TB SPINE with Neurology-“ What is expected from you”.
How do I present a case of TB Spinewith neurological deficit How to examine a spine case How to diagnose TB spine What are the other possible diagnosis How to differentiate from them clinically How they are investigated in your hospital Possible options in management How is it managed in your hospital Common problems involving spine Common problems causing similar deficit
How to examine a spine case The sequence to present the case…like aCNS case protocol or ortho way- Easy steps to find the motor and sensorylevel- Specific findings and tests to be done in aspine with neurology case What to say of bladder and bowel Should we do all the tests for sensationslike vibration, fine touch etc
The sequence to present the case…like aCNS case protocol or ortho way You should present the case as you willproceed to do spine exam
History should take into considerationPathology part – TB and its D/DArea of involvement – SpineComplications – neuro deficit
History TB – general symptoms and local symptomsspecific to area of involvement Leading questions specific to TB of spine Negative history of DDsAnkylosing spondylitisDisc degTumorsSepticTrauma
History Common problem Perfect diagnosis Not able to justify that
Expose the back and legs. Look for the following:– sinuses; scars and nodes– deformity and asymmetries - postural orpermanent; direction / plane i.e. kyphosis ortilt– muscle spasm, fasciculation, wasting -specifically calf and buttock– legs / arms - wasting, movement, muscleimbalance, size
palpation You have to know your anatomy to know whatyou are feeling! With the patient standing and then perhapslater, lying supine, palpate the back for the:– skin temperature– deformity of the spine - steps or a steady contour?
vertebral tenderness - localised or general ?paraspinal spasm and muscle tendernesssacro-iliac tenderness in sacroilitis
Elsewhere:– feel for peripheral pulses– palpate groin and abdomen for abscesses– Chest, abdominal, rectal examination
Movts and measurements Measurement of mobility of the spine Movements Chest expansion costovertebral movements are gauged byasking the patient to breathe in and out: thedistance between maximal inspiration andexpiration is normally 5cm.
Special tests Straight Leg Raising Test (SLR) Bowstring Sign Crossed SLR Reverse sciatic tension test Schobers test Femoral stretch
the patient is then asked to lie supine and thestraight leg raise test is performed. carry out neurological testing of power; sensation - reflexes - do a rectal examination - check tone, power,sensationNeurological examination
Easy steps to find the motor and sensorylevel What to say of bladder and bowel- Should we do all the tests for sensationslike vibration, fine touch etc What the examiner is looking in a spineneurology case
Neurological assessment Neurological assessment is an essential part ofthe examination of the spine. The examination should involve a fullassessment of muscle wasting, fasiculation,tone, power, coordination / proprioception,sensation and reflexes. perianal reflexes and sphincter tone should betested.
SEGMENTAL NEUROLOGY When examining the cervical spine it is essential toexamine the segmental neurology. Root lesions may be indicated by weakness in theupper limbs in a segmental distribution, with loss ofdermatomal sensation and altered reflexes. If cervical cord compression is suspected the lowerlimbs should also be examined specifically looking forupgoing planters and hyperreflexia.
Sensation. Know your C5 to T1 dermatomes. Test light touch and sharp/dull sensation.
REFLEXES Muscle stretch reflexes. Test the followingreflexes: Biceps - C5/6 Brachioradialis - C5/6 Pronator - C 6/7 Triceps - C7/8
Sensation Know your L4 to S1 dermatomes Light touch, sharp/dull sensation
Some tips get the patient to stand on their toes, thuschecking plantar flexion of the foot and the S1nerve root. If necessary, test each foot separately, givingthem some support with an outstretched arm. Ask them to rock onto their heels - test of L4/L5
Should we do all the tests for sensationslike vibration, fine touch etc What the examiner is looking in a spineneurology case
The examination should include the following:– Careful assessment of spine– Examination for abscesses– Abdominal evaluation for psoas / iliac mass Meticulous neurologic examination
TB Spine – History The presentation of Pott disease dependson the following:– Stage of disease– Affected site– Presence of complications such asneurologic deficits, abscesses, or sinustracts
TB Spine – History The reported average duration of symptoms atdiagnosis is 4 months but can be considerablylonger, even in most recent series. This is due to the nonspecific presentation ofchronic back pain.
