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VIJESH VIJAYAN

2008 MBBS
TB IS CALLED AS WHITE PLAGUE OR
CAPTAIN OF ALL MEN OF DEATH

SPINE IS THE COMMONST SITE OF BONE AND


JOINT TB
UPPER THORACIC SPINE IN CHILDREN
LOWER THORACIC AND - IN ADULTS
UPPER LUMBAR
EPIDEMIOLOGY
1/3 RD OF WORLD POPULATION HARBOUR TB
INFECTION
INDIA IS ONE OF THE WORST AFFECTED
COUNTRIES
ONE PERSON PER MINUTE DIE OF TB IN INDIA
TB IS AN ANCIENT DISEASE

EVIDENCE OF SPINAL TB HAS BEEN


FOUND IN SOME EGYPTIAN
MUMMIES
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%
PATHOLOGY
TB SPINE IS ALWAYS SECONDARY
REACTIVATION OF HEMATOGENOUS FOCI OR
SPREAD FROM PARAVERTEBRAL LYMPH NODE
HEMATOGENOUS SPREAD VIA PARAVERTEBRAL
VENOUS PLEXUS OF BATESON
RESPONSE WILL BE EITHER
PROLIFERATIVE OR EXUDATIVE
PROLIFERATIVE: C/C GRANULOMA WITH FIBROSIS
EXUDATIVE : NON REACTIVE, WIDE CAESEATION
NECROSIS, IN IMMUNOCOMPROMISED
TB GRANULOMA
TYPES OF VERTEBRAL TB
1. PARADISCAL - COMMONST , CONTIGOUS AREA
OF TWO ADJACENT VERTEBRA ALONG WITH
INTER VERTEBRAL DISC IS AFFECTED
2. CENTRAL -BODY OF SINGLE VERTEBRA ,
NEARBY DISC MAY BE NORMAL
3. ANTERIOR-ANTERIOR PART OF THE BODY
4. POSTERIOR- POSTERIOR COMPLEX (PEDICLE ,
LAMINA , SPINOUS PROCESS OR TRANSVERSE
PROCESS) AFFECTED
AFTER EFFECT
PARADISCAL : C/C GRANULOMATOUS
INFLAMMATION -> EROSION OF MARGINS OF
THE VERTEBRAE -> COMPROMISE OF NUTRITION
OF IV DISC-> DISC DEGN-> DESTRUCTION
CENTRAL : WEAKENING OF TRABECULAE ->
COLLPSE OF VERTEBRAE
ANTERIOR : INFN SPREAD UP OR DOWN UNDER
ANT. LONGI.LIGAMENT
POSTERIOR : BONY DESTRUCTION CAN
COMPRESS THE CORD
COLD ABSCESS
PUS & TRABECULAR DEBRIS OF DISEASED
VERTEBRA
NOT ASSO. WITH USUAL SIGNS OF
INFLAMMATION - COLD ABSCESS
NOTE: PUS CAN TRACK IN ANY DIRECTION
1.BACKWARDS : COMPRESS CORD
2. ANTERIORLY: PRE VERTEBRAL ABSCESS
3. SIDES : PARA VERTEBRAL ABSCESS
4.ALONG MUSCULOFASCIAL PLANES :
EX.PSOAS ABSCESS
HEALING

