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TB Spine ortho.pptx

The document discusses the pathology and management of spinal tuberculosis, a significant public health concern caused by Mycobacterium tuberculosis, which can lead to serious complications like paraplegia and spinal deformity. It outlines the epidemiology, risk factors, diagnostic methods, and treatment protocols, including both medical and surgical approaches, emphasizing the importance of early diagnosis and timely intervention. It also covers various imaging techniques and classifications for better diagnosis and management of the disease.

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Discuss Pathology and Management of Tuberculosis of the Spine Dr Shindang PJ Orthopedic department, NHA
Outline • Introduction • Epidemiology • Pathology • Classification • Management • Follow up • Prognosis • Prevention • Future trends • Complications • Conclusion • References
Introduction • TB spine is an infection of the spine caused by M. tuberculosis resulting in spondylodiscitis, abscess formation, and mechanical instability of the spine. • Pott’s paraplegia – paraplegia resulting from tuberculosis of the spine • Oldest disease Known to man yet still of public health importance • Frequently encountered extrapulmonary form of tuberculosis. • Early diagnosis and prompt treatment are necessary to prevent permanent neurological disability and to minimize spinal deformity.
Introduction • Found in Egyptian mummies dating back to 3400 BC • Percival Pott in 1779 presented the classic description of spinal tuberculosis. • Robert Koch 1882 discovered Mycobacterium tuberculosis
Epidemiology • Global TB burden • 8-10 million new cases per year worldwide • Over one million deaths annually • The highest incidence occurs in Sub-Saharan Africa and south-east Asia • The highest prevalence is in the Indian sub-continent • In endemic countries TB Spine • Common in children and young adults • Common cause of nontraumatic paraplegia • Equally affects males and females
Epidemiology • 10% of Extra Pulmonary TB have skeletal involvement • TB spine accounts for 50% of TB of the MSS • 1-2% of all cases of TB
Risk factors • Immune-deficiency states • Overcrowding • low socioeconomic status • Significant exposure to active TB patients • High risk occupations such as healthcare workers
Relevant Anatomy
Relevant Anatomy
PATHOLOGY • A secondary form of TB • AETIOLOGY; Caused mainly by M. tuberculosis and occasionally by M. bovis, M. africanum, M. microti • M. Tb is an acid-fast bacillus, non-flagellated obligate aerobe. • Weakly Gram +ve. • Stained with Zehl-Neilson stain, cultured on Lowenstein-Jensen medium. • No toxin or biofilm • Caseous granuloma • Spread is chiefly hematogenous • Blood supply favors bony involvement on each side of the bone sparing the disc in adults
Pathology Focus of infection (primary site) lungs, Lymph node Route of infection: hematogenous spread (paravertebral venous plexus of Bateson). Infection begins in the metaphysis of vertebral body Advances and destroys the cortex, intervertebral disc and adjacent vertebrae Infectious exudate may spread beneath the anterior longitudinal ligament to neighboring vertebrae
Pathology • Tissue necrosis and breakdown of inflammatory cells result in a paraspinal abscess. • The pus may be localized, or it may track along tissue planes. • Progressive necrosis of bone leads to a kyphotic deformity. • Typically, the infection begins in the anterior aspect of the vertebral body adjacent to the disk. • The infection then spreads to the adjacent vertebral bodies under the longitudinal ligaments. • Noncontiguous (skip) lesions are also seen occasionally
Regional distribution. • CERVICAL 12% • CERVICODORSAL 5% • DORSAL(THORACIC) 42% • LUMBAR 26% • DORSOLUMBAR 12% • LUMBOSACRAL 3%
Types of Lesion 1. Paradiscal (commonest) 2. Central 3. Anterior 4. Appendicular 5. Articular(synovial)
Lesion • Paradiscal • Commonest • Spread is via arteries • Adjacent to intervertebral disc space • Subsequent destruction of subchondral bone • Disc space is reduced • Central type • Spread is via Batson plexus of veins • The lesion is in the central portion of the body and extends centrifugally to involve the whole body of the vertebrae • Body yields under gravity and muscle action to compression and collapse • Disc space intact
Lesion • Anterior • Destruction of the cortical bone with spread to the subperiosteal and sub-ligamentous plane • Stripping of periosteum with Subsequent ischemia with resultant vertebral body collapse • Appendicular(uncommon) • The pedicle and lamina of the vertebrae are primarily affected • Spread is via the posterior external venous plexus • Involves posterior arch without the involvement of vertebral body
Pathological sequelae. • Paravertebral abscesses e.g. cold abscess in the neck,Psoas,lumbar abscesses • Gibbus , kyphosis • Paraplegia: the most serious complication • Tuberculous meningitis-rupture of abscess into dura-pachymeningitis; arachnoiditis= paralysis
PRINCIPLES OF MANAGEMENT • Resuscitation • Multidisciplinary Team • Prompt diagnosis • History and examination • Investigations • Effective treatment • Medical • Surgical • Prevention • Complications
Resuscitation • Correct Anemia • Treat dehydration • Nutritional rehabilitation • Sepsis • UTI • Bed sores
History • Prolong periods of ill heath • Back pain; Vague initially, later becomes progressively severe • Constitutional symptoms 20-30% of patients (fever, malaise, loss of weight and appetite). • Night cries • Weakness/Heaviness of limbs • Fecal/Urinary incontinence
Examination findings • Features of chronic illness • Alderman’s gait • Deformity • Gibbus • Kyphosis • Kyphoscoliosis • Pigeon chest • Neurologic examination • +/- Features of UMNL • Lumps: Abscess • Sinuses • pressure sores
