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Potts spine new

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Potts spine new

  1. 1. TUBERCULOSIS OF SPINE DR.B.PRAVEEN KUMAR PG FINAL YR M.S (ortho) GANDHI HOSPITAL TELANGANA 17/06/2015 1
  2. 2. Outline 7/24/2015 1. Introduction 2. Clinical features 3. Pathology , pathogenesis & pathophysiology 4. Diagnosis 5. Management 2
  3. 3. Introduction  One fifth of TB population … in India.  Spinal tubercular account for 30-60% of the Musculoskeletal TB infections  Always secondary  Most common : 1st three decades  SEX : M=F  Most affected : Thoraco-lumbar region 3
  4. 4. REGIONAL DISTRIBUTION  CERVICAL 12%  CERVICODORSAL 5%  DORSAL 42%(THORACIC)  LUMBAR 26%  DORSOLUMBAR 12%  LUMBOSACRAL 3% 7/24/2015 4
  5. 5. Clinical features of spinal TB  Clinical kyphosis 95%  Palpable cold abscess 20%  Radiological paraverebral abscess 21%  Neurological involvement 20%  Tubercular sinuses (active/healed) 13%  Associated extra spinal skeletal foci 12%  Associated visceral foci 12%7/24/2015 5
  6. 6. A.Active stage 1.Pain: Back pain (Commonest), Diffuse in early stages, but later become localised to the affected diseased segments. It may be a radicular pain. Depending upon the nerve root affected, it may present as: 1.Cervical root- Arm pain 2.Dorsal root- Girdle( pectoral ) pain 3.Dorso-lumbar root- Abdomen pain 4.Lumbar root- Groin pain , or 5.Lumbo-Sacral root- Sciatic pain CLINICAL FEATURES 6
  7. 7. 2.Spine Stiffness: spasm of para-vertebral muscle 3.Night cries 4.Deformity: Knuckle /Gibbus/Kyphus. 5.Cold abscess: May be present 6.Paraplegia (if neglected in early stages) 7/24/20157
  8. 8. 7.Constitutional Symptoms (Only in 20% cases): Malaise, weight loss, loss of appetite, night sweats, evening rise of temperature. B. Healed stage No systemic features but deformity persists. Radiological evidence of bone healing But several of these signs and symptoms may be absent. Important: c/f presentation depends on 1.Stage 2 Site 3.Presence of complications :neurologic deficits, abscesses, or sinus tracts 7/24/20158
  9. 9. DEFORMITIES : KYPHOSIS Knuckle 1 or 2 vertebra Gibbus 2 or 3 vertebra Angular kyphosis More than 3 vertebra
  10. 10. PATHOLOGY Hameatogenous spread
  11. 11. Infectious exudate may spread anteriorly beneath Anterior longitudinal ligament &neighbouring vertebrae Advances&destroys the cortex,intervertebral disc&adjacent vertebrae Infection begins in cancellous area of vertebral body(Central/anterior/epiphyseal in location) Route of infection :1.hematogenous (Batesons plexus)2.Lymph node spread 3.Direct spread Focus of infection : possible from any sites M/C pulmonary ,abdomen 7/24/2015 11
  12. 12. Granuloma formation Tissue necrosis & inflammatory response Paraspinal Abscess LocalizedTrack along tissue planes Progressive necrosis of vertebral body-Kyphotic deformityAdjacent vertebral bodies under the longitudinal ligaments Along the fascial planes Ex: Psoas abscess PARAVERTEBRAL ABSCESS
  13. 13. PARAVERTEBRAL ABSCESS Cervical region • Between vertebral bodies, pharynx and trachea Upper thoracic • ‘V’ shaped shadow, stripping lung apices laterally and downwards Below T4 – Fusiform shape (Bird’s nest) • Below Diaphragm – unilateral & blilateral psoas shadow.
