Case A 26-year-old pregnant female G2P2L1 at 23 weeks of gestation developed over a 10 days period subacute onset paraplegia (Frankel A; complete motor, sensory T10 level) with bowel bladder incontinence. Plain radiographs obtained with abdominal shielding showed a collapse of the fifth thoracic vertebral body [Figure 1] accompanied by a radio opaque shadow in the paravertebral area showing a classic appearance of spinal TB. The MRI confirmed collapse of the T5 with a prevertebral/paravertebral abscess formation contributing to cord compression [Figure 2].
The patient was started on four drug anti-tubercular drug therapy: isoniazid, rifampicin, pyrazinamide, and ethambutol. Tissue diagnosis was avoided as it would involve additional X-ray exposure for obtaining a specimen by fluoroscopy/computed tomography (CT)-guided biopsy. In view of the classic radiologic picture, with widespread cases of TB in our country, plus her history of cervical tubercular lymphadenitis 1 year before presentation, anti-tubercular therapy was started empirically.
An obstetric consult revealed that the fetus was viable but had severe IUGR, with Doppler studies revealing reduced flow in the umbilical artery.
A decompressive laminectomy with instrumented fusion was performed in the thoracic spine. In the left lateral position, the surgeons utilized a "Versatile approach" allowing for simultaneous anterior and posterior decompression; the fusion included a Hartshill rectangle [Figure 3] with sublaminar wiring and bone grafting. During the surgery, a senior obstetric anesthetist was present to prevent maternal hypotension, hypoxemia, and hypothermia; fetal monitoring was additionally performed by the attending obstetrician postoperatively. Successive ultrasound scans were also obtained to avoid maternal/fetal complications.
When 3 weeks of antitubercular drug therapy resulted in no neurological recovery, a decision for operative decompression was taken.
The pathology was consistent with necrotizing granulomatous osteomyelitis. Nucleic acid based amplification tests detected the presence of Mycobacterium tuberculosis. On culture, there was growth of M. tuberculosis which was sensitive to all four first-line antitubercular drugs.
The postoperative course was uneventful. She regained partial power in the lower extremities within the 1st postoperative week. Although spasticity persisted for 14 months, motor recovery was complete at 3 postoperative months, and she additionally regained normal bowel and bladder function. At 18 months, a CT scan documented fusion [Figure 4]. Antitubercular drug therapy was stopped after radiological and serological evidence of cessation of disease process as per institutional protocols.
Postoperative obstetric ultrasonography showed a single live intrauterine pregnancy with IUGR. However, the 4-week post surgery ultrasound showed reversal of end diastolic flow in the umbilical artery, and eventually confirmed intrauterine fetal demise. Despite the failure to save the fetus in this case, the authors concluded that surgical decompression/fusion for acute paraplegia due to TB of the spine remains a viable option for pregnant patients with significant TB-related neurological deficits.