OCCURS BY FIBROSIS

IN THE SPINE BONY ANKYLOSIS FOLLOWS MORE


OFTEN
LYTIC AREAS ARE REPLACED BY NEW BONE AND
ADJACENT VERTEBRA UNDERGO FUSION
CLINICAL FEATURES
PRESENTATION VARIES FROM NON SPECIFIC
BACK ACHE TO CATASTROPHIC PARAPLEGIA
COMPLAINTS:
PAIN
STIFFNESS
COLD ABSCESS ( IF EVIDENT EXTERNALLY)
PARAPLEGIA
DEFORMITY
CONSTITUTIONAL SYMPTOMS
PAIN
BACKACHE : COMMON PRESENTING COMPLAINT
INITIALLY DIFFUSE & LATE LOCALISED
RADICULAR PAIN
DEPENDING ON ROOT:
PAIN IN ARM CERVICAL ROOTS
GIRDLE PAIN DORSAL ROOTS
GROIN PAIN - LUMBAR ROOTS
COLD ABSCESS
CERVICAL : RETROPHARYNGEAL / AT POST
BORDER OF STERNO MASTOID IN POST
TRIANGLE OF THE NECK / AT AXILLA
THORACIC : MEDISTINAL / ANTERIOR CHEST
WALL ALON THE SPINAL NERVES
LUMBAR : PRE VERTEBRAL SWELLING/ PSOAS
ABSCESS / ABSCESS PRESENTING AT GROIN
STIFFNESS : EARLY SYMPTOM
PARAVERTEBRAL MUSCLES UNDERGO
SPASM
PARAPLEGIA
DEFORMITY IN CHILDREN
CONSTITUTIONAL SYMPTOMS : FEVER , WEIGHT
LOSS
EXAMINATION
SHOULD HAVE A HIGH INDEX OF SUSPICION
AIMS : LOOK FOR FINDINGS OF TB SPINE
LOCALISE SITE OF LESION
DETECT COMPLICATIONS- COLD ABSCESS /
PARAPLEGIA
1. GAIT : SHORT STEPS
2. ATTITUDE & DEFORMITY
3. PARAVERTEBRAL SWELLING
4. TENDERNESS ON THE AFFECTED SPINE
5. REDUCED MOBILITY
DEFORMITY : GIBBUS
NEUROLOGICAL EXAMINATION
AIMS: DETECT ANY COMPRESSION
LEVEL OF COMPRESSION
SEVERITY OF COMPRESSION
LIMBS UPPER OR LOWER BASED ON SITE
MOTOR , SENSORY , REFLEXES , BOWEL AND
BLADDER FUNCTIONS

GENERAL EXAMINATION
PHYSICAL EXAMINATION
SYSTEMIC ILLNESS : DM , HYPERTENSION
INVESTIGATIONS
RADIOLOGY :
X-RAY SPECIFY THE LEVEL
2 VIEWS AP & LATERAL
CHEST X-RAY
X-RAY ABDOMEN
KUB - IF PSOAS ABSCESS SUSPECTED
FINDINGS
1. REDUCTION OF DISC SPACE- EARLY SIGN
COMPARE WITH NORMAL
LATERAL X-RAY IS BETTER

IMPORTANCE : SECONDARIES TO
BONES USUALLY PRESERVE THE DISC
2. DESTRUCTION OF VERTEBRAL BODY
EROSIONS AND WEDGING
3. DEFORMITY : DEPEND ON THE NO.
OF VERTEBRA AFFECTED
BONE DESTRUCTION
DESTRUCTION
OF THE BONE
COLD ABSCESS
1. PARAVERTEBRAL ABSCESS : A SOFT TISSUE
SHADOW CORRESPONDING TO AFFECTED
VERTEBRA.
WIDENED MEDIASTINUM
RETROPHARYNGEAL ABSCESS
PSOAS ABSCESS
RETROPHARYNGEAL ABSCESS
MEDISTINAL WIDENING
OTHER FINDINGS
RAREFACTION : ABOVE AND BELOW AFFECTED
VERTEBRA
OBLIQUE X RAY MAY SHOW POSTERIOR
COMPLEX INVOLVEMENT
SIGNS OF HEALING : ADJACENT VERTEBRAE
UNDERGO FUSION
OTHERS
CT : ACCURATE CONFIRMATIONS
MRI : TO ASSES NEURAL STATUS
MYELOGRAPHY : SUSPECTED SPINAL TUMOR
SYNDROME
BIOPSY : CT GUIDED NEEDLE OR OPEN BIOPSY
RETROPHARYNGEAL
SWELLING

CAN PRESENT AS
DYSPHAGIA
PSOAS ABSCESS
PSOAS ABSCESS
GENERAL INVESTIGATIONS

ESR
MANTOUX
ELISA : ANTI TB ANTIBODY
CHEST X RAY : FOR PULMONARY TB
D/D S
BACK ACHE : 1. TRAUMATIC
2. SECONDARIES OR MYELOMA
3. PROLAPSED DISC
4.ANKYLOSING SPONDYLITIS

