Tuberculosis of the spinal column, also known as Pott's disease, is caused by infection with Mycobacterium tuberculosis bacteria. It most commonly affects the lower thoracic and thoracolumbar regions of the spine. Clinical features include back pain, spinal deformity, and possible paralysis. Diagnosis involves x-rays, CT scans, MRI, and microbiological testing. Treatment consists of a lengthy multi-drug antibiotic regimen lasting 18 months or longer to prevent disability and complications like abscesses. Proper treatment is important to avoid development of multi-drug resistant tuberculosis strains.
This document discusses pyogenic vertebral osteomyelitis, including causes, symptoms, diagnostic imaging, treatment, and outcomes. The main points are:
- Pyogenic vertebral osteomyelitis is most commonly caused by hematogenous spread from a pulmonary or genitourinary infection, though direct inoculation or spread from adjacent structures can also occur.
- Common symptoms include back pain, fever, and neurological deficits depending on location and severity of infection.
- MRI is the best imaging modality to diagnose and evaluate the extent of infection and involvement of soft tissues and neural structures.
- Treatment involves intravenous antibiotics based on culture and sensitivity results for 2-6 weeks, followed by oral antibiotics. Sur
The ankle is a three bone joint composed of the tibia, fibula, and talus. The talus articulates superiorly with the tibial plafond and posteriorly and medially with the posterior and medial malleoli. Laterally, it articulates with the fibular malleolus. The ankle joint is saddle-shaped and wider anteriorly than posteriorly. During dorsiflexion, the fibula rotates externally through the tibiofibular syndesmosis to accommodate the widened anterior surface of the talar dome. Displacement of the talus within the ankle mortise by only 1 mm decreases the contact area by 42%.
This document provides guidance on interpreting knee x-rays and films. It discusses proper positioning for various knee views, including sunrise, tunnel, lateral, and Merchant views. Common findings on knee films are fractures of the patella, tibial plateau, fibular head, and distal femur. Dislocations and occult fractures must also be considered. The document provides tips on evaluating films for specific injuries like patellar fractures and sleeve fractures in children.
syndesmotic injury mechanism and treatment subject reviewSunil Poonia
This document summarizes a presentation on distal tibiofibular syndesmosis injuries. It begins with an overview of syndesmosis anatomy and the mechanisms of injury. Diagnosis involves physical exams like stress tests and imaging of tibiofibular spaces. Treatment may involve conservative immobilization or surgery using techniques like syndesmotic screws or suture buttons to reduce and stabilize the injury. Precise reduction and fixation are important for proper healing.
Chronic osteomyelitis is a bone infection lasting over 6 weeks. It is characterized by recurrent inflammation, draining sinuses, and dead bone. Common causes are Staphylococcus aureus and other bacteria. Over time, the infection causes bone necrosis and formation of sequestra - dead bone pieces. Surgical treatment aims to thoroughly debride infected tissue, remove sequestra, and reconstruct the bone defect. Antibiotic therapy and soft tissue coverage are also important for treatment. Complications can include pathological fractures, deformity, and malignant transformation if not properly treated.
This document summarizes various shoulder injuries including sprains, dislocations, tendinitis, fractures, and nerve injuries. It describes the mechanisms of injury, signs and symptoms, special tests used for diagnosis, and recommends referring patients to an orthopedist. Key details are provided for sternoclavicular joint sprains, acromioclavicular joint sprains, glenohumeral dislocations, rotator cuff injuries, bicep tendon injuries, clavicle and scapula fractures, and thoracic outlet syndrome.
Clay Shoveler's Fracture and Hangman's Fracture are types of cervical spine fractures that occur at the lower cervical or upper thoracic vertebrae. Clay Shoveler's Fracture is an avulsion fracture of the spinous process that results from flexion injuries like MVAs or wrestling. Hangman's Fracture is a bilateral C2 pars interarticularis fracture from hyperextension injuries like falls. Odontoid fractures are also common and are classified based on their location; Type II and III fractures involving the dens base or body often require surgical fixation if displaced over 5mm.
This document provides an overview of Monteggia fracture dislocations, beginning with definitions, history, epidemiology, classification, mechanisms of injury, clinical features, management, complications, and recent updates. Monteggia fractures, first described in 1814, constitute 1-2% of forearm fractures. Bado's 1958 classification divides them into four types based on the direction of radial head dislocation and location of the ulna fracture. Type I is the most common, involving anterior radial head dislocation and ulna fracture. Nonoperative treatment typically involves closed reduction and casting, while surgery is indicated for failed reductions. Complications can include nerve injuries, ossification, and compartment syndrome.
This document discusses pyogenic vertebral osteomyelitis, including causes, symptoms, diagnostic imaging, treatment, and outcomes. The main points are:
- Pyogenic vertebral osteomyelitis is most commonly caused by hematogenous spread from a pulmonary or genitourinary infection, though direct inoculation or spread from adjacent structures can also occur.
- Common symptoms include back pain, fever, and neurological deficits depending on location and severity of infection.
- MRI is the best imaging modality to diagnose and evaluate the extent of infection and involvement of soft tissues and neural structures.
- Treatment involves intravenous antibiotics based on culture and sensitivity results for 2-6 weeks, followed by oral antibiotics. Sur
The ankle is a three bone joint composed of the tibia, fibula, and talus. The talus articulates superiorly with the tibial plafond and posteriorly and medially with the posterior and medial malleoli. Laterally, it articulates with the fibular malleolus. The ankle joint is saddle-shaped and wider anteriorly than posteriorly. During dorsiflexion, the fibula rotates externally through the tibiofibular syndesmosis to accommodate the widened anterior surface of the talar dome. Displacement of the talus within the ankle mortise by only 1 mm decreases the contact area by 42%.
This document provides guidance on interpreting knee x-rays and films. It discusses proper positioning for various knee views, including sunrise, tunnel, lateral, and Merchant views. Common findings on knee films are fractures of the patella, tibial plateau, fibular head, and distal femur. Dislocations and occult fractures must also be considered. The document provides tips on evaluating films for specific injuries like patellar fractures and sleeve fractures in children.
syndesmotic injury mechanism and treatment subject reviewSunil Poonia
This document summarizes a presentation on distal tibiofibular syndesmosis injuries. It begins with an overview of syndesmosis anatomy and the mechanisms of injury. Diagnosis involves physical exams like stress tests and imaging of tibiofibular spaces. Treatment may involve conservative immobilization or surgery using techniques like syndesmotic screws or suture buttons to reduce and stabilize the injury. Precise reduction and fixation are important for proper healing.
