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 % INCIDENCECOMMON 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