TUBERCULOSIS OF

SPINE

Dr: Chhabilal Bastola

Intern, Dept. of orthopedics

BPKIHS,DHARAN,NEPAL

3/19/2015

1

Outline

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1. Introduction

2. Relevent Anatomy

3. Pathology and pathogenesis

4. Approach and clinical features

5. Diagnosis ,Differentials diagnosis

6. Lab workup ,rule in/ out

7. Management plan

8. others

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Introduction

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Spinal tubercular infections account for 1/3rd to more than ½ of the Musculoskeletal TB infections

Always secondary

Most common : 1st three decades

Equally distributed among both sexes

Most affected : Thoraco-lumbar region

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CAMPBELL’S OPERATIVE ORTHOPAEDICS, TWELFTH

EDITION

Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

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10-09-2014

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10-09-2014

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Clinical features of spinal TB SM TULI SERIES

(1965-1974)

Clinical kyphosis 95%

Palpable cold abscess 20%

Radiological periverebral abscess 21%

Neurological involvement 20%

Tubercular sinuses (active/healed) 13%

Associated extra spinal skeletal foci 12%

Associated visceral or gladular foci 12%

Skipped lesion in spine 7%

Lateral shift(radiological ) 5%3/19/2015

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Clinical features :Neurology Asia 2010; 15(3) : 239 – 244

A.Active stage

1.Pain: Back pain (Commonest), Diffuse in

early stages, but later become localised to the

affected diseased segments.

It may be a radicular pain.

Depending upon the nerve root affected, it may present

as:

1.Cervical root- Arm pain

2.Dorsal root- Girdle( pectoral ) pain

3.Dorso-lumbar root- Abdomen pain

4.Lumbar root- Groin pain , or

5.Lumbo-Sacral root- Sciatic pain

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CLINICAL FEATURES 10

2.Spine Stiffness: spasm of para-vertebral

muscle

3.Night cries:why?

4.Deformity: Knuckle /Gibbus/Kyphus.

5.Cold abscess: May be present

6.Paraplegia (if neglected in early stages)

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7.Constitutional Symptoms (Only in 20%

cases): Malaise, weight loss, loss of appetite,

night sweats, evening rise of temperature.

B. Healed stageNo systemic features but deformity persists.

Radiological evidence of bone healing

But several of these signs and symptoms may be absent.

Important: presentation depends on

1.Stage 2 Site3.Presence of complications :neurologic deficits,

abscesses, or sinus tracts3/19/201512

Infectious exudate may spread anteriorly beneath Anterior longitudinal ligament &neighbouring vertebrae

Advances&destroys epiphyseal cortex,intervertebraldisc&adjacent vertebrae

Infection begins in cancellous area of vertebral body(Central/anterior/epiphyseal in location)

Route of infection :1.hematogenous (Batesons plexus)2.Lymph node spread 3.Direct spread

Focus of infection : possible from any sites M/C pulmonary ,abdomen

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PATHOGENESIS:Cold Abscess

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Tuberculous granulation tissue + caseous matter + necrotic bone

Accumulate beneath the Anterior longitudinal ligament.

Gravitate along the fascial planes

Present externally at some distance from the site of the original lesion.

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COLD ABSCESS :CERVICAL

SPINE

ANTERIORLY : 1.Retropharyngeal abscess,

2.paravertebral abscess

ON SIDE :post. 1.Border of SCM

2. POST of neck

ALONG MUSCULOFASCIAL PLANE : 1.Axilla

2.Arm

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COLD ABSCESS :THORACIC

SPINE

ANTERIORLY 1.mediastinal abscess

2. paravertebral abscess

ON SIDE : 1.psoas abscess

2. lumbar abscess

ALONG MUSCULO-FASCIAL PLANE:

1.Ant. Chest wall

2.Mid-axillary line

3.posterior chest wall

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COLD ABSCESS :LUMBAR

SPINE

ANTERIORLY :prevertebral abscess

: paravertebaral abscess

ON THE SIDE : lumbar abscess

: psoas abscess

ALONG MUSCULOFASCIAL PLANE : groin ,leg

along sciatic nerve to pelvis, gluteal region, posterior aspect of thigh and poplitealRegion(KNEE)

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Management plan

DIAGNOSIS is CLINICO RADIOLOGICAL

other investigation can be taken as back

ups

LAB STUDIES

Microbiological studies

Histopathological work up

Radiological

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LAB STUDIES

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1.Hematological : CBC,ESR(ESR may be

markedly elevated (neither specific nor reliable).)

