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Spinal tuberculosis (simplified)
- 1. PATIENT'S SUMMARY SITE : BACK DURATION : 6 MONTHS (WORSENED OVER 2 MONTHS) ASSOCIATED SYMPTOMS : NUMBNESS OF LIMB & WEIGHT LOSS ALLEVIATING FACTOR : ANALGESIC & INJECTION BY GP SEVERITY : 7/10 DIABETIC AGE: 58 YEARS OLD GENDER : WOMAN COMPLAINT : BACK PAIN ABLE TO WALK WITH MINIMAL PAIN PRESENCE OF SWELLING OVER LOWER THORACIC SPINE CARDIOVASCULAR, CHEST AND NEUROLOGICAL EXAMINATION ARE NORMAL OCCUPATION : HOUSEWIFE SOCIAL : NON SMOKER/ DRINKER
- 2. The supply of medical-grade face masks is low. Priority for these masks should be given to people in the frontlines. If you need to go outside, wear a community face mask. PATHOGENESIS SYMPTOM & CLINICAL MANIFESTATIONS FURTHER INVESTIGATION PRINCIPLE OF MANAGEMENT COMPLICATIONS 1. 2. 3. 4. 5. PERCIVAL POTT DESCRIBE TB IN SPINAL COLUMN - 1779
- 3. PATHOGENESIS Mycobacterium tuberculosis gram +ve Acid Fast Bacili Hematogenous dissemination from primary focus distributed or spread by way of the bloodstream, 10.5005/jp/books/12787_95 Mycobacterium tuberculosis
- 4. Common site of vertebral involvement is paradiscal. paradiscal vessels typically supply the subchondral bone on either side of the disc space Spinal TB is usually secondary to hematogenous spread from a primary site of infection (most commonly the lungs). PATHOGENESIS (II) Mycobacterium tuberculosis deformed vertebrae fused - pain & neurologic deficit spread to vertebral body above & below disc Fibular annular wall weakens, decay, collapse Disc close, squeeze down on nerve root -pain Bone collapsed under weight body Bacili reach Disc space deformed s. column compresses s. cord -functional impairment
- 5. FIGURE 1 ‘GIBBUS FORMATION’ IN THE THORACO-LUMBAR REGION OF A PATIENT WITH SPINAL TUBERCULOSIS (LEFT). THE MAGNETIC RESONANCE SHOWS SPINAL TUBERCULOSIS AT T10–T12. SPINAL TUBERCULOSIS CAUSES THE DESTRUCTION, COLLAPSE OF VERTEBRAE, AND ANGULATION OF VERTEBRAL COLUMN (RIGHT) SYMPTOMS & CLINICAL MANIFESTATIONS LOCAL PAIN PROMINENT SPINAL DEFORMITY GIBBUS LOCAL TENDERNESS STIFFNESS/ SPASM OF MUSCLE COLD ABSCESS slowly develops when tuberculous infection extends to adjacent ligaments and soft tissues. CONSTITUTIONAL SYMPTOM MALAISE LOSS OF WEIGHT LOSS APPETITE NIGHT SWEATS EVENING RISE IN TEMP GENERALIZED BODY FATIGUE ACHES BACK PAIN is the MOST frequent symptom of spinal tb!! SPINAL DEFORMITY is the HALLMARK feature of spinal tb!!
- 6. MOST FREQUENT SYMPTOMS OF SPINAL TUBERCULOSIS INTENSITY OF PAIN VARIES FROM CONSTANT MILD DULL ACHING TO SEVERE DISABLING ADVANCED RISK DISRUPTION SPINAL INSTABILITY NERVE ROOT COMPRESSION PATHOLOGIC FEATURES MORE ABOUT BACK PAIN Pain may be AGGREGRATED SPINAL MOTION COUGHING WEIGHT BEARING TYPICALLY LOCALIZED TO SITE OF INVOLVEMENT MOST COMMONLY IN THORACIC REGION
- 7. SPINAL DEFORMITY occurs with lesions involving thoracic vertebrae severity depends on the number of vertebrae involved KYPHOSIS SPINAL DEFORMITY is the HALLMARK feature of spinal tuberculosis THE TYPE OF DEFORMITY DEPENDS ON THE LOCATION OF TUBERCULOSIS VERTEBRAL LESSION
- 8. COMMON WITH INVOLVEMENT OF THORACIC AND CERVICAL NERVE LEVEL OF SPINAL CORD INVOLVEMENT DETERMINES THE EXTENT OF NEUROLOGICAL MANIFESTATIONS patients manifest with symptoms of cord or root compression earliest signs are pain, weakness, and numbness of the upper and lower extremities, eventually progressing to tetraplegia NEUROLOGIC DEFICITS CERVICAL SPINAL TUBERCULOSIS INVOLVE THORACIC OR LUMBAR upper extremity function remains normal while lower- extremity symptoms progress over time eventually leading to paraplegia paralysis that occurs in the lower half of the body LUMBAR & SACRAL VERTEBRAL DAMAGE upper extremity cauda equina compression. Patients may have weakness, numbness, and pain, but have decreased or absent reflexes among the affected muscle groups
- 9. puss accumulate behind prevertebral fascia to form a retropharyngeal abscess it may tract down to mediastinum entering trachea, esophagus, or the pleural cavity. dysphagia, respiratory distress, or hoarseness of voice FORMATION OF COLD ABSCESS AROUND VERTEBRAL LESSION COMMON AND CAN GROW TO A VERY LARGE SIZE THE SITE OF COLD ABSCESS ON THE REAGION DEPENDS ON THE REAGION OF VERTEBRAL COLUMN AFFECTED abscess usually presents as a fusiform or bulbous paravertebral swellings and may produce posterior mediastinal lumps most commonly present as a swelling in the groin and thigh. Abscess can descend down beneath the inguinal ligament to appear on the medial aspect of thigh CERVICAL REGION THORACIC REGION LUMBAR VERTEBRAE
