Dr Golwala - Tuberculosis of Spine -Past President Lecture

1,842 views

Published on

This is the presentation sent by Dr Paresh Golwal -Past President GOA

Published in: Education, Health & Medicine
0 Comments
2 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
1,842
On SlideShare
0
From Embeds
0
Number of Embeds
95
Actions
Shares
0
Downloads
158
Comments
0
Likes
2
Embeds 0
No embeds

No notes for slide

Dr Golwala - Tuberculosis of Spine -Past President Lecture

  1. 1. Tuberculosis of spine DR.PARESH P.GOLWALA PROFESSOR AND HEAD, DEPT. OF ORTHOPAEDICS S.B.K.S.M.I.R.C., PIPARIYA Dr. Paresh Golwala 1
  2. 2. HISTORY RIGVEDA AND ATHARVA VEDAS: 3500 – 1800 BC  CHARAKA AND SUSHRUTA: 1000 – 600 BC  HIPPOCRATES: 400 – 300 BC  DESCRIBED AS YAKSHMA Dr. Paresh Golwala 2
  3. 3. HISTORY PERCIVAL POTT – (1779) DESCRIBED TB SPINE AS A KIND OF LOWER LIMB PALSY WHICH IS FREQUENTLY FOUND TO ACCOMPANY A CURVATURE OF THE SPINE  LAENAEC – (1781- 1826) IDENTIFIED AND DESCRIBED TUBERCLE BACILLI IN 1817  BCG VACCINE IN 1945  SPECIFIC AKT IN 1948-1951  Dr. Paresh Golwala 3
  4. 4. TB SPINE Disease of developing world  Affects young wage earners  Dr. Paresh Golwala 4
  5. 5. NATURAL COURSE WITHOUT CHEMOTHERAPY Dr. Paresh Golwala 5
  6. 6. STAGE OF ONSET Lasts 1 month to 1 year  Localised disease --- warm, tender swelling --- Localised osteoporosis with minimised destruction  Dr. Paresh Golwala 6
  7. 7. STAGE OF DESTRUCTION Lasts 1 to 3 years  Gross destruction of bones and joints with deformity, subluxation, contractures and abscess formation abscess ruptured  Sinuses develop and secondary pyogenic infections occur  LOWERED Defence mechanism  Severe cachexia  Dr. Paresh Golwala 7
  8. 8. STAGE OF DESTRUCTION Miliary tuberculosis and/or meningitis  1/3rd of patients die  Dr. Paresh Golwala 8
  9. 9. STAGE OF REPAIR AND ANKYLOSIS        Occures 3 years after onset Improved general condition Resorpton of abscesses Healed sinuses Destroyed bones remineralised Fusion in deformed position(kyphosis) Unsound ankylosis-unsatisfactory (pain on movement and weight bearing) Dr. Paresh Golwala 9
  10. 10. SO,OVERALL RESULTS WITHOUT AKT ARE UNSATISFACTORY
  11. 11. LEVEL OF OCCURANCE     Dorsolumbar Junction Dorsal Lumbar Cervical Dr. Paresh Golwala 11
  12. 12. BOVINE T.B. Abdomen Pelvic venous plexus Vertebrae Dr. Paresh Golwala 12
  13. 13. TWO TYPES OF AFFECTION  In children the blood supply is central to the vertebrae. That is why the affection is central .  In adults the blood supply is paradiscal that is why the affection is paradiscal . Dr. Paresh Golwala 13
  14. 14. PATHOLOGY Bacteraemia Deposition in Bone Necrosis + Casseation with Hyperemia (increased blood supply) Cavity in the bone Surrounding Osteoporosis Dr. Paresh Golwala 14
  15. 15. PATHOLOGY CONTD… … Weight bearing stimulus Collapse of vertebrae Dr. Paresh Golwala 15
  16. 16. PATHOLOGY CONTD… …       No blood supply to disc that is Nucleus pulposus intervertebral disc Nutrition to disc is from paradiscal region. 90% of disc content is water. With the affection in paradiscal region the disc gets dehydrated and looses height --- reduction in disc space. With surrounding cavity and destruction the disc is resorbed. This leads to pus formation and the surrounding ligaments are swollen --- soft tissue shadow. Dr. Paresh Golwala 16
