Tb spine

tuberculosis of spine

1. TUBERCULOSIS OF SPINE PRESENTER: DR. AMOL GAIKWAD PG TRAINEE DEPARTMENT OF ORTHOPAEDICS, GMCH MODERATER: DR. D.N.BORAH ASSISTANT PROFESSOR DEPARTMENT OF ORTHOPAEDICS, GMCH 1

2. HISTORY • Documented in 5000-year-old mummies

3. “YAKSHMA”

4. In 1779, Percival Pott

5. One fifth of TB population is in India. 3% suffering from skeletal TB. Vertebral TB M/C form of skeletal TB (50%). Almost 50% are from pediatric group. 2 nd greatest killer next to HIV.

6. In 2017, WHO released a report which revealed as many as 4.23 lakh deaths from TB in India 19.36 lakh TB cases came into picture in India in 2016.

7. AIM - WHO • Early diagnosis. • Expeditious medical treatment. • Aggressive surgical approach. • Prevent deformity. • Best outcome. 7

8. Anatomy of Vertebra

9. 3% Lumbosacral 26% Lumbar 12% Dorsolumbar 42% Dorsal 5% Cervicodorsal 12% Cervical (including atlanto occipital) REGIONAL DISTRIBUTION (Tuberculosis of the skeletal system by S.M.TULI 5 th ed )

10. Secondary infection. Primary site in the lung, viscera or lymph glands. Hematogenous Spread / Batson plexus of veins. Delayed hypersensitivity immune reaction. Inflammatory reaction with Langhan’s giant cells, epithelioid cells , and lymphocytes. The granulation tissue proliferates, producing thrombosis of vessels. PATHOLOGY

11. PATHOLOGY Granulomatous inflammation leads to erosion of vertebrae. Associated disc degenaration due to end arteritis, finally complete destruction. Weakening of trabeculae compression collapse. – Deformity. 11

12. FORMATION OF ABSCESS Collect under ant-long-ligament Formation of cold abscess Expression of collection of tuberculous debris Vertebral collapse Diverted forward along different anatomical sites Slides along VB and invade the vertebral canal through intervertebral foramen.

13. COLD ABSCESS Abscess - collection of liquefied tissue in the body which is body’s defense reaction to foreign material NO signs of inflammation Collection of dead tubercular bacilli, serum, leucocytes, bone debris and caseous material. Can track in to any direction- along musculo-facial planes or neurovasular bundle.

14. Spread of Cold Abscess Paraspinal regions at the back Anterior/ posterior cervical triangles Brachial plexus in the axilla Intercostal spaces on the chest wall Abscesses from dorsolumbar and lumbar spine- track down the psoas sheath. Palpable in the iliac fossa, lumbar triangle, upper part of the thigh below inguinal ligament or even track downwards upto the knee or sometimes upto the great toe 15

15. Psoas Abscess Iliac abscess contained in the sheath of the iliac muscle. The abscess that has tracked down the psoas sheath penetrates through the iliacus muscle sheath. Becomes palpable as a mass in the iliac fossa Abscess that remains confined to the psoas sheath may not be palpable clinically. 16

16. TYPES OF VERTEBRAL INVOLVEMENT PARADISCAL (arterial spread) CENTRAL ( venous spread) ANTERIOR (sub periosteal tracking of pus) APPENDICIAL

17. Most common pattern of spinal tuberculosis. Narrowing of the disc space. Destruction of subchondral bone. Subsequent herniation of the disc. 1. Paradiscal Lesions :

18. Subperiosteal lesion under the ALL. The periosteal stripping renders the vertebrae avascular and susceptible to infection. Both pressure and ischemia combine to produce anterior scalloping. (multiple vertebrae) Collapse of the VB & diminution of the disc space is minimal More common in thoracic spine in children. 2. Anterior Lesions :

19. Centered on the vertebral body. Disc is not involved. Infection starts from the center of the vertebral body. Batson’s venous plexus Posterior vertebral artery Concentric collapse producing a vertebra plana appearance. 3. Central Lesions :

20. Isolated infection involving pedicles , laminae (neural arch), transverse processes, & spinous process. Uncommon lesion (< 5%). In conjunction with the typical paradiscal variant in 30%. Rarely present as synovitis of facet joints. 4. Appendicial Lesions :

21. CLINICAL FEATURES Constitutional symptoms Pain in the back ( m/c ) Swelling Stiffness Neurological symptoms Deformity

22. PHYSICAL EXAMINATION Attitude and gait In upper cervical disease – wry neck In upper thoracic disease – Military attitude In lumbosacral – Alderman’s Gait In lower lumbar – Pronounced lordosis

23. 2. Deformity of spine: Kyphosis 1 vertebrae – Knuckle gibbus 2-3 vertebrae - Angular gibbus >3 vertebrae – Round kyphosis Scoliosis Lordosis

24. 3. Abscess / Sinus formation : Dysphagia and dyspnoea – Retropharyngeal abscess Hoarseness of voice due to – Abscess in disease of upper thoracic region. Flexion contracture of hip – Psoas abscess

25. 4. Movement of spine : painful due to protective muscular spasm 5. Paralysis : Association - 10-30% Type - Incomplete generally More common in thoracic region.