GIBBUS SCOLIOSIS
INVESTIGATIONS FOR T.B SPINE AIMS • To confirm the diagnosis • To rule out differentials • To monitor response to treatment • To prepare patient for surgery
Radiologic Investigations • X-RAY • Commonest investigation • Readily available • Features are seen after about 6 months • The whole spine should be evaluated • For diagnosis • Monitoring during treatment
X-ray features • Narrowing of disc space • Local osteoporosis • Kissing lesions • Wedged collapse • Vertebra plana • Vertebra destruction • Scalloping • Para-spinal soft tissue shadows • Kyphosis , scoliosis, • Skip lesions (7%)
ANT. WEDGE COMPRESSION
RADIOLOGICAL CLASSIFICATION OF T.B SPINE BY Lagundoye et al • Type I - Disc space narrowing only • Type ii -kissing lesions • Type iii -Wedge collapse of vertebra • Type iv -Vertebra plana • Type v -Lesion localized in the body/or its appendages • Type vi - Paraspinal abscess • Type vii -Complete body destruction
Clinico radiologic classification of TB Spine
MAGNETIC RESONANCE IMAGING • Most preferred imaging • Sensitivity (97%) and specificity (78.6%) • With/without gadolinium-enhanced • Shows disc/vertebra changes • Shows skip lesions • Shows spinal cord affectation, compression, edema, cavitations • Para spinal abscesses
THORACOLUMBAR MRI
LUMBOSACRAL MRI
CT SCAN • Sensitivity of 90.9% and specificity of 94.6% • Shows pattern of bony destruction(osteolytic, sclerotic, fragmentary) • Calcification within abscess • Outlines hidden areas of the spine e.g. posterior elements • CT guided biopsy
BONE SCAN Tc99 BONE SCAN • Technetium 99,Gallium • Not specific • Aids to localize active disease • Increase uptake in 60% of patients with active T.B • < 5mm lesion can be detected • Avascular segments/abscess shows cold spot • Detects metastatic disease
HAEMATOLOGIC INVESTIGATIONS FBC + DIFF • Relative Lymphocytosis • Anaemia ESR • Raised in active disease • Usually > 20mm/hr • Also used for monitoring Retroviral screening
Investigations PPD INJECTION • Mantoux test • PPD(tuberculin skin test) • Placed in the left flexural area • > 10mm • >5mm( HIV infected) • The width of induration is measured after 72 hrs. • Accesses evidence of exposure • False neg /positive causes
Mantoux
• Biopsy of vertebrae/ Abscess aspirate • Biopsy and culture is the Gold standard • AFB staining/ histology( caseous necrosis , epitheloid cells,) and culture • By percutaneous CT guided or open Solid media ( Lowestein Jensen , middlebrook) Liquid broth(1-3 wks) BACTEC MEDIA( 1-2 WKS)
Investigations PCR It detects circulating TB DNA/RNA in the blood. Specificity 80- 90%, sensitivity 61-90% Distinguish Mycobacterium tuberculosis from other types Detect as few as 10-50 bacilli Not readily available ELISA Detects Ig G against TB Rapid Antibody –antigen test 60-80 % Sensitive QuantiFERON TB Gold Assay Detects t-cell-mediated gamma interferon in the plasma Results ready in 24 hrs.
GeneXpert test • Molecular test for TB • has a sensitivity of 95.6% and specificity of 96.2% • Detect TB presence and test for rifampicin resistance • Used to diagnose MDRTB • Detects TB DNA in blood and sputum • Uses blood, abscess aspirate, urine, csf • Rapid- 90mins • Detect both dead and live bacteria
Tests for patients with active TB • Sputum AFB X 3 • Ziehl - Neelsen staining- pink rods • Active pulmonary TB • Gastric aspirate/bronchial washout/Ascitic fluid/CSF/Urine • Results takes 3- 8 wks • Requires > 500 bacilli for + ve result • CHEST X-RAY • May show evidence of active or healed lesion • Consolidation • Apical scaring/hilar opacities/cavitations • Pleural effusion • Lung collapse
• Liver function test-  monitoring of treatment Liver enzymes/protein levels • E/ U /Cr – monitoring of renal status • PSA • Alkaline phospahatase • Bence jones protein
DIFFERENTIAL DIAGNOSIS PYOGENIC SPONDYLITIS - Sudden onset,high fever, severe pain, neutrophilia. Radiologic features: rapid bone destruction, marked bone sclerosis, loss of iv space. common in the lumbar vert. Heal with bony ankylosis BRUCELLAR SPONDYLITIS - Common in patients working in animal husbandry/abbatoir. commoner in lumbar vert. Psoas abscess common, disc space thining, step-like vertebra erosion and ankylosis,no gibus. FUNGI INFECTION (ASPERGILLOSIS,COCCIDIOMYCOSIS) -Less pain,common in immunocompromised, increased esr,normal wbc. lytic lesion without pus, fungi ball on chest Xray
DIFFERENTIAL DIAGNOSIS CONT. PRIMARY BONE TUMORS( GCT,ABC,),LYMPHOMA -Osteolytic,expansile lesions in the body , disc are spared,spleen/liver enlargement Multiple myeloma There is involvement of one or two vertebrae, with collapse and eccentric destruction ESR elevated, Anemia, Reversal od A/G ratio Urine bence Jones protein Confirm with myeloma cells in BM METASTATIC TUMORS -FEATURES OF PRIMARIES,ELDERLY PTS,USUALLY INVOLVES PEDICLES AND SPARE THE DISC PARASITIC INFECTIONS EG.HYDATID DZX,SCHISTOSOMA -COMMON WHERE SHEEP HUSBANDARY,XRAY SHOWS TRANSLUCENT AREA WITH SCEROTIC MARGINS TRAUMATIC VERTEBRA FRACTURES -HX OF TRAUMA,FRACTURE LINES,INTACT DISC SPACE
OTHER DIFFERENTIAL DIAGNOSIS • Scheuermann’s disease • Pathologic fractures from osteoporosis • Degenerative Disc prolapse • Sickle cell disease • Ankylosing spondylitis • Sarcoidosis
Classification 1. Oguz et al. classification (based on the number of vertebrae involved and the presence of complications.) Type 1 one disc level and soft tissue infiltration without abscess, collapse and neurologic deficit Type 2 Degeneration involving one or two disc levels with abscess formation and mild kyphosis. Neurological deficit may be present Type 3 Degeneration involving one or two disc levels with abscess formation, instability and deformity that cannot be corrected without instrumentation 2. Based on location of the lesion: cervical, thoracic, thoracolumbar, lumbar or sacral.
