TB and fungi spine neurosurgery infection tuberculosis and fungal infection of the spine Dr Adnan Al banna د عدنان البنا

1. TUBERCULOSIS OF SPINE
PRESENTER:
DR. Adnan Mohamed Al Banna
Specialist Neurosurgeon
DEPARTMENT OF Neurosurgery
MODERATER:
DR. Abd Elhafeez
Shehab El deen
PROFESSOR
OF Neurosurgery

2. HISTORY

3. "/aKSHMn"
✓~ ~

5. One fifth of TB
population is in India.
0.08AL.3REN
7Bsrefteris # £AH'YEAR
twleeatesee/S
MORETRAN
28U0wons
ea. QUARTER
ofthewerispop:ltion
areinfectedwith'
,n,,u
iv +
3% suffering
skeletal TB.
from 15MILLON
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si n sin
r m v im i«r 4w
4 mt t!
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i t
ir
..r f r
Vertebral TB M/C form
of skeletal TB (50%).
Almost 50% are from
pediatric group.
2" greatest killer next
to HIV.
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24,000
aw0AES
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Despiteour
textefforts..
.thereisan
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4,00
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t
ownt
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ill
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6. 2017, WHO released a report which revealed as many
4.23 lakh deaths from TB in India
In
as
19.36 lakh TB cases came into picture in India in 2016.

7. A I M - W H O
• Early diagnosis.
• Expeditious medical treatment.
• Aggressive surgical approach.
• Prevent deformity.
• Best outcome.

8. Anatomy of Vertebra
Superiorarticularprocess
Superor
Pedicle
-I.......
Superiorvertebral
notch
Pedicle
Iran$verseprocess
Vertebral
body •_-- • I
I
- - - - I
Anterior . »
Fusedcostal
element
Vertebral
arch
Lamina
Lamina -' Inferior
Vertebralbody Inferiorarticular
process
Inferiorvertebralnotch
Spin0usprocessl
Posterior

9. REGIONAL
(Tuberculosis of the
DISTRIBUTION
S.M.TULI 5"ed)skeletal system by
Cervical (including
occipital)
Cervicodorsal
atlanto 12%
5%
Dorsal
Dorsolumbar
42%
12%
Lumbar 26%
Lumbosacral 3%

10. PATHOLOGY
Secondary infection.•
• Primary site in the lung, viscera or lymph
glands.
• Hematogenous Spread / Batson plexus of
• Delayed hypersensitivity immune reaction.
Inflammatory reaction with Langhan's
giant cells, epithelioid cells, and
lymphocytes.
The granulation tissue proliferates,
producing thrombosis of vessels.

11. . wL
PATHOLOGY
• Granulomatous
inflammation leads to
erosion of vertebrae.
',
II
,I
it, I
~
de»
l[[el]
I
ilt , I
~
,•Associated disc degenaration
due to end arteritis, finally
complete destruction.
lGl
' t a ' .
I ' K '
lIil"
7
1'
,
l
f
' I
•Weakening of trabeculae
compression collapse. -
Deformity.
l [ .
I
I
4'
' I
l e ]
11

13. FORMATION OFABSCESS
·Vertebral collapse
· Expression of colle ous debris
·Formation
·Collect u
Slides along VB and invade the
vertebral canal through
intervertebral foramen.
Diverted forward along
different anatomical sites

14. COLD ABSCESS
•Abscess- collection of liquefied tissue
in the body which is body's defense
reaction to foreign material
•NO signs of inflammation
Lil
'
•Collection of dead tubercular bacilli,
serum, leucocytes, bone debris and
caseous material.
•Can track in to any direction- along
musculo-facial planes or neurovasular
bundle.

15. Spread of Cold Abscess
•
•
•
•
Paraspinal regions at the back
Anterior/ posterior cervical triangles
Brachial plexus in the axilla
Intercostal spaces on the chest wall
•Abscesses from dorsolumbar and lumbar
down the psoas sheath.
spine- track
• Palpable in the iliac fossa, lumbar triangle, upper part
of the thigh below inguinal ligament or even track
downwards upto the knee or sometimes upto the great
toe

16. Psoas Abscess .Iliac abscess contained in the
sheath of the iliac muscle.
PsoasMuscleAbscess
• The abscess that has tracked
down the psoas sheath
penetrates through the
iliacus muscle sheath.
• Becomes palpable as a
in the iliac fossa
mass
•Abscess that remains
confined to the psoas sheath
may not be palpable
clinically.

17. TYPES OF VERTEBRAL
INVOLVEMENT
1. PARADISCAL (arterial spread)
2.CENTRAL ( venous spread)
(sub periosteal tracking of3. ANTERIOR
pus)
4.APPENDICIAL

18. Paradiscal Lesions :1.
• Most common pattern of spinal
tuberculosis.
• Narrowing of the disc space.
• Destruction of subchondral
bone.
• Subsequent herniation of the
disc.

19. Paradiscal

20. 2. Anterior Lesions :
• Subperiosteal lesion under the ALL.
• The periosteal stripping renders the vertebrae
avascular and susceptible to infection.
• Both pressure and ischemia combine to produce
anterior scalloping. (multiple vertebrae)
• Collapse of the VB & diminution of the disc space
minimal
is
• More common in thoracic spine in children.

21. Anterior
Lesi0us

22. 3. Central Lesions :
• Centered on the vertebral body.
• Disc is not involved.
• Infection starts from the center
body.
Batson's venous plexus
Posterior vertebral artery
of the vertebral
• Concentric collapse producing a vertebra plana
appearance.

