Tuberculosis of Spine for Medical students, Neurosurgeons, Orthopedic Surgeons and Nursing students. Covers history, presentation, clinical features, pathoanatomy, treatment and surgical options. Data taken from textbook by S M Tuli.

1. Pott’s Spine
Maj Mayank Jain
Base Hosp Delhi Cantt

2. Topics for Further Reading
● Mycobacterium tuberculosis
● Diagnosis of Osteoarticular TB
● Cold Abscess
● Stages of Osteoarticular TB
● Antitubercular drugs

7. 10 million
CASES PER YEAR WORLDWIDE !

8. TB of Spine
● Most common extrapulmonary form
of TB
● ~10% pts with extrapulmonary TB
have skeletal involvement - Tuli
● 2-3% of all MTB is osteoarticular
infection - Campbell
● Spinal TB is approx ⅓ to ½ of these
skeletal cases - Campbell
● Thoracolumbar junction is the most
common site

9. Spine involvement
Arterial spread
● Arterial arcade in subchondral
region of each vertebra
● This forms a rich vascular plexus
● Hematogenous spread to
paradiscal regions

10. Spine Involvement
Venous
● Batson’s paravertebral venous
plexus
● Valveless system
● Reverse flow in raised intra
abdominal and intrathoracic
pressure e.g. Coughing
● Spread to noncontiguous vertebral
sites (Skip Lesions)

11. Spine involvement
Local Spread
● Anterior longitudinal
ligament
● Posterior ligamentous
complex

12. Types of Vertebral Involvement
● Paradiscal
○ Most common
○ Through epiphyseal arteries
● Central
○ Common in children
○ Hematogenous spread
● Anterior
○ More in thoracic spine
○ Anterior longitudinal ligament spread
● Appendiceal / Posterior
○ Pedicle, lamina and processes
○ Venous or direct spread
● Synovial
○ True tubercular arthritis
○ Seen in occipito-atlanto-axial joint

13. Symptoms and Signs
Active stage
● General
○ Malaise
○ Weight loss
○ Anorexia
○ Night sweats
○ Evening rise of temp
● Local
○ Stiff painful spine
○ Localized tender kyphosis
○ Spasms
○ Night cries
○ Cold abscess

14. Symptoms and Signs
Healed stage
● General
○ constitutional symptoms recover
● No pain / tenderness in spine
● No spasms of vertebral muscles
● Deformity - persists

15. Investigations
● ESR - increased
● Lymphocyte predominance
● ELISA for antibody against mycobacterial antigen (60-80% sensitive)
● PCR (40% sensitive)
● Mendel-Mantoux / Tuberculin / Pirquet / PPD test
● Tissue samples
○ ZN Stain
○ Culture in Lowenstein Jensen Medium for 4-6 weeks (50% sensitive)
● IGRA (Interferon Gamma release assays)
○ ESAT6 and CFP10 tuberculosis antigens used
○ Assays T cell response to stimulation by these

16. Radiology
● Chest X rays
○ Abnormal in 2/3rd
● MRI
○ Lags behind by 4 to 6
months to show healing
○ May show deterioration 4-5
months after starting ATT
● Bone Scans
○ Can pick subclinical
disease
● Paradiscal type
○ Disc space narrowing
(earliest sign)
○ loss of definition of
paradiscal margin
○ small necrotic foci (CT)
○ hotspot in bone scan

24. Differential Diagnosis
Young Children
● Congenital Spinal Deformities
● Calve’s disease
Adolescents
● Schmorl’s disease
● Scheuermann’s Disease
Elderly
● Metastatic / Primary tumors

25. Differential Diagnosis
Infections
● Acute spinal pyogenic osteomyelitis
● Pyogenic discitis
● Typhoid spine
● Brucella spondylitis
● Mycotic Spondylitis
● Syphilitic infections
○ Arthralgic Syohilitic Spondylitis
○ Gummatous Syphilitic Spondylitis
○ Charcots’ disease of the spine

26. Differential Diagnosis
Infections
● Acute spinal pyogenic osteomyelitis
● Pyogenic discitis
● Typhoid spine
● Brucella spondylitis
● Mycotic Spondylitis
● Syphilitic infections
○ Arthralgic Syohilitic Spondylitis
○ Gummatous Syphilitic Spondylitis
○ Charcots’ disease of the spine

27. Differential Diagnosis
Tumorous conditions
● Hemangioma
● Giant cell tumors
● Aneurysmal bone cyst
● Ewing’s sarcoma
● Osteogenic sarcoma
● Multiple myeloma
● Hodgkin’s disease and leukemias
● Metastases
● Histiocytosis X

28. Differential Diagnosis
Developmental Anomalies
● Hemivertebrae
● Block vertebrae
● Synostosis of neural arches
Spinal Osteochondrosis
Trauma
Osteoporosis
Spondylolisthesis
Hydatid disease

29. Differential Diagnosis
Developmental Anomalies
● Hemivertebrae
● Block vertebrae
● Synostosis of neural arches
Spinal Osteochondrosis
Trauma
Osteoporosis
Spondylolisthesis
Hydatid disease

