PRESENTATION BY:

DR. K TARUN RAO

PG IN DEPT OF ORTHOPEDICS

CAIMS, KARIMNAGAR.

Tuberculosis (TB), which is caused by bacteria of the Mycobacterium tuberculosis complex, is one of the oldest diseases known to affect humans and a major cause of death worldwide.

ETIOLOGICAL AGENT:- M. tuberculosis - is a rod-shaped, non-spore-forming,

thin aerobic weakly grampositive bacterium measuring 0.5 μm by 3 μm .

However, once stained, the bacilli cannot be decolorized by acid alcohol. This characteristic justifies their classification as acid-fast bacilli.

Acid fastness is due mainly to the organism’s high content of mycolic acids, long-chain cross-linked fatty acids, and other cell-wall lipids.

WHY ARE MOST ANTIBIOTICS INEFFECTIVE? In the mycobacterial cell wall, lipids (e.g., mycolic

acids) are linked to underlying arabinogalactan and peptidoglycan. This structure results in very low permeability of the cell wall, thus reducing the effectiveness of most antibiotics.

Microorganisms other than mycobacteria that display some acid fastness include species of Nocardia and Rhodococcus, Legionella micdadei, and the protozoa Isospora and Cryptosporidium.

CELL WALL STRUCTURE:-

PREDISPOSING FACTORS:- 1) Malnutrition

2) poor sanitation

3) over crowding

4)close contact with TB patients

5) multiple pregnancy

6) immunodeficiency states.

PATHOPHYSIOLOGY:-

In order of frequency, the extrapulmonary sites most commonly involved in TB are the :-

1) lymph nodes,

2) pleura,

3)genitourinary tract,

4)bones and joints, (50% of it being vertebral TB)

5)meninges,

6) peritoneum, and

7)pericardium.

PATHOLOGY:-

Pathology:- Any osteoarticular tubercular lesion, is the result of a

hematogenous dissemination from a primarily infected visceral focus.

The primary focus may be active or quiescent, apparent or latent,either in the lungs or in the lymph glands of the mediastinum,mesentry or cervical region,or kidneys or other viscera.

The infection reaches skeletal system through vascular channels , generally the arteries as a result of bacillemia or rarely in axial skeletal through batson’s plexus of veins

It is most common during first 3 decades.The disease is equally distributed in both sexes.

Symptoms and signs:-Active stage: 1)constitutional symptoms: malaise , weight loss ,loss of

appetite, night sweats(TNF-alfa released by macrophages) , evening rise of temperature ( IL-1).

2) back pain

3) spine stiffness: spasm of para -vertebral muscle

4)night cries.(release of spasm of muscles and movement of structures involved)

5)deformity : knuckle( 1 or 2vertebrae) / gibbus (2 or 3 vertebrae)/ kyphus (angular kyphosis more than 3 vertebrae)

6)cold abscess may be present.

7) paraplegia (if neglected in early stages)

But several of these signs and symptoms may be absent.

Healed stage:Pt neither looks ill nor feel ill,

No systemic features but the deformity that occurred during active stage however, persists.

ESR falls.

There is radiological evidence of bone healing in serial x-rays.

Healing is indicated by

Decreased soft tissue shadow

Return of normal density

Bony ankylosis

COLD ABSCESS:- An abscess is a collection of liquefied tissue(pus) in

the body, which is body’s defence reaction to foreign material.

It is called cold abscess because it is not accompanied by the classic signs of inflamation i.e. heat , redness, fever, pain etc., which are usually found with pyogenicabscess.

OTHER CAUSES OF COLD ABSCESS:-

1) actinomycosis

2) leprosy

3) fungal infections

4) Autosomal dominant hyperimmunoglobulin E syndrome( jobs syndrome)

- recurrent staphylococcal cold abscess

- eczema

- increased igE

PATHOGENESIS:-Phagocytosis of tubercle bacilli by RES (monocytes,

macrophages)

Tuberculous granulomas( langhans gaint cells)

Small patches of central caseous necrosis

Coalesce into a large yellow mass

Break down of center to form cold abscess.

A typical tuberculous granuloma, with central necrosis and scattered giant cells surrounded by lymphocytes and histiocytes:-

Absceses and sinuses:- Abscesses or sinuses from the cervical or dorsal

regions can present themselves far away from the

vertebral column along the fascial planes or course of neurovascular bundles.They may be present in the paraspinal region at the back in the posterior /anterior cervical triangles ,along the intercostal spaces on the chest wall.