Kumar staging Predestructive stage patient presents in <2 months of onset of disease with the straightening of curvatures and spasm of the perivertebral muscles Early destructive stage patient presents between 2 and 4 months of onset of disease with decreased disc spaces and paradiscal erosion Mild angular kyphosis stage patient presents between 4 and 9 months of onset with two to three vertebral involvement and kyphotic angle of 10°–30° Moderate angular kyphosis stage when patient presents between 6 and 24 months with more than 3 vertebral involvement and kyphotic angle of 30°–60° Severe kyphosis stage patient presents after 24 months with more than 3 vertebral involvement and kyphotic angle of more than 60°.
Treatment • To eradicate the mycobacterium • To prevent / treat instability • To prevent / treat deformity • To prevent neurologic deficit Goals
Middle Path Regime • Tuli and Kumar advocated drugs as the basis of treatment and reserves surgery for specific indications • Operative treatment is combined with 6–12 months of bed rest, followed by 18–24 months of spinal bracing. • It’s the most widely accepted protocol
Middle Path Protocol • Admission, bed rest • Chemotherapy. • X-ray and ESR once in three months. • Gradual mobilization in the absence of neurological complications. • Spinal braces—18 months to 2 years. • Abscesses are aspirated or drained. • Sinuses heal within 6–12 weeks. • If no neural complications develop; if response is obtained within 3–4 weeks of triple-drug therapy, surgery is unnecessary. • Operative debridement for patients who do not show arrest of disease after 3–6 months of chemotherapy.
Non-Operative management 1. MEDICAL THERAPY Indications • Organism Identified and antibiotic sensitivity • Uncomplicated TB spine • As an adjunct to surgical therapy • Complicated cases where surgery may not be useful • Therapeutic trial
First line drugs • Isoniazid –5(4-6)mg/kg/day, Peripheral neuropathy • Rifampicin –10(8-12)mg/kg/day, Hepatotoxicity • Pyrazinamide –25(20-30)mg/kg/day, Gout • Ethambutol-15(13-17)mg/kg/day, Optic neuritis • or • Streptomycin-15(12-18) mg/kg/day, Ototoxicity
Second line drugs • Thiacetazone -2.5(2-3)mg/kg/day, bacteriostatic • PAS, 10-12 g/day, bacteriostatic • Ethionamide, 15-20mg/kg/day, bacteriostatic • Cycloserine,0.5-1gm/day • Kanamycin, 15-20mg/kg/day, bacteriocidal • Capreomycin, 12-18mg/kg/day, bacteriocidal • Ciprofloxacin, 1-1.5g/day, bacteriocidal
Standard regimen Intensive Phase 4drugs for 2 months •1.Isoniazid, 5-15mg/kg-300mg •2.Rifampicin 10—20mg/kg-600mg •3.Ethambutol 15-25mg/kg-800mg •4.Pyrazinamide 30-40mg/kg-1.5gm Continuation Phase INH and Rifampicin
Duration of continuation therapy • Isoniazid and rifampicin given for • 10 months for the 12 months, regimen-Canadian Thoracic Society • 7 months for the 9 months, regimen-American Thoracic Society • 7 months for the 9 months, regimen-WHO 2010 • 16 months for the 18 months, regimen-Old school • 4 months for the 6 months , NICE Guidlines
2. Mobilization with a suitable orthotics • Collar • Halo vests • Minerva jacket 3. Physiotherapy.
Treatment: Operative Goals are • to achieve adequate decompression, • debridement, • maintenance and reinforcement of stability, • correction and prevention of deformity.
Indications Patient without neurological complications • Progressive bone destruction in spite of ATT • Failure to respond to conservative therapy • Evacuation of paravertebral abscess • For biopsy • Mechanical reasons: instability • Prevention of severe kyphosis in young children Patients with neurological complications • New or worsening neural complications or lack of improvement with conservative treatment • Paraplegia of rapid onset or severe paraplegia • Late-onset paraplegia • Painful paraplegia in elderly patients • Spinal tumor syndrome (epidural spinal tuberculoma without osseous involvement)
Treatment: Surgery • Surgery: Options • Costo-transversectomy • Anterior decompression and fusion (Hodgson and Stock) • Hong Kong procedure • Radical debridement, grafting and fusion • Posterior decompression and spinal fusion • Non-instrumentation • Hibbs and Albee 1911 • Instrumentation • Drainage of abscess
Surgical Approaches • For spinal TB in the cervical spine, an anterior approach is most common. • For the thoracic spine: • anterior and anterolateral decompression by thoracoabdominal approach • posteriorly there is costo-transversectomy • lumbar level spinal TB: • Posterior • anterior • antero-lateral
Anterior approach • Anterior approaches enable adequate exposure, debridement, and reconstruction. • Disadvantage • Graft slippage - 50 - 80% • Fracture • Absorption, or subsidence of graft. • Mortality 4% morbidity 18%
Posterior approach • Commonly used approach • The ability to achieve adequate exposure for circumferential spinal cord decompression, and better deformity control through pedicle screws • Possibility of extension of instrumentation • Avoidance of thoracotomy-related complications • Transpedicular decompression and posterior instrumentation facilitates faster recovery and also prevents deformity progression and neurological sequelae in early disease
Combined approaches Indications • Osteoporotic bones, • Multiple vertebral body involvement • Severe kyphotic deformities. • severe destructive lesions and junctional pathologies that are inherently unstable • Posterior instrumentation with anterior decompression and fusion can be performed in 1 or 2 stages. • Anterior debridement removes infected foci and allows for direct neural decompression and rigid anterior reconstruction. • Posterior instrumentation enables better deformity correction and reduces the stress on grafts placed anteriorly, thus helping in maintaining sagittal deformity correction. • it is associated with high morbidities
INDICATION FOR INSTRUMENTATION • Pan vertebral disease: Instrumentation should be done to prevent subluxation /dislocation of the spine. • Long segment disease: Disease of 4 or more vertebral bodies. • In the lumbar & cervical spine: There are no costotransverse & costovertebral articulations as in the dorsal spine. • When kyphosis correction is done • Injunctional areas such as the CD spine and DL spine
Treatment: Surgery • Surgery: Abscess drainage • Indication • Large abscess • Cord compression • Septic features • Principles • Incision over non dependent area • Incision is closed • Drain not longer than 2 days
Treatment: Cervical • Decompression • Anterior approach (Southwick Robinson) • Transoral • Stabilization • Instrumented + fusion • Cages • Cervical plate • Cervical rods and screws
Treatment: Thoracic • Abscess • Costotransversectomy • Transpedicular drainage • Decompression • Anterolateral extrapleural approach • Anterior transthoracic • Costotransversectomy
COSTOTRANSVERSECTOMY This approach helps in evacuating abscesses in the dorsal spine . • Midline incision Elevate soft tissue & periosteum from spinous process & laminae over abscess. • Resect transverse process at its base • Resect 5cm of contiguous rib • Open abscess by blunt dissection • Wash and close in layers
TRANS THORACIC TRANSPLEURAL APPROACH • Hodgson & stock described propagated for anterior clearance of lesion & Reconstruction by bone grafting. • Patient in lateral decubitus position with bean bag. • Incision over corresponding involved vertebra & expose subperiosteally. • Disarticulate rib from transverse process • Incise parietal pleura & reflect it off the spine. • Pleural adhesions cleared gradually.
