3. TB IS CALLED AS “WHITE PLAGUE’’ OR
”CAPTAIN OF ALL MEN OF DEATH”
SPINE IS THE COMMONST SITE OF BONE AND
JOINT TB
UPPER THORACIC SPINE – IN CHILDREN
LOWER THORACIC AND - IN ADULTS
UPPER LUMBAR
4. EPIDEMIOLOGY
1/3 RD OF WORLD POPULATION HARBOUR TB
INFECTION
INDIA IS ONE OF THE WORST AFFECTED
COUNTRIES
ONE PERSON PER MINUTE DIE OF TB IN INDIA
5. TB IS AN ANCIENT DISEASE
EVIDENCE OF SPINAL TB HAS BEEN
FOUND IN SOME EGYPTIAN
MUMMIES
6. BONES & JOINTS ARE THE 4TH COMMONST SITE
OF EXTRA PULMONARY TB
CONSTITUTE ~10% OF EXTRA PULMONARY TB
WEIGHT BEARING JOINTS ARE MOST AFFECTED
SPINE : 40%
HIPS : 13%
KNEES : 10%
7. PATHOLOGY
TB SPINE IS ALWAYS SECONDARY
REACTIVATION OF HEMATOGENOUS FOCI OR
SPREAD FROM PARAVERTEBRAL LYMPH NODE
HEMATOGENOUS SPREAD VIA PARAVERTEBRAL
VENOUS PLEXUS OF BATESON
RESPONSE WILL BE EITHER PROLIFERATIVE
OR EXUDATIVE
PROLIFERATIVE: C/C GRANULOMA WITH FIBROSIS
EXUDATIVE : NON REACTIVE, WIDE CAESEATION
NECROSIS, IN IMMUNOCOMPROMISED
10. TYPES OF VERTEBRAL TB
1. PARADISCAL - COMMONST , CONTIGOUS AREA
OF TWO ADJACENT VERTEBRA ALONG WITH
INTER VERTEBRAL DISC IS AFFECTED
2. CENTRAL -BODY OF SINGLE VERTEBRA ,
NEARBY DISC MAY BE NORMAL
3. ANTERIOR-ANTERIOR PART OF THE BODY
4. POSTERIOR- POSTERIOR COMPLEX (PEDICLE ,
LAMINA , SPINOUS PROCESS OR TRANSVERSE
PROCESS) AFFECTED
11. AFTER EFFECT
PARADISCAL : C/C GRANULOMATOUS
INFLAMMATION -> EROSION OF MARGINS OF
THE VERTEBRAE -> COMPROMISE OF NUTRITION
OF IV DISC-> DISC DEGN-> DESTRUCTION
CENTRAL : WEAKENING OF TRABECULAE ->
COLLPSE OF VERTEBRAE
ANTERIOR : INFN SPREAD UP OR DOWN UNDER
ANT. LONGI.LIGAMENT
POSTERIOR : BONY DESTRUCTION CAN
COMPRESS THE CORD
12. COLD ABSCESS
PUS & TRABECULAR DEBRIS OF DISEASED
VERTEBRA
NOT ASSO. WITH USUAL SIGNS OF
INFLAMMATION - COLD ABSCESS