23. 'ii+
a
I•
Cetral
Lesions

24. 4. Appendicial Lesions :
• Isolated infection involving pedicles
laminae (neural arch), transverse
processes, & spinous process.
,
• Uncommon lesion (< 5%).
• In conjunction with the typical
paradiscal variant in 30%.
• Rarely present as synovitis of facet
joints.

25. App&dcial Leso

26. CLINICAL FEATURES
Constitutional symptoms•
• Pain in the back ( m/c)
• Swelling
• Stiffness
• Neurological symptoms
• Deformity

27. PHYSICAL EXAMINATION
1. Attitude and gait
In
In
In
In
upper cervical disease - wry neck
upper thoracic disease - Military attitude
lumbosacral - Alderman's Gait
lower lumbar - Pronounced lordosis
Normal
soas
Muscle
Shorene
Psoas
Muscle

28. 2. Deformity ofspine:
• Kyphosis
1 vertebrae - Knuckle gibbus
2-3 vertebrae - Angular gibbus
>3 vertebrae - Round kyphosis
• Scoliosis
• Lordosis

29. Abscess / Sinus formation:3.
•
•
Dysphagia and dyspnoea - Retropharyngeal abscess
Hoarseness of voice due to - Abscess in disease of upper thoracic
e Retropharyngeal
•
•
•
Neck
A x l l a
L Paravertebral
•
¢ L u m b a r
Petit's triangle
•Gluteal

30. Movement ofspine :4.
painful due to protective muscular spasm
Paralysis :
Association - 10-30%
Type - Incomplete generally
More common in thoracic region.
5.
•
•
•

31. RADIOLOGICAL DIAGNOSIS:
X-RAYS1.
CT SCAN2.
3. MRI SPINE
4. BONE SCAN
-t l
."
".
i : =
5- "
l
p - ~
e

32. 1. X ray f indings :
• Early changes :-
> haziness and local osteoporosis of end plates of two
u
:.
adjacent vertebrae
> narrowing of intervertebral disc space.
• Late changes :•
paravertebral shadow
-
>
»
ant wedge compression collapse
central or concertina collapse
destruction of post element
- deformity
X ray changes appear after 3-5 months.

33. vertebral shadow- X rayPara
1. Cervical region - Shadow in Retropharyngeal space
Upper thoracic
mediastinum
- V-shaped shadow2.
- Change in contour of tracheal shadow
3. Below 4th thoracic - Fusiform or bird nest shadow
4. Below D1o - Bilateral widening of psoas shadow
- tense thoracic vertebral abscess showing5. Aneurysmal
phenomenon scalloping effect

34. Figures 2 and 3: AP and lateral thoracic spine
demonstrating paraspinal abscess and focal
kyphosis due to vertebral body destruction

35. 2. CT SCAN
c 1
- P a t t e r n s o f b o n y d e s t r u c t i o n .
- C a l c i f i c a t i o n s i n a b s c e s s
( p a t h o g n o m i c f o r T b )
R e g i o n s
v i s u a l i z e
w h i c h
o n p l a i n
a r e d i f f i c u l t t o«
f i l m s , li k e :
1 .
2 .
3 .
4 .
5 .
C r a n i o - v e r t e b r a l j u n c t i o n ( C V J )
C e r v i c o - d o r s a l
S a c r u m
r e g i o n ,
S a c r o - i l i a c j o i n t s .
P o s t e r i o r
b e c a u s e
s p i n a l t u b e r c u l o s i s
l e s i o n s l e s s t h a n 1 . 5 c m
a r e u s u a l l y m i s s e d d u e t o
o v e r l a p p i n g o f s h a d o w s o n x r a y s .

36. 3. MRI
- L a c k o f i o n i z i n g r a d i a t i o n , h i g h
r e s o l u t i o n & 3 D i m a g i n g •c o n t r a s t
• D e t e c t
v e r t e b r a l
m a r r o w
b o d i e s ,
i n f i l t r a t i o n i n
l e a d i n g t o e a r l y
d i a g n o s i s .
- C h a n g e s o f d i s c i t i s
- A s s e s s m e n t o f e x t r a d u r a l
a b s c e s s e s / s u b l i g a m e n t o u s
s p r e a d .
- S k i p l e s i o n s
• S p i n a l c o r d i n v o l v e m e n t .
- S p i n a l a r a c h a n o i d i t i s .

38. 4. BONE SCAN (Technitium (Tc) - 99 m)
• Increased uptake (60% patients) with active tuberculosis
> 5mm lesion size can be detected.•
• Avascular segments and abscesses show a cold spot due to
decreased uptake.
• Highly sensitive but nonspecific.
• Aid to localize the site of active disease
involvement
and to detect multilevel
»,
-, I

39. Angle of Kyphosis
(c)
1967). A
(a) (b)
Fig. 23.2: Method of measurement of angle of kyphosis (Dickson is
the posterior margins ofthboedies ofdrawn along ie healthy vertebrae above and
below the site of disease; angle K'is the angle of kyphosis. Angle K' increases with
increase in the degree of kyphosis. Another method is by determining the angle
between the upper end-plate of the normal vertebra roximn l to the
affectedertvebrae and the lowerend-ptateofThie normal vertebra distal to the
affected vertebrae (c)

40. Clinico-radiological classification
(Kumar et al '88)
0 ' ' · p 0 0 'D '' •
1) Pre-destructive straighteningofcurvatures <2 months
Spasmofperivertebral muscles
MRI:marrowedema
decreaseddiscspace+paradiscalerosionEarlydestructive 24months2)
MRI:marrowedema;breakofosseous
CT:marginal erosion orcavitations
margin
49 months3) Mildangularkyphosis 2-3vertebrae involvement
(K:10-30degree)
4) Moderate angular kyphosis > 3vertebral involvement 624month
(K:30-60degree)
5) Severekyphosis >3vertebrae involvement

41. INVESTIGATIONS
LABORATORY TESTS
Mantoux / Tuberculin skin test•
• ESR may be markedly elevated (neither specific nor reliable).
• ELISA : for antibody to mycobacterial antigen-6 ,
sensitivity 94% and specificity of 100%
• PCR:sensitivity 40% only.

