Skeletal tuberculosis

Skeletal tuberculosis by Dr Bipul Borthakur

1. DR. BIPUL BORTHAKUR PROFESSOR & HOD DEPARTMENT OF ORTHOPAEDICS SILCHAR MEDICAL COLLEGE SKELETAL TUBERCULOSIS

2. BONE TUBERCULOSIS Spine – Pott’s spine (50% of all cases of skeletal Tuberculosis) Joints - Tubercular arthritis: Hip Joint Knee joint and Triple deformity Shoulder joint and Caries Sicca Elbow joint Wrist and Carpus Sacroiliac joints Long and flat bones - Tubercular osteomyelitis Short bones – Tubercular dactylitis ( spina ventosa )

3. PRINCIPLES OF MANAGEMENT General and systemic treatment is like that of TB in general Any concomitant disease must be treated Hospitalization required only for- Complications Deformity correction under supervision

4. SURGERY IN BONE AND JOINT TUBERCULOSIS Exploration and appropriate operation mandatory when- Lesion not responding favorably to drugs Doubt in diagnosis Refractory recrudescence of infection Juxta-articular osseous focus threatening the joint

5. TUBERCULOSIS OF SPINE first described by Sir Percival Pott in 1779 , hence the name Potts disease Usually two continuous vertebrae involved but several vertebrae maybe affected, skip lesions and solitary vertebral involvement may occur skip lesions -- 4 -10 % of cases. 12% cases - has associated other osteo-articular tuberculous involvement

6. CLINICAL FEATURES any age group; majority <30 years Male=female Rare in the 1st year of life but when it occurs, tends to be more severe Constitutional symptoms: Malaise Loss of weight/appetite Night sweats Evening rise of temperature

7. CLINICAL FEATURES Specific Symptoms: Pain/Night cries Stiffness/spasm of vertebral muscles Localized/Persistent backache Deformity Restricted ROM Enlarged lymph nodes Abscess and sinuses Neurological deficit

8. NEUROLOGICAL COMPLICATIONS 10-30% cases – Neurological deficit Age: 1st 3 decades Disease below L1 vertebrae rarely causes Paraplegia Highest incidence of paraplegia: TB of lower thoracic vertebrae Commonest pathology for non traumatic paraplegia in developing countries still remains Tuberculosis

9. Staging of Neurological Deficit Goel 1967, Tuli 1985, Kumar 1988, Jain 2002 Stage Severity Clinical Features I Negligible unaware of neurodeficit plantar extensors or ankle clonus + II Mild aware of deficit walks with support III Moderate Non ambulatory due to spastic paralysis (in extension) sensory deficit <50 % IV Severe III + Flexor spasm / Paralysis in flexion / Flaccid/ Sensory deficit > 50 % / Sphincter Involved

10. CLINICAL FEATURES OF POTT’S PARAPLEGIA Paraplegia itself – Rare Spontaneous muscle twitching in lower limbs Clumsiness while walking Extensor plantar response Exagerrated reflexes – Sustained patellar and ankle clonus Motor affected first – then Sensory Sense of position and vibration – last to disappear

11. Regional distribution of Spine TB (in pre-MRI era) • Cervical – 12% • Cervicodorsal – 5% • Dorsal – 42% • Dorsolumbar – 12% • Lumbar – 26% • Lumbosacral (including sacrum) – 3%

12. Types of vertebral lesions 5 types: Paradiscal - Arterial spread 2. Central – Venous spread 3. Anterior- Subperiosteal spread 4. Appendiceal / neural arch 5. Synovial

13. LABORATORY INVESTIGATIONS CBC: Hb % ↓ ESR: Raised:active stage of disease Normal ESR over period of 3 months : stage of repair CRP Biopsy In case of doubt, mandatory to prove the diagnosis by obtaining the diseased tissues

14. Smear and culture Culture: gold standard Staining: Zeill - Neilson stain - sensitivity 25 to 75 % Culture: Lowenstein jensen - median incubation period: 4 to 6weeks Bactec For faster culture of Mycobacterium tuberculosis( Bactec radiometric culture) takes < 2 weeks (7-14 days)

15. PCR Ideal for detection of paucibacillary TB case ADVANTAGES Highly efficient, sensetive & rapid method for Dx – 3days Can differentiate typical mycobacteria from atypical mycobacteria DISADVANTAGES Not able to differentiate live from dead organism Does not tell about the activity of the disease PCR – not a substitute for culture

16. IMAGING MODALITIES Conventional Radiographs – often negative in early disease >30 to 50 % of mineral must be lost before a radiolucent lesion becomes conspicuous; takes about 2 to 5 months

17. Computed tomography early detection of bone and soft tissue changes better anatomic localization and evaluation of difficult areas such as cranio -vertebral junction, cervico -dorsal junction, sacrum guidance for biopsy, surgical approach Disadvantages- Early signs (inflammatory marrow changes) in vertebral body not well depicted Effect on the thecal sac and spinal cord and neural elements : difficult to evaluate properly

18. Magnetic resonance imaging modality of choice MRI Scores over CT in Detection of early disease (marrow edema) Skip lesions more easily and more often detected Detection of epidural, meningeal and cord involvement Planning the surgical approach Diffusion weighted MR imaging : distinguish between tubercular and neoplastic vertebral disease (metastasis , myeloma)

19. PET CT high sensitivity : chronic osteomyelitis determine multiple occult foci of involvement in single scan Baseline for monitoring response to treatment and information on disease spread Guide the site of biopsy or other interventional procedures Limitations– uptake patterns are indistinguishable from malignant processes

