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POTT’S SPINE-1676656384.pptx
1.
2. POTT’S SPINE
Tubercular spondylitis has been documented
in ancient mummies from Egypt and Peru
and is one of the oldest demonstrated
disease.Percival Pott presented the classic
description of spinal TB in 1779.
Spinal TB constitutes about 50% of all cases
of osteoarticular TB.
MC site: Lower thoracic and lumber region
followed by middle thoracic and cervical
vertebrae.
5. ANATOMY
Vertebre develops from the sclerotome on
either side of notochord
Each pair of sclerotome (common blood
supply) form Lower half of one vertebra
and upper half of one below it along with
intervening disc.
Therefore ,infections via the arteries
involve the embryological section.
6. SPINAL TUBERCULOSIS
Pathology
• Spinal tuberculosis is usually a secondary infection from
a primary site in the lung or genitourinary system.
• Spread to the spine is hematogenous in most instances.
• Delayed hypersensitivity immune reaction.
• Initially : a pre-pus inflammatory reaction with
Langerhan’s giant cells, epithelioid cells, and
ymphocytes.
• The granulation tissue proliferates, producing thrombosis
of vessels.
7. SPINAL TUBERCULOSIS
• Tissue necrosis and breakdown of inflammatory cells
result in a paraspinal abscess.
• The pus may be localized, or it may track along tissue
planes.
• Progressive necrosis of bone leads to a kyphotic
deformity.
• Typically, the infection begins in the anterior aspect of the
vertebral body adjacent to the disk.
8. • The infection then spreads to the adjacent vertebral
bodies under the longitudinal ligaments.
• Noncontiguous (skip) lesions are also seen
occasionally
9. Pathogenesis Of Spinal
Tuberculosis
Five stages by Kumar KA (1988)
Stage
Stage
Stage
of
of
of
Implantation
early destruction
advanced destruction and
collapse
Stage of
Stage of
neurological involvement
residual deformity
11. PARADISCAL
Commonest type
Spread through arterial supply
Bacteria lodge in the contiguous areas of two
adjacent vertebrae granulomatous
inflammation leading to erosion of vertebral
margins loss of nutrition of intervertebral
disc Disc degeneration
When the intervertebral discs have been
completely destroyed,the adjacent bodies
fuse with each other.
12.
13. CENTRAL LESIONS
Body of single vertebra is affected.
Starts in the centre of the vertebral body.
Infection at this site probably reaches through
Batson’s venous or branches of post.vertebral
artry.
Lytic area develops in the centre of vertebral body
leading to balooning of vertebral body
mimicking tumour
Later stages-concentric collapse resembling
Verebra Plana.
Disc space is not/minimally affected
14.
15.
16.
17. Anterior lesions— Infection starts in the anterior
part of vertebral body and spreads under
the ant. Longitudinal ligament.
Post/Appendiceal— Pedicle,lamina,spinous
process or transverse process of
vertebra are affected.
18.
19.
20. CLINICAL FEATURES
Constitutional symptoms,such as fever, night sweats,loss of
weight and appetite may occur before symptoms related to
spine.
1. Pain-can be Localised to the site(MC early
symptoms)
Radicular
worsen with activity and at night(night
cries)
2. Stiffness-Protective mechanism of body where paravertebral
muscle go into spasm to prevent movement at the affected
vertebra.
21. 3. Cold abcess- Patient may present the first time with
swelling(cold abcess) or due to its compression
effects:-
Retropharyngeal abscess --Dysphagia,dyspnea,
Hoarseness of voice
Mediastinal abscess --Dysphagia
Psoas abscess -- Flexion deformity of
hip
-No usual signs of inflammation like heat ,redness
etc.
-Follows paths of least resistance along facial
planes,blood vassels &nerves.
22. PRESENTATION OF COLD ABSCESSES
FROM DIFFERENT REGIONS OF SPINE
Cervical spine- Exudate collects behind prevertebral
facia and may protrude as Retropharyngeal abscess, It
may track down in mediastinum to enter into
trachea,esophagus or pleural cavity.It may spread
lateraly into sterno-cleido mastoid and form abscess in
neck.
Thoracic spine- It may confined locally and may appear
on X-ray as fusiform or bulbous paravertebral abscess
.It can compress spinal cord or penetrate the
ant.longitudinal ligament to form a mediastinal
abscess or pass downward through medial arcuate
ligament to form lumber abcess.