Abscesses from the dorso-lumbar and the lumbar spine follow the psoas sheath abscesses may be palpable in the iliac fossa, in the lumbar triangle , in the upper part of the thigh below the inguinal ligament or even downwards up to the knee . sometimes bilateral psoas abscess.

Sinus and abscess

Composition:-

Mostly composed of :-

1) serum

2) leucocytes

3) caseous material

4) bone debris

5) tubercle bacilli.

Clinical features:-1)Painless swelling which is:-

- incidious in onset,

- soft and smooth mass,

- cystic consistency,

- fluctuation present,

- slip sign negative,

- no transillumination.

2) Sinus or ulcer may be present,

3) Superadded infections with pyogenic organisms

4) Constitutional symptoms may be present like low grade fever, loss of weight and loss of appetite.

Local pressure effects due to swellings:-C-spine:-

The exudate collects behind prevertebralfascia and protrude forward as retropharyngeal abscess causing 1) dysphagia

2) dysphonea

3) dyspnoea

4) hoarseness of voice.

the abscess may track down in mediastinum to enter trachea, oesophagus or pleural cavity. It may spread laterally into the sternocleidomastoid muscle and form abscess in the neck.

T- spine:-The exudate may be confined locally as

paravertebral abscess

It may enter in to spinal canal and copmpressspinal cord leading to early onset pott’s paraplegia.

It can penetrate anterior longitudinal ligament to form mediastinal abscess.

Pass down through medial arcuate ligament to form a lumbar abscess.

Rarely , the thoracic cold abscess may follow the intercostal nerve to appear anywhere along the course of nerve.

length > width( Bird nest abscess)

Width > length(Globular abscess)

Lumbar abscess:-Abscess can have pus tract along the

psoas muscle towards the groin and present as psoasabscess.

Flexion deformity of hip can develop due to the abscess ( pseudo flexion deformity of hip)

Can gravitate beneath the inguinal ligament to appear on the medial aspect of thigh.

It can spread laterally beneath iliac fossa to emerge at the iliac crest near the ASIS

The exudate can follow vessels to form an abscess in scarpa’s triangle or gluteal region.

Psoas muscle:-The psoas major is divided into a superficial and deep part. The deep part originates from the transverse processes of lumbar vertebrae I-V. The superficial part originates from the lateral surfaces of the last thoracic vertebra, lumbar vertebrae I-IV, and from neighboring intervertebral discs.

Action:- flexion, lateral rotation and weak adduction of hip.

Psoas abscess:-

BILATERAL PSOAS ABSCESS

TREATMENT:- 1) anti tubercular drugs

2) aspiration

3) ultrasound guided pigtail catheter drainage

4) surgical management.

ASPIRATION:-Palpable cold abscess must be drained as early

as possible and instil 1gm streptomycin +/- INH in solution.

Technique:- ZIG-ZAG aspiration using wide bore needle from non-dependent area to prevent sinus formation.

SURGICAL:- open drainage may be performed if aspiration failed to

clear it.

Drainage using non-dependent incision, later closure of wound with out placing a drain to prevent sinus formation.

Correcting underlying bone lesion / defect.

cold abscess of chest wall sometimes may require rib resection , clavicle and sternum resection along with abscess excision.

Regional distribution of tuberculosis lesions in vertebral column

Cervical (including atlanto-occipital) : 12%

Cervico-dorsal: 5%

Dorsal : 42%

Dorsolumbar : 12%

Lumbar : 26%

Lumbo-sacral (including sacrum) : 3%

Clinical features of spinal tuberculosis Clinical kyphosis :95%

Palpable cold abscesses : 20%

Radiological perivertebral abscesses: 21%

Tuberculosis sinuses (active/healed): 13%

Associated extra-spinal skeletal foci : 12%

Associated visceral or glandular foci : 12%

Neurological involvement : 20%

Lateral shift (radiological) : 5%

Skipped lesions of spine : 7%

TYPES OF Vertebral lesion:- 1)Paradiscal type-ARTERIAL SPREAD

2)Central type (central part of the vertebral body) –VENOUS SPREAD

3)Anterior type (involving anterior surface of the vertebral body) – SUBPERIOSTEAL SPREAD

4)Appendicial type (involving pedicles, laminae, spinous process or transverse processes ).

ARTERIAL SUPPLY OF VERTEBRA

BATSON’S PLEXUS OF VEINS :-

1) Paradiscal lesions It is the most common type of lesion.

Narrowing of the disc space is often the earliest radiological finding.

