Tuberculosis of spine


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Tuberculosis of spine

  1. 1. By Dr Shahid LatheefDepartment of OrthopaedicsYenepoya Medical CollegeMangalore
  2. 2. • The primary problems today are : The delay in diagnosis (average 3months) The long recovery period (average 12months) The great cost of treating such infections. Resurgence in HIV patients.• Paralysis is reported to occur in up to 50% of patients with spinal infections .
  3. 3. • Early diagnosis• Expeditious medical treatment• Aggressive surgical approach• Prevent deformity• Best outcome “The captain of the men of death”
  4. 4. • Presentation depends on : • Stage of disease • Site • Presence of complications such as neurologic deficits, . abscesses, or sinus tracts.• Average duration of symptoms at the time of diagnosis is 3 – 4 months.• Back pain is the earliest & most common symptom.• Constitutional symptoms.• Neurologic symptoms (50 % of cases).
  5. 5. • Physical examination of the spine : • Localised tenderness and paravertebral muscle spasm, • Kyphotic deformity • Cold abscess / swelling / sinus tract • Cervical spine TB is a less common presentation, characterized by pain & stiffness with dysphagia / stridor more common in lower cervical spine involvement
  6. 6. LAB STUDIES• Mantoux / Tuberculin skin test• ESR may be markedly elevated (neither specific nor reliable).• ELISA : for antibody to mycobacterial antigen-6 , sensitivity of 60 – 80%.• PCR
  7. 7. • Microbiology studies to confirm diagnosis • Ziehl-Neelsen staining: Quick and inexpensive method. • Bone tissue or abscess samples stain for acid-fast bacilli (AFB), & isolate organisms for culture & drug susceptibility. • Culture results - few weeks. • Positive only in 50% of cases.
  9. 9. • More than 50% of bone has to be destroyed.• May take approximately six months.• The classic roentgen triad in spinal tuberculosis is primary vertebral lesion disc space narrowing and paravertebral abscess.
  10. 10. • Typical tubercular spondylitic features in long standing paraspinal abscesses a} produce concave erosions around the anterior margins of the vertebral bodies producing a scalloped appearance called the Aneurysmal phenomenon. b} fusiform paraspinal soft tissue shadow with calcification in few• Skip lesions as involvement of non contiguous vertebrae (7 – 10 % cases).
  11. 11. • DEFORMITIES: . Anterior wedging . Gibbous deformity. . Vertebra plana = single collapsed vertebra
  12. 12. • 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.
  13. 13. • Lack of ionizing radiation, highcontrast resolution & 3D imaging.• Detect marrow infiltration in vertebral bodies, leading to early diagnosis.• Changes of diskitis• Assessment of extradural abscesses / subligamentous spread.• Skip lesions• Spinal cord involvement.• Spinal arachanoiditis.
  14. 14. USG - to find out primary in abdomen - Detect cold abscess - Guided aspirationRadionucleotide Scan T 99m• Increased uptake in up to 60 per cent patients with active tuberculosis.• >= 5mm lesion size can be detected.• Avascular segments and abscesses show a cold spot due to decreased uptake.• Highly sensitive but nonspecific.• Aid to localise the site of active disease and to detect multilevel involvement
  15. 15. • Patterns of Vertebral Involvement • The primary focus of infection in the spine can be either in the vertebral body or in the posterior elements.•• Four patterns : Paradiscal ( Commonest) Central Anterior, & Appendiceal
  16. 16. 1. Paradiscal Lesions:• Most common• Adjacent to the I/V disc leading to a narrowing of the disc space.• Destruction of subchondral bone with subsequent herniation of the disc into the vertebral body or by direct involvement of the disc.• MR imaging shows low signal on T1-weighted images and high signal on T2-weighted images in the endplate, narrowing of the disc, and large paraspinal and sometimes epidural abscesses.
  17. 17. 2. ANTERIOR TYPE…• Subperiosteal lesion under the ALL.• Pus spreads over multiple vertebral segments• Strips the periosteum and ALL from the anterior surface of the vertebral bodies.• Periosteal stripping renders the vertebrae avascular and susceptible to infection.• Both pressure and ischemia combine to produce anterior scalloping
  18. 18. • Collapse of the VB & diminution of the disc space is usually minimal & occurs late.• More common in thoracic spine in children.• MR imaging shows the subligamentous abscess, preservation of the discs, and abnormal signal involving multiple vertebral segments representing vertebral tuberculous osteomyelitis.