26. RADIOLOGICAL DIAGNOSIS: 1. X-RAYS 2. CT SCAN 3. MRI SPINE 4. BONE SCAN

27. X ray findings : Early changes :- haziness and local osteoporosis of end plates of two adjacent vertebrae narrowing of intervertebral disc space. Late changes :- paravertebral shadow ant wedge compression collapse - deformity central or concertina collapse d estruction of post element X ray changes appear after 3-5 months.

28. Para vertebral shadow- X ray 1. Cervical region - Shadow in Retropharyngeal space 2. Upper thoracic - V-shaped shadow mediastinum - Change in contour of tracheal shadow 3. Below 4th thoracic - Fusiform or bird nest shadow 4. Below D10 - Bilateral widening of psoas shadow 5. Aneurysmal - tense thoracic vertebral abscess showing phenomenon scalloping effect

29. 2. CT SCAN

30. 3. MRI

31. Increased uptake (60% patients) with active tuberculosis > 5mm lesion size can be detected. Avascular segments and abscesses show a cold spot due to decreased uptake. Highly sensitive but nonspecific. Aid to localize the site of active disease and to detect multilevel involvement 4. BONE SCAN (Technitium (Tc) – 99 m )

32. Clinico -radiological classification (Kumar et al ’88 )

33. Mantoux / Tuberculin skin test ESR may be markedly elevated (neither specific nor reliable). ELISA : for antibody to mycobacterial antigen-6 , sensitivity 94% and specificity of 100% PCR : sensitivity 40% only. INVESTIGATIONS LABORATORY TESTS

34. IFN – Release assays (IGRAs) measure T cell release of IFN- gamma in response to tuberculosis antigens ESAT- 6, CFP-10 and TB7.7 .

35. Biopsy : For definitive diagnosi s CT or ultrasound guided or open biopsy during a surgical procedure. Ziehl-Neelsen staining: a quick and inexpensive method Culture : - results are available only after a few weeks - positive only in 60% of cases; most specific. 3. Histology: demonstration of tubercle, 80% cases. MICROBIOLOGY STUDIES:

36. DIFFERENTIAL DIAGNOSIS 1. SPINAL INFECTIONS - p yogenic - b rucellosis - f ungi / syphilis 2. NEOPLASTIC - Extradural – Lymphoma / Metastasis etc. - Intradural extramedullary – Meningioma / neurofibroma DEGENERATIVE / OSTEOPOROTIC TRAUMA 5. CONGENITAL DEFECTS 6. SPINAL OSTEOCHONDROSIS

37. NEUROLOGICAL COMPLICATION Most dreaded and crippling complication. Incidence 10-30%. MC age group – first three decades of life. MC region – thoracic.

38. PATHOLOGY OF TB PARAPLEGIA Inflammatory oedema : - vascular stasis and liberation of toxins. Extradural mass: commonest mechanism Bony disorder : sequestrum, gibbus , subluxation Intrinsic changes of cord - peridural fibrosis - infarction - myelomalacia , gliosis , atrophy

39. SEDDONS CLASSIFICATION OF PARAPLEGIA Associated with healed disease (ii) Due to compression by debris, sequestrum, canal stenosis and severe deformity (iii) Appears many years (after 2 years of onset of disease (iv) Prognosis – poor Associated with active disease (ii) Due to compression by inflammatory oedema , granulation tissue, abscess, casseous tissue (iii) Occurs within first 2 years of onset (iv) Prognosis – better Paraplegia of late onset Paraplegia of early onset

40. TULI & KUMAR’S GRADING OF PARAPLEGIA III + flexor spasm/paralysis in flexion/flaccid , sensory deficit > 50% /sphincter involved Severe IV Nonambutatory paralysis in extension sensory deficit < 50% Moderate III Aware of deficit but manages to walk with support/ UMN features Mild II Unaware of neural deficit, physician detects plantar extensor or ankle clonus Negligible I

41. SEQUENCES OF PARALYSIS Spastic motor paresis (clonus is first most prominent early sign) Spastic paraplegia in extension Spastic paraplegia in flexion Bladder and bowel involvement (very advanced stage) Flaccid paralysis with anaesthesia with loss of sphincter (last stage) [N:B: Sense of position and vibration is last to disappear]

42. SEQUENCE OF RECOVERY muscle wasting sphincter function voluntary motor activity pain touch temperature Vibration and jt. sense

43. TREATMENT Objective : 1) To eradicate or at least arrest the disease. 2) To treat major complications like paraplegia. 3) To prevent or correct deformity.