NEUROLOGICAL
SPINAL TUMOR
TRAUMATIC
SECONDARIES IN THE SPINE
TREATMENT
PT SHOULD BE GIVEN A HIGH PROTEIN DIET
& GOOD ATMOSPHERE
1. MULTIDRUG THERAPY OF TB
2. REST TO THE SPINE : CHILDREN BODY CAST ,
COLLAR IF CERVICAL
3. MOBILISATION : ADVISED TO AVOID SPORTS
FOR TWO YEARS
RX COLD ABSCESS
SMALLER ONES SUBSIDE WITH TB THERAPY
IN SUPERFICIAL ABSCESSES :
ASPIRATION : USING THICK NEEDLE
EVACUATION
PSOAS ABSCESS : EXTRAPERITONEALLY VIA KIDNEY
INCISCION
MRCB CONTROLLED TRIAL
BED REST NOT NECESSARY
STREPTOMYCIN NOT NECESSARY
POP JACKETS PROVIDE NO BENEFIT
DEBRIDEMENT IS NOT A GOOD OPERATION

COMPLICATIONS
COLD ABSCESS
NEUROLOGICAL COMPLICATIONS : PARAPLEGIA
20 % INCIDENCE
COMMON IN DORSAL SPINE TB
CAUSES :
INFLAMMATORY EDEMA
EXTRADURAL PUS & GRANULATION TISSUE
COMMOMN
SEQUESTRA
INTERNAL GIBBUS
INFARCTION OF SPINAL CORD
EXTRADURAL GRANULOMA
TYPES
EARLY ONSET
LATE ONSET

C/F :
EITHER A KNOWN TB OR NEUROLOGICAL
SYMPTOMS PRESENTING FOR THE 1ST TIME
GRADUAL ONSET
CLONUS ANKLE OR PATELLAR PROMINENT
PARALYSIS : STAGES
1. MUSCLE WEAKNESS : SPASTICITY AND
INCORDINATION
2. PARAPLEGIA IN EXTENSION
3. PARAPLEGIA IN FLEXION
COMPLETE FLACCID PARALYSIS
GRADES : GOEL (1967)
BASIS IS EXTENT OF MOTOR INVOLVEMENT
GRADE ONE : CLINICIAN DETECTS THE DEFECIT
GRADE TWO : SYMPTOMATIC BUT MANAGES TO WALK
GRADE THREE: UNABLE TO WALK
PARAPLEGIA IN EXTENSION
PARTIAL SENSORY LOSS
GRADE FOUR : UNABLE TO WALK
PARAPLEGIA IN EXTENSION
NEAR COMPLETE SENSORY LOSS
SPHINCTER DISTURBANCES
TREATMENT
INVESTIGATIONS : CT & MRI ( INVESTIGATION
OF CHOICE)
CONSERVATIVE : ANTI TB RX , REST TO SPINE ,
NEUROLOGICAL EXAMINATION TO ASSES Px
SURGICAL :
INDICATIONS : PARAPLEGIA IN CONSERVATIVE Rx
SUDDEN ONSET SEVERE PARAPLEGIA
SEVERE PARAPLEGIA : IN FLEXION, MOTOR / SENSORY
LOSS > 6 MONTHS OR COMPLETE MOTOR LOSS ONE
MONTH DESPITE CONSERVATIVE Rx
PARAPLEGIA WITH UNCONTROLLED SPASTICITY
RELATIVE INDICATIONS :
RECURRENT PARAPLEGIA
PARAPLEGIA IN OLD AGE
PAINFUL PARAPLEGIA
COMPLICATIONS : UTI / STONES
PROCEDURES
1. COSTO TRANSVERSECTOMY

2. ANTEROLATERAL DECOMPRESSION

3. RADICAL DEBRIDEMENT AND ARTHRODESIS


( HONKONG OPERATION)

4. LAMINECTOMY
PROGNOSIS
AGE : CHILDREN HAS BETTER Px
DURATION OF PARAPLEGIA : LONG STANDING
HAS BAD Px
SEVERITY : MOTOR ALONE HAS GOOD Px
ONSET OF PARAPLEGIA : A/C ONSET HAS BETTER
SUDDEN PROGRESS : BAD Px