- 12. SENSITIVITY SPECIFICITY NEXT Sensitivity refers to a test's ability to designate an individual with disease as positive Specificity of a test is its ability to designate an individual who does not have a disease as negative A highly sensitive test means that there are few false negative results, and thus fewer cases of disease are missed A highly specific test means that there are few false positive results
- 13. MRI more SENSITIVE than more SPECIFIC than CT readily demonstrate involvement of vertebral bodies, disk destruction, cold abscess, vertebral collapse and spinal deformities X-RAY COMPUTED TOMOGRAPHY (CT) PLAIN RADIOGRAPH MRI CT demonstrates abnormalities EARLIER than plain radiography Other findings; soft tissue involvement and paraspinal tissue abscess. demonstrate calcification within cold abscess or visualizing epidural lesions containing bone fragments Early stages (less than 30% vertebral destruction) – not much role Later stages (beyond 30% vertebral destruction) – can present with disc space reduction, endplate rarefaction, vertebral body destruction, instability, and spinal deformity 15% sensitivity 100% sensitivity 100% sensitivity 80% specificity
- 14. Confirmation can be made by demonstration of acid-fast bacilli(AFB) on pathological specimen Using the Ziehl-Neelsen technique, tubercle bacillus presents with a bright red stain. ERYHTHROCYTE SEDIMENTATION RATE (ESR) CYTOLOGICAL AND MICROBIOLOGICAL CONFIRMATION POLYMERASE CHAIN REACTION TEST (PCR) In patients with spinal tuberculosis, there is markedly elevated ESR with a normal white blood cell count PCR analysis is a reliable method for Mycobacterium tuberculosis diagnosis of spinal tuberculosis 25%-75% sensitivity 99% specificity 94% sensitivity 100% specificity 60 - 90% sensitivity
- 15. C- REACTIVE PROTEIN (CRP) RENAL FUNCTION TEST LIVER FUNCTION TEST (LFT) 71% sensitivity CRP is an acute phase reactant whose level rise in response to IL-6 mediated pyogenic infection such as TB LFT (also known as a liver panel) are blood tests that measure different enzymes, proteins, and other substances made by the liver Also commonly known as RFT Test, Kidney Profile or Kidney Panel. Management of kidney disease or pathologies affecting renal function albumin, calcium, carbon dioxide, creatinine, chloride, glucose, phosphorous, potassium, sodium
- 16. The Journal of Spinal Cord Medicine The Journal of Spinal Cord Medicine
- 17. Basic treatment : take a REST lie in BED ANTITUBERCULOUS TREATMENT The treatment response is apparent in form of pain relief, decrease in neurological deficit, and even correction of spinal deformity The antituberculosis treatment regimen is divided into two phases: an intensive (initial) phase and a continuation phase 2 months, combination of 4 first-line drugs: isoniazid, rifampicin, streptomycin, and pyrazinamide 4 months, (isoniazid and rifampicin) are given many experts still prefer a durations of 12–24 months or until radiological or pathological evidence of regression of disease occurs
- 18. https://doi.org/10.1590/S1806-37132010000500016 ANTITUBERCULOUS DRUG ADVERSE EFFECT If hepatotoxicity is suspected, on the basis of clinical findings or laboratory test results-the medication should be discontinued and patients should be referred to a specialized center. many experts still prefer a durations of 12–24 months or until radiological or pathological evidence of regression of disease occurs WHO 9 months of treatment for tuberculosis The American Thoracic Society 6 months of chemotherapy for spinal tuberculosis in adults and 12 months in children. The British Thoracic Society the 6-month four-drug regimen
- 20. D4 - L2 =Taylor Braces T and L = Jewett Braces C1-C7 = SOMI Braces L3 and below = Goldthwaite Measures that are helpful in minimizing the increase in kyphosis prolonged protection of the spine with suitable braces in later stages. FUNCTION ? BRACES PROTECTION
- 21. SURGERY? LESS KYPHOSIS IMMEDIATE RELIEF OF COMPRESSED NEURAL TISSUE QUICKER RELIEF OF PAIN HIGHER % OF BONY FUSION QUICKER BONY FUSION LESS RELAPSE EARLIER RETURN TO PREVIOUS ACTIVITY
- 22. SPINAL DEFORMITY KYPHOSIS RETROPHARYNGEAL ABSCESS collection of pus in the back of the throat POTT'S PARAPLEGIA caused by formation of debris, pus, and granulation tissue due to destruction of bone and Intervertebral disk neurological complication that develops after a variable period in a patient with healed tuberculosis