POTT’S SPINE-1676656384.pptx

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1. POTT’S SPINE

2. Pott’s Spine Tubercular spondylitis has been documented in ancient mummies from Egypt and Peru and is one of the oldest demonstrated disease.Percival Pott presented the classic description of spinal TB in 1779. Spinal TB constitutes about 50% of all cases of osteoarticular TB. MC site: Lower thoracic and lumber region followed by middle thoracic and cervical vertebrae.

3. Regional Distribution 1 Cervical 12% 2 Cervicodorsal 5% 3 Dorsal 42% 4 Dorsolumbar 12% 5 Lumbar 26% 6 Lumbosacral 3%

4. Spine Anatomy http://www.sofamo r danek. c om h t tp : / /www.colu m bia s pi ne. org h t tp : / /www.fla-or tho .com Spinous process Inte r ver t eb r al disc Pedicle LUMBAR Tra ns v er se process Vertebral body THORAC I C CERVICAL

5. Anatomy Vertebre develops from the sclerotome on either side of notochord Each pair of sclerotome (common blood supply) form Lower half of one vertebra and upper half of one below it along with intervening disc. Therefore ,infections via the arteries involve the embryological section.

6. SPINAL TUBERCULOSIS Pathology • Spinal tuberculosis is usually a secondary infection from a primary site in the lung or genitourinary system. • Spread to the spine is hematogenous in most instances. • Delayed hypersensitivity immune reaction. • Initially : a pre-pus inflammatory reaction with Langerhan’s giant cells, epithelioid cells, and ymphocytes. • The granulation tissue proliferates, producing thrombosis of vessels.

7. SPINAL TUBERCULOSIS • Tissue necrosis and breakdown of inflammatory cells result in a paraspinal abscess. • The pus may be localized, or it may track along tissue planes. • Progressive necrosis of bone leads to a kyphotic deformity. • Typically, the infection begins in the anterior aspect of the vertebral body adjacent to the disk.

8. • The infection then spreads to the adjacent vertebral bodies under the longitudinal ligaments. • Noncontiguous (skip) lesions are also seen occasionally

9. Pathogenesis Of Spinal Tuberculosis Fi v e st a ges by Kumar KA (1 9 8 8 )  Sta g e  St a ge  Sta g e of of of Im p la n ta t ion e ar l y d e structi o n a d vanced d e struction a n d coll a pse  St a ge of  Sta g e of n e u ro l o g ical i n volve m e n t resid u al d e for m ity

10. Patterns of Vertebral Involvement Four patterns : Paradiscal Central Anterior Appendiceal (Posterior)

11. Paradiscal Commonest type Spread through arterial supply Bacteria lodge in the contiguous areas of two adjacent vertebrae  granulomatous inflammation leading to erosion of vertebral margins loss of nutrition of intervertebral disc Disc degeneration When the intervertebral discs have been completely destroyed,the adjacent bodies fuse with each other.

12. Central Lesions Body of single vertebra is affected. Starts in the centre of the vertebral body. Infection at this site probably reaches through Batson’s venous or branches of post.vertebral artry. Lytic area develops in the centre of vertebral body leading to balooning of vertebral body mimicking tumour Later stages-concentric collapse resembling Verebra Plana. Disc space is not/minimally affected

13. Anterior lesions— Infection starts in the anterior part of vertebral body and spreads under the ant. Longitudinal ligament. Post/Appendiceal — Pedicle,lamina,spinous process or transverse process of vertebra are affected.

14. Clinical Features Constitutional symptoms,such as fever, night sweats,loss of weight and appetite may occur before symptoms related to spine. 1. Pain -can be Localised to the site(MC early symptoms) Radicular worsen with activity and at night(night cries) 2. Stiffness -Protective mechanism of body where paravertebral muscle go into spasm to prevent movement at the affected vertebra.

15. 3. Cold abcess - Patient may present the first time with swelling(cold abcess) or due to its compression effects:- Retropharyngeal abscess --Dysphagia,dyspnea, Hoarseness of voice Mediastinal abscess --Dysphagia Psoas abscess -- Flexion deformity of hip -No usual signs of inflammation like heat ,redness etc. -Follows paths of least resistance along facial planes,blood vassels &nerves.

