Centre portion of each
intervertebral disc is filled
with gel like elastic
PULPOSUS) which along
with sturdy elastic collagen
from vertebra to vertebra
Annulus fibrosus enhances
rotational stability of
spine and helps to resist
EMBRYOLOGY OF VERTEBRAL
Formed from sclerotome portions of somites(derived
from paraxial mesoderm)
Each sclerotome-loosely arranged cells cranially &
densely packed cells caudally.
Some of the densely packed cells move cranially
opposite the centre of myotome
Remainin densely packed cells fuse with loosely
arranged cells of immediately caudal sclerotome
MESENCHYMAL CENTRUM(primordium of body of
Nerves lie in close relation to IVD and intersegmental
arteries lie on each side of vertebral bodies.
Notochord persists and enlarges only in the region of
IVD…..contributes to formn of NUCLEUS PULPOSUS
which later gets surrounded by circular fibres of
Resegmentation of sclerotomes into definitive
vertebrae causes myotomes to bridge the
IVD…gives them the capacity to move the spine
Spinous and transverse processes develop from
chondrification centres(which appear at 6th week of
embryonic life) in vertebral arch.
Ossification in vertebral arches-8th week
At birth-each vertebra has 3 bony parts connected
by cartilageBony halves fuse during 1st 3-5yrs
Five secondary ossificn centres appear in vertebrae
All secondary centres unite with rest of vertebrae-
TUBERCULOSIS OF SPINE
Vertebral TB-M.C form of skeletal TB(50% of all
cases of TB of bones&joints)
M.C-1st 3 decades
Equal in both sexes
Any one/several vertebrae
M.C-Lowr thoracic & lumbar spine
Infectious exudate may spread anteriorly beneath anterior
longitudinal ligament~>neighbouring vertebrae
Advances&destroys epiphyseal cortex,intervertebral
Infection begins in cancellous area of vertebral
body(Central/anterior/epiphyseal in location)
Note:infection of posterior bony arch and
tyransverse process is unusual
Granulation tissue develops posteriorly-encircles &
compresses spinal cord & nerve roots(more likely in
thoracic spine ‘cause of small calibre of spinal canal
Posterior element involvt of C2(axial
CT image showing reactive sclerosis)
Penetrates the ligament
Migrates in various directions.
Abscess tracks along lines of least
resistance(along fascial planes,blood
vessels & nerves
to sterno mastoid
(a point at postr
confined as a
for a long time
Exudate may spread laterally to extrapleural space-
induces NON SPECIFIC PLEURAL EFFUSION
If exudate penetrates ALL,
gravitates through diaphragm to
the LUMBAR ASPECT
Rarely,thoracic cold abscess may track backward b/w
transverse processes&follow intercostal nerve-erupts on
• Tuberculous exudate enters PSOAS SHEATH
• Appears below inguinal ligament on medial aspect of thigh
• May spread laterally beneath iliac fascia
• Emerges at iliac crest at the anterior superior iliac spine
• Follows great vessels….may erupt alongside femoral vessels in
triangle of Scarpa or in gluteal region
• Or forms an abscess abpve iliac crest posteriorly
Route of spread
TB of spine is always secondary.
Bacteria reach spine via hematogenous route from
lungs or lymph nodes.
TYPES OF VERTEBRAL TB
1) PARADISCAL –
BETWEEN THE TWO
OF TWO ADJACENT
2) CENTRAL- BODY OF
SINGLE VERTEBRA IS
3) ANTERIOR- INFECTION IS LOCALISED TO THE
ANTERIOR PORTION OF THE VERTEBRAE.
4)POSTERIOR-POSTERIOR COMPLEX i.e
PEDICLE,LAMIINA,SPINOUS OR TRANSVERSE
PROCESS ARE INVOLVED.
5)APPENDICEAL-RARE, INVOLVES TRANSVERSE
Collection of pus and tubercular debris from
Can travel in any direction.
Spread beneath the anterior longitudinal
ligament- pre vertebral abscess.
Spread posteriorly and cause pressure over the
Spread through the sides of the vertebra –
para vertebral abscess.
Sometimes penetrates the anterior longitudinal
ligament – lines of least resistance i.e. fascial
Constitutional symptoms antedate local spinal
loss,night sweats,afternoon or evenin rise of temp
Frequently iniated by an exanthem or trauma.
Spine- -Stiff and painful on movt.
- Pain is localised to site of involvement/referred
dependin on specific nerve root irritation
- Localised KYPHOTIC deformity.
(Tender to percussion)
If any suspicion of TB spine………..
