Osteoarticular tuberculosis is a common disease globally and in India, with involvement of bones and joints in around 30% of tuberculosis cases. It occurs most commonly in the spine, hip, knee, and other joints. It spreads hematogenously from a primary pulmonary or other visceral lesion. Spinal involvement often leads to deformities like gibbus formation or neurological complications like paraplegia. Treatment involves anti-tubercular medications like ATT along with rest and surgery if needed to drain abscesses or decompress nerves. Hip involvement can progress through stages of synovitis, arthritis, and advanced destruction requiring treatments like joint debridement, arthrodesis, or excision arthroplasty.

1. A Glimpse on Osteo-articular
Tuberculosis
Dr Khushwant Singh Rathore
Senior Resident
AIIMS, Jodhpur

2. The tubercle bacillus has co-existed with
Homo sapiens since time immemorial.
The Vedas and Samhita of Charaka & Sushruta
recognized the disease as “Yakshma”
Tuberculous lesions have been found even in Egyptian
mummies.

3. Prevalence
The prevalence of the disease is around 30 million globally and approximately
30% or 10 million cases exist in India, 21-3% of the 10 million have involvement of
bones & joints.
The predisposing factors
1). Malnutrition
2). Environmental conditions and living standards such as poor sanitation, over
crowded housing and slum dwelling.
3). A diabetic status is an important pre-disposing factor.
4). Acquired immune-deficiency syndrome has certainly led to a resurgence of
tuberculosis.
Osteo-articular disease is always secondary to a primary lesion in the
lung or other viscera.

4. Aetio-pathogenesis
Osteo-articular tuberculosis occurs in the following order:-
Spine>hip>knee>foot>elbow>wrist>hand>shoulder>bursal
sheaths>others.
The major method of spread is haematogenous.
The most common method of spread to the vertebral body is
through Batson's pre-vertebral venous plexus.

5. Primary focus in viscera
Haematogenous seeding in skeletal tissue
Ingested by mononuclear cells
Coalesce to form epitheloid cells
Lymphocytes form a ring around epitheloid cells to form a
tubercle.

6. casseation in centre of tubercle
The host inflammatory response intensifies, resulting in
exudation and liquefaction, and a cold abscess is formed
A cold abscess is composed of serum, leukocytes,
caseation, bone debris, and bacilli.
Abscess tracks along paths of least resistance to
present over skin as swelling which may rupture
to form sinus

7. Disease Presentations
 Spine – Pott’s disease & Pott’s paraplegia
 Joints - Tubercular arthritis
 Long and flat bones - Tubercular osteomyelitis
 Short bones – Tubercular dactylitis(spina ventosa)
 Tendon sheath & bursae- TB bursitis & tenosynovitis

8. Tuberculosis of the
Spine

9.  Most frequent site of osseous involvement by TB
 the disease was first described by Sir Percival Pott in
1779, hence the name Pott's disease
 There has been a resurgence of the disease in the
developed countries following the HIV pandemic.
 Defined - as an infection by Mycobacterium tuberculosis
of one or more of the extradural components of the
spine namely the vertebra, intervertebral disks, paraspinal
soft tissues and epidural space
Introduction

10.  Usually by hematogenous route
 Peri-vertebral arterial or venous plexus is still in debate, but arterial
route considered more important.
 Primary focus in the lung or other extra-osseous foci such as lymph
nodes, GIT or any other viscera
 Lower thoracic and lumbar vertebrae are most often affected
 Usually two continuous vertebrae are involved but several vertebrae
may be affected, skip lesions and solitary vertebral involvement may
occur
 The so-called skip lesions or a second lesion not contiguous with the
more obvious lesion is seen in 4 -10 % of cases.
Pathophysiology

12. CLINICAL FEATURES
 PRESENTATION VARIES FROM NON SPECIFIC BACK ACHE TO
CATASTROPHIC PARAPLEGIA
 COMPLAINTS:
PAIN
STIFFNESS
COLD ABSCESS ( IF EVIDENT EXTERNALLY)
PARAPLEGIA
DEFORMITY
CONSTITUTIONAL SYMPTOMS (20-30% patients only)

13. EXAMINATION
 SHOULD HAVE A HIGH INDEX OF SUSPICION
 AIMS : LOOK FOR FINDINGS OF TB SPINE
 LOCALISE SITE OF LESION
 DETECT COMPLICATIONS- COLD ABSCESS /
PARAPLEGIA
 GAIT : SHORT STEPS
 ATTITUDE & DEFORMITY
 PARAVERTEBRAL SWELLING
 TENDERNESS ON THE AFFECTED SPINE
 REDUCED MOBILITY

14. DEFORMITY : GIBBUS

15. NEUROLOGICAL EXAMINATION
 AIMS: DETECT ANY COMPRESSION
LEVEL OF COMPRESSION
SEVERITY OF COMPRESSION
 LIMBS – UPPER OR LOWER BASED ON SITE
MOTOR , SENSORY , REFLEXES , BOWEL AND BLADDER FUNCTIONS
GENERAL EXAMINATION
PHYSICAL EXAMINATION
SYSTEMIC ILLNESS : DM , HYPERTENSION

16. GENERAL INVESTIGATIONS
 ESR
 MANTOUX
 ELISA : ANTI TB ANTIBODY
 CHEST X RAY : FOR PULMONARY TB

17. Conventional Radiographs –
 Initial investigation
 often negative in early disease
 More than 30 to 50 % of mineral must be lost before a radiolucent
lesion becomes conspicuous on the plain films and this takes about 2
to 5 months
Imaging modalities