16. Presentation of cold abscesses from different regions of spine Cervical spine- Exudate collects behind prevertebral facia and may protrude as Retropharyngeal abscess , It may track down in mediastinum to enter into trachea,esophagus or pleural cavity.It may spread lateraly into sterno-cleido mastoid and form abscess in neck. Thoracic spine- It may confined locally and may appear on X-ray as fusiform or bulbous paravertebral abscess .It can compress spinal cord or penetrate the ant.longitudinal ligament to form a mediastinal abscess or pass downward through medial arcuate ligament to form lumber abcess. Lumber spine- Most commonly enters the psoas sheath Psoas abscess,also abscess in scarpa’s triangle,medial aspect of thigh

17. 4.Fallacious history of trauma- Trauma may draw attention to a pre-existing lesion or may activate a latent tubercular focus 5. Paraplegia -Rarely it is the presenting symptom. 6. Wedging :- Dorsal spine : Line of weight bearing passes ant to vertebrae.Ant wedging occurs.In late stages leading to kyphotic deformity Cervical and lumber spine : Wedging is less due lordotic curvature 7. Gibbus -If patient presents late

18. Examination Gait - Patient walks with short steps to avoid jerking the spine.In TB of cervical spine,patient often supports his head with both hands under the chin and twists his whole body in order to look sideways. Attitude and deformity :- Cervical spine : Stiff,straight neck Thoracic spine : Kyphus or gibbus,walks very carefully Lumber spine : Loss of lumber lordosis

19. 3. Paravertebral swelling - Superficial cold abcess may present as fullness or swelling on the back,along the chest wall, usually fluctuant. It is important to look for cold abcesses in not so obvious locations,depending upon the region of spine involved . 4. Neurological Examination- To determine if there is any neurological compression and to determine level and severity of neurological compression 5. General examination- For any active or healed lesion,for any other systemic illnesses like,diabetes,HT,jaundice etc.

20. Thi n king Abo u t Disease Pott’s Clin i cal Presentation 1) 2) 3) 4) 5) 6) spasm (8 8 %)

21. Investigation Radiological examination : - 1. Xray spine-AP,Lateral 2. CXR-for primary focus 3. Xray abd-KUB,if psoas abcess is suspected or to find out Primary in abd. The classic roentgen triad in spinal tuberculosis is primary vertebral lesion, disc space narrowing and paravertebral abscess. On an avg. 2.5 to 3.8 vertebrae are involved

22. Clini c o - Radio lo gi c al Cla s s i fi c at i on Kumar(1 9 8 8 ) Degree of d e formity bone de s truction and ST A GE ST A GE ST A GE STAGE ST A GE I II I I I IV V

23. Thi n king Abo u t Disease Conv e ntion a l Radio l ogi c al Pott’s Pre s ent a tion Par a d i scal (5 4 %) Cen t ral (1 9 %) An t er i or (4 % ) Ap p e n dici a l (4%) Atl a nto axial (1%) Nor m al (2 % ) M u lti p le (1 8 %)       

24. Radiographs : General Features Feature s of Pott’s on radio g rap h include • – – – – – – – Signs of infection with lytic lucencies in anterior portion of vertebrae Disk space narrowing Erosions of th e endplate Sclerosis resulting from chronic infection Compression fracture Continuous vertebral bod y collapse Kyphosis; gi b bous (sever e kyphosis) • Atypica l features – – – – – Soft tissue swelling from paraspinal a b scesses, + /‐ calcification Involvement of only o n e vertebral body Involvement of se v eral vertebral bodie s without intervertebral discitis Bowing of rib cag e secondar y t o collapse of multiple vertebral bodies Destruction of la t e ra l o r posterior aspects of vertebral bodies

25. Paradisca l : Reduction in disc space- Initialy there is demineralization with indistinct bony margins-gradually disc space narrowing occurs.The disc space may eventualy disappear leading to wedging. Lateral X-ray is better for evaluation of disc space. Takes 3-5 months for bony destruction to become visible on X-ray More than 30 % of mineral must be removed from bone for a radiolucent lesion to be visible

26.  Tuberculous spondylitis. Lateral radiograph demonstrates obliteration of the disk space (straight arrow) with destruction of the adjacent end plates (curved arrow) and anterior wedging.

