koch's spine

dorsolimbar tuberculosis

1. DORSO-LUMBAR TUBERCULOSIS -Dr J.V.Modi Professor and HOD BJMC

2. INTRODUCTION Tuberculosis - oldest disease afflicting humans. Seen in Egyptian mummies - back to 3400 BC. Among overall cases, - 10% involve musculoskeletal system - Among them 50% involves spine. According to WHO – 1/3 rd world’s population affected by tuberculosis - among them 1/5 th of TB population is in india .

3. Every day 1000 dies of tuberculosis in india . Neurological involvement- 47% Dorso -lumbar spine involved most commonly.

4. TB and HIV 10% cases occur in HIV patients Disseminated and extrapulmonary disease is more common with CD4<200

5. REGIONAL DISTRIBUTION SPINE TB Cervical(12%) Cervicodorsal (5%) Dorsal(42%) Dorso lumbar(12%) Lumbar(26%) Lumbosacral (3%)

6. WHY MOST COMMONLY OCCURS AT DL JUNCTION??? Greater extent of movement Degree of weight bearing and microfracture Large spongy cancellous bone Proximity to kidney and cistern chili D-L region ---> lumbar ---> upper dorsal - --> cervical ---> sacral.

7. PATHOGENESIS secondary infection- lung - genitourinary system. spread - hematogenous route. Initially starts with , Inflammatory reaction. Then there is proliferation of granulation tissue, invasion of macrophages, epitheloid cells, lymphocytes and tissue necrosis.

8. - Tissue necrosis and breakdown of inflammtory cells result in paraspinal abscess, which mostly accumulate in the anterior aspect of vertebral bodies under anterior longitudinal ligament. - Skip lesions are also seen ocassionally .

9. CLINICAL PRESENTATION Presentation depends on the following: Stage of disease Site Presence of complications such as neurologic deficits, abscesses, or sinus tracts. The reported average duration of symptoms at the time of diagnosis is 3-4 months.

10. CLINICAL FEATURES Common in 1 st three decades of life. Males=females Back pain is the earliest and most common symptom. Patients have usually had back pain for weeks prior to presentation

11. 1)Constitutional symptoms(40% cases) Malaise Loss of appetite Night sweats Evening rise of temperature 2)Specific symptoms Night crises Stiffness Restricted ROM Enlarged lymph nodes Abscess Neurological deficit

12. TYPES OF TB SPINE 1) Caseous exudative : More common in children More destruction and residual deformity More exudation Abscess formation 2)Granular type More in adults Less destructive Insiduous onset Abscess formation rare

13. INVESTIGATIONS 1)CBC- Decreased Hb , Lymphocytosis 2) ESR- Raised in active stage of the disease Normal ESR for 3 months suggest patient is in recovery phase. 3) MONTOUX/TUBERCULIN SKIN TEST- positive test can be observed 1 to 3 months after infection. 4) ZIEHL-NEELSEN STAINING - Inexpensive method - Detects acid fast bacilli - Culture are available only after a few weeks.(2-3 week) - Positive only 50% cases. Culture media LOWENSTEINE-JENSEN

14. 5 ) ELISA- antibody detection 6)PCR - TB gene expert-TB GOLD(result within 4-6 hr) 7 )Radiological- Plain radiograph CT scan MRI spine Bone scan(Tc-99m)

15. FINDINGS ON PLAIN XRAY Reduced disc space Blurred paradiscal margins Deformities a) anterior wedging b) gibbus deformity c) vertebra plana =single collapsed vertebra

16. KYPHOSIS angular Round More than 3 vertebra involvement Gibbus 2 or 3 vertebra involvement Knuckle 1 vertebra involvement

17. collapse Deformity

18. CT SCAN MRI - Pattern of bony destruction - Detect marrow infiltration - calcification in abscess in vertebral bodies. -detects early lesion before - changes of discitis they appear on xray -helps in differentiating intradural from extradural lesions - Skip lesions - S pinal cord involvement.

19. SPINAL LESION OF TUBERCULOSIS Intradural involvement-very rare Extradural involvement- Paradiscal (due to arterial spread) Central(venous spread) Anterior(due to subperiosteal spread) Appendical

20. Comparision of various types of spine TB Paradiscal lesions Central type of lesions Most common lesion 2 nd most common Arterial supply Spread through venous plexus Reduced disc space(earliest sign ) Minimal disc space reduction Loss of vertebral margins Concentric collapse Increased prevertebral soft tissue Anterior type lesion Appendicial lesion Starts beneath the anterior longitudinal ligament Isolated infection of pedicles ,lamina/transverse process/ spinous process Collapse and disc space reduction minimal and late Intact disc space Erosion mechanical

21. Clinico radiological classification of spinal tuberculosis STAGE CLINICO RADIOLOGICAL FEATURE DURATION PRE DESTRUCTIVE straightening of curvatures spasm of perivertebral muscles <2 MONTHS EARLY DESTRUCTIVE decreased disc space with paradiscal erosions 2-4 MONTHS MILD ANGULAR KYPHOSIS 2-3 vertebrae involvement ( kyphotic angle 10-30*) 4-9 MONTHS MODERATE ANGULAR KYPHOSIS >3 vertebrae involvement (K:30-60*) 6-24 MONTHS SEVERE KYPHOSIS >3 vertebrae involvement(K>60*) >2 YEARS

22. DIFFERENTIAL DIAGNOSIS It includes, - Spinal infection- tuberculosis, brucellosis, fungal - Neoplastic - lymphoma, metastasis - Degenerative - Neuropathic spine