Destruction of subcondral bone

Prolapse of the nucleus pulposus into the soft necrotic vertebral bodies

Paradiscal lesions

Paradiscallesion

2)Central lesions(tuberculosis of the centrum) Central disease arises as a result of infection which

starts from the center of the vertebral body reached through batson’s venous plexus or through the branches of posterior vertebral artery.

Vertebral body collapse.

Resembles Vertebra plana or pan cake vertebra( when a vertebral body has lost almost its entire height anteriorly and posteriorly)

Central lesion /vertebra plana

3)Anterior lesions:- This lesion occurs when the infection starts beneath

the anterior longitudinal ligament and the periosteum.

Pus spreads by stripping anterior longitudinal ligament , periosteum from anterior surface of the vertebral body.

Vertebral body collapse due to pressure and ischemia, followed by disc space narrowing.

Lesion is relatively more common in thoracic spine .

Anterior lesion:-

4)Appendicial lesions:- Isolated tuberculosis infection of the pedicles and

laminae(neural arch),transverse processes and spinousprocesses does occur but uncommonly.

Radiographically, these lesions may be appreciated by erosive lesions, paravertebral shadows and intact disc space.

Occurs in isolation or conjunction with typical paradiscaltuberculosis were considered to be very rare <5%

Appendicular lesion

Skipped lesions:- More than one

TB Lesion in vertebral column with one or more healthy vertebrae in between the 2 lesion.

7% on routine xray

More frequently detected on CT/MRI

Management:-Diagnosis:- Clinico radiological &

Lab studies

Microbiological studies

Ct scan

Mri scan

Usg

Radionuclide scan

myelography

Diagnosis:- Complete blood picture:- increased ESR /increased

lymphocyte count

ELISA: for antibody to mycobacterial antigen ,sensitivity 60-80%

PCR : sensitivity of 40%

Chest radiograph

Mantoux / tuberculin test

Microbiology:- zeihl-neelsen staining / acid fast staining

Cultures :4-6 weeks in LOWENSTEIN-JENSEN MEDIUM positive only in 50% cases. ( L-J medium).

IFN – GAMA release assays (IGRA’s):- Assays that measure t-cell release of IFN in response to stimulation with highly specific tubersulosis antigen ESAT6 & CFP 10

MENDEL-MANTOUX TEST OR TUBERCULIN TEST OR PIRQUET TEST OR PPD TEST:-

5 mm or more is positive in

An HIV-positive person

Persons with recent contacts with a TB patient

Persons with nodular or fibrotic changes on chest X-ray consistent with old healed TB

Patients with organ transplants, and other immunosuppressedpatients

10 mm or more is positive in

Recent arrivals (less than five years) from high-prevalence countries

Injection drug users

Residents and employees of high-risk congregate settings (e.g., prisons, nursing homes, hospitals, homeless shelters, etc.)

Mycobacteriology lab personnel

Persons with clinical conditions that place them at high risk (e.g., diabetes, prolonged corticosteroid therapy, leukemia, end-stage renal disease, chronic malabsorption syndromes, low body weight, etc.)

Children less than four years of age, or children and adolescents exposed to adults in high-risk categories

15 mm or more is positive in

Persons with no known risk factors for TB

FALSE NEGATIVE RESULT:-Reaction to the PPD or tuberculin test is suppressed by

the following conditions:

1)Recent TB infection(less than 8–10 weeks)

2) Infectious mononucleosis

3)Live virus vaccine - The test should not be carried out within 3 weeks of live virus vaccination (e. g. MMR vaccine or Sabin vaccine).

4) Sarcoidosis

5) Hodgkin's disease

6) Corticosteroid therapy/steroid use

7) Malnutrition

8) Immunological compromise- Those on immuno-suppressive treatment or those with HIV and low CD4 T cell counts, frequently show negative results from the PPD test.

This is because the immune system needs to be functional to mount a response to the protein derivative injected under the skin. A false negative result may occur in a person who has been recently infected with TB, but whose immune system hasn't yet reacted to the bacteria.

PLAIN RADIOGRAPH:-

Classic radiological triad :-

1)primary vertebral lesion ;

2) disc space narrowing ;

3)paravertebral abscess.

The foci of less than 1.5cms in diameter are not demonstratable in a conventional radiograph.

30-40% of calcium must be removed from a particular area to show a radiolucent region on xray.

Plain radiograph findings:- Disc space narrowing ( commonest & earliest)

Erosion of end plate

Signs of infection with lucency in ant. portion of vertebra

Deformities (knuckle , gibbus ,kyphus, anterior wedging , vertebra plana)

Sclerosis resulting from chronic infection

Compression fracture (concertinal collapse = single collapse vertebra)

Soft tissue swelling from paraspinal abscess+/- calcification

Bowing of rib cage with multiple vertebral fracture.