Lumber spine- Most commonly enters the psoas
sheathPsoas abscess,also abscess in scarpa’s
triangle,medial aspect of thigh
23. 4.Fallacious history of trauma- Trauma may draw
attention to a pre-existing lesion or may activate a
latent tubercular focus
5. Paraplegia-Rarely it is the presenting symptom.
6. Wedging :-
Dorsal spine : Line of weight bearing passes ant to
vertebrae.Ant wedging occurs.In late stages
leading to
kyphotic deformity
Cervical and lumber spine : Wedging is less due
lordotic curvature
7. Gibbus-If patient presents late
24. EXAMINATION
1. Gait- Patient walks with short steps to avoid
jerking the spine.In TB of cervical
spine,patient often supports his head with
both hands under the chin and twists his
whole body in order to look sideways.
2. Attitude and deformity :-
Cervical spine : Stiff,straight neck
Thoracic spine : Kyphus or gibbus,walks
very
carefully
Lumber spine : Loss of lumber lordosis
25. 3. Paravertebral swelling- Superficial cold abcess may
present as fullness or swelling on the back,along
the chest wall, usually fluctuant. It is important to
look for cold abcesses in not so obvious
locations,depending upon the region of spine
involved.
4. Neurological Examination- To determine if there is
any neurological compression and to determine
level and severity of neurological compression
5. General examination- For any active or healed
lesion,for any other systemic illnesses
like,diabetes,HT,jaundice etc.
27. INVESTIGATION
Radiological examination :-
1. Xray spine-AP,Lateral
2. CXR-for primary focus
3. Xray abd-KUB,if psoas abcess is
suspected or to find out Primary in abd.
The classic roentgen triad in spinal tuberculosis is
primary vertebral lesion, disc space narrowing and
paravertebral abscess.
On an avg. 2.5 to 3.8 vertebrae are involved
30. Radiographs: General Features
Features of Pott’s on radiograph include
•
–
–
–
–
–
–
–
Signs of infection with lytic lucencies in anterior portion of vertebrae
Disk space narrowing
Erosions of the endplate
Sclerosis resulting from chronic infection
Compression fracture
Continuous vertebral body collapse
Kyphosis; gibbous (severe kyphosis)
• Atypical features
–
–
–
–
–
Soft tissue swelling from paraspinal abscesses, +/‐ calcification
Involvement of only one vertebral body
Involvement of several vertebral bodies without intervertebral discitis
Bowing of rib cage secondary to collapse of multiple vertebral bodies
Destruction of lateral or posterior aspects of vertebral bodies
31. 1. Paradiscal : Reduction in disc space- Initialy
there is demineralization with indistinct bony
margins-gradually disc space narrowing
occurs.The disc space may eventualy
disappear leading to wedging.
Lateral X-ray is better for evaluation of disc
space.
Takes 3-5 months for bony destruction to
become visible on X-ray
More than 30 % of mineral must be removed
from bone for a radiolucent lesion to be
visible
32. Tuberculous spondylitis. Lateral radiograph demonstrates
obliteration of the disk space (straight arrow) with destruction of
the adjacent end plates (curved arrow) and anterior wedging.
33. There is narrowing of the disk space at L4-5,
with end plates indistinctly outlined. CT
section through the disk space clearly
shows destructive changes of the disk and
vertebral end plate characteristic of
infection
34. RADIOLOGICAL EXAMINATION
2. Central : Lytic area in the centre of vertebral body which
enlarges and baloons out like tumour.Disc space is
preserved.
3. Anterior : Shallow excavation on anterior or lateral
surface of vertebral body.
4.TB of posterior elements is usually not detected in early
stages in radiographs.
Late Stages --Kyphotic deformity,lateral shift and
scoliosis,if one side of vertebrae is completely destroyed
Hemivertebrae
Signs of healing—bone density improves,sclerosis, fusion
of contiguous vertebrae.
Skip lesions as involvement of non contiguous vertebrae (7
– 10 % cases).
35. X-ray dorsolumbar spine showing vertebra plana of T10 vertebra.
Disc space is well maintained.
36. Subligamentous spread of spinal tuberculosis. Lateral radiograph
demonstrates erosion of the anterior margin of the vertebral
body (arrow) caused by an adjacent soft-tissue abscess.
