tubercular spine and management including surgical and medical

tubercular spine

1. TUBERCULOSIS OF SPINE (POTT’S DISEASE)

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

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

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

5. TYPES OF VERTEBRAL TUBERCULOSIS PARADISCAL – COMMONEST TYPE, CONTIGOUS AREA OF TWO ADJACENT VERTEBRA ALONG WITH INTER VERTEBRAL DISC IS AFFECTED CENTRAL – BODY OF A SINGLE VERTEBRA IS AFFECTED. ANTERIOR – INFECTION IS LOCALISED TO THE ANTERIOR PART OF VERTEBRAL BODY. POSTERIOR (APPENDICIAL) – POSTERIOR COMPLEX OF VERTEBRA I.E. PEDICLE, LAMINA, SPINOUS PROCESS ARE AFFECTED.

6. SKIP LESIONS: SOME TIMES MORE THAN ONE TUBERCULOUS LESION MAY BE PRESENT IN THE VERTEBRAL COLUMN WITH ONE OR MORE HEALTHY VERTEBRA IN BETWEEN.

7. CLINICAL FEATURES CONSTITUTIONAL SYMPTOMS- FEVER, WEIGHT LOSS ETC. PAIN PRESENTING SYMPTOM, IT AGGRAVATES AT NIGHT (NIGHT CRY) PARAVERTEBRAL SWELLING – A SUPERFICIAL COLD ABSCESS MAY APPEAR AS PARAVERTEBRAL SWELLING. IT MAY BURST THROUGH THE SKIN FORMING A DISCHARGING SINUS. DEFORMITY: KNUCKLE- PROMINENCE OF A SINGLE SPINOUS PROCESS. GIBBUS – 2-3 SPINOUS PROCESS PROMINENCE. KYPHUS ->3 SPINOUS PROCESS PROMINENCE.

8. Cold abscess THIS IS A COLLECTION OF PUS AND TUBERCULAR DEBRIS WITH BACILLI FROM A DISEASED VERTEBRA. THE ABSCESS IS CALLED COLD BECAUSE IT IS NOT ASSOCIATED WITH SIGNS OF INFLAMMATION. THE COLD ABSCESS PENETRATES THE BONE AND LIGAMENTS AND CAN TRACK ALONG THE PLANE OF LEAST RESISTANCE. ANTERIORLY- PREVERTEBRAL ABSCESS, RETROPHARYNGEAL ABSCESS POSTERIORLY- ALONG THE POSTERIOR DIVISIONS OF SPINAL NERVES, PARAVERTEBRAL ABSCESS

9. 3. ALONG 12TH THORACIC / ILIOINGUINAL NERVE –RENAL ABSCESS. 4. THROUGH UPPER OPENING OF PSOAS SHEATH- PSOAS ABSCESS. 5. PASSING BEHIND MEDIAN ARCUATE LIGAMENT –INTRAABDOMINAL ABSCESS.

10. INVESTIGATION ROUTINE BLOOD INVESTIGATIONS: CBC, ESR AND CRP RADIOLOGY REDUCTION OF DISC SPACE- EARLY SIGN DESTRUCTION OF VERTEBRAL BODY: EROSIONS AND WEDGING DEFORMITY 3. CT scan

11. CT MRI BIOPSY : CT GUIDED NEEDLE OR OPEN BIOPSY

12. Differential Diagnosis TRAUMATIC SECONDARIES OR MYELOMA PROLAPSED DISC ANKYLOSING SPONDYLITIS SPINAL TUMOR SPINAL INFECTIONS ( BACTERIAL, ATYPICAL MYCOBATERIAL, FUNGAL) TUMOUR LIKE CONDITIONS LIKE GCT, HAEMANGIOMA, ANEURYSMAL BONE CYST

13. TREATMENT CONSERVATIVE TREATMENT (MIDDLE PATH REGIME): REST IN HARD BED ANTITUBERCULOUS DRUGS GRADUAL MOBILISATION- AFTER 3-9 WEEKS OF STARTING TREATMENT WITH SUITABLE SPINAL BRACES. DRAINAGE OF COLD ABSCESS WHEN PRESENT INSPITE OF CONSERVATIVE TREATMENT.

14. SURGICAL MANAGEMENT: PARAPLEGIA APPEARING DURING USUAL CONSERVATIVE TREATMENT. PARAPLEGIA GETTING WORSE OR REMAINING STATIONARY DESPITE ADEQUATE CONSERVATIVE TREATMENT. RAPID ONSET PROGRESSIVE PARAPLEGIA. PROGRESSIVE DEFORMITY SPINAL INSTABILITY

15. Extraspinal musculoskeletal tuberculosis Tuberculosis can affect any bone in the body from cervical spine to foot bones. It can also affect the synovial sheath of the tendons (tenosynovitis) The incidence of skeletal tuberculosis is 1 – 4%.

16. 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 )

17. TB HIP 15% of skeletal tuberculosis. The initial focus may start in the; 1. Acetabular roof 2. Greater trochanter 3. Femoral epiphysis 4.Synovial membrane

18. In the hip joint, head and neck are intracapsular so a bony lesion invades the joint early. May become so extensive that pathological dislocation of joint may occur.

19. Pathogenesis Primary focus heamatogenous spread / by direct extension Joint Synovial membrane Tuberculous synovitis Synovial effusion Articular cartilage damage Subchondral bone erosion

20. STAGES OF TB HIP Stage of synovitis: There is effusion into the joint which demands the hip to be in a position of maximum capacity i.e. flexion, abduction and external rotation. Stage of apparent lengthening Stage of arthritis: Articular cartilage is damaged. Leads to spasm of powerful muscles around the hip. Flexors and Adductors are the stronger muscles. Thus the hip goes into flexion, adduction and internal rotation.

21. • Stage of apparent shortening. Stage of erosion: Cartilage gets destroyed. Head and acetabulum gets eroded. Pathological subluxation or dislocation occurs. Hip is in flexion, adduction and internal rotation. True shortening of the limb.

22. CLINICAL FEATURES Limping – earliest, commonest symptom Antalgic gait Pain – referred to medial aspect of knee - max towards end of the day Deformity

23. DIAGNOSIS Radiology: • Soft tissue swelling • Localised osteoporosis • Haziness of articular margins • Decreased joint space • In advanced cases; Collapse of the bone, Sub luxation/dislocation of joint.

24. CT Scan MRI USG Aspiration of cold abscess Synovial Biopsy Cultures positive in 80% cases HPE & PCR –diagnostic

25. PROGNOSIS Depends upon the stage of the disease. Early disease (synovitis & early arthritis) may heal leaving a normal / near normal hip. Advanced arthritis results in fibrous ankylosis.

26. 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

27. Surgery In stage of Synovitis; Synovectomy & Arthrotomy. Stage of Early arthritis; Synovectomy & Debridement of loose bodies and granulation tissue

28. In stage of Advanced arthritis Arthrodesis Girdle stone excision Arthroplasty usually done after 6 months after the start of the ATT.

29. 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

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