27. There is narrowing of the disk space at L4-5, with end plates indistinctly outlined. CT section through the disk space clearly shows destructive changes of the disk and vertebral end plate characteristic of infection

28. Radiological Examination 2 . Central : Lytic area in the centre of vertebral body which enlarges and baloons out like tumour.Disc space is preserved. 3. Anterior : Shallow excavation on anterior or lateral surface of vertebral body. 4.TB of posterior elements is usually not detected in early stages in radiographs. Late Stages -- Kyphotic deformity,lateral shift and scoliosis,if one side of vertebrae is completely destroyed Hemivertebrae Signs of healing— bone density improves,sclerosis, fusion of contiguous vertebrae. Skip lesions as involvement of non contiguous vertebrae (7 – 10 % cases).

29. X-ray dorsolumbar spine showing vertebra plana of T10 vertebra. Disc space is well maintained.

30. Subligamentous spread of spinal tuberculosis. Lateral radiograph demonstrates erosion of the anterior margin of the vertebral body (arrow) caused by an adjacent soft-tissue abscess.

31. Destruction of the right side of the vertebral body and the neural arch, with the remainder of the body maintaining its shape. The lower disc space is narrowed on the right side; the upper space is almost normal and there is a small paravertebral abscess.

32. Evidence of cold abcess on X-rays Paravertebral abcess : Paravertebral soft tissue shadow corresponding to the site of affected vertebrae in AP view can Fusiform [bird nest abcess ] : L> W,seen in dorsal spine area. Globular or tense : W> L,pus under pressure a/w paraplegia Widened mediastinum : Abscess from dorsal spine may present as widened mediastinum

33. Aneurysmal phenomena : Concave erosions along the margins of vertebral bodies produced by long standing tense paravertebral abcess,usually in dorsal spine Retropharyngeal abcess : In cervical spine TB,seen on lateral view : increase in soft tissue thickness (>4mm) in front of C3 vertebral body. Psoas Abcess : In dorso-lumber and lumber TB,psoas shadow on X-ray of abd may show a bulge.

34. X-rays of cervical region showing retropharyngeal abscess.

35. CT Scan CT demonstrates abnormalities earlier than plain radiography. It is of great value in the demonstration small paravertebral abscess,not otherwise seen on plain X-ray or any calcification within the cold abscess or visualizing epidural lesions containing bone fragments.

36. A CT scan showing destruction of the neural arch on both sides, as well as of the vertebral body. Arrows, anterior spinal abscess

37.                                                                                   Tuberculous spondylitis. Axial CT scan demonstrates lytic destruction of the vertebral body (black arrow) with an adjoining soft-tissue abscess (white arrow). Calcified psoas abscess. Axial CT scan demonstrates bilateral tuberculous psoas abscesses with peripheral calcification (arrows).

38. Current Trends In Imag i ng ROLE OF CT S C A N  CT I M AGING shows f o cus of - - - - - Bo n e Early L e vel I nf e ction Er o sions Of L e sion Am o u n t Of Bo n e Destr u ction Poster i or El e m e nt L e sions

39. CT : Features Features o n CT • Soft tissue findings ‐ Abscess with calcificatio n is diagnostic o f spina l TB; CT is excellent modality to visualiz e soft tissue calcifications • Pattern an d severity o f bony destruction ‐ Patter n of ver t ebr a l bo d y destructio n‐ framentary , osteolytic, loc a liz e d and sclerotic , and subperiosteal • Used t o guid e needle i n percutaneous needle biopsy of paraspina l abscess

40. MRI Investigation of choice to evaluate the type and extent of compression of cord,to know the spread of disease under the anterior or post.ligament, most effective to demonstrate neural compression,helps to differentiate between TB and pyogenic infection :- TB – Thin and smooth enhancement of the abcess wall Pyogenic – Thick and irregular MRI is more sensitive than x-ray and more specific than CT in the diagnosis of spinal tuberculosis.

41. Cord changes Conventional radiograph -no information CT –inadequate assesment MRI -gives invaluable information Cord oedema or focal myelomalacia is seen as hyperintense signal and It can also diagnose extraosseous extradural granuloma.

