Contribution: Dr Rajiv Jha, Dr GR Sharma, Prof Pawan Kumar

1. Post Operative Severe Acute Neck
Pain- A diagnostic Dilemma!
Dr Rajiv Jha, Dr GR Sharma, Prof Pawan Kumar

2. Introduction
• Neck pain (or cervicalgia) is a common
problem, with two-thirds of the population
having neck pain at some point in their lives

3. Objective
To analyze the co-incidence of tuberculous
cervical spondylitis after tracheal intubation,
and to find the risk factors, presentations, and
outcome of the disease process.

4. Study Design
• A prospective study
• September 2009- September 2010
• NNRC,Bir Hospital / Department Of
Neurosurgery OHRC

5. Age
0
0.5
1
1.5
2
2.5
3
3.5
0-10 20-Nov 21-30 31-40 41-50 51-60 >60
N0

6. Sex
3
8
M
F

7. Clinical Presentation
• Isolated neck pain - 4
• Neck pain with radiculopathy -6
• Neck pain with focal neurological deficit - 1

8. Objective Findings
• Restricted neck movements – 11
• Radiculopathy – 6
• Focal neurological deficit - 1

9. DD
• Manipulation after ET intubation
• Rheumatoid arthritis
• Osteoarthritis
• Infection
• Cervical spondylosis
• Cervical PIVD
• Spinal tumor etc.

10. investigations
• ESR
• CRP
• RA Factor
• X-Ray Cervical Spine

11. ESR RAF CRP X-ray C. Spine
Patient 1 42 -ve Abnormal
Patient 2 29 -ve +ve Abnormal
Patient 3 37 -ve +ve Abnormal
Patient 4 25 -ve Abnormal
Patient 5 56 -ve +ve Abnormal
Patient 6 27 -ve Abnormal
Patient 7 114 -ve Abnormal
Patient 8 68 -ve +ve Abnormal
Patient 9 12 -ve Abnormal
Patient 10 32 -ve +ve Abnormal
Patient 11 34 -ve +ve Abnormal

12. P Dahal 30/F I Bhattarai 40/F

13. CK Shrestha 36/F R Devi 45/F

14. Provisional Diagnosis
• Cervical Tubercular Spondylitis

15. Further Investigations
• MRI Cervical spine
• Mantoux Test
• S. Mycodot
• S. ADA
• Chest X-ray

16. MRI C Spine Mantoux
Test
S. Mycodot S. ADA CXR
Patient 1 Abnormal 14 +ve 31 Normal
Patient 2 Abnormal 18 +ve Normal
Patient 3 Abnormal 13 +ve Normal
Patient 4 Abnormal 14 Normal
Patient 5 Abnormal 12 +ve Normal
Patient 6 Abnormal 11 Normal
Patient 7 Abnormal 13 37 Normal
Patient 8 Abnormal 21 +ve 39 Normal
Patient 9 Abnormal 9 Normal
Patient 10 Abnormal 11 +ve Normal
Patient 11 Abnormal 10 +ve Normal

18. P Dahal 30/F S Pradhan 42/M

19. MRI C Spine
Cervical Level involved
Patient 1 C3,4 and C6,7
Patient 2 C3,4,5
Patient 3 C5,6
Patient 4 C4,5
Patient 5 C5,6,7
Patient 6 C3,4
Patient 7 C6,7
Patient 8 C4,5
Patient 9 C4,5,6
Patient 10 C6,7
Patient 11 C5,6

20. Final Diagnosis
• Cervical tubercular spondylitis

21. Management
• Chemotherapy: By controlling the morbid
process and improving the prognosis for spinal
tuberculosis, antituberculosis agents are the
mainstay of management
• Surgical procedures - still play an important
role

22. Drug Treatment Regimens
• The standard triple chemotherapy (isoniazid, rifampin, and
pyrazinamide), should be given for at least 12 months
• triple chemotherapy for a period of 18 months is recommended for
slowly responsive cases or, alternatively, a 12-month four drug regimen
(soniazid, rifampin, ethambutol, and pyrazinamide) is appropriate for
such cases.
• rifampin and isoniazid for 6 or 9 months, to be at least as effective as
the 18-months course of isoniazid and para-amino salicylic acid
(Griffith )
• 6 months of three-drug chemotherapy in conjunction with radical
surgery was adequate for the management of tuberculosis of the spine
because it produced results comparable with 9-month and 18-month
chemotherapeutic regimens. (Upadhayay et al)
• HRZE(3 months) followed by HR(15 months) –
NNRC protocol

23. F/U

24. Surgical procedures
• Cervical traction
• Posterior fusion
• Anterior radical surgery
• Two-stage operation:(Posterior instrumentation
followed by anterior radical surgery +Anterior
release and graft, followed by posterior
instrumentation)
• Three-stage operation (anterior release followed
by posterior instrumentation and delayed
anterior radical surgery).

25. Overview
• In 1779- Percivall Pott
• Most lethal infectious disease - 3 million deaths/year
• Bone and soft-tissue tuberculosis accounts for approximately 10% of
extrapulmonary tuberculosis cases and between 1% and 2% of total
cases.
• Tuberculous spondylitis is the most common manifestation of
musculoskeletal tuberculosis, accounting for approximately 40-50%
of cases.
• Cervical spine – 10%,thoracic spine -50% and lumbar spine – 40%
• Spread – haematogenous/local extension/Batson’s venous plexus
• the frequency of Pott Disease is related to socioeconomic factors
and historical exposure to the infection.
• Pott disease does not have a sexual predilection
• Pott disease occurs primarily in adults

26. WHO. World tuberculosis toll on the rise.
Asian Medical News 2001:3:9.
• Tuberculosis has become the world's most deadly infectious disease, killing nearly
3 million people per year.
• Each year there are 8 million new cases of tuberculosis, and 50% of them are
infectious.
• There are approximately 20 million active cases, and 1.7 billion (one third of the
world's population) are, or have been, infected with the tuberculosis bacillus.
• Most tuberculosis deaths are in the developing world, with 1.8 million occurring in
Asia annually. In some East and Central African countries, reported cases of
tuberculosis have nearly doubled in the last 4 to 5 years; one of the main reasons
for the resurgence of tuberculosis is the spread of human immunodeficiency virus
(HIV) infection.
• Spinal tuberculosis, the most common form of articuloskeletal tuberculosis, is a
paucibacillary disease with slow-growing bacilli. In HIV-negative patients, between
3% and 5% of tuberculosis cases are skeletal, compared with 60% of cases in HIV-
positive patients. These statistics emphasize the need to prepare for a resurgence
of spinal tuberculosis during the coming years.

27. Summary
• With the increased prevalence of spinal tuberculosis, a review of
the management of spinal tuberculosis and its complications is
timely.
• In all early cases and in the moderately advanced cases without
unacceptable complications, conservative chemotherapy should be
pursued as the mainstay of treatment.
• In advanced cases with spinal deformity and/or neurologic deficit,
surgery should be considered with chemotherapy.
• As a result of early detection, the introduction of chemotherapy,
and improved surgical techniques, patients with kyphosis rarely are
seen today, particularly in urban centers that have an effective
medical system.

28. Conclusion