Tb spine and pott’s paraplegia

Tb spine and pott’s paraplegia

1. TB SPINE AND POTT’S PARAPLEGIA PRESENTER : DR. KARTHIK S J JUNIOR RESIDENT MODERATOR : DR. PRABHU E PROFESSOR AND HOU DEPT OF ORTHOPAEDICS RLJALAPPA HOSPITAL KOLAR

2. GLOBAL TUBERCULOSIS - REPORT WHO reports 10 million new cases of tuberculosis and 1.2 million people die due to disease every year ( 0.17 million – CORONA) Eight countries accounted for 66 % new cases : India, China, Indonesia, Phillipines , Pakistan, Nigeria, Bangladesh and South Africa 4.8 lakh have MDR TB with only 56% treatment success

3. HISTORY: Percival Pott first described Tuberculosis of Spinal column in 1779, stating a classical description as a destruction of disc space and the adjacent vertebral bodies, collapse of spinal element and kyphotic deformity It is estimated that India alone got one fifth of the total world population of tuberculous patients Nearly 6 million radiologically proven cases are found in India and 1 to 3 percent has involvement of skeletal system

4. MICROBIOLOGY Mycobacterium tuberculosis: Bacillus with high lipid and Peptidoglycan rich cell wall Slow growing, aerobic organism Acid and alkali fas t In favourable conditions, doubling time is 20 hours In unfavourable conditions, it can grow only intermittently or remain dormant for a prolonged period This explains why TB is difficult to diagnose, treat and eradicate

5. PREDISPOSING FACTORS: Malnutrition Poor Sanitation Over crowding Close contact with TB patient Immuno deficiency state

6. SURGICAL ANATOMY: VERTEBRAL BODIES It is compared to a compressed long bone with intervertebral disc interposed Hyaline cartilage intervenes between 6 years : Ring or annular epiphysis appears on the periphery of cephalic and caudal surface 8 years : Calcification in the ring epiphysis starts 18 years : Fuse with the vertebral bodies

7. SURGICAL ANATOMY : INTERVERTEBRAL JOINT Second Cervical to first Sacral vertebra : Articulations Series of fibro cartilagenous joints formed by intervertebral discs between the vertebral bodies Series of paired synovial joints between the posterior articular process A typical vertebra articulates at 6 articulating surfaces Two discs, Two proximal facet joints, Two distal facet joints

8. SURGICAL ANATOMY : INTERVERBRAL DISC Lies between the bodies of vertebra Central portion : Semigelatinous – nucleus pulposus Peripheral ring : Lamellated fibrous tissue – Annulus fibrosus Schmorl’s node : If there is deficiency in the hyaline cartilage and the bone end plate, nucleus pulposus herniates into the cancellous bone of vertebral bodies where it may encircled by the reactive bone Fetal life: Small blood vessels penetrate the annulus. It regress soon after birth; 18 years – discs are relatively avascular

9. BLOOD SUPPLY OF VERTEBRAL COLUMN: Branches from each segmental intercostal artery or lumbar artery supplying adjacent halves of two vertebra ( lower half of one above and upper half of one below) Inside the vertebral body the arterioles ends as tortuous loops under the epiphyseal end plates Juxta epiphyseal , paradiscal areas – more vascular

10. BATSON’S PLEXUS Batson’s perivertebral plexus of veins : Veins from the vertebral column drains here. Emerge from the posterior aspect of vertebral bodies to form postcentral anastomosis It has ramifications into the base of brain and chest wall and has free anastomosis with the intercostal, lumbar and pelvic veins Retrograde flow of blood from the viscera to the spine may be responsible for the spread of infection It is responsible for the association of chest wall abcess with vertebral TB or tuberculous meningitis with spinal tuberculosis