TRANS THORACIC TRANSPLEURAL APPROACH • It allows adequate exposure for debridement & grafting • Identify segmental vessels & ligate. • ICN useful guide to intervertebral foramina. • Reflect periosteum overlying spine & expose involved vertebrae. • Lesion is debrided & anterior decompression of spinal canal achieved
Treatment: Thoracic
Treatment: Lumbar • Abscess • Lumbar paravertebral abscess • Transpedicular drainage • Decompression • Approach through Hypogastric para median trans peritoneal approach. • Retroperitoneal • Transperitoneal
Advantage of surgery • Less kyphosis • Immediate relief of compressed neural tissue • Quicker relief of pain • A higher percentage of bony fusion • Less relapse • Earlier return to previous activities • Less bone loss • Prevent late neurological problems due to kyphosis and fibrosis
Neurologic complications of spinal TB • Most feared complication • Occurs in 30% of cases • Kumar’s classification, ASIA classification • Paraplegia of early onset will resolve with ATT • Paraplegia of late onset usually requires surgical decompression
Paravertebral abscesses PARAVERTEBRAL ABSCESS ACCUMULATE UNDER ANTERIOR LONGITUDINAL LIGASMENT GRAVITATE ALONG FASCIAL PLANES PRESENT EXTERNALLY AT SOME DISTANCE FROM THE SITE OF THE ORIGINAL LESION LUMBAR PSOAS ABSCESS ALONG THE SHEATH
Abscess formation • Cervical spine →Posterior/ Anterior triangle • Upper thoracic →Intercostal Spaces on the chest wall • Lower thorax and Lumbar → Thigh and inguinal region: Psoas Abscess • Treatment • Anti Tubercular Drugs • Percutaneous CT guided needle aspiration • MIS • Surgical Drainage
Kyphosis • TB spine is a common cause of Kyphosis • More severe curves are seen in children • Surgery is indicated if Kyphotic Angle is ≥ 60% • Prevention is Key • Early treatment with ATT • Posterior decompression and screw fixation
TB spine in children • 35% of cases of TB in India • Vertebrae is cartilagenous • Progressive deformity occurs in 39% • Aim of treatment • Early eradication of TB • Identification of children that are likely to develop progressive
TB spine in Children • Clinical Risk factors for Kyphosis correction • Age less than 11 yrs • Affectation of 3 or more vertebrae Kyphotic angle >30 at presentation • Disease at the lower thoracic and thoracolumbar junction • Radiologic Spine at risk (Rajasekaran et al): • 2 or more spines at risk plus clinical risk factors is an indication for surgery
Complications • Disease • Quadriplegia • Paraplegia • kyphosis • Tuberculoma • Tuberculous meningitis, arachnoiditis • Secondary infection • Amyloid disease • Death • Intervention • Drugs • Hepatitis • Peripheral neuropathy • Optic neuropathy
Complications • Intervention • Surgery • Graft migration • Fixation failure • Cord compression/ injury • Pneumothorax, pleural effusion • Ileus • Injury to surrounding structures
Follow up/ Monitoring • Aim • Response to therapy and complications • Compliance (DOTS) • Development of neurological deficit • Deformity • All patients were examined clinically and radiologically at 3, 6, and 12 months after surgery and then once a year.
Follow up/ Monitoring • Modality • Regular weighing • Erythrocyte sedimentation rate (ESR) • Full blood count • Lymphocyte count • Liver function tests • Visual acuity • Electrolyte, urea, and creatinine • Chest X-ray and regional areas • “Healed status” • Clinical and radiological evidence of healing without any recurrence after 2 years
Rehabilitation • Aims to return the patient to the pre-morbid state • Physiotherapy • Occupational therapy • Psychotherapy
Prevention • Primary prevention • Health Education • BCG Immunization • Good standard of living • Proper Housing unit • Secondary prevention • Early diagnosis and treatment • Screening of high risk individuals • Tertiary prevention • Rehabilitation • Limitation of disability
Prognosis • Mortality • Very high before advent of anti TB drugs • 70% patients with surgery • Severity of neurological deficit • 11% in patients with severe neurologic deformity • Kyphosis • Neurologic, respiratory and cardiac failure • Associated with non operative management
Prognosis • Neurology • May improve with chemotherapy • Better after anterior decompression 94% • 79% after non operative • 48% with severe neurology recovered • Poor results • Atrophic cord • Pachymeningitis
Local experience
Future Trends • Xpert MTB/RIF Ultra, as they found it, to have better detection rates of Mycobacterium tuberculosis in specimens with low numbers of bacilli.
Conclusion • Tuberculosis of the spine is a severe debilitating disease • High index of suspicion is required in patients with chronic back pain • Mainstay of treatment is chemotherapy • Surgery has a big role to play
References • Onuminya JE, Morgan E, Shobode MA. Spinal tuberculosis - Current management approach. Niger J Orthop Trauma 2019;18:35-43 • Mohammad R. R et al Spinal Tuberculosis: Diagnosis and Management Asian Spine Journal Vol. 6, No. 4, pp 294~308, 2012 • Kirkman MA, Sridhar K. Posterior listhesis of a lumbar vertebra in spinal tuberculosis. Eur Spine J 2011;20:1-5. • Rajasekaran S. The natural history of post-tubercular kyphosis in children. Radiological signs which predict late increase in deformity. J Bone Joint Surg Br 2001;83:954-62. • Neradi, D., Sengupta, D.K. (2022). Epidemiology of Tuberculosis of Spine. In: Dhatt, S.S., Kumar, V. (eds) Tuberculosis of the Spine. Springer, Singapore. https://doi.org/10.1007/978-981-16-9495-0_3 • Google images

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TB Spine ortho.pptx

  • 1.