42. IFN- Release assays (IGRAs)
measure
antigens
T cell release of IFN- gamma in response to tuberculosis
ESAT- 6, CFP-10 and TB7.7.

43. MICROBIOLOGY STUDIES:
Biopsy : For definitive diagnosis
• CT or ultrasound guided or open biopsy during a surgical
procedure.
Ziehl-Neelsen staining: a quick and inexpensive method1.
Culture: - results are available only after a few weeks1.
- positive only in 60% of cases; most specific.
Histology: demonstration of tubercle, 80% cases.3.

44. DIFFERENTIAL
SPINAL INFECTIONS
DIAGNOSIS
1.
- pyogen
.c1
- brucellosis
- fungi / syphilis
NEOPLASTIC
- Extradural - Lymphoma / Metastasis etc.
- Intradural extramedullary - Meningioma /
neurofibroma
2.
3. DEGENERATIVE / OSTEOPOROTIC
4. TRAUMA
5. CONGENITAL DEFECTS
6. SPINAL OSTEOCHONDROSIS

45. NEUROLOGICAL COMPLICATION
• Most dreaded and crippling complication.
• Incidence 10-30%.
• MC age group - first three decades of life.
• MC region - thoracic.

46. PATHOLOGY OF TB PARAPLEGIA
Inflammatory oedema :
- vascular stasis and liberation of toxins.
- Extradural mass: commonest mechanism
• Bony disorder : sequestrum, gibbus, subluxation
> Intrinsic changes of cord
-
-
-
peridural fibrosis
infarction
myelomalacia , gliosis , atrophy

47. SEDDONS CLASSIFICATION OF
PARAPLEGIA
Paraplegia of early onset Paraplegia of late onset
(i) Associated with active
disease
Due to compression by
inflammatory oedema,
granulation tissue,
abscess, casseous
tissue
(i) Associated with healed
disease
(ii) (ii) Due to compression
debris, sequestrum,
stenosis and severe
deformity
by
canal
(iii) Appears many years (after
2 years of onset of disease
(iv) Prognosis - poor
(iii) Occurs within first
years of onset
(iv) Prognosis - better
2

48. TULI & KUMAR'S GRADING OF
PARAPLEGIA
Negligible Unaware of neural deficit,
physician detects plantar
extensor or ankle clonus
Aware of deficit but manages to walk
with support/ UMN features
I
Mild11
Moderate Nonambutatory
paralysis in extension
sensory deficit < 50%
III + flexor spasm/paralysis in
flexion/flaccid , sensory deficit
> 50% /sphincter involved
111
SevereIV

49. SEQUENCES OF
motor paresis ( clonus is
PARALYSIS
first most prominent early• Spastic
sign)
Spastic
Spastic
•
•
•
•
paraplegia in extension
paraplegia in flexion
Bladder and bowel involvement (very advanced stage)
Flaccid paralysis with anaesthesia with loss of sphincter (last
stage)
[N :B: Sense of position and vibration is last to disappear]

50. SEQUENCE OF RECOVERY
and jt.Vibration sense
t
sphincter'function
• " 'asting

51. TREATMENT
Objective:
1) To eradicate or at least arrest the disease.
2) To treat major
paraplegia.
3) To prevent or correct deformity.
complications like

52. TULI'S MIDDLE PATH REGIME FOR
TREATMENT OF KOCH'S SPINE
Bed rest - with or without traction1)
2) Drugs - ATT any one regime as preferred
3)Radiograph & ESR radiologically the kyphosis and
disease activity by ESR is measured 3 monthly.
4)Gradual mobilization with exercise
5)Abscess:
*
*
*
Repeated aspiration.
Streptomycin and/or INH instillation.
Sur ical evacuation ifs m tomatic.

53. Sinuses :
Usually heal by 6-12 weeks of ATT.
* Excision of the tract with or without debridement.
6)
7) Neurological complication :
5 indications for surgery (mainly decompression surgery)
Not showing progressive recovery after 3-6 weeks of Rx.Pt.
developing neurological complication during Rx.
Neurological status becoming worse while undergoing Rx.
Recurrence of neurological complication.
(I)
(ii)
(iii)
(iv)
(v)In advanced cases with motor, sensory or sphincter
involvement or having severe flexor spasm
8) Operative debridem ent
- in nonresponsive 3-6m of chemotherapy.
- cases with recurrence of disease.

