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Pottsspine & paraplegia by dr ashutosh
1. Pott’s spine & Paraplegia
PRESENTEDBY-
Dr. Ashutosh Kumar
AP Dept Of Orthopaedics
RMCH Bareilly
2. Epidemiology
• An estimated 2 million people have active Spinal TB
worldwide
India
• 1/5th of total TB Cases
• vertebral tuberculosis is commonest form of skeletal T.B.
5. Radiological Investigations
• Paradiscal lesions:
– Commonest lesions
– Spreads through arterial
supply
– Reduced disc space –
Earliest sign
– Loss of vertebral margins
– Increased pre-vertebral soft
tissue shadow.
6. Types of vertebral lesions
• 4 types:
1. Paradiscal- Arterial spread
2. Central – Venous spread
3. Anterior- Subperiosteal spread
4. Appendicular
vertebral body: areas of distruction or balooning
7. Radiological Investigations
• Central type:
– Spread through the batson’s
venous plexus/ branches of
posterior vertebral artery.
– At the end concentric
collapse resembling vertebr
plana
– Minimal Disc space reductio
a
n
9. Radiological Investigations
• Anterior type of lesion
– Starts beneath the
anterior longitudinal
ligament & periosteum
– Collapse and disc space
reduction is usually
minimal and occurs late
– Erosion is primary
mechanical
11. Radiological Investigations
• Appendicular type of
lesion
– Rare
– Isolated infections of
pedicles / lamina/
transverse processes/
Spinous process.
– Intact disc space
– Para vertebral shadows
12. Clinical Features
Constitutional
symptoms:
• Malaise
• Loss of
weight/appetite
• Night sweats
• Evening rise of
temperature
Active stage
Specific Symptoms:
• Pain/Night cries
• Stiffness
• painful Restricted ROM
• localised Deformity
• Enlarged lymph nodes
• Abscess
• Neurodeficit : motor appear first Sense of position and
vibration – last to disappear
• Spontaneous muscle twitching in lower limbs
• Clumsiness while walking
• Extensor plantar response
• Exagerrated reflexes – Sustained clonus of patella and ankle
13. Clinical Features
Healed stage
Constitutional symptoms:
• Malaise
• Loss of weight/appetite
• Night sweats
• Evening rise of temperature
Specific Symptoms:
• no pain and tenderness of spine
• Stiffness
• Deformity
• Restricted ROM
• Enlarged lymph nodes
• Abscess
• Neurodeficit
• ESR - normal
14. Neurological deficit
• 10-30% cases – Neurological deficit
• Disease below L1 vertebrae rarely causes Paraplegia
• Highest Incidence of paraplegia seen in TB of lower thoracic vertebrae
15. Classification of TB Paraplegia
Early onset paraplegia (group A)
• Appears within 2 years of onset –
during the Active phase
• Underlying pathology
– Inflammatory edema
– TB Granulation tissue
– Abscess
– Caseous tissue
– Ischaemis lesion of cord (Rare)
• Good prognosis
Late onset paraplegia (Group B)
• Appears more than 2 years of disease
in vertebral column
• Underlying pathology –due to
mechanical pressure on cord
– TB Debris
– TB Sequestra from body and disc
– Internal gibbus
– Canal stenosis / Severe deformity
• Poor prognosis
16. Staging of Neurological Deficit
Goel 1967, Tuli 1985, Kumar 1988, Jain 2002
Stage Severity Clinical Features
I Negligible Patient unaware of neurodeficit, physician detects plantar
extensors or ankle clonus
II Mild Patient aware of deficit but walks with support
III Moderate Non ambulatory due to spastic paralysis (in extension), sensory
deficit less than 50 %
IV Severe III + Flexor spasm / Paralysis in flexion / Flaccid/ Sensory deficit
more than 50 % / Sphincter Involved
17. Pathology of TB Paraplegia
Extradural mass : (mc), pus, granulation tissue. casseous material
Inflammatory edema : early cases. vascular stasis, toxins
bony disorders : sequestrum, gibbus, dislocation
meningeal changes: peridural fibrosis
infarction of spinal cord: irreversible
