A case of spinal tuberculosis with acute spastic paraplegia managed with medical therapy and surgical fixation: A comprehensive clinical and nursing perspective
Leema Rebekal Rosy1, Bhuvaneshwari2
1Assistant Nursing Superintendent, Kauvery Hospital, Tennur, Trichy
2Nursing Supervisor, Kauvery Hospital, Tennur, Trichy
Abstract
Spinal tuberculosis (Pott’s disease) is the most common form of extrapulmonary tuberculosis and a leading cause of preventable paraplegia in endemic regions. We present the case of a 15-year-old girl who developed acute spastic paraplegia secondary to tuberculous spondylodiscitis with paravertebral abscess. Diagnosis was confirmed by MRI and GeneXpert testing of aspirated pus. She was initiated on modified anti-tubercular therapy (ATT) and intravenous steroids, followed by laminectomy with pedicle screw fixation. This case highlights the importance of early diagnosis, adherence to national guidelines, combined medical-surgical intervention, and multidisciplinary nursing care in achieving favourable outcomes in spinal tuberculosis.
Introduction
Spinal tuberculosis accounts for approximately 50% of skeletal TB cases and remains a significant cause of morbidity in developing countries. It often presents with back pain, progressive neurological deficits, and constitutional symptoms. Delayed diagnosis can lead to irreversible paraplegia due to spinal cord compression. Management requires a combination of prolonged ATT, surgical decompression in selected cases, and intensive nursing care. Treatment in India is guided by the National TB Elimination Program (NTEP), which provides standardized regimens, monitoring protocols, and treatment adherence strategies. This case emphasizes the clinical challenges and multidisciplinary management approach.
Case Presentation
A 15-year-old school student presented with complaints of numbness in both legs for the past 15 days, progressive weakness, severe back pain for the past 20 days and difficulty in walking. She gradually developed gait disturbances, limb weakness and urinary difficulty.
History
- Lower back pain, insidious, aggravated on movement, relieved by rest.
- Progressive weakness of both lower limbs, difficulty in stair climbing, limping gait.
- Later developed difficulty in getting up from squatting position, urinary symptoms, and impaired mobility.
- Associated weight loss (~10 kg in 1 year).
- No history of cranial nerve deficits, seizures, bowel/bladder incontinence, or respiratory symptoms.
On examination
- Conscious, oriented, pale.
- Severe tenderness in lumbar spine.
- Motor system: Upper limb power 5/5, lower limb weakness (1/5 at hip and knee, 3/5 at ankle), Hyperreflexia in lower limbs, bilateral extensor plantar response.
- Sensory: Touch and pain intact.
Investigations
MRI spine: Pre- and paravertebral abscess with extradural compression of spinal cord at multiple levels.
GeneXpert of pus aspirate: Mycobacterium tuberculosis detected.
Diagnosis
Spinal Tuberculosis with Acute Spastic Paraplegia.
Sagittal MRI showing vertebral collapse with paravertebral abscess compressing the spinal cord.
Axial MRI demonstrating paravertebral abscess causing spinal cord compression.
Coronal MRI showing extension of abscess into surrounding soft tissues.
MRI spine showing vertebral body destruction with pre- and paravertebral abscess, leading to spinal cord compression — features consistent with spinal tuberculosis.
Medical Management
Adherence to National TB Guidelines (NTEP)
According to the NTEP 2023 guidelines, all diagnosed TB cases should receive weight-based daily regimen under direct observation whenever possible. For extrapulmonary TB (including spinal TB), treatment duration is usually 6–9 months, extendable to 12 months in complicated cases (with CNS or spinal involvement). Corticosteroids are recommended in spinal TB with neurological involvement.
Our hospital policy strictly follows the NTEP guidelines, with mandatory notification, drug regimen documentation, treatment adherence monitoring and DOTS-based follow-up.