TB Spine – History Back pain is the earliest and most commonsymptom.– Patients with Pott’s disease usuallyexperience back pain for weeks beforeseeking treatment.– The pain caused by Pott’s disease can bespinal or radicular.
TB Spine – History Insidious onset of localised pain in the spine. This is usually accompanied by fever, malaise,anorexia and weight loss. Clumsiness in walking and weakness in lowerlimbs may be present. There may be evidences of associatedextraskeletal tuberculosis Presence of hoarseness, dysphagia, respiratorystridor or torticollis indicate cervical involvement.
TB Spine – History The onset of is usually insidious and of slowevolution. Potential constitutional symptoms of Pott’sdisease include fever and weight loss. Patient might have constitutional symptomslike low-grade fever, anorexia and weight loss.
TB Spine – History They usually precede local symptoms andsigns such as pain, tenderness and swelling ofthe affected part. However absence of constitutional symptomsdoes not rule out the possibility of the diseaseas it is common for patients to present withoutany constitutional symptoms.
TB Spine – History Neurologic abnormalities occur in 50% ofcases and can include spinal cord compressionwith paraplegia, paresis, impaired sensation,nerve root pain, and/or cauda equinasyndrome.
On examination - TB Spine - spasm Muscle spasm makes the back rigid. Motion of the spine is limited in all direction. When picking an object up from the floor, thepatient flexes his hips and knees, keeping thespine in extension.
In TB Spine - spasm Spasm of the paravertebral muscles in thelumbar region is also elicited by passivehyperextension of the hips with the patient inprone position-this also puts stretch on theiliopsoas muscle, which is in spasm andcontracture owing to psoas abscess
In TB Spine - deformity Almost all patients with Pott disease havesome degree of spine deformity A kyphus in the thoracic region may be the firstnoticeable sign. As the kyphosis increases, the ribs will crowdtogether and a barrel chest deformity willdevelop. When the lesion is situated in the cervical orlumbar spine, a flattening of the normallordosis is the initial finding.
In TB Spine - cervical Cervical spine tuberculosis is a less commonpresentation but is potentially more seriousbecause severe neurologic complications aremore likely.
In TB Spine - cervical– This condition is characterized by pain andstiffness.– Patients with lower cervical spine diseasecan present with dysphagia or stridor.– Symptoms can also include torticollis,hoarseness, and neurologic deficits.
In TB Spine - cervical Pott disease that involves the upper cervicalspine can cause rapidly progressivesymptoms.– Retropharyngeal abscesses occur in almostall cases.– Neurologic manifestations occur early andrange from a single nerve palsy tohemiparesis or quadriplegia.
In TB Spine - HIV The clinical presentation of spinal tuberculosisin patients infected with the humanimmunodeficiency virus (HIV) is similar to thatof patients who are HIV negative; however,spinal tuberculosis seems to be more commonin persons infected with HIV.
In TB Spine - Thoracic Although both the thoracic and lumbar spinalsegments are nearly equally affected inpersons with Pott disease, the thoracic spineis frequently reported as the most commonsite of involvement. Together, they comprise 80-90% of spinaltuberculosis sites. The remaining cases correspond to thecervical spine.
Cold abscess The abscesses may be palpated as fluctuantswellings in the groin, iliac fossa, retropharynx,or on the side of the neck, depending upon thelevel of the lesion.
Cold abscess Large cold abscesses of paraspinal tissues orpsoas muscle may protrude under the inguinalligament and may erode into the perineum orgluteal area. Tuberculous necrotic material from the cervicalspine may collect in the form of a cold abscessin the retropharyngeal region; at the posteriorborder of sternomastoid; in the back of neckalong spinal nerves and in the axilla alongaxillary sheath
Cold abscess Pott disease that involves the upper cervicalspine can cause rapidly progressivesymptoms.– Retropharyngeal abscesses occur in almostall cases.– Neurologic manifestations occur early andrange from a single nerve palsy tohemiparesis or quadriplegia.