37. Destruction of the right side of the vertebral body and the neural arch, with
the remainder of the body maintaining its shape. The lower disc space is
narrowed on the right side; the upper space is almost normal and there is a
small paravertebral abscess.
38.
39. Evidence of cold abcess on X-rays
Paravertebral abcess : Paravertebral soft tissue
shadow corresponding to the site of affected
vertebrae in AP view can
Fusiform [bird nest abcess] : L>W,seen in dorsal
spine area.
Globular or tense : W>L,pus under pressure a/w
paraplegia
Widened mediastinum : Abscess from dorsal
spine may present as widened mediastinum
40. Aneurysmal phenomena : Concave erosions
along the margins of vertebral bodies
produced by long standing tense
paravertebral abcess,usually in dorsal spine
Retropharyngeal abcess : In cervical spine
TB,seen on lateral view : increase in soft
tissue thickness (>4mm) in front of C3
vertebral body.
Psoas Abcess : In dorso-lumber and lumber
TB,psoas shadow on X-ray of abd may
show a bulge.
43. CT SCAN
CT demonstrates abnormalities earlier than plain radiography. It is of great
value in the demonstration small paravertebral abscess,not otherwise
seen on plain X-ray or any calcification within the cold abscess or
visualizing epidural lesions containing bone fragments.
44. A CT scan showing destruction of the neural arch on both sides,
as well as of the vertebral body. Arrows, anterior spinal abscess
45.
46. Tuberculous spondylitis. Axial
CT scan demonstrates lytic
destruction of the vertebral
body (black arrow) with an
adjoining soft-tissue abscess
(white arrow).
Calcified psoas abscess.
Axial CT scan demonstrates
bilateral tuberculous psoas
abscesses with peripheral
calcification (arrows).
47. Current Trends In Imaging
ROLE OF CT SCAN
CT IMAGING shows focus of
-
-
-
-
-
Bone
Early
Level
Infection
Erosions
Of Lesion
Amount Of Bone Destruction
Posterior Element Lesions
48. CT: Features
Features on CT
• Soft tissue findings
‐ Abscess with calcification is diagnostic of spinal TB; CT is
excellent modality to visualize soft tissue calcifications
• Pattern and severity of bony destruction
‐ Pattern of vertebral body destruction‐ framentary, osteolytic,
localized and sclerotic, and subperiosteal
• Used to guide needle in percutaneous needle biopsy of
paraspinal abscess
49. MRIInvestigation of choice to evaluate the type and
extent of compression of cord,to know the
spread of disease under the anterior or
post.ligament, most effective to demonstrate
neural compression,helps to differentiate
between TB and pyogenic infection :-
TB – Thin and smooth enhancement of the
abcess wall
Pyogenic – Thick and irregular
MRI is more sensitive than x-ray and more specific
than CT in the diagnosis of spinal tuberculosis.
50. CORD CHANGES
Conventional radiograph-no information
CT –inadequate assesment
MRI -gives invaluable information
Cord oedema or focal myelomalacia is seen as hyperintense signal and It can
also diagnose extraosseous extradural granuloma.
51. Current Trends In Imaging
ROLE OF MRI SCAN
MR IMAGING IDENTIFIES
-
-
Cord compression / changes
Soft tissue shadows and
intraosseus abscesses
Skip lesions
-
- Sub ligamentous spread of
infection and epidural extension
The Imaging Method Of Choice
-
52. MRI: Features
•
•
•
Highly sensitive and specific for
Provides early detection
spinal TB
Best to distinguish exact
tissue involvement
extent of spinal cord and soft
• Features
–
–
–
Edema of vertebrae and disk space
Signs of spinal compromise i.e. cord compression
Note: Poorly visualizes calcification in abscesses
53. MRI: Spinal Cord Involvement
PACS, BIDMC
Sagittal T2W (Images 1-3)and axial T1W (Image 4)
High intensity activity in T12 to L3 vertebrae indicative of infection (*) (*). Complete destruction of
vertebral bodies with osseous retropulsion into the spinal canal, causing cauda equina (*). On axial
view, note destruction of vertebral body with loss of circular shape(*).