30. Differential Diagnosis
Developmental Anomalies
● Hemivertebrae
● Block vertebrae
● Synostosis of neural arches
Spinal Osteochondrosis
Trauma
Osteoporosis
Spondylolisthesis
Hydatid disease

31. Complications and Sequelae
● Sinus formation
● Neurological deficit
● Pott’s Paraplegia
● Kyphosis
● Retropharyngeal abscess
● Mediastinal abscess ->Mediastinal
syndrome
● Psoas Abscess
● TB arteritis and pseudoaneurysm
● Costopelvic impingement

32. Pott’s Paraplegia
Etiology of neurodeficit
- mechanical pressure
- instability from subluxation / dislocation
- stenosis
- ossification of ligamentum flavum

33. Pott’s Paraplegia
Classification (Griffith, Sedon, Roaf)
Gp A
- early onset paraplegia
- "paraplegia associated with active disease"
- within 2 yr
- pathology
- inflammatory edema
- granulation
- abscess
- caseous tissue
- rare ischemic lesion of cord
Gp B
- late onset paraplegia
- "paraplegia associated with healed disease"
- >2 yr of vertebral disease
- pathology
- caseous tissue
- debris
- sequestra
- internal gibbus
- canal stenosis
- severe deformity

34. Pott’s Paraplegia
Stages of Cord Compression (Goel, Tuli, Kumar, Jain)
- I - pt unaware of deficit
- II - aware but manages to walk
- III - paraplegia in extension
- IV - paraplegia with flexion

35. Prognosis in Potts Paraplegia

36. Deformity
Kumar Clinicoradiological
Classification (Tubercular
Spondylitis)
- I - pre destructive
- II - early destructive
- III - mild angular kyphosis
- IV - moderate angular kyphosis
- V - severe kyphosis / humpback

37. Deformity
Rajasekaran classification of deformity progression in children
1 - continued deformity in entire growth period
- 1A - increases continuously
- 1B - lag period 3-6 yrs
2 - decreases during growth
- seen only in post TB kyphosis
- 2A - immediately after active period
- 2B - after lag of 3-6 yr
3 - no major change in deformity

38. TREATMEN
T

39. Treatment : Pre ATT Era
- Artificial abscess (Pott)
- Laminectomy (Chipault)
- Laminotomy (Fraser)
- Costo transversectomy (Menard)
- Posterior mediastinotomy (Obalinski)
- Calve's operation (aspirating abscess without sinus)
- Lateral rhachiotomy of Capener (risk of lat subluxation)
- Anterolateral decompression (Dott and Alexander)
- Posterior spinal fusion (Albee and Hibbs)

40. Treatment : Pre ATT Era
- Artificial abscess (Pott)
- Laminectomy (Chipault)
- Laminotomy (Fraser)
- Costo transversectomy (Menard)
- Posterior mediastinotomy (Obalinski)
- Calve's operation (aspirating abscess without sinus)
- Lateral rhachiotomy of Capener (risk of lat subluxation)
- Anterolateral decompression (Dott and Alexander)
- Posterior spinal fusion (Albee and Hibbs)

41. Treatment : Pre ATT Era
- Artificial abscess (Pott)
- Laminectomy (Chipault)
- Laminotomy (Fraser)
- Costo transversectomy (Menard)
- Posterior mediastinotomy (Obalinski)
- Calve's operation (aspirating abscess without sinus)
- Lateral rhachiotomy of Capener (risk of lat subluxation)
- Anterolateral decompression (Dott and Alexander)
- Posterior spinal fusion (Albee and Hibbs)

42. Treatment : Post ATT Era
Modern Conservative
- pharmacological
- indications
- no neurodeficit
- active infection
- regimens
- HRZE (2) + HR (9-18)
- extended treatment
- HIV
- drug resistance

43. Middle Path Regimen : Tuli
- Rest
- Hard bed
- POP bed
- cervicodorsal traction
- ATT
- intensive HRO x 5-6 mth
- continuation x 7-8 mth
- HZ x 3-4mth
- HR x 4-5 mth
- prophylactic phase - HE x 3-5 mth
- 3-6 monthly - ESR + Radiograph
- 6 monthly MRI /CT
- Gradual mobilization in braces
- Abscess aspiration + streptomycin infiltration (1 Gm)
- Sinus - few may require excision
- Neural decompression - failure to improve, neurodeficit
- Excision - post spinal disease
- Operative debridement - no improvement in 3-6 mth
- Post spinal arthrodesis - symptomatic unstable lesions
- Rehab - brace upto 12-24 mth

44. WHO INDEX-TB Guidelines - for extrapulmonary
TB in India
2RHZE/10RHE
All patients require close monitoring for development or progression of
neurological deficit in the first 4 weeks of treatment.
Some patients require surgical intervention.
Total treatment duration: 12 months (extendable to 18 months on a case-bycase
basis)
Optimum management of spinal TB requires the involvement of multiple
specialists including a spinal orthopaedic surgeon, microbiologist/infectious
diseases specialist and spinal radiologist, as well as physiotherapists and
orthotists. All presumptive spinal TB cases should be referred and managed in
specialist centres.

