Moderator: Dr peeyush sharma
Presenter: Dr Pramod mahender
• This entity was first described by Percivall
Pott. He noted this as a painful kyphotic
deformity of the spine associated with
• Tuberculosis of the spine is one of the
oldest diseases afflicting humans.
Evidences of spinal tuberculosis have been
found in Egyptian mummies dating back to
• One fifth of TB population is in India.
• Three percent are suffering from
• 50% of these suffer from spinal lesion
and almost 50% are from pediatric
group. An estimated 2 million or more
patients have active spinal tuberculosis.
• Every day 1000 die of tuberculosis in
• Pott disease is usually secondary to an extraspinal
source of infection.
• The basic lesion is a combination of osteomyelitis and
• The area usually affected is the anterior aspect of the
vertebral body adjacent to the subchondral plate.
• Tuberculosis may spread from that area to adjacent
In adults, disk disease is secondary to the spread of
infection from the vertebral body.
In children, because the disk is vascularized, it can
be a primary site.
• Progressive bone destruction leads to vertebral collapse and
kyphosis. The spinal canal can be narrowed by abscesses,
granulation tissue, or direct dural invasion. This leads to
spinal cord compression and neurologic deficits.
• Kyphotic deformity occurs as a consequence of collapse in
the anterior spine. Lesions in the thoracic spine have a greater
tendency for kyphosis than those in the lumbar spine.
• The collapse is minimal in cervical spine because most of the
body weight is borne through the articular processes.
• Healing takes place by gradual fibrosis and calcification of
the granulmatous tuberculous tissue. Eventually the fibrous
tissue is ossified, with resulting bony ankylosis of the
• Paravertebral abscess formation occurs in almost every case.
With collapse of the vertebral body, tuberculous granulation
tissue, caseous matter, and necrotic bone and bone marrow
are extruded through the bony cortex and accumulate beneath
the anterior longitudinal ligament.
• These cold abscesses gravitate along the fascial planes and
present externally at some distance from the site of the
• In the lumbar region the abscess gravitates along the psoas
fascial sheath and usually points into the groin just below the
• In the thoracic region, the longitudinal ligaments limit the
abscess, which is seen in the radiogram as a fusiform
radiopaque shadow at or just below the level of the involved
• Thoracic abscess may reach the anterior chest wall in the
parasternal area by tracking via the intercostal vessels.
The lesion could be:
• Florid - invasive and destructive lesion.
• Non destructive - lesion suspected clinically but
identifiable by modern investigations like CT scan
• Encysted disease
• Carries sicca
• Periosteal lesion.
• Recently, two distinct patterns of
spinal TB can be identified, the classic
form, called spondylodiscitis (SPD) a
• atypical form characterized by
spondylitis without disk involvement
• SPwD seems to be the most common
pattern of spinal TB.
Anatomically the lesion could be
1. Paradiscal - destruction of
adjacent end plates and
diminution of disc space.
2. Appendeceal (Posterior) -
involvement of pedicles,
laminae, spinous process.
3. Central - Cystic or lytic,
4. Anterior –longitudinal lig,
5. Synovitis in post facet
• Presentation depends on the following:
– Stage of disease
– Presence of complications such as neurologic deficits, abscesses,
or sinus tracts
• The reported average duration of symptoms at the time of
diagnosis is 3-4 months.
• Back pain is the earliest and most common symptom.
– Patients have usually had back pain for weeks prior to
– Pain can be spinal or radicular.
• Constitutional symptoms include fever and weight loss.
• Neurologic abnormalities occur in 50% of cases and can
include spinal cord compression with paraplegia, paresis,
impaired sensation, nerve root pain, or cauda equina
• Cervical spine tuberculosis is a less common presentation is
characterized by pain and stiffness.
Patients with lower cervical spine disease can present
with dysphagia or stridor.
Symptoms can also include torticollis, hoarseness, and
• The clinical presentation of spinal tuberculosis in patients
infected with the human immunodeficiency virus (HIV) is
similar to that of patients who are HIV negative; however,
the relative proportion of individuals who are HIV positive
seems to be higher.
Natural course of disease
• 53% died within 10 yrs of onset
• Early stage of healing– focus surrounded by
sclerotic bone Ivory vertebra
• Early radiological sign of healing– sharpening of
fuzzy paradiscal margins & reappearance and
minrralization of tuberculae
• Several vertebrae destroyed– fibrous tissue
• Disc space destroyed bony ankylosis/bone block
• Tuberculin skin test (purified protein derivative
[PPD]) demonstrates a positive finding in 84-95%
of patients who are non–HIV-positive.
• Erythrocyte sedimentation rate (ESR) may be
markedly elevated .
• The enzyme-linked immunosorbent assay (ELISA)
has a reported sensitivity of 60 to 80 per cent
• The polymerase chain reaction
• A brucella complement fixation test
• IFN- Release Assays (IGRAs)
• Recently, two in vitro assays that measure T
cell release of IFN- in response to
stimulation with the highly tuberculosis-
specific antigens ESAT-6 and CFP-10 have
become commercially available.
• Microbiology studies to confirm diagnosis:
Obtain bone tissue or abscess samples to
stain for acid-fast bacilli (AFB), and isolate
organisms for culture and susceptibility.
CT-guided procedures can be used to guide
percutaneous sampling of affected bone or
soft tissue structures. These study findings
may be positive in only about 50% of the
X Ray appearances
• Lytic destruction of anterior portion of vertebral body
• Increased anterior wedging
• Collapse of vertebral body
• Reactive sclerosis on a progressive lytic process
• Enlarged psoas shadow with or without calcification
• Vertebral end plates are osteoporotic.
