Spinal Tuberculosis by Dr. Monsif Iqbal

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This is the case presentation of a middle aged lady who presented with severe backache for the last one month with topic review after the case presentation

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Spinal Tuberculosis by Dr. Monsif Iqbal

  1. 1. Spinal Tuberculosis Dr. Monsif Iqbal Department of Surgery POF Hospital, Wah Cantt
  2. 2. CASE PRESENTATION
  3. 3. Patient Profile• Name : Rukhsana• Age : 45 years• Sex : Female• Address : Wah Cantt• D.O.A : 26/06/2011• M.O.A : OPD
  4. 4. • Presenting Complaints – Severe Backacke 5-7 days• History of present illness
  5. 5. Past History• h/o Cholecystectomy 01 month back• Diagnosed as a case of HCV 01 month back
  6. 6. Drug HISTORY• No histroy of any drug intake
  7. 7. PHYSICAL EXAMINATION1. GPE: A middle aged lady, lying in bed His vitals are; – Pulse: 85/min – B.P: 130/80 mm of Hg – Oxygen Sat: 96% – Temp: Afebrile Rest of GPE unremarkable.
  8. 8. NEUROLOGICAL EXAMINATION• Tenderness in the lumbar spine (L1, L2)• SLR – Right 60 degress – Left 70 degrees• Sensory system intact• Motor system intact• Reflexes normal• Plantars downgoing
  9. 9. Rest of the systemic examination• Abdomen – Cholecystectomy scar• Chest – NAD
  10. 10. Investigations on the day of admission• Blood CP• ESR• LFTs• X-ray Lumbo-sacral Spine
  11. 11. X-Ray Chest (PA view)
  12. 12. T1 weighted image
  13. 13. T2 weighted image
  14. 14. T1 weighted Slide
  15. 15. T2 weighted Slide
  16. 16. • So clinically the diagnosis of Spinal Tuberculosis was made
  17. 17. Spinal Tuberculosis
  18. 18. Introduction• According to WHO(2010), about one third of the world’s population is infected by Mycobacterium TB, and 9 million individuals develop TB each year• One third of total TB population is in South-East Asia.• Three percent are suffering from skeletal TB.• Vertebral TB is the most common form of skeletal TB and accounts for 50% of all cases of skeletal TB.
  19. 19. • The mortality rate is 27/100,000 of the population.• Neurological complications are the most crippling complications of spinal TB (Incidence : 10 to 43%).
  20. 20. Spinal Tuberculosis
  21. 21. Pathology of Spinal TB• Spinal tuberculosis is usually a secondary infection from a primary site in the lung or genitourinary system.• Spread to the spine is hematogenous in most instances.• Delayed hypersensitivity immune reaction.• The basic lesion is a combination of osteomyelitis and arthritis…. Affects the anterior part of vertebra…
  22. 22. • Kyphosis• Paravertebral Abscess
  23. 23. Clinical Presentation• Presentation depends on : – Stage of disease, – Site – Presence of complications such as neurologic deficits, abscesses, or sinus tracts.• Average duration of symptoms at the time of diagnosis is 3 – 4 months.• Back pain is the earliest & most common symptom.• Constitutional symptoms.• Neurologic symptoms (50 % of cases).
  24. 24. • Cervical spine Tuberculosis• Spinal TB in HIV patients
  25. 25. Spinal Tuberculosis Diagnosis• Lab Studies – Mantoux / Tuberculin skin test ( purified protein derivative {PPD}) – ESR – ELISA : for antibody to mycobacterial antigen-6 , sensitivity of 60 – 80%. – PCR : sensitivity of 40% only. – Brucella complement fixation test (useful in endemic areas as brucella can clinically mimic tuberculosis).
  26. 26. – IFN – Release assays (IGRAs) Recently, two in vitro assays that measure T- cell release of IFN in response to stimulation with the highly specific tuberculosis antigens ESAT- 6 & CFP-10 have become commercially available.• Microbiology studies – Ziehl-Neelsen staining – Cultures positive in 50 % of the cases only