changes in spinal cord: myelomalacia, syringomalacia
extradural garnuloma and tuberculoma
18. Investigations
• CBC:
– Hb% ↓
– Lymphocytosis
• ESR:
– Raised in active stage of disease
– Normal ESR over period of 3 months suggests patient is in stage of repair
19. Investigations
• Mantoux test
– Erythema of more than 20 mm at 72 hours – Positive
– Negative test, in general, rules out the disease
20. Investigations
• Biopsy
– In case of doubt, it is mandatory to prove the diagnosis by obtaining the diseased
tissue
21. Investigations
• Smear and culture
– Pus: Zeill- Neilson stain → Acid Fast bacilli
– Culture of pus in Lowenstein jensen media
– Bactec For faster culture of Mycobacterium
tuberculosis
22. Investigation
• Serological Investigations
– ELISPOT (Enzyme- linked immunospot)
– T-cell based assay from blood
– IgM & IgG antibodies : High sensitivity, low specificity
– PCR: more sensitive
23. Radiological Investigations
• Xray: Plain radiograph signs
– Reduced disc space
– Blurred paradiscal margins
– Destruction of bodies
– Loss of trabecular pattern
– Increased prevertebral soft tissue shadow
– Subluxation /dislocation
– Decreased lordosis/Kyphosis
24. Radiological Investigations
• Xray: Plain radiograph signs
– Reduced disc space
– Blurred paradiscal margins
– Destruction of bodies
– Loss of trabecular pattern
– Increased prevertebral soft tissue shadow
– Subluxation /dislocation
– Decreased lordosis/Kyphosis
25. Radiological Investigations
• Xray: Plain radiograph signs
– Reduced disc space
– Blurred paradiscal margins
– Destruction of bodies
– Loss of trabecular pattern
– Increased prevertebral soft tissue shadow
– Subluxation /dislocation
– Decreased lordosis/Kyphosis
26. Radiological Investigations
• Xray: Plain radiograph signs
– Reduced disc space
– Blurred paradiscal margins
– Destruction of bodies
– Loss of trabecular pattern
– Increased prevertebral soft tissue shadow
– Subluxation /dislocation
– Decreased lordosis/Kyphosis
27. Radiological Investigations
• Xray: Plain radiograph signs
– Reduced disc space
– Blurred paradiscal margins
– Destruction of bodies
– Loss of trabecular pattern
– Increased prevertebral soft tissue shadow
– Subluxation /dislocation
– Decreased lordosis/Kyphosis
28. Radiological Investigations
adow
• Xray: Plain radiograph signs
– Reduced disc space
– Blurred paradiscal margins
– Destruction of bodies
– Loss of trabecular pattern
– Increased prevertebral soft tissue sh
– Subluxation /dislocation
– Decreased lordosis/Kyphosis
29. Radiological Investigations
• Skipped lesions:
– More than one TB
Lesion in vertebral
column with one or
more healthy vertebrae
in between the 2 lesion.
– More frequently
detected on CT/MRI
30. Radiological Investigations
• Lateral shift and scoliosis
– More destruction of vertebrae
on one side
• Kyphotic deformity
– Due to collapse of bone
– Forward angulations
32. Computed tomography (CT)
• Calcifications in abscess (pathognomic for Tb)
• Regions which are difficult to visualize on plain films, like :
1. Cranio-vertebral junction (CVJ)
2. Cervico-dorsal region,
3. Sacrum
4. Sacro-iliac joints.
5. Posterior spinal tuberculosis
because lesions less than 1.5cm are usually missed due to
overlapping of shadows on x rays.
33. MRI
• Detect marrow infiltration in vertebral bodies, leading to early
diagnosis.
• Changes of diskitis
• Assessment of extradural abscesses / subligamentous
spread.
• Skip lesions
• Spinal cord involvement.
• Spinal arachanoiditis.
34. USG
- to find out primary in abdomen
- Detect cold abscess
- Guided aspiration
Radionucleotide Scan T 99m
• Increased uptake in active tuberculosis.
• Avascular segments and abscesses show a cold spot due to
decreased uptake.