11. BLOOD SUPPLY TO SPINAL CORD One anterior and two posterior spinal arteries Anterior spinal A : Union of terminal branches of vertebral artery at level of foramen magnum ( Anterior 2/3) Posterior spinal A : Branches of Vertebral artery at the level of Medulla oblongata ( Remaining posterior part ) Anterior and Posterior Radicular arteries which enters through the intervertebral foramina Artery of Adamkiewicz : Originates from left intercostal or left lumbar artery between 10 th thoracic and 2 nd lumbar segents

12. TUBERCULOSIS OF SPINE Vertebral tuberculosis is the commonest form of skeletal tuberculosis It constitutes 50 percent of all tuberculosis of bones and joints It is most common during the first 3 decades

13. PATHOLOGY: TB of spine is always secondary Bacteria reach the spine via hematogenous route Spreads via para-vertebral plexus of veins i.e., BATSON’S PLEXUS

14. Tubercle: Accumulation of PMN cells (Released by macrophage and monocytes) Transformation to Epitheloid cells Formation of Langhans giant cells (Occurrence of caseation necrosis ) Lymphocytes appear and form a ring around the peripheral part of lesion Tubercle formation

15. COLD ABCESS: Marked exudative reaction is a common feature of Tuberculosis in skeletal system Cold abcess : Formed by collection of products of liquefaction and the reactive exudation Components: Serum, Leukocytes, Caseous material, Bone debris, Tubercle bacilli Migrates in various directions Feels warm ( not as such in pyogenic infections ) It may burst to form a sinus or ulcer ( undermined edges )

16. TUBERCULAR SEQUESTRA: Osseus destruction : lysis of bone leading to compression /collapse/ deformation Necrosis : due to ischemic infarction of segments of bones Due to loss of nutrition the adjacent articular cartilage or intervening disc degenerates and become separated as sequestra Intervertebral disc is not involved primarily ( Relatively avascular structure) The early involvement of the paradiscal regions of vertebra jeoparadizes the nutrition to the disc

17. Tuberculous granulomatous debris and abcess may be compressed between the sound vertebra above and below Local extension, retropulsion and propulsion of the material may occur Spreading and extending due to osteoperiosteal infiltration, passing along deep to anterior longitudinal ligament

18. TUBERCLE : FUTURE COURSE It may resolve completely The disease may heal completely with varying degrees of residual deformities or/and loss of function Lesion may be completely walled off and caseous necrosis may get calcified Low grade chronic fibromatous granulating and caseating lesion may still persist Infection may spread locally or via bloodstream

19. TALL VERTEBRA: Pott’s disease which had healed with ankylosis and appreciable kyphosis : considerable increase in height of vertebral bodies of lumbar spine may be present “ Tall Vertebra ” : Develops when disease occurs in the growth period As the deformity develops gradually, neural elements tolerate the progressive kyphosis for several years They reach adulthood with intact neural status

20. SIGNS AND SYMPTOMS: ACTIVE STAGE HEALED STAGE Symptoms are insidious but sometimes acute 1. Regains the lost weight Symptoms: malaise, loss of weight, loss of appetite, night sweats and evening rise of temperature 2. No evening rise of temperature or night cries 2. Localised kyphotic deformity which is tender on percussion 3. Deformity persists 3. Spasm of vertebral muscles present 4. ESR falls and radiological evidence of bone healing present 4. Night cries 5. Knuckle kyphosis may be detected by palpation

21. ABCESS AND SINUS: Abcess from cervical or dorsal regions can present themselves far away from the vertebral column along the fascial planes or course of neuro vascular bundles Present at paraspinal regions at back/ posterior or anterior cervical triangles / along the brachial plexus/ along intercostal spaces in chest wall From dorsolumbar and lumbar spine : psoas abcess – palpable in iliac fossa/ lumbar triangle or in upper part of thigh or even track towards upto knee ( Hip flexion/ Pseudo hip flexion deformity)

22. REGIONAL DISTRIBUTION: CERVICAL 12% CERVICODORSAL 5% DORSAL 42% DORSOLUMBAR 12% LUMBAR 26% LUMBOSACRAL 3%

23. RADIOLOGY: Spinal TB is difficult to diagnose radiologically in early stages 4 sites : Paradiscal Central Anterior Appendical 3

