Tb spine

tb

1. TUBERCULOSIS OF THE SPINE VIJESH VIJAYAN 2008 MBBS

2. ALSO CALLED POTT’S DISEASE OR TUBERCULOUS SPONDYLITIS

3. TB IS CALLED AS “ WHITE PLAGUE ’’ OR ” CAPTAIN OF ALL MEN OF DEATH ” SPINE IS THE COMMONST SITE OF BONE AND JOINT TB UPPER THORACIC SPINE – IN CHILDREN LOWER THORACIC AND - IN ADULTS UPPER LUMBAR

4. EPIDEMIOLOGY 1/3 RD OF WORLD POPULATION HARBOUR TB INFECTION INDIA IS ONE OF THE WORST AFFECTED COUNTRIES ONE PERSON PER MINUTE DIE OF TB IN INDIA

5. TB IS AN ANCIENT DISEASE EVIDENCE OF SPINAL TB HAS BEEN FOUND IN SOME EGYPTIAN MUMMIES

6. BONES & JOINTS ARE THE 4 TH COMMONST SITE OF EXTRA PULMONARY TB CONSTITUTE ~10% OF EXTRA PULMONARY TB WEIGHT BEARING JOINTS ARE MOST AFFECTED SPINE : 40 % HIPS : 13% KNEES : 10%

7. PATHOLOGY TB SPINE IS ALWAYS SECONDARY REACTIVATION OF HEMATOGENOUS FOCI OR SPREAD FROM PARAVERTEBRAL LYMPH NODE HEMATOGENOUS SPREAD VIA PARAVERTEBRAL VENOUS PLEXUS OF BATESON RESPONSE WILL BE EITHER PROLIFERATIVE OR EXUDATIVE PROLIFERATIVE : C/C GRANULOMA WITH FIBROSIS EXUDATIVE : NON REACTIVE, WIDE CAESEATION NECROSIS, IN IMMUNOCOMPROMISED

8. TB GRANULOMA

9. TYPES OF VERTEBRAL TB 1. PARADISCAL - COMMONST , CONTIGOUS AREA OF TWO ADJACENT VERTEBRA ALONG WITH INTER VERTEBRAL DISC IS AFFECTED 2. CENTRAL -BODY OF SINGLE VERTEBRA , NEARBY DISC MAY BE NORMAL 3. ANTERIOR-ANTERIOR PART OF THE BODY 4. POSTERIOR- POSTERIOR COMPLEX (PEDICLE , LAMINA , SPINOUS PROCESS OR TRANSVERSE PROCESS) AFFECTED

10. AFTER EFFECT PARADISCAL : C/C GRANULOMATOUS INFLAMMATION -> EROSION OF MARGINS OF THE VERTEBRAE -> COMPROMISE OF NUTRITION OF IV DISC-> DISC DEGN-> DESTRUCTION CENTRAL : WEAKENING OF TRABECULAE -> COLLPSE OF VERTEBRAE ANTERIOR : INFN SPREAD UP OR DOWN UNDER ANT. LONGI.LIGAMENT POSTERIOR : BONY DESTRUCTION CAN COMPRESS THE CORD

11. COLD ABSCESS PUS & TRABECULAR DEBRIS OF DISEASED VERTEBRA NOT ASSO. WITH USUAL SIGNS OF INFLAMMATION - COLD ABSCESS NOTE: PUS CAN TRACK IN ANY DIRECTION 1.BACKWARDS : COMPRESS CORD 2. ANTERIORLY: PRE VERTEBRAL ABSCESS 3. SIDES : PARA VERTEBRAL ABSCESS 4.ALONG MUSCULOFASCIAL PLANES : EX. PSOAS ABSCESS

12. HEALING OCCURS BY FIBROSIS IN THE SPINE BONY ANKYLOSIS FOLLOWS MORE OFTEN LYTIC AREAS ARE REPLACED BY NEW BONE AND ADJACENT VERTEBRA UNDERGO FUSION

13. CLINICAL FEATURES PRESENTATION VARIES FROM NON SPECIFIC BACK ACHE TO CATASTROPHIC PARAPLEGIA COMPLAINTS: PAIN STIFFNESS COLD ABSCESS ( IF EVIDENT EXTERNALLY) PARAPLEGIA DEFORMITY CONSTITUTIONAL SYMPTOMS