42. Current Trends In Imag i ng ROLE OF M R I SC A N  MR IMAGING IDENTIFIES - - Cord co m pr e ssion / ch a n g es Soft tissue sha d ows a n d i n tr a osse u s a b sces s es Skip l esio n s - - Sub li g a m e n to u s spread of i n f e ction a n d e p i d ur a l e xte n sion The I m a g ing M e thod Of Choice -

43. MRI: Features • • • Highly sensitive and specif i c for Provides early detection spinal TB Best to distinguish exact tissue involvement extent of spinal cord and soft • Features – – – Edema o f vertebrae and disk space Signs o f spina l compromise i.e . cor d compression Not e : Poorly visualize s calcificatio n i n abscesses

44. MRI: Spinal Cord Involvement PACS, B I DMC Sagittal T2W (Images 1-3)and axial T1W (Image 4) High i n tensity activity in T12 to L3 vertebrae indicative of infection ( * ) ( * ). Complete destruction of vertebral bo di es with osseous retro p ulsion i n to the spinal canal, causing cauda equina ( * ). On axial view, note destruction of vertebral b o d y wi t h l os s o f c i r c u la r s ha p e ( * ). 4 3 2 1

45. D9 D9 L1 L1 L3 L3 B on e Sc hoo l @ B an g a lore

46. ‘ Gibbus formation’ in the thoraco-lumbar region of a patient with spinal tuberculosis (left). The magnetic resonance shows spinal tuberculosis at T10–T12. Spinal tuberculosis causes the destruction, collapse of vertebrae and angulation of vertebral column

47. X-ray of cervical region which shows spinal tuberculosis of cervical six to seven vertebrae and a retropharyngeal abscess (left). T1-weighted image of an MRI of same patient, which shows destruction of C6–C7 vertebrae

48. T2WI MRI-bilateral psoas abscess

49. Current Trends In Imag i ng ROLE OF BO N E SC A N  Helps in detection of e a rly le s ions w h en radiol o gi c ally n o rmal  Helpful in d iagn o sing s k ip le s ion s / in v ol v em e nt of other bo n es  95% se n sitivity

50. Advantage of Bone Scan B on e F S e c h o b o l @ 2 B an g 1 a l o 1 re May 2 11 J an 2 11

51. Myelography To determine the level of obstruction May be indicated in cases with ‘spinal tumour syndrom’ In cases of multiple vertebral lesion When pt has not recovered after decompression

52. FNAC : Especially of cold abcess,ZN Stain,C/S Biopsy : May be required in cases of doubtful diagnosis Other Investigation : To support the diag:- Increased ESR,Decreased Hb,relative lymphocytosis,Mantoux

53. The Sero-immun o logical and Bioc h emical Investigations  POLYMER A SE C H AIN R E A C TI O N - Sim p le a n d wid e ly u s ed - Highly se n sitive but less sp e cific  ROLE OF IgM A N D OTHE R S - L o w s p e c if i city a n d s e n s it i vity - Of l o w pre d ictive v a lue in s p inal TB e x tra - p u lmo n ary di s e a s e s and other

54. Differential Diagnosis Congenital defects like Schmorl’s disease, Scheurermann’s disease. Infetious conditions like Acute pyogenic,Typhoid spine,Brucella spondylitis,Mycotic Spondylitis,Syphillis Tumours Conditions :- Benign : Hemangioma,Giant cell tumour,Aneurysmal bone cyst. Malignant : Ewing’s sarcoma,Osteogenic sarcoma,Multiple myeloma,secondaries Traumatic conditions

55. Even th o u g h, classi c al clinical a n d ra d i o l o g i cal f e a t ur e s h a ve b e en d escrib e d in the li t er a tur e , spin a l t u b e rculosis d o es mi m ic ot h er lesi o ns Can be MIS S ED, MIS T AKEN or MISDIAGNOSED

56. The Missed Lesions @ C B a T n g a lore MRI X - Ray

57. The Mistaken Lesion X - Ray CT MRI

58. The Misdiagn o sed Lesion M R I X - Ray

59. Treatment Before availability of ATT,mortality rate was 30 % or severe crippling deformities Aim of treatment is to achieve healing of disease & to prevent,detect early and promptly any complication like paraplegia Rest : Bed rest for pain relief and to prevent further collapse and dislocation of diseased vertebrae.in children body cast is used.For cervical spine Minerva jacket&coller

60. Building up of patient’s resistance : High protein diet. ATT : This remains the cornstone of management, completed by rest,nutritional support and splinting, as necessary.However, there is difference of opinion reg.the duration of drug therapy.Short course chemotherapy for nine months has shown good results in patients with disease coused by succeptible microorganisms. Antibiotics : For persistently draining sinuses which get secondary infection. Bed soar care and to treat other comorbid conditions.

