TB of the spine commonly affects the thoracic and lumbar regions. It spreads hematogenously and causes destruction of vertebral bodies. Common presentations include chronic back pain and deformities. Advanced cases may involve neurological deficits due to spinal cord compression. Diagnosis involves imaging tests like x-rays and MRI. Treatment is with anti-TB medications along with rest. Surgery is indicated for complications like paraplegia. Prognosis depends on factors like age, duration of symptoms and severity of neurological involvement.

1. VIJESH VIJAYAN
2008 MBBS

3. TB IS CALLED AS “WHITE PLAGUE’’ OR
”CAPTAIN OF ALL MEN OF DEATH”
 SPINE IS THE COMMONST SITE OF BONE AND
JOINT TB
 UPPER THORACIC SPINE – IN CHILDREN
 LOWER THORACIC AND - IN ADULTS
UPPER LUMBAR

4. EPIDEMIOLOGY
 1/3 RD OF WORLD POPULATION HARBOUR TB
INFECTION
 INDIA IS ONE OF THE WORST AFFECTED
COUNTRIES
 ONE PERSON PER MINUTE DIE OF TB IN INDIA

5. TB IS AN ANCIENT DISEASE
EVIDENCE OF SPINAL TB HAS BEEN
FOUND IN SOME EGYPTIAN
MUMMIES

6.  BONES & JOINTS ARE THE 4TH COMMONST SITE
OF EXTRA PULMONARY TB
 CONSTITUTE ~10% OF EXTRA PULMONARY TB
 WEIGHT BEARING JOINTS ARE MOST AFFECTED
SPINE : 40%
HIPS : 13%
KNEES : 10%

7. PATHOLOGY
 TB SPINE IS ALWAYS SECONDARY
 REACTIVATION OF HEMATOGENOUS FOCI OR
SPREAD FROM PARAVERTEBRAL LYMPH NODE
 HEMATOGENOUS SPREAD VIA PARAVERTEBRAL
VENOUS PLEXUS OF BATESON
 RESPONSE WILL BE EITHER PROLIFERATIVE
OR EXUDATIVE
 PROLIFERATIVE: C/C GRANULOMA WITH FIBROSIS
 EXUDATIVE : NON REACTIVE, WIDE CAESEATION
NECROSIS, IN IMMUNOCOMPROMISED

8. TB GRANULOMA

10. TYPES OF VERTEBRAL TB
 1. PARADISCAL - COMMONST , CONTIGOUS AREA
OF TWO ADJACENT VERTEBRA ALONG WITH
INTER VERTEBRAL DISC IS AFFECTED
 2. CENTRAL -BODY OF SINGLE VERTEBRA ,
NEARBY DISC MAY BE NORMAL
 3. ANTERIOR-ANTERIOR PART OF THE BODY
 4. POSTERIOR- POSTERIOR COMPLEX (PEDICLE ,
LAMINA , SPINOUS PROCESS OR TRANSVERSE
PROCESS) AFFECTED

11. AFTER EFFECT
 PARADISCAL : C/C GRANULOMATOUS
INFLAMMATION -> EROSION OF MARGINS OF
THE VERTEBRAE -> COMPROMISE OF NUTRITION
OF IV DISC-> DISC DEGN-> DESTRUCTION
 CENTRAL : WEAKENING OF TRABECULAE ->
COLLPSE OF VERTEBRAE
 ANTERIOR : INFN SPREAD UP OR DOWN UNDER
ANT. LONGI.LIGAMENT
 POSTERIOR : BONY DESTRUCTION CAN
COMPRESS THE CORD

12. COLD ABSCESS
 PUS & TRABECULAR DEBRIS OF DISEASED
VERTEBRA
 NOT ASSO. WITH USUAL SIGNS OF
INFLAMMATION - COLD ABSCESS
 NOTE: PUS CAN TRACK IN ANY DIRECTION
1.BACKWARDS : COMPRESS CORD
2. ANTERIORLY: PRE VERTEBRAL ABSCESS
3. SIDES : PARA VERTEBRAL ABSCESS
4.ALONG MUSCULOFASCIAL PLANES :
EX.PSOAS ABSCESS