    Discuss Pathology and Managementof Tuberculosis of the Spine Dr Shindang PJ Orthopedic department, NHA
  • 2.
    Outline • Introduction • Epidemiology •Pathology • Classification • Management • Follow up • Prognosis • Prevention • Future trends • Complications • Conclusion • References
  • 3.
    Introduction • TB spineis an infection of the spine caused by M. tuberculosis resulting in spondylodiscitis, abscess formation, and mechanical instability of the spine. • Pott’s paraplegia – paraplegia resulting from tuberculosis of the spine • Oldest disease Known to man yet still of public health importance • Frequently encountered extrapulmonary form of tuberculosis. • Early diagnosis and prompt treatment are necessary to prevent permanent neurological disability and to minimize spinal deformity.
  • 4.
    Introduction • Found inEgyptian mummies dating back to 3400 BC • Percival Pott in 1779 presented the classic description of spinal tuberculosis. • Robert Koch 1882 discovered Mycobacterium tuberculosis
  • 5.
    Epidemiology • Global TBburden • 8-10 million new cases per year worldwide • Over one million deaths annually • The highest incidence occurs in Sub-Saharan Africa and south-east Asia • The highest prevalence is in the Indian sub-continent • In endemic countries TB Spine • Common in children and young adults • Common cause of nontraumatic paraplegia • Equally affects males and females
  • 6.
    Epidemiology • 10% ofExtra Pulmonary TB have skeletal involvement • TB spine accounts for 50% of TB of the MSS • 1-2% of all cases of TB
  • 7.
    Risk factors • Immune-deficiencystates • Overcrowding • low socioeconomic status • Significant exposure to active TB patients • High risk occupations such as healthcare workers
  • 8.
  • 9.
  • 10.
    PATHOLOGY • A secondaryform of TB • AETIOLOGY; Caused mainly by M. tuberculosis and occasionally by M. bovis, M. africanum, M. microti • M. Tb is an acid-fast bacillus, non-flagellated obligate aerobe. • Weakly Gram +ve. • Stained with Zehl-Neilson stain, cultured on Lowenstein-Jensen medium. • No toxin or biofilm • Caseous granuloma • Spread is chiefly hematogenous • Blood supply favors bony involvement on each side of the bone sparing the disc in adults
  • 11.
    Pathology Focus of infection(primary site) lungs, Lymph node Route of infection: hematogenous spread (paravertebral venous plexus of Bateson). Infection begins in the metaphysis of vertebral body Advances and destroys the cortex, intervertebral disc and adjacent vertebrae Infectious exudate may spread beneath the anterior longitudinal ligament to neighboring vertebrae
  • 12.
    Pathology • Tissue necrosisand breakdown of inflammatory cells result in a paraspinal abscess. • The pus may be localized, or it may track along tissue planes. • Progressive necrosis of bone leads to a kyphotic deformity. • Typically, the infection begins in the anterior aspect of the vertebral body adjacent to the disk. • The infection then spreads to the adjacent vertebral bodies under the longitudinal ligaments. • Noncontiguous (skip) lesions are also seen occasionally
  • 13.
    Regional distribution. • CERVICAL12% • CERVICODORSAL 5% • DORSAL(THORACIC) 42% • LUMBAR 26% • DORSOLUMBAR 12% • LUMBOSACRAL 3%
  • 14.
    Types of Lesion 1.Paradiscal (commonest) 2. Central 3. Anterior 4. Appendicular 5. Articular(synovial)
  • 15.
    Lesion • Paradiscal • Commonest •Spread is via arteries • Adjacent to intervertebral disc space • Subsequent destruction of subchondral bone • Disc space is reduced • Central type • Spread is via Batson plexus of veins • The lesion is in the central portion of the body and extends centrifugally to involve the whole body of the vertebrae • Body yields under gravity and muscle action to compression and collapse • Disc space intact
  • 16.
    Lesion • Anterior • Destructionof the cortical bone with spread to the subperiosteal and sub-ligamentous plane • Stripping of periosteum with Subsequent ischemia with resultant vertebral body collapse • Appendicular(uncommon) • The pedicle and lamina of the vertebrae are primarily affected • Spread is via the posterior external venous plexus • Involves posterior arch without the involvement of vertebral body
  • 17.
    Pathological sequelae. • Paravertebralabscesses e.g. cold abscess in the neck,Psoas,lumbar abscesses • Gibbus , kyphosis • Paraplegia: the most serious complication • Tuberculous meningitis-rupture of abscess into dura-pachymeningitis; arachnoiditis= paralysis
  • 18.
    PRINCIPLES OF MANAGEMENT •Resuscitation • Multidisciplinary Team • Prompt diagnosis • History and examination • Investigations • Effective treatment • Medical • Surgical • Prevention • Complications
  • 19.
    Resuscitation • Correct Anemia •Treat dehydration • Nutritional rehabilitation • Sepsis • UTI • Bed sores
  • 20.
    History • Prolong periodsof ill heath • Back pain; Vague initially, later becomes progressively severe • Constitutional symptoms 20-30% of patients (fever, malaise, loss of weight and appetite). • Night cries • Weakness/Heaviness of limbs • Fecal/Urinary incontinence
  • 21.
    Examination findings • Featuresof chronic illness • Alderman’s gait • Deformity • Gibbus • Kyphosis • Kyphoscoliosis • Pigeon chest • Neurologic examination • +/- Features of UMNL • Lumps: Abscess • Sinuses • pressure sores
  • 22.
  • 23.
    INVESTIGATIONS FOR T.BSPINE AIMS • To confirm the diagnosis • To rule out differentials • To monitor response to treatment • To prepare patient for surgery
  • 24.