Palpate spinous processes by sliding finger
from cervical spine to sacrum…….so that even a
small knuckle kyphosis (step/prominence) is not
missed…………..thus making the diagnosis before
gross vertebral destruction has occurred.
Stiffness,weakness&awkwardness of lower
extremities herald onset of PARAPLEGIA.
CHARACTERISTICS OF SPECIFIC
Pain over cervical vertbrae/referred to
Pain aggravated by pressure on top of head
Deformity-normal lordosis is reduced & head is
supported in hands
Paralysis of arms before legs
Occasionally death due to dislocation
LOW CERVICAL & UPPER THORACIC
Pain along brachial plexus or intercostal nerves
Marked rigidity with angular kyphosis
Cord symptoms L.C
Arms affected first
Neck rigidity-head&neck turn as one
Pain referred to lower extremities(esp lateral
aspect of thighs)
Marked angular kyphosis
Iliac or psoas abscess
Referred pain to lower extremities
Flexion of hips
ABSCESSES & SINUSES…..
Cervical&dorsal-Can present away from vertebral
Paraspinal regions,posterior/anterior cervical
triangles,along brachial pkexus in axilla,along
intercostal spaces on chest wall.
Dorsolumbar&lumbar-Abscess freq tracks down
psoas sheath……palpable in iliac fossa,lumbar
triangle,upper part of thigh below inguinal
Psoas abscess-Pseudo-hip flexion deformity(No limitation
of internal & external rotation of hip jt when tested in
position of flexion deformity)
- Can present as a lump in iliac foss
- HEALED STAGE
- -Not ill
- -Regains lost weight
- -No evening rise of temp
- -No spinal pain/tenderness
- -ESR falls
-Radiological E/O bone healing in serial Xrays
-But deformity persists
Bony ankylosis of L3-L4 resulting in kyphosis in an old
case of TB spondylitis
Mantoux-helpful in children<2-3yrs….not diagnostic
Depending on site of lesion TB spine………..
Earliest radiological finding-narrowing of disc
Loss of definition of paradiscal margins
Bones look rarefied and osteopenic(40% Ca loss-
Observed before osseous destructive changes
Trabecular destruction-atleast 3-5 months from
beginning of infectious process
Late changes-Anterior wedge compression in
anterior vertebral involvement
Central vertebral body collapse(CONCERTINA
COLLAPSE) in central involvement.
Destruction of posterior elements in posterior
Soft tissue swelling&calcificn-highly predictive of TB
Healing stages-vertebral body&posterior elements
Upper thoracic-V-shapd/bulbous/heart shaped
Low thoracic&thoracolumbar-fusiform shadow
occupy site of psoas shadow
. Increased density and lessening of
size of shadow indicates calcification and healing
Axial CT-vertebral body
destruction,paravertebral abscess ext
into spinal canal
MODERN IMAGING TECHNIQUES
• Assessmt of destructive lesions of vertebral column
• Paravertebral soft tissue swellings
• Degree of neural compromise
• Specially useful in-
1) posterior spinal disease
3)Sacroiliac joint TB
• Suspected areas of disease should be localized before
ISOTOPE BONE SCAN-Localises diseased area by
demonstratin a hot spot even when lesions<5mm
Note:atleaqst 30-40% calcium must be removed
from a particlr area for radiolucent changes to
Axial CT image showing vertebral
body destruction&adj soft tissue mass
• Diagnosis of TB in rare sites incl posterior
elements,vertebral appendages&sacroiliac jt
• Excellent modality to judge health of spinal
cord…detects cord compression.
To diagnose presence & size of tuberculous abscess in
lumbar vertebral disease.
GALLIUM SCAN-For disseminated TB
BIOPSY-By percutaneous technique with CT
guidance………biopsy mateial subjected to culture
BIOPSY & CULTURE-MOST DEFINITIVE
Radiological & MRI e/o healing lags behind biological
healing processes in spinal TB.
X-rays,MRI-Upto 5months of starting multidrugtherapy
may actually show deterioration in most pts.
If images don’t show improvement whwn repeated>6
months after onset of Rx….consider alternate
diagnosis/therapeutically refractory disease.
Rarely-healing accomp by fat replacemt of healed
AIMS OF Rx
Halt progression of destruction and deformity
Prevent and overcome paraplegia.
Treatment should be
prolonged ….and a cautious
attitude maintained for many
years…as recrudescence of
disease can occur even years
Isoniazid(INH)-most effective anti-TB drug
Pyridoxine 50mg to be supplemented daily
Ethambutol-25mg/kg/day X 60days
15mg/kg single dose thereafter.