  14. 14. COLD ABSCESS :CERVICAL SPINE  ANTERIORLY : 1.Retropharyngeal abscess, 2.paravertebral abscess  ON SIDE : 1.post.Border of SCM 2. POST of neck  ALONG MUSCULOFASCIAL PLANE : 1.Axilla 2.Arm 7/24/2015 14
  15. 15. COLD ABSCESS :THORACIC SPINE  ANTERIORLY 1.mediastinal abscess 2. paravertebral abscess  ON SIDE : 1.psoas abscess 2. lumbar abscess  ALONG MUSCULO-FASCIAL PLANE: 1.Ant. Chest wall 2.Mid-axillary line 3.posterior chest wall 7/24/2015 15
  16. 16. COLD ABSCESS :LUMBAR SPINE  ANTERIORLY :prevertebral abscess : paravertebaral abscess  ON THE SIDE : lumbar abscess : psoas abscess  ALONG MUSCULOFASCIAL PLANE : groin ,leg along sciatic nerve to pelvis, gluteal region, posterior aspect of thigh and popliteal Region(KNEE) 7/24/2015 16
  17. 17. Pathophysiology  Potts disease is usually secondary  The basic lesion is a combination of osteomyelitis and arthritis.  The area usually affected is the anterior aspect of the vertebral body  Tuberculosis spread from that area to adjacent intervertebral disks. disk is secondary to the spread of infection from the vertebral body.
  18. 18.  Progressive bone destruction leads to vertebral collapse, kyphosis & neurological involvement  Kyphotic deformity occurs in collapse of anterior spine.  Kyphotic def:; DORSAL SPINE THAN LUMBAR  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:::FIROUS ANKYLOSIS
  19. 19. 7/24/2015 paravertebral abscess Accumulate beneath the Anterior longitudinal ligament. Gravitate along the fascial planes Present externally at some distance from the site of the original lesion. Thoracic ….fusiform shadow(longituninal lig limits) Lumbar…..psaos abscess along sheath 19
  20. 20. LOCATION OF VERTEBRAL LESIONS Paradiscal M/C Anterior Central Appendecea l
  21. 21. PARADISCAL LESIONS Most common • Adjacent to the I/V disc leading to narrowing disc space Disk space narrowing • Destruction of subchondral bone with herniation of disc into the body. • Direct involvement of the disc.
  22. 22. Adjacent to the I/V Disc leading to a narrowing of the disc space 7/24/2015 22 PARADISCAL DISTRUCTION OF VERTIBRAL BODIES ,NARROWING OF IVD SPACE AND kyphotic DEFORMITY
  23. 23. ANTERIOR LESIONS • Subperiosteal lesion under ALL • Pus spreads –by stripping ALL, periosteum from anterior surface of vertebral body • Vertebral body collapse due to pressure and ischemia, followed by disc space narrowing. • Relatively common in Thoracic spine
  24. 24. CENTRAL LESIONS Center of vertebral body • Reaches through Batson’s venous plexus or through posterior vertebral artery Vertebra plane • Vertebral body collapse •
  25. 25. APPENDICULAR LESIONS Uncommon lesion <5% • Isolated infection of pedicles, lamina (neural arch0, transverse processes Occurs in isolation or conjunction with paradiscal lesions Radiographically appears as erosive lesions, paravertebral shadows with intact disc space.