61. Mobilisation : Gradual as improvement begins  sit & walk,the spine is supported with coller(cervical),brace (dorso-lumber spine) Cold abcesses may subside with ATT,if present superficially may need aspration(antigravity insertion of needle through a zig-zag tract) or evacuation(wound closed without a drain) Sinuses: Mostly heal within 6-12 weeks.If no improvement  Excision of tract

62. Pot t Disease: Treatment • • Various imagin g modalitie s ar e usefu l i n determinin g exten t of disease. Treatmen t options the n depend on the degre e of spin a l destruction. O g uz e t al.- h t tp: / / ww w . s pri ng erlink.com . ezp- p rod 1 .h u l.h ar v a rd.ed u/ c o n ten t /h48 2 j21x5548q078 / f u ll t e x t.p df Most practicing clinici a ns simply defin e Pott’ s a s EARLY or LATE disease. GATA Classification

63. Anti Tub e rcular Dru g s  Sp e cific a n t i -t u b e rcul o us dr u gs h a ve revol u ti o nized the o u tcome of spin a l tu b ercul o sis which is n o w consid e red cura b le to be  It h a s t o b e r e al i zed th a t surg i cal tre a tm e nt can n ot re p l a ce che m o t h e ra p y

64. Anti Tub e rcular Dru g s  One in 2 0 n e w cases of t u b e rcul o sis is consid e red to be m u lti d ru g -resistant  T h er e f o re, in spi n al t u b e rcul o sis, 3 m o n t hs of in t e n sive che m ot h er a py with 4 d ru g s fo l low e d by 1 2 -15 m o nt h s o f m ai n te n a n ce t h er a py with two d ru g s is n e cessary

65. The Role of Empi r ical Treatment  Always an a ttem p t s ho u ld be made to pr o ve the d i a g n o s i s be f o r e t h e r a py is i n it i at e d  Howe v e r , y o u ng p a ti e nts with c l a s s i c al c l i n i c o - ra d io l og i c a l f e at u res and hi g h ESR may b e em p ir i c a lly s ta r ted on ATT  If em p ir i c a l th e r a py is i n it i at e d, met i c u l o us moni t or i ng to e n s ure s u st a in e d i mpr o v e ment is necessary

66. Empirical Treatment 3 wee k s Post Pre C h emo  Feb r ile  Pain Chemo Afe b ri l e Pain E S R 18     E S R 84 m m /hr mm / hr

67. Con t roversial Surgeries LAMIN E CTOMY  Is CO N TR A I N DI CA TED in s p i n a l t u b e r c u l o s i s becaus e th e diseas e i s presen t anteriorl y an d by do i ng a p o s te r ior d e c o mpr e s s io n , the s p ine b e c o mes c om p l e te l y u n s t a b le  It is o n ly i n d i c a ted in c a s es of p o s t e r i o r e l e me n t d i s e a s e and s p i n a l t um o ur s y n d r o me

68. P r e-laminectomy M R I P os t -laminectomy CT B on e Sc hoo l @ B an g a lore P os t -laminectomy M R I

69. Limi t ed Surgeries In Tuberculo s is of Spine  DRAINAGE OF COLD ABSC E SS  COSTO-TRANSV E RSEC T O MY  LUMB A R TRANSVERSECTOMY

70. Limi t ed Surgeries In Tuberculo s is of Spine DRAIN A GE OF COLD ABSCESS

71. Limi t ed Surgeries In Tuberculo s is of Spine  C O S T O - TR A NS V ER S ECT O MY Excision of p o rti o n of a rib a n d the art i cula t ing tr a nsverse pr o cess

72. C o nv e ntio n al Limited Surgeries  A N T E R O- LA T E R AL D E COMP R E S SION Fir s t de s c r i b ed by Cap e n e r ( 1 9 3 3 ). Only op e ra t ion in whi c h d e c o mp r e s s i on of the c o rd is p e rf o rm e d by rem o vi n g t h e a ct u al c a u s e of com p r e s s i o n La t er a l R achoto m y by Ca p ener

73. Co n ventional Radical Surgery  Hodgson et a l.( 1 9 6 ) Deve l o p ed t h e conc e pt of ra d ical excision of the dise a sed verte b ral b o di e s a n d t h e i r re p l a cem e nt by b o ne gr a fts in all c ases spin a l tu b ercul o sis of

74. Indication for surgery 1. Doubtful diagnosis where open biopsy is necessary 2. Failure to respond to ATT 3. Radiological evidence of progression of bony lesion or paraspinal abcess shadow. 4. Imminent vertebral collapse. 5. Instability of spine and subluxation or dislocation of vertebral body.