NOTE: PUS CAN TRACK IN ANY DIRECTION
1.BACKWARDS : COMPRESS CORD
2. ANTERIORLY: PRE VERTEBRAL ABSCESS
3. SIDES : PARA VERTEBRAL ABSCESS
4.ALONG MUSCULOFASCIAL PLANES :
EX.PSOAS ABSCESS
13. HEALING
OCCURS BY FIBROSIS
IN THE SPINE BONY ANKYLOSIS FOLLOWS MORE
OFTEN
LYTIC AREAS ARE REPLACED BY NEW BONE AND
ADJACENT VERTEBRA UNDERGO FUSION
14. CLINICAL FEATURES
PRESENTATION VARIES FROM NON SPECIFIC
BACK ACHE TO CATASTROPHIC PARAPLEGIA
COMPLAINTS:
PAIN
STIFFNESS
COLD ABSCESS ( IF EVIDENT EXTERNALLY)
PARAPLEGIA
DEFORMITY
CONSTITUTIONAL SYMPTOMS
15. PAIN
BACKACHE : COMMON PRESENTING COMPLAINT
INITIALLY DIFFUSE & LATE LOCALISED
‘RADICULAR PAIN’
DEPENDING ON ROOT:
PAIN IN ARM – CERVICAL ROOTS
GIRDLE PAIN – DORSAL ROOTS
GROIN PAIN - LUMBAR ROOTS
16. COLD ABSCESS
CERVICAL : RETROPHARYNGEAL / AT POST
BORDER OF STERNO MASTOID IN POST
TRIANGLE OF THE NECK / AT AXILLA
THORACIC : MEDISTINAL / ANTERIOR CHEST
WALL ALON THE SPINAL NERVES
LUMBAR : PRE VERTEBRAL SWELLING/ PSOAS
ABSCESS / ABSCESS PRESENTING AT GROIN
17. STIFFNESS : EARLY SYMPTOM
PARAVERTEBRAL MUSCLES UNDERGO
SPASM
PARAPLEGIA
DEFORMITY – IN CHILDREN
CONSTITUTIONAL SYMPTOMS : FEVER , WEIGHT
LOSS
18. EXAMINATION
SHOULD HAVE A HIGH INDEX OF SUSPICION
AIMS : LOOK FOR FINDINGS OF TB SPINE
LOCALISE SITE OF LESION
DETECT COMPLICATIONS- COLD ABSCESS /
PARAPLEGIA
1. GAIT : SHORT STEPS
2. ATTITUDE & DEFORMITY
3. PARAVERTEBRAL SWELLING
4. TENDERNESS ON THE AFFECTED SPINE
5. REDUCED MOBILITY
21. NEUROLOGICAL EXAMINATION
AIMS: DETECT ANY COMPRESSION
LEVEL OF COMPRESSION
SEVERITY OF COMPRESSION
LIMBS – UPPER OR LOWER BASED ON SITE
MOTOR , SENSORY , REFLEXES , BOWEL AND
BLADDER FUNCTIONS
GENERAL EXAMINATION
PHYSICAL EXAMINATION
SYSTEMIC ILLNESS : DM , HYPERTENSION
22. INVESTIGATIONS
RADIOLOGY :