13. HEALING
 OCCURS BY FIBROSIS
 IN THE SPINE BONY ANKYLOSIS FOLLOWS MORE
OFTEN
 LYTIC AREAS ARE REPLACED BY NEW BONE AND
ADJACENT VERTEBRA UNDERGO FUSION

14. CLINICAL FEATURES
 PRESENTATION VARIES FROM NON SPECIFIC
BACK ACHE TO CATASTROPHIC PARAPLEGIA
 COMPLAINTS:
PAIN
STIFFNESS
COLD ABSCESS ( IF EVIDENT EXTERNALLY)
PARAPLEGIA
DEFORMITY
CONSTITUTIONAL SYMPTOMS

15. PAIN
 BACKACHE : COMMON PRESENTING COMPLAINT
 INITIALLY DIFFUSE & LATE LOCALISED
 ‘RADICULAR PAIN’
 DEPENDING ON ROOT:
PAIN IN ARM – CERVICAL ROOTS
GIRDLE PAIN – DORSAL ROOTS
GROIN PAIN - LUMBAR ROOTS

16. COLD ABSCESS
 CERVICAL : RETROPHARYNGEAL / AT POST
BORDER OF STERNO MASTOID IN POST
TRIANGLE OF THE NECK / AT AXILLA
 THORACIC : MEDISTINAL / ANTERIOR CHEST
WALL ALON THE SPINAL NERVES
 LUMBAR : PRE VERTEBRAL SWELLING/ PSOAS
ABSCESS / ABSCESS PRESENTING AT GROIN

17.  STIFFNESS : EARLY SYMPTOM
PARAVERTEBRAL MUSCLES UNDERGO
SPASM
PARAPLEGIA
DEFORMITY – IN CHILDREN
CONSTITUTIONAL SYMPTOMS : FEVER , WEIGHT
LOSS

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

19. DEFORMITY : GIBBUS

21. 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

22. INVESTIGATIONS
 RADIOLOGY :
• X-RAY – SPECIFY THE LEVEL
• 2 VIEWS AP & LATERAL
• CHEST X-RAY
• X-RAY ABDOMEN
• KUB - IF PSOAS ABSCESS SUSPECTED

23. FINDINGS
 1. REDUCTION OF DISC SPACE- EARLY SIGN
• COMPARE WITH NORMAL
LATERAL X-RAY IS BETTER
IMPORTANCE : SECONDARIES TO
BONES USUALLY PRESERVE THE DISC
2. DESTRUCTION OF VERTEBRAL BODY
EROSIONS AND WEDGING
3. DEFORMITY : DEPEND ON THE NO.
OF VERTEBRA AFFECTED

24. BONE DESTRUCTION

27.  DESTRUCTION
OF THE BONE

28. COLD ABSCESS
 1. PARAVERTEBRAL ABSCESS : A SOFT TISSUE
SHADOW CORRESPONDING TO AFFECTED
VERTEBRA.
 WIDENED MEDIASTINUM
 RETROPHARYNGEAL ABSCESS
 PSOAS ABSCESS

29. RETROPHARYNGEAL ABSCESS

31. MEDISTINAL WIDENING

33. OTHER FINDINGS
 RAREFACTION : ABOVE AND BELOW AFFECTED
VERTEBRA
 OBLIQUE X RAY MAY SHOW POSTERIOR
COMPLEX INVOLVEMENT
 SIGNS OF HEALING : ADJACENT VERTEBRAE
UNDERGO FUSION

34. OTHERS
 CT : ACCURATE CONFIRMATIONS
 MRI : TO ASSES NEURAL STATUS
 MYELOGRAPHY : SUSPECTED SPINAL TUMOR
SYNDROME
 BIOPSY : CT GUIDED NEEDLE OR OPEN BIOPSY