Cold abscess Involvement of the dorsolumbar spine may lead to coldabscess in the rectus sheath and lower abdominal wallalong the intercostal, ilioinguinal and iliohypogastricnerves; in the thigh along the psoas sheath; in the back along the posterior spinal nerves; in the buttock along superior gluteal nerve; in the Petits triangle along the flat muscles ofabdominal wall or, in the ischiorectal fossa along the internal pudendalnerve.
Gait The gait of the person with Pott’s disease ispeculiar, reflecting the protective rigidity of thespine. His steps are short, as he is trying to avoid anyjarring of his back. In tuberculosis of the cervical spine, he holdshis neck is extension and supports his headwith one hand under the chin and the otherover the occiput.
Neurology Neurologic deficits may occur early in thecourse of Pott disease. Signs of such deficits depend on the level ofspinal cord or nerve root compression.
Neurology If paraplegia develops, there will be spasticityof the lower limbs with hyperactive deeptendon reflexes, a spastic gait, a varyingdegree of motor weakness, and disturbancesof bladder and anorectal function.
Extraspinal tuberculosis Many persons with Pott disease (62-90%) ofpatients in reported series have no evidence ofextraspinal tuberculosis, further complicating atimely diagnosis..
Rare presentation The presence of a sinus in the back with a thinwatery discharge is a strong evidence oftuberculous involvement of the posterior archof vertebral bodies. Rarely, tuberculous spondylitis may present assynovitis of posterior vertebral articulations,atlanto-occipital or atlanto-axial joints or asspinal tumour syndrome
How to say the final diagnosis Anatomoical Pathological Level Neuro – Cord compression Level – Motor, Sensory and Reflex Cord level, Vertebral level
What to say of bladder and bowel History Subject may be already catheterised
Provisional diagnosis Only one Diagnosis if there are no reasons (points) against that diagnosis Otherwise give DD
Investigations1. ESR2. Mantoux / Elisa -3. Xrays including chest4. CT5. MRI6. CT-guided procedures.7. Microbiology studies are used to confirmdiagnosis.
What are the common surgical treatmentsgiven Treatment – ATT –regime, duration. Surgical
Indications for surgical treatment Neurologic deficit (acute neurologicdeterioration, paraparesis, paraplegia) Spinal deformity with instability or pain No response to medical therapy (continuingprogression of kyphosis or instability) Large paraspinal abscess Nondiagnostic percutaneous needle biopsysample
Surgical options Costo-transversectomy ALD Anterior decompression and fusion Anterior decompression and fusion andinstrumentation ( posterior or anterior) Thoracoscopic surgery Posterior approach with transpediculardecompression and fusion withinstrumentation.
Resources and experience are key factors inthe decision to use a surgical approach. The lesion site, extent of vertebral destruction,and presence of cord compression or spinaldeformity determine the specific operativeapproach (kyphosis, paraplegia, tuberculousabscess). Vertebral damage is considered significant ifmore than 50% of the vertebral body iscollapsed or destroyed or a spinal deformity ofmore than 5° exists.
The most conventional approaches includeanterior radical focal debridement and posteriorstabilization with instrumentation. In Pott disease that involves the cervical spine,the following factors justify early surgicalintervention: High frequency and severity of neurologicdeficits Severe abscess compression that may inducedysphagia or asphyxia Instability of the cervical spine
Contraindications: Vertebral collapse of a lesser magnitudeis not considered an indication forsurgery because, with appropriatetreatment and therapy compliance, it isless likely to progress to a severedeformity.
ICS 2010a combined meeting ofSPINE SOCIETY OF EUROPE &ASSOCIATION OF SPINE SURGEONS OF INDIA3,4,5 September 2010International & National FacultyVenue:Golden Landmark Resort, Mysore.Theme: Iatrogenic complications in SpineResidential and Non-Residential Packages