  17. 17. PATHOLOGY CONTD… …    Casseation – pus formation In x-ray --- soft tissue shadow So differentiate from malignancy Dr. Paresh Golwala 17
  18. 18. COLD ABSCESS    2 or more vertebra affected. Pus spread due to pressure If spread anteriorly – Cervical --- posterior to esophagus / oropharynx / nasopharynx – Dorsal --- along the ribs – DL / Lumbar --- along psoas sheath --psoas abscess Dr. Paresh Golwala 18
  19. 19.  If spread posteriorly – Pressure over the cord – Causes Paraplegia or Quadruplegia depending on the level Dr. Paresh Golwala 19
  20. 20. POTT’S PARAPLEGIA     Pus under pressure Collapse of vertebrae --- Sequestrum Meningitis --- Pachy Meningitis Thrombosis of artery supplying spinal cord (Artery of Adam & Kiewz) (At D9-10 level) Dr. Paresh Golwala 20
  21. 21. CLINICAL FINDINGS Dr. Paresh Golwala 21
  22. 22. SYMPTOMS         Backache Backache --- Radiating Pain Backache With Pus Discharging Sinus, Cold Abscess Backache With Neurological Deficit Constitutional Symptoms Night Pain / Night Cries H/O Immuno Suppression Any age Dr. Paresh Golwala 22
  23. 23. SIGNS       Gibbus --- Angular Kyphosis Smooth Kyphosis --- 2-3 Vertebrae Muscle Spasm --- Coin Test Level Of Tenderness Cold Abscess Neurological Deficit – – – – – Lumbar --- LMN D.L. Junction --- Mixed Dorsal --- UMN Cervical --- LL – UMN, UL – LMN Lesion --- C1-CL1 –UL-UMN C5 – T1 – UL - LMN Dr. Paresh Golwala 23
  24. 24. INVESTIGATIONS  X-RAY: – – – – – –    Soft Tissue Shadow Collapse Osteoporosis Erosion Adult --- Decreased / No Disc Space Children --- Central Lesion Hb, TC, DC, ESR --- Increased --- Prognostic Importance Liver Function Test MRI --- Neurological Deficit Dr. Paresh Golwala 24
  25. 25. AIM OF TREATMENT Eradication of infection correction / prevention of angular deformity recovery of neurological deficit Dr. Paresh Golwala 25
  26. 26. TREATMENT  CONSERVATIVE : – Bed rest --- 3 months --- Wedging / compression is more than 50% – AKT --- DOTS Category 1 – Rifampicin, Isoniazide, Ethambutol, Pyrizinamide along with Inj. Streptomycin --- preferably for two months – Rifampicin, Isoniazide, Ethambutol for another 7 to 8 months depending on healing --- ESR / X-RAY / Clinical Dr. Paresh Golwala 26
  27. 27.  OPERATIVE : – – –   Backache Alone --- Conservatively Backache With Cold Abscess Backache With Neurological Deficit Historically in India mid path regime was followed with the advent of MRI and after study from Rajshekharan more emphasis has been put on to prevent post Tuberculous Kyphosis --- internal Gibbus Hongkong school believes in anterior curettage and stabilization of vertebrae --- gold standard treatment Dr. Paresh Golwala 27
  28. 28. NEWER INDICATIONS OF SURGERY Global disease: instability  Long segment disease > 3 vertebrae with severe kyphosis  Spinal cord compression:  Pus Granulation tissue Caseous tissue Discs Bony sequestra Dr. Paresh Golwala 28
  29. 29.  Cord compression on MRI does not correlate with neural deficit (76% encroachment of canal may also have intact neural state) Dr. Paresh Golwala 29