2.Mantoux / Tuberculin skin test

4. PCR : 99.9

3. ELISA : for antibody to mycobacterial antigen-6 ,

sensitivity of 60 – 80%.

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Microbiological studies

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Histopathological

workup(Pre/PostOP)

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Plain radiograph

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1. Disc space narrowing (COMMONEST )

2. Erosion of end plate

3. Signs of infection with lucency in ANT. Portion of vertebra

4. Deformities (knuckle, gibbus ,kyphus Anterior

wedging,Vertebra plana

5. Sclerosis resulting from chronic infection

6. Compression fracture (Concertinal collapse /Vertebra

plana = single collapsed vertebra)

7. soft tissue swelling from paraspinal abscess +/- calcification

8. Bowing of rib cage with multiple vertebral fracture

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Paravertebral / prevertebral

Shadows(Radiological evidence of cold

abscess)

Abscess in cervical region: as a soft tissue shadow b/n vertebral bodies and pharynx & trachea.

On average, normal space b/n pharynx and spine above level of Cricoid cartilage is 0.5 cm and below it is 1.5 cm

In lateral view, the tracheal shadow isConcave anteriorly (parallel to the upper dorsal vertebrae),if there is a change in normal contour &/or its distance is >8mm from the vertebrae, it is strong indicator of the disease from C7 to D4

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Prevertebral Shadows

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RETROPHARYNGEAL ABSCESS

Abscess below the level of D4 vertebrae – Fusiform shape (Bird

nestappearance)

An abscess under tension may produce- Globular shape

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Paravertebral

Shadows 28

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CT- SCAN OF SPINE

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Patterns of bony destruction.

Calcifications in abscess (pathognomic for TB)

Regions which are difficult to visualize on plain

films, like :

1. Cranio-vertebral junction (CVJ)

2. Cervico-dorsal region,

3. Sacrum

4. Sacro-iliac joints.

5. Posterior spinal tuberculosis because

lesions less than 1.5cm are usually missed due to

overlapping of shadows on x rays.

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CT Features

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MAGNECTIC RESONANCE

IMAGING

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Lack of ionizing radiation, highcontrast resolution & 3D

imaging.

highly sensitive &specicific for spinal TB

Spinal cord & soft tissue involvement

Detect marrow infiltration in vertebral bodies(EDEMA),

leading to early

diagnosis

Skip lesions

Spinal arachanoiditis.

Changes of diskitis (EDEMA)

Assessment of extradural abscesses / subligamentous

spread

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REGIONAL DISTRIBUTION

DORSAL

42%(THORACIC)

LUMBAR 26%

DORSOLUMBAR 12%

CERVICAL 12%

CERVICODORSAL 5%

LUMBOSACRAL 3%

SM TULI SERIES (1965-1974

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Four patterns

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1.PARADISCAL ( Commonest)

2.CENTRAL

3.ANTERIOR

4.APPENDICEAL

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Adjacent to the I/V Disc leading to a

narrowing of the disc space

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PARADISCAL

Subperiosteal lesion under the ALL.

Pus spreads over multiple vertebral segments

Strips the periosteum and ALL from the anterior surface of the vertebral

bodies.

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Centred on the vertebral body.

Batson’s venous plexus

Appearance is indistinguishable from that of lymphoma or metastasis.

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Isolated Pedicles & laminae (neural arch), transverse

processes & spinous process.

• (< 5%)

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DIFFERENTIAL DIAGNOSIS(J

MAHESHWORI )

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Back pain

1. Traumatic

2. Secondaries to spine /myeloma/lymphoma

3. Prolapsed disc

4. Ankylosing spondylitis

Neurological deficit

1. Spinal tumor

2. Traumatic

3. Secondaries to spine

Radiologically

SPINAL INFECTIONS : pyogenic, BRUCELLA SPONDYLITIS

NEUROPATHIC SPINE : Diabetes

NEOPLASTIC : commonly lymphoma/ metastasis/primary

DEGENERATIVE

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TB spine

pyogenic

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• Long standing history of months

to

Years

• Presence of active pulmonary

tuberculosis

• Most common location thoracic

spine

followed by thoraco-lumbar region.