24. PARADISCAL TYPE: Commonest type The paradiscal lesion begins in the vertebral m etaphysis, erodes the cartilage plate and destroys the disc . The cartilaginous end plate acts as a barrier, but once invaded, destruction of the disc progresses rapidly due to its relative avascularity , and the infection goes on to involve the adjacent vertebrae. The early resorption of the disc leads to narrowing of the disc space

25. PARAVERTEBRAL SHADOWS: Extension of tuberculous granulation tissue and the collection of abcess in the paravertebral region In cervical region, it presents as a shadow between vertebral bodies, pharynx and trachea Upper thoracic abcess – V shaped shadow stripping over the lung apices laterally and downwards Abcess below the level of 4 th dorsal vertebra : typical fusiform shape ( bird nest appearance )

26. Abcess above the level of vertebral attachment of diaphragm : Remain within thorax Below the diaphragm : Extend along the course of psoas muscle Psoas abcess : Widening of psoas shadow Abcess under tension : Globular shape Psoas abcess can be aspirated through Petit’s triangle while iliopsoas abcess can be aspirated through Petit’s triangle as well as iliac fossa

27. Long standing paravertebral abcess : Scalloping effect / Aneurysmal phenomenon as concave erosions along the anterior margins of vertebral bodies Healthy discs, because of their elasticity : Saw tooth apperance

28. KYPHOTIC DEFORMITY: Paradiscal bodies shows areas of destruction and one or both bodies are usually wedged with forward angulation Involvement of large number of vertebra : Severe kyphotic deformity Forward wedging of one or two vertebra : Knuckle kyphos Wedge collapse of 3 or more vertebral bodies : Angular kyphosis Moderate wedging of large number of vertebra : Round kyphosis Gibbus deformity / Kyphotic deformity are interchangeable expressions

29. CENTRAL TYPE: In the central type of lesion the infection begins in the midsection of the body. It extends centrifugally to involve the whole body. The infection ususally spreads through Batson plexus of veins or through branches of posterior vertebral artery Following the infection, marked hyperemia and osteoporosis occur The body, which is thus softened, easily yields under gravity and muscle action, leading to compression, collapse and bony deformation. Diminution of disc space is minimal and paravertebral shadow is not marked

30. ANTERIOR TYPE: This lesion occurs when infection starts beneath the anterior longitudinal ligament. Peripheral portion of the vertebral body shows erosion in lateral or oblique views as shallow excavations More common in thoracic spine More erosion is caused when the abcess is near the aorta permitting the transmission of aortic pulsation to the abcess

31. APPENDICIAL TYPE: Isolated tuberculous infection of the pedicles, lamina, transverse process, spinous process Uncommon Radiologically : Appreciated by erosive lesions, paravertebral shadows and intact disc space CT/ MRI are best modalities to diagnose Appendicial type

32. LATERAL SHIFT AND SCOLISIS: Lateral curvature and lateral deviation : Rare deformity It occurs in those patients where there is involvement of posterior spinal articulations in addition to the usual paradiscal lesions Majority of cases donot have neurological complications

33. NATURAL COURSE OF DISEASE : Before the modern anti TB drugs : Patients developed crippling deformities, cold abcess , multiple discharging sinus, spread of infection to other parts of body, paraplegia and amyloidosis In modern era : If adequately treated in early stage, healing takes place well with a little radiological deformity IVORY VERTEBRA : In the healing stage, new bone formation occurs as a result of secondary infection usually associated with sinus formation

34. MODERN IMAGING TECHNIQUES: CT SCAN It is useful tool in assessing the destructive lesions of the vertebral column It is of special help for posterior spinal disease, TB of cranio vertebral and cervico dorsal region, sacro iliac joints and sacrum Delineation of shape, extent and route of spread of cold abcess can be visualized by CT scan