4
3
2
1
55. ‘Gibbus formation’ in the thoraco-lumbar region of a patient with spinal
tuberculosis (left). The magnetic resonance shows spinal tuberculosis at
T10–T12. Spinal tuberculosis causes the destruction, collapse of vertebrae
and angulation of vertebral column
56. X-ray of cervical region which shows spinal tuberculosis of cervical six
to seven vertebrae and a retropharyngeal abscess (left). T1-weighted
image of an MRI of same patient, which shows destruction of C6–C7
vertebrae
59. Current Trends In Imaging
ROLE OF BONE SCAN
Helps in detection of
early lesions when
radiologically normal
Helpful in diagnosing
skip lesions/ involvement
of other bones
95% sensitivity
61. MYELOGRAPHY
To determine the level of obstruction
May be indicated in cases with ‘spinal tumour syndrom’
In cases of multiple vertebral lesion
When pt has not recovered after decompression
62. FNAC : Especially of cold abcess,ZN Stain,C/S
Biopsy : May be required in cases of doubtful
diagnosis
Other Investigation : To support the diag:-
Increased ESR,Decreased Hb,relative
lymphocytosis,Mantoux
63. The Sero-immunological and
Biochemical Investigations
POLYMERASE CHAIN REACTION
- Simple and widely used
- Highly sensitive but less specific
ROLE OF IgM AND OTHERS
- Low specificity and sensitivity
- Of low predictive value in spinal TB
extra-pulmonary diseases
and other
65. Even though, classical clinical and
radiological features have been described
in the literature, spinal tuberculosis does
mimic other lesions
Can be
MISSED, MISTAKEN or MISDIAGNOSED
69. TREATMENT
Before availability of ATT,mortality rate was 30
% or severe crippling deformities
Aim of treatment is to achieve healing of
disease & to prevent,detect early and
promptly any complication like paraplegia
Rest: Bed rest for pain relief and to prevent
further collapse and dislocation of diseased
vertebrae.in children body cast is used.For
cervical spineMinerva jacket&coller
70. Building up of patient’s resistance : High protein diet.
ATT : This remains the cornstone of management,
completed by rest,nutritional support and splinting,
as necessary.However, there is difference of opinion
reg.the duration of drug therapy.Short course
chemotherapy for nine months has shown good
results in patients with disease coused by
succeptible microorganisms.
Antibiotics : For persistently draining sinuses which
get secondary infection.
Bed soar care and to treat other comorbid conditions.
71. Mobilisation : Gradual as improvement begins
sit & walk,the spine is supported with
coller(cervical),brace (dorso-lumber spine)
Cold abcesses may subside with ATT,if
present superficially may need
aspration(antigravity insertion of needle
through a zig-zag tract) or
evacuation(wound closed without a drain)
Sinuses: Mostly heal within 6-12 weeks.If no
improvement Excision of tract
72. Pott Disease: Treatment
•
•
Various imaging modalities are useful in determining extent of disease.
Treatment options then depend on the degree of spinal destruction.
Oguz et al.- http://www.springerlink.com.ezp-
prod1.hul.harvard.edu/content/h482j21x5548q078/fulltext.pdf
Most practicing
clinicians simply
define Pott’s as
EARLY or LATE
disease.
GATA Classification
73. Anti Tubercular Drugs
Specific anti-tuberculous drugs have
revolutionized the outcome of spinal
tuberculosis which is now considered
curable
to be
It has to be realized that surgical treatment
cannot replace chemotherapy
74. Anti Tubercular Drugs
One in 20 new cases of tuberculosis is
considered to be multidrug-resistant
Therefore, in spinal tuberculosis, 3 months
of intensive chemotherapy with 4 drugs
followed by 12-15 months of maintenance
therapy with two drugs is necessary
75. The Role of Empirical Treatment
Always an attempt should be made to prove the
diagnosis before therapy is initiated
However, young patients with classical clinico-
radiological features and high ESR may be
empirically started on ATT
If empirical therapy is initiated, meticulous
monitoring to ensure sustained improvement is
necessary
77. Controversial Surgeries
LAMINECTOMY
Is CONTRAINDICATED in spinal tuberculosis
because the disease is present anteriorly and by
doing a posterior decompression, the spine
becomes completely unstable
It is only indicated in cases of posterior element
disease and spinal tumour syndrome
81. Limited Surgeries In
Tuberculosis of Spine
COSTO-
TRANSVERSECTOMY
Excision of portion of
a rib and the
articulating
transverse process
82. Conventional Limited Surgeries
ANTERO-LATERAL
DECOMPRESSION
First described by
Capener (1933).
