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TUBERCULOSIS OF
SPINE
Dr: Chhabilal Bastola
Intern, Dept. of orthopedics
BPKIHS,DHARAN,NEPAL
3/19/2015
1
Outline
3/19/2015
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
2
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
3
CAMPBELL’S OPERATIVE ORTHOPAEDICS, TWELFTH
EDITION
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
3/19/2015
4
3/19/2015
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10-09-2014
6
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.
14
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.
30
CT Features
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MAGNECTIC RESONANCE
IMAGING
3/19/2015
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
32
3/19/2015
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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 )
3/19/2015
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
40
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
41
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"
3/19/201542
Complication of spinal tuberculosis
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Paraplegia
Cold abscess
Spinal deformity
Sinuses
Secondary infection
Amyloid disease
Fatality
43
SPINE TUBERCULOSIS WITH
PARAPLEGIA (potts paraplegia)
3/19/2015
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
44
KUMAR’S CLASSIFICATION OF TUBERCULOUS
PARA/TETRAPLEGIA (Predominantly based on
motor
weakness)
3/19/2015
MOTOR
SEVERE MOTOR
SENSORY
SEV. SENSORY +AUTONOMIC
45
SEDDON’S CLASSIFICATION OF
TUBERCULOUS PARAPLEGIA
10-09-2014
46
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)
3/19/2015
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.
48
MANAGEMENT
10-09-2014
49
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
51
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
53
ABSOLUTE INDICATIONS FOR
SURGERY:
3/19/2015
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
54
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
3/19/2015
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10-09-2014
56
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
3/19/2015
57
• ABSCESS DRAINAGEA.
B. • HONGKONG’s PROCEDURE
C.• COSTOTRANSEVERSECTO
MY
D.ALD(LATERAL RACHOTOMY)+ CAGE + INSTRUMENTATION / BONE GRAFTING
SURGERY
3/19/2015
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3/19/2015
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3/19/2015
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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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64
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
3/19/2015 65
Thanking you
3/19/2015
Dr chhabi lal bastola
Intern -2014
BPKIHS ,DHARAN,NEPAL
Dept of orthopedics
66
Additional slides
3/19/2015
67
Clinico Radiological Classification (Kumar
1988)
10-09-2014
68
Differential diagnosis (CHILDREN )
10-09-2014
69
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 )
10-09-2014
70
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
71
3/19/2015
72
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
Recommended