• Aid to localise the site of active disease and to detect multilevel
involvement
38. Middle path regime
• Rationale
– “ All Spine Tuberculosis cases do
not require surgery and all those
who do not respond to
conservative measures should be
operated”
40. Middle path regime
• Admission for
– paraplegics
– who require surgical evacuation of pus or debridement of vertebral lesion
– those who agreed for fusion of spine
• Chemotherapy
• X-ray & ESR once in every 3 months
• MRI/ CT at 6 months interval for 2 years for Craniovertebral ,cervicodorsal, lumbosacral& sacroiliac joints
• Gradual mobilization
– 3-9 weeks- back extention exercise 5-10 min 3-4 times
– Spinal brace--- 18 months-2 years
42. Middle path regime
• Abcesses – aspirate near surface
– Instille 1gm Streptomycin +/- INH in sol
– all radiologicaly visible abcesses need not be drained.
– prevertebral abcess in cervical region are drained when complicated by dificulty in deglutition and
respiration.
• Neural complications if responds 3-4 weeks :- surgery unnecssary
• Excisional surgery for posterior spinal disease a/w abcess & sinus because of danger of
2' infection of meninges if dissease does not come in control in 4 wk.
• Operative debridement for patients –
– if no arrest after 3-6 months
– recurrence of disease
43. Middle path regime
• post spinal arthrodesis - symptomatic unstable sinal lesion in which
dissease otherwise seems to be arrested.
• laminectomy has no role , except in canal stenosis, spinal tumor
syndrome, non healing post spinal dissease
44. Middle path regime
• DONT RUSH IN FOR SURGERY SO LONG AS PATIENT IS ABLE TO
WALK.
• THE MOMENT patient is unable to walk, anterior decompression/
transposition is carried out.
• preferd op. aproach
• CERVICAL : anterior aproach
• DORSAL : anterolateral / transpleural aproach
• LUMBAR : transverse vertebrotomy aproach
45. Middle path regime
• Absolute Indications of surgery
1. No progressive recovery after fair trial of conservative
treatment
2. Neurological complications develops during conservative
treatment
3. Worsening of neurological deficit during t/t
4. Recurrence of neurological complications
5. Pressure effects (deglutition/respiration)
6. Advanced cases of neurological involvement(Sphincter
disturbances, flaccid paralysis or severe flexor spasm)
46. – post op:
• hard bed and rest
– for 3-5 months if paraplegic
– for 2-4 months in abscence of paraplegia.
– then mobilised with spinal braces
– braces are discarded after 1-2 years after surgery
47. Operative Management
Surgery Indications
1 Decompression(+/- fusion) Too advanced disease, Failure to
respond to conservative therapy
2 Debridement +/-
decompression +/- fusion
Recurrence of disease or of neural
complications
3 Anterior transposition of cord
(Extrapleural anterolateral
approach)
Sever Kyphosis (>60 degree) + /
neural deficit
4 Laminectomy Extradural granuloma/ Old healed
disease presenting as secondary
canal stenosis/ Posterior spinal
disease
48. Follow up
• Patient evaluated at 3 months interval upto 2 years.
Evaluation
Clinical:
Radiological:
Decreased soft tissue shadow
Disappearance of erosions
Return of mineralization
Graft incorporation
Bony ankylosis
Weight gain
Pain relief
Free ROM
Resolution of abscesses
Neurological recovery
49. Recovery
first objective evidence of onset of recovery - 3 wks
Time taken for near complete recovery varies between 3-6 months
• No significant neural recovery occurs after 12-18 months
50. Results
• Definition of favorable status-
– No residual neural impairment
– No sinus/ cold abscess
– No impairment of physical activity due to spinal disease / lesion
– Presence of radiographic quiescent disease
51. Recurrence/ Relapse
• Extradural granuloma
• Severe kyphosis
• Reactivation of lesion
– Poor nutrition
– Resistant organism
– Immuno compromised status
53. spinal braces
C1-C7 FOUR POST
COLLAR
D1-D3 taylor brace with
cervical collor,
SOMI
D4-L2 taylor brsce
jawette brace
(ASH)
L3-L5 goldthwait
brace
Jawette brace
Taylor brace