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Kumar’s clinico-radiological classification:-

stage Clinico-radiological features Usual duration

1.Pre destructive Straightening of curvatures,spasm of perivertebral muscles,scinti-scan would show hyperemia mri shows marrow edema

<3 months

2.Early - destructive Diminished disc-space+paradiscalerosion (knuckle<10degree)mri shows marrow edema and break of osseous margins, ct scan shows marginal erosions or cavitations

2-4 months

3.Mild angular kyphosis

2-3 vertebrae involved k:10-30 degree 3-9 months

4.Moderate angularkyphos

>3vertebrae involved k:30-60 degree 6-24 months

5.severe kyphos(humpback)

>3vertebrae involved k:>60 degree >2 years

Angle of kyphosis

Paravertebral / prevertebralshadows (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 is Concave 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 vertebrae.

Paravertebral shadowAbscess below the level of D4 vertebrae – Fusiform shape (Bird nestappearance)An abscess under tension may produce- Globular shape

Prevertebral shadow

Ct scan of spine:-

It is useful tool in assessing patterns of bony destruction.

Delineation of the shape, extent and route of spread of a cold abscess can also be very well visualized

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

MRI:- Highly sensitive & specific for spinal TB.

Spinal cord & soft tissue involvement.

Detect marrow infiltration in vertebral bodies(EDEMA), leading to early diagnosis.

Skip lesions.

Changes of discitis (EDEMA).

Assessment of extradural abscesses / subligamentous spread.

Poor for calcification.

Radionuclide bone scan:- Increased uptake in 60% patients with active

tuberculosis

>= 5mm lesion can be detected

Avascular segments & abscesses show cold spot

Localize active disease and skip lesions

Highly sensitive but non specific

USG:-1)Employed to diagnosis the presence of tubercular

abscesses in the lumbar vertebral disease.

2)Guided aspiration.

3) to find out primary in abdomen.

Differential diagnosis:-1)Pyogenic infections:-

It is sudden in onset with severe localized pain,spasm and swinging temperature like acute osteomyelitis.

In early stages,there is bone destruction which is rapidly replaced by bony sclerosis and new bone formation observed radiologically from 8th week onwards.

The intervertebral disc space shows varying degree of destruction.low grade pyogenic infection may have an insidious course and onset like tuberculosis.

Most common causative organism staphylococcus aureus.

Antistaphylococcal titer and/or examination of biopsy material useful in final diagnosis

2)Typhoid spine:-It is a rare complication of enteric fever , most cases

present at time intervals of 4 weeks to a few months after the disappearance of clinical features of typhoid fever.

Clinically the condition is manifested by an excruciating pain and muscle spasm.

Radiological picture resembles that of tuberculosis and allow pyogenic spondylitis.

Confirmation can be obtained by agglutinations test therapeutic trail or by biopsy.

3)Brucella spondylitis:- This can produce changes which can be very similar to those

seen in tuberculosis of the spine.

History of undulent fever ( rising and falling type) may be suggestive of diagnosis.

however diagnosis is best established by identification of the causative organisms, agglutination tests or by the biopsy.

Brucella infections of the spine , skeletal system and synovial sheath is essentially encountered in endemic areas and in communities consuming unboiled/unpasturized milk.

4)Mycotic spondylitis:- The most frequent infecting fungi are of actinomyces group

or blastomycosis group.

In blastomycosis , paravertebral abscess formation is a common feature.

In actinomyces, sclerosis and destruction of bone proceed hand in hand.

The anterior and lateral surfaces of the several vertebral bodies may be involved and show an irregular saw-tooth apperance by periosteal new bone formation .collapse of the vertebra is rare, sometimes the involved vertebrae appears as honeycomb or lattice like and accompanied by multiple sinus formation and involvents of subcutaneous tissue.

Confirmation of diagnosis from discharging sinuses, pus or from diseased bone.

5)Syphilitic infection of the spine:-Three main types of syphilitic infection of the spine

1.artharlgic type

2.gummatous type and

3. charcot’s disease of spine.

Most common site of involvement is thoracolumbar and lumbar spine.

X ray shows a gross disorganization and destruction of the involved vertebrae along with proliferative new bone formation extending into adjacent paraspinal tissues .

When neuroarthropatic changes are present, varying degrees of subluxation of the vertebrae is eveident.