Chronic osteomyelitis is a bone infection lasting over 6 weeks. It is characterized by recurrent inflammation, draining sinuses, and dead bone. Common causes are Staphylococcus aureus and other bacteria. Over time, the infection causes bone necrosis and formation of sequestra - dead bone pieces. Surgical treatment aims to thoroughly debride infected tissue, remove sequestra, and reconstruct the bone defect. Antibiotic therapy and soft tissue coverage are also important for treatment. Complications can include pathological fractures, deformity, and malignant transformation if not properly treated.
This document summarizes various shoulder injuries including sprains, dislocations, tendinitis, fractures, and nerve injuries. It describes the mechanisms of injury, signs and symptoms, special tests used for diagnosis, and recommends referring patients to an orthopedist. Key details are provided for sternoclavicular joint sprains, acromioclavicular joint sprains, glenohumeral dislocations, rotator cuff injuries, bicep tendon injuries, clavicle and scapula fractures, and thoracic outlet syndrome.
Clay Shoveler's Fracture and Hangman's Fracture are types of cervical spine fractures that occur at the lower cervical or upper thoracic vertebrae. Clay Shoveler's Fracture is an avulsion fracture of the spinous process that results from flexion injuries like MVAs or wrestling. Hangman's Fracture is a bilateral C2 pars interarticularis fracture from hyperextension injuries like falls. Odontoid fractures are also common and are classified based on their location; Type II and III fractures involving the dens base or body often require surgical fixation if displaced over 5mm.
This document provides an overview of Monteggia fracture dislocations, beginning with definitions, history, epidemiology, classification, mechanisms of injury, clinical features, management, complications, and recent updates. Monteggia fractures, first described in 1814, constitute 1-2% of forearm fractures. Bado's 1958 classification divides them into four types based on the direction of radial head dislocation and location of the ulna fracture. Type I is the most common, involving anterior radial head dislocation and ulna fracture. Nonoperative treatment typically involves closed reduction and casting, while surgery is indicated for failed reductions. Complications can include nerve injuries, ossification, and compartment syndrome.
Dr. Mahak Jain presented on spondylolisthesis. Key points include:
1) Spondylolisthesis is the forward translation of one vertebra on another, commonly caused by defects in the pars interarticularis known as spondylolysis.
2) It is classified based on etiology, with dysplastic, isthmic, degenerative, traumatic, and pathological types.
3) Treatment depends on factors like grade, symptoms, and etiology, ranging from conservative care to surgical options like decompression, fusion, and instrumentation.
4) Studies show surgery with fusion has better outcomes for pain and function than nonsurgical treatment or decompression alone for degenerative
1) Fractures of the humeral shaft can result from a fall on an outstretched hand or direct blow to the arm.
2) Treatment involves either hanging casts or surgery depending on the severity of the fracture and any complications.
3) Complications can include injury to the radial nerve and non-union of the bone fragments, so careful assessment of nerve function is important both before and after treatment.
Pain from acute vertebral fracture appears to be due in part to instability (non-union or slow union at the fracture site), while more than 1/3 of patients become chronically painful.
Traditional treatment for patients with painful VCFs includes bed rest, narcotic analgesics and bracing, resulting in increased pain because of acceleration bone loss and muscle weakness.
Degenerative spine disease involves three main areas: the intervertebral disc, vertebral bodies/end plates, and posterior elements. Changes to the intervertebral disc include decreased water/proteoglycan content leading to distorted collagen fibers and tears in the annulus fibrosis. Vertebral endplates can show three stages of degeneration. Posterior element changes include facet joint osteoarthritis with osteophytes/hypertrophy, ligamentum flavum hypertrophy/cysts, and spinal canal/foraminal stenosis. Imaging plays an important role in evaluating these degenerative changes and their effects.
LCPD or Perthes disease - idiopathic avascular necrosis of femoral head, characterized mainly in child age 4-7 years - with a feature of limping and pain in the hip or groin
Tuberculosis of the hip joint is the second most common site of bone and joint TB after the spine. It typically affects people in their first three decades of life. The infection spreads from a primary focus such as the lungs to the hip joint via the bloodstream. It can initially involve different areas of the hip and pelvis before spreading to the joint. Patients present with hip pain, limping, and constitutional symptoms. Treatment involves anti-TB drugs along with rest, traction, and surgery if needed to address complications like joint destruction and deformity. Surgical options depend on the stage of disease and can include synovectomy, arthrodesis, osteotomy, or arthroplasty.
SPONDYLOLISTHESIS: DIAGNOSIS, CLASSIFICATION, EVALUATION AND MANAGEMENTBenthungo Tungoe
Spondylolisthesis is the forward slippage of one vertebra on another. There are several classifications including developmental, isthmic, degenerative, traumatic, and postsurgical types. Developmental spondylolisthesis is usually asymptomatic and rarely progresses after adulthood. Isthmic spondylolisthesis has a risk of progression over 25% slippage or in symptomatic cases. Degenerative spondylolisthesis results from sagittal facet orientation or disc degeneration and increases in older females. The natural history depends on factors like age, gender, slip severity and progression.
This document discusses congenital hyper extension and dislocation of the knee. It begins with an introduction describing the spectrum of the condition from positional contractures to rigid dislocation. It is often associated with other developmental hip and foot conditions. Structurally, the anterior knee capsule and quadriceps mechanism are contracted. Clinically, it presents with a hyperextended knee at birth. Treatment depends on severity, with non-operative treatment using casting for mild cases and surgical release for more severe or non-responsive cases.
This document provides an overview of the anatomy of the ankle joint and ankle arthrodesis (fusion). It describes the bones and ligaments that make up the ankle joint, including the tibia, fibula, and talus. It discusses the indications, contraindications, surgical technique, and postoperative care of ankle arthrodesis, which is performed to treat ankle arthritis and pain. The optimal position for fusion is slight dorsiflexion with mild hindfoot valgus and external rotation. Preoperative planning involves assessing bone quality, alignment, and arthritis in other joints like the subtalar.
This document summarizes information about congenital pseudoarthrosis of the tibia (CPT), including:
1. CPT is characterized by a spontaneous fracture that heals poorly, often associated with anterolateral bowing of the tibia. While the term is a misnomer, an alternative name has not been established.
2. Key aspects of CPT include nonunion of a tibial fracture that develops spontaneously or after minor trauma in a dysplastic bone segment. It usually develops in the first two years of life and commonly affects the tibia and fibula.
3. Treatment approaches aim to achieve union at the fracture site while preventing refracture, correcting limb length inequality and growth abnormalities, and preventing
Pigmented villonodular synovitis (PVNS) is a benign proliferative disorder of unknown cause that affects synovial joints, bursae, and tendon sheaths. It is characterized by inflammation and overgrowth of the joint lining. There are two primary forms - a diffuse form affecting the entire synovial lining and a rare localized form occurring in small joints. While the cause is unknown, it is thought to be neoplastic in nature. Treatment involves complete surgical resection or radiation therapy to prevent recurrence, as incomplete removal can allow regrowth. Radiation therapy provides effective local control with minimal side effects.
