all its forms (Duraiswami and Tuli 1971). Greco-Roman civilization recognized it as phthisis or consumption. Tuberculous lesions have been recorded in Egyptian mummies. In the Western World, the clinical features and communicability of tuberculosis were known before 1000 B.C. (Yeager 1963). Lichtor and Lichtor (1957) also reported paleo-pathological evidence of tuberculosis of bones, joints and spine in prehistoric humans.
It was the celebrated French physician Laennec (1781–1826), inventor of the stethoscope, who discovered in the beginning of nineteenth century, the basic microscopic lesion, the ‘tubercle’, the name by which the disease is universally known at present. It is an irony of fate that Laennec, himself at the early age of 45, fell prey to this dreaded disease.
The world at large has nearly 30 million people suffering from tuberculosis. Due to marked improvement in the socio-economic status of affluent countries and the availability of extremely effective antitubercular drugs up to early 1980s, there was great hope for complete elimination of the disease. Unfortunately the optimism was shortlived because of the impact of acquired immunodeficiency syndrome (AIDS) pandemic. Tuberculosis has again become epidemic in many parts of the world (Barnes 1993, Patel 1995, Reichman 1997). After 1985, many affluent countries are recording an increase in the number of patients by 10 to 30 percent annually. According to current estimates of WHO tuberculosis now kills 3 million people a year worldwide. There is paucity of authentic figures at the national level regarding the incidence of disease in India and other developing countries. However, it is estimated that India alone has got one-fifth of the total world population of tuberculous patients. Thus, there are nearly 6 million radiologically proven cases of tuberculosis in India, and perhaps a quarter of these are sputum positive (Editorial, Clinician 1968).4
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Fig. 1.1: It indirectly reflects the incidence of tuberculous disease in England. The incidence was markedly lowered not by chemotherapy or vaccination but by improvement in the socio-economic status of the society
Of all the patients suffering from tuberculosis nearly one to three percent have involvement of the skeletal system.
Although osteoarticular tuberculosis was becoming a disappearing problem (prior to 1985) in many Western countries, however, in economi-cally developing countries like Nigeria, India, Southeast Asia and Korea this continued to pose one of the major public health problems. A surgeon could gain experience in the management of tuberculosis of the bone and joints only if he chooses to work in economically less developed countries (Editorial, Br. Med. J. 1968). The adjoining graph (See Fig. 1.1) is a broad indicator of the incidence of tuberculosis in Europe. One can appreciate that marked reduction of the incidence occurred much before the discovery of the causative organism, or availability of B.C.G. vaccination or the effective antitubercular drugs. It is obvious that for a triumph over this disease the socio-economic status of the society in general must be improved. Unfortunately any major advances in the economic uplift of the people usually occur in small increments. Tuberculosis will exist in man so long as there are pockets of malnutrition, poor sanitation, living in crowded areas, exanthematous fevers, repeated pregnancies, immunodeficient states, alcohol abuse and advanced age present in the society. For the same reasons, and because of more frequent and convenient exchange of population between various countries even affluent countries can however not remain absolutely immune from this disease (Scott 1982). An increased incidence has been reported in persons with histories of intravenous drug abuse (Mallolas 1988), and in senior citizens.5
Regional Distribution
Like other skeletal structures, vertebral column may lodge any infectious process. The most common chronic vertebral infection, however, is tuber-culosis. Even in a country like U.K. where tuberculosis was almost eradi-cated, Shaw and Thomas (1963) reported that out of 72 cases of surgically explored chronic infectious lesions of the spine, 52 (72 percent) were proved to be tuberculous, and 12 lesions (16.7 percent) were thought tuberculous on clinical and radiological grounds, though the isolation of the organism failed. Thus, nearly 88 percent of cases of chronic infections of the spine were of tuberculous origin. Similar observations were reported by Kemp et al. (1973).
Vertebral tuberculosis is the most common form of skeletal tuberculosis and it constitutes about 50 percent of all cases of skeletal tuberculosis in reported series (Sanchis-Olmos 1948, Wilkinson 1949, Girdlestone 1950, Sevastikoglou 1953, Mukopadhaya 1956, 1957, Falk 1958, Roaf 1958, Sinha 1958, Konstam 1963, Paus 1964, Grewal and Singh 1956, Tuli 1967, Martini 1988). The regional distribution of 1074 lesions of osteoarticular tuberculosis in 980 patients treated in the Department of Orthopedics, Banaras Hindu University, during the period 1965–67 is shown in Table 1.1. In general, the regional distribution is in agreement with the figures from other centers of the world (Somerville and Wilkinson 1965, Sevastikoglou 1953, Sanchis Olmos 1948, Davies et al. 1984, Martini 1988). The work presented here is based upon personal observations, during the treatment of patients with tuberculosis of the skeletal system for the last 35 years. The observations were made on nearly 2000 cases, including nearly 400 cases of tuberculous paraplegia managed from 1965 to 1995. The number of cases which were available for various follow-up studies are mentioned in appropriate sections.