18. Abscess formation –
 Paravertebral soft tissue opacity
 Usually out of proportion to the degree of osseous destruction
 commonly bilateral and uniform
 may be globular indicating pus under tension
 may be minimal in the central variety of tubercular lesion
 cervical region - widening of the pre-vertebral soft tissues
 dorsal spine - the posteromedial pleural line is displaced laterally &
the abscess produces as typical fusiform shape called the "birds nest"
appearance

19. RETROPHARYNGEAL ABSCESS MEDISTINAL WIDENING

20. Birds nest abscess Psoas Abscess

22. Advantages –
 early detection of bone and soft tissue changes when plain films are
normal
 better anatomic localization and characterization of lesions
 evaluation of areas difficult to evaluate on plain films such as cranio-
vertebral junction, cervico-dorsal junction, sacrum
 providing guidance for biopsy and surgical approach
Computed Tomography

23.  modality of choice
 advantages –
 multiplanar capability
 the direct demonstration of early bone marrow involvement or edema
 unsurpassable assessment of spinal canal and neural involvement
 Soft tissue and Intraosseous abscesses are also well demonstrated on
MR imaging
 Higher sensitivity for early infiltrative disease including endplate
changes and marrow infiltration than bone scan and plain films
Magnetic Resonance Imaging

24.  MRI Scores over CT in-
 Detection of early disease (marrow edema)
 Skip lesions more easily and more often detected. Incidence of multilevel
noncontiguous vertebral tuberculosis is generally reported to be between
1.1 and 16 %
 Detection of epidural, meningeal and cord involvement
 Planning the surgical approach

25. • COMPLICATIONS
COLD ABSCESS
NEUROLOGICAL COMPLICATIONS : PARAPLEGIA

26. Types of paraplegia
 EARLY ONSET – during active phase, < 2 years
 INFLAMMATORY EDEMA
 EXTRADURAL PUS & GRANULATION TISSUE – COMMOMN
 SEQUESTRA
 INFARCTION OF SPINAL CORD
 EXTRADURAL GRANULOMA
 LATE ONSET – during healed phase, > 2 years
internal gibbus
recurrence

27. TREATMENT
What is Middle path regime?(why called middle path)
 Rest in bed
 Chemotherapy (ATT 4HRZE + 8 HRE)(ATT?)
 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

28. RX of COLD ABSCESS
 SMALLER ONES SUBSIDE WITH TB THERAPY
 IN SUPERFICIAL ABSCESSES :
 ASPIRATION : USING THICK NEEDLE
 EVACUATION
 PSOAS ABSCESS : drain retroperitoneally

29. Rx of paraplegia
 CONSERVATIVE : ANTI TB RX , REST TO SPINE ,
 SURGICAL :
 INDICATIONS : PARAPLEGIA IN CONSERVATIVE Rx
 SUDDEN ONSET SEVERE PARAPLEGIA
 SEVERE PARAPLEGIA : IN FLEXION, MOTOR / SENSORY
LOSS > 6 MONTHS OR COMPLETE MOTOR LOSS ONE
MONTH DESPITE CONSERVATIVE Rx
 PARAPLEGIA WITH UNCONTROLLED SPASTICITY

30. PROCEDURES
 1. COSTO TRANSVERSECTOMY
 2. ANTEROLATERAL DECOMPRESSION
 3. RADICAL DEBRIDEMENT AND ARTHRODESIS
( HONKONG OPERATION)
 4. LAMINECTOMY

31.  Involvement in about 15 % cases of osteo-articular TB
 Lesions can arise in acetabulum, synovium, femoral epiphysis or
metaphysis or spread to the hip from foci in the greater trochanter or
ischium.
 If upper end of femur involved(being entirely intracapsular), the joint
is involved early in disease
 Erosion or lytic lesions may also occur in the greater trochanter or the
overlying bursa, without involvement of the hip joint for a long period
of time
Tuberculosis of Hip

32. Clinical - Irritable hip, FABER with APPARENT LENTHENING
Radiography –
 Plain radiograph usually normal
 Displacement of fat planes (effusion)
 Soft tissue swelling and deossification
 Radiologically significant osteoporosis appears 12 to 18 weeks after
onset of symptoms
Stage of synovitis

33. Ultrasound, CT and MRI
 more sensitive in this stage to detect increased joint space and
accumulation of fluid.

34. Clinical – FADIR + Stage of apparent shortening
 Peri-articular erosions
 Reduction of joint space (destruction of articular cartilage)
 Lesions can usually be picked up on CT before they are apparent
on plain radiographs
Stage of early arthritis

35.  Clinical – FADIR + stage of true shortening
 Destruction of articular cartilage, acetabulum, femoral head, capsule
and ligaments
 Capsule may get thickened and contracted
 Upper end of femur may displace upwards and dorsally breaking the
Shenton’s line
 Lower part of acetabulum empty (Wandering acetabulum)
 If femoral head, neck are grossly destroyed and collapsed in on
enlarged acetabulum, this appearance is called "mortar and pestle"
appearance
Stage of advanced arthritis

36. Stage of advanced arthritis -
Complete destruction, deformity & subluxation
Wandering acetabulum

37. Mortar & pestle appearance
• Gross destruction of head
• Enlarged acetabulum

38. • Management
1. Synovitis + early arthritis
rest+ traction+ ATT
2. advanced arthritis
joint debridement &
achieve favourable ankylosis by traction
if painful ankylosis
excision arthroplasty
arthrodesis
corrective osteotomy
THR(After 2 years)

39. THANKS