TB Spine case presentation

1. CASE PRESENTATION
INTERN DR AMIT POUDEL

2. PATIENT PARTICULARS
• 52yrs/ male, from Yamgha- 8 palpa
• Literate
• Hindu
• Farmer
• Admitted on 2072-02-05 via emergency

3. c/o
• Back-ache for 7 months
• Tingling sensation below the umbilicus for 7 months
• Weakness of the lower limbs for 15 days
• Decreased sensation of the lower limbs for 15 days
• Inablity to walk for 1 day

4. Back- ache
• Mostly in the thoraco- lumbar region
• Insidious in onset and gradual in progression
• Dull aching pain in the beginning which progressed to severe pain
during the later course of the disease.
• Initially no radiation of the pain but later occasionally radiated to the
outer aspect of the thigh.

5. • Mostly associated with movement and exercise
• Initially used to occur during the night but later occurred throughout
the day and night.

6. Tingling sensation
• part of body below the umbilicus.
• b/l symmetrical
• Non progressive
• Hands are not involved

7. Weakness
• Muscles below the umbilicus
• Initially was mild in intensity and he could carry his normal activity
with support of a cane
• Later the weakness progressed so that he was unable to stand on his
own

8. Decrease in sensation
• Decreased sensation in the lower limbs as compared to the upper
limbs
• But could perceive all the sensation throughout the period of disease
progression.

9. No h/o
• Evening rise of temperature
• Loss of weight and appetite
• Chest pain and sputum production
• Local trauma
• Mass in the back
• Glove and stocking pattern of paraesthesia

10. Past hx
• Took medication for fever from district hospital 2 yrs back. Relieved
after 20 days of medication.
• No h/o of DM, HTN, Syphilis, HIV, Blood transfusion
• No any surgical intervention in the past.

11. Family history
• Elder brother was a k/c/o PTB 20 yrs back and died of the same
disease.
• No other family members with TB known.
• No other significant medical history in the family.

12. Personal history
• Ex- smoker
• Left smoking 3 yrs ago
• Has not consumed alcohol.
• Consumes both veg and non veg diet.

13. O/E
• GC- fair
• PILCCOD – nil
• GCS- E4M5V6
• Vitals- stable

14. S/E
• CVS- S1S2 present, no murmur
• RS- B/l equal air entry
Nvbs
• P/A- Soft, nontender, no organomegaly

15. CNS
• Well oriented to time place and person
• CN- intact
• Motor examination
Bulk B/L equal
Tone normal tone of muscle on both the sides but RT>LT

16. • Power rt lt.
• Iliopsoas (L1L2L3) 4/5 4/5
• Adductor longus (L2L3) 5/5 3/5
• Quadriceps femoris (L3L4) 5/5 4/5
• Tibialis anterior (L4L5) 4/5 5/5
• Extensor digitorum longus (L5) 5/5 4/5
• Extensor hallucis longus (L5) 5/5 4/5
• Flexor digitorum longus (S1S2) 5/5 4/5
• Co-ordination of the muscle could not be tested.

17. • Sensory examination
• Sensation impaired below the level of T10
• Temperature sensation (impairment in rt > lt)
• Pain sensation ( B/L similar)
• Touch sensation (B/L similar) (both for crude and fine)
• Vibration sensation ( B/L similar)

18. • Reflexes
rt lt
• Knee +++ +++
• Ankle + +
• Planter flexor flexor
• Reflexes in the upper limb was bilaterally symmetrical and normal.

19. Local examination of the spine
• Look
• Normal curvature of spine
• No evidence of abscess or mass
• No evidence of gibbus
• Feel
• No any abnormality felt during the palpation of the spine
• Tenderness absent
• No mass or abscess

20. • Movement and measurement of the spine was not done

21. Investigation
• Haematology
• Hb-12.5 mg/dl
• ESR-16 MM/1ST HOUR
• WBC COUNT- 10,100 cells/cumm
• Neutrophils-70%
• Lymphocytes- 25%
• Eosinophils- 02%
• Monocytes -03%

22. • Urine (RME) - WNL
• Blood urea – 22.0 mg/dl
• Serum creatinine – 1.0 mg/dl
• Na – 133.0 meq/l
• K – 4.8 meq/l
• RBS – 78 mg/dl

23. • X ray thoraco lumbar spine
• Shows evidence of decreased joint space between T5-T6 vertebra
• Destruction of lower margin of T5 vertebra
• Destruction of upper margin of T6 vertebra

24. • MRI of spine
• Wedging and inhomogenous signal intensity is seen in T5, T6 vertebra and
T5T6 intervertebral disc with epidural soft tissue component causing thecal
compression and spinal cord narrowing. Cord is compressed and shows T2
hypersensitivity s/o cord oedema. Large prevertebral and paraspinal soft
tissue component is also seen. The prevertebral soft tissue is extending from
T4-T7 level .
• Radiological features are suggestive of infective etiology ( pott’s ).

25. • Sputum examination - Negative

26. diagnosis
• TB spine with neurological involvement (Grade II)

27. Treatment
• Treatment as per the national tuberculosis programme guidelines
• ATT (4 tab of HRZE) PO X OD
• Cap methylcobalamin 1 cap PO X OD
• Cap multivitamin 1 cap PO X OD
• Complete bed rest
• Normal diet

28. National Tuberculosis Programme Guidelines
• Based on case definition, a TB patient falls into 1 of 2 categories
for treatment.
TB TREATMENT CATEGORY PATIENT
• Category 1 new sputum smear-positive PTB,sputum negative PTB and
extra pulmonary TB.
• Category 2 relapse treatment failure treatment after default.

29. • SEVERE EXTRAPULMONARY TB
• meningitis
• miliary
• pericarditis
• Peritonitis
• bilateral or extensive pleural effusion
• spinal
• intestinal
• genitor-urinary

30. • Nepal NTP use daily regimen, if recommended for 7 month
continuation phase in patient with
• TB Meningitis,
• Miliary TB and
• Spinal TB with neurological complication

31. Fixed dose combination
• 1.Isoniazide [75 mg] + Rifampicin [150 mg] + Pyrazinamide [400mg] +
Ethambutol [275mg] (HRZE)
• 2. Isoniazide (150mg) +Rifampicin [150mg] (HR)
• 3. Isoniazide [75 mg] + Rifampicin [150 mg] + Ethambutol [275mg]
(HRE)
• So in a 60 kg patient the required dose of ATT is 4 tablets of the first
fixed dose regimen.

32. Future plans
• Discharge the patient with thoracolumbar belt advising for very
limited movement.
• Regular follow up for re- evaluation.
• Surgery if indicated.

33. Indications of surgery
• Absolute indications:
1. Paraplegia developing when the patient is on adequate medical line of
treatmen
2. Paraplegia not showing improvement with adequate medical line of
treatment.
3. Paraplegia progressing even with adequate medical line of treatment.
4. Complete paraplegia with no improvement with adequate medical line of
treatment.
5. Severe spastic paraplegia.
6. Paraplegia of rapid onset.
7. Long standing paraplegia >6 months, paraplegia in flexion, flaccid
paraplegia, etc.

34. • Relative indications:
1. Recurrent paraplegia.
2. Paraplegia in old age.
3. Painful paraplegia.
4. Paraplegia with complications such as urinary infection and stones.
.

35. Surgical Procedures
• Drainage of abscess
• Costotransversectomy
• Anterolateral decompression
• Anterior decompression and fusion
• Laminectomy