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7. Presentation Spinal Tuberculosis-modified.ppt
- 1. Dr Suraj Bajracharya AssociateProfessor and Head Clinical Coordinator KIST Medical College Teaching Hospital Spinal Tuberculosis
- 2. Introduction Spinal TB firstdescribed by Percival Pott in 1779 “Pott’s Diseaes”
- 3. Incidence Approximately 10% ofTB cases affect the skeleton and 5% are in the spine More common during first three decade of life Equally distributed among both sexes Most common level of the lesion is T-L spine
- 4. Types of vertebralTB 1.Paradiscal 2.Central 3.Anterior 4.Posterior
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- 6. Anterior type with anteriorcold abscess
- 7. Central type ofSpinal tuberculosis
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- 9. Pain Localized to oneregion Localized tenderness Referred pain -Cervical spine ear pain, arm pain -T-L spine chest pain, intercostal neuralgia pain abdomen
- 10. Rigidity Cervical lesion Rigidity ofthe neck Thoraco-lumbar lesion Rigidity of the back Coin test positive
- 11. Deformity Cervical or Lumbarspine Loss of normal lordosis first, followed by gibbus Thoracic spine Angular kyphosis (gibbus) Gibbus depends upon number of vertebrae involved Gross kyphosis is seen in children
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- 13. Cold abscess The formationof cold abscess is an invariable feature of tuberculosis of the spine The abscess remains deep to the deep fascia it remains cold to touch without any inflammatory reaction and hence it is called cold abscess Gravitational tracking down from the site of origin to different place
- 14. Cold abscess Cervical spine Posterior,anterior cervical triangles along the brachial plexus in the axilla Thoracic spine Posterior mediastinum along the intercostal nerves lateral or anterior chest wall, posteriorly under the sacrospinalis muscle Lumbar spine Tracking down the psoas sheath, they are palpable in illiac fossa, in the lumbar triangle, in the femoral triangle below the inguinal ligament or even up to the knee
- 15. Contd… Psoas abscess canbe bilateral “ hip flexion deformity ” pseudo-hip flexion “ lump in the illiac fossa” Always rule out tuberculosis of the T10 to sacrum or disease of the SI joint, pelvic bone and hip joint Clinico-radiologically in the initial stage there will be no lesion
- 16. Paraplegia Complications occurs inonly 10% of the cases Highest incidence in patients with the lesions over the thoracic spine During clinical examination: Look for the early sign Slight spascity of the legs causing unsteady gait Exaggerated knee and ankle jerks Extensor plantar response Late onset Motor power, sensory loss, jerks and clonus
- 17. Early onset paraplegia(Group A) during the active stage of the disease up to 2yrs Late onset paraplegia (Group B) Lesion has reactivated after years of quiescence Types of paraplegia
- 18. Stage Clinical features INegligible Pt. unaware of neural deficit, physician detects plantar extensor and or ankle clonus II Mild Pt. aware of deficit but manages to walk with support III Moderate Nonambulatory because of paralysis (in extension) sensory deficit less than 50% IV Severe III + flexor spasm (paralysis in flexion) sensory deficit more than 50% with bowel and bladder involvement Classification of Paraplegia Tuli Classification for Assessment of Neurological Status in Spinal Tuberculosis
- 19. Plain X-rays Most difficultto recognize in early stage Paradiscal type of lesion Narrowing of the disc space is the earliest radiological sign Imaging
- 20. Paravertebral Shadows It isproduced by extension of tuberculous granulation tissue and the collection of the abscess in the paravertebral bodies Fusiform Globular Retropharyngeal abscess
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- 23. Imaging Central type ofthe lesion the infection probably reaches the centre through Batson’s venous plexus or the branches of the posterior vertebral artery Diseased vertebra losses the normal bony trabeculae
- 24. Imaging Anterior type oflesion infection starts beneath the anterior longitudinal ligament and the periosteum Scalloping effect saw tooth appearance
- 25. Imaging Skipped lesion More thanone tuberculos lesion may be present between healthy vertebrae Appendicle type of lesion Isolated tuberculous infection of the pedicles, transverse process, laminae and spinous process occur uncommonly Computer Tomography Para spinal abscess not seen on X-rays, destruction of the vertebrae CT guided Biopsy Magnetic Resonance Imaging To evaluate the health of the cord, compression
- 26. Skipped lesions –seen in lumbar and dorsal spine
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- 29. Investigations • Haematological investigation –Hb – Total count / ESR/CRP – PCR, ELISA test, D- dimer • Radiological investigations – Radiographs – CT Scan – MRI • Histo-pathological investigations
- 30. Differential Diagnosis Infectious Conditions •Pyogenicinfection •Typhoid spine •Brucella spondylitis •Mycotic spondylitis •Syphilitic condition of the spine Tumorus conditions •Hemangioma •Giant-cell-tumor •Aneurysmal bone cyst
- 31. Differential Diagnosis Primary malignanttumor •Multiple myeloma •Lymphomas •Secondaries •Histiocytosis Developmental abnormalities •Block vertebra •Hemivertebra •Spinal Osteochondrosis Traumatic condition Osteporotic Condition Hydatid Disease
- 32. Management Principle of Management •Promoterecovery •Achieve healing •Rehabilitation Conservative Management Four drugs anti-tubercular treatment Followed by rest or ambulation with the help of the braces If the patient does not improve Operative treatment
- 33. Treatment • Conservative treatment –Antitubercular multi drug treatment for duration upto 12 to 18 months – Braces, Orthosis – Supportive treatment • Surgical treatment
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- 36. Absolute Indications 1. Paraplegiaoccurring during usual conservative treatment. 2. Paraplegia getting worse or remaining stationary despite adequate conservative treatment. 3. Severe paraplegia with rapid onset may indicate severe pressure from a mechanical accident or abscess. 4. Any severe paraplegia such as paraplegia in flexion, motor or sensory loss for more than six months, complete loss of motor power for one month despite adequate conservative treatment. 5. Paraplegia accompanied by uncontrolled spasticity of such severity that reasonable rest and immobilization are not possible.
- 37. Relative Indications 1. Recurrentparaplegia, even with paralysis that would cause no concern in the first attack 2. Paraplegia with onset in old age: Indications for surgery are stronger because of the hazards of recumbence 3. Painful paraplegia, pain resulting from spasm or root compression 4. Complications such as urinary tract infection and stones
- 38. Rare Indications 1. Paraplegiadue to posterior spinal disease 2. Spinal-tumor syndrome 3. Severe paralysis secondary to the cervical disease 4. Severe cauda equina paralysis
- 39. Operative procedures a) Costo-transversectomy Indicatedin child with paraplegia and when tense abscess is visible in X-Ray b) Antero-lateral decompression Spine is opened from its lateral side and access is made to the front and side of the cord
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- 44. Operative procedures c) RadicalDebridement and arthodesis Transthoracic or transperitoneal approaches d) Laminectiomy spinal tumor syndrome
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- 48. PROGNOSIS a) Age ofthe patient b) Duration of the paraplegia c) Severity d) Onset of the paraplegia e) Sudden progress of the paraplegia