S/E-Visual disturbances……avoid in children
0.75-1g/day X 60days
1g/day 2-3times weekly thereafter
AVOID IN RENAL
Oral single daily dose given ½ hr before
Relatively mild toxic effects
Colors urine&othr body fluids bright orange
Delays emergence of drug resistant strains of
HRE X 6MONTH….
If at the end of 6months,clinical & radiological
IE X 12-18MONTHS
Failure to respond to first line drugs……(due to
bacterial resistance/allergic intolerance/toxic
effects)…..use SECOND LINE DRUGS
Failure to respond despite adq chemotherapy with
radiological e/o progression of disease or neurological
1) Failure to respond to ATT
2) Radiological e/o progression(enlargmt of
paraspinal abscess shadow)
3) Imminent vertebral collapse
4) Instability of spine
5) Progressive neurological deficit
1) Excise infected tissue as completely as possible
2) Decompress intraspinal neural elements
3) Reduce spinal deformity
4) Provide stability by spinal fusion
1) Removal of all diseased tissue by thorough
2) Correction of deformity
3) Interbody bone grafting & stabilization.
4) Relief of pressure on intraspinal contents.
WHAT IS DONE??????
Major focus of disease is removed
Spinal deformity reduced
Intraspinal neural elements decompressed
Bone defect obliterated
Spinal stability provided by autogenous bone grafts
PREOPERATIVELY, an ATT regimen is
Severe destruction-external skeletal fixation with a
Following removal of diseased focus,distraction aids
in overcoming kyphosis.
Lesions of C4-C6-lateral approach or anterior
Lesions of C7-T4-posterior thoracoplasty approach
by removing third rib on left side
Lesions below T40Spine is approached from left
Incision- Along a rib that’s 2ribs
higher than the rib that arises at apex of kyphosis.
Albee procedure-aims to unite the spinous processes
by a single cortical graft(s/c aspect of
tibia)….fixed by sewing muscles over it.
Hibbs procedure-only local bone is used
Pott’s paraplegia can be due to –
- inflammatory causes- oedema,abscess
- mechanical causes-tubercular debris
- intrinsic causes-pathological dislocation
- spinal tumour d/s- extradural granuloma
Most commonly occurs in TB of dorsal spine because
spinal canal is narrowest in this part
GROUP A_-Early onset - This comes up in active stage of the disease
within first 2 years.
Compressive Agents are inflammatory edema, granulation, abscess,
casseous material, sequestra and rarely ischaemic lesion.
GROUP B -Late onset- Usually after 2 years of onset of the disease.
due to recurrence or by mechanical pressure. This can be better divided into
paraplegia with active disease and with healed disease.
Active disease - Caseous material, debris, sequestrated disc or
bone, internal gibbus, stenosis and deformity can cause
Healed disease - Usually internal gibbus and acute kyphotic
deformity can also give late onset paraplegia. Usually there is a
continuous traction, compression leading to paraplegia.
Kumar’s classification of
stage Clinical features
1 Negligible Unaware of neural deficit,
Upgoing Plantar / Ankle clonus
2 Mild Walk with support
3 Moderate Nonambulatory,
Paralysis in extention,sensory loss
4 Severe 3+ paralysis in flexion/sensory
loss>50%/ Sphinters involved
CLINICAL FEATURES OF PARAPLEGIA-
- increased reflexes
- positive Babinski’s sign
In Pott’s paraplegia , motor functions are affected
The paralysis follows the following stages-
muscle weakness, spasticity , incoordination,
paraplegia in extension , flexor spasms,paraplegia
in flexion and flaccid paraplegia lastly.
TREATMENT OF POTT’S PARAPLEGIA
2)SPINE PUT TO ABSOLUTE REST
3)PARALYSED LIMBS SHOULD BE TAKEN CARE OF.
4)REPEATED NEUROLOGICAL EXAMINATION TO
CHECK FOR WORSENING.
1. No sign of Neurological recovery after trial of 3-4
2. Neurological complication during treatment
3. Neuro deficit becoming worse
4. Recurrence of neuro complication
5. Prevertebral cervical abscesses,neurological signs&
difficulty in deglutition& respiration
6. Advanced cases- Sphincter involvement,
Severe flexor spasms
MIDDLE PATH REGIMEN
Widely accepted regimen for tb spine
Admission,rest in bed or pop cast.
X-ray and ESR once in 3 months
Gradual mobilisation in the absence of neurological
Spinal braces-18 months to 2 years.
Abscesses are aspirated out drained.
Sinuses heal within 6-12 weeks
If no neurological complications develop and patient
is responding to the 3-drug therapy , surgery is
Excisional surgery for posterior spinal disease.
Operational debridement for patients who do not
show arrest of disease after 3-6 months of