45. WHO INDEX-TB Guidelines - for extrapulmonary
TB in India
Patients without neurological deficit should be advised to return to the clinic
immediately if new symptoms develop, and all ambulant patients should be
assessed weekly for neurological signs. Patients with neurological deficit require
staging and grading of their deficit.
These patients should be assessed weekly with neural charting to detect neural
recovery or deterioration. Repeat X-rays of the spine are suggested every 3
months following initiation of treatment to assess for radiological healing. Repeat
MRI scans are suggested at 6, 9, 12 and 18 months following initiation of
treatment to assess healing. At the end of treatment, all patients require follow up
every 6 months for at least 2 years, and should be told to return to the clinic
promptly if they develop new symptoms in the interim.

46. WHO INDEX-TB Guidelines - for extrapulmonary
TB in India
While some require early surgical intervention, most patients can be managed
with ATT alone in the initial phase of treatment.
Surgery may be required for two principal purposes in spinal TB-to establish
diagnosis, or to treat spinal deformity, instability and neurological deficit. Where
available, percutaneous biopsy under CT guidance reduces the need for open
biopsy, but this may still be required in some cases, particularly where imaging
results are atypical for spinal TB and the diagnosis is uncertain. Patients with
large, fluctuant cold abscesses may require therapeutic aspiration to relieve
symptoms and promote healing.

47. WHO INDEX-TB Guidelines - for extrapulmonary
TB in India
Indications for surgery in TB spine with neurological deficit:
● Neural complications developing or getting worse or remaining stationary
during the course of non-operative treatment (3–4 weeks)
● Paraplegia of rapid onset
● Spinal tumour syndrome
● Neural arch disease
● Severe paraplegia – flaccid paraplegia, paraplegia in flexion, complete
sensory loss and complete loss of motor power for more than 6 months
● Painful paraplegia in elderly patients.

48. WHO INDEX-TB Guidelines - for extrapulmonary
TB in India
Indications for surgery in spinal TB without neurological deficit:
● When diagnosis is uncertain and open biopsy is indicated
● Mechanical instability – panvertebral disease, where bony involvement of
both the vertebral body and posterior complex is seen on imaging, or disease
affects facet joints bilaterally
● Suspected drug resistance – where patients show inadequate clinical
improvement or deterioration on ATT
● Spinal deformity – severe kyphotic deformity at presentation, or in children at
high risk of progression of kyphosis with growth after healing of disease.

49. WHO INDEX-TB Guidelines - for extrapulmonary
TB in India
Indications for instrumented stabilization:
● Panvertebral disease
● Long segment disease where a > 4–5 cm long graft is required to bridge the
gap after surgical decompression in dorsal spine
● In lumbar and cervical spine
● When kyphosis correction surgery is contemplated
● Lesion in a junctional area.

50. Preparation for surgery
● Multidrug therapy at least 3 to 6
weeks before surgery to
suppress the infection
● Medical treatment for
comorbidities
● Nutritional support
● Correct hypoproteinemia
● Obtain relevant imaging studies

51. Abscess Drainage : Cervical Spine
Retropharyngeal abscess
- Through posterior triangle of neck
- only in an emergency
- Cyanosis
- respiratory difficulty
- Done via extraoral approach
- Allows only drainage of abscess
- Anterior cervical approach
- Allows exposure from C2 to C7
- allows bony reconstruction to be
done at the time of abscess
drainage

52. Abscess Drainage : Dorsal Spine
- Costotransversectomy
- Originally by Haidenhaim
- Described by Ménard in 1894

53. Radical Procedures : Dorsal Spine
- Radical Debridement and Arthrodesis
by Dorsolateral Approach (Roef et al)

54. Abscess Drainage : Lumber Spine
- Paravertebral abscess drainage
- Incision lateral to the midline
parallel to the spinous processes

55. Abscess Drainage : Pelvis
- Psoas Abscess
- Entirely extraperitoneal
- follow the course of the iliopsoas
muscle
- Drainage of psoas abscess
- posteriorly through the Petit
triangle
- lateral incision along the crest of
the ilium
- anteriorly under the Poupart
ligament

56. Abscess Drainage : Pelvis
- Pelvic Abscess
- Lougheed and White
- Tuberculosis involving the lower lumbar
and lumbosacral areas, soft-tissue
abscesses may gravitate into the pelvis,
forming a large abscess anterior to the
sacrum
- Pelvic abscess drainage posteriorly by
coccygectomy

57. A Golden Day Dream by Emily Mary Osborn. Oil
on canvas. In the 19th century Europe,
tuberculosis began to represent spiritual purity,
even holiness, and temporal wealth, leading
many young, upper-class women to purposefully
pale their skin to achieve the consumptive
appearance.

58. Cristóbal Rojas Poleo's famous work La miseria
(the misery), which the artist painted in 1886. The
oil on canvas depicts a desolate scene of a
young husband sitting next to his supine wife
who has just died in an impoverished setting of
tuberculosis.