Hoffa's Fracture: Diagnosis, management & New Classification System by BAGARI...Vaibhav Bagaria
Hoffa's Fracture - coronal split fracture of distal femur, its diagnosis, management strategy, a new classification and tips and tricks of management. First described Hoffa, a new classification system by Bagaria et al helps plan the surgery for these tricky fracture. The most crucial step is not to miss these fractures in ER.
Congenital talipes equinovarus (CTEV), also known as clubfoot, is a complex deformity of the foot characterized by four components - talus in plantar flexion (equinus), subtalar joint in medial rotation and inversion, and forefoot adduction. It has multifactorial etiology with both genetic and environmental factors playing a role. Treatment involves serial casting of the foot based on Ponseti's method to gradually correct the deformity, which may be augmented with a small percutaneous tenotomy of the Achilles tendon if needed. Proper bracing is then used to maintain the correction achieved. Imaging such as X-rays and MRI can help evaluate the severity of deformity and
The document summarizes information about clavicle fractures, including their epidemiology, anatomy, mechanisms of injury, classification systems, treatment options, and evidence for management approaches. Specifically, it finds that:
1) Clavicle fractures are among the most common fractures and midshaft fractures account for 69-80% of cases.
2) They are often caused by a direct blow to the shoulder and result in characteristic deformities from surrounding muscle and ligament forces.
3) Nonoperative treatment is usually indicated for nondisplaced fractures but recent evidence shows displaced or shortened fractures have higher risks of poor outcomes like pain, weakness and nonunion.
The document discusses intervertebral discs, disc prolapse, and degenerative changes in the spine. It provides the following key points:
- Intervertebral discs act as shock absorbers between vertebrae and allow some spinal motion. Discs are made up of an inner gelatinous nucleus pulposus surrounded by the annulus fibrosus.
- Disc prolapse occurs when the nucleus pulposus extrudes through tears in the annulus fibrosus. Imaging like MRI and CT can detect disc prolapses and herniations.
- Degenerative changes in the spine include osteophytosis, ligament calcification and ossification, and a reduction in the size of the spinal
1. Spinal cord injuries are commonly caused by motor vehicle accidents, falls, and sports. The cervical spine is most frequently injured.
2. Initial evaluation involves stabilizing the patient with a cervical collar and assessing for neurological deficits. Imaging such as X-rays and CT/MRI are used to classify fractures and guide treatment.
3. Treatment depends on the fracture type but may involve halo immobilization, surgery to stabilize fractures or decompress the spinal cord, or bracing for stable injuries. The goal is to restore spinal alignment and prevent further neurological injury.
Here are the key steps in the ORIF procedure:
1. Patient is placed in lateral decubitus position and a right-angled lateral incision is made to minimize soft tissue damage.
2. The fracture line at the angle of Gissane is identified.
3. Fragments are temporarily held in place with K-wires under fluoroscopy while the reconstruction restores the 3D shape of the calcaneus.
4. The "constant" sustentacular fragment is used to begin the reconstruction, working anteriorly and medially.
5. Traction may be needed to restore the posterior facet.
6. The lateral wall fragment is closed like a door last to complete the
This document provides information on Potts spine, including its pathophysiology and management principles. It discusses how tuberculosis spreads to the spinal column, causing destruction of vertebral bodies and discs, collapse, and deformity. Risk factors, symptoms, investigations, classifications of lesions and paraplegia, medical management using antitubercular therapy, and indications for surgical treatment are summarized. The goals of surgery are decompression, deformity correction, and spinal stabilization.
Dr. Mahak Jain presented on spondylolisthesis. Key points include:
1) Spondylolisthesis is the forward translation of one vertebra on another, commonly caused by defects in the pars interarticularis known as spondylolysis.
2) It is classified based on etiology, with dysplastic, isthmic, degenerative, traumatic, and pathological types.
3) Treatment depends on factors like grade, symptoms, and etiology, ranging from conservative care to surgical options like decompression, fusion, and instrumentation.
4) Studies show surgery with fusion has better outcomes for pain and function than nonsurgical treatment or decompression alone for degenerative
1) Fractures of the humeral shaft can result from a fall on an outstretched hand or direct blow to the arm.
2) Treatment involves either hanging casts or surgery depending on the severity of the fracture and any complications.
3) Complications can include injury to the radial nerve and non-union of the bone fragments, so careful assessment of nerve function is important both before and after treatment.
Pain from acute vertebral fracture appears to be due in part to instability (non-union or slow union at the fracture site), while more than 1/3 of patients become chronically painful.
Traditional treatment for patients with painful VCFs includes bed rest, narcotic analgesics and bracing, resulting in increased pain because of acceleration bone loss and muscle weakness.
Degenerative spine disease involves three main areas: the intervertebral disc, vertebral bodies/end plates, and posterior elements. Changes to the intervertebral disc include decreased water/proteoglycan content leading to distorted collagen fibers and tears in the annulus fibrosis. Vertebral endplates can show three stages of degeneration. Posterior element changes include facet joint osteoarthritis with osteophytes/hypertrophy, ligamentum flavum hypertrophy/cysts, and spinal canal/foraminal stenosis. Imaging plays an important role in evaluating these degenerative changes and their effects.
LCPD or Perthes disease - idiopathic avascular necrosis of femoral head, characterized mainly in child age 4-7 years - with a feature of limping and pain in the hip or groin
Tuberculosis of the hip joint is the second most common site of bone and joint TB after the spine. It typically affects people in their first three decades of life. The infection spreads from a primary focus such as the lungs to the hip joint via the bloodstream. It can initially involve different areas of the hip and pelvis before spreading to the joint. Patients present with hip pain, limping, and constitutional symptoms. Treatment involves anti-TB drugs along with rest, traction, and surgery if needed to address complications like joint destruction and deformity. Surgical options depend on the stage of disease and can include synovectomy, arthrodesis, osteotomy, or arthroplasty.
SPONDYLOLISTHESIS: DIAGNOSIS, CLASSIFICATION, EVALUATION AND MANAGEMENTBenthungo Tungoe
Spondylolisthesis is the forward slippage of one vertebra on another. There are several classifications including developmental, isthmic, degenerative, traumatic, and postsurgical types. Developmental spondylolisthesis is usually asymptomatic and rarely progresses after adulthood. Isthmic spondylolisthesis has a risk of progression over 25% slippage or in symptomatic cases. Degenerative spondylolisthesis results from sagittal facet orientation or disc degeneration and increases in older females. The natural history depends on factors like age, gender, slip severity and progression.
