Pott's Spine. (Tuberculosis Spine) pptx

The slide contains Introduction
Clinical features
Pathology, pathogenesis & pathophysiology
Diagnosis
Management

1. Shashi Prakash I Year, M.Sc. Nursing, CON, ILBS 17/06/2015 1 POTT’S SPINE Shashi Prakash I Year, M.Sc. Nursing, CON, ILBS 17/06/2015 Shashi Prakash I Year, M.Sc. Nursing, CON, ILBS

2. Outl i ne Introduction Clinical features Pathology , pathogenesis & pathophysiology Diagnosis Management 2

3. This entity was first described by Percivall Pott . He noted this as a painful kyphotic deformity of the spine associated with paraplegia. •Tuberculosis of the spine is one of the oldest diseases afflicting humans.

4. Introduction One fifth of TB population is in India. Spinal tubercular account for 30-60% of the Musculoskeletal TB infections Always secondary Most common : 1 st three decades SEX : M=F Most affected : Thoraco-lumbar region 3

5. REGIONAL DISTRIBUTION 4 CERVICAL 12% CERVICODORSAL 5% DORSAL 42% DORSOLUMBAR 12% LUMBAR 26% LUMBOSACRAL 3%

6. PREDISPOSING FACTORS

7. TB of spine is always secondary. Bacteria reach the spine via hematogenous route. Spreads via para-vertebral plexus of veins i.e., BATSON’S PLEXUS PATHOLOGY

8. Paradiscal : This is the commonest type .In this, the contagious areas two adjacent vertebrae along with the intervening disc are affected. Central : Body of single vertebrae affected leading to early collapse of the weakened vertebrae. The nearby disc maybe normal. The collapse may be a ‘ wedging’ or ‘ concertina’ collapse. Anterior : Infection is localised to anterior part of vertebral body. Infection spreads up and down under the anterior longitudinal ligament. Posterior : Posterior complex vertebrae i.e., the pedicle, lamina, spinous process and transverse process is affected.

9. LOCATION OF VERTEBRAL LESIONS Par a d i scal Ant e ri o r Ce n tr a l App e n d e c eal

10. PARADISCAL LESIONS • Most common Adjacent to the I/V disc leading to narrowing disc space Disk space narrowing Destruction of subchondral bone with herniation of disc into the body. Direct involvement of the disc.

11. Adjacent to the I/V Disc leading to a narrowing of the disc space 7/24/2 15 22 PARADISCAL Destruction of vertebral bodies ,narrowing of IVD Space and kyphotic deformity

12. ANTERIOR LESIONS Vertebral body collapse due to pressure and ischemia, followed by disc space narrowing. Relatively common in Thoracic spine

13. CENTRAL LESIONS Center of vertebral body Reaches through Batson’s venous plexus or through posterior vertebral artery Vertebra plane Vertebral body collapse •

14. APPENDICULAR LESIONS Uncommon lesion <5% Occurs in isolation or conjunction with paradiscal lesions Radiographically appears as erosive lesions, paravertebral shadows with intact disc space.

15. A.Active stage 1. Pain : Back pain (Commonest), Diffuse in early stages, but later become localised to the affected diseased segments. It may be a radicular pain . Depending upon the nerve root affected, it may present as: 1.Cervical root- 2.Dorsal root- 3.Dorso-lumbar root- 4.Lumbar root- 5.Lumbo-Sacral root- Arm pain Girdle( pectoral ) pain Abdomen pain Groin pain , or Sciatic pain CLINICAL FEATURES 6

16. 2. Spine Stiffness: spasm of para-vertebral muscle 3. Night cries 4. Deformity: Knuckle/Gibbus/ Kyphus . 5. Cold abscess: Patient may present with a swelling ‘cold abscess’ or problems secondary to its compression effects on nearby vicera . 6. Paraplegia (if neglected in early stages) 7

17. 7.Constitutional Symptoms (Only in 20% cases): Malaise, weight loss, loss of appetite, night sweats, evening rise of temperature. But several of these signs and symptoms may be absent . B . Healed stage No systemic features but deformity persists. Radiological evidence of bone healing Important: c/f presentation depends on 1 . Stage 2 . Site 3. Presence of complications :neurologic deficits, abscesses, or sinus tracts

18. DEFORMITIES : KYPHOSIS Knuckle 1 or 2 vert e bra Gibbus 2 or 3 vert e bra Angular kyph o sis More than 3 vertebra

19. EXAMINATION Aim of examination is : —to pick up findings suggestive of TB —to localise the site of lesion —find skip lesions —to detect any associated complications Physical general examination - to detect active or healed primary lesion. The patient may have some other systemic illness ( diabetes, HTN, jaundice etc) Following is the systematic way in which one should process to examine a case of suspected TB of spine :

20. Gait - Patient walks with short steps in order to avoid jerking the spine. In TB of cervical spine, the patient often supports his head with both hands under the chin and twists his whole body in order to look sideways. Attitude and deformity - Tb of cervical spine patient has a stiff, straight neck. In dorsal spine TB, part of the spine becomes prominent (gibbus or kyphus) Para-vertebral swelling - A superficial cold abscess may present as swelling on — the back, along the chest wall or anteriorly. It is easy to diagnose b/a of its fluctuant nature. Tenderness - Elicited by pressing upon the side of spinous process. Movement - Limited spinal movements.