75. Conventional Indications Surgery Griffith and Sed d on for Absol u te In d icati o ns Rel a tive In d icati o ns Rare I n d i cati o ns

76. Absol u te Indic a tions  Par a pl e gia d u ring conservative tre a tm e nt  Par a p l e g ia worse n i n g d u ri n g tr e a t m e nt  Com p le t e m o tor loss for 1 m o n th d e spite cons e rvative tr e a t m e nt  Par a pl e gia with u n contr o ll e d spasticity  Severe a n d ra p id o n set p a ra p le g ia  Sev e re fl a ccid p a ra p l e g i a/ se n sory l o ss

77. Rel a tive in d icati o ns Rare in d icati o ns Rec u rr e nt p a r a p l e g ia Par a p l e g ia Painf u l and p a r a p l e g ia Par a p l e g ia Post e ri o r eleme n t d i s e a s e Spi n al t u mor s y nd r ome Sev e re c e r v i c al l e s i on c p a r a p l e g ia 1. 1. in e l d e rly s pa s tic 2. 2. 3. 3. with 4. c o mpli c at i ons (UTI) Cau d a e q u i n o p at h y 4.

78. Conv e ntio n al Treat m ent: Tuli  Anti tu b ercul a r dr u gs are t h e m o st i m p o rt a nt t h er a p e u t ic m e asure  ATT m u st be con t in u ed for a b o u t 1 8 m o nt h s( m u st incl u de Iso n iazi d e)  Pat i e n ts with e a rly dise a se can achi e ve fu l l cli n ical h e a li n g  In d icati o ns of surgery are m a in l y f or com p licat i o n s th a n for the dise a se contr o l

79. The M i ddle Path Regimen of Tuli – Surgical Indic a tions  No n e u r o l o g i c a l r e c o v e ry af t er 4 w e e k s of A T T  Dev e lo p ment of ne u ro l og i c a l de f ic i t duri n g the c o u r se of c h em o th e r a py  Re c u r r e n c e o f ne u r o l o g i c a l d e fi c it aft e r i n i ti a l impr o v e ment  Wo r s e n i ng of n e u r o l o g i c al d e fi c it while on c h em o th e r a py  Adva n c e d case of ne u ro l og i c a l in v ol v eme n t

80. B R ITISH M E DIC A L R E S E A R CH C O U N CIL When a p pr o pri a te facil i ti e s and exp e rtise are avai l a b le ra d ical sur g eri e s h a ve d e fi n ite a d van t a g e over n o n -o p er a tive tre a tm e nt J B o ne Jo i nt S u rg 60 (B), 6 1 (B) 64 However lo n g t erm fo l low u p o f surger i es showed consid e ra b le (B) and 67 r a dical loss of ( B) correction a n d fa i lure of t h e b o n e g raft le a di n g to pr o gr e s s ion of k y p h osis P a r t has a rathy et a l, R a j a shek a r a n et a l, S u nd a ra r aj and Moon et al et a l

81. Curr e nt Trends In The Surgical Man a gem e nt of Spinal Tube r culosis Aims  Correcti o n of k y p h osis  Early fusi o n  Preve n ti o n of  Prev e n t i o n of pr o gr e s s ion of k y p h osis l a te o nset p a ra p l e g i a

82. Curr e nt Trends In The Surgical Man a gem e nt of Spinal Tube r culosis Debr i dem e nt, an t er i or in s tr u ment a ti o n and fu s ion Ant e ri o r de b ri d em e nt a n d a nt e ri o r c o l u mn re c on s tr u ct i on with b o ne graf t ing or C A GE Deb r i d em e nt, p o s t e r i o r i n s tr u me n ta t i o n a nd fu s i o n

83. Anterior Debridement And Reconstruction  Hel p s in n e u ro l o g ical recov e ry a n d pr o d u ces e a rly fusi o n  However, achi e ves o n ly li m it e d c orrecti o n of k y p h osis a n d m ay n o t b e a ble to pr e vent pr o gr e ssion

84. Ant e rior D e bridem e nt R e const r uction And

85. A n terior Ra d ical De b rideme n t And Anterior Instrumentation Be n li I T B e o n t e a S c l h . o o E l @ u B r a n S g a l p or e ine J 2 03