This document discusses congenital hyper extension and dislocation of the knee. It begins with an introduction describing the spectrum of the condition from positional contractures to rigid dislocation. It is often associated with other developmental hip and foot conditions. Structurally, the anterior knee capsule and quadriceps mechanism are contracted. Clinically, it presents with a hyperextended knee at birth. Treatment depends on severity, with non-operative treatment using casting for mild cases and surgical release for more severe or non-responsive cases.
This document provides an overview of the anatomy of the ankle joint and ankle arthrodesis (fusion). It describes the bones and ligaments that make up the ankle joint, including the tibia, fibula, and talus. It discusses the indications, contraindications, surgical technique, and postoperative care of ankle arthrodesis, which is performed to treat ankle arthritis and pain. The optimal position for fusion is slight dorsiflexion with mild hindfoot valgus and external rotation. Preoperative planning involves assessing bone quality, alignment, and arthritis in other joints like the subtalar.
This document summarizes information about congenital pseudoarthrosis of the tibia (CPT), including:
1. CPT is characterized by a spontaneous fracture that heals poorly, often associated with anterolateral bowing of the tibia. While the term is a misnomer, an alternative name has not been established.
2. Key aspects of CPT include nonunion of a tibial fracture that develops spontaneously or after minor trauma in a dysplastic bone segment. It usually develops in the first two years of life and commonly affects the tibia and fibula.
3. Treatment approaches aim to achieve union at the fracture site while preventing refracture, correcting limb length inequality and growth abnormalities, and preventing
Pigmented villonodular synovitis (PVNS) is a benign proliferative disorder of unknown cause that affects synovial joints, bursae, and tendon sheaths. It is characterized by inflammation and overgrowth of the joint lining. There are two primary forms - a diffuse form affecting the entire synovial lining and a rare localized form occurring in small joints. While the cause is unknown, it is thought to be neoplastic in nature. Treatment involves complete surgical resection or radiation therapy to prevent recurrence, as incomplete removal can allow regrowth. Radiation therapy provides effective local control with minimal side effects.
Hoffa's Fracture: Diagnosis, management & New Classification System by BAGARI...Vaibhav Bagaria
Hoffa's Fracture - coronal split fracture of distal femur, its diagnosis, management strategy, a new classification and tips and tricks of management. First described Hoffa, a new classification system by Bagaria et al helps plan the surgery for these tricky fracture. The most crucial step is not to miss these fractures in ER.
Congenital talipes equinovarus (CTEV), also known as clubfoot, is a complex deformity of the foot characterized by four components - talus in plantar flexion (equinus), subtalar joint in medial rotation and inversion, and forefoot adduction. It has multifactorial etiology with both genetic and environmental factors playing a role. Treatment involves serial casting of the foot based on Ponseti's method to gradually correct the deformity, which may be augmented with a small percutaneous tenotomy of the Achilles tendon if needed. Proper bracing is then used to maintain the correction achieved. Imaging such as X-rays and MRI can help evaluate the severity of deformity and
The document summarizes information about clavicle fractures, including their epidemiology, anatomy, mechanisms of injury, classification systems, treatment options, and evidence for management approaches. Specifically, it finds that:
1) Clavicle fractures are among the most common fractures and midshaft fractures account for 69-80% of cases.
2) They are often caused by a direct blow to the shoulder and result in characteristic deformities from surrounding muscle and ligament forces.
3) Nonoperative treatment is usually indicated for nondisplaced fractures but recent evidence shows displaced or shortened fractures have higher risks of poor outcomes like pain, weakness and nonunion.
The document discusses intervertebral discs, disc prolapse, and degenerative changes in the spine. It provides the following key points:
- Intervertebral discs act as shock absorbers between vertebrae and allow some spinal motion. Discs are made up of an inner gelatinous nucleus pulposus surrounded by the annulus fibrosus.
- Disc prolapse occurs when the nucleus pulposus extrudes through tears in the annulus fibrosus. Imaging like MRI and CT can detect disc prolapses and herniations.
- Degenerative changes in the spine include osteophytosis, ligament calcification and ossification, and a reduction in the size of the spinal
1. Spinal cord injuries are commonly caused by motor vehicle accidents, falls, and sports. The cervical spine is most frequently injured.
2. Initial evaluation involves stabilizing the patient with a cervical collar and assessing for neurological deficits. Imaging such as X-rays and CT/MRI are used to classify fractures and guide treatment.
3. Treatment depends on the fracture type but may involve halo immobilization, surgery to stabilize fractures or decompress the spinal cord, or bracing for stable injuries. The goal is to restore spinal alignment and prevent further neurological injury.
Here are the key steps in the ORIF procedure:
1. Patient is placed in lateral decubitus position and a right-angled lateral incision is made to minimize soft tissue damage.
2. The fracture line at the angle of Gissane is identified.
3. Fragments are temporarily held in place with K-wires under fluoroscopy while the reconstruction restores the 3D shape of the calcaneus.
4. The "constant" sustentacular fragment is used to begin the reconstruction, working anteriorly and medially.
5. Traction may be needed to restore the posterior facet.
6. The lateral wall fragment is closed like a door last to complete the
This document provides information on Potts spine, including its pathophysiology and management principles. It discusses how tuberculosis spreads to the spinal column, causing destruction of vertebral bodies and discs, collapse, and deformity. Risk factors, symptoms, investigations, classifications of lesions and paraplegia, medical management using antitubercular therapy, and indications for surgical treatment are summarized. The goals of surgery are decompression, deformity correction, and spinal stabilization.
1. Tuberculous spondylodiscitis is caused by Mycobacterium tuberculosis infecting the vertebrae, most commonly through hematogenous spread from another site like the lungs. It results in destruction of vertebral bone and discs.
2. Clinical features include chronic back pain, stiffness, deformity, and neurological deficits in severe cases. Diagnosis involves imaging like x-rays, CT, and MRI along with microbiological tests.
3. Treatment involves anti-tuberculosis chemotherapy for at least 12 months along with surgery if there is neurological involvement, worsening symptoms, or inadequate response to medication. Surgical goals include debridement, decompression, correction of deformity, and spinal stabilization
The document discusses spinal tuberculosis, noting that it causes delays in diagnosis, long recovery periods, and high costs. Key points include:
- Paralysis occurs in up to 50% of spinal tuberculosis patients.
- Early diagnosis, expedient treatment, aggressive surgery, and preventing deformity lead to the best outcomes.
- Diagnosis relies on tests like tuberculin skin tests, imaging like MRI to identify bone destruction and abscesses, and microscopy and culture of samples.
- Patterns of bone involvement include paradiscal, central, anterior, and appendiceal lesions.
- Complications include paralysis, cold abscesses, deformities, and secondary infections.
