Tuberculous spondylodiscitis.pptx

Tuberculous spondylodiscitis

1. Tuberculous spondylodiscitis BY DR.K.GOUTHAM JUNIOR RESIDENT DEPT OF ORTHOPAEDICS TMCH

2. Introduction: Organism : Mycobacterium tuberculosis Always secondary 15% of patients with TB will have extrapulmonary involvement The spine is the most common site for skeletal TB Accounts for >50% of skeletal TB M/C site THORACIC spine - high vascularity of the vertebral marrow -proximity to structures like cisterna chili, kidneys, lungs , lymphnode

3. Pathophysiology : Vertebral infection by bacillus results from haematogenous dissemination from a primary focus Primary focus can be active, quiescent , latent OTHER ROUTES Batson’s paravertebral venous plexus lymphatic drainage from para aortic lymph nodes

4. Pathoanatomy : Early infection – metaphysis of the vertebral body is affected spread along the anterior longitudinal ligament, results in abscess formation Chronic infection : severe kyphosis will occur due to destruction of adjacent vertebral body and intervertebral discs

5. Kyphosis - in adults it will remain static after healing - in children it is progressive (40%) due to growth spurt Classification of progression: (by Rajasekaran ) Type 1 – increase in deformity until cessation of growth (treated with surgery) Type 2 – decreasing progression with growth Type3 – minimal changes

6. Clinical features: ACTIVE PHASE Specific symptoms: Pain / ‘night cry’ Stiffness Deformity Restricted ROM Enlarged lymph nodes Neurodeficit Abscess Constitutional symptoms: Malaise Loss of weight/appetite Night sweat Evening rise in temperature

7. CLINICAL FEATURES HEALED STAGE Stiffness Deformity Restriction of ROM Neurological deficit

8. Back pain : chronic inflammation (nagging) pressure due to abscess(aching) segmental instability (severe pain ) Sudden exacerbation in night( night cry)- due to release of spasm of muscles and movement of affected structures Tripod sign – instability Radicular pain

9. Neurological defect : (PARAPLEGIA) - 10-50% of pott spine - dorsal spine is most commonly involved - motor functions affected before sensory involvement - sense of position and vibration last to disappear

10. Sites of spinal TB:

11. PARADISCAL LESION : most common type subchondral bone destruction and narrowing of disc space is seen MRI – low signal on T1 and high signal in T2 in the end plates , narrowing of disc and abscess if present

12. ANTERIOR TYPE: subperiosteal lesion under vthe ALL pus spread over the multiple vertebral segments periosteal stripping predisposes to infection Most common in children, thoracic in spine CENTRAL TYPE : center of the vertebra is affected disc is not involved vertebral body collapses causing vertebre plana app.

13. Basic principle of management : Early diagnosis expeditious medical treatment aggressive surgical approach prevent deformity best outcome

14. INVESTIGATION PLAIN XRAY: Localised osteoporosis Adjacent end plate irregularity Increased prevertebral shadow Irregularity in anterior vertebral wall Destruction of More than 2 vertebra with involvement of disc space Aneurysmal phenomenon – concave erosion along the ant wall of vertebra Vertebra plana

15. Skipped lesions: More than one TB lesion in vertebral column with one or more healthy vertebra in between the 2 lesion 7% of routine xray More frequently detected in MRI/CT scans

16. Anterior type of lesion Starts beneath the anterior longitudinal ligament &periosteum Collapse and disc space reduction is usually minimal and occurs late Erosion is primary

17. Paradiscal lesions: Commonest type Spread through arterial supply Reduced disc space is the earliest sign Loss of vertebral margins Increased prevertebral soft tissue shadows

18. Central type: Spread through BATSON’S venous plexus/ branches of posterior vertebral artery Minimal disc space reduction At the end concentric collapse

19. Appendicular type of lesion : Rare Isolated infection of pedicle/lamina/ transverse process/spinous process Intact disc space

20. Healing is indicated by :- Decreased soft tissue shadow Return of normal density Bony ankylosis

21. Risk factors for buckling collapse ("spine at risk signs") retropulsion subluxation lateral translation toppling

22. CT SCAN: Indications: demonstrates lesions <1.5cm better than radiographs inaccurate for defining epidural extension findings CALCIFICATION OF ABSCESS Types of destruction: fragmentary osteolytic subperiosteal sclerotic

23. MRI SCAN : Indications remains preferred imaging study for diagnosis and treatment diagnose adjacent levels multiple levels involved in 16-70% Changes in inter vertebral disc Earliest vertebral body pathology T1 – hypo intense marrow in abscess T2- hyper intense marrow , disc, soft tissues Preservation of disc + heterogenous involvement is seen in TB Peridiscal bone destruction + homogenous enhancement in pyogenic spondylodiscitis