44. TULI’S MIDDLE PATH REGIME FOR TREATMENT OF KOCH’S SPINE 1 ) Bed rest - with or without traction 2) Drugs – ATT any one regime as preferred 3) Radiograph & ESR – radiologically the kyphosis and disease activity by ESR is measured 3 monthly. 4)Gradual mobilization with exercise 5)Abscess: * Repeated aspiration. * Streptomycin and/or INH instillation. * Surgical evacuation if symptomatic.

45. 6) Sinuses : * Usually heal by 6-12 weeks of ATT. * Excision of the tract with or without debridement. Neurological complication : 5 indications for surgery (mainly decompression surgery) (I) Not showing progressive recovery after 3-6 weeks of Rx. (ii) Pt. developing neurological complication during Rx. (iii) Neurological status becoming worse while undergoing Rx. (iv) Recurrence of neurological complication. (v)In advanced cases with motor, sensory or sphincter involvement or having severe flexor spasm Operative debridement - in nonresponsive 3-6m of chemotherapy. - cases with recurrence of disease.

46. 9). Excisional surgery: - posterior spinal disease associated with abscess / sinus formation +/- neural involvement. 10). Posterior Spinal Arthrodesis: - severe kyphotic deformity (prevention / correction). - mechanical instability. - spine at risk signs. 11). Post – operative: - hard bed for 2-3 weeks/ neurological recovery. - brace for 2 years.

47. DRUGS IN MIDDLE PATH REGIME

48. PROGNOSTIC FACTORS

49. SURGICAL TREATMENT HISTORY: Abscess drainage- Pott (1779) Laminectomy & laminotomy : Chipault (1896 ) Costo-transversectomy: Menard (1896) Calves operation (1917) Lateral rhachiotomy of Capener (1933) Anterolateral decompression of Dott & Alexander(1947)

50. INDICATIONS- SURGICAL TREATMENT Doubtful diagnosis. Failure to respond to conservative Rx after 3-6 weeks therapy. Symptomatic abscess. Neurological indications. Mechanical instability. Deformity. Recurrence of disease. Posterior spinal disease. Spinal tumor syndrome.

51. TYPES OF SURGERY

52. SURGICAL APPROACHES

53. ABSCESS DRAINAGE 1. Atlanto occipital and atlanto axial region – Fang and Ong(1962) Trans oral approach

54. Trans Thyrohyoid approach

55. Retropharyngeal approach (C2-D1)

56. 2. Dorsal spine - Costotransversectomy

57. Seddons Technique – similar to Menard technique but here more extensive approach is used and resection of rib is generally more than 3.

58. Drainage of paravertebral abscess Through lumbodorsal fascia between Erector spinae and quadratus lumborum muscle. 7 cm longitudinal paraspinal incision

59. 3. Drainage of psoas abscess Through Petit’s triangle Through lateral incision –along the middle third of the crest of the ilium

60. 5-8 cm long skin incision in ant aspect of thigh 2-3 cm distal to pubic tubercle. plane of dissection – along medial border of sartorius muscle. protect femoral nerve. Ludloff approach:

61. ANTERIOR APPROACH TO THE CERVICAL SPINE (C2 to D1) • Oblique / transverse incision. • Plane b/w SCM & carotid sheath laterally & T-O, thyroid medially. • Longitudinal incision in ALL open a perivertebral abscess, or the diseased vertebrae may be exposed by reflecting the ALL & the longus colli muscles. Hodgson approach via posterior triangle by retracting SCM, Carotid sheath, T & O anteriorly & to the opposite side. Smith & Robinson

62. SURGICAL APPROACHES TO DORSAL SPINE Anterior transpleural transthoracic approach (Hodgson & Stock, 1956) Anterolateral extrapleural approach (Griffiths, Seddon & Roaf , 1956) Posterolateral approach (Martin,1970)

63. TRANSTHORACIC TRANSPLEURAL • Left sided incision preferable. • Along the rib which in the mid-axillary line, lies opposite the center of the lesion. • A J-shaped parascapular incision for C7 – D8 lesions, scapula lifted up. After cutting the muscles & periosteum, rib is resected sub periosteally .

64. • Parietal pleural incision applied & lung freed from the parieties & retracted anteriorly. • A plane developed b/w the descending aorta & the paravertebral abscess / diseased vertebral bodies. Intercostal vessels and hemiazygous vein ligated & cut. • T-shaped incision over the paravertebral abscess. • Debridement / decompression with or without bone grafting.