Only operation in which
decompression of the
cord is performed by
removing the actual
cause of compression
Lateral
Rachotomy
by Capener
83. Conventional Radical Surgery
Hodgson et al.( 1960)
Developed the concept of
radical excision of the
diseased vertebral bodies
and their replacement by
bone grafts in all cases
spinal tuberculosis
of
84. INDICATION FOR SURGERY
1. Doubtful diagnosis where open biopsy is necessary
2. Failure to respond to ATT
3. Radiological evidence of progression of bony lesion or paraspinal
abcess shadow.
4. Imminent vertebral collapse.
5. Instability of spine and subluxation or dislocation of vertebral body.
86. Absolute Indications
Paraplegia during conservative treatment
Paraplegia worsening during treatment
Complete motor loss for 1 month despite
conservative treatment
Paraplegia with uncontrolled spasticity
Severe and rapid onset paraplegia
Severe flaccid paraplegia/ sensory loss
87. Relative indications Rare indications
Recurrent
paraplegia
Paraplegia
Painful and
paraplegia
Paraplegia
Posterior element
disease
Spinal tumor
syndrome
Severe cervical
lesion c paraplegia
1. 1.
in elderly
spastic
2. 2.
3.
3.
with
4.
complications (UTI) Cauda equinopathy
4.
88. Conventional Treatment: Tuli
Anti tubercular drugs are the most
important therapeutic measure
ATT must be continued for about 18
months( must include Isoniazide)
Patients with early disease can achieve
full clinical healing
Indications of surgery are mainly for
complications than for the disease control
89. The Middle Path Regimen of Tuli –
Surgical Indications
No neurological recovery after 4 weeks of ATT
Development of neurological deficit during the
course of chemotherapy
Recurrence of neurological deficit after initial
improvement
Worsening of neurological deficit while on
chemotherapy
Advanced case of neurological involvement
90. BRITISH MEDICAL RESEARCH COUNCIL
When appropriate facilities and expertise
are available radical surgeries have
definite advantage over non-operative
treatment
J Bone Joint Surg 60 (B), 61 (B) 64
However long term follow up of
surgeries showed considerable
(B) and 67
radical
loss of
(B)
correction and failure of the bone graft
leading to progression of kyphosis
Parthasarathy et al, Rajashekaran et al, Sundararaj
and Moon et al
et al
91. Current Trends In The Surgical
Management of Spinal Tuberculosis
Aims
Correction of kyphosis
Early fusion
Prevention of
Prevention of
progression of kyphosis
late onset paraplegia
92. Current Trends In The Surgical
Management of Spinal Tuberculosis
Debridement, anterior instrumentation and fusion
Anterior debridement and anterior column
reconstruction with bone grafting or CAGE
Debridement, posterior instrumentation and fusion
93. Anterior Debridement And
Reconstruction
Helps in neurological recovery and
produces early fusion
However, achieves only limited correction
of kyphosis and may not be able to
prevent progression
96. can be
Role of Posterior
Instrumentation And Fusion
Aggressive correction of
achieved
kyphosis
Prevents recurrence of kyphosis
Not beneficial without anterior
debridement and fusion
97. Combined Anterior Decompression And
Grafting / CAGE With Posterior
Bone
Instrumentation And Fusion
Single stage through
two approaches-
Combined anterior
and posterior
Single posterior
approach
98. Combined Anterior Decompression And
Bone Grafting / CAGE With Posterior
Instrumentation And Fusion
LIMITATIONS
-
-
Needs appropriate facilities and expertise
Intensive anaesthetic and postoperative
care
Secondary infection and implant failure
-
99.
100. PROCEDURES
1. Anteriolateral decompression with
interbody bone grafting.Grafts placed
anteriorly.
2. Costo transversectomy with dempression
3. Metallic implants& titanium cage filled with
cancellous bone when whole body is
destroyed.
4. Kyphotic deformity is prevented by ant
debridement,ant inerbody fusion&post
fusion.
