tuberculosis of spine

1. DORSO-LUMBAR
TUBERCULOSIS

2. INTRODUCTION
•Tuberculosis - oldest disease afflicting
humans.
•Seen in Egyptian mummies - back to 3400
BC.
•Among overall cases,
- 10% involve musculoskeletal
system
- Among them 50% involves spine.
world’s
population
of TB population
is
•According to WHO –
1/3rd affected by
tuberculosis
- among them
1/5th in india.

3. • Every day 1000 dies of tuberculosis in
india.
• Neurological involvement- 47%
• Dorso-lumbar spine involved most
commonly.

4. TB and HIV
• 10% cases occur in HIV patients
• Disseminated and extrapulmonary
disease is more common with CD4<200

5. REGIONAL DISTRIBUTION
SPINE TB
• Cervical(12%)
• Cervicodorsal(5%
)
• Dorsal(42%)
• Dorso
lumbar(12%)
• Lumbar(26%)
• Lumbosacral(3%)

6. WHY MOST COMMONLY OCCURS
AT DL JUNCTION???
• Greater extent of movement
• Degree of weight bearing and
microfracture
• Large spongy cancellous bone
• Proximity to kidney and cistern chili
D-L region ---> lumbar ---> upper dorsal
---> cervical ---> sacral.

7. PATHOGENESIS
• secondary infection- lung
- genitourinary
system.
• spread - hematogenous route.
• Initially starts with , Inflammatory
reaction. Then there is proliferation of
granulation tissue,
invasion of macrophages,
epitheloid cells, lymphocytes
and
tissue necrosis.

8. - Tissue necrosis and breakdown of inflammtory
cells result in paraspinal abscess, which mostly
accumulate in the anterior aspect of vertebral
bodies under anterior longitudinal ligament.
- Skip lesions are also seen
ocassionally.

9. CLINICAL PRESENTATION
• Presentation depends on the following:
– Stage of disease
– Site
– 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.

10. CLINICAL FEATURES
• Common in 1st three decades of
life.
• Males=females
• Back pain is the earliest
and most common symptom.
– Patients have usually
had back pain for
weeks prior to
presentation

11. 1)Constitutional symptoms(40%
cases)
• Malaise
• Loss of appetite
• Night sweats
• Evening rise of temperature
2)Specific symptoms
• Night crises
• Stiffness
• Restricted ROM
• Enlarged lymph nodes
• Abscess
• Neurological deficit

12. TYPES OF TB
SPINE
1)Caseous exudative :
• More common in children
• More destruction and residual
deformity
• More exudation
• Abscess formation
2)Granular type
• More in adults
• Less destructive
• Insiduous onset
• Abscess formation rare

13. INVESTIGATIONS
1)CBC-Decreased Hb, Lymphocytosis
2) ESR-Raised in active stage of the disease
Normal ESR for 3 months suggest patient is in
recovery phase.
3) MONTOUX/TUBERCULIN SKIN TEST- positive
test can be observed 1 to 3 months after infection.
4) ZIEHL-NEELSEN STAINING - Inexpensive method
- Detects acid fast bacilli
- Culture are available only after a
few
weeks.(2-3 week)
- Positive only 50% cases.

14. 5) ELISA- antibody detection
6)PCR- TB gene expert-TB GOLD(result within
4-6 hr)
7)Radiological- Plain radiograph
CT scan
MRI
spine
Bone scan(Tc-99m)

15. FINDINGS ON PLAIN XRAY
• Reduced disc space
• Blurred paradiscal margins
• Deformities
a)anterior wedging
b) gibbus deformity
c)vertebra plana=single collapsed
vertebra

16. KYPHO
SIS
angular
Round
More than
3 vertebra
involvemen
t
Gibbu
s 2 or
3
vertebr
a
involvemen
Knuckle
1 vertebra
involvemen
t

17. Destructio
n of
vertbrae
Osteoprosi
s due to
hyperemia
Disease
itself
Ischemic
necrosis due
to
endarteritis

18. CT
SCAN
- Pattern of bony
destruction
- calcification in abscess
-detects early lesion
before they appear on
xray
MRI
- Detect marrow
infiltration in vertebral
bodies.
- changes of discitis
-helps in differentiating
intradural from
extradural lesions
- Skip lesions
- Spinal cord
involvement.

