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1. Pre-op planning of a
pott’s spine with
kyphotic deformity
Presenter- Dr Rakesh Kumar
Neurosurgery resident
Svims , Tirupathi

2. • Mid back pain for 5 months and aggravating
since 2 months.
• h/o fever on and off associated with chills,
high grade, for 5 months
• h/o weakness of both lower limbs for 3
months, insidious onset, gradually progressive,
bedridden now.

3. • h/o cotton wool sensations, difficulty in
percieving hot and cold sensations since 2
months.
• h/o difficulty in rolling over the bed, lifting
head .
• no h/o bowel and bladder complaints,
• No h/o trauma

4. • Past History:
not a k/c/o DM,HTN,CAD
no h/o similar complaints in the past
DRUG H/O :- started on ATT since 1 month.
• Personal history:
diet-mixed
appetite-normal,
sleep- disturbed
bowel and bladder –regular

5. GENERAL EXAMINATION:-
Moderately built and nourished.
T- normal
BP- 120/80 mm HG
RR- 19/min
Pulse- 84/m

6. • Local examination-
A swelling of around 3*3 cm present over the
upper midback which is hard in consistency
,tender, nonfluctent, and irreducible suggestive
of knuckle deformity.

7. CNS Examination
• Cranial nerve examination-
all normal
• Motor system
Tone- increased in both lower limbs
(grade 2 hypertonia)
Bulk- normal in both lower limbs
Power- right left
Upper limb
Shoulder- 5/5 5/5
Elbow- 5/5 5/5
Wrist- 5/5 5/5
Lower limb
Hip- 2/5 2/5
Knee- 2/5 2/5
Ankle- 2/5 2/5
EHL- 2/5 2/5
• DTR: BJ TJ S KJ AJ
Right - 2+ 2+ 2+ 3+ 3+
Left - 2+ 2+ 2+ 3+ 3+
plantar -both extensor
Sensory-All sensations lost below the
level of nipple on both sides.

15. • ESR- 54 mm/hr.
• CT guided biopsy done – suggestive of
tubercular pathology.
• Chest x-ray- normal

16. • Diagnosis- D5 pott’s spine with complete
collapse with kyphotic deformity with
paraparesis.

17. • The indications of surgery in spinal
tuberculosis include:
1) Progressive neuro-deficit
2) Persisting pain due to instability
3) Severe deformity

18. Risk factors for severe progression are
as follows:
• 1) An age below ten years and loss of one or
one and a half vertebral bodies.
• 2) A pre-treatment kyphosis angle of greater
than 30 degrees, especially in children.
• 3) Cervical thoracic and thoracolumbar
junctional lesions.
• 4) Presence of ‘spine at risk’ radiological signs

19. “Spine at risk” radiological signs.
• {a} Separation of the facet joint, (b) Retropulsion,
(c) Lateral translation, (d) Toppling

20. • Presence of spinal instability signs
-Mainly caused by dislocation of facet joints
• Each sign assigned a score of one
• A score of three or more predicts
• Increase in kyphosis by more than 30°
• Final deformity of more than 60°
The practical value of these signs lies in the fact that
they appear very early in the course of the disease, even
during the active phase of infection . This allows for
early intervention in the form of surgery before the
onset of progression of the deformity.

21. • The five basic principles of surgical
management-
-Debridement
-Decompression of the spinal canal
-Correction of deformity
-Reconstruction of the anterior defect
-Spinal stabilization

22. Surgical Approaches
• Anterior transthoracic, transpleural and/or
retroperitoneal diaphragm cutting approach.
• Posterolateral (extracavitary) decompression
and posterior instrumentation.
• Combined Anterior and Posterior Surgery
• Minimally Invasive Surgery

24. • Type IA = no column
deficiency with mobile,
flexible disc spaces,
• Type IB = no column
deficiency with fused and
immobile disc spaces,

25. • type IIA = anterior
column deficiency
only,
• Type IIB = posterior
column deficiency
only,

26. • Type IIIA = both anterior
and posterior column
deficiency with a Cobb
angle of ≤60°,
• Type IIIB = both anterior
and posterior column
deficiency with a Cobb
angle of >60°, and
• Type IIIC = both anterior
and posterior column
deficiency with buckling
collapse.

27. A treatment algorithm to guide selection of appropriate posterior approach
osteotomies based on the classification presented in the study. PSO = pedicle
subtraction osteotomy, DBO = disc bone osteotomy, and VCR = vertebral
column resection.

28. The 5 surgical osteotomies of progressive complexity, based on the
classification proposed by Schwab et al.17, that are commonly
performed for kyphosis as well as our added procedure—anterior in
situ strut graft fusion—for severe buckling collapse in Type-IIIC
kyphosis.

29. Posterior approach:
• Associated with minimal complications.
• Advantages of the posterior approach include
the ability to achieve circumferential
decompression, stronger three column fixation
with pedicle screws, and avoiding entry into
the thoracic and abdominal cavity.

32. Laminectomy completed and a temporary rod inserted to
stabilise the spine while decompression is carried out

33. Rib and transverse process resected and vertebral body
resection performed unilaterally. The rod is switched
contra-laterally and similar procedure is performed

34. Vertebral resection is performed with a high speed burr and curettes. The
posterior cortex is the last to be excised as it protects the cord against
inadvertent damage

35. Compression of the screws to achieve correction

36. Anterior approach:
• The anterior approach provides direct access to
the disease pathology and is ideal for debriding
and reconstructing the defect.
• Involves debridement of the tuberculous focus
with removal of the diseased vertebrae, posterior
longitudinal ligament (PLL), and adjacent disk
spaces until bleeding healthy bone is reached,
followed by performing an anterior fusion using a
rib graft or a tricortical iliac crest graft.

37. Combined approach:
• A combined anterior and posterior procedure (anterior
debridement, grafting, and posterior instrumentation).
• In active disease, the posterior procedure followed by
an anterior procedure facilitates restoring sagittal
alignment, placing an adequately sized graft or cage,
and producing compressive forces on the anterior graft.
• However, the selection of the first approach depends
on the surgeon’s preference.

38. • Indications for the combined approach –
-multisegment contiguous TB (especially in the
thoracolumbar junction)
-revision surgery
-significant kyphosis.

39. •THANK YOU

47. CT Findings (TB)
• NECT
○ Endplate destruction with vertebral body fragmentation
○ Calcified chronic paravertebral abscesses: TS > BS
• CECT
○ Diffuse or peripherally enhancing epidural and paraspinal soft tissue
MR Findings
• T1WI
○ Hypointense marrow in contiguous vertebrae
○ Hypointense intraosseous, extradural, paraspinal
abscesses

48. ○ Inflammatory marrow change
DIFFERENTIAL DIAGNOSIS (TB)
Pyogenic Osteomyelitis
• Peak incidence in older patients
• Predilection for lower lumbar spine
• Initial infection in subchondral bone adjacent to endplate
○ Intervertebral discs typically affected
• Posterior element involvement less common
• Soft tissue calcifications and spinal deformity infrequent
Fungal Osteomyelitis