35.  RETROPHARYNGEAL
SWELLING
CAN PRESENT AS
DYSPHAGIA

36.  PSOAS ABSCESS

37.  PSOAS ABSCESS

38. GENERAL INVESTIGATIONS
 ESR
 MANTOUX
 ELISA : ANTI TB ANTIBODY
 CHEST X RAY : FOR PULMONARY TB

39. D/D S
 BACK ACHE : 1. TRAUMATIC
• 2. SECONDARIES OR MYELOMA
• 3. PROLAPSED DISC
• 4.ANKYLOSING SPONDYLITIS
• NEUROLOGICAL
• SPINAL TUMOR
• TRAUMATIC
• SECONDARIES IN THE SPINE

40. TREATMENT
 PT SHOULD BE GIVEN A HIGH PROTEIN DIET
& GOOD ATMOSPHERE
1. MULTIDRUG THERAPY OF TB
2. REST TO THE SPINE : CHILDREN BODY CAST ,
COLLAR IF CERVICAL
3. MOBILISATION : ADVISED TO AVOID SPORTS
FOR TWO YEARS

41. RX COLD ABSCESS
 SMALLER ONES SUBSIDE WITH TB THERAPY
 IN SUPERFICIAL ABSCESSES :
 ASPIRATION : USING THICK NEEDLE
 EVACUATION
 PSOAS ABSCESS : EXTRAPERITONEALLY VIA KIDNEY
INCISCION

42. MRCB CONTROLLED TRIAL
 BED REST NOT NECESSARY
 STREPTOMYCIN NOT NECESSARY
 POP JACKETS PROVIDE NO BENEFIT
 DEBRIDEMENT IS NOT A GOOD OPERATION
COMPLICATIONS
 COLD ABSCESS
 NEUROLOGICAL COMPLICATIONS : PARAPLEGIA

44. 20 % INCIDENCE
COMMON IN DORSAL SPINE TB
 CAUSES :
 INFLAMMATORY EDEMA
 EXTRADURAL PUS & GRANULATION TISSUE –
COMMOMN
 SEQUESTRA
 INTERNAL GIBBUS
 INFARCTION OF SPINAL CORD
 EXTRADURAL GRANULOMA

45. TYPES
 EARLY ONSET
 LATE ONSET
 C/F :
 EITHER A KNOWN TB OR NEUROLOGICAL
SYMPTOMS PRESENTING FOR THE 1ST TIME
 GRADUAL ONSET
 CLONUS – ANKLE OR PATELLAR – PROMINENT

46. PARALYSIS : STAGES
 1. MUSCLE WEAKNESS : SPASTICITY AND
INCORDINATION
 2. PARAPLEGIA IN EXTENSION
 3. PARAPLEGIA IN FLEXION
 COMPLETE FLACCID PARALYSIS

47. GRADES : GOEL (1967)
 BASIS IS EXTENT OF MOTOR INVOLVEMENT
 GRADE ONE : CLINICIAN DETECTS THE DEFECIT
 GRADE TWO : SYMPTOMATIC BUT MANAGES TO WALK
 GRADE THREE: UNABLE TO WALK
PARAPLEGIA IN EXTENSION
PARTIAL SENSORY LOSS
GRADE FOUR : UNABLE TO WALK
PARAPLEGIA IN EXTENSION
NEAR COMPLETE SENSORY LOSS
SPHINCTER DISTURBANCES

48. TREATMENT
 INVESTIGATIONS : CT & MRI ( INVESTIGATION
OF CHOICE)
 CONSERVATIVE : ANTI TB RX , REST TO SPINE ,
NEUROLOGICAL EXAMINATION TO ASSES Px
 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

49.  RELATIVE INDICATIONS :
 RECURRENT PARAPLEGIA
 PARAPLEGIA IN OLD AGE
 PAINFUL PARAPLEGIA
 COMPLICATIONS : UTI / STONES

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

51. PROGNOSIS
 AGE : CHILDREN HAS BETTER Px
 DURATION OF PARAPLEGIA : LONG STANDING
HAS BAD Px
 SEVERITY : MOTOR ALONE HAS GOOD Px
 ONSET OF PARAPLEGIA : A/C ONSET HAS BETTER
 SUDDEN PROGRESS : BAD Px