35. MRI SCAN: It is useful in the diagnosis of tuberculous infection of difficult and rare sites like cranio vertebral region cervico dorsal region disease of posterior elements and vertebral appendages infections of sacro iliac region sacrum and coccyx

36. ULTRASOUND ECHOGRAPHS: To diagnose the presence of tubercular abcess in lumbar vertebral disease To assess the composition of iliopsoas mass and the quantity of the liquid material contained therein In case of doubt for confirmation a biopsy of small prevertebral abcess or of atypical vertebra may be obtained by core biopsy needle under fluoroscopic control Open biopsy with debulking / decompression is mandatory if semi invasive techniques donot prove the pathology

37. CLINICO RADIOLOGICAL CLASSIFICATION: STAGE CLINICO RADIOLOGICAL FEATURES USUAL DURATION I : PRE DESTRUCTIVE Straightening of curvatures, spasm of prevertebral muscles, MRI shows marrow edema < 3 months II : EARLY – DESTRUCTIVE Diminished disc space + paradiscal lesion ( knuckle < 10 deg ) ; MRI : shows marrow edema; CT : marginal erosions or cavitations 2 – 4 months III, IV, V – all have vertebral body destruction + collapse + appreciable kyphosis III – Mild angular kyphos 2 -3 vertebra involved (K: 10 -30 deg ) 3 -9 months IV – Moderate angular kyphos > 3 vertebra ( K : 30 to 60 deg ) 6 – 24 months V – Severe kyphos ( Humpback deformity ) > 3 vertebra involved ( K: > 60 deg ) > 2 years

38. BIOLOGICAL HEALING AND IMAGING Radiological evidence of healing : lags behind the biological process in spinal TB. If images donot show improvement when repeated after 6 months of therapy, one should consider the possibility of alternative pathology or therapeutically refractory disease Once the disease is healed, bony architecture is restored

39. DIFFERENTIAL DIAGNOSIS: Clinical and radiological re examinations after 6 to 12 weeks are of great help in arriving final diagnosis In case of doubt, histological and micro biological investigations should be sent

40. CONSIDERATION OF AGE: Congenital defects of spine Calves disease in young children Schmorl’s disease Scheuerman’s disease in adolescent All these conditions may have no constitutional symptoms but a characteristic radiological appearance Primary tumour of vertebra Metastasis should be considered in adults

41. PYOGENIC INFECTIONS: Onset is sudden with severe localised pain, spasm and swinging temperature Early stages : Bone destruction present, rapidly replaced with sclerosis and new bone formation IVD shows varying degrees of destruction ASO titre/ Microbiological investigations : Final diagnosis

42. TYPHOID SPINE: Most cases present in the time interval of 4 weeks to few months after the disappearance of typhoid fever Radiological picture : Resembles that of tuberculosis and low grade pyogenic spondylitis Confirmations : Agglutination test, Therapeutic trial or by biopsy

43. SYPHILITIC INFECTION OF SPINE: Arthralgic type Gummatous type Charcoat’s disease Most common site: Thoraco lumbar and Lumbar spine Diagnosis : Serological tests, Tissue biopsy or response to Anti syphilitic treatment

44. TUMOUROUS CONDITIONS: Hemangioma : most common beningn tumour (D12 to L4) Radiologically : Pin head appearance Involved vertebra shows characteristic coarsening of vertebral trabeculations and more prominent in vertical than in horizontal trabeculae ( Corduroy appearance ) Giant cell tumour and Aneurysmal Bone cyst: Osteolytic expansile and usually eccentric growth on radiological examination; Disc space is not involved in early stages RESPPONSE TO RADIATION TREATMENT IS OBSERVED IN THESE CASES

45. MULTIPLE MYELOMA: There is involvement of only one or two vertebra and there is collapse and eccentric destruction Involvement of multiple bones, High ESR, Anemia , reversal of AG ratio, Urine Bence Jones Proteins are the charecteristics Diagnosis : Confirmation of myeloma cells in the bone marrow