  26. 26. Management plan DIAGNOSIS  CLINICO RADIOLOGICAL &  LAB STUDIES  Microbiological studies  Histopathological study  CT SCAN  MRI SCAN  USG  RADIONUCLIDE SCAN  MYELOGRAPHY 7/24/2015 26
  27. 27. DIAGNOSIS Complete blood picture • ESR Increased / Increased Lymphocyte count ELISA • For antibody to mycobacterial antigen • Sensitivity 60-80% PCR • Sensitivity of 40% Chest radiograph
  28. 28. Mantoux / tuberculin skin test Microbiology ZEIHL-NEELSEN STAINING/ACID FAST STAINING Cultures :4-6 weeks(L-J MEDIUM) Positive only in 50% cases IFN – Release assays (IGRA’s) Assays that measure T-cell release of IFN – in response to stimulation with highly specific tuberculosis antigens ESAT6 & CFP 10
  29. 29. Histopathological workup(Pre/PostOP) 7/24/2015 29
  30. 30. PLAIN RADIOGRAPH > 50% of bone destruction Classic Radiological triad Fusiform paraspinal soft tissue shadow Skip lesions 7-10%
  31. 31. Plain radiograph 7/24/2015 1. Disc space narrowing (COMMONEST & EARLIEST ) 2. Erosion of end plate 3. Signs of infection with lucency in ANT. Portion of vertebra 4. Deformities (knuckle, gibbus ,kyphus Anterior wedging,Vertebra plana 5. Sclerosis resulting from chronic infection 6. Compression fracture (Concertinal collapse = single collapsed vertebra) 7. soft tissue swelling from paraspinal abscess +/- calcification 8. Bowing of rib cage with multiple vertebral fracture 31
  32. 32. 7/24/2015 32 IMAGE 1 IMAGE 2
  33. 33. 7/24/2015 33
  34. 34. 7/24/2015 34 End plate erosion,disc space narrowing& compression fracture Vertebal end plate sclerosis&compes sion fracture
  35. 35. 7/24/2015 35 Compressive fracture with IVD narrowing Compressive fracture with osteosclerosi s
  36. 36. Kumar’s clinico-radiological Classification stage features Usual duration I Pre- destructive Straightening, spasm, hyperemia <3 mo II Early- destructive Diminished space paradiscal erosion Knuckle <10 2-4 mo III Mild kyphos 2-3 verte k:10-30 3-9 mo IV Moderate kyphos >3 verte K:30-60 6-24 mo V Severe kyphos >3 verte K:>60 >2 years
  37. 37. Paravertebral / prevertebral Shadows(Radiological evidence of cold abscess)  Abscess in cervical region: as a soft tissue shadow b/n vertebral bodies and pharynx & trachea.  On average, normal space b/n pharynx and spine above level of Cricoid cartilage is 0.5 cm and below it is 1.5 cm  In lateral view, the tracheal shadow is Concave anteriorly (parallel to the upper dorsal vertebrae), if there is a change in normal contour &/or its distance is >8mm from the vertebrae, it is strong7/24/2015 37
  38. 38. Prevertebral Shadows 7/24/2015 38 RETROPHARYNGEAL ABSCESS
  39. 39. Abscess below the level of D4 vertebrae – Fusiform shape (Bird nestappearance) An abscess under tension may produce- Globular shape 7/24/2015 Paravertebral Shadows39
  40. 40. CT- SCAN OF SPINE 7/24/2015 USE FULL FOR  Patterns of bony destruction.  Calcifications in abscess (pathognomic for TB)  Regions which are difficult to visualize on plain films, like : 1. Cranio-vertebral junction (CVJ) 2. Cervico-dorsal region, 3. Sacrum 4. Sacro-iliac joints. 5. Posterior spinal tuberculosis because lesions less than 1.5cm are usually missed due to overlapping of shadows on x rays. 40
  41. 41. MAGNECTIC RESONANCE IMAGING 7/24/2015  highly sensitive &specicific for spinal TB  Spinal cord & soft tissue involvement  Detect marrow infiltration in vertebral bodies(EDEMA), leading to early diagnosis  Skip lesions  Changes of diskitis (EDEMA)  Assessment of extradural abscesses / subligamentous spread  Poor for calcification 41