20. USG to find out primary in abdomen Detect cold abscess Guided aspiration Radionucleotide Scan T 99m ↑ uptake in up to 60% patients with active tuberculosis >= 5mm lesion size can be detected Aid to localize the site of active disease detect multilevel involvement

21. BASIC PRINCIPLES OF MANAGEMENT Early Diagnosis Expeditious medical treatment with ATT DOTS daily regimen Aggressive surgical approach Prevent Deformity

22. Present management Conservative treatment with ATT Radical surgery Monitoring Radiographs and ESR at 3-6 months interval MRI at 6 months interval for 2 years Gradual mobilization Encouraged in absence of neurological deficit with support of spinal braces As soon as the diseased part permits

23. Absolute Indications of surgery No progressive recovery after fair trial of conservative treatment Neurological complications develops during conservative treatment Worsening of neurological deficit during t/t Recurrence of neurological complications Pressure effects (deglutition/respiration) Advanced cases of neurological involvement (Sphincter disturbances, flaccid paralysis or severe flexor spasm)

24. FOLLOW UP evaluated at 3 months interval upto 2 years Evaluation Clinical: Weight gain Pain relief Free ROM Resolution of abscesses Neurological recovery Radiological: Decreased soft tissue shadow Disappearance of erosions Return of mineralization Graft incorporation Bony ankylosis

25. TB HIP 2nd only to spine Spine: Hip ratio – 10:7 Hematogenous dissemination Articular cartilage destruction begins peripherally TB Arthritis- does not form proteolytic enzymes in joint space. Hence central areas of articular cartilage preserved for long time.

26. COMMON SITES  Initial focus may start in Acetabular roof – most common Epiphysis/Femur Head- joint involved rapidly Metaphyseal region/ Femur neck Greater trochanter - least common; may involve the overlying trochanteric bursa

27. CLINICAL FEATURES Commonest age : 1st three decades Limping – earliest , commonest symptom Antalgic gait Pain – referred to medial aspect of knee - max towards end of the day Deformity

28. DIAGNOSIS Clinico -radiological - X-Rays, CT Scan, MRI and USG Synovial fluid aspiration AFB positive in 10 – 20% of cases Cultures positive in 50% of cases Aspiration of cold abscess Synovial Biopsy Cultures positive in 80% cases HPE & PCR – diagnostic

29. MANAGEMENT Early diagnosis , effective chemotherapy – vital to save the joint Depends upon the stage of clinical presentation Rx includes : ATT Absolute bed rest Traction Arthroplasty Arthrodesis THA

30. After 4-6 months of Rx – Ambulation with crutches / orthosis Ambulation : 1st 12 weeks :non weight bearing 2nd 12 weeks :partial weight bearing Unprotected weight bearing : 18 -24 months after onset of Rx

31. TB KNEE 10 % of osteo-articular tuberculosis Any age group Symptoms Pain palpable synovial thickening Tenderness in the medial or lateral joint line and patello -femoral segment of the joint Initial focus: synovium or subchondral bone of distal femur, proximal tibia or patella

32. TB ANKLE AND FOOT ANKLE Swelling - front of joint, around the malleoli and tendoachilles insertion Marked osteoporosis with/ without erosion, unsharpness of articular surfaces with reduction joint space FOOT Common : calcaneum , subtalar and midtarsal joints Radiograph: osteolytic lesion with or without coke-like sequestrum

33. TB SHOULDER Rare ; more frequent in adults The classical sites could be – head of humerus Glenoid spine of the scapula Classical dry type : more common- adults fulminating variety with cold abscess/sinus formation: more common- children

34. TB ELBOW 2-5 % cases Most frequent sites medial and lateral condyles of humerus articular surface of olecranon head of radius Rarely synovial in origin, Infants and children : sequestra may be present Radiographic features Osteoporosis blurring of articular cortex and early diminution of joint space Periostitis

35. TB WRIST AND CARPUS rare Adults ; more localized lesions in children Radiographic features intense osteoporosis erosions of articular margins and cartilage destructions periosteal reaction Biopsy, when in doubt.

36. TB SACROILIAC JOINTS frequently missed Young adults > children usually unilateral Clinically: Tenderness over sacroiliac joint MRI ideal Radiographic features – Irregularity, fuzziness of articular surfaces Both sclerosis and erosions predominate on the iliac side while punched out lesions may be seen in ilium or sacrum

37. Long and flat bones- TB osteomyelitis TB osteomyelitis : 3 % of MSK tuberculosis In 7 % of them, multiple skeletal site of lesions Earliest lesion: eccentric osteolytic lesion in the shaft near the epiphysis or metaphysis Solitary involvement predominant Multiple sites of involvement are seen in children , while in adults , involvement is more often confined to a single bone

38. Tuberculosis of short bones(TB Dactylitis ) primarily childhood; hands > feet affects short tubular bones distal to wrist; Monostotic and diaphyseal involvement Clinically marked swelling on the dorsum of the hand soft tissue abscess Often follows a benign course , as opposed to acute osteomyelitis Radiography Cystic expansion of short tubular bones have led to the name of " spina ventosa ”

39. Atypical Mycobacterial Infection immunocompromised patients , renal transplants or those receiving cortico -steroids Infection can lead to osteomyelitis , septic arthritis, tenosynovitis and bursitis Radiologically – multiple lesions may be seen metaphysis and diaphysis of long bones usually affected osteoporosis is NOT marked