46. OTHER CONDITIONS: Lymphomas Secondary neoplastic deposits Histiocytosis – X Spinal osteochondrosis Traumatic conditions Osteoporotic conditions Spondylolisthesis Hydatid Disease

47. NEUROLOGICAL COMPLICATIONS- POTT’S PARAPLEGIA It is the most dreaded and crippling complication of spinal tuberculosis Incidence : 10 to 30 percent Paraplegia most commonly results due to the involvement of the spinal cord, thus below the level of first lumbar vertebra rarely causes paraplegia due to the involvement of cauda equina Pathology : Compression paraplegia

48. TUBERCULOUS PARAPLEGIA- CLASSIFICATION: GROUP A : EARLY ONSET PARAPLEGIA : Occurs during the active phase of the disease Within first 2 years of onset Underlying pathology : Inflammatory edema , Tuberculous granulation tissue, Tubercular abcess , Tuberculous caseous tissue or ischemic lesion of spinal cord Good prognosis

49. GROUP B : LATE ONSET PARAPLEGIA: Appears > 2 years after the disease Underlying pathology : Tuberculous caseous tissue, Tubercular debris, Sequestra from vertebral body and disc, internal gibbus , stenosis of vertebral canal or severe deformity Prognosis is less favourable

50. STAGE CLINICAL FEATURES I Negligible Patient unaware of neural deficit, physician detects plantar extensor/ ankle clonus II Mild Patient aware of deficit but manages to walk with support III Moderate Non ambulatory because of paralysis(in extension), sensory deficit < 10 % IV Severe Stage III + Flexor spasm/ paralysis in flexion/ flaccid/ sensory deficit > 10%/ sphincters involved

51. PATHOLOGY OF TUBERCULOUS PARAPLEGIA: Inflammatory edema : Due to vascular stasis and due to toxins from the tuberculous inflammation in the neighbouring vertebrae Extradural mass : A state of tuberculous osteitis of the vertebral bodies with an abcess in the extradural space causing compression of the cord from the anterior aspect Components : Fluid, Pus, Granulation tissue, Caseous material Best visualised by MRI

52. Bony disorders: Sequestra from avascular portions may be responsible for narrowing of the spinal canal and pressure on the cord Angulation of the diseased spine : Due to the formation of bony ridge called internal Gibbus on the anterior wall of spinal canal Concomitant mechanical instability can produce neural complications in TB or in pathological subluxation or dislocation

53. Meningeal changes: Thick layer of tuberculous granulation tissue lying outside the dura Extra dural granulation : May contract and undergo cicatrisation in long standing cases Peri dural fibrosis : Responisble for recurrence of paraplegia

54. Infarction of Spinal cord: Caused by : Endarteritis, Periarteritis or thrombosis of any tributary to the anterior spinal artery caused by inflammation reaction Paralysis caused by infaraction is irreversible Rarely it may occur because of surgery or due to thrombo embolic phenomenon

55. Changes in spinal cord: Unrelieved compression of the spinal cord shows loss of neurons and white matter in the damaged segment The lost cells and fibres are replaced by gliosis and loss of myelin may be seen Neuronal plasticity : It is induced when compression or deformation of the cord takes place slowly over a length of time. A sudden compression or gross deformation would almost lead to near transection of the neural elements

56. EXTRADURAL GRANULOMA: It may be responsible for the neurological complications without any radiological evidence of involvement of vertebra These cases are called as “ Spinal tumour syndrome” The patients who did not recover after satisfactory decompression may be persumed to have these factors MRI is the investigation of choice. Intradural tuberculomas can be managed by ATT drugs; But extradural tuberculoma has to be managed by surgical decompression

57. SIGNS AND SYMPTOMS: In a paraplegia of slow onset : Spontaneous twitching of muscles in the lower limbs, clumsiness in walking, extensor plantar response and exaggerated reflexes Sustained clonus of ankle and patella may be present Motor functions are affected more than sensory because the diseased area lies nearer to the motor tracts