101. Conclusion
Early diagnosis and treatment prevent
complications
Threat of MDR-TB
Intensive chemotherapy and
PCR / CT / MRI / Bone scan
diagnosis
More aggressive and radical
advocated:
monitoring
help in early
surgeries are
To
To
To
correct and prevent progression of kyphosis
achieve better healing and
lessen the chance of late onset paraplegia
103. Cold Abscess
Classic local signs of
acute infection (calor
rubor) not evoked
and
Pus accumulates
beneath anterior
longitudinal ligament and
extends along paths of
least resistance
104. Cold Abscess - cervical spine
Retropharyngeal abscess-
dysphagia, difficult phonation
Neck swelling- behind
sternomastoid in posterior
triangle of neck
Mediastinum
Axilla and cubital fossa (along
vessel and nerve)
Spinal canal
105. Cold Abscess - thoracic spine
Prevertebral-
posterior
mediastinum
Empyema- rupture
into pleura
Track along
intercostal nerves
106. Cold Abscess - thoracic spine
Extrapleural space-
Spreads laterally
Spinal canal- cord
compression
paraplegia
and
Bone School
107. Lower thoracic spine
Track down through lateral
arcuate ligament
Kidney bed
Anterior abdominal wall (via
nerve planes)
Medial arcuate ligament
Psoas sheath
Thigh swelling
108. Lumbar spine- Psoas Abscess
Psoas abscess can
travel along sciatic
nerve to pelvis,
gluteal region,
posterior aspect of
thigh and
region
popliteal
110. Mechanical Causes of
Progression of Kyphosis
Involvement of anterior
and middle column
produces progressive
kyphosis
Involvement of only the
middle or the posterior
column may not produce
kyphosis
Active continuous
growth of the posterior
column leads to
progression
111.
112.
113. Deformity
Knuckle deformity: Wedging
adjacent vertebral bodies
of 1 or 2
Gibbus deformity: wedge collapse of
2-3 vertebral bodies anteriorly
Round kyphus deformity:
more than 3 vertebrae
wedging of
114. Pott’s Paraplegia
Paraplegia is the result of
interference
conductivity
tracts of the
with the
of the pyramidal
spinal cord and is
most often associated with
the tuberculosis of the dorsal
spine (10 – 30 %)
It can be early or late onset
115. Why paraplegia is common
dorsal spine?
in
Commonest site for tuberculosis
Thoracic kyphosis helps in squeezing
products into the canal
Cord : canal ratio is smaller
Spinal cord terminates below L1
1.
the
2.
3.
4.
Ant. Lon. Lig. Is loose in thoracic spine
whereas in lumbar pus enters the psoas
5.
116. Pott’s Paraplegia
EARLY ONSET PARAPLEGIA
Occurs when disease is active
Usually within 2 years of onset of
disease
Usually prognosis is good
the
LATE ONSET PARAPLEGIA
Paraplegia of healed disease
Occurs 2 years after the onset of
disease
Has poor prognosis
the
117. Causes of early onset paraplegia
Seddon-1935
A) Inflammatory causes:
1. Abscess/ inflammatory tissue
caseating mass
and
2. Spinal tumor syndrome (circumscribed
tuberculous mass)
3. Posterior spinal disease
4. Infective thrombosis
118. Causes of early onset
Seddon-1935
paraplegia
B) Mechanical causes:
Pathological subluxation/
dislocation
1.
Cord compression by sequestra/
loose fragments of bone/
granulation tissue/ debris/ disc
2.
119. Causes of late onset
Seddon-1935
paraplegia
A) Inflammatory causes:
Continued activity or
reactivation
B)
1.
Mechanical causes:
Cord stretched over internal
gibbus/ transverse ridge
Vascular and dural fibrosis
2.
120. Causes of Paraplegia
Extrinsic causes
1)
a)
In active disease:
Abscess
2)
a)
In healed disease
Transverse ridge
internal gibbus
/
Granulation tissue
b)
Fibrosis of dura
Sequestered
and disc
Pathological
subluxation /
dislocation
bone b)
c)
d)
121. Causes of Paraplegia
Intrinsic causes:
Tubercular
Rare causes:
Infective thrombosis
of the cord
Spinal tumor
syndrome
1.
1.
involvement of the
dura/
cord
meninges/ 2.
122. Pott’s Paraplegia
Classification - Kumar & Tuli
Stage Clinical features
I Negligible Patient unaware of neural deficit, physician detects
plantar extensor and/or ankle clonus.
II Mild Patient aware of deficit but manages to walk with
support, clumsiness of gait.
III Moderate Paralysis in extension, sensory deficit less than 50%
IV Severe III + flexor spasm/ paralysis in flexion/ flaccid/ sensory
deficit more than 50%/ sphincters involved.
Bone School @ Bangalore