23. DD: PYOGENIC SPONDYLITIS TUBERCULAR • Chronic back pain -Long standing history of months to years • Presence of active pulmonary tuberculosis -60% • Most common location thoracic spine followed by thoraco -lumbar region. • > 3 contiguous vertebral body involvement common • Vertebral collapse -67% • Posterior elements involvement • Skip lesions common PYOGENIC • Acute onset-History of days to months. • Not present. • Most common location lumbar spine. • Mostly involves 1 spinal segment • 21% only. • Rare • Rare

24. DD-NEOPLASTIC LESIONS In early stages of central type of tuberculosis of spine, there is no involvement of intervertebral disc thereby mimicking neoplastic lesion. However, in chronic tubercular lesion intervertebral disc is involved making it easy to differentiate from neoplastic lesion (disc not involved -“ good disk, bad news; bad disk, good news” )

25. COMPLICATIONS OF SPINALTUBERCULOSIS - Paraplegia - Cold abscess - Spinal deformity - Secondary infection - Fatality - Amyloid disease

26. POTT’S PARAPLEGIA Incidence : 10 - 30 % Dorsal spine most common Motor functions affected before / greater than sensory. Sense of position & vibration last to disappear Pathology: Extradural granulation  Contraction  Peridural fibrosis  Recurrent paraplegia Physical findings: Spasticity Exaggerated reflexes- clonus

27. PATHOPHYSIOLOGY

28. SEDDON’S CLASSIFICATION OF TUBERCULOUS PARAPLEGIA : GROUP A (EARLY ONSET PARAPLEGIA) a/k/a Paraplegia associated with active disease : - During the active phase of the disease within first 2 years of onset - Pathology can be inflammatory edema, granulation tissue, abscess , caseous material or ischemia of cord . GROUP B (LATE ONSET PARAPLEGIA) a/k/a Paraplegia associated with healed disease: - Usually after 2 years of onset of disease . - Can be due to recrudescence of the disease or due to mechanical pressure on the cord. - Pathology can be sequestra , debris, internal gibbus or stenosis of the canal.

29. KUMAR’S CLASSIFICATION OF TUBERCULOUS PARA/TETRAPLEGIA (Predominantly based on motor weakness) Stage Clinical features I Negligible Patient unaware of neural deficit , Plantar extensor and / or ankle clonus II Mild Patient aware of deficit but manages to walk with support (Spastic paresis) III Moderate Nonambulatory because of paralysis (in extension) , sensory deficit less than 50% IV Severe III + Flexor spasms / paralysis in flexion /sensory deficit more than 50% / sphincters involved

30. BASIC PRINCIPLES OF MANAGEMENT Early diagnosis Medical Treatment – AKT and brace Surgical Approach to drain abscess, debridement and fusion Stabilization to Prevent Deformity

31. Spinal TB Treatment Chemotherapy(AKT) (18 months) Surgery ( Debridement+fusion+fixation ) Anterior approach Combined Approach Posterior Approach

32. RNTCP GUIDELINES Category Type Regimen I All “new” pulmonary, extrapulmonary and other TB patients 2(HRZE)3 + 4(HR ) II All relapses, treatment after defaults, failures and others. 2(HRZES)+ 1(HRZE)+ 5(HRE) ENTIRE DUARTION OF CHEMOTHERAPY LASTS FOR 16-18 MONTHS 10 MG PYRIDOXINE FOR PREVENTION OF PERIPERAL NEUROPATHY

33. SMYPTOMS COMMONLY SEEN AFTER TAKING AKT Hepatits ( isoniazide ) Peripheral neuritis( isoniazide ) Color changes in urine( rifampicine ) Optic neutitis ( ethambutol ) Deafness( steptomycin )

34. SURGICAL INDICATIONS failure of conservative management Abscess formation Progressive neurological deficiet Advanced cases- Sphincter involvement, flaccid paralysis or severe flexor spasms Residual kyphotic deformity

35. Various surgical Approaches Cervical Dorsal Lumbar Anterior Anterior trans thoracic Antero lateral approach to lumbar spine Anterior trans abdominal approach Posterior midline spinal Approach-MC used in all posterior method of spine TB

36. SURGICAL STEPS (ALL POSTERIOR)

37. FOLLOW UP AND EVALUATION Followup at every three months interval upto 1.5 year. Clinical: Investigation Weight gain - CBC Pain relief - ESR Free ROM - CRP Resolution of Abscess Radiological Decreased soft tissue shadow Disappearance of erosion Return of mineralisation Bony Ankylosis

38. CASE-1 15 year female patient H/O back pain since last 1 year B/L spastic paraparesis and bowel bladder involvement since last 1 month. Clinically kyphotic deformity at D9,D10,D11 level X-ray shows collapsed D10 vertebra MRI shows D9-D10-D11 koch’s spine with anterior epidural abscess

39. Preop xray AP preop xray ( lat ) preop CT scan Preop MRI preop clinical

40. Post Operative status Intraop clinical image immediate post op xray follow up xray

41. CASE-2 49 year female patient H/O back pain since last 2 months Constitutional features present Clinically pain and tenderness at D10 level and ankle clonus present X-ray shows collapsed D10 vertebra MRI shows D8-D9-D10 koch’s spine with anterior epidural abscess ESR, CRP raised.

42. Pre op Xray Pre op MRI Post OP X ray

43. THANK YOU