190 SAMJ VOL 75 18 FEB 1989
Tuberculous paraplegia during pregnancy
A report of 4 cases
S. GOVENDER, S. C. MOODLEY, M. J. GROOTBOOM
Summary was confirmed on closed-needle biopsy of the 3rd and 4th
lumbar venebrae (Fig. 1). She defaulted from treatment after
Four patients who developed tuberculous paraplegia during 6 months. At 36 weeks' gestation she presented to hospital
pregnancy are described. They delivered at term without with weakness and inability to walk.
complications and then underwent successful decompression
S AIr Med J 1989; 75: 190-192.
A woman· who was treated for pulmonary tuberculosis at the
age of 20 years developed spasticity of the lower limbs over a
In reviewing published repons, there have been none on period of 2 weeks. Clinically she was 30 weeks' pregnant with
tuberculous paraplegia during pregnancy. I-3 Before the intro- a kyphotic deformity of the dorsal spine at the level of the 7th
duction of chemotherapy for tuberculosis, the morbidity and thoracic vertebra when she presented to hospital (Fig. 2).
monality rates were high in pregnant women. 4 With the A diagnosis of tuberculous spondylitis was based on radio-
exception of malformations in the offspring of women on graphy, a Mantoux test and on the strong family history of
streptomycin, the risk of an adverse outcome of pregnancy is tuberculosis. All patients were started on antituberculosis
no greater among pregnant women on antituberculosis therapy therapy consisting of isoniazid 300 mg daily, ethambutol 1200
than among healthy women. Successful pregnancy in women mg daily, rifampicin 750 mg daily and pyridoxine 25 mg daily.
who are paraplegic because of spinal cord trauma has been The pregnancies were constantly monitored. Careful attention
reponed. >.6 Patients with this condition must be carefully was paid to the skin to prevent decubitus ulcers. The urinary
monitored because medical and obstetrical complications are tract was also carefully monitored for any infections and the
common. nutritional and haematological status of the patients were
assessed. At term, each patient was transferred to the labour
ward and underwent successful normal vaginal deliveries under
Case reports supervision. Patient 2 required an episiotomy.
After delivery all patients had radiographic assessment of
Case 1 the involved area and then underwent decompression and
A 38-year-old woman, para 5 gravida 6, developed spastic fusion. In 3 patients a transthoracic decompression was done
paraplegia with loss of bladder and bowel control. She was 24 and for the lumbar lesion an anterior retroperitoneal approach
weeks' pregnant and had kyphosis of the dorsal spine at the was used. The fIndings at surgery were pus and sequestra
level of the 8th thoracic venebra. She had been treated for compressing the cord. Patient 2 again became pregnant 2 years
pulmonary tuberculosis 4 years previously. Radiography was after completing the treatment and had a successful normal
strongly suggestive of tuberculosis and antituberculosis treat- vaginal delivery at term.
ment was starred. .
All patients recovered fully within 3 months after surgical
A 23-year-old woman, para I gravida 2, with a family
decompression and walked independently at the end of 5
history of tuberculosis, developed weakness, loss of weight and
months. Successful bony fusion was evident in 3 cases. In 1
night sweats during the 3rd trimester of pregnancy. Clinically,
case a rib graft had fractured but the patient remained asymp-
a gibbus was evident at the thoracolumbar junction with
spasticity of both lower limbs. She was 28 weeks' pregnant. In
view of the strong family history, she was treated with anti-
Case 3 Tuberculosis of the spine remains common among people in
the lower socio-economic groups in southern Africa. Classic
A 39-year-old woman para 4 gravida 5, had had backache tuberculous paraplegia involves two venebral bodies with
for I year. She was treated for tuberculosis after the diagnosis narrowing of the intervening disc space. The usual cause of
paraplegia is pus and sequestra compressing the cord. 7 In
general, although there are exceptions to the rule, it is also
Department of Orthopaedic Surgery and Obstetrics and true that the shorter the duration of paraplegia and the earlier
Gynaecology, University of Natal and King George V Hos-
pital, Durban the signs of recovery, the greater is the potential for recovery.7
S. GOVENDER, FR.CS. All our patients, who had been paralysed for approximately 4
S. C. MOODLEY, F.CO.G (S.A.) months, before decompression recovered fully. While it is
H. J. GROOTBOOM, F.CS. (S.A.) known that some patients with paraparesis may respond to
chemotherapy, it is clear that others develop progressive neuro-
Accepted 29 Apr 1988. logical signs on chemotherapy alone. 3•8 Furthermore, delay in
SAMT VOL 75 18 FEB 1989 191
Fig. 1. Anteroposterior radiograph showing destruction of L3 and L4 with narrowing of disc space (left). Lateral radiograph 2 years after
successful fusion (right).
Fig. 2. Lateral radiograph showing destruction of 07 and 08 (left); follow-up reveals fracture of the graft 3 years after surgery (right).
192 SAMJ VOL 75 18 FEB 1989
diagnosis leads to progression of the disease to a state where adequate pelvises and therefore were allowed normal vaginal
recovery is sometimes not possible. Therefore urgent surgical delivery. Episiotomies in paraplegics should be repaired with
decompression of the spinal canal of the neurologically impaired non-absorbable sutures (silk or nylon) or delayed absorbable
patient is adVised. Adendorff er al. 7 recommended prompt sutures (Vicryl or Dexon). Catgut sutures are poorly absorbed
spinal decompression, together with chemotherapy (isoniazid, and often cause abscesses. 6 The episiotomy in 1 of our patients
streptomycin, rifampicin, pyrizinamide), for 3 months as the was repaired with silk. Therefore in the successful management
optimal management in the non-pregnant patient. of a pregnant paraplegic a team effort involving a physician, a
Since our patients were pregnant, we used a combination of neurologist, rehabilitation personnel, an obstetrician, an anaes-
antituberculosis drugs safe for the fetus. Surgical decompression thetist and an urologist is required.
was undertaken after delivery because the pregnant uterus
causes poor accessibility, and also in order to minimise the
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