This document provides an overview of tuberculosis (TB) of the spine and Pott's paraplegia. It discusses the microbiology of Mycobacterium tuberculosis, predisposing factors for spinal TB, the surgical anatomy of the spine, pathology and signs/symptoms of spinal TB. Diagnosis involves clinical features, lab investigations like ESR, imaging studies. Treatment involves managing any Pott's paraplegia as well as surgical or nonsurgical management of the spinal TB.
Transient synovitis, also known as irritable hip, is the most common cause of acute hip pain in children aged 3-8 years. It involves transient inflammation of the hip synovium that causes pain and limping. Symptoms include unilateral hip or groin pain and limping. Diagnosis is usually made after ruling out trauma and infection via x-rays and physical exam. Treatment focuses on rest, anti-inflammatory drugs, and recovery typically occurs within 2 weeks. Legg-Calvé-Perthes disease involves osteonecrosis of the femoral head and requires containment of the hip through bracing or surgery depending on the age and extent of involvement.
1. Spinal tuberculosis commonly affects the thoracic and lumbar spine in young adults. It can cause neurological deficits through mechanisms such as inflammatory edema, extradural masses, and meningeal involvement.
2. Diagnosis is based on imaging findings on X-ray, CT, or MRI showing bone destruction and abscesses. Treatment involves chemotherapy and sometimes surgery to debride tissue, drain abscesses, or correct deformities.
3. Complications of spinal tuberculosis include paraplegia, cold abscesses, spinal deformities, and recurrence which may require longer treatment or surgical intervention.
This document discusses bone and joint infections, focusing on osteomyelitis, septic arthritis, and tuberculosis of the bone and joints. It covers the typical causative organisms, presentations, investigations, treatments and potential sequelae of each condition. For osteomyelitis, it describes the progression of infection and radiological appearance. Septic arthritis is an emergency requiring drainage of pus and high dose antibiotics. Bone and joint tuberculosis commonly affects the spine, hips and knees, presenting with pain, stiffness and deformity on x-ray. Treatment involves prolonged antibiotic therapy with possible surgery for severe cases or paralysis.
Tuberculosis of the spine, also known as Pott's disease, is caused by Mycobacterium tuberculosis infection that spreads to the vertebrae. It most commonly involves the lower thoracic spine. Symptoms may include back pain, stiffness, deformity, and neurological deficits in 20% of cases. Diagnosis is made through clinical features, imaging such as x-rays showing vertebral destruction, and tests like tuberculin skin test or biopsy. Treatment involves anti-tuberculosis medications and surgery to correct deformities or treat neurological complications. Management aims to diagnose early, begin medical treatment promptly, and use surgery aggressively to prevent deformity and achieve good outcomes.
Pott's disease, or tuberculosis of the spine, is an extrapulmonary form of tuberculosis that infects the spine. It was first described in 1779 by Sir Percival Pott. Infection can spread to the spine hematogenously or contiguously from other sites. This leads to destruction of vertebral bodies and discs, causing spinal deformities like kyphosis. Advanced cases can cause paraplegia through cord compression. Diagnosis involves imaging and microbiological tests. Prompt treatment is needed to prevent neurological deficits and deformities.
Spinal tuberculosis, also known as Pott's disease, is caused by tuberculosis infection of the spine. It most commonly affects the thoracic and lumbar regions of the spine. Diagnosis involves imaging like x-rays, CT scans, and MRI (the gold standard) combined with clinical signs and symptoms. Treatment depends on the severity and extent of spinal destruction, ranging from antibiotic therapy alone for early or localized disease to surgical interventions like debridement and spinal fusion for advanced cases involving abscesses or neurological deficits. Proper diagnosis and treatment are important to achieve resolution of symptoms and prevent long-term complications like kyphosis and paraplegia.
Tuberculosis can infect the vertebrae and bones, usually spreading from the lungs via blood. It causes osteomyelitis and arthritis, often affecting the lower thoracic and upper lumbar vertebrae. Symptoms include localized back pain, fever, weight loss, and sometimes neurological signs. Diagnosis involves tests showing elevated ESR, positive Mantoux test, and MRI identifying bone changes. Treatment involves antibiotics and sometimes surgery to correct spinal instability or decompress the spinal cord.
Dorso-lumbar tuberculosis is a common form of spinal tuberculosis that usually involves the lower thoracic and upper lumbar regions. It spreads hematogenously from a primary infection, most commonly in the lungs or genitourinary system. Clinically it presents with chronic back pain and stiffness. Investigations like radiography, CT, MRI and biopsy help in diagnosis. Treatment involves anti-tubercular medications for 18 months along with bracing. Surgery to debride and fuse the affected segments may be needed if there is neurological involvement, deformity or abscess formation. Long term follow up is important to monitor healing and prevent complications like paraplegia.
Tuberculosis of the spine, also known as Pott's disease, was first described in 1799. It is caused by the bacterium Mycobacterium tuberculosis which spreads hematogenously from a primary infection site to the spine. India has a high prevalence of spinal tuberculosis, accounting for around 1-3% of all TB cases. The disease most commonly affects the lower thoracic and upper lumbar spine. Clinical features include back pain, stiffness, deformity, and neurological deficits in advanced cases. Diagnosis involves imaging like X-rays and MRI to identify vertebral body destruction, as well as tests to detect M. tuberculosis from biopsy or aspirate samples. Advanced disease can compress the spinal cord, potentially causing parapleg
1. The document summarizes a seminar on tuberculosis of the hip joint. It discusses the history, epidemiology, pathogenesis, clinical features, stages, differential diagnosis, investigations and management of tuberculosis of the hip. 2. Key points include that tuberculosis of the hip is caused by Mycobacterium tuberculosis and spreads hematogenously from a primary focus. It presents with limping and pain and progresses through stages of synovitis, arthritis, advanced arthritis and destruction of the joint. Investigations include hematological tests, radiology and synovial fluid analysis.
1. Spinal cord injuries and diseases can be traumatic due to external forces or non-traumatic due to underlying conditions. Common non-traumatic diseases include tumors, infections, inflammation, and vascular abnormalities.
2. Assessment involves evaluating neurological function, imaging like MRI to identify abnormalities, and diagnostic tests like lumbar puncture. Management depends on the specific condition but may require surgery, antibiotics, steroids, or other treatments.
3. Outcomes depend on the level and completeness of injury, with earlier treatment often leading to better recovery of function. Quality of life is significantly impacted due to paralysis and other functional limitations.
1. Tuberculosis of the spine, also known as Pott's disease, is the most common form of skeletal tuberculosis. It accounts for 50% of all bone and joint tuberculosis cases.
2. Characteristic features on radiology include destruction of the intervertebral disc space and adjacent vertebral bodies, resulting in collapse and kyphotic deformity.
3. Treatment involves a prolonged course of multi-drug anti-tuberculosis therapy to prevent neurological complications and disabling deformities. With modern treatment, patients can often heal with minimal residual deformity.