58. PARAPLEGIA STAGES: Spastic motor paralysis Spastic paraplegia in extension Spastic paraplegia in flexion As the compression increases the patient develops flexor spasms which in later stages remains established in flexion In very advanced cases bladder and anal sphincters may be involved In extremely severe cases spasticity disappers and paralysis become flaccid

59. MYELOGRAPHY: In cases of Spinal Tumour syndrome / cases with multiple vertebral lesions myelography is indicated It is useful in assessing the level of obstruction It is also used in conditions where patients donot recover after decompression

60. CLINICAL FACTORS INFLUENCING PROGNOSIS CORD INVOLVEMENT BETTER PROGNOSIS RELATIVELY POOR PROGNOSIS Degreee Partial ( Stage I, II, III) Complete ( Stage IV) Duration Shorter Longer (> 12 months) Type Early onset Late onset Speed of onset Slow Rapid Age Younger Older General condition Good Poor Vertebral disease Active Healed Kyphotic deformity < 60 degree > 60 degree Cord on MRI Normal Myelomalcia Preoperative Wet lesion Dry lesion

61. TREATMENT OF POTTS PARAPLEGIA:

62. USUAL CAUSES AND MANAGEMENT PROTOCOL INFLAMMATORY 1. Inflammatory edema Recovers by rest and drug therapy 2. Tuberculous granulation tissue Mostly recovers by rest and drug therapy 3. Tubercular abcess Conservative management ; Rarely requires decompression 4. Tuberculous caseous tissue Rarely by conservative ; Requires Evacuation and Decompression

63. MECHANICAL 1. Tubercular debris Operative removal and decompression 2. Sequestra from vertebral body and disc Operative removal and decompression 3. Constriction of cord due to stenosis Operative decompression 4. Localised pressure Operative decompression

64. Intrinsic 1. Prolonged stretching of cord Decompression, Release of cord and anterior transposition may lead to recovery 2. Infective thrombosis Difficult to recover 3. Pathological dislocation of spine Rare complication; Indiscriminate laminectomy and irrepairable severance of cord 4. Tuberculous meningomyelitis Myelitis doesnot recover completely 5. Syringo myelic changes Poor recovery SPINAL TUMOUR SYNDROME Diffuse extradural granuloma/ tuberculoma Laminectomy

65. MANAGEMENT OF TB SPINE: BASIC PRINCIPLES OF MANAGEMENT: Early diagnosis Aggressive medical treatment Surgical approach Prevent Deformity Best outcome

66. MIDDLE PATH REGIMEN: Rest in hard bed or Plaster of Paris Bed In cases of cervical and cervico dorsal lesions, traction is used to put the diseased part in rest POP bed is used for children or for a few un co operative patients

67. B.DRUGS: INTENSIVE PHASE ( 5 to 6 months) CONTINUATION PHASE ( 7 to 8 months ) PROPHYLACTIC PHASE Isoniazid 300 to 400mg Isoniazid and Pyrazinamide (1500mg) for 3 to 4 months Isoniazid and Ethambutol ( 1200mg) fot 4 to 5 months Rifampicin 450 to 600mg Isoniazid and Rifampicin for another 4 to 5 months Ofloxacin 400 to 600mg For hospitalised patients Streptomycin replaces one of the drugs except Isoniazid Supportive therapy with Multivitamins, Hematinics may be added if necessary

68. C. Radiographs and ESR are taken at 6 months interval. For Cranio vertebral/ cervicodorsal / Lumbosacral regions, CT or MRI has to be repeated at 6 to 12 months interval D. General mobilization of the patient is encouraged in the absence of neural deficit with the help of suitable spinal braces