  19. 19. 3. Central Lesions : • Centred on the vertebral body. Batson‟s venous plexus or posterior vertebral artery. • Disc not involved. • Vertebral collapse occur - vertebra plana appearance. • MR - signal abnormality of the vertebral body with preservation of the disc. • DD: Appearance is indistinguishable from that of lymphoma or metastasis.
  20. 20. 4) Appendicial lesion• Isolated Pedicles & laminae (neural arch), transverse processes & spinous process.• Uncommon lesion (< 5%).• ? In conjunction with the typical paradiscal Variant• Radiographically - erosive lesions, paravertebral shadows with intact disc space.• Rarely, present as synovitis of facet joints.
  21. 21. Collapse of the vertebral body Tuberculous granulation tissue + caseous matter + necroticbone Accumulate beneath the anterior longitudinal ligament. Gravitate along the fascial planes Present externally at some distance from the
  22. 22. • Cervical region - b/w vertebral bodies , pharynx and trachea• Upper thoracic - „V‟ shaped shadow , stripping lung apices laterally anddownwards• Below T4 – fusiform shape (bird nest appearence)• Below diaphragm – unilateral / bilateral psoas shadow
  23. 23. • “POTT‟S SPINE”• Kyphosis 1-2 knucle 3 or more Angular (Gibbus) More – Round kyphosis• Scoliosis
  24. 24. • SPINAL INFECTIONS- pyogenic, brucella & fungal.• NEUROPATHIC spine• NEOPLASTIC commonly lymphoma/ metastasis• DEGENERATIVE Biopsy is definitive.
  25. 25. • Long standing history of • History of days to months.months toYears • Not present.• Presence of active pulmonarytuberculosis -60% • Most common location lumbar• Most common location thoracic spine.spinefollowed by thoraco-lumbarregion. • 19% only. Mostly involves 1 spinal• > 3 contiguous vertebral body segment – 2vertebrae &involvement common- 42%. intervening disc.• Vertebral collapse -67% • 21% only.
  26. 26. • Bone destruction : 73% • 48%• Posterior elements involvement • Rarecommon• Skip lesions common • Rare•Disc is involved with less • Disc destruction is most often seenfrequency inand severity. Disc spared in pyogenic osteomyelitis.centraltype TB.• Paraspinal and epiduralabscesses-60%
  27. 27. • Paraspinal and epidural • 30%abscesses-60% 1. Rare1. large involving many features + abscess character.contiguousvertebral bodies level 2. Not seen.2. calcification if present ispathognomic. 3. Heterogenous enhancement. Thick3. Smooth rim enhancement - irregular Rim enhancement only74% 9%• TO SUMMARISE: atypical cases.
  28. 28. • Predilection for the lumbar spine.• Intact vertebral architecture despite evidence of diffuse vertebral osteomyelitis.• Gibbus deformity rare.• Smaller paraspinal abscesses• Facet joint involvement
  29. 29. • Patients with diabetes mellitus, syringomyelia, syphilis, or other neuropathic disorder• Destructive changes in the vertebralbodies large osteophytes, extensive vertebral sclerosis.• Loss of disk space but no hyperintensity or enhancment• No paraspinal soft-tissue lesion
  30. 30. A destructive bone lesion A destructive boneassociated with a poorly lesion associated with a welldefined preservedvertebral body endplate, with disk space with sharpor endplates suggestswithout a loss of disk height, neoplasticsuggests an infection, which infiltration.has abetter prognosis “Good disk, bad news; bad disk, good news"
  31. 31. Central type TB
  32. 32. • Children• 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
  33. 33. Adolescents• Scheurmans disease -ischemic lesion of appophysis of several vertebra -rounded kyphosis -minimal local symptoms• Schmorls disease
  34. 34. • Paraplegia• Cold abscess• Spinal deformity• Sinuses• Secondary infection• Amyloid disease• Fatality
  35. 35. • Incidence : 10 – 30 %• Dorsal spine most common• Motor functions affected before / greater than sensory.• Sense of position & vibration last to disappear.