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These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
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3. INTRODUCTION
Tuberculosis of the vertebral column , first
described by Percival Pott and since associated
with his name.
Is a slowly developing disease, characterized by
pain, spinal deformity and occasionaly paralysis
4. • Spinal tuberculosis is the commonest form of
skeletal tuberculosis
• About 50% of all cases of tuberculosis of bones
and joints
• Is usually secondary to primary elsewhere
5. ETIOLOGY
CAUSATIVE ORG:
• Mycobacterium tubercule bacilli are gram
positive , acid fast bacilli, aerobic , grows at
temperature between 30 – 40 degree and can be
grown on LJ medium
• Can be killed by heat at 60 degree in 15 to 20
min.
• Survives for many weeks in moist condition.
6. PREDISPOSING FACTORS
• Malnutrition
• Poor sanitation
• Living in crowded areas
• Close contact with TB patients
• Exanthematous fever
• Immunodeficiency states
• Hiv and aids
• Chronic alcoholism
7. PATHOGENESIS
• A minimum of 2 t0 3 years is required between the
primary and skeletal TB
• Hematogenous dissemination from a infected visceral
focus
• Primary focus may be active or quiescent, apparent or
latent
• Either in lungs ,lymph glands , mediastinum,
mesentry,or cervical region or other viscera
8. • The infection reaches the skeletal system through the
vascular channels generally the arteries as a result of
bacillemia or rarely in axial skeleton through bastons
plexus of veins
• The disease begins as infection of a single vertebrae.
• The primary error is a tubercular endarteritis the
marrow is converted into pale myxomatous tissue in the
devitalized tissue, a tuberculous follicle develops until it
is visible to naked eye as a small yellow gray nodule.
9. • The centre of the body being caseous the superimposed
weight of the verterbral column is now borne by fragile
shell of compact bone , which sooner collapses resulting
the angular deformity – kyphus, gibbus or hunch back.
• The IV disc in not involved primarily because it is a
relatively avascular structure
• The involvement of paradiscal bone effects its nutrition
and this altered or necrosed disc may be involved by the
infection later.
10. • The cartilaginous plate which acts a barrier once
destroyed leads to disc invasion and destruction rapidly.
11.
12. Most common level of lesion is lower thoracic and
thoracolumbar region.
Thoracic is most commonly involved because
Incresead stress of weight bearing
Relatively large amount of spongy tissues
Close relationship between cysterna chyli, thoracic duct
and anterior surface of the vertebral body.
Role of trauma- repeated mechanical stress in the mobile
and weight bearing parts of the body results in minor
hematoma or bone marrow edema
Trauma activates the latent tuberculous focus
14. TYPES OF VERTEBRAL LESIONS
Paradiscal type:
• Commonest
• Adolescents
• Spreads through epiphyseal arteries
• Involvement of adjacent bodies with decreased
disc space
15.
16. Central type:
• Children
• Either through baston’s plexus or through branches of
posterior vertebral artery
• Normal bony trabecuale lost
• Reduction of disc space is minimal
• Concentric collapse
Anterior type:
• Common in thoracic region
• Begins underneath ALL
• Anterior shallow erosion of vertebral bodies on xray
• Collapse of body and decreased disc space are minimal
• Clinical pictures resembles intraspinal tumor and hence
known as spinal tumor syndrome
17. Posterior type :
• Lesion may be in pedicle, transverse process,
laminae, or spinous process
• Higher incidence of neurological deficits
• Pedicle and post articulation are destroyed as a
result combination of both lateral deviation and
rotation has been observed
• Lateral shift and scoliosis may also be seen
18. Articular type:
• Involves facet joints
• Associated with radiculopathy
• Very less incidence
• Common in elderly
19. CLINICAL FEATURES
• Equal sex predilection
• Common in first three decades
• Insidious in onset
• Back pain is common presenting symptom
• Diffuse later localized
• Stiffness very early symptom
• Is a protective mech wherein the paravertebral
muscles go into spasm to prevent the movement
20. • During sleep the muscle spasm relaxes – night
cries
• Pressure symptoms:dysponea, dysphagia,
hoarness of voice, inability to extend hip(psoas
abscess)
• Deformity:gradually increasing promince of
spine- gibbus
21. • Paraplegia:
• Other constitutional symptoms:
• Weakness, loss of weight, loss of appetite,
evening temp, night sweats.
22. • Signs:
• On general ex:
Signs of anemia, debilities, involvement of lungs,
lymphnodes
Local attitude:
Upper cervical: wry neck
Upper thoracic: militiary position
Lower thoracic:alderman”s gait
Upper lumbar:prominent abdomen
Lower lumbar:increased lordosis
23. Upper cervical Wry neck
Lower cervical The head is thrown backwards and to
one side and may be supported by
hand
Upper thoracic Militiary attitude:
Shoulders are raised and the arms and
shoulders drawn backwards
The head appears sunken, owing to
apparent shortening of the neck
Lower thoracic Alderman”s gait:
Thorax and head thrown backwards
the abdomen is promient
Patient walks with legs apart and
waddles
24. • Gait
• Tenderness : to pressure and percussion at local
site
• Movements: decreased in all directions mostly
forward flexion
• Neurological deficits:paraplegia or quadriplegia
or paresis with or without region of involvement
of bowel and bladder
• Deformity: kyphotic deformity is common
25. Angulation of spine (kyphosis)
• Result of collapse of affected vertebrae
• 1 0r 2 – knuckle
• 3 or more- wedge collapse - angular kyphosis
• Large number- round kyphosis
• Scoliosis
• Lordosis:to compensate the kyphosis
27. Cold abscess
• Commonest complication
• 20 % of all cases
• Body of vertebrae collapses – collection of
tuberculous detritus consists granulation
tissues,caseous matter, disintegrated bone
marrow
• It first collects under ALL – disseminates along
one or other courses
• Superficial abscess –bursts- sinus or ulcer
28.
29. Neurological complications
• Potts paraplegia
• Above L1 high incidence
• Thoracic is common
Classification
• Based on motor involvement(goel , tuli, kumar)
• Progressive severity of neurological deficits due
to cord compression
30. goel , tuli, kumar
stage Clinical features
I negligible Patient unaware of neural deficits, physician detects
plantar extensor
II mild Patient aware of deficit but manages to walk with
support
III moderate Nonambulatory because of paralysis
Sensory deficits less than 50 %
IV severe III + flexor spasms/paralysis in flexion/flaccid/
sensory deficits > 50 % , sphincters involved
31. Cord involvement Better prognosis Poor prognosis
degree partial complete
duration shorter Longer ( >12 months)
type Early onset Late onset
Speed of onset slow rapid
age younger older
General condition good poor
Vertebral disease active healed
Kyphotic deformity < 60 degree > 60
Cord on mri normal myelomalacia
preoperative Wet lesion Dry lesion
32. Investigations
Blood:
• Hb : anemia
• Tc:increased lymphocytes
• Lymphocyte : monocyte ratio:5:1 is favorable
• CRP
Mantoux test:in doubtful cases in children with
negative mantoux rules out TB
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.