  42. 42. 7/24/2015 42 Infection and distruction of total body Compression of spinal cord causes cauda equina Total vertebral body distruction
  43. 43. RADIONUCLIDE BONE SCAN Increased uptake in 60% patients with active tuberculosis >= 5mm lesion can be detected Avascular segments & abscesses show cold spot Localize active disease and skip lesions Highly sensitive but non specific
  44. 44. 7/24/2015 44 USG - to find out primary in abdomen - Detect cold abscess - Guided aspiration
  45. 45. Myelography  Spinal tumor syndrome  Multiple vertebral lesions  Patients not recovered after decompression 1.Block present : second decompression 2.Block not present : intrinsic damage 1.Ischemic infarction 2.Interstitial gliosis 3.atrophy 4. tuberculous myelitis 5.Myelomalacia
  46. 46. DIFFERENTIAL DIAGNOSIS 7/24/2015 Back pain 1. Traumatic 2. Secondaries to spine /myeloma/lymphoma 3. Prolapsed disc 4. Ankylosing spondylitis Neurological deficit 1. Spinal tumor 2. Traumatic 3. Secondaries to spine Radiologically  SPINAL INFECTIONS : pyogenic, BRUCELLA SPONDYLITIS  NEUROPATHIC SPINE : Diabetes  NEOPLASTIC : commonly lymphoma/ metastasis/primary  DEGENERATIVE 47
  47. 47. TB spine pyogenic 7/24/2015 • Long standing history of months to yrs • active PTB may be seen • Most common location thoracic spine • > 3 contiguous vertebral body inv • Vertebral collapse very common • Bone destruction : more • Skip lesions common • Pra vertebral abscesses-Common • History of days to months. • Not present. • Most common location lumbar spine. • Mostly involves 1 spinal segment – 2vertebrae & intervening disc. • less common • very less • Rare • Rare
  48. 48. A destructive bone lesion associated with a poorly defined vertebral body endplate & with loss of disc space which has a better prognosis A destructive bone lesion associated with a well preserved disk space & sharp endplates “Good disk, bad news; bad disk, good news" 7/24/2015 49
  49. 49. Complication of spinal tuberculosis 7/24/2015  Paraplegia  Cold abscess  Spinal deformity  Sinuses  Secondary infection  Amyloid disease  Fatality 50
  50. 50. TUBERCULOUS SPINE WITH PARAPLEGIA Incidence 10-30% Dorsal spine most common Motor functions affected > sensory Sense of position & vibration last to disappear
  51. 51. STAGES OF PARAPLEGIA Paraplegia in extension Paraplegia in flexion Paraplegia in flaccidity Depends on the severity of involvement of long tracts
  52. 52. KUMAR’S CLASSIFICATION OF TUBERCULOUS PARA/TETRAPLEGIA (Predominantly based on motor weakness) 7/24/2015 MOTOR SEVERE MOTOR SENSORY SEV. SENSORY +AUTONOMIC 53
  53. 53. SEDDON’S CLASSIFICATION OF TUBERCULOUS PARAPLEGIA 10-09-2014 54 GROUP A (EARLY ONSET PARAPLEGIA) a/k/a Paraplegia associated with active disease :  Active phase of the disease within first 2 years of onset.  Pathology - inflammatory edema, granulation tissue, abscess, caseous material or ischemia of cord. GROUP B (LATE ONSET PARAPLEGIA) a/k/a Paraplegia associated with healed disease :  After 2 years of onset of disease.  Recrudescence of the disease or due to mechanical pressure on the cord.  Pathology can be sequestra, debris, internal gibbus or stenosis of the canal
  54. 54. BASIC PRINCIPLES OF MANAGEMENT • Early diagnosis • Expeditious medical treatment • Aggressive surgical approach • Prevent deformity • Best outcome “The captain of the men of death”
  55. 55. Three approach 7/24/2015 56  CONSERVATIVE PLAN  MIDDLE PATH REGIME  RADICAL SURGERY APPROACH