  36. 36. • Inflammatory Edema : Vascular stasis , Toxins.• Extradural Mass : Tuberculous osteitis of VB & Abscess.• Meningeal Changes : • Dura as a rule not involved•Extradural granulation •--- Contraction / Cicatrization •--- Peridural fibrosis •---- Recurrent Paraplegia
  37. 37. • Bony disorders : Sequestra , Internal Gibbus•Infarction of Spinal Cord : Endarteritis, Periarteritis or thrombosis of tributary to ASA.• Changes in Spinal Cord : Thinning (Atrophy), Myelomalacia & Syrinx
  38. 38. GROUP A (EARLY ONSET GROUP B (LATE ONSETPARAPLEGIA) a/k/a Paraplegia PARAPLEGIA) a/k/a Paraplegiaassociated with active associated with healed disease :disease : Active phase of the disease  After 2 years of onset ofwithin first 2 years of onset. disease. Pathology - inflammatory  Recrudescence of theedema, granulation tissue, disease or due to mechanicalabscess, caseous material or pressure on the cord.ischemia of cord.  Pathology can be sequestra, debris, internal gibbus or stenosis of the canal
  39. 39. • Rest in hard bed• Chemotherapy• X-ray & ESR once in 3 months• 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
  40. 40. • 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 .• Post op spinal brace→18 months-2 years
  41. 41. • 3 (HRZE) / 3 (HRZS) + 3 (HRZ) + 12 (HR) Pediatric age group, Streptomycin (for two months) replaces Ethambutol to avoid optic neuropathy .• 4 (HRZE) + 14(HR)
  42. 42. • Artificial abscess- Pott (1779)• Laminectomy & laminotomy : Chipault (1896 )• Costo-transversectomy: Menard (1896)• Calves operation (1917)• Lateral rhachiotomy of Capener (1933)• Anterolateral decompression of Dott & Alexander(1947)
  43. 43.  No sign of neurological recovery after trial of 3-4 weeks therapy Neurological complications develop during conservative treatment Neuro deficit becoming worse on drugs & bed rest Recurrence of neurological complication Prevertebral cervical abscess with difficulty in deglutition & respiration Advanced cases- Sphincter involvement, flaccid paralysis or
  44. 44. • Recurrent paraplegia• Painful paraplegia– d/t root compression, etc• Posterior spinal disease• Spinal tumor syndrome resulting in cord compression• Rapid onset paraplegia (due to thrombosis, etc)• Doubtful diagnosis & for mechanical instability after healing• Cauda equina paralysis
  45. 45. • Cervical spine –T1 Anterior approach• Dorsal spine –DL junction Anterolateral approach• Lumbar spine &Lumbosacral junction Extraperitoneal Transverse Vertebrotomy
  46. 46. • Smith & Robinson Oblique / transverse incision. Plane b/w SCM & carotid sheath laterally & T-O medially. Longitudinal incision in ALL open a perivertebral abscess, or the diseased vertebrae may be exposed by reflecting the ALL & the longus colli muscles.• Hodgson approach via posterior triangle by retracting SCM, Carotid sheath, T & O anteriorly & to the opposite side.
  47. 47. • Anterior transpleural transthoracic approach (Hodgson & Stock, 1956)• Anterolateral extrapleural approach (Griffiths, Seddon & Roaf, 1956)• Posterolateral approach (Martin,1970) {Dura is exposed by hemilaminectomy first & then extended laterally to remove the posterior ends of 2 – 4 ribs, corresponding transverse processes & the pedicles}.
  48. 48. • Left sided incision preferable• Incision made along the rib which in the mid-axillary line, liesopposite the centre of the lesion (i.e. usually 2 ribs higher than thecentre 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 resected subperiosteally.
  49. 49. • Parietal pleural incision applied & lung freed fromthe parieties & retracted anteriorly.• A plane developed b/w the descending aorta & the paravertebral abscess / diseased vertebral bodies by ligating the intercostal vessels & branches of hemiazygos veins.• T-shaped incision over the paravertebral abscess.• Debridement / decompression with or without bone grafting.
  50. 50. • Griffith et al -- prone position• Tuli --- Right lateral positionAdvantage:- 1. avoid venous congestion 2 . avoid excessive bleeding 3. permits free respiration 4. Lung & mediastinal contents fall anteriorly• Parts to remove : Posterior part of rib (~8cm from the TP) Transverse process (TP) Pedicle Part of the vertebral body
  51. 51. • • Semicircular incision• • For severe kyphosis, additional 3-4 transverse processes and• ribs have to be removed.• • Intercostal nerves serve as guide to the intervertebral• foramina & the pedicles.