54.
55. Radiological techniques:
Xray AP and Lateral views
• Earliset finding is rarefaction present on either side
of IVD space
• Narrowing of disc space
• Lytic destruction of ant vertebral end plate
• Osteolytic destruction of vertebral body
• Pathological collapse
• Spinal deformity
• Sclerosis reactive bone formation
• Abscess shadow varies region of involvement
56.
57.
58.
59.
60. • K is the angle of kyphosis
by the technique of
dickson
• A line drawn from along
the posterior margin of
the bodies of the healthy
vertebrae above and
below the site of disease.
• Angle k increases with
increase in degree of
kyphosis
61. CT- SCAN OF SPINE
• Patterns of bony destruction.
• 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
62. MAGNECTIC RESONANCE IMAGING
• highly sensitive &specicific for spinal TB
• Spinal cord & soft tissue involvement
• Detect marrow infiltration in vertebral
bodies(EDEMA), leading to early diagnosis
• Skip lesions
• Changes of diskitis (EDEMA)
• Assessment of extradural abscesses /
subligamentous spread
• Poor for calcification
67. MEDICAL MANAGEMENT
• There is a lack of consensus regarding the ideal duration
of multidrug chemotherapy for spinal TB.
• WHO recommends nine months of treatment for TB of
bones and joints (2HREZ + 7 HR) because of the serious
risk of disability in addition to difficulties in assessing
treatment response.
68. Current guidelines
• All cases of bone and joint TB – extended ATT
• It includes two months of intensive phase and 10-16
months of continuation phase
For spine
• 2 HRZE and 10 HRE upto 18 months
• Repeat Xray every third month
• MRI at 6 , 9 , 12 , 18 months
• At the end of the treatment, Follow up every six
months for two years
69.
70.
71. MDR TB
• TB is defined as resistance to at least both
Isoniazid and Rifampicin.
• Extensively drug-resistant tuberculosis or XDR-
TB is defined as resistance to any
fluoroquinolone and at least one injectable
second-line antibiotic in addition to Isoniazid
and Rifampicin resistance
72. • primary reasons for the emergence of MDR
strains, unscientific use of multi-drug
chemotherapy by clinicians, making it one of the
most dangerous iatrogenic creations.
• India ranks second amongst the high-burden
MDR-TB countries.
73. • 1. Early detection of MDR and prompt initiation of effective
treatment are important for successful outcomes
• 2. A biopsy is a must, and all efforts must me made to culture
the organism to obtain drug sensitivity testing.
• 3. A lab competent in microbiological testing should be
chosen.
• 4. It is imperative to involve a chest physician or an infectious
disease specialist for treatment.
• 5. Never add a single drug to a failing regimen
• 6. MDR-TB regimen should be composed of at least five drugs
likely to be effective, including four second-line anti-TB drugs
that are likely to be effective plus pyrazinamide
75. INDICATIONS
• Paraplegia during conservative treatment (6
weeks)
• Paraplegia worsening during treatment (6
weeks)
• Complete motor loss for 1 month despite of
conservative treatment
• Paraplegia with uncontrolled spasticity
• Severe and rapid onset paraplegia
• Severe flaccid paraplegia/ sensory loss
76. OTHER INDICATIONS:
• Spinal deformity
• Childhood spine tuberculosis
• Disease (Poor response to medical treatment)
• Drug resistance
• Diagnosis in doubt
77. Surgical management
• Anterior spinal cord decompression and
reconstruction
• Posterior instrumentation without
anterior column reconstruction
• Posterior approach with anterior column
reconstruction
• Anterior and posterior approach
78. Anterior spinal cord decompression
and reconstruction
As tuberculosis affects the anterior spinal column, anterior
debridement and fusion has long been the gold standard of
treatment.
It has several advantages, which include direct access to
pathology, safe and effective decompression without
handling of the spinal cord and optimal reconstruction of
the anterior column without damaging intact posterior
elements.
79. • In patients with extensive spinal destruction
(more than 2 VB loss in the thoracic spine and
more than 1 VB loss in thoracolumbar and
lumbar spine) or severe kyphosis, standalone
anterior spinal instrumentation is
biomechanically inferior to posterior
pedicle screw construct
80. • In the past few decades, surgeons have gained
expertise in accessing the anterior column
via the posterior approach, and the
indications for a standalone anterior surgery are
dwindling.
81. Posterior instrumentation without
anterior column reconstruction
• Tuberculosis presents as posterior element
disease with spinal cord compression.
• In these patients, a standalone posterior
approach is an obvious choice
• In patients with less severe anterior column
destruction, a posterior approach to decompress
the spinal cord via transfacetal or transpedicular
approach may be successful
82. •
• As the antibiotics heal the anterior column and
restore its integrity, the posterior
instrumentation helps to maintain spinal
alignment.
• However, frequently the technique of spinal cord
decompression via a posterior approach may
involve excision of anterior column sufficient
enough to warrant grafting of anterior column
83. Posterior approach with anterior
column reconstruction
• This approach is most popular to treat spinal
tuberculosis of the thoracic and lumbar area.
• The posterior approach is the workhorse of a
spinal surgeon, and most surgeons are far more
comfortable with it compared to the anterior
approach
84. • As per necessity, a progressive sacrifice of the
posterior elements can provide increasing access
to the anterior column. (Transfacetal,
transpedicular, extracavitary lateral approach)
• The approach also may involve spinal cord
handling if one is not careful, and frequently a
less experienced surgeon may end up doing a
suboptimal job fearing injuring to the neural
structures.
85. Anterior and posterior approach
• Extensive anterior column destruction (3 or
more vertebral bodies in thoracic spine or more
than 1 vertebral body in the lumbar spine) with
or without severe kyphosis, warrants a global
access to take advantages of both anterior
and posterior approach
86.
87. • Usually, posterior approach is performed first to
correct the alignment and stabilize the spine
followed by anterior spinal cord decompression
• reconstruction using a structural graft or cage.
• A global approach can be morbid and potentially
could be staged to avoid complications.
88. Take home message
• Clinical features can be subtle, and the clinician needs to have a
high degree of suspicion for spinal tuberculosis to be able to
diagnose this infection early.
• There are no radiological features that are pathognomonic for spinal
tuberculosis
• A biopsy is recommended not only for diagnosis but also to treat it
with effective antibiotics.