86. can be Role of Poste r ior Instrumentat i on And Fusion  Ag g ressive correct i on of achi e ved kyph o sis  Preve n ts recurre n ce of k y p h osis  Not b e n e fici a l w i t h o u t a n t e ri o r d e bri d e m e n t a n d f usion

87. Combined Ant e rior De c ompression And Graf t ing / CAGE With Post e rior Bone Instrum e nt a t i on And Fusion  Sin g le s ta g e th r o u gh two ap p r o a c h e s - Combin e d an t er i or a n d po s te r i o r  Sin g le p o s t e r i o r approach

88. Combin e d Anterior Dec o mpr e s s ion And Bone Grafting / CAGE With Post e rior In s trume n tation And Fus i on  LIM I TATIONS - - Ne e ds a p pr o pr i a t e f a cili t i e s a n d exp e rtise In t e n sive a n a e sthe t ic a n d p o stop e rat i ve care Seco n d a ry in f ecti o n a nd i m pl a nt fa i lure -

89. Procedures Anteriolateral decompression with interbody bone grafting.Grafts placed anteriorly. Costo transversectomy with dempression Metallic implants& titanium cage filled with cancellous bone when whole body is destroyed. Kyphotic deformity is prevented by ant debridement,ant inerbody fusion&post fusion.

90. Concl u sion  Ear l y di a g n o s is a n d t r e atm e nt p r e v e n t c o mpli c at i ons  Thr e at of MD R- TB  In t e n s i ve c h em o th e r a py a n d  PCR / CT / M R I / Bone s c a n di a gn o sis  Mo r e a g g r e s s i v e a nd r a d i c a l a d v o c a te d : m o n i to r i n g he l p in e a rly s u r g e ri e s a r e To To To c o r r e ct a n d p r e v e nt p r o g r e s s i o n o f ky p h o s i s a c hi e ve b e tter h e al i ng and l e s s en t h e c h a n c e of l ate o n s e t p a r a p l e g i a

91. Complicatio n s  Cold a b s c e s s and si n us  Spi n al d e fo r mity  Pott ’ s p a r a p l e g ia

92. Cold Absce s s  Classic local sig n s o f acu t e i n f e ction (cal o r ru b or) n o t e voked a n d  Pus accumu l at e s b e n e ath a n ter i or lo n gi t u d in a l l i g a m e nt a n d exte n ds al o ng p a ths of le a st resistance

93. Cold Absce s s - cervical spine  Ret r o p h a r y n g e a l a b s c e s s - dysphagia , diffi c ult ph o na t ion  Ne c k swe l li n g - b e h i nd s t e r n o ma s to i d in p o s t e r i o r tr i a n g l e of n e c k  Me d i a s t i n um  Axil l a an d c u b i tal fo s sa ( a l o ng v e s s el a n d n e r v e )  Spi n al c a n al

94. Cold Abscess - thoracic spine Pre v e r te b r a l - po s te r ior me d i a s t i n um  E m p y em a - ru p tu r e i n to pl e u r a  Track al o ng i n te r c o s t al nerves 

95. Cold Abscess - thoracic spine  Ext r a p l e u r al space - Spre a ds la t er a lly  Spi n al c a n a l - c o rd c o mp r e s s i on pa r ap l eg i a a n d B on e Sc hoo l

96. Lo w er t horacic spine Tra c k down thr o ugh l a ter a l ar c ua t e l i g ament  Ki d ney bed Ant e ri o r a b domi n al wall (via nerve pla n es) Medi a l a r c ua t e l i g ament  Ps o as s h ea t h Th i gh swe l l i ng

97. L u mbar spine- Ps o as Absce s s  Pso a s ab s c e ss c a n tr a v e l al o ng s c ia t ic n e r v e to pe l v i s, g l ut e al r e g i o n , p o s t e r i o r as p e c t of th i gh a n d r e g i on p o p li t e a l

98. Infection And Progres s ion Of K y phosis  Infection G ranu l ation T issue Kyphos i s Destruction Co l lapse  Infec t ion Kyphos i s Os t eopenia Col l apse  Infection A VN Co l lapse Kyphos i s

99. Mec h anical Ca u ses of Progression of Ky p ho s is Involv e ment of a nterior a n d mid d le co l umn produc e s prog r essive kyph o sis  Involv e ment of o nly the mid d le or the po s terior co l umn m ay not p r od u ce kyph o sis  Active c onti n uo u s gro w th of the p o sterior co l umn leads to progressi o n 

