Vol. 4 No. 2, 2011.pmd


Introduction:
Skeletal tuberculosis (TB) usually constitutes 1–3% of
extrapulmonary TB, and spinal involvement is about half
of them.1 TB of the cervical spine is so unusual that it
comprises only 3% of cases of Pott’s disease. In addition,
retropharyngeal abscess as a presenting manifestation of
tuberculosis of the cervical spine is rare.2 The most
dangerous area for skeletal TB is the cervical region, due
to the greater risk of quadriplegia and death.3 This article
describes an extremely rare case of multifocal Pott’s
disease, along with retropharyngeal and paravertebral
abscess.

Case report:
A 13-year-old boy had 7½ months history of fever, anorexia,
weight loss, and cervical lymphadenopathy with
discharging sinus. Initially he was admitted in a tertiary
care hospital, where, a CT scan of chest & neck revealed
“retropharyngeal, pre & paravertebral abscess, multiple
vertebral destruction, and cervical & right paratracheal
lymphadenopathy” (Figure 1). For the last 6 months, he
was on supervised anti-TB chemotherapy on the basis of
FNAC of cervical lymph node which revealed caseating
granuloma. Despite getting Anti-TB drugs, and
symptomatic improvement in terms of resolution of fever,
improvement of appetite and weight, he developed neck
pain along with quadriplegia, 5 days before presenting to
us.

On admission, both his upper and lower limb power was 0/
5 with complete sensory loss up to C2 and absent deep
tendon reflexes with equivocal plantar response.

Multifocal Extensive Spinal Tuberculosis with Retropharyngeal Abscess
Farzana Shumy1, Ahmad Mursel Anam2, M A Jalil Chowdhury3, Md. Abul Kalam Azad2, Samsun Nahar2
1Medical Officer, 2Post Graduate Trainee and 3Professor, Department of Medicine, Bangabandhu Sheikh Mujib Medical University,
Shahbag, Dhaka-1000, Bangladesh.

Abstract:
An unusual case of a young boy presenting with spinal tuberculosis involving cervical & thoracic vertebrae, along with
retropharyngeal abscess is reported. The patient presented with progressive quadriparesis, fever, night sweat and
cervical lymphadenopathy.  The lab studies confirmed tuberculosis and patient received anti-tubercular chemotherapy.
After development of quadriparesis, spinal surgery was done. The post operative course was uneventful and the patient
is on gradual neurological recovery.

[BSMMU J 2011; 4(2): 128-130]

Address for Correspondence:  Farzana Shumy,  House # 61/B,
Road # 6/A, Dhanmondi RA, Dhaka 1209,  Bangladesh.  E-mail:
farzanashumy@hotmail.com

He had raised ESR (85 mm in the 1st hour) with positive
Mantoux Test (20 mm after 72 hours). MRI of cervical &
dorsal spine, done this time, showed “C4 & D4 vertebral
body heights are reduced with anterior wedging causing
localized kyphotic deformity with epidural extension of
the perivertebral mass resulting in cord compression. Disk
space between C4-C5 and D4-D5 are obliterated.
Perivertebral mass at craniovertebral junction to C5 level
and D2 to D4-5 level with epidural extension present.
Atlanto-axial subluxation with an intervening mass are
causing further cord compression (Impression: Features
are suggestive of tubercular spondylodiscitis at multiple
levels with epidural mass causing cord compression)”
(Figure 2).

All other biochemical investigations, including random
blood sugar, were normal.

Histopathological examination of tissue from intervertebral
disc and paravertebral region of C3-C4 region showed
caseating granuloma.

Fig.-1: CT scan of chest showing paravertebral abscess
(arrow).

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To manage quadriplegia, trans-oral and trans-cervical
decompression of spinal cord at C2,3,4 level and fusion of
loose graft was done. He was already on continuation
phase of anti-tubercular chemotherapy.

After surgery, patient regained his upper limb power and
sensory function of all limbs.

Discussion:
The retropharyngeal space is a potential space in the
fascial planes between the prevertebral and
buccopharyngeal fascia.2 Tuberculous retropharyngeal
abscess is usually a consequence of chronic TB of the
cervical spine, because pus spreads directly through the
anterior longitudinal ligament.4

Our patient’s presenting features, like neck pain and
retropharyngeal abscess and collapse of cervical
vertebrae, as demonstrated in CT scan, can be explained
in this manner.

Primary focus in the lungs or the lymph nodes acts as a
source for haematogenous dissemination, resulting in
spinal tuberculosis.5 In this case; the patient had cervical
lymphadenopathy as well as right paratracheal
lymphadenopathy, either of which can be responsible.

Three recognized patterns of vertebral body involvement
are paradiskal, anterior and central lesions. Paradiskal

lesion, adjacent to the vertebral body, leads to narrowing
of disc space. Central lesion targets the vertebral body
without involving disc. Anterior lesions are subperiosteal
lesions under the anterior longitudinal ligament. The
central type spreads along the Batson’s plexus of veins,
while paradiskal infection spreads through the arteries.
The anterior type of vertebral body tuberculosis results
from the extension of the abscess beneath the anterior
longitudinal ligament and periosteum. Pus spread over
multiple vertebral segments, stripping the periosteum and
anterior longitudinal ligament from anterior surface of
vertebral bodies. MRI image shows abnormal signal
involving multiple vertebral segments.6 These, probably,
were the processes, in which multiple vertebral
involvement, along with perivertebral abscess in both
cervical and thoracic region, took place in our patient,
although extensive bone destruction involving multiple
vertebrae is an uncommon finding in tuberculous
spondylitis.

Spinal tuberculosis likes to target the thoracic and the
lumbar spine; involvement of the cervical region and
sacrum is less common.7 As cross-sectional diameter of
the spinal canal is relatively smaller than the diameter of
the cervical cord; neurologic deficits are easier and earlier,
if cervical spine is involved. Neurologic symptoms can
manifest by any of the following process: subluxation of
vertebrae, impingement of bone, disc, and abscess on the
spinal cord or nerve root, local inflammatory response,
and tuberculous vasculitis.1

CT scan of our patient demonstrated, spinal cord
compression due to collapse of vertebra along with epidural
extension of perivertebral mass, which explains the
neurological deficit in our patient.

Spinal involvement with skip lesion has also been found
in Brucellosis. Histopathology usually demonstrates
noncaseating granulomatous tissue. Spinal brucellosis
may be distinguished from tuberculosis by MRI also. In
brucellosis, the vertebral body is usually morphologically
intact despite evidence of osteomyelitis and the disc is
moderately reduced in size despite evidence of
involvement.8

Surgical intervention in Pott’s disease is indicated if there
is neurologic deficit, spinal deformity with instability or
pain, no response to anti-TB chemotherapy (evidenced
by continuing progression of kyphosis or instability) and
large paraspinal abscess.9

Fig.-2: MRI of cervical and upper dorsal spine showing
destruction of cervical (thin black arrow) & thoracic
(thick black arrow) vertebrae, with epidural abscess
causing cord compression (thin white arrow), along with
retropharyngeal abscess (thick white arrow).

BSMMU J Vol. 4, Issue 2, July 2011

129



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with Posterior Mediastinal Extension and Quadriplegia in A
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2 . Al Soub H. Retropharyngeal Abscess Associated with
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Br J Neurosurg 2001; 15(2): 142–146.

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7 . Shanley DJ. Tuberculosis of the Spine: Imaging Features. AJR
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9 . Watts HG, Lifeso RM. Current Concepts Review - Tuberculosis
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