After 1987, sophisticated investigations like ultrasound, isotope bone scan, CT scan and MRI were available in some patients. The analysis of such investigations are mentioned in appropriate sections.
In a national survey of tuberculosis in England and Wales (Davies et al. 1984) the overall rates of tuberculosis were much higher in those of Indian subcontinental ethnic origin than in those of “white” descent. The Indian subcontinental patients were younger than the white patients, 55 percent were under 35 years as compared to 18 percent of the white group. The reasons for the differences are complex. The age of patients with orthopaedic tuberculosis in developing countries tends to be even younger than in the Indian subcontinental patients in Britain.
The major areas of predilection are in the following order: spine, hip, knee, foot, elbow, hand, shoulder, bursal sheaths and others. Mandible and tempromandibular joint appear to be the least common location where the tuberculous infection was observed by us in 2 cases from 1965 to 1994.6
Table 1.1   Regional distribution of 1074 lesions of osteoarticular tuberculosis amongst 980 patients in B.H.U. Hospital (1965–67)
No. of cases
Sacroiliac joint
Tarsal bones
Metatarsals and phalanges
Greater trochanter and/or trochanteric bursa
Metacarpals and phalanges
Clavicle and sterno-clavicular joint
Wrist (Carpal bones)
Long bones of upper limb
Long bones of lower limb
Skull and facial bones
Pelvic bones
  1. Pubic symphysis
  2. Iliac bone
  3. Ischeal tuberosity
  4. Ischio-pubic ramus
Total number of lesions
Note: There were 87 patients who had disseminated skeletal tuberculosis.
There are, however, sporadic cases reported in the literature (Meng 1940, Sepheriadou-Mavropoulou 1986).
Prophylaxis Against Tuberculosis
Selective immunization of groups at special risk is strongly recommended. These include household contacts of active cases, nurses, medical students, hospital workers and all those whose duties bring them in contact with patients or fomites. The protection afforded by B.C.G. in the control of tuberculosis is estimated to be in the region of 80 percent.
It is customary to perform tuberculin test in each individual prior to B.C.G. vaccination and to offer B.C.G. only to those persons who do not 7react to tuberculin and are thus assumed to be uninfected previously. Normal reaction to B.C.G. vaccination is a spontaneously regressive primary complex at the site of vaccination. The injection is made with a standard tuberculin syringe. For an adult 0.1 ml of the vaccine is injected intradermally proximal to the insertion of deltoid or lateral aspect of thigh. A satisfactory vaccination produces whitish wheal 5 to 7 mm in diameter. The wheal gets absorbed in 20 to 30 minutes. By 3 to 4 weeks an area of infiltration (induration) along with erythema develops at the site of vaccination. Between 4th and 5th week it develops into a papule (lump) 5 to 8 mm in diameter with a small nodule in its center. The papule increases in size to a maximum of 8 to 10 mm by about the 6th week. In many a crust (scab) appears on the papule by about the 4th to 5th week. The crust may get detached leaving behind a superficial ulcer (5 to 6 mm diameter). The ulcer and the lesion heal slowly over 3 to 6 months leaving behind a scar. Rarely there is delay in healing and regional lymph glands remain enlarged for a few months.
Even under the best conditions 10 to 20 percent of the vaccinated population may not get the protection. About one case out of ten thousand vaccinated children in European countries may develop B.C.G. osteitis, and extremely rarely a child may develop a generalized B.C.G. infection. Fortunately, B.C.G. osteitis runs a benign course (Shanmugasundaram 1982). The interval from B.C.G. vaccination to onset of symptoms ranges from a few months to 5 years. The most common localizations are the epiphysis and metaphysis of long tubular bones, occasionally extending across the epiphyseal line. Nearly 10 percent may have multiple lesions. Clinicoradiologically the lesions resemble chronic osteomyelitis. Examination of the tissue removed would show histological picture resembling tuberculosis, culture may grow the same strain of B.C.G. as was vaccinated, and guinea pig test is as a rule negative. Fortunately these patients respond favorably to modern antitubercular drugs within about 6 months.
Chemoprophylaxis may be considered in the infants and children staying in contact with an infected mother or attendants. Certain groups at special risk as mentioned above may be given chemoprophylaxis. Isoniazid is usually used in a dose of 5 mg/kg body weight daily, continued for at least 6 months. Davidson and Le (1992) have suggested addition of rifampicin (along with isoniazid) for 3 to 6 months. They suggested preventive (prophylactic) chemotherapy for:
  • Close-contacts of an infectious tuberculous patient.
  • Persons with positive tuberculin test with abnormal chest x-ray without active disease but who have not received adequate antituberculous drugs.8
  • Tuberculosis-infected persons without active disease when they develop high risk conditions like diabetes, corticosteroid therapy, immunosuppressive therapy, HIV infection, hematological and reticuloendothelial malignancies, end-stage renal disease, silicosis, chronic undernutrition and weight loss.
  • Tuberculin skin test converters at any age.
  • Tuberculin skin test reactors younger than 35 years.