• > 3 contiguous vertebral body

involvement common-

• Vertebral collapse very common

• Bone destruction : more

• Skip lesions common

• Paraspinal and epidural

abscesses-

Common

calcification if present is

pathognomic.

• History of days to months.

• Not present.

• Most common location lumbar

spine.

• Mostly involves 1 spinal

segment – 2vertebrae & intervening

disc.

• less common

• very less

• Rare

• Rare

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A destructive bone lesion

associated with a poorly

defined

vertebral body endplate, with

or

without a loss of disk height,

suggests an infection, which

has a

better prognosis

A destructive bone

lesion associated with a well

preserved

disk space with sharp

endplates suggests

neoplastic

infiltration.

“Good disk, bad news;

bad disk, good news"

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Complication of spinal tuberculosis

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Paraplegia

Cold abscess

Spinal deformity

Sinuses

Secondary infection

Amyloid disease

Fatality

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SPINE TUBERCULOSIS WITH

PARAPLEGIA (potts paraplegia)

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Incidence : 10 – 30 %

Dorsal spine most common:

Motor functions affected before / greater than

sensory.

Sense of position & vibration last to disappear.

Paraplegia is the result of interference with the

conductivity of the pyramidal tracts of the spinal

cord and is most often associated with the

tuberculosis of the dorsal spine .

It can be early or late onset

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KUMAR’S CLASSIFICATION OF TUBERCULOUS

PARA/TETRAPLEGIA (Predominantly based on

motor

weakness)

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MOTOR

SEVERE MOTOR

SENSORY

SEV. SENSORY +AUTONOMIC

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SEDDON’S CLASSIFICATION OF

TUBERCULOUS PARAPLEGIA

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GROUP A (EARLY ONSET

PARAPLEGIA) a/k/a Paraplegia

associated with active

disease :

Active phase of the disease within

first 2 years of onset.

Pathology - inflammatory

edema, granulation tissue, abscess,

caseous material or ischemia of cord.

GROUP B (LATE ONSET

PARAPLEGIA) a/k/a Paraplegia

associated with healed disease :

After 2 years of onset of

disease.

Recrudescence of the

disease or due to mechanical

pressure on the cord.

Pathology can be sequestra,

debris, internal gibbus or stenosis of

the canal

Three approach

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CONSERVATIVE PLAN

MIDDLE PATH REGIME

RADICAL SURGERY APPROACH

NOA REGIMEN(J Nep Med assoc 2006; 45: 279-

280)

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Musculoskeletal Tuberculosis is classified

into three

categories.

Category I : Tubercular spondylitis (Pott’s

Spine with

or without neurological deficits).

Category II : Tubercular arthritis and

tubercular os-

teomyelitis.

Category III : Tubercular tenosynovitis,

bursitis and

other musculoskeletal soft tissue Tuber-

culosis.

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MANAGEMENT

10-09-2014

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National Tuberculosis Programme

Nepal Third Edition 2012

Immunotherapy

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1st week ------------------- O.1ml BCG ID

2nd week------------------- O.1ml BCG ID

3rd week--------------------O.5ml DPT IM

4th week --------------------O.5ml DPT IM

+

Inj. Levamisole 15 mg OD for 3 weeks

MIDDLE PATH REGIME SM TULI TB OF

MUSCULOSKELETAL SYSTEM

3/19/2015

Rest in hard bed

Chemotherapy

X-ray & ESR once in 3 months kyphosis

measurement MRI/ CT at 6 months interval for 2

years

Gradual mobilization is encouraged in absence of

neural deficits with spinal braces & back extension

exercises at 3 – 9 weeks.

Abscesses – aspirate when near surface & instil

1gm

Streptomycin +/- INH in solution

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CHEMOTHERAPY

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MIDDLE PATH REGIME

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Sinus heals 6-12 weeks

Neural complications if showing progressive

recovery on ATT b/w 3-4 weeks :surgery

unnecessary

Excisional surgery for posterior spinal disease

associated with abscess / sinus formation +/-

neural involvement.