Patient’s ATT Regimen
The patient was initiated on a modified regimen due to the severity of neurological involvement, based on NTEP guidelines and supported by local antibiogram patterns:
- Rifampicin (R) – 300 mg (R-CIN)
- Isoniazid (H) – 300 mg (Solonex)
- Pyrazinamide (Z) – 500 mg (Pyzina)
- Ethambutol (E) – 800 mg
- Levofloxacin (Lfx) – 750 mg (added as per treating team’s decision for better CNS penetration and resistance coverage)
- Streptomycin (S) – 0.75 g IM thrice weekly
Adjunctive Medications
- IV Dexamethasone (tapered to oral Decmax)
- Pantoprazole (GI prophylaxis)
- Vitamin supplementation (Folvite, Neurobion, Benadon, Shelcal, Lumina D3)
- Analgesics (Dolo 650 mg SOS)
Antibiogram Findings
Biopsy and pus culture identified Mycobacterium tuberculosis sensitive to first-line drugs (Rifampicin, Isoniazid, Ethambutol, Pyrazinamide). The strain also showed sensitivity to Levofloxacin. No MDR-TB pattern was detected. This supported the continuation of first-line ATT with adjunct Levofloxacin.
Physiotherapy and Rehabilitation
- Passive and later active ROM exercises.
- Mobilization with Taylor brace.
- Strict bed rest initially, gradual assisted ambulation.
Surgical Intervention
- On the 12th day of admission, she underwent laminectomy with pedicle screw fixation.
- Abscess drainage and decompression of spinal cord.
- Post-operative course was uneventful, and ATT was continued.
Nursing Diagnoses
- Impaired physical mobility related to lower limb weakness and spinal fixation.
- Acute pain related to spinal tuberculosis and post-operative wound.
- Risk for infection related to surgical site and long-term ATT.
- Imbalanced nutrition, less than body requirements related to chronic illness and weight loss.
- Impaired urinary elimination related to spinal cord compression.
- Anxiety and knowledge deficit related to disease condition and prolonged treatment.
Nursing Management
Impaired Physical Mobility
- Assessment: Assessed muscle strength, range of motion,
- Positioning: Ensured proper alignment with spinal brace, frequent position changes with log-rolling technique.
- Mobility Support: Provided assistance with high sitting, initially passive ROM → later active ROM exercises.
- Education: Taught patient and family safe techniques for transfers, use of support devices, and importance of exercise.
Acute Pain
- Assessment: Used VAS (Visual Analogue Scale) to evaluate pain regularly.
- Pharmacological Management: Administered prescribed analgesics (Dolo, steroids) timely.
- Non-Pharmacological Measures: Provided warm compresses, relaxation techniques, distraction, and comfortable positioning.
- Evaluation: Reassessed after interventions to measure effectiveness.
Risk for Infection
- Asepsis: Maintained strict aseptic technique during wound care and catheter care.
- Monitoring: Observed surgical site for redness, swelling, discharge; monitor vital signs for fever.
- Hand Hygiene: Reinforced hand hygiene practices for patient, attendants, and staff.
- Education: Instructed patient and family on signs of infection and importance of completing ATT.
Imbalanced Nutrition
- Assessment: Monitored weight, dietary intake, and signs of malnutrition.
- Diet Plan: Provided high-protein, high-calorie diet enriched with vitamins and minerals.
- Supplements: Ensured compliance with prescribed vitamins (Folvite, Neurobion, Shelcal, Vitamin D3).
- Collaboration: Worked with dietician to individualize diet plan.
- Evaluation: Regularly tracked weight gain and improvement in appetite.
Impaired Urinary Elimination
- Assessment: Monitored, bladder fullness, urine output
- Interventions: Encouraged oral fluids , provided adequate hydration.
- Catheter Care: Maintained catheter hygiene, prevented catheter-associated infections.
- Education: Taught patient bladder training techniques and signs of urinary infection.
Anxiety and Knowledge Deficit
- Assessment: Identify patient’s and family’s concerns, fear about paralysis, and long-term treatment.
- Counselling: Provided psychological support, encourage verbalization of feelings.
- Education: Explained disease process, importance of ATT adherence, duration of therapy (12–18 months).
- Involvement: Included family members in care planning to enhance compliance.
- Reinforcement: Offered continuous reassurance and highlight progress in recovery.
Additional Nursing Considerations
- Prevention of Pressure Ulcers: Used pressure-relieving devices, maintain skin hygiene, inspect pressure areas daily.
- Respiratory Care: Encouraged deep breathing and incentive spirometry to prevent hypostatic pneumonia due to immobility.
- Thromboprophylaxis Support: Encouraged limb physiotherapy and mobility to prevent deep vein thrombosis.