100. Defor m ity  Knuckle deformit y : We d gi n g a d jace n t verte b ral b o di e s o f 1 o r 2  Gi b bus deformit y : wed g e co l la p se of 2 -3 verte b ral b o di e s a n ter i orly  Rou n d kyph u s deformit y : m o re th a n 3 verte b rae we d g i ng o f

101. Pott’s Paraplegia Par a p l e g ia is t h e re s u l t o f  in t er f er e n c e c o n d u c ti v ity tr a c t s of the w ith the of the p y r a mid a l s p i n al c o r d a nd is mo s t oft e n as s o c i a ted with the tu b e r c u l o s i s of the d o r s al s p i n e (10 – 30 %) It c a n be e ar l y o r l ate o n s e t 

102. W h y para p legia is comm o n dorsal spine? in Co m m o n e st site f o r t u b e rcul o sis Th o racic k y p h osis h e lps in squ e ezing pr o d u cts i n to t h e can a l Cord : ca n al rat i o i s small e r Sp i n a l cord ter m in a tes b e low L 1 1. the 2. 3. 4. An t . L o n. L ig . I s l o ose in thor a cic spi n e wher e as in lu m b a r p u s e nt e rs t he pso a s 5.

103. Pott’s Paraplegia  EA R LY ON S ET PA R AP L EGIA  Occurs w h en d i se a se is a c tive  Us u al l y w i thin 2 years of o nset of dis e ase  Us u al l y progn o sis is go o d the  LA T E ON S ET PA R AP L EGIA  P a rapl e gia of he a l e d dis e ase  Occurs 2 ye a rs a f ter the on s et of dis e ase  H a s po o r progn o sis the

104. Ca u ses of early o n set para p legia S e ddo n - 1935 A) Infl a mm a tory c a u s e s : 1. Absces s / in f la m m a tory tissue caseat i ng m a ss a n d 2. Sp i n a l t u m or syndr o me (circumscrib e d tu b ercul o us m a s s ) 3. Poster i or spin a l dise a se 4. In f ective thr o m b osis

105. Ca u ses of early o n set S e ddo n - 1935 para p legia B) Mechanic a l c a use s : Pat h o l o g i c al s u b l u x at i o n / d i s l o c at i on 1. Cord c om p r e s s i o n by s e q u e s tr a / l o o s e fr a gm e nts of b o n e / g r a n u l at i on t i s s u e / de b ri s / disc 2.

106. Ca u ses of late o n set S e ddo n - 1935 paraplegia A) Inflammato r y caus e s: Con t i n u e d a c ti v ity or r e a c ti v at i on B) 1. Me c hanic a l c a use s : Cord s tr e t c h e d ov e r i nt e r n al gi b bu s / tran s v e r s e rid g e Vas c u l ar a n d dura l fi b r o s i s 2.

107. Causes of Paraplegia Extrins i c c a us e s 1) a) In a c ti v e di s e a s e : Abs c e s s 2) a) In hea l ed dis e a s e Tra n s v e r se ri d ge i n te r n a l gib b us / Gra n u l at i on t i s s ue b) Fib r o s is of d u ra Seq u e s te r ed a n d di s c Pat h o l o g i c al s u b l u x at i on / d i s l o c at i on b o ne b) c) d)

108. Causes o f Paraple g ia Intrin s ic c a us e s : Tube r c u lar Rare c a us e s : Inf e ct i ve th r omb o sis of the c o r d Spi n al t u mor s y nd r ome  1.  1. i n v o l v em e nt of the d u r a / cord meni n g e s/ 2.

109. Pott’s Paraple g ia Classification - Kum a r & Tuli Stage Cli n ic a l fe a tures I N e g l i g i b le P a tie n t u na w are of n e ur a l d e ficit, p h y sic i an d e tects p l a n tar e x te n sor a n d/ o r a n kle cl o n u s. II Mi l d P a tie n t a w a r e of d e ficit b u t ma n a g es to w a l k w ith su p p o rt, cl u msi n ess of g a it. III Mo d er a te P a ra l y sis in e x te n si o n, se n sory d e ficit l e ss th a n 5 0% IV S e vere I I I + fl e x or sp a sm/ p a ra l y sis in f l e x i o n/ flacc i d/ se n sory d e ficit more th a n 5 % / sp h i n cters i n vo l ve d . B on e Sc hoo l @ B an g a lore

110. THANK YOU

111. T h a n k B on e Sc hoo l @ B an g a lore Y ou