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1. 1 Skeletal Tuberculosis - NEERA YADAV(80) -BATCH 2020 1

2. Introduction Skeletal TB a c co unts f or 1-4% of total cases of extrapulmonary tuberculosis. Although spine is the commonest site (constituting about 50%) of skeletal TB. The other bones and joints can also be involved. Skeletal TB generally occurs due to haematogenous spread from a primary focus. 2

3. 3 Classification

4. Etiopathogenesis Common Causative Organism is Mycobacterium tuberculosis. Bone and joint tuberculosis is always secondary to some primary focus in the lungs,lymph nodes etc. Mode of spread from the primary focus may be either haematogenesis or by direct extension from a neighbouring focus. PATHOLOGY -- Tb of bone produces similar response as in lungs i.e. Chronic granulomatous inflammation with caseation necrosis .

5. (A) . Proliferative Response – Chronic Granulomatous inflammation with a lot of fibrosis. (B) . Exudative Response – Extensive caseation Necrosis without much cellular reaction.This results in extensive pus formation. The infected granulation tissue and pus find their way to the subperiosteal and soft tissue planes.Here they present as cold abscesses and may burst out to form sinuses. JOINT INVOLVEMENT Joint Involvement is usually in the form of low grade synovitis, with thickening of the synovial membrane. Then,it starts destroying the cartilage from periphery. This inflammatory synovium at periphery is called Pannus.

6. HEALING It occurs by fibrosis ,which results in significant limitation or near complete loss of joint movement ( FIBROUS ANKLYOSIS). If considerable destruction of the articular cartilage has occured ,joint space is completely lost and is traversed by bony trabeculae between the bones forming the joint ( BONY ANKYLOSIS). 6

7. Clinical Features Constitutional symptoms: – The patient may be apathetic and pale Loss of weight and appetite Low grade fever(especially in the afternoons) Night sweats,tachycardia 7

8. Local clinical features — These are specific to the site involved. But generally:- Pain Swelling (may be due to cold abscess) Night cries (in children due to rubbing of the two surfaces on movements during sleep after muscle relaxation) Painful limitation of movements Muscle wasting Sinus formation Deformities (in later stages) 8

9. Investigation Radiological Examination- X ray examination of affected part in Antero-posterior and lateral view is single most important investigation. TB Osteomyelitis : It present as a well defined area of bone destruction, typically with minimal reactive new born formation. TB Arthritis : Reduction of joint space,erosion of articular surfaces, and periarticular rarefaction. Chest X-ray-to detect any tubercular lesion in the lungs. MRI scan and Bone scan are useful in early diagnosis. 9

10. 10 Other investigations Blood Examination – lymphocytic leucocytosis,high ESR M antou x test – useful in children. Serum Elisa – for detecting anti mycobacterium antibodies. Synovial fluid aspirat ion Aspiration of cold abscess- Histopathological examination,Smear for AFB & culture. Biopsy - in doubtful diagnosis,may be from synovium,bone . FNAC from lymph node

11. Treatment Aim of the treatment is to- 1. Control of the infection & 2. Care of the diseased part In most cases conservative treatment is sufficient,but sometimes operative interventions are required. Conservative tre atment (A) ( ANTI TUBECULAR DRUGS) - It is usual practice to start treatment with 4 drugs for 3 months– RIFAMPICIN,ISONIAZID,PYRAZINAMIDE,ETHAMBUTOL In multifocal cases 5 drugs RF,INH,PZ,ETH and STREPTOMYCIN are used for initial period . (B). REST – The affected part should be rested during the period of pain. In upper extremities with plastic slab In lower extremities traction can be applied. 11

12. CARE OF THE AFFECTED PART (a) Proper positioning of the joint . (b) Mobilisation – prevents contractures and helps regain movement. (c) Excercise (d) Weight Bearing . 12

13. - Biopsy: FNAC may be performed. - Treatment of cold abscess - Curettage of the lesion: if in the vicinity of joint,infection is likely to spread. - Synovecto my : in synovial TB,not responding to conservative treatment. -Joint debridement: surgical removal of infected and necrotic material. - Salvage operations are the procedures to perform in markedly destroyed joints in order to salvage whatever useful functions are possible.( e.g.Girdlestone arthroplsty ) -Decompression: in cases of paraplegia secondary to spinal tb . Surgery in Skeletal TB

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