19. SPINAL LESION OF
TUBERCULOSIS
• Intradural involvement-very
rare
• Extradural involvement-
– Paradiscal (due to arterial spread)
– Central(venous spread)
– Anterior(due to subperiosteal
spread)
– Appendical

20. DIFFERENTIAL
DIAGNOSIS
• It includes,
- Spinal infection- tuberculosis, brucellosis,
fungal
- Neoplastic- lymphoma, metastasis
- Degenerative
- Neuropathic spine

21. COMPLICATIONS OF
SPINALTUBERCULOSIS
- Paraplegia
- Cold abscess
- Spinal deformity
- Secondary infection
- Fatality
- Amyloid disease

22. POTT’S
PARAPLEGIA
• Incidence : 10 - 30 %
• Dorsal spine most common
• Motor functions affected before / greater than sensory.
• Sense of position & vibration last to disappear
• Pathology:
– Extradural granulation  Contraction  Peridural fibrosis 
Recurrent paraplegia
• Physical findings:
– Spasticity
– Exaggerated reflexes-clonus

23. PATHOPHYSIOLOGY
Secondary infection
Osteomyelitis, abscess, granulation
tissue Bone destruction
Vertebral Collapse snd Gibbus formation
Endarteritis, periarteritis or thrombus
formation Spinal Cord ischemia, Thinning,
Myelomalacia Neural Deficit

24. KUMAR’S CLASSIFICATION OF TUBERCULOUS
PARA/TETRAPLEGIA (Predominantly based on motor
weakness)
Stage Clinical features
I Negligible Patient unaware of neural deficit,
Plantar extensor and / or ankle clonus
II Mild Patient aware of deficit but manages to walkwith
support (Spastic paresis)
III Moderate Nonambulatory because of paralysis (in extension),
sensory deficit less than 50%
IV Severe III + Flexor spasms / paralysis in flexion/sensory deficit
more than 50% / sphincters involved

25. BASIC PRINCIPLES OF
MANAGEMENT
• Early diagnosis
• Medical Treatment – AKT and
brace
• Surgical Approach to drain
abscess, debridement and
fusion
• Stabilization to Prevent
Deformity

26. Spinal
TB
Treatmen
t
Chemotherapy(A
KT) (18 months)
Surgery
(Debridement+fusion+fixati
on)
Anterior
approach
Combined
Approach
Posterior
Approach

27. RNTCP
GUIDELINES
Category Type Regime
n
I All “new” pulmonary,
extrapulmonary and other
TB patients
2(HRZE)3 + 4(HR)
II All relapses, treatment after
defaults, failures and others.
2(HRZES)+
1(HRZE)+
5(HRE)
•ENTIRE DUARTION OF CHEMOTHERAPY LASTS FOR 16-
18 MONTHS
•10 MG PYRIDOXINE FOR PREVENTION OF PERIPERAL
NEUROPATHY

28. SURGICAL INDICATIONS
• failure of conservative management
• Abscess formation
• Progressive neurological deficiet
• Advanced cases- Sphincter involvement, flaccid paralysis or severe
flexor spasms
• Residual kyphotic deformity

29. Various surgical
Approaches
Cervical Dorsal Lumbar
Anterior Anterior trans thoracic Antero lateral
approach to lumbar
spine
Anterior trans Posterior midline spinal
abdominal approach Approach-MC used in all
posterior method of
spine
TB

30. FOLLOW UP AND
EVALUATION
• Followup atevery three months interval upto 1.5
year.
• Clinical: Investigation
1. Weight gain - CBC
2. Pain relief - ESR
3. Free ROM - CRP
4. Resolution of Abscess
• Radiological
1. Decreased soft tissue shadow
2. Disappearance of erosion
3. Return of mineralisation
4. Bony Ankylosis

31. THANK
YOU