  56. 56. MIDDLE PATH REGIME 7/24/2015  Rest on hard bed  Chemotherapy  X-ray & ESR once in 3 months kyphosis measurement MRI/ CT at 6 months interval for 2 years  Gradual mobilization is encouraged in absence of neural deficits with spinal braces & back extension exercises at 3 – 9 weeks.  Abscesses – aspirate when near surface & instil 1gm Streptomycin +/- INH in solution 61
  57. 57. CHEMOTHERAPY 7/24/2015 62
  58. 58. MIDDLE PATH REGIME 7/24/2015  Sinus heals 6-12 weeks  Neural complications if showing progressive recovery on ATT b/w 3-4 weeks :surgery unnecessary IF NOT  Excisional surgery for posterior spinal disease associated with abscess / sinus formation +/- neural involvement.  Operative debridement–if no arrest of symptoms after 3-6 months of ATT / with recurrence of disease 63
  59. 59. ABSOLUTE INDICATIONS FOR SURGERY: 7/24/2015  Paraplegia during conservative treatment (6 weeks)  Paraplegia worsening during treatment (6 weeks)  Complete motor loss for 1 month despite of conservative treatment  Paraplegia with uncontrolled spasticity  Severe and rapid onset paraplegia  Severe flaccid paraplegia/ sensory loss 64
  60. 60. Other indications  Relative indications  1. Recurrent paraplegia  2. Paraplegia in elderly  3. Painful and spastic paraplegia Rare indications 1. Posterior element disease 2. Spinal tumor syndrome 3. Severe cervical lesion c paraplegia 4. Cauda equinopathy 7/24/2015 65
  61. 61. 10-09-2014 66
  62. 62. Type of Surgery…
  63. 63. APPROACH 1. Cervical spine – Anterior retropharyngeal (smith-Robinson’s) Anterior approach – Anterior/Medial border of sternocleidomastoid 2. Dorsal spine (D1 to L1) – 1 Transthoracic transpleural 2 Anterolateral decompression(D2 – L1) 3. Lumbar spine – Anterolateral(Lumbovertebrotomy) Extraperitoneal Ant. approach
  64. 64. Tuli’s recommended approch  Cervical spine –T1  Anterior approch  Dorsal spine –DL junction  Antrolateral approch  Lumbar spine &Lumboscral junction Extraperitoneal Transverse Vertebrotomy
  65. 65. Posterior fixation:  Fixation of posterior element of diseased vertebra by instrumentation are done: 1.To prevent and correct kyphotic deformity. 2. To maintain stability of the spine Fig : Pedicel screw fixation
  66. 66. TB Paraplegia or Quadriplegia MDT, Bed rest for 6 weeks Progressive neurological recovery No improvement Continue MDT, walking allowed when recovery complete Surgical decompression Recovering Not recovering FLOW CHART FOR THE MANAGEMENT OF PARAPLEGIA :SM TULI 7/24/201571
  67. 67. Not recovering MRI / Myelogram (IMMUNOMODULATION THERAPY) No block Block present Intrinsic damage to cord has occurred Repeat surgical decompression No recovery RecoveryContinue MDT, Rehabilitation Continue MDT and permit walking when recovery complete 7/24/201572
  68. 68. INFLUENCING PROGNOSIS IN CORD INVOLVEMENT 7/24/2015 73
  69. 69. ANTERIOR APPROACH TO THE CERVICAL SPINE (C2 to D1)  Smith & Robinson Oblique / transverse incision. Plane b/w SCM & carotid sheath laterally & T-O medially. Longitudinal incision in ALL open a perivertebral abscess, or the diseased vertebrae may be exposed by reflecting the ALL & the longus colli muscles.  Hodgson approach via posterior triangle by retracting SCM, Carotid sheath, T & O anteriorly & to the opposite side.
  70. 70. SURGICAL APPROACHES TO DORSAL SPINE  Anterior transpleural transthoracic approach  Anterolateral extrapleural approach  Posterolateral approach {Dura is exposed by hemilaminectomy first & then extended laterally to remove the posterior ends of 2 – 4 ribs, corresponding transverse processes & the pedicles}.