Diagnosis is confirmed by serological tests, tissue biopsy or by response to antisyphilitic treatment.

Tumorous conditions:-1)HEMANGIOMA:- Most common benign tumors of the

vertebral column.

Most common area being from D12 to L4 .

Diagnosed by pin head appearance on axial sections in CT and MRI scan.

Involved vertebra – shows coarsening of vertebral trabaculations more prominent in vertical than in horizontal trabaculae (corduroy appearance).

2)GIANT CELL TUMOR & ANEURYSMAL BONE CYST of spine produce typical osteolytic expansile & usually eccentric growth. This is confused with expansil type of central tuberculous lesion in vertebral body.

Disc space is not involved in early stage.

Investigation: repeated X-ray at 6-12wks intervals,MRI &CT-scan.

Final confirmation of diagnosis is only by HISTOLOGY.

3)PRIMARY MALIGNANT TUMOR:- Very rare but ewings sarcoma and osteogenic sarcoma occasionally

occur.

Vertebral tumors had rapid course of the disease with progressive paraplegia and radiological evidence of destruction of bony trabaculae,soft tissue paravertebral shadowusually on one side and mild diminution of disc space in late stages

Diagnosis was confirmed only on biopsy from the vertebral bodies.

Osteosarcomas, fibrosarcomas and chondrosarcomas are very rare and confirmed only by histological examination .

Chordoma is thought to arise from the remnants of notochord, most common sites are cephalic and caudal ends of spinal column

Xray appearance is predominantly alytic and destructive lesion .

4)Multiple myeloma:- This condition may rarely resemble tuberculosis clinically

and radiologically,especially if there is involvement of only one or two vertebrae and there is collapse and eccentric destruction.

Involvement of multiple bones, high sedimentation rate, anemia , reversal of albumin globulin ratio and myeloma cells detected on bone marrow.

Diagnosis may confirm by presence of myeloma cells in biopsy.

5)Lymphomas:- Hodgkin’s disease and leukemias may rarely involve the vertebral

column.

Hodgkin disease may show deposits in the vertebra as diffuse sclerosis of the bone with disruption of trabeculae pattern and paravertebral soft tissue shadows

Leukemias may occasionally present as vague pain in the back associated with collapse of several vertebral bodies and generalized osteoporosis.

Enlargement of spleenn liver and lymph nodes with characteristic blood changes help to arrive at correct diagnosis.

Traumatic conditions:

Careful history,clinical examnination and x-rays are almost always able to diagnose a recent case of fracture or fracture dislocation of the spine.

Radiological features of healed fracture :

Traumatic compression fracture is wedge-shaped with intact disc spaces and there may be marginal spurring and spondylolitic changes .

When fracture is associated with damage of intervertebral disc ,in long- standing cases complete and incomplete osseous bridging is seen on both sides of the disc space in AP and lat view .

Disc may show patchy calcification.

In case of old trauma , there is no paravertebral shadow.

Complications of spinal tuberculosis:-

Paraplegia

Cold abscess

Spinal deformity

Sinuses

Secondary infection

TUBERCULOSIS OF SPINE WITH PARAPLEGIA:-

Neurological complication is the most dreaded and crippling complication of spinal tuberculosis.

Overall incidence is 10-30%.

Common during first 3 decades of life.

Highest incidence of paraplegia is associated with tuberculosis disease of the lower thoracic region.

Classification of TB ParaplegiaGriffiths, Seddon and Roaf 1956 (Pre anti-tubercular era)

Early onset paraplegia (group A)

Late onset paraplegia (Group B)

Appears within 2 years of onset – during the Active phase

Underlying pathology Inflammatory edema

TB Granulation tissue

Abscess

Caseous tissue

Ischaemic lesion of cord (Rare)

Good prognosis

Appears more than 2 years of disease in vertebral column

Underlying pathology –due to mechanical pressure on cord

TB Debris

TB Sequestra from body and disc

Localized Internal gibbus

Canal stenosis / Severe kyphotic deformity

Poor prognosis

Kumars classification of tuberculosis para/tetraplegia (predominantly based on motor weakness):-

STAGE - 1:-

patient walks normally, not aware of any motor weakness. Phycisian on clinical examination finds ankle clonus and extensor plantar response with or without brisk tendon reflexes.

STAGE – 2 :-

patient presents with c/o clumsiness or spasticity or jumpiness of limbs while walking. Pt is able to walk with or with out support. c/e reveilssigns of spastic paresis.

STAGE – 3 :-

bedridden, cannot walk coz of severe weakness. Reveals spastic paraplegia in extension. Sensory deficit if present is generally less than 50%.