24. ULTRASOUND : To find out primary in abdomen Detect cold abscess Guided aspiration Radionucleotide scan T99m: Increased uptake seen in upto 60% patient with acute tuberculosis > 5mm lesions can be detected Avascular segment and abscesses show cold spot Highly sensitive but nonspecific Localise the site of active disease

25. CBC : relative lymphocytosis , low hemoglobin ESR: usually elevated but may be normal in up to 25% PPD (purified protein derivative of tuberculin) positive in ~ 80% Diagnosis CT guided biopsy with cultures and staining effective at obtaining a diagnosis - should be tested for acid-fast bacilli (AFB) - mycobacteria (acid-fast bacilli) may take 10 weeks to grow I culture - PCR allows for faster identification (95% sensitivity and 93 accuracy) -smear positive in 52% -culture positive in 83%

26. Clinico radiological classification of tb spine:

27. TREATMENT CASES OF SPINAL TB CONSERVATIVE TREATMENT WITH CHEMOTHERAPY MIDDLE PATH REGIME RADICAL SURGERY

28. TREATMENT CHEMOTHERAPY IN SPINAL TB: Drugs : 2RHZE/10RHE All patients require close monitoring for development or progression of neurological deficit in the first 4 weeks of treatment. Some patients require surgical intervention. Total treatment duration : 12 months (extendable to 18 months on a case-by case basis) Follow up -Patients without neurological deficit should be advised to return to the clinic immediately if new symptoms develop, and all ambulant patients should be assessed weekly for neurological signs.

29. Patients with neurological deficit require staging and grading of their deficit.These patients should be assessed weekly with neural charting to detect neural recovery or deterioration. Repeat X-rays of the spine are suggested every 3 months following initiation of treatment to assess for radiological healing. Repeat MRI scans are suggested at 6, 9, 12 and 18 months following initiation of treatment to assess healing. At the end of treatment, all patients require follow up every 6 months for at least 2 years, and should be told to return to the clinic promptly if they develop new symptoms in the interim

30. MIDDLE PATH REGIME : RATIONALE “All spinal tuberculosis cases do not require surgery and all those who do not respond to conservative measures should be operated” REST: In hard bed POP bed for children Cervical TB patients requires traction in early stage to put the diseased part in rest

31. Supportive treatment : Hematinics , multivitamins, High protein diet Monitoring: Xray and ESR at 3-6 months interval MRI of 6 months interval Gradual mobilisation: - Encouraged in absence of neurological deficit with support of spinal braces

32. Abscess drainage: Superficial abscess drained and Streptomycin , INH solution injected at the site Cervical paravertebral abscess drained if causing difficulty in respiration / swallowing Drainage of perispinal abscess considered when its radiological size increases even after treatment

33. ABSOLUTE INDICATION FOR SURGERY: NO progressive recovery after fair trial of conservative treatment Neurological complications develops during the conservative treatment Worsening of neurological deficit Recurrence of neurological complication Pressure effects Advanced cases of neurological involvement

34. Goals of surgical treatment: Debridement and drainage of large abscesses Decompression of spinal cord and neural structures Kyphosis correction Reconstruction of the anterior column Stabilization of the spine with instrumentation DECOMPRESSION DEFORMITY STABILITY

35. Kyphosis correction - > 60° in adult - progressive kyphosis in child - ≥3 vertebrae involved with loss of ≥1.5 vertebral bodies in thoracic spine - children ≤ 7 years with ≥3 vertebral bodies affected in T/TL spine and ≥ 2 at risk signs are likely to have progression and should undergo correction

36. SURGICAL APPROACHES : Anterior decompression with stabilization Combined anterior decompression with posterior stabilization through two approaches All posterior approach for anterior decompression and posterior stabilisation

37. ANTERIOR APPROACH Most common region involved is the vertebral body Advantage : direct access to the diseased region , visualization of neural structures, ability to insert strut graft Anterior decompression surgeries performed initially involved radical removal of the entire vertebra that are involved Removal of infected foci upto bleeding normal bone is sufficient + efficient chemotherapy in clearing the residual infection

38. Technique : Cervical spine Standard technique for debridement and decompression of cervical sub axial lesions SMITH ROBINSON APPROACH Thoracic spine : Transthoracic , retropleural or transplural approach is used Thoracolumbar , lumbar spine: Retroperitoneal approach

39. Combined approach : Indication : patient with significant vertebral destruction and kyphosis Anterior decompression and posterior instrumentation are performed through two separate approaches in single or two stage Posterior pedicle screw fixation is performed either in the 1 st stage or in the 2 nd stage

40. All posterior approach: The current standard of surgical care Posterior pedicle screw fixation is performed by a posterior midline approach followed by decompression and reconstruction of the anterior column through a transpedicular and anterolateral route with the same approach Advantages : Excellent exposure for circumferential spinal cord decompression Instrumentation can be extended for multiple levels Allows better control of the deformity correction Since extra pleural approach , can be performed in patients with pulm TB

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