• Intervertebral disks may be shrunk or destroyed.
• Vertebral bodies show variable degrees of destruction.
• Fusiform paravertebral shadows suggest abscess
• Bone lesions may occur at more than one level.
X Ray appearances
Discovertebral lesions, detected in 93% of patients,
• Localized fluffy osseous destruction with surrounding
osteoporosis is the earliest signs.
• concentric collapse and may look like A.V.N.
• Local lytic lesion may cause problem of diagnosis from
• destruction of adjacent vertebrae, Konstram (K) angle
appears and shows the progress on follow up.
• Skipped lesion (10% cases) can be diagnosed on
suspicion and in correct size film.
X-ray of the thoracolumbar spine (Lateral view) showing
wedge collapse of L1 and L2 vertebral bodies.
X-ray of the spine in a child showing complete
destruction of D12 and L1 vertebral bodies leaving
only the pedicles.
stage features Usual duration
I Pre- Straightening, spasm, <3 mo
destructive hyperemia in scinti
II Early- Diminished space 2-4 mo
destructive paradiscal erosion Knuckle
III Mild kyphos 2-3 verte k:10-30 3-9 mo
IV Moderate >3 verte K:30-60 6-24 mo
V Severe kyphos >3 verte K:>60 >2 years
• CT scanning provides much better bony detail of
irregular lytic lesions, sclerosis, disk collapse, and
disruption of bone circumference.
• Low-contrast resolution provides a better
assessment of soft tissue, particularly in epidural
and paraspinal areas.
• It detects early lesions and is more effective for
defining the shape and calcification of soft tissue
• In contrast to pyogenic disease, calcification is
common in tuberculous lesions.
• MRI is the criterion standard for evaluating disk
space infection and osteomyelitis of the spine
• MRI findings useful to differentiate tuberculous
spondylitis from pyogenic spondylitis include thin
and smooth enhancement of the abscess wall and
well-defined paraspinal abnormal signal,
whereas thick and irregular enhancement of
abscess wall and ill-defined paraspinal abnormal
signal are suggestive of pyogenic spondylitis.
• contrast-enhanced MRI appears to be important in
the differentiation of these two types of spondylitis.
• most effective for demonstrating neural
• Spinal tumor syndrome
• Multiple vertebral lesions
• Patients not recovered after
4. Block present : second decompression
5. Block not present : intrinsic damage
4. tuberculous myelitis
5. Infarction of spinal cord - Ant spinal
6. Changes in Spinal cord-
change,Atrophy –upto 50%dec in dia-good
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,
Plantar extensor/ 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
Evolution of treatment
• Artificial abscess- Pott in 1779
• Laminectomy & laminotomy :
• Costo-transversectomy: Menard in 1896
• Posterior mediastinotomy
• Calves operation 1917
• Lateral rhachiotomy of carpener 1933
• Anterlateral decompression of Dott&
BASIC PRINCIPLES OF
• Early diagnosis
• Expeditious medical treatment
• Aggressive surgical approach
• Prevent deformity
• Expect good outcome
• Studies performed by the British Medical
Research Council indicate that tuberculous
spondylitis of the thoracolumbar spine
should be treated with combination
chemotherapy for 6-9 months. According to
a 1994 recommendation by the US Centers
for Disease Control and Prevention, this is
the treatment of choice.
What is Middle path regime?
• Admission rest in bed
• X-ray & ESR once in 3 months
• MRI/ CT at 6 months interval for 2 years
• Craniovertebral ,cervicodorsal, lumbosacral&
• Gradual mobilization
• 3-9 weeks- back extention exercise 5-10 min 3-4
• Spinal brace--- 18 months-2 years
• Abcesses – aspirate near surface
• Instille 1gm Streptomycin +/- INH in sol
• Sinus heals 6-12 weeks
• Neural complications if responds 3-4 weeks :-
• Excisional surgery for posterior spinal disease
• Operative debridement for patients –if no arrest
after 3-6 months- spinal arthrodesis (recommended)
• Post op--Spinal brace--- 18 months-2 years
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
• Recurrent paraplegia
• Painful paraplegia– d/t root compression,etc
• Posterior spinal disease--involving the post
elements of vertb
• Spinal tumor syndrome resulting in cord
• Rapid onset paraplegia due to thrombosis,trauma
• Severe paraplegia
• Secondary to cervical disease and
• cauda equina paralysis
• Costotransversectomy– in tense paravertebral
remove– transverse process
rib – 2 inchs
• Posterior part of rib
• Transverse process
• Part of the vertebral body
• Griffith Seddon Roaf -- prone position
• Tuli --- right lateral position
• Advantage:- 1 avoid venous congestion
2 avoid excessive bleeding
3 permits freer respiration
4 better look at site
Posterior Spinal Arthrodesis
• By– Albee & Hibbs
• Albee– tibial graft inserted longitudinally in
to the split spinous vertebral process
• Hibbs– overlapping numerous small osseous flap
from contiguous laminae spinous
process & articular facets
• Indications– 1 mechanical instability
2 to stabilise craniovertebral region
3 as part of panvertebral operation
Yilmaz C, Selek HY, et al. Anterior instrumentation
for the Treatment of Spinal Tuberculosis. J Bone and
Joint Surg 1999; 81-A : 1261-67
• “we feel that every attempt should be
made to minimize this deformity with
some form of instrumentation wherever
indicated, and preferably anteriorly.’”