65. ANTEROLATERAL DECOMPRESSION • Lateral position advantages :- 1. avoid venous congestion. 2. avoid excessive bleeding. 3. permits free respiration. 4. lung & mediastinal contents fall anteriorly. • Griffith et al -- Prone position • Tuli -- Right lateral position

66. Semicircular incision. Medial flap raised. Paraspinal muscles divided. Subperiosteal exposure of medial end of ribs and transverse process. Cut the ribs 8 cm laterally and remove the medial end with transverse process. Retract anteriorly the periosteum , intercostal muscle and vessels, the parietal pleura with lungs. Intercostal nerves serve as guide to the intervertebral foramina & the pedicles.

67. 76 Curved blunt dissector inserted through intervertebral foramina. All diseased bodies and disc removed from anterior and lateral aspect thus decompressing the cord. Grafting ( strut grafts) can be given +/- Post fusion.

68. ANTERO-LATERAL APPROACH TO LUMBAR SPINE ( LUMBOVERTEBROTOMY) • Left side approach • Semicircular incision • Expose and remove transverse process subperiosteally . Retract the psoas muscle anteriorly and laterally. • Preserve lumbar nerves.

69. 45 ⁰ right lateral position. Similar incision nephroureterectomy or sympathectomy . Abdominal muscles are split in layers in line of skin incision. Strip peritoneum off posterior abdominal wall and kidney, preserving ureter. Longitudinal incision along psoas fibers for abscess drainage ( preserve lumbar vessels running transversely). EXTRA PERITONEAL ANTERIOR APPROACH TO LUMBAR SPINE

70. If no abscess - psoas muscle released from its origin and retracted laterally along with the sympathetic chain. Aorta , IVC along with the peritoneum and its contents are retracted to the right and anteriorly. Expose the vertebral bodies and excise the disease 79

71. Left side preferred. Lazy “S” incision. Strip & reflect the parietal peritoneum along with ureter & spermatic vessels towards right side exposing the psoas , abdominal aorta and the common iliac vessels. Retract psoas laterally and vessels medially with peritoneum. EXTRA PERITONEAL APPROACH TO LUMBO-SACRAL REGION

72. TRANSPERITONEAL HYPOGASTRIC/ SUPRAPUBIC ANTERIOR APPROACH TO LUMBO-SACRAL REGION Supine position. Midline incision from umbilicus to pubis. Lumbo -sacral region identified distal to aortic bifurcation and left common iliac vein. Longitudinal incision on parietal peritoneum over lumbo -sacral region in midline. Avoid injury to sacral nerve & artery and sympathetic ganglion.

73. POSTERIOR SPINAL ARTHRODESIS • Albee – Tibial graft inserted longitudinally in to the split spinous processes across the diseased site. • Hibbs – Overlapping numerous small osseous flaps from contiguous laminae , spinous processes & articular facets . Indications : 1. Mechanical instability of spine in otherwise healed disease. 2. To stabilize the craniovertebral region (in certain cases of T.B.) 3. As a part of panvertebral operation

74. SURGERY IN SEVERE KYPHOSIS HIGH RISK PATIENTS: • Patients < 10 years • Dorsal lesions • Involvement of > 3 vertebrae • Severe deformity in presence of active disease (>60 ).

75. TREATMENT OF PARAPLEGIA IN SEVERE KYPHOSIS • Griffiths et al (1956) : - anterior transposition of cord through laminectomy. • Rajasekaran (2002) : posterior stabilization f/b anterior debridement and bone grafting ( titanium cages) in active stage of disease. - Anterior debridement f/b posterior instrumentation and anterior fusion for healed disease.

76. SURGICAL CORRECTION OF SEVERE KYPHOTIC DEFORMITY To perform an osteotomy on the concave side of the curve and wedge it open ( secured with autogenous iliac grafts) 2. To remove a wedge on the convex side and close this wedge, (compression rods and hooks)

77. POST OP CARE Nursed on a hard bed / POP posterior shell (children) upto 3 months. Careful and assisted turning of the patient is permitted from the first day. At the end of 3-6 months / neurological recovery pt. mobilized with the help of spinal brace. Spinal brace is discarded after 1- 1 ½ years. 86

78. SPINAL BRACES CERVICAL SPINE : Four post cervical brace Minerva Jacket SOMI Brace

79. UPPER DORSAL SPINE D1-D3: No simple brace to control the spine effectively. Only satisfactory method is to extend the usual spinal brace upward with the attachment of a cervical collar.

80. D4-L2 VERTEBRAE TAYLOR’S BRACE: - prototype of all spinal orthosis. ANTERIOR SPINAL HYPER EXTENSION (ASH) BRACE: - acceptable to young girl as it gets accommodated according to body contour. MILWAUKEE BRACE: - growing age ; mainly used for correction of scoliosis.

81. Maintain high suspicion not to overlook diagnosis. Early diagnosis is essential for good results. Early MRI is an essential tool for diagnosis of Potts spine. Not all patients can be treated by chemotherapy alone and neither do all patients require surgery.