• New diagnostic tests, such as GeneXpert and LPA, can be used to
diagnose MDR-TB early in the course of treatment
• Surgeons who treat spinal tuberculosis should follow recommended
guidelines when prescribing multi-drug chemotherapy
• It is advisable to involve a chest physician or an infection disease
specialist early in the course of treatment.
89. • Management of MDR-TB is complex and potentially
morbid, and all efforts should be taken not to
generate iatrogenic cases of MDR-TB by prescribing
irrational and unscientific chemotherapy
• Surgical management is reserved for complications
of spinal tuberculosis.
• Childhood spinal TB can have a malignant
progression of deformity, in spite of effective
medical management and these should be identified
early.
• The treating physician or orthopedic surgeon should
be cognisant of the indications for surgery and make
an appropriate referral to a spine surgeon, especially
90. BRUCELLOSIS
• Brucellosis results in a noncaseating, acid-fast–
negative granuloma caused by a gram-negative
capnophilic coccobacillus.
• individuals involved in animal husbandry and
meat processing (workers in abattoirs).
• Symptoms include polyarthralgia, fever, malaise,
night sweats, anorexia, and headache.
91. • Bone involvement, most frequently of the spine,
occurs in 2% to 30% of patients.
• The lumbar spine is the most frequently involved
spinal region.
• Radiographic changes of steplike erosions of the
margin of the vertebral body require 2 months
or more to develop.
92. Brucellosis of lumbar spine. Note vertebral sclerosis, spondylolisthesis,
steplike irregularity in anterior vertebral body,
and anterior osteophytes
93. • Treatment usually consists of antibiotic therapy
for 4 months and close monitoring of the
Brucella titers.
• Nas et al. recommended 6 months of antibiotic
therapy (rifampicin and doxycycline) with
surgery for spinal cord compression, instability,
or radiculopathy.
94. FUNGAL INFECTIONS
• Fungal infections generally are noncaseating,
acid-fast– negative infections.
• They usually occur as opportunistic infections in
immunocompromised patients.
• Symptoms usually develop slowly.
• Pain is less prominent as a physical symptom
• than in other forms of spinal osteomyelitis.
95. • Direct culture by biopsy is the only method of
absolute determination of the infecting organism
• Aspergillus and cryptococcal infections are of
special note with regard to spinal infections.
• predominant lumbar involvement and
neurological involvement.
96. • Pain, tenderness, and an elevated ESR and CRP
are the most common symptoms.
• Cryptococcal infection is a less opportunistic but
more prevalent fungal infection.
• These organisms are found in avian excreta and
usually infect the human respiratory system.
97. • Radiographs show lytic lesions that on biopsy
reveal non–acid-fast, caseating granulomas
without pus.
• The indications for radical surgery are the same
as for tuberculosis.
98. EPIDURAL SPACE INFECTION
• The incidence of this infection is increased in
immunosuppressed patients.
• direct extension from infected adjacent
structure, hematogenous spread, and iatrogenic
inoculation.
• Epidural abscess usually spans three to five
vertebral segments.
99. • Spinal epidural abscess caused by direct
extension from a vertebral osteomyelitis usually
is on the ventral side of the canal anterior to the
thecal sac.
• Clinical findings :
• (1) a more rapid development of neurological
symptoms (days instead of weeks);
• (2) a more acute febrile illness; and
• (3) signs of meningeal irritation, including
radicular pain with a positive straight-leg raising
test and neck rigidity
100. • MRI is crucial to the determination of diagnosis
• A few authors have reported successful
treatment without surgical drainage.
• For selected patients with an epidural abscess
presenting with back pain alone or neurological
symptoms that have been stable for more than
72 hours follow-up is necessary
• any deterioration of the patient’s neurological
status or development of systemic sepsis
requires urgent surgical decompression.
101. • Acute or chronic isolated dorsal (posterior),
lateral, and some ventral (anterior) infections
are best treated with total laminectomy.
• Epidural infections associated with osteomyelitis
are best exposed by anterior or posterolateral
exposures that allow treatment of the
osteomyelitis and the epidural infection.
102. POSTOPERATIVE INFECTIONS
• The rate of postoperative spine infections ranges
from less than 3% in discectomies and
laminectomies to approximately 12% in patients
with instrumented fusions.
• Increased exposure and blood loss, increased
operative time, and increased dead space.
• Age older than 60 years, previous surgical
infection, poorly controlled diabetes, obesity,
alcohol abuse, and smoking.
103. OPERATING ROOM
• Prophylactic antibiotics should be given 30 minutes
• prior to the incision and redose after 3 to 4 hours or
1500-mL blood loss.
• Reduce traffic in and out of the operating room.
• Release soft tissue retraction regularly.
• Irrigate regularly.
• Maintain strict aseptic techniques.
• Close and seal wounds.
• Maintain sterile dressings in the immediate
• Postoperative period unless the wound is chemically
sealed.
104. POSTOPERATIVE MANAGEMENT
• Concomitant infections (e.g., urinary tract
infections, pneumonia) should be aggressively
evaluated and treated.
• Sterile dressings should be maintained for 48
hours.
• Nutritional status of the patient should be
carefully maintained, particularly during the
postoperative period
105. PYOGENEIC VERTEBRAL OSTEOMYELITIS
• Usually caused by s.aureus (hematogenous spread)
• Risk factors: old and debiliated patients , IV drug users
• Recent history of pneumonia, UTI, skin infections,
immunologic compromise,
• Unremitting spinal pain at any level is characteristic
• Neurologic deficits seen around 40 % in older patients, mostly
in cephalic level of spine
• Laboratory studies – elevated ESR, CRP and WBC count
106. Plain radiographs shows
• Osteopenia
• Paraspinous soft tissue swelling
• Erosion of vertebral end plates
• Disc space destruction
• Gadolinium enhances the MRI sensitivity
107. Treatment:
Non operative:
• After tissue diagnosis 6 to 12 weeks of IV antibiotics
is the treatment of choice
Operative:
• Open biopsy indicated when tissue diagnosis has not
made
• Anterior debridement and strut grafting are for
refractory cases.
• May required posterior stabilization
108. osteodiscits
• Blood borne infections can primarily invade the
disc space in children
• S.aureus is the most common offender , gram
negative org are common in older patients
• Children are most common affected
• History – may or may have spinal procedures as
spinal injection
109. • Inability to walk or stand
• Back pain with tenderness
• Restricted range of motion
• Laboratory studies: elevated ESR, CRP, WBC
Imaging:
• Loss of lumbar lordosis
• Disc space
• End plate erosions
• Findings do not occur until 10 days to 3 weeks
110. Treatment:
• Typically medical:
• Obtain percutaneous biopsy if possible
• Targeted antibiotic therapy once culture and
sensitivity completed.
111. Surgical includes :
• Patient medically systemically ill
• Evidence of epidural abscess
• Unable to obtain percutaneous biopsy.