STAGE – 4 :-

pt has paraplegia with flexor spasms. A case of paraplegia in extension who develop complications like spontaneous flexor spasms , >50% of sensory deficit and/or sphincter disturbances also included. Flaccid paralysis due to very severe cord compression or flacid paralysis due to sudden compression also included.

Pathology of tuberculousparaplegia:-The essential pathology of paraplegia associated with

tuberculosis of vertebra in majority of cases ispressure on the tissues of the cord as follows:

1)Inflamatory edema:-

Edema of the spinal cord due tovascular stasis and due to toxins from thetuberculous inflammation ,recovers by rest and drugtherapy.

KYPHOTIC DEFORMITY WITH CORD COMPRESSION

2)Extradural mass :-

The commonest mechanism by which the spinal cord function is affected is a state of tuberculous osteitis of the vertebral bodies with an abscess in the extra dural space causing compression of the cord from anterior aspect.

3)Bony disorders :-

1)Sequestra from avascular portions of the diseased vertebral bodies or intervertebral disc may be responsible for narrowing of spinal canal and pressure on the cord.

2) Angulation of the diseased spine may lead to the formation of a bony ridge or spur called internal Gibbus.

3)Rarely, a Pathological Dislocation may damage the neural structures.

4) Meningeal changes:

Dura is not involved

Cicatrisation of extradural TB granulation tissue (Peridural fibrosis)

Poor recovery despite adequate surgical decompression

5)Infarction of spinal cord:

This is unusual but important cause of paralysis. Infarction is caused by endarteritis , periarteritis or thrombosis of an anterior spinal artery or other spinal arteries caused by inflammatory reaction.

Irrepairable.

Ischaemic necrosis seen as an area of High intensity in T2 MRI.

Can also happen postoperatively.

PERIDURAL FIBROSIS:-

5)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 fibers are replaced by gliosis and the neural fibers show a gross loss of myelin

Mri shows myelomalacic and syringomyelic changes

6)Extradural granuloma and tuberculoma :-

very rarely a small tuberculoma of the spinal cord or diffuse extradural granuloma of the cord may be responsible for neurological complications with out any radiological evidence such cases present as spinal tumor syndrome.

Clinical features of Pott’sParaplegia:-

Paraplegia itself – Rare

Spontaneous muscle twitching in lower limbs

Clumsiness while walking

Extensor plantar response

Exaggerrated reflexes – Sustained clonus of patella and ankle

Motor affected first – then Sensory

Sense of position and vibration – last to disappear

Prognosis of recovery of cord functions:-

Cord involvement Better prognosis Poor prognosis

Degree Partial (Stage I & II) 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 Myelomalacia

Treatment of pott’s paraplegia:-

Treatment of tuberculous paraplegia is still controversial.

Paraplegia of early onset associated with inflammatory causes is likely to recover in most of the cases, by anti tubercular drugs alone.

Paraplegia of late onset due to mechanical causes requires surgical decompression of the cord in majority

TREATMENT:-

Conservative plan Middle path regime Radical surgery approach Supportive treatment like

1) rest2) braces3) high protein diet4) multivitamins and hematinics5) hygiene6) back care7) chest? Urinary tract care8) improve immune status9) treat other co morbid conditions.

ANTI-TUBERCULAR DRUGS:-

1st line chemotherapy drugs:-Bactericidal drugs Dose

Isoniazid 5 mg/kg (300-400mg in single/two divided doses)

Rifampicin 10-15 mg/kg (450-600mg in single/two divided doses)

Streptomycin 20 mg/kg ( max 1gm)

Pyrazinamide 40 mg/kg in single/two divided doses

Bacteriostatic drugs Dose

Ethambutol 15-25 mg/kg in single/two divided doses

CATEGORY TYPE OF PATIENT INTENSIVE PHASE

CONTINOUSPHASE

DURATION

CAT 1 New sputum smear-positive,New sputum smear-negative but seriously ill,New extrapulmonarytuberculosis,

2(HRZE)3 4(HR)3 6 MONTHS

CAT 2 Sputum smear-positive relapse,Sputum smear-positive failure,Sputum smear-positive treatment after default,

2(HRZES)3+1(HRZE)3

5(HRE)3 8 MONTHS

CATEGORIZATION AND TREATMENT REGIMES IN RNTCP NEW GUIDELINES 2015-2016

CATEGORY TYRPE OFPATIENT

INTENSIVE PHASE

CONTINOUS PHASE

DURATION

CAT 4* MDR TB 4(KLCZEEt) 12-8(LCEEt) 18-24 MONTHS

CAT 5 XDR TB 6-12 (HhCmCzLAMP)