  71. 71. TRANSTHORACIC TRANSPLEURAL  Left sided incision preferable  Incision made along the rib which in the mid-axillary line, lies opposite the centre of the lesion (i.e. usually 2 ribs higher than the centre of the vertebral lesion).  For severe kyphosis, a rib along the incision line should be removed.  J-shaped parascapular incision for C7 – D8 lesions, scapula uplift & rib resection.  After cutting the muscles & periosteum, rib is resected
  72. 72. TRANSTHORACIC TRANSPLEURAL….  Parietal pleural incision applied & lung freed from the parieties & retracted anteriorly.  A plane developed b/w the descending aorta & the paravertebral abscess / diseased vertebral bodies by ligating the intercostal vessels & branches of hemiazygos veins.  T-shaped incision over the paravertebral abscess.  Debridement / decompression with or without bone
  73. 73. ANTEROLATERAL DECOMPRESSION  Griffith et al -- prone position  Tuli --- Right lateral position Advantage:- 1. avoid venous congestion 2 . avoid excessive bleeding 3. permits free respiration 4. Lung & mediastinal contents fall anteriorly  Parts to remove : Posterior part of rib (~8cm from the TP) Transverse process (TP) Pedicle Part of the vertebral body
  74. 74. ANTEROLATERAL DECOMPRESSION….  • Semicircular incision  • For severe kyphosis, additional 3-4 transverse processes and  ribs have to be removed.  • Intercostal nerves serve as guide to the intervertebral foramina & the pedicles.
  75. 75. ANTERO-LATERAL APPROACH TO LUMBAR SPINE ( LUMBOVERTEBROTOMY)  Left side approach  Semicircular incision  Expose and remove transverse process subperiosteally.  Preserve lumbar nerves
  76. 76. CONT…  45 ⁰ right lateral position with bridge centred over the area to be exposed.  Similar incision as nephroureterectomy or sympathectomy  Strip peritoneum off posterior abdominal wall and kidney, preserving ureter.  Longitudinal incision along psoas fibres for abscess drainage  Retract the sympathetic chain  Double ligation of lumbar vessels.
  77. 77. EXTRA PERITONEAL APPROACH TO LUMBO-SACRAL REGION  Left side preferred ( left Common iliac vessels longer & retracted easily).  Lazy “S” incision  Strip & reflect the parietal peritoneum along with ureter & spermatic vessels towards right side.
  78. 78. POSTERIOR SPINAL ARTHRODESIS Albee– Tibial graft inserted longitudinally in to the split spinous processes across the diseased site. Hibbs– overlapping numerous small osseous flaps from contiguous laminae , spinous processes & articular facets Indications–  1. Mechanical instability of spine in otherwise healed disease.  2. To stabilize the craniovertebral region (in certain cases of T.B.)
  79. 79. SURGERY IN SEVERE KYPHOSIS HIGH RISK PATIENTS: - Patients < 10 years - Dorsal lesions - Involvement of >= 3 vertebrae - Severe deformity in presence of active disease, especially in children is an absolute indication for decompression , correction and stabilization. Staged operations-  1. Anteriorly at the site of disease,  2. Osteotomy of the posterior elements at the deformity &  3. Halopelvic or halofemoral tractions post-
  80. 80. TREATMENT OF PARAPLEGIA IN SEVERE KHYPHOSIS  Griffiths et al :anterior transposition of cord through laminectomy  Rajasekaran : posterior stabilization f/b Anterior debridement and bone grafting ( titanium cages) in active stage of disease and vice versa for healed disease.  Antero-lateral (Preferred approach) .
  81. 81. SURGICAL CORRECTION OF SEVERE KYPHOTIC DEFORMITY  Fundamentals of correction: 1. to perform an osteotomy on the concave side of the curve and wedge is open ( secured with strong autogenous iliac grafts) . 2. to remove a wedge on the convex side and close this wedge ( Harrington compression rods and hooks)
  82. 82. Radical debridement and arthrodesis(hongkong procedure)  Excision of diseased tissue and anterior arthrodesis is about the same at all levels of spine  Remove debris,pus ,sequsterated bone/disc  Partially correct kyphosis by direct pressure posteriorly on spine  After cutting mortise in vertebra at each end insert strut bone grafts correct length keeping the vertebra sprung apart  IBG are taken  Put streptomycin and isoniazide into cavity before closure
  83. 83.  Order of recovery irrespective of mode of rx
  84. 84. Take home message  MRI is the gold standard for diagnosis of potts spine  Maintain high suspicion not to overlook diagnosis EARLY DAIGNOSIS ATT GOOD OUT COME REST
  85. 85. 7/24/2015 91

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