54. 9). Excisional surgery:
- posterior spinal disease associated with
abscess sinus formation +/- neural
involvement.
/
10). Posterior Spinal Arthrodesis:
- severe ky photic deformity
correction).
- mechanical instability.
- spine at risk signs.
(prevention /
11). Post - operative:
- hard bed for 2-3 weeks/
2 years.
neurological recovery.
- brace for

55. DRUGSINMIDDLEPATHREGIME
Drugs
"
5- 6months +Intensive
(forreplicatingmycobacteria)
Continuation
(forpersisters,slowgrowing
ordormantorintracellular
mycobacteria)
Rifampicin&
ofloxacillin
Pyrazinamide x3-4
monthsf/b
INH
7- 8months INH +
Rifampicinx4-5
months
+ Ethambutol4-5 monthsProphylactic INH

56. PROGNOSTIC FACTORS
RELATIVELYPOORPROGNOSIS
Complete(stageIV)
CORD
Degree
INVOLVEMENT BETTER
Partial
Shorter
Slow
Younger
Good
Active
PROGNOSIS
Duration
Speedofonset
Age
Generalcondition
Vertebraldisease
Kyphoticdeformity
CordonMRI
Peroperative
Longer
Rapid
UIer
(>12months)
Poor
Healed
<60° >60°
Myelomalacia/Syrinx
Drylesion
Normal
Wetlesion

57. SURGICAL
HISTORY:
TREATMENT
• Abscess drainage- Pott (1779)
• Laminectomy & laminotomy : Chipault (1896)
• Costo-transversectomy: Menard (1896)
• Calves operation (1917)
• Lateral rhachiotomy of Capener (1933)
• Anterolateral decompression of Dott &Alexander(1947)

58. INDICATIONS- SURGICAL TREATMENT
•
•
Doubtful diagnosis.
Failure to respond to conservative
therapy.
Symptomatic abscess.
Neurological indications.
Rx after 3-6 weeks
•
•
•
•
•
•
•
Mechanical
Deformity.
instability.
Recurrence of disease.
Posterior spinal disease.
Spinal tumor syndrome.

59. TYPES
SURGERY
OF SURGERY
INDICATIONS
Decompression (+/- fusion) Tooadvanced ds,failure
conservativetherapy
torespond to
Debridement +/- decompression
fusion
+/-2 Recurrenceof disease
complication
or of neural
Anterior transpositionofcord
(Extrapleural anterolateralapproach)
Severekyphosis(>60) + neuraldeficits3
4 Laminectomy Extraduralgranuloma/tuberculoma(STS), Old
healeddiseasepresenting assecondarycanal
stenosis/posteriorspinaldisease

60. SURGICAL APPROACHES
c1-c2 CERVICAL DORSAL DORSO•
LUMBAR
LUMBARWORKERS c7-D1 L5-S1' ' .
.Kirkaldy-Willis
(1965)
Transperitone al,
paramedian
incision in
Trendelenburg
position
Anterior Transpleural
through bed of
3%rib
Anterolateral or
transpleur al
Anterolateral Retroperitone al
sympathectomy
or ureter
approach
....
:
.
. Transpleural via
bed of 3' rib
/split sternal for
extensive lesion
Transoral/
transthyroi
d
Through
anterior or
posterior
Anterior
transpleur al
decompression
Bed of 11" rib
extrapleural
extraperitone
al /left
transpleural
via bed of 9"?
rib
Bed of 12 rib
Renal approach Transperitone al in
Trendelenburg
position. Lower
midline incision
Trans-sternal for
D3-D4.Anterior
transpleur al for
D5-012
Anterior Anterior cervical Retroperitone al
approach
Retro peritoneal
through oblique
renal incision
Anterior Anterior
Retrophary
ngeal extra
mucosal
Transoral
for
drainage
Anterior Low anterior
cervical
Anterolateral or
transpleur al
Anterolateral Retroperitone al
approach
Retroperitoneal or
Retropsoas
transverse
vertebrotomy
·:4:

61. ABSCESS DRAINAGE
1. Atlanto occipital and atlanto axial region -
Fang and Ong(1962) Trans oral approach

62. Trans Thyrohyoid approach
~
--~-=-~~-' - ~2
A s 4y )
1 ~ - 5
~ 7
'
_
A B
·
1
1•
3i . _
5

63. Retropharyngeal approach (C2-D1)
bular
Sterno
al
coA
Divided
digastnic
m u s c l e
Hypoglos s al
nerve
s a l
I nerve
Incisionin
longuscolli
muscle
E
C
--- - .,;r- - -· - - -
superior
t hyroi d vei ns

64. E s o p h a g u s - - •
B

65. Seddons Technique •
similar to Menard technique but here more extensive
approach is used and resection of rib is generally more
than 3.
hi e d s c a p e h t t p : / v m e d s c a p e c o m

66. Drainage ofparavertebral abscess
•Through lumbodorsal fascia
between Erector spinae and
quadratus lumborum muscle.
7 cm longitudinal
1n€1sIn
paraspinal•
Abscess7'

67. 3. Drainage ofpsoas abscess
•Through Petit's triangle
Latercutaneous branch
from doral amu ofT7
Rectus abdomins mule -+Vr
Lateral cutaneous branch ) , + h
otsubcostalnerve
(ventralms of 12
Ltet uMeous btnh J 4 4 S h ]
of iionypoga tn rerve(LI
LateralcutaneousDMnesi f # j
fromdorsalramioft1,23)
•Through lateral incision -along the middle third of the
crest of the ilium

68. Ludloffapproach:
•5-8 cm long skin incision in ant aspect of thigh 2-3 cm
distal to pubic tubercle.
plane of dissection - along medial border of sartorius
muscle.
protect femoral nerve.
•
•

69. Tuli's recommended approach
• Cervical spine --T1
Anterior approach
• Dorsal spine -DL junction
Anterolateral approach
• Lumbar spine &Lumbosacral junction
Extraperitoneal Transverse Vertebrotomy

70. ANTERIOR APPROACH TO THE CERVICAL
SPINE
Smith & Robinson
(C2 to D)
•
•
•
Oblique / transverse incision.
Plane b/w SCM & carotid sheath laterally &T-0 , thyroid medially.
Longitudinal incision in ALL open a perivertebral abscess, or the
diseased vertebrae may be exposed
longus colli muscles.
by reflecting the ALL & the
- - - O m o h y o i d
w t S t e r n o h y o i d
S t e r n o c l e i d o ma s t o i d
Thyroid
c a r t i l a g e u
c "
roid and
Hodgson approach via posterior
SCM, Carotid sheath, T & 0 anteriorly
triangle by retracting
& to the opposite side.

