Spinal Tuberculosis Explained in TB Patients

Tuberculosis is a infectious granulomatous disease. Once common throughout the world but later its prevalence declined mainly due to effectiveness of public health programs, people education and advanced chemotherapy.In the last decade the annual incidence of TB specially extra-pulmonary has risen again due to general increase in old population, drug abusers , immuno-compromised and AIDS infection.
In this ppt all basic to HO/PG level concept of Spinal TB is clearly explained. I have mention some extra things in brackets with italian font. Remember TB is one of the most common infectious disease so every exam has its questions. Must remember its drugs, dosages, maximum dose and its side effects.

1. Spinal Tuberculosis
(Pott’s Disease)
Dr Waris Ali
House Officer
DOST Unit 2

2. Objectives
●Introduction to TB
●Spinal Tuberculosis
●Pathology of Spinal TB
●Types of lesion in spinal TB
●Clinical features
●Diagnosis
●Treatment (non-operative and operative)
●complications

3. Introduction
Tuberculosis is a chronic granulomatous infectious disease caused by
Mycobacterium tuberculosis.
Primarily affects the lungs but may spread to other organs
(Extrapulmonary manifestations)
Bones or Joints are affected in about 5% of patients with tuberculosis
Skeletal manifestations of TB seen chiefy in spine and large synovial joints
but infection may appear in any bone , joint ,synovial and bursal sheath.

4. Spinal Tuberculosis
Tuberculosis of spine is a form of extrapulmonary tuberculosis that affects the
vertebral column.
Also known as Pott’s disease or TB Spondylitis
Spine– Most common extrapulmonary location of tuberculosis
May be seen in HIV-positive population with a CD4+ counts of 50 to 200 (can
occur in immunocompromised pts)
Usually due to the hematogenous spread from other sites, often lungs.
Thoracolumbar region is the commonest region to get affected.

5. Originates in the metaphysis
of the vertebral body and
spreads under the anterior
longitudinal ligament
This leads to destruction of
several contiguous levels or
results in skip lesions (15%) or
abscess formation (50%).

6. Pathology
Tuberculosis of spine is always secondary.
Tubercular infection of bone and synovial tissue produces similar
response as it produces in lungs. Ie; Chronic granulomatous
inflammation with caseation necrosis
Bacteria reach the spine via the hematogenous route—Usually
through the arterial system or Batson’s (paravertebral) venous
plexus

7. Once the bacteria lodge in the vertebral bodies, they cause
granulomatous inflammation , caseous necrosis and bone
destruction
The infection can then spread to adjacent vertebrae and
intervertebral discs, eventually forming paravertebral or psoas
abscess.

8. Types of vertebral tuberculosis
Lesion in the vertebrae may be of the following types
1.Paradiscal
2.Central
3.Anterior (Sub-ligamentous)
4.Posterior

9. Paradiscal Type
Commonest type
Contiguous areas of two adjacent vertebrae
along with the intervening disc are affected.
Bacteria lodge in contiguous area of two
vertebrae- granulomatous inflammation
results in erosion of margins of these
vertebrae, Nutrition of intervening disc
compromised-results in disc degeneration
and as the process continues complete
destruction

10. Central Type
The body of single vertebrae is affected.
This leads to early collapse of weakened vertebrae
Nearby disc maybe normal

11. Anterior Type
Infection is localised to the
anterior part of vertebral body
Infection spreads up and down
under the Anterior longitudinal
ligament

12. See Anterior longitudinal ligament and posterior parts of vertebrae

13. Posterior Type
In this type , the posterior complex of vertebrae
are affected.

Ie; the pedicle , lamina , spinous process and
transverse process are affected.

14. Clinical Features
●Pain : Back pain, commonest
●Stiffness : protective mechanism
●Cold abscess
●Paraplegia
●Deformity: Gibbus
●Constitutional symptoms
Fever, weight loss

15. Diagnosis
X-ray:
Reduction of disc space
Destruction of vertebral body
Soft tissue shadow—abscess
Rarefaction–lessening of density of
bone
About two thirds of patients have
abnormal chest radiographs.

16. CT Scan
May detect a small paravertebral
abscess, not otherwise seen on
plain x ray
Indicate precisely extent of
destruction of vertebral body and
posterior elements
Specially useful in cases where
MRI is contraindicated or
unavailable.

17. MRI
Investigation of choice
Shows soft tissue
involvement, spinal cord
compression and extent of
vertebral destruction
Other general investigations
like ESR, Mantoux test, Heaf
test or Genexpert are done to
support diagnosis of TB.

18. Treatment
Nonoperative
Chemotherapy is the
mainstay of treatment.
REST: rest to affected part and
when it improves gradual
controlled movements.
Most high incidence regions
use a combination of drugs,
usually three or four include
INH, RF,ETH, PZ.

19. To minimize resistant and act against mycobacteria, ATT are available in a
combination single tablet.
Many use full drug treatment for 9-12 months.
Dosages are weight dependant and needs to be adjusted as the patient
improves in health status and gains weight.
The must be monitored for the drugs side effects of hepatitis, depression
and loss of visual acuity
If resistant mycobacteria are confirmed on PCR or culture ,Second lines
agents are required usually involving fluoroquinolones or aminoglycosides.
(note: must tell the pt side effects when start ATT. most common side effect orange
colour urine. Do LFTs too)

21. Surgical indications:
Neurologic deficit
Spinal instability
Progressive kyphosis
Failed medical management
Advanced disease with caseation, fibrosis, and avascularity that limits
antibiotic penetration

22. Surgical Procedures
1.Costo-transvectomy
Posterolateral approach
This operation consists of removal of a
section of rib (about 2 inch) and transverse
process.
Done to relieve tense abscess and thus
enough to decompress the neural tissues.
Indicated in a child with paraplegia and when
a tense abscess is present.
May not produce adequate decompression

23. 2. Antero-lateral Decompression
Spine is open from its lateral side and access is made to the
front and side of the cord, thus called Anterolateral
decompression (ALD).
Structures removed in order to achieve adequate exposure of
the cord are; the rib , transverse process,pedicle and part of
vertebral body.
The cord is laid free from caseous material, bony spur or
sequestrum pressing on it.

24. 3 Radical Debridement (Hongkong Procedure)
Radical debridement of diseased vertebrae and replacement with bone
graft done
Advantages include less progressive kyphosis, earlier healing, and a
decrease in sinus formation.
• Adjuvant chemotherapy beginning 10 days before surgery has been
recommended
• Use of antitubercular medications after surgery is mandatory
Modified Hong Kong operation" adds spinal instrumentation to the
graft for greater stability

26. Complications
Kyphosis: Spinal deformity characterized by forward curvature of
spine , leading to a hunchback appearance
Paraplegia: loss of motor and sensory function in the lower
extremities due to compression of spinal cord
Neurological deficit: weakness , numbness or tingling sensations in
the legs and feet due to nerve compression

27. Abscess formation: formation of pus filled pockets around the affected
vertebrae , leading to pain and swelling.
Vertebral collapse: Weakening and collapse of vertebrae ,resulting in loss of
spinal stability and height
Spinal cord compression: Compression of spinal cord due to abscess
formation, vertebral collapse or bony fragments ,leading to neurological
deficits.
Meningitis: Infection of membranes surrounding the brain and spinal cord ,
leading to symptoms such as fever , headache and neck stiffness

28. Thank You!