14. PAIN BACKACHE : COMMON PRESENTING COMPLAINT INITIALLY DIFFUSE & LATE LOCALISED ‘RADICULAR PAIN’ DEPENDING ON ROOT: PAIN IN ARM – CERVICAL ROOTS GIRDLE PAIN – DORSAL ROOTS GROIN PAIN - LUMBAR ROOTS

15. COLD ABSCESS CERVICAL : RETROPHARYNGEAL / AT POST BORDER OF STERNO MASTOID IN POST TRIANGLE OF THE NECK / AT AXILLA THORACIC : MEDISTINAL / ANTERIOR CHEST WALL ALON THE SPINAL NERVES LUMBAR : PRE VERTEBRAL SWELLING/ PSOAS ABSCESS / ABSCESS PRESENTING AT GROIN

16. STIFFNESS : EARLY SYMPTOM PARAVERTEBRAL MUSCLES UNDERGO SPASM PARAPLEGIA DEFORMITY – IN CHILDREN CONSTITUTIONAL SYMPTOMS : FEVER , WEIGHT LOSS

17. EXAMINATION SHOULD HAVE A HIGH INDEX OF SUSPICION AIMS : LOOK FOR FINDINGS OF TB SPINE LOCALISE SITE OF LESION DETECT COMPLICATIONS- COLD ABSCESS / PARAPLEGIA 1. GAIT : SHORT STEPS 2. ATTITUDE & DEFORMITY 3. PARAVERTEBRAL SWELLING 4. TENDERNESS ON THE AFFECTED SPINE 5. REDUCED MOBILITY

18. DEFORMITY : GIBBUS

19. NEUROLOGICAL EXAMINATION AIMS: DETECT ANY COMPRESSION LEVEL OF COMPRESSION SEVERITY OF COMPRESSION LIMBS – UPPER OR LOWER BASED ON SITE MOTOR , SENSORY , REFLEXES , BOWEL AND BLADDER FUNCTIONS GENERAL EXAMINATION PHYSICAL EXAMINATION SYSTEMIC ILLNESS : DM , HYPERTENSION

20. INVESTIGATIONS RADIOLOGY : X-RAY – SPECIFY THE LEVEL 2 VIEWS AP & LATERAL CHEST X-RAY X-RAY ABDOMEN KUB - IF PSOAS ABSCESS SUSPECTED

21. FINDINGS 1. REDUCTION OF DISC SPACE- EARLY SIGN COMPARE WITH NORMAL LATERAL X-RAY IS BETTER IMPORTANCE : SECONDARIES TO BONES USUALLY PRESERVE THE DISC 2. DESTRUCTION OF VERTEBRAL BODY EROSIONS AND WEDGING 3. DEFORMITY : DEPEND ON THE NO. OF VERTEBRA AFFECTED

22. BONE DESTRUCTION

23. DESTRUCTION OF THE BONE

24. COLD ABSCESS 1. PARAVERTEBRAL ABSCESS : A SOFT TISSUE SHADOW CORRESPONDING TO AFFECTED VERTEBRA. WIDENED MEDIASTINUM RETROPHARYNGEAL ABSCESS PSOAS ABSCESS

25. RETROPHARYNGEAL ABSCESS

26. MEDISTINAL WIDENING

27. OTHER FINDINGS RAREFACTION : ABOVE AND BELOW AFFECTED VERTEBRA OBLIQUE X RAY MAY SHOW POSTERIOR COMPLEX INVOLVEMENT SIGNS OF HEALING : ADJACENT VERTEBRAE UNDERGO FUSION

28. OTHERS CT : ACCURATE CONFIRMATIONS MRI : TO ASSES NEURAL STATUS MYELOGRAPHY : SUSPECTED SPINAL TUMOR SYNDROME BIOPSY : CT GUIDED NEEDLE OR OPEN BIOPSY

29. RETROPHARYNGEAL SWELLING CAN PRESENT AS DYSPHAGIA

30. PSOAS ABSCESS

31. PSOAS ABSCESS

32. GENERAL INVESTIGATIONS ESR MANTOUX ELISA : ANTI TB ANTIBODY CHEST X RAY : FOR PULMONARY TB

33. D/D S BACK ACHE : 1. TRAUMATIC 2. SECONDARIES OR MYELOMA 3. PROLAPSED DISC 4.ANKYLOSING SPONDYLITIS NEUROLOGICAL SPINAL TUMOR TRAUMATIC SECONDARIES IN THE SPINE