  52. 52. • Left side approach• Semicircular incision• Expose and remove transverse process subperiosteally.• Preserve lumbar nerves
  53. 53. • 45 ⁰ right lateral position with bridge centred over the area to be exposed.• Similar incision as nephroureterectomy or sympathectomy• Strip peritoneum off posterior abdominal wall and kidney, preserving ureter.• Longitudinal incision along psoas fibres for abscess drainage• Retract the sympathetic chain• Double ligation of lumbar vessels.
  54. 54. • Left side preferred ( left Common iliac vessels longer & retracted easily).• Lazy “S” incision• Strip & reflect the parietal peritoneum along with ureter & spermatic vessels towards right side.
  55. 55. • Supine position• Midline incision from umbilicus to pubis.• Lumbo-sacral region identified distal to aortic bifurcation and left common iliac vein.• Longitudinal incision on parietal peritoneum over lumbo- sacral region in midline.• Avoid injury to sacral nerve & artery and sympathetic ganglion.
  56. 56. • By– Albee & Hibbs• Albee– Tibial graft inserted longitudinally in to the splitspinous processes across the diseased site.• Hibbs– overlapping numerous small osseous flaps from contiguous laminae , spinous processes & articular facetsIndications–• 1. Mechanical instability of spine in otherwise healed disease.• 2. To stabilize the craniovertebral region (in certain cases of T.B.)• 3. As a part of panvertebral operation
  57. 57. • HIGH RISK PATIENTS: - Patients < 10 years - Dorsal lesions - Involvement of >= 3 vertebrae - Severe deformity in presence of active disease, especially in children is an absolute indication for decompression , correction and stabilization.Staged operations-• 1. Anteriorly at the site of disease,• 2. Osteotomy of the posterior elements at the deformity &• 3. Halopelvic or halofemoral tractions post-operatively.
  58. 58. • Griffiths et al (1956) :anterior transposition of cord through laminectomy• Rajasekaran (2002): posterior stabilization f/b anterior debridement and bone grafting ( titanium cages) in active stage of disease and vice versa for healed disease.• Antero-lateral (Preferred approach) .
  59. 59. • Fundamentals of correction: 1. to perform an osteotomy on the concave side of the curve and wedge it open ( secured with strong autogenous iliac grafts) . 2. to remove a wedge on the convex side and close this wedge ( Harrington compression rods and hooks)
  60. 60. • • Less than 1% of all spinal tuberculosis.• • Young patients (14 to 65 years), F: M = 2:1.• • Infection from primary sites (paranasal sinuses, nasopharyngeal or• retropharyngeal lymph nodes) spreads retrograde via lymphatic route.• PRESENTATION:• 2 months to 2 years to produce symptoms• – Cervico-medullary compression,• – Cranial nerve deficits• – Atlanto-axial instability,• – Abscess formation
  61. 61. • DIAGNOSIS:• X-ray / CT Scan / MRI :• • Destruction of lateral masses,• • Secondary atlanto-axial subluxation• • Basilar invagination,• • Adjacent bony destruction,• • Increase in the pre-vertebral shadow/ prevertebral enhancing soft tissue• mass.• • Spinal cord signal changes / compression.
  62. 62. CONSERVATIVE :• – Absolute bed rest• – Cervical traction for unstable spine• – Prolonged external immobilization• – ATT X 18 monthsSURGERY :• Gross bony destruction with instability• Abscess formation• Severe or progressive neurological deficit• Unstable spine following conservative therapy(failed• therapy)• Doubtful diagnosis (esp. with neoplasm)
  63. 63. • Tuberculosis of Skeletal System SM Tuli - 4th edn• Spine Surgery – Edward C. Benzel 2nd edn• Campbell‟s Operative Orthopaedics – 11th edn• Synopsis of Spine Surgery – Howard S Ann• The Story of Orthopaedics - Mercer Rang• Harrison‟s Principle‟s of medicine – 17th edn• Chapman‟s Orthopaedic Surgery – 3rd edn
  64. 64. THANKYOU Dr Shahid Latheef +917795664142