21. Management P lan D iagnosis: Clinical radiological Lab studies Microbiological studies Histopathological study CT Scan MRI Scan USG Radionuclide Scan Myelography 26

22. DIAGNOSIS Complete blood picture ESR Increased / Increased Lymphocyte count ELISA For antibody to mycobacterial antigen Sensitivity 60-80% PCR Sensitivity of 40% Chest radiograph

23. Mantoux / tuberculin skin test Micro b io l ogy : Z E IH L -NE E LSEN STAINING/ACID FAST STAINING Cultures : 4-6 weeks(L-J MEDIUM) Positive only in 50% cases IFN – Release assays (IGRA’s) Assays that measure T-cell release of IFN – in response to stimulation with highly specific tuberculosis antigens ESAT6 & CFP 10

24. 32 IMAGE 1 IMAGE 2

25. 7/24/2 15 33

26. 34 End plate erosion,disc space narrowing& compression fracture Vertebal end plate sc le r o si s &c o m pe s sion fracture

27. 35 Compressive fracture with IVD narrowing C o mpr e ssive fracture with ost e osc l er o si s

28. Prevertebral Shadows 7/24/2 15 38 RETROPHARYNGEAL A B S C E S S

29. Abscess below the level of D4 vertebrae – Fusiform shape ( Bird nest appearance ) An abscess under tension may produce- Globular shape Paravertebral Shadows 39

30. CT SCAN

31. MRI

32. 7/24/2 15 42 Infection and distruction of total body Compression of spinal cord causes cauda equina Total vertebral body distruction

33. 44 USG to find out primary in abdomen Detect cold abscess Guided aspiration

34. Myelography Spinal tumor syndrome Multiple vertebral lesions Patients not recovered after decompression 1. Block present : second decompression 2. Block not present : intrinsic damage Ischemic infarction Interstitial gliosis A trophy tuberculous myelitis Myelomalacia

35. Complication of spinal tuberculosis Paraplegia Cold abscess Spinal deformity Sinuses Secondary infection Amyloid disease Fatality 50

36. MANAGEMENT Early diagnosis M edical treatment S urgical approach Prevent deformity Best outcome

37. TREATMENT Aim of treatment is to achieve healing of disease & to prevent, detect early & promptly any complication like paraplegia. Rest: Bed rest for pain relief & to prevent further collapse & dislocation of diseased vertebrae. For cervical spine Minerva jacket & collar.

38. Building up of patient’s resistance: High protein diet. ATT: This remains the cornstone of management completed by rest, nutritional support & splinting, as necessary. There is difference of opinion regarding the duration of drug therapy. Short course chemotherapy for 9-10 months has shown good results in patients. Antibiotics: For persistently draining sinuses which get secondary infection. Bed sore care & to treat other comorbid conditions.

39. Mobilisation : Gradual as improvement begins Sit & walk, the spine is supported with collar(cervical), brace( dorso -lumbar spine). Cold abscesses may subside with ATT, if present superficially may need aspiration(antigravity insertion of needle through a zig-zag tract) or evacuation. Sinuses: Mostly heal within 6-12 weeks If no improvement Excision of tract.

40. Three approach 56 Conservative plan Middle path regime Radical surg e r y a p pro a ch

41. CONSERVATIVE TREATMENT

42. SUPPORTIVE TREATMENT Rest Braces High protein diet Multivitamins Hygiene Bed sore care Chest/urinary tract care Improve immune status Treat other comorbid conditions.

43. MIDDLE PATH REGIME Rest on hard bed Chemotherapy X-ray & ESR once in 3 months kyphosis measurement MRI/ CT at 6 months interval for 2 years Gradual mobilization is encouraged in absence of neural deficits with spinal braces & back extension exercises at 3 – 9 weeks. Abscesses – aspirate when near surface & instill 1gm Streptomycin +/- INH in solution 61

44. MIDDLE PATH REGIME Sinus heals 6-12 weeks Neural complications if showing progressive recovery on ATT b/w 3-4 weeks : surgery unnecessary IF NOT Excisional surgery for posterior spinal disease associated with abscess / sinus formation +/- neural involvement. Operative debridement–if no arrest of symptoms after 3-6 months of ATT / with recurrence of disease 63

45. CHEMOTHERAPY

46. SURGICAL TREATMENT

47. Type of Surgery…

48. Nursing Management

49. Take home message MRI is the gold standard for diagnosis of potts spine Maintain high suspicion not to overlook diagnosis GOOD OUT COME EARLY DAIGNOSIS ATT REST

50. SUMMARY

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