    Radiologic Investigations • X-RAY •Commonest investigation • Readily available • Features are seen after about 6 months • The whole spine should be evaluated • For diagnosis • Monitoring during treatment
  • 25.
    X-ray features • Narrowingof disc space • Local osteoporosis • Kissing lesions • Wedged collapse • Vertebra plana • Vertebra destruction • Scalloping • Para-spinal soft tissue shadows • Kyphosis , scoliosis, • Skip lesions (7%)
  • 26.
  • 27.
    RADIOLOGICAL CLASSIFICATION OF T.B SPINEBY Lagundoye et al • Type I - Disc space narrowing only • Type ii -kissing lesions • Type iii -Wedge collapse of vertebra • Type iv -Vertebra plana • Type v -Lesion localized in the body/or its appendages • Type vi - Paraspinal abscess • Type vii -Complete body destruction
  • 28.
  • 29.
    MAGNETIC RESONANCE IMAGING •Most preferred imaging • Sensitivity (97%) and specificity (78.6%) • With/without gadolinium-enhanced • Shows disc/vertebra changes • Shows skip lesions • Shows spinal cord affectation, compression, edema, cavitations • Para spinal abscesses
  • 30.
  • 31.
  • 32.
    CT SCAN • Sensitivityof 90.9% and specificity of 94.6% • Shows pattern of bony destruction(osteolytic, sclerotic, fragmentary) • Calcification within abscess • Outlines hidden areas of the spine e.g. posterior elements • CT guided biopsy
  • 33.
    BONE SCAN Tc99 BONESCAN • Technetium 99,Gallium • Not specific • Aids to localize active disease • Increase uptake in 60% of patients with active T.B • < 5mm lesion can be detected • Avascular segments/abscess shows cold spot • Detects metastatic disease
  • 34.
    HAEMATOLOGIC INVESTIGATIONS FBC +DIFF • Relative Lymphocytosis • Anaemia ESR • Raised in active disease • Usually > 20mm/hr • Also used for monitoring Retroviral screening
  • 35.
    Investigations PPD INJECTION • Mantouxtest • PPD(tuberculin skin test) • Placed in the left flexural area • > 10mm • >5mm( HIV infected) • The width of induration is measured after 72 hrs. • Accesses evidence of exposure • False neg /positive causes
  • 36.
  • 37.
    • Biopsy ofvertebrae/ Abscess aspirate • Biopsy and culture is the Gold standard • AFB staining/ histology( caseous necrosis , epitheloid cells,) and culture • By percutaneous CT guided or open Solid media ( Lowestein Jensen , middlebrook) Liquid broth(1-3 wks) BACTEC MEDIA( 1-2 WKS)
  • 38.
    Investigations PCR It detects circulatingTB DNA/RNA in the blood. Specificity 80- 90%, sensitivity 61-90% Distinguish Mycobacterium tuberculosis from other types Detect as few as 10-50 bacilli Not readily available ELISA Detects Ig G against TB Rapid Antibody –antigen test 60-80 % Sensitive QuantiFERON TB Gold Assay Detects t-cell-mediated gamma interferon in the plasma Results ready in 24 hrs.
  • 39.
    GeneXpert test • Moleculartest for TB • has a sensitivity of 95.6% and specificity of 96.2% • Detect TB presence and test for rifampicin resistance • Used to diagnose MDRTB • Detects TB DNA in blood and sputum • Uses blood, abscess aspirate, urine, csf • Rapid- 90mins • Detect both dead and live bacteria
  • 40.
    Tests for patientswith active TB • Sputum AFB X 3 • Ziehl - Neelsen staining- pink rods • Active pulmonary TB • Gastric aspirate/bronchial washout/Ascitic fluid/CSF/Urine • Results takes 3- 8 wks • Requires > 500 bacilli for + ve result • CHEST X-RAY • May show evidence of active or healed lesion • Consolidation • Apical scaring/hilar opacities/cavitations • Pleural effusion • Lung collapse
  • 41.
    • Liver functiontest-  monitoring of treatment Liver enzymes/protein levels • E/ U /Cr – monitoring of renal status • PSA • Alkaline phospahatase • Bence jones protein
  • 42.
    DIFFERENTIAL DIAGNOSIS PYOGENIC SPONDYLITIS- Sudden onset,high fever, severe pain, neutrophilia. Radiologic features: rapid bone destruction, marked bone sclerosis, loss of iv space. common in the lumbar vert. Heal with bony ankylosis BRUCELLAR SPONDYLITIS - Common in patients working in animal husbandry/abbatoir. commoner in lumbar vert. Psoas abscess common, disc space thining, step-like vertebra erosion and ankylosis,no gibus. FUNGI INFECTION (ASPERGILLOSIS,COCCIDIOMYCOSIS) -Less pain,common in immunocompromised, increased esr,normal wbc. lytic lesion without pus, fungi ball on chest Xray
  • 43.
    DIFFERENTIAL DIAGNOSIS CONT. PRIMARYBONE TUMORS( GCT,ABC,),LYMPHOMA -Osteolytic,expansile lesions in the body , disc are spared,spleen/liver enlargement Multiple myeloma There is involvement of one or two vertebrae, with collapse and eccentric destruction ESR elevated, Anemia, Reversal od A/G ratio Urine bence Jones protein Confirm with myeloma cells in BM METASTATIC TUMORS -FEATURES OF PRIMARIES,ELDERLY PTS,USUALLY INVOLVES PEDICLES AND SPARE THE DISC PARASITIC INFECTIONS EG.HYDATID DZX,SCHISTOSOMA -COMMON WHERE SHEEP HUSBANDARY,XRAY SHOWS TRANSLUCENT AREA WITH SCEROTIC MARGINS TRAUMATIC VERTEBRA FRACTURES -HX OF TRAUMA,FRACTURE LINES,INTACT DISC SPACE
  • 44.
    OTHER DIFFERENTIAL DIAGNOSIS • Scheuermann’s disease •Pathologic fractures from osteoporosis • Degenerative Disc prolapse • Sickle cell disease • Ankylosing spondylitis • Sarcoidosis
  • 45.
    Classification 1. Oguz etal. classification (based on the number of vertebrae involved and the presence of complications.) Type 1 one disc level and soft tissue infiltration without abscess, collapse and neurologic deficit Type 2 Degeneration involving one or two disc levels with abscess formation and mild kyphosis. Neurological deficit may be present Type 3 Degeneration involving one or two disc levels with abscess formation, instability and deformity that cannot be corrected without instrumentation 2. Based on location of the lesion: cervical, thoracic, thoracolumbar, lumbar or sacral.
  • 46.
    Kumar staging Predestructive stagepatient presents in <2 months of onset of disease with the straightening of curvatures and spasm of the perivertebral muscles Early destructive stage patient presents between 2 and 4 months of onset of disease with decreased disc spaces and paradiscal erosion Mild angular kyphosis stage patient presents between 4 and 9 months of onset with two to three vertebral involvement and kyphotic angle of 10°–30° Moderate angular kyphosis stage when patient presents between 6 and 24 months with more than 3 vertebral involvement and kyphotic angle of 30°–60° Severe kyphosis stage patient presents after 24 months with more than 3 vertebral involvement and kyphotic angle of more than 60°.
  • 47.
    Treatment • To eradicatethe mycobacterium • To prevent / treat instability • To prevent / treat deformity • To prevent neurologic deficit Goals
  • 48.
    Middle Path Regime •Tuli and Kumar advocated drugs as the basis of treatment and reserves surgery for specific indications • Operative treatment is combined with 6–12 months of bed rest, followed by 18–24 months of spinal bracing. • It’s the most widely accepted protocol
  • 49.
    Middle Path Protocol •Admission, bed rest • Chemotherapy. • X-ray and ESR once in three months. • Gradual mobilization in the absence of neurological complications. • Spinal braces—18 months to 2 years. • Abscesses are aspirated or drained. • Sinuses heal within 6–12 weeks. • If no neural complications develop; if response is obtained within 3–4 weeks of triple-drug therapy, surgery is unnecessary. • Operative debridement for patients who do not show arrest of disease after 3–6 months of chemotherapy.
  • 50.
    Non-Operative management 1. MEDICAL THERAPY Indications •Organism Identified and antibiotic sensitivity • Uncomplicated TB spine • As an adjunct to surgical therapy • Complicated cases where surgery may not be useful • Therapeutic trial
  • 51.
    First line drugs •Isoniazid –5(4-6)mg/kg/day, Peripheral neuropathy • Rifampicin –10(8-12)mg/kg/day, Hepatotoxicity • Pyrazinamide –25(20-30)mg/kg/day, Gout • Ethambutol-15(13-17)mg/kg/day, Optic neuritis • or • Streptomycin-15(12-18) mg/kg/day, Ototoxicity
  • 52.
    Second line drugs •Thiacetazone -2.5(2-3)mg/kg/day, bacteriostatic • PAS, 10-12 g/day, bacteriostatic • Ethionamide, 15-20mg/kg/day, bacteriostatic • Cycloserine,0.5-1gm/day • Kanamycin, 15-20mg/kg/day, bacteriocidal • Capreomycin, 12-18mg/kg/day, bacteriocidal • Ciprofloxacin, 1-1.5g/day, bacteriocidal
  • 53.
    Standard regimen Intensive Phase 4drugs for2 months •1.Isoniazid, 5-15mg/kg-300mg •2.Rifampicin 10—20mg/kg-600mg •3.Ethambutol 15-25mg/kg-800mg •4.Pyrazinamide 30-40mg/kg-1.5gm Continuation Phase INH and Rifampicin
  • 54.
    Duration of continuationtherapy • Isoniazid and rifampicin given for • 10 months for the 12 months, regimen-Canadian Thoracic Society • 7 months for the 9 months, regimen-American Thoracic Society • 7 months for the 9 months, regimen-WHO 2010 • 16 months for the 18 months, regimen-Old school • 4 months for the 6 months , NICE Guidlines
  • 55.
    2. Mobilization witha suitable orthotics • Collar • Halo vests • Minerva jacket 3. Physiotherapy.
  • 56.
    Treatment: Operative Goals are •to achieve adequate decompression, • debridement, • maintenance and reinforcement of stability, • correction and prevention of deformity.
  • 57.
    Indications Patient without neurological complications •Progressive bone destruction in spite of ATT • Failure to respond to conservative therapy • Evacuation of paravertebral abscess • For biopsy • Mechanical reasons: instability • Prevention of severe kyphosis in young children Patients with neurological complications • New or worsening neural complications or lack of improvement with conservative treatment • Paraplegia of rapid onset or severe paraplegia • Late-onset paraplegia • Painful paraplegia in elderly patients • Spinal tumor syndrome (epidural spinal tuberculoma without osseous involvement)
  • 58.
    Treatment: Surgery • Surgery:Options • Costo-transversectomy • Anterior decompression and fusion (Hodgson and Stock) • Hong Kong procedure • Radical debridement, grafting and fusion • Posterior decompression and spinal fusion • Non-instrumentation • Hibbs and Albee 1911 • Instrumentation • Drainage of abscess
  • 59.
    Surgical Approaches • Forspinal TB in the cervical spine, an anterior approach is most common. • For the thoracic spine: • anterior and anterolateral decompression by thoracoabdominal approach • posteriorly there is costo-transversectomy • lumbar level spinal TB: • Posterior • anterior • antero-lateral
  • 60.
    Anterior approach • Anteriorapproaches enable adequate exposure, debridement, and reconstruction. • Disadvantage • Graft slippage - 50 - 80% • Fracture • Absorption, or subsidence of graft. • Mortality 4% morbidity 18%
  • 61.
    Posterior approach • Commonlyused approach • The ability to achieve adequate exposure for circumferential spinal cord decompression, and better deformity control through pedicle screws • Possibility of extension of instrumentation • Avoidance of thoracotomy-related complications • Transpedicular decompression and posterior instrumentation facilitates faster recovery and also prevents deformity progression and neurological sequelae in early disease
  • 62.
    Combined approaches Indications • Osteoporoticbones, • Multiple vertebral body involvement • Severe kyphotic deformities. • severe destructive lesions and junctional pathologies that are inherently unstable • Posterior instrumentation with anterior decompression and fusion can be performed in 1 or 2 stages. • Anterior debridement removes infected foci and allows for direct neural decompression and rigid anterior reconstruction. • Posterior instrumentation enables better deformity correction and reduces the stress on grafts placed anteriorly, thus helping in maintaining sagittal deformity correction. • it is associated with high morbidities
  • 63.
    INDICATION FOR INSTRUMENTATION •Pan vertebral disease: Instrumentation should be done to prevent subluxation /dislocation of the spine. • Long segment disease: Disease of 4 or more vertebral bodies. • In the lumbar & cervical spine: There are no costotransverse & costovertebral articulations as in the dorsal spine. • When kyphosis correction is done • Injunctional areas such as the CD spine and DL spine
  • 64.
    Treatment: Surgery • Surgery:Abscess drainage • Indication • Large abscess • Cord compression • Septic features • Principles • Incision over non dependent area • Incision is closed • Drain not longer than 2 days
  • 65.
    Treatment: Cervical • Decompression •Anterior approach (Southwick Robinson) • Transoral • Stabilization • Instrumented + fusion • Cages • Cervical plate • Cervical rods and screws
  • 66.
    Treatment: Thoracic • Abscess •Costotransversectomy • Transpedicular drainage • Decompression • Anterolateral extrapleural approach • Anterior transthoracic • Costotransversectomy
  • 67.
    COSTOTRANSVERSECTOMY This approach helpsin evacuating abscesses in the dorsal spine . • Midline incision Elevate soft tissue & periosteum from spinous process & laminae over abscess. • Resect transverse process at its base • Resect 5cm of contiguous rib • Open abscess by blunt dissection • Wash and close in layers
  • 68.
    TRANS THORACIC TRANSPLEURAL APPROACH •Hodgson & stock described propagated for anterior clearance of lesion & Reconstruction by bone grafting. • Patient in lateral decubitus position with bean bag. • Incision over corresponding involved vertebra & expose subperiosteally. • Disarticulate rib from transverse process • Incise parietal pleura & reflect it off the spine. • Pleural adhesions cleared gradually.
  • 69.
    TRANS THORACIC TRANSPLEURAL APPROACH •It allows adequate exposure for debridement & grafting • Identify segmental vessels & ligate. • ICN useful guide to intervertebral foramina. • Reflect periosteum overlying spine & expose involved vertebrae. • Lesion is debrided & anterior decompression of spinal canal achieved
  • 70.
  • 71.
    Treatment: Lumbar • Abscess •Lumbar paravertebral abscess • Transpedicular drainage • Decompression • Approach through Hypogastric para median trans peritoneal approach. • Retroperitoneal • Transperitoneal
  • 72.
    Advantage of surgery •Less kyphosis • Immediate relief of compressed neural tissue • Quicker relief of pain • A higher percentage of bony fusion • Less relapse • Earlier return to previous activities • Less bone loss • Prevent late neurological problems due to kyphosis and fibrosis
  • 73.
    Neurologic complications ofspinal TB • Most feared complication • Occurs in 30% of cases • Kumar’s classification, ASIA classification • Paraplegia of early onset will resolve with ATT • Paraplegia of late onset usually requires surgical decompression
  • 74.
    Paravertebral abscesses PARAVERTEBRAL ABSCESS ACCUMULATE UNDER ANTERIOR LONGITUDINAL LIGASMENT GRAVITATEALONG FASCIAL PLANES PRESENT EXTERNALLY AT SOME DISTANCE FROM THE SITE OF THE ORIGINAL LESION LUMBAR PSOAS ABSCESS ALONG THE SHEATH
  • 75.
    Abscess formation • Cervicalspine →Posterior/ Anterior triangle • Upper thoracic →Intercostal Spaces on the chest wall • Lower thorax and Lumbar → Thigh and inguinal region: Psoas Abscess • Treatment • Anti Tubercular Drugs • Percutaneous CT guided needle aspiration • MIS • Surgical Drainage
  • 77.
    Kyphosis • TB spineis a common cause of Kyphosis • More severe curves are seen in children • Surgery is indicated if Kyphotic Angle is ≥ 60% • Prevention is Key • Early treatment with ATT • Posterior decompression and screw fixation
  • 78.
    TB spine inchildren • 35% of cases of TB in India • Vertebrae is cartilagenous • Progressive deformity occurs in 39% • Aim of treatment • Early eradication of TB • Identification of children that are likely to develop progressive
  • 79.
    TB spine inChildren • Clinical Risk factors for Kyphosis correction • Age less than 11 yrs • Affectation of 3 or more vertebrae Kyphotic angle >30 at presentation • Disease at the lower thoracic and thoracolumbar junction • Radiologic Spine at risk (Rajasekaran et al): • 2 or more spines at risk plus clinical risk factors is an indication for surgery
  • 80.
    Complications • Disease • Quadriplegia •Paraplegia • kyphosis • Tuberculoma • Tuberculous meningitis, arachnoiditis • Secondary infection • Amyloid disease • Death • Intervention • Drugs • Hepatitis • Peripheral neuropathy • Optic neuropathy
  • 81.
    Complications • Intervention • Surgery •Graft migration • Fixation failure • Cord compression/ injury • Pneumothorax, pleural effusion • Ileus • Injury to surrounding structures
  • 82.
    Follow up/ Monitoring •Aim • Response to therapy and complications • Compliance (DOTS) • Development of neurological deficit • Deformity • All patients were examined clinically and radiologically at 3, 6, and 12 months after surgery and then once a year.
  • 83.
    Follow up/ Monitoring •Modality • Regular weighing • Erythrocyte sedimentation rate (ESR) • Full blood count • Lymphocyte count • Liver function tests • Visual acuity • Electrolyte, urea, and creatinine • Chest X-ray and regional areas • “Healed status” • Clinical and radiological evidence of healing without any recurrence after 2 years
  • 84.
    Rehabilitation • Aims toreturn the patient to the pre-morbid state • Physiotherapy • Occupational therapy • Psychotherapy
  • 85.
    Prevention • Primary prevention •Health Education • BCG Immunization • Good standard of living • Proper Housing unit • Secondary prevention • Early diagnosis and treatment • Screening of high risk individuals • Tertiary prevention • Rehabilitation • Limitation of disability
  • 86.
    Prognosis • Mortality • Veryhigh before