  27. 27. Spinal Tuberculosis Diagnosis• Radiological Diagnosis – Plain Radiograph – CT Scan – MRI Spine
  28. 28. Plain Radiograph• Typical tubercular spondylitic features in long standing paraspinal abscesses – produce concave erosions around the anterior margins of the vertebral bodies producing a scalloped appearance called the Aneurysmal phenomenon. – fusiform paraspinal soft tissue shadow with calcification in few .• Skip lesions as involvement of non contiguous vertebrae (7 – 10 % cases).• DEFORMITIES: 1. Anterior wedging 2. Gibbous deformity. 3. Vertebra plana = single collapsed vertebra .
  29. 29. wedge collapse of L1 and L2 vertebral bodies
  30. 30. X-ray of the spine in a child showing completedestruction of D12 and L1 vertebral bodies leaving only the pedicles.
  31. 31. CT Scanning• CT scanning provides much better bony detail of irregular lytic lesions, sclerosis, disk collapse, and disruption of bone circumference.• Low-contrast resolution provides a better assessment of soft tissue, particularly in epidural and paraspinal areas.• It detects early lesions and is more effective for defining the shape and calcification of soft tissue abscesses.• In contrast to pyogenic disease, calcification is common in tuberculous lesions.
  32. 32. MRI Spine• MRI is the modality of choice as delineates leptomeningeal disease better, direct evaluation of intramedullary lesions, associated osseous signal change and epidural abscesses.• Typical (spondylo-discitis) and atypical (spondylitis without discitis) types.• Differentiate tuberculous spondylitis from pyogenic spondylitis• most effective for demonstrating neural compression
  33. 33. Patterns of Vertebral Involvement
  34. 34. Deformities in Spinal Tuberculosis• Kyphotic deformity (more common in thoracic spine) occurs as a consequence of collapse in the anterior spine• Knuckle Kyphosis : forward wedging of one or two VB causing small kyphos• Angular Kyphosis : wedge collapse of 3 or more VB
  35. 35. Differential Diagnosis• The differential diagnosis of the tuberculous spine includes: 1. SPINAL INFECTIONS- pyogenic, brucella & fungal. 2.NEOPLASTIC commonly lymphoma/ metastasis 3.DEGENERATIVE• No pathognomonic imaging signs allow tuberculosis to be readily distinguished from other conditions. Biopsy is definitive.
  36. 36. Complications of Spinal Tuberculosis• Paraplegia• Cold abscess• Spinal deformity• Sinuses• Secondary infection• Amyloid disease• Fatality
  37. 37. What is Middle path regime?• Rest in bed• Chemotherapy• X-ray & ESR once in 3 months• 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
  38. 38. • Sinus heals 6-12 weeks after treatment.• Neural complications if showing progressive recovery on ATT b/w 3-4 weeks :- surgery unnecessary• Excisional surgery for posterior spinal disease associated with abscess / sinus formation +/- neural involvement.• Operative debridement–if no arrest after 3-6 months of ATT / with recurrence of disease .• Post op spinal brace→18 months-2 years
  39. 39. All first-line anti-tuberculous drug names have a standard three-letter and a single-letter abbreviation:• Ethambutol is EMB or E,• isoniazid is INH or H,• Pyrazinamide is PZA or Z,• Rifampicin is RMP or R,• Streptomycin is STM or S.
  40. 40. Surgical Indications• No sign of neurological recovery after trial of 3-4 weeks therapy• Neurological complications develop during conservative treatment• Neuro deficit becoming worse on drugs & bed rest• Recurrence of neurological complication• Prevertebral cervical abscess with difficulty in deglutition & respiration• Advanced cases- Sphincter involvement, flaccid paralysis or severe flexor spasms
  41. 41. THANKS

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