- Medication Adherence: Supervised intake of ATT, educate about side effects, and stress the importance of not missing doses.
Discussion
Spinal tuberculosis, also known as Pott’s spine, is the most common form of skeletal tuberculosis and continues to be a significant cause of morbidity and disability, particularly in endemic regions such as India. It accounts for nearly half of all osteoarticular tuberculosis cases. The pathogenesis involves haematogenous spread of Mycobacterium tuberculosis from a primary pulmonary or extra pulmonary focus to the vertebral column, most frequently affecting the thoracic and lumbar spine. The infection typically begins in the anterior part of the vertebral body, progresses to adjacent vertebrae, and often leads to caseous necrosis, abscess formation, vertebral collapse, and ultimately spinal deformity and neurological compromise.
In our patient, the disease manifested with progressive back pain, constitutional symptoms, and neurological deficits culminating in acute spastic paraplegia. MRI findings of vertebral destruction, paravertebral abscess, and cord compression, along with GeneXpert confirmation of Mycobacterium tuberculosis, established the diagnosis. The presence of neurological deficits, severe pain, and radiological evidence of cord compression placed this case in the category of complicated spinal tuberculosis requiring urgent intervention.
Medical Management and Guidelines
The cornerstone of management is anti-tubercular therapy . According to the National Tuberculosis Elimination Programme (NTEP) guidelines, extrapulmonary TB including spinal TB is managed with daily fixed-dose combinations for at least 6 months, with possible extension to 9–12 months in cases with bone, joint, or spinal involvement. Adjunct corticosteroid therapy is recommended in cases of central nervous system involvement or when there is spinal cord compression to reduce inflammatory oedema and improve neurological recovery.
Our hospital’s management was aligned with NTEP recommendations. The patient was treated with a modified regimen of first-line ATT (Rifampicin, Isoniazid, Ethambutol, Pyrazinamide) along with Levofloxacin and Streptomycin for enhanced coverage and CNS penetration. The antibiogram showed sensitivity to first-line drugs, and no multidrug resistance was detected. This justified the continuation of the regimen with additional Levofloxacin for enhanced efficacy. Intravenous steroids were initiated to reduce cord oedema, later tapered to oral form.
Surgical Considerations
Surgical intervention is indicated in spinal TB under certain conditions: severe neurological deficits, progressive deformity, instability, large abscesses causing compression, or failure of medical therapy. In this case, laminectomy with pedicle screw fixation on the 12th day of admission due to acute neurological deterioration and extensive cord compression. Surgery provided decompression of the spinal cord, stabilization, and pain relief. Post-operative recovery was favourable, and the patient continued ATT with physiotherapy support.
Nursing Role in Management
Nursing management is crucial in holistic care. Beyond direct clinical interventions, nurses ensured prevention of complications such as pressure ulcers, respiratory infections, and urinary tract infections due to immobility. Education of the patient and family regarding ATT adherence, side-effect monitoring, and nutrition was a central component. Nursing staff also provided emotional support, helping the patient cope with the anxiety of prolonged treatment and temporary disability. Close monitoring for infection control and aseptic handling of surgical wounds reduced post-operative complications.
Broader Implications
This case reflects the classical but severe presentation of spinal TB in adolescents, demonstrating how delayed diagnosis or progression can lead to irreversible neurological impairment. It emphasizes the importance of early recognition of back pain with neurological symptoms as potential TB in endemic areas. The combination of NTEP-guided ATT, adjunctive steroids, timely surgery, physiotherapy, and dedicated nursing care ensures the best outcomes. It also highlights the need for hospital protocols to strictly adhere to national guidelines, ensure mandatory TB notification, and follow-up for treatment adherence.
Comparative studies show that with standardized ATT, surgical intervention where indicated, and multidisciplinary care, neurological recovery rates can be significantly improved, reducing long-term disability. Early diagnosis with advanced imaging (MRI), rapid molecular diagnostics (GeneXpert), and integrated care pathways are the key to successful management of spinal TB today.
Conclusion
Spinal tuberculosis should be suspected in patients with chronic back pain and neurological deficits, especially in endemic regions. Adherence to NTEP guidelines, prompt initiation of ATT, appropriate surgical decompression, and holistic nursing care are essential to prevent disability. Hospital policies aligned with national protocols play a vital role in ensuring standardization of care.