18 (HhCzLAMP)

24-30 MONTHS

H: Isoniazid (300 mg) R: Rifampicin (450 mg), Z: Pyrazinamide(1500 mg) E: Ethambutol (1200 mg), S: Streptomycin (750 mg)

K: Kanamycin , L :Levofloxacin , Et : Ethionamide,

C : cycloserine , Hh: high dose isoniazid,

Cm: capriomycin, Cz: clofazimine, L : Linezolid,

A: Amoxy clav, M : Moxifloxacin , P : PAS (p- amino salicylic acid)

CAT 4* DOTS PLUS ; CAT3 HAS BEEN MERGED IN CAT 1

Newer drugs Amikacin, Kanamycin, Capriomycin

Ethionamide

Cycloserine

ciprofloxacin, Ofloxacin, Levofloxacin

Rifabutin

Clarithromycin

Clofazimine

MIDDLE PATH REGIME:- Rest in hard bed or plaster of paris bed

Drugs (chemo- therapy)

Radiographs and ESR are taken 3 to 6 months interval MRI or CT scan may be advisable at 6 to 12 months interval for about 2 years

Gradual mobilization of patient is encouraged in absence of neural deficit with spinal braces after 3-9 weeks of starting treatment and back extension exercises 5 to 10 mins, 3 to 4 times a day continued for 18 months to 2 years

Abscesses are aspirated when near the surface, and 1gm steptomycin with or without INH in solution is instilled at each aspiration

CHEMOTHERAPY

INH 300-400MG; Rifampicin 450-600mg; ofloxaxin400-600mg; pyrazinamide 1500mg;ethambutol 1200mg

Sinuses heals with in 6 to 12 weeks .

Neural complications if showing progressive recovery on triple drug therapy between 3 to 4 weeks surgery is unnecessary.if not decompression of the cord is performed .

Excisional surgery is recommended for posterior spinal disease associated with abscess or sinus formation (with or with out neural involvement).

Operative debridement is advised for cases who do not show arrest of the activity of spinal lesions after 3 to 6 months of ATT

Sinus and abscess

Psoas abscess:-

BILATERAL PSOAS ABSCESS

Posterior spinal arthodesis is recommended for symptomatic unstable spinal lesions.

Post operative pts with neural complications 3 to 5 months after sx made good recovery pt is mobilized out of bed with spinal braces, the spinal brace is gradually discarded about 12 to 24 months after the operation.

SURGERY INDICATIONS

Decompression (+/-Fusion)

Advance disease, failure to respond to 3-6 weeks conservative therapy

Debridement +/-decompression +/-fusion

Recurrence of disease or of neural complication

Anterior transposition of cord ( extrapleuralanterolateralapproach)

Severe Kyphosis (>60 deg) + neural

deficits.

laminectomy Extradural granuloma / tuberculoma/ Old healed disease presenting as secondary canal stenosis / posterior spinal disease.

ABSOLUTE INDICATIONS FOR OPERATIVE DECOMPRESSION

Neurological complications which do not start showing signs of progressive recovery to a satisfactory level after a fair trail of conservative therapy 3-4 weeks.

Patients with spinal caries in whom neurological complications develop during the conservative treatment.

Patients with neurological complications which become worse while they are undergoing therapy with antituberculous drugs and bed rest .

Patients who have a recurrence of neurological complications .

Patients with prevertebral cervical abscesses neurological signs and difficulty in deglutination and respiration .

Advanced cases of neurological involvements such as marked sensory and sphincter disturbances,flaccidparalysis or severe flexor spasms .

Tuli’s recommended approach

Cervical spine –T1

Anterior approach

Dorsal spine –DL junction

Anterolateral approach

Lumbar spine &Lumbosacral junction

Extraperitoneal Transverse Vertebrotomy

Atlanto - axial region (C1-C2)– transoral approach and transthyrohyoid approach developed by fang and ong.

Retropharyngeal extramucosal approach by mc afee

Cervical spine – Anterior approach

(smith-Robinson’s)

Cervico-dorsal region:

Transpleural thoracotomy, extrapleural anterolateral approach by kirkaldy-willisand thomas .

APPROACHES

Dorsal spine (D1 to L1) –

1) Transpleural anterior approach by hodgson and stock.

2) Anterolateral extrapleural by griffiths,seddon and roaf.

Thoracolumbar region: Extra-pleural anterolateral by kirkaldy-willis.

