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Musculoskeletal Tuberculosis overview
- 1. Dr Ramkrishna Dahal Clinical fellow in Spinal Reconstructive Surgery Grande International Hospital
- 2. Identify most common Musculo-skeletal tubercular infections. Differentiate with other similar looking pathologies.
- 3. Historical aspects and epidemiology Case Illustrations Potts spine Tubercular arthritis Tubercular osteomyelitis Tuberculosis of tendon sheath and bursa Drug resistance Take home messages
- 4. Oldest recognized disease of mankind Sir Percival Pott in 1779 Robert koch discovered mycobacterium in 1882 Potts spine mentioned in Righbeda and Atharbabeda Most frequent infectious disease after malaria worldwide.
- 7. 27 yrs/F -Pain in left foot -Painful weight bearing initially on presentation -Not able to bear weight at all after 2 months
- 9. -Painless and weight bearing on last visit
- 10. On presentation
- 16. Plasma cell neoplasm with Amyloid deposition
- 18. Most frequent site Upto 50 % Resurgence of disease following HIV pandemic in developed world
- 19. Any age group but majority <30 yrs Fever Back pain Pain on mobility Constitutional symptoms Local tenderness Deformity
- 20. Hematogenous Perivertebral arterial/venous plexus Primary focus in lungs, GIT, Lymphnodes Thoracolumbar junction most commonly affected> mid thoracic >cervical C1-C2 in <1% Skip lesion in 4-10%
- 21. Para discal region Blurred para discal margin Cancellous area of vertebral body Spread of the infection beneath ALL to adjacent level
- 22. No proteolytic enzyme so disc is spared unlike pyogenic infection Floating disc sign Disc destruction only when both side of disc loose its nutritional support by bony destruction In children comparatively early involvement of the disc due to hydration of disc
- 23. Paradiscal Central Anterior ◦ Spread beneath ALL ◦ Symptoms severe than radiograph findings Appendiceal ◦ Usually in contiguity with vertebral body involvement ◦ Isolated posterior elements involvement rare< 2 % ◦ MC in cervical and upper thoracic region
- 24. NAT: Neural Arch tuberculosis ◦ Pedicle most common site ◦ Pediculo-laminar involvement Pyogenic spondylitis: ◦ Facet joint involvement Paraplegia associated with NAT has better prognosis than with typical TB spine
- 26. Exudate follows the path of least resistance along the fascial plane, blood vessels and nerves to distant site as cold abscess
- 28. Look for primary lesion Chemotherapy Percutaneous drainage in zigzag fashion Pigtail catheter under USG guidance Surgery
- 29. Paraparesis upto 30 % Higher incidence in cervical region disease quadriparesis upto 40%
- 30. Early onset paraplegia Late onset paraplegia: ◦ Poor outcome Motor function involved greater and earlier than sensory
- 31. Lymphocytosis High ESR Mantoux AFB Culture and sensitivity PCR ◦ Rapid method ◦ Differentiate between typical and atypical mycobacterium ◦ Does not differentiate between live and dead organism
- 32. Upto 30 % bone loss 2 to 5 months to be visible in x-ray MRI: investigation of choice DW-MRI to differentiate TB with MM, Mets
- 33. Two adjacent vertebrae involved in upto 50% of cases Disc space remain intact for longer duration of disease
- 34. Knuckle : single vertebra Angular gibbus: two-three Round gibbus: >3 vertebrae
- 35. Globular- abscess under tension Bird nest app: thoracic region (Fusiform app) Aneurysmal effect: ◦ D4-D10 level Calcification in paraspinal abscess is pathognomonic for tubercular abscess.
- 37. Spinal cord has physiological reserve to withstand pressure if it develops slowly 40-50% decrease in cord diameter- compatible with good cord function Cord edema Myelomalacia Cord atrophy Spinal tumor syndrome
- 40. Regression of the lesion Static lesion Well defined outlines Evidence of sclerosis Fusion of adjacent vertebrae- surest sign of healing spinal TB Healed TB: clinical and radiological evidence of healing with no sign of recurrence
- 41. Slow progession MRI: ◦ Preservation of disc space ◦ Multiple contiguous lesion ◦ Frequent involvement of posterior elements than in pyogenic ◦ Well defined para spinal lesion ◦ Calcification and thick rim of enhancement
- 42. Disc space narrowing seen in 7-10 days End plate erosion/ sclerosis seen in 10-21 days
- 44. Like tuberculosis course is indolent Gas within disc Lower lumbar spine Absence of gibbus Minimal paraspinal mass
- 45. Mets in adult Eosinophilic granuloma in children
- 46. Begins in synovium or in the metaphyseal spongiosa Marginal erosion are more common in weight bearing joints Rice bodies in synovium
- 47. Phemister triad ◦ Periarticular osteopenia ◦ Marginal erosion ◦ Gradual reduction in joint space
- 48. Radiological staging ◦ Stage of synovitis ◦ Stage of early arthritis ◦ Stage of advanced arthritis ◦ With subluxation/dislocation Early loss of joint space seen in rheumatoid arthritis, helps differentiate from TB.
- 49. Fibrous ankylosis in TB, bony ankylosis in pyogenic arthritis. Triple deformity of knee ◦ Flexion ◦ ER/Valgus ◦ Posterior subluxation of tibia
- 50. Caries Sicca: ◦ Atrophic type of TB shoulder ◦ Benign course ◦ No pus ◦ Small pitted erosion on the humeral head
- 51. Sinus tract Always culture and biopsy should be taken from sinus tract specimen Suspect TB if no growth from sinus material Isolated Staph. Epidermidis growth
- 52. TB of SI joint ◦ Usually U/L ◦ a/w TB spine Potts puffy tumor: ◦ TB osteomyelitis of skull with overlying abscess.
- 53. Tubercular dactylitis: ◦ Primarily disease of childhood ◦ Short tubular bone distal to carpus and tarsus ◦ Bones of hand> bones of feet ◦ Often benign course without pyrexia ◦ Spina ventosa ◦ Differentiate from enchondroma
- 56. Eradicate the infection Relieve pain Preserve and restore bone and joint function
- 57. Mono-resistance: resistance to one first-line anti-TB drug only Poly-resistance: resistance to more than one first-line anti-TB drug, other than both isoniazid and rifampicin Multidrug resistance (MDR): resistance to at least both isoniazid and rifampicin
- 58. Extensive drug resistance (XDR): resistance to any fluoroquinolone, and at least one of three second-line injectable drugs (capreomycin, kanamycin and amikacin), in addition to multidrug resistance
- 59. The MDR-TB burden largely falls on 3 countries – India, China and the Russian Federation. Account for nearly half of the global cases. Worldwide, only 55% of MDR-TB patients are currently successfully treated.
- 60. Drug resistance emerges when anti-TB medicines are used inappropriately Poor quality drugs Patients stopping treatment prematurely.
- 61. Always think of tuberculosis in chronic indolent course of musculoskeletal diseases. Not everything that looks like tuberculosis is tuberculosis. Histopathological report is mandatory before starting chemotherapy.