• X-RAY – SPECIFY THE LEVEL
• 2 VIEWS AP & LATERAL
• CHEST X-RAY
• X-RAY ABDOMEN
• KUB - IF PSOAS ABSCESS SUSPECTED
23. FINDINGS
1. REDUCTION OF DISC SPACE- EARLY SIGN
• COMPARE WITH NORMAL
LATERAL X-RAY IS BETTER
IMPORTANCE : SECONDARIES TO
BONES USUALLY PRESERVE THE DISC
2. DESTRUCTION OF VERTEBRAL BODY
EROSIONS AND WEDGING
3. DEFORMITY : DEPEND ON THE NO.
OF VERTEBRA AFFECTED
33. OTHER FINDINGS
RAREFACTION : ABOVE AND BELOW AFFECTED
VERTEBRA
OBLIQUE X RAY MAY SHOW POSTERIOR
COMPLEX INVOLVEMENT
SIGNS OF HEALING : ADJACENT VERTEBRAE
UNDERGO FUSION
34. OTHERS
CT : ACCURATE CONFIRMATIONS
MRI : TO ASSES NEURAL STATUS
MYELOGRAPHY : SUSPECTED SPINAL TUMOR
SYNDROME
BIOPSY : CT GUIDED NEEDLE OR OPEN BIOPSY
39. D/D S
BACK ACHE : 1. TRAUMATIC
• 2. SECONDARIES OR MYELOMA
• 3. PROLAPSED DISC
• 4.ANKYLOSING SPONDYLITIS
• NEUROLOGICAL
• SPINAL TUMOR
• TRAUMATIC
• SECONDARIES IN THE SPINE
40. TREATMENT
PT SHOULD BE GIVEN A HIGH PROTEIN DIET
& GOOD ATMOSPHERE
1. MULTIDRUG THERAPY OF TB
2. REST TO THE SPINE : CHILDREN BODY CAST ,
COLLAR IF CERVICAL
3. MOBILISATION : ADVISED TO AVOID SPORTS
FOR TWO YEARS
41. RX COLD ABSCESS
SMALLER ONES SUBSIDE WITH TB THERAPY
IN SUPERFICIAL ABSCESSES :
ASPIRATION : USING THICK NEEDLE
EVACUATION
PSOAS ABSCESS : EXTRAPERITONEALLY VIA KIDNEY
INCISCION
42. MRCB CONTROLLED TRIAL
BED REST NOT NECESSARY
STREPTOMYCIN NOT NECESSARY
POP JACKETS PROVIDE NO BENEFIT
DEBRIDEMENT IS NOT A GOOD OPERATION
COMPLICATIONS
COLD ABSCESS
NEUROLOGICAL COMPLICATIONS : PARAPLEGIA
43.
44. 20 % INCIDENCE
COMMON IN DORSAL SPINE TB
CAUSES :
INFLAMMATORY EDEMA
EXTRADURAL PUS & GRANULATION TISSUE –
COMMOMN
SEQUESTRA
INTERNAL GIBBUS
INFARCTION OF SPINAL CORD
EXTRADURAL GRANULOMA
45. TYPES
EARLY ONSET
LATE ONSET
C/F :
EITHER A KNOWN TB OR NEUROLOGICAL
SYMPTOMS PRESENTING FOR THE 1ST TIME
GRADUAL ONSET
CLONUS – ANKLE OR PATELLAR – PROMINENT
46. PARALYSIS : STAGES
1. MUSCLE WEAKNESS : SPASTICITY AND
INCORDINATION
2. PARAPLEGIA IN EXTENSION
3. PARAPLEGIA IN FLEXION
COMPLETE FLACCID PARALYSIS
47. GRADES : GOEL (1967)
BASIS IS EXTENT OF MOTOR INVOLVEMENT
GRADE ONE : CLINICIAN DETECTS THE DEFECIT
GRADE TWO : SYMPTOMATIC BUT MANAGES TO WALK
GRADE THREE: UNABLE TO WALK
PARAPLEGIA IN EXTENSION
PARTIAL SENSORY LOSS
GRADE FOUR : UNABLE TO WALK
PARAPLEGIA IN EXTENSION
NEAR COMPLETE SENSORY LOSS
SPHINCTER DISTURBANCES
48. TREATMENT
INVESTIGATIONS : CT & MRI ( INVESTIGATION
OF CHOICE)
CONSERVATIVE : ANTI TB RX , REST TO SPINE ,
NEUROLOGICAL EXAMINATION TO ASSES Px
SURGICAL :
INDICATIONS : PARAPLEGIA IN CONSERVATIVE Rx
SUDDEN ONSET SEVERE PARAPLEGIA
SEVERE PARAPLEGIA : IN FLEXION, MOTOR / SENSORY
LOSS > 6 MONTHS OR COMPLETE MOTOR LOSS ONE
MONTH DESPITE CONSERVATIVE Rx
PARAPLEGIA WITH UNCONTROLLED SPASTICITY
49. RELATIVE INDICATIONS :
RECURRENT PARAPLEGIA
PARAPLEGIA IN OLD AGE
PAINFUL PARAPLEGIA
COMPLICATIONS : UTI / STONES
51. PROGNOSIS
AGE : CHILDREN HAS BETTER Px
DURATION OF PARAPLEGIA : LONG STANDING
HAS BAD Px
SEVERITY : MOTOR ALONE HAS GOOD Px
ONSET OF PARAPLEGIA : A/C ONSET HAS BETTER
SUDDEN PROGRESS : BAD Px
