Potts paraplegia, Lecture for mbbs students

1. Dr Lokesh Chugh
Senior Resident
Deptt. of orthopaedics
GMC Amritsar

2. Introduction
 T.B. spine with neurological
involvement
 20% incidence
 M/c in dorsal spine
 As spinal canal is narrowest in
dorsal spine

3. Pathology
 Pressure on neural tissues within
canal by the products from diseased
vertebrae
Inflammatory edema
Extradural abscess and granulation
tissue
Sequestra of extruded disc

4.  Internal gibbus
 Infarction of spinal cord
 Extradural granuloma

5. Types of Pott’s paraplegia
 Early onset : paraplegia during active stage of
disease.
Usually within 2 yrs of onset of disease.
 Late onset: paraplegia occuring several years after
disease has become quiescent.
Usually occurs at least 2 years after the onset of
the disease.

6. Causes of paraplegia in T.B. spine
 Early onset :
Inflammatory causes
Abscess-m/c
Granulation tissue
Circumscribed tuberculous
focus
Posterior spinal disease
Infective thrombosis of spinal
blood supply

7.  Mechanical causes
Sequestrum in canal
Infected degenerated disc in
canal
Pathological dislocation

8.  Late onset
Recurrence of disease
Prominent anterior wall of spinal canal
in case of severe kyphosis ( internal
gibbus)
Fibrous septae following healing
More than one cause may be responsible
for particular patient

9. Clinical features
 Onset : gradual, some cases may be
sudden
 Spastic to start
 Clonus is most prominent early
sign
 Clinical features of associated
tuberculosis spine: weight loss,
night sweat, night cries, evening
rise of temperature

10. Stages of paraplegia
 Muscle weakness, spasticity and
incoordination: due to pressure on
corticospinal tract, anteriorly placed.
 Paraplegia in extension: tone of muscle
increased

11.  Paraplegia in flexion: absence of paraspinal tract
functions in addition to corticospinal tract.
 Complete flaccid paraplegia: all transmission
across cord stops

12. Grades of Pott’s paraplegia
 Grade 1: patient unaware of neural deficit
Doctor elicits babinski positive, ankle or patellar
clonus.
 Grade 2: spasticity while walking
Patient is able to walk with or without support

13.  Grade 3 : patient not able to walk because of severe
weakness.
Paraplegia in extension.
partial loss of sensation.
 Grade 4: unable to walk.
Paraplegia in flexion
Near complete loss of sensation with sphincter
disturbances

14. Investigations
 +/- History of spinal tuberculosis
 Clinical features: paraplegia
 Blood investigation: raised ESR, lymphocytosis
 X ray
 CT scan: vertebral destruction
 MRI : investigation of choice

15. Treatment principles
Promote recovery ( ATT/
decompression surgery)
Achieve healing ( supporting
spine till diseased segment
becomes stable)
Rehabilitation to prevent
contractures

16. Conservative
 ATT: mainstay of treatment
 Intensive phase: 2 months HRZE
 Continuation phase: 8 to 16 months HRE
 MDR TB: 5 drugs in intensive phase.
( pyrazinamide+ 4 second line drugs)

17.  Absolute rest
Cervical spine : sling traction
Dorsolumbar spine: bed rest
 Repeated neurological examination of
limb is carried out to detect any
deterioration or improvement
Bracing 6-12 months.

18. Operative treatment
Indications
 Paraplegia occuring during
conservative treatment
 Paraplegia deteriorates or remains
stationary despite conservative
treatment
 Severe paraplegia with rapid onset

19.  Complete loss of motor power for
one month despite adequate
treatment
 Motor or sensory loss for more
than 6 months
 paraplegia with uncontrolled
spasticity

20. Relative indication of surgery
 Recurrant paraplegia
 Paraplegia in old age
 Painful paraplegia: spasm or
root compression

21. SURGERY
 COSTO TRANSVERSECTOMY
Removal of section of rib and
transverse process.
Indicated in child with
paraplegia with tense abscess

22. Anterolateral decompression
 Removal of rib, transverse
process, pedicle and part of
body of vertebra is done
 laminae and facet joint are
not removed.

23. Other surgeries
 Radical debridement and
arthrodesis
Dead and diseased vertebrae
excised and replaced with rib
graft
 Laminectomy : spinal cord
syndrome

24. Cervical spine surgery
 Anterior decompression

25. Prognosis of pott’s paraplegia
Good prognosis
 Children respond better than
adults
 Acute onset has better prognosis
Poor prognosis
 Long duration paraplegia
 More severe grade( eg. With
sphincter involvement)
 Sudden progress

26. THANK YOU