Lumbar spine – Retroperitoneal approach by arct and hodgson.

Lumbo-sacral region (L5-S1): Hypogastric paramediantransperitoneal approach by kirkaldy-willis, paus,arct, hodgson and pun et al.

ANTERIOR APPROACH TO THE CERVICAL

SPINE (C2-D1)

Cervical spine is best approached by anterior approach.

If several cervical vertebral bodies are to be exposed Oblique incision following anterior/medial border of the sternocleidomastoid muscle

If only one or 2 vertebral bodies are to be exposed a short transverse incision at the appropriate level should be used

Pt kept in supine with a low sand bag in between scapulae.

It is preferable to work from the left side because less chance of injury to the recurrent laryngeal nerve.

A transverse skin incision is made at the level of the vertebra to be operated beginning the incision at midline and extending it laterally for about 7-10 cm well over the belly of sternocleidomstoid .

Skin and platysma are cut transversely in the same line

Blunt dissection between the sternocleidomastoid and carotid sheath laterally and esophagus and trachea medially

Ant surface of the vertebral bodies are now visualized the are to be operated must be confirmed by lat x ray

A longitudinal incision may open a perivertebralabscess or the diseased vertebra by reflecting ALL and longus colli muscle

TRANSTHORACIC TRANSPLEURAL(D1-L1)

Left sided

incision preferable

Incision made along the rib which in the mid-axillary line, lies

opposite the centre of the lesion (i.e. usually 2 ribs higher than the centre of the vertebral lesion).

For severe kyphosis, a rib along the incision line should be removed.

J-shaped parascapular incision for C7 – D8 lesions, scapula uplift & rib resection.

After cutting the muscles & periosteum, rib is resectedsubperiosteally.

TRANSTHORACIC TRANSPLEURAL CONT… 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 by ligatingthe intercostal vessels & branches of hemiazygos veins.

T-shaped incision over the paravertebral abscess.

Debridement / decompression with or without bone grafting.

ANTERIOR RETROPERITONEAL APPROACH (L1-L5) Patient placed in the 45 degrees right lateral position with a

bridge centered over the area to be operated.

Incision resembles that of nephroureterectomy or that of sympathectomy.

extending from renal angle posteriorly to the lower part of lateral margin of the rectus abdominis anteriorly .

Layers of abdominal muscles are split or incised in the line of the skin incision.

Parietal peritoneum is gently stripped off the posterior abdominal wall and the kidney ,ureter is protected by reflecting anteriorly along the parietal peritoneum.

If psoas abscess is present it is drained and diseased bodies are exposed.

If no psoas abscess is present psoas muscle is stripped from its origin from the vertebral bodies and retracted laterally

The aorta and inferior vena cava are gently displaced to the right side after double ligation of the respective lumbar arteries and veins.

The sympathetic chain maybe retracted laterally diseased bodies are exposed and dealt with.

ANTERIOR RETROPERIOTONEAL APPROACH (L1-L5)

Anterior debridement, fusion and posterior instrumentation

Anterior debridement fusion with posterior instrumentation

Spinal braces:- Spinal braces are mostly used for ambulation of cases

of spinal tuberculosis.

Commonly used spinal braces for lesions from fourth dorsal to second lumbar vertebra are jewett brace, ASH (anterior spinal hyperextension) brace , taylor brace.

Jewett brace ASH brace Taylor brace

MILWAUKEE BRACE OR JEWETT BRACE:-

Recommended for tuberculouslesions in dorsal spine throughout the growing age, especially if the number vertebra involved is more than 2 or there is panvertebral disease or radiologicallythere is wedging in anterio-posterior as well as lateral views or after performance of pan vertebral operation.

ANTERIOR SPINAL HYPER EXTENSION BRACE:-

(ASH BRACE)

Found to be more acceptable by young girls and ladies as it gets accomadated in contours of the body and clothing. The rapid metal upright extends anteriorly from symphisis pubis to manubrium sterni, a band pasing around trunk holds the up right in front and a pad over vertebral column.

ASH brace has replaced taylors brace for adults.

For lesions from third lumbar to lumbo sacral region goldthwait brace or lumbar corset is used.

Cervico dorsal junction is very difficult area for satisfactory bracing. A tylor brace extended to four-post collar,or a SOMI (sternal-occipital-mandibular-immmobilizer) brace cauded with extensions.

Lumbosacral orthosis SOMI

REFERENCES:-

TUBERCULOSIS OF THE SKELETAL SYSTEM .

--- SM TULI .(5TH EDITION)

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