  30. 30. INTRINSIC CAUSES OF CORD COMPRESSION Cord oedema  Myelomalacia  Direct affection of meninges and cord  Infective thrombosis and endarteritis  Poor prognosis  Dr. Paresh Golwala 30
  31. 31.  PARAPLEGIC PATIENT: – Not responding to drugs after 1 month of AKT – Sudden bladder bowel involvement  RELATIVE INDICATIONS: – Kyphosis --- severe – Children costo transversectomy Dr. Paresh Golwala 31
  32. 32. DECOMPRESSION PARAPLEGIC / NEUROLOGICAL DEFICIT       Rib Transverse process Pedicle Curette vertebrae anteriorly Leaves big void anteriorly --- instability --kyphosis --- later internal Gibbus Not a favoured procedure now a days. Dr. Paresh Golwala 32
  33. 33. ANTERIOR SURGERY       Gold standard treatment Radical surgery Deals with the precise pathology Stabilizes vertebrae Decompresses thoroughly Done in our institute Dr. Paresh Golwala 33
  34. 34. PREFERRED APPROACHES       Cervical Spine --- Anterior Cervico Dorsal --- Thoracotomy Through Second Rib Dorsal --- Thoracotomy Dorsolumbar Junction --- Thoraco Abdominal Approach Lumbar --- Retroperitoneal Lumbosacral --- Anterior Laparotomy Dr. Paresh Golwala 34
  35. 35. INSTRUMENTATION Anterior : preferred by most  Posterior : TULI et al  Dr. Paresh Golwala 35
  36. 36. BONE GRAFTING Tricortical iliac crest : good , preferred  Rib graft : good osteo-induction likely to fracture or collapse  Fibular good strength femoral : and tibial poor osteo induction  Dr. Paresh Golwala 36
  37. 37. HARDWARE Anterior plating or screw and rod fixation OR  Post segmental pedicle screw fixation  Dr. Paresh Golwala 37
  38. 38. RAJNIBEN PATIDAR, 25/F FRANKEL’S GR- D PREOP: L3-4 KOCH’S WITH PSOAS ABSCESS Dr. Paresh Golwala 38
  39. 39. Dr. Paresh Golwala 39
  40. 40. RAJNIBEN : IMMEDIATE POST OP Dr. Paresh Golwala 40
  41. 41. RAJNIBEN : 3 MONTHS POST OP Dr. Paresh Golwala 41
  42. 42. YOGESH PATEL, 18/M, KOCH’S C 3, FRANKEL’S GR- D PREOP Dr. Paresh Golwala 42
  43. 43. Dr. Paresh Golwala 43
  44. 44. YOGESH : IMMEDIATE POST OP Dr. Paresh Golwala 44
  45. 45. YOGESH : 3 MONTHS POST OP Dr. Paresh Golwala 45
  46. 46. KANJIBHAI,34/M, KOCH’S D3-4 FRANKEL’S GR- A PREOP Dr. Paresh Golwala 46
  47. 47. Dr. Paresh Golwala 47
  48. 48. POST OP Dr. Paresh Golwala 48
  49. 49. MALE PATIENT – 60 YEARS WITH HUGE COLD ABSCESS – PREOP - MRI Dr. Paresh Golwala 49
  50. 50. MALE PATIENT – 60 YEARS WITH HUGE COLD ABSCESS – PREOP – CT SCAN Dr. Paresh Golwala 50
  51. 51. MALE PATIENT – 60 YEARS WITH HUGE COLD ABSCESS POSTOP Dr. Paresh Golwala 51
  52. 52. MALE PATIENT – 60 YEARS WITH HUGE COLD ABSCESS POSTOP Dr. Paresh Golwala 52
  53. 53. COMPLICATIONS  Paraplegia – Difficult to rehabilitate – Bed sores – UTI  Unyielding TB infection associated with HIV may lead to death. Dr. Paresh Golwala 53
  54. 54. AUTONOMIC DYSFUNCTION SPINAL CORD LESION WITH NEUROLOGICAL DEFICIT IS ASSOCIATED WITH SIGNIFICANT DYSFUNCTION OF SYMPATHETIC NERVOUS SYSTEM  LOSS OF SUPRA-SPINAL CONTROL OF SYMPATHETIC NERVOUS SYSTEM  ASSOCIATED WITH CERVICAL AND  Dr. Paresh Golwala 54
  55. 55. AUTONOMIC DYSFUNCTION CONT…  COMPLICATED BY 3 PHENOMENON BELOW THE LEVEL OF LESION: 1) REDUCED SYMPATHETIC ACTIVITY LEADS TO ORTHOSTATIC HYPOTENSION 2) LOW RESTING BLOOD PRESSURE Dr. Paresh Golwala 55
  56. 56. Dr. Paresh Golwala 56

×