Operative debridement–if no arrest after 3-6

months of ATT / with recurrence of disease

Posterior spinal arthrodesis : symptomatic unstable

lesion

Post op spinal brace→12 months-24

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ABSOLUTE INDICATIONS FOR

SURGERY:

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Paraplegia during conservative treatment (6 weeks)

Paraplegia worsening during treatment (6 weeks)

Complete motor loss for 1 month despite conservative

treatment

Paraplegia with uncontrolled spasticity

Severe and rapid onset paraplegia

Severe flaccid paraplegia/ sensory loss

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Other indications

Relative

indications

1. Recurrent

paraplegia

2. Paraplegia in

elderly

3. Painful and

spastic

paraplegia

4. Paraplegia with

Rare indications

1. Posterior element

disease

2. Spinal tumor

syndrome

3. Severe cervical

lesion c paraplegia

4. Cauda equinopathy

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10-09-2014

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Management of spinal tuberculosis: a systematic

review and meta-analysis

Asian Spine J 2014;8(1):97-111 http://dx.doi.org/10.4184/asj.2014.8.1.97

SURGERY

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• ABSCESS DRAINAGEA.

B. • HONGKONG’s PROCEDURE

C.• COSTOTRANSEVERSECTO

MY

D.ALD(LATERAL RACHOTOMY)+ CAGE + INSTRUMENTATION / BONE GRAFTING

SURGERY

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Posterior fixation:

Fixation of posterior element

of diseased vertebra by

instrumentation are done:

1.To prevent and correct

kyphotic deformity.

2. To maintain stability

of the spine

Fig : Pedicel screw fixation

TB Paraplegia or Quadriplegia

MDT, Bed rest for 6 weeks

Progressive neurological recovery No improvement

Continue MDT, walking allowed

when recovery complete

Surgical decompression

Recovering Not recovering

FLOW CHART FOR THE MANAGEMENT OF PARAPLEGIA

:SM TULI 3/19/201562

Not recovering

MRI / Myelogram

(IMMUNOMODULATION THERAPY)

No block Block present

Intrinsic damage to cord has

occurredRepeat surgical decompression

No recovery Recovery Continue MDT,

Rehabilitation

Continue MDT and permit

walking when recovery

complete

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CLINICAL FACTORS

INFLUENCING

PROGNOSIS IN CORD

INVOLVEMENT

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REFERENCES1.Tuberculosis of Skeletal System SM Tuli - 4th edn

2.Spinal tuberculosis (Pott’s disease): its clinical presentation,

surgical management, and outcome. A survey study on 694 patients

3.Davidson principles and practice of medicine 22ndedition

4.Essential orthopedics :j maheshweri

5. Ann R Coll Surg Engl 2007; 89: 405–409

doi 10.1308/003588407X183328

6. J Nep Med assoc 2006; 45: 279-28

7. 20(2):167–178 © 2005 Lippincott Williams & Wilkins, Inc., Philadelphia

8. NOAJ July-December 2013|Vol 3| Issue 2

9. Asian Spine J 2014;8(1):97-111 • http://dx.doi.org/10.4184/asj.2014.8.1.97

10. AJR 1995;164:659-664 0361-803X/95/1643-659 ?)Amenican Roentgen Ray Society

11. Ann Saudi Med 2004;24(6):437-441

13.Neurosurg Rev (2001) 24:8–13

14.Extrapulmonary Tuberculosis: A retrospective review of 194 cases

at a tertiary care hospital in Karachi, Pakistan

15.Neurology Asia 2010; 15(3) : 239 – 244

16.Internet photos and poewpoint presentations from class & websites

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Thanking you

3/19/2015

Dr chhabi lal bastola

Intern -2014

BPKIHS ,DHARAN,NEPAL

Dept of orthopedics

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Additional slides

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Clinico Radiological Classification (Kumar

1988)

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Differential diagnosis (CHILDREN )

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Congenital anomalies of spine

Hemivertebra

Block vertebra

Defect or synostosis of neural arc

No signs and symptoms of TB, no paravertebral

shadow

/ associated anomalies

Calves disease

Differential

diagnosis(ADOLOSCENT )

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Scheurmans disease

-ischemic lesion of appophysis of several

vertebra

-rounded kyphosis

-minimal local symptoms

Schmorls disease

3/19/2015

Management of spinal tuberculosis: a systematic

review and meta-analysis

Asian Spine J 2014;8(1):97-111 http://dx.doi.org/10.4184/asj.2014.8.1.97

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The most common method of spinal infection

is through the arterial spread of pyogenic

bacteria.

BUT not for tuberculosis : venous channel is

important for it