69. 3 to 9 weeks : Patient is put on back extension exercises for 5 to 10 minutes ( 3 to 4 times a day ) Spinal brace is continued for 18 months to 2 years E. Abcess are drained when near the surface and one gram of streptomycin with or without INH is instilled at each aspiration F. Sinus may heal within 6 to 12 weeks of treatment ; Some may require longer treatment and excision

70. G. Neural complications : Patients who are on triple drug regimen and shows recovery of neurological complications within 3-4 weeks , Surgical decompression is not indicated. Surgical Decompression should be performed if the patient donot recover after a fair trial of conservative therapy In patients with motor, sphincter, sensory involvement or having severe flexor spasms, operative management should not be delayed

71. H. Excisional surgery : Recommended for posterior spinal disease associated with abcess or sinus formation I : Operative management : Adviced for cases who donot show arrest of activity of spinal lesions after 3 to 6 months of chemo therapeutic regimen J. Posterior Spinal Arthrodesis : For symptomatic unstable spinal lesions These lesions show significant destruction of more than 2 vertebra and lack of regeneration of vertebral bodies during the process of healing

72. K. Post operative : Patient should be nursed on a hard bed for 2 to 3 weeks; In cases with neural complications , 3 to 5 months after the operation when the patient had a good recovery, patient is mobilized out with spinal braces The spinal brace is discarded after 12 to 24 months of surgery

73. INDICATIONS FOR VARIOUS SURGICAL PROCEDURES: Decompression ± fusion : Neurological complications which failed to response after 3 to 6 weeks of treatment’ Debridement ± fusion : Failure of response after 3 to 6 months of non operative management Debridement ± Decompression ± fusion : Recurrence of neurological complications Prevention of severe kyphosis by posterior fusion ± debridement : Young children with extensive dorsal lesions Anterior transposition of cord : Neural complications due to severe kyphosis

74. TUBERCULSOSIS OF SACRUM AND COCCYX: Rare localisation of tuberculous infection (<1%) Tuberculous abcess may form anteriorly in pre sacral space Persistent pain in sacro coccygeal region with local warmth and tenderness may be present In neglected cases it may form sinus and drains in the gluteal region or peri anal areas

75. SURGICAL MANAGEMENT : Tuli’s recommended approach: Cervical spine –T1 : Anterior approch Dorsal spine –DL junction: Anterolateral approch Lumbar spine & Lumboscral junction : Extraperitoneal Transverse Vertebrotomy

76. Posterior fixation Fixation of posterior element of diseased vertebra by instrumentation are done: To prevent and correct kyphotic deformity. To maintain stability of the spine

77. SURGERIES: Antero lateral decompression : Spine is exposed from the anterior and the lateral side; Cord is laid free from the granulation tissue/ sequestrum / caseous material. It is the most commonly used method Costo – transversectomy : Ribs and the transverse process of vertebra is removed and the pus is drained Radical debridement and arthrodesis Laminectomy and posterior stabilisation : In cases of Spinal cord syndrome and in cases where neural complications present

78. TREATMENT OF PARAPLEGIA IN SEVERE KHYPHOSIS Griffiths et al (1956) :anterior transposition of cord through laminectomy Rajasekaran (2002): posterior stabilization followed by anterior debridement and bone grafting ( titanium cages) in active stage of disease and vice versa for healed disease

79. SURGICAL CORRECTION OF SEVERE KYPHOTIC DEFORMITY Fundamentals of correction: 1. to perform an osteotomy on the concave side of the curve and wedge it open ( secured with strong autogenous iliac grafts) . 2. to remove a wedge on the convex side and close this wedge ( Harrington compression rods and hooks)

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

81. DRAINAGE OF PSOAS ABCESS: Through lateral incision –along the middle third of the crest of the ilium Th r ou g h P etit ’ s trian g le

82. SPINAL BRACES: For diseases from fourth dorsal to second lumbar vertebra : Traditional braces extending from seventh cervical vertebra to lower end of sacrum is used

83. TAYLOR BRACE MILWAUKEE BRACE

84. ASH BRACE SOMI BRACE