34. TREATMENT PT SHOULD BE GIVEN A HIGH PROTEIN DIET & GOOD ATMOSPHERE 1. MULTIDRUG THERAPY OF TB 2. REST TO THE SPINE : CHILDREN BODY CAST , COLLAR IF CERVICAL 3. MOBILISATION : ADVISED TO AVOID SPORTS FOR TWO YEARS

35. R X COLD ABSCESS SMALLER ONES SUBSIDE WITH TB THERAPY IN SUPERFICIAL ABSCESSES : ASPIRATION : USING THICK NEEDLE EVACUATION PSOAS ABSCESS : EXTRAPERITONEALLY VIA KIDNEY INCISCION

36. MRCB CONTROLLED TRIAL BED REST NOT NECESSARY STREPTOMYCIN NOT NECESSARY POP JACKETS PROVIDE NO BENEFIT DEBRIDEMENT IS NOT A GOOD OPERATION COMPLICATIONS COLD ABSCESS N EUROLOGICAL COMPLICATIONS : PARAPLEGIA

37. POTT’S PARAPLEGIA

38. 20 % INCIDENCE COMMON IN DORSAL SPINE TB CAUSES : INFLAMMATORY EDEMA EXTRADURAL PUS & GRANULATION TISSUE – COMMOMN SEQUESTRA INTERNAL GIBBUS INFARCTION OF SPINAL CORD EXTRADURAL GRANULOMA

39. TYPES EARLY ONSET LATE ONSET C/F : EITHER A KNOWN TB OR NEUROLOGICAL SYMPTOMS PRESENTING FOR THE 1 ST TIME GRADUAL ONSET CLONUS – ANKLE OR PATELLAR – PROMINENT

40. PARALYSIS : STAGES 1. MUSCLE WEAKNESS : SPASTICITY AND INCORDINATION 2. PARAPLEGIA IN EXTENSION 3. PARAPLEGIA IN FLEXION COMPLETE FLACCID PARALYSIS

41. GRADES : GOEL (1967) BASIS IS EXTENT OF MOTOR INVOLVEMENT GRADE ONE : CLINICIAN DETECTS THE DEFECIT GRADE TWO : SYMPTOMATIC BUT MANAGES TO WALK GRADE THREE: UNABLE TO WALK PARAPLEGIA IN EXTENSION PARTIAL SENSORY LOSS GRADE FOUR : UNABLE TO WALK PARAPLEGIA IN EXTENSION NEAR COMPLETE SENSORY LOSS SPHINCTER DISTURBANCES

42. TREATMENT INVESTIGATIONS : CT & MRI ( INVESTIGATION OF CHOICE) CONSERVATIVE : ANTI TB R X , REST TO SPINE , NEUROLOGICAL EXAMINATION TO ASSES Px SURGICAL : INDICATIONS : PARAPLEGIA IN CONSERVATIVE Rx SUDDEN ONSET SEVERE PARAPLEGIA SEVERE PARAPLEGIA : IN FLEXION, MOTOR / SENSORY LOSS > 6 MONTHS OR COMPLETE MOTOR LOSS ONE MONTH DESPITE CONSERVATIVE Rx PARAPLEGIA WITH UNCONTROLLED SPASTICITY

43. RELATIVE INDICATIONS : RECURRENT PARAPLEGIA PARAPLEGIA IN OLD AGE PAINFUL PARAPLEGIA COMPLICATIONS : UTI / STONES

44. PROCEDURES 1. COSTO TRANSVERSECTOMY 2. ANTEROLATERAL DECOMPRESSION 3. RADICAL DEBRIDEMENT AND ARTHRODESIS ( HONKONG OPERATION) 4. LAMINECTOMY

45. PROGNOSIS AGE : CHILDREN HAS BETTER Px DURATION OF PARAPLEGIA : LONG STANDING HAS BAD Px SEVERITY : MOTOR ALONE HAS GOOD Px ONSET OF PARAPLEGIA : A/C ONSET HAS BETTER SUDDEN PROGRESS : BAD Px