71. SURGICALAPPROACHES TO
SPINE
DORSAL
• Anterior transpleural transthoracic
(Hodgson & Stock, 1956)
approach
• Anterolateral extrapleural
Seddon & Roaf, 1956)
approach ( Griffiths,
• Posterolateral approach (Martin,1970)

72. TRANSTHORACIC TRANSPLEURAL
• Left sided incision preferable.
• Along the rib which in the mid-axillary line, lies
opposite the center of the lesion.
•A J-shaped parascapular incision
scapula lifted up.
for D8 lesions,C7 -
After cutting the
sub periosteally.
muscles & periosteum, rib is resected

73. Parietal pleural incision applied & lung
parieties & retracted anteriorly.
freed from the•
A plane developed b/w the descending aorta & the
paravertebral abscess / diseased vertebral bodies.
•
• Intercostal vessels and hemiazygous vein ligated & cut.
• T-shaped incision over the paravertebral abscess.
• Debridement / decompression with or without bone
grafting.

74. ANTEROLATERAL DECOMPRESSION
•
•
Griffith et
Tuli
al -- Prone
Right
position
lateral position
· Lateral position
advantages:-
1. avoid venous congestion.
2. avoid excessive bleeding.
3. permits free respiration.
4. lung & mediastinal contents;
fall anteriorly.
Trapeziu
smusle
Abscessdebrs
B
Intercostalnerves
C

75. • Semicircular incision.
• Medial flap raised. Paraspinal muscles divided.
• Subperiosteal exposure of medial end of ribs and
transverse process.
Cut the ribs 8 cm laterally and remove the medial
end with transverse process.
•
• Retract anteriorly the periosteum, intercostal
muscle and vessels, the parietal pleura with lungs.
• Intercostal nerves serve as guide to the intervertebral
foramina & the pedicles.

76. • Curved blunt dissector inserted through intervertebral
foramina.
• All diseased bodies and disc removed from anterior and
lateral aspect thus decompressing the cord.
Grafting ( strut grafts) can be given +/- Post fusion.•

77. ANTERO-LATERAL APPROACH
LUMBAR SPINE
( LUMBOVERTEBROTOMY)
Left side approach
TO
•
• Semicircular incision mpr
Abdominalaorta
Interiorvenacava
Psoas major
oflumbarvertebra
process
• Expose and remove
transverse process
subperiosteally.
• Retract the psoas muscle anteriorly and laterally.
• Preserve lumbar nerves.

78. EXTRA PERITONEAL ANTERIOR
APPROACH TO LUMBAR
45 °right lateral position.
SPINE
•
EE:• Similar incision nephroureterectomy or
sympathectomy. 11~) •·
• Abdominal muscles are split in layers in
line of skin incision.
s
I
• Strip peritoneum off posterior abdominal
wall and kidney, preserving ureter.
« ,
t 4 t
• %• Longitudinal incision along psoas fibers for
abscess drainage ( preserve lumbar vessels
running transversely).

79. • If no abscess - psoas muscle released from its origin and
retracted laterally along with the sympathetic chain.
• Aorta , IVC along with the peritoneum and its contents
retracted to the right and anteriorly.
are
• Expose the vertebral bodies and excise the disease
orta
IV. cava

80. EXTRA PERITONEAL APPROACH TO
LUMBO-SACRAL
Left side preferred.
REGION
•
• Lazy "S incision.
• Strip & reflect the parietal
peritoneum along with ureter
& spermatic vessels towards
right side exposing the psoas
abdominal aorta and the
common iliac vessels.
,
• Retract psoas laterally and
vessels medially with
peritoneum.

81. TRANSPERITONEAL HYPOGASTRIC/
SUPRAPUBIC ANTERIOR APPROACH
LUMBO-SACRAL REGION
Supine position.
Midline incision from umbilicus to pubis.
Lumbo-sacral region identified distal to aortic bifurcation and left
common iliac vein.
Longitudinal incision on parietal peritoneum over lumbo-sacral
region in midline.
TO
•
•
•
•
• Avoid injury to sacral nerve &artery and sympathetic ganglion.
a u Common
and vein
iliac artery
Middle
sacral
artery
A B

82. POSTERIOR SPINAL ARTHRODESIS
· Albee - Tibial graft inserted longitudinally in to the split spinous
processes across the diseased
Overlapping numerous small
site.
osseous flaps from
& articular facets.
· Hibbs-
contiguous laminae, spinous processes
Indications :
1. Mechanical instability of spine in otherwise healed disease.
2. To stabilize the craniovertebral region (in certain cases of
T.B.)
3. As a part of panvertebral operation
.- - -Pedicle screws are adde d
to give strength to fusing
ve rte brae
P e d i c l e s c r e w - l

83. SURGERYINSEVEREKYPHOSIS
HIGH RISK PATIENTS:
• Patients < 10 years
• Dorsal lesions
• Involvement of > 3 vertebrae
• Severe deformity in presence of active disease (>60).

84. TREATMENT OF PARAPLEGIA IN
SEVERE KYPHOSIS
· Griffiths et al (1956):
- anterior transposition of cord through
laminectomy.
·
-
Rajasekaran (2002) :
posterior stabilization f/b anterior debridement
and bone grafting ( titanium cages) in active stage
of disease.
Anterior debridement f/b posterior-
instrumentation and anterior fusion for healed
disease.

85. SURGICAL CORRECTION OF SEVERE
KYPHOTIC DEFORMITY
1. To perform an osteotomy on the concave side of the curve
and wedge it open ( secured with autogenous iliac grafts)
2 . To remove a wedge on the convex side and close this wedge,
(compression rods and hooks)

86. POST OP CARE
•Nursed on a hard bed/ POP
upto 3 months.
posterior shell (children)
• Careful and assisted
from the first day.
turning of the patient is permitted
·At the end of 3-6 months / neurological recovery pt.
mobilized with the help of spinal brace.
• Spinal brace is discarded after ½ years.1- 1

87. SPINAL BRACES
• CERVICAL SPINE :
Four post cervical
brace
·Minerva Jacket
SOMI Brace

93. Fungal Spondylodiscitis

94. Fungal infections have become more common as the number of patients
with immuno- deficiency disorders has grown, given that this type of
patients need antibiotic treatment to fight opportunistic bacterial
infections, and this favors the growth of fungal flora . Fungal infections
have been reported in patients with acquired immuno-deficiency
syndrome (AIDS), use of medication that lowers native immunological
defenses and patients in critical care. For the most part, the main agent
isolated has been Candida, on second place Aspergillus, and also
Cryptococcus or Coccidioides .
Hematogenous spread is the most common path of infection. There are
two theories supporting this: the venous theory and the arteriolar theory.
Wiley and Trueta mention that the bacteria can conglomerate in the
arteriolar network near the end plates. Batson developed the venous
theory, stating that retrograde flux of the pelvic venous plexus to the
paravertebral plexus via veins from the meningoarachnoid complex can be
given.
A fungal infection must be considered when the biopsies and cultures
are negative and symptoms persist even after antibiotic therapy has been
initiated.

95. Etiology
Fungal infections of the spine are uncommon. The frequently
occur in immuno-suppressed hosts with mean age is 50 years
old.
The incidence of fungal infections has risen markedly in recent
years. Several factors have contributed to this increase; immuno-
suppressive drugs, prolonged use of broad-spectrum antibiotics,
widespread use of indwelling catheters, and AIDS .
Comorbids like diabetes, embolism or previous surgery are also
relevant. After reaching bloodstream it reaches the vertebral
body by the subcondral vascular heaves of the joint platforms,
where it adheres given that the blood flow is slower.
Fungal infections of the spine are mainly caused by Candidiasis
and Aspergillosis for Candida organism to become
pathogenic, the host must be immunocompromised.

96. Candida species are part of the normal flora and are commonly found on the skin and
gastrointestinal tract .
Candida may gain access to the vascular system of susceptible patients via IV lines or
monitoring devices and the implantation of prosthetic materials.
Candida spondylodiscitis should be considered in any patient with spinal
symptoms and a history of candidemia, the infection shows symptoms usually
weeks or months after the first candidemia episode. Candida albicans It is the most
common species found, however the infection by C. glabrata, is becoming more
common, this may be secondary to the general trend of increasing Candida infections
and widespread use of azole antifungals .
Aspergillus spondylodiscitis is due to Aspergillus fumigatus in 80% of cases followed
by Aspergillus flavus, the organisms is pathogenic only in immnuno-compromised
host Aspergillus species are ubiquitous saprophytic fungi that produce numerous
small spores. The small size of the spores allows for ready dispersion onto air
currents from contaminated air-handling systems and deposition into human lung
alveoli . Patients with AIDS and chronic granulomatous disease, those on long-term
antibiotics and IV drug abusers are especially at risk of developing the
disseminated form . Osseous involvement may occur by direct extension from the
lung or by Hematogenous spread. The vertebral bodies are the most commonly
infected sites by Aspergillus.
Other fungi are endemic and are limited to specific geographic areas; the two most
common endemic fungi that give rise to spinal infections are Coccidioides immitis and
Blastomyces dermatitidis .

97. Coccidioidomycosis is a fungal disease caused by Coccidioides immitis and C.
posadii. The disease is localized to geographic regions with arid soil due to high
temperatures and low humidity. C. immintis in endemic in parts of the
south-western United States, Central America, and parts of South America .
Disease prevalence is increasing with the rise in tourism to those countries. The
hicolum needed for infection can be quite small, even a few arthroconidia
Spine lesion are frequently multiple and generally lytic, disease often develops
through Hematogenous or lymphatic spread and can involve one or multiple
sites.
The other endemic fungal infection is Blastomyces dermatitidis is a
dimporphic fungus endemic in areas bordering the Mississippi and Ohio
rivers. Primary infection in humans occurs by inhalation of conidia, the long
bones, vertebrae, and ribs are the most common sites of osseous involvement .
Cryptococcus, Candida, and Aspergillus are found worldwide.
Cryptococcus neoformans is found in the soil and in pigeon feces. The disease is
the fourth most common infection in HIV-infected patients .
Cryptococcosis may be localized to the lung or generalized. Central
nervous system involvement is common in the disseminated form .
Osseous involvement occurs in approximately 5% to 10% of patients .

98. In immuno-suppressed patients rare fungal infections may
occur, Blastoschizomyces capitatus has been found in
spondylodiscitis which is a normal human flora of the skin an
GI track, it mimics candidiasis but with a fatal course.
Scedosporium prolificans with only 2 cases reported can cause
disseminated disease on immuno- suppressed persons, resistant
to antifungal therapy requiring extensive debridement for cure.
Trichosporon fungemia is a rare and fatal fungal infection that
occurs in patients with prolonged neutropenia associated with
hematologic malignancies. Individuals susceptible to this
pathogen should be in constant evaluation because
spondylodiscitis can manifest years after the infection has cure.
Diagnosis can be difficult because no clinical or laboratory
values suggest infectious process it can confuse with oncologic
pathology, and make a therapeutic delay, so an open biopsy or
closed needle aspiration should be considered.

99. Clinical Presentation
A typical patient with fungal spondylodiscitis debuts as lower back pain or
dorsal pain, with at least a month since initial onset. Insidious, progressive,
intermittent pain that usually progresses to constant pain is a very common
clinical manifestation of this disease .
Only a third of the patients present fever and approximately 20% present
neurological symptoms and the most common presenting complaint is diffuse back
pain.
Patient risk factors are usually related to an impaired immune system but may also be
due to environmental factors. Patients with a history of immune disorders,
malignancies, corticosteroid use, receiving parenteral nutrition, diabetes, solid organ
transplantation, IV drug use, and patients with prolonged IV access sites or previous
surgery are at especially high risk .
A physical examination of a patient with a suspected fungal infection of the spine is
mandatory. A baseline neurological examination documenting any sensory or motor
deficits can be used to determine progression or resolution of the disease process.
Assessment of spinal balance, especially in the sagittal plane gives an idea of advanced
infections, causing spinal deformity. Signs of recent significant weight loss and
cutaneous sequelae of disease may also be suggestive of fungal infection. A detailed
pulmonary exam is especially important with suspected Aspergillus infections but also
with Coccidioides and Cryptococcus .

100. Fungus most
frequent
Location/ feature Mode of transmission Affected segment of the
spine
Candidiasis Albicans
Are normal commensals
of humans and are
throughout the
Gastrointestinal tract
Sputum, disease skin.
For Candida organisms
to become pathogenic,
the host must be
immune-compromised.
Lower thoracic or lumbar
spine (95%)
Aspergillosis Fumigatus The organisms is
pathogenic only in
immune-compromised
host
By inhalation of small
spores
(conidia)
Lumbar spine
Coccidioidomyc
osis
Immitis Endemic, disease
prevalence is increasing
with the rise in tourism
By inhalation of the
spores or through
abrasion of the skin
Infection may involve
multiple levels, the
surrounding soft tissues, and
the disc space.
Blastomycosis Dermatitidis
Endemic, the organism
exists in warm, moist
soil rich in organic
debris.
Inhalation of conidia Thoracic and lumbar
region
Cryptococcosis Neoformans
Most commonly in
pigeon feces and soil. Is
the fourth most
life-threatening infection
in patients with AIDS
By inhalation after the
organisms is
aerosolized
Thoracic mainly
Trichosporon capitatum
Occurs in patients with
prolonged neutropenia
associated with
hematologic
malignancies
------- Thoracic and lumbar

101. Diagnosis
Diagnosis of fungal spinal infections is often delayed and late initiation of
antifungal therapy may be associated with a worse outcome, particularly in
terms of neurological recovery. A rise in inflammatory such as with cell count,
erythrocyte sedimentation rates, and C-reactive protein levels can alert the
possibility of a spinal infection [48,49]. However, these are not specific for
fungal infections. Antibody and antigen tests are seldom helpful in the diagnosis
of spinal infections for Candida and Aspergillus.
Blood culture is very accessible but has low sensitivity (50-70%), this can be
improved with centrifugation, and nevertheless only 51% of the patients
mentioned in the reviews have blood culture results [6].Biopsy of the lesion
must be done for diagnostic confirmation. (1→3)-β-D:-glucan (BDG) levels
are useful with sensitivity and specificity reported up to 90% in patients with
invasive candidiasis .
This test is positive in other fungal infections as aspergillosis and fusariosis,
even though, high false positives rates have been reported. The detection of
fungal nucleic acid via polymerase chain reaction (PCR) holds promise as a
diagnostic tool. So fart technology has demonstrated high sensitivity and
specificity for detecting isolates of Candida and Aspergillus

102. Diagnosing fungal spondylodiscitis is currently based in risk factors,
microbiology, blood tests, antigen detection/antibody testing and imaging.
The gold standard to establish a fungal infection diagnosis is to obtain a
tissue sample for histological o culture confirmation [51,52]. The sample can
be obtained by computed tomography guided needle aspiration (CT
FNAC), the procedure can be repeated in case negative cultures are
reported. If negative cultures persist, biopsy should be considered .
Endoscopic biopsy can be performed, accompanied by a discectomy at
the same time and drainage. It has been demonstrated that the best
sample is obtained when computed tomography (CT)- guided fine needle
aspiration cytology (FNAC), which is why this is the preferred choice
nowadays. The culture obtained by biopsy permits differentiation of the
microorganism causing the infection in more than half of the patients
[8,28,50-53].
If the first sample results as a negative culture, a second sampling is
indicated and current recommendations are to obtain a minimum of 6
samples of different parts of the lesion .Open biopsy will eventually be
discouraged. The samples must be sent for stains in search of
mycobacteria, fungi and histological analysis to dismiss malignancy

104. Histology
Biopsy and histopathology assessments are critical in the
diagnosis of fungal infections. Accurate diagnosis is dependent
on the skill of the pathologist and adequacy of organisms
received in aspirates or tissue biopsies. It is important that
microscopic appearances are correlated with microbiology
findings, as well as other tests for specific host antibodies,
fungal antigens, and fungal antibodies

105. Image Studies
The imaging of fungal infection is fairly nonspecific and mimics either tuberculous or
pyogenic infection. Plain x-rays can be useful, nevertheless, visible changes can only be
viewed after a few months after infection has taken place, and does not help differ infection
from bony destruction. Certain patterns do occur more commonly with certain fungal
infections, paravertebral soft-tissue swelling with involvement of the posterior structures
is more common in late Coccidioides infections.With Blastomyces, collapse and gibbous
deformity tend to be seen more commonly .In Cryptococcus, lytic lesions within vertebral
bodies can resemble those in coccidioidomycosis or the cystic form of tuberculosis with
discrete margins and surrounding abscess formation. In fungal infections of the spine, CT
and MRI are effective in determining the extent of disease spread. In contrast to pyogenic
infections, fungal infections often spare the disc. When the causative agent is Candida or
Aspergillus, the infection is focused on the intervertebral body space, decreasing its height,
causing destruction of the end plates and adjacent bone and the presence of paraspinal
abscesses. A hypo-intense image is seen in T2 as in short-tau inversion- recovery (STIR)
(more sensitive than T2) in the bony marrow, suggesting the presence of underlying fibrosis
due to the indolent infectious process, very different from pyogenic infections that are
significantly more aggressive .
There are no radiological findings that can help differentiate fungal infections (Candida and
Aspergillus mainly) from other discitis. The positron emitting tomography with fluorine 18
fluorodeoxyglucose (FDG PET) shows promising results when Magnetic resonance imaging
(MRI) has no clear signs

106. Disc space T2 hyperintensity, enhancement,
height loss
Vertebral body (VB)
Endplate destruction, T1 hypo,
T2 hyperintensity, enhancement.
Osteolysis/bone
destruction/bone erosion
Paraspinal/epidural space
involvement
Small paraspinal abscesses, ill-
defined inflammation
Anterior sub-ligamentous spread Common
Adjacent vertebral levels
involvement
Uncommon
Multilevel involvement Common (Coccidioidomycosis)
Deformity (Gibbous) Mainly in Blastomycosis

107. Treatment
Antifungal treatment is the first choice of treatment in
fungal is chosen with this drug, the recommendation is to
have 4-6 weeks of i.v. fluconazole at 400 mg per day,
followed by 2-6 months of oral treatment. Nevertheless,
Gottlieb et al mentions that itraconazole is the first choice
and can be used in replacement of Amphotericin B, and
the treatment period is shorter if surgical debridement is
made.
Currently resistance rates have increased, the
widespread use of drug, even when it has not been
indicated.
Once the medical treatment has been finished, the long
term prognosis for functional recovery and pain relief
continues to be uncertain. Some of the patients have
residual chronic pain that can be incapacitating

108. Isavuconazole a new option for treatment of fungal infections
has a broad spectrum of activity, providing an advantage over
other currently available broad-spectrum azole antifungals and
a clinically useful alternative to voriconazole for the treatment
of invasive Aspergillosis. Isavuconazole has activity against a
number of clinically important yeasts and molds, including
Candida spp, Aspergillus spp, Cryptococcus neoformans, and
Trichosporon spp . It has been proven that combined treatment
(surgical and medical) relieves pain quicker, allows histological
diagnosis and stabilizes the spine .
Medical treatment failure, the onset of neurological
deficit or progression of symptoms, particularly when imaging
studies demonstrate the nervous compression, are clear
indications for surgical treatment, having to realize
debridement, decompression and stabilization.

109. Also, significant deformity can be considered a surgical
indication. Surgical treatment is accepted when abscesses
are damaging neurological structures. Early
decompression maximizes functional recovery but after
48 hrs the prognosis is uncertain .
The goal of surgical treatment is to debride, sample,
drain, decompress and stabilize the spine, which can be
done in the same surgery or in a second look.
Therefore, laminectomy without stabilization is
contraindicated, because progression to kyphosis is a
certainty and could cause further damage to the
neurological structures.
Until very recently, minimally invasive techniques had a
primary indication in mild cases with little bony
destruction. Currently, this technique can be used in more
severe cases. Currently, open surgery is the gold standard

110. Surgical approach depends on the dominant side of the
infection. Anterior approach is the standard procedure for
debridement of the vertebral body and stabilization.
Although, given the instability in these cases, posterior initial
approach is recommended for mechanical stability followed by
anterior approach .
Autologous iliac crest graft or fibular bone graft are the
ideal structural grafts, given that the rib graft has been proven
insufficient unless is vascularized .
Tricortical graft is needed for two reasons: as a biological
matrix and as structural support. This prevents the kyphosis
postoperatively

112. Home Message :
Fungal Spinal infections remain a rare
pathology, although an increased incidence
has been reported due to a progressively more
susceptible population (particularly in patients
with immuno- compromised) and improved
diagnostic acuity.
In an inmuno-deficient patient with lumbar
pain, progressive onset that has atypical
changes in the spine imaging, negative cultures
and has persistent symptoms despite of
antibiotic treatment, fungal infection should be
considered.

113. Treatment of fungal spondylitis is often delayed
because of difficulty with the diagnosis. Delay in the
diagnosis led to poorer results in terms of neurologic
recovery. Patients should be given a guarded prognosis
and informed of the many possible complications of the
disease.
The initial treatment should be medical, with
antifungal drugs. The duration of treatment is
important. Surgical treatment should be considered in
patients with neurologic involvement, collapsed
vertebrae, and persistent infection in spite of medical
treatment. Questions remain whether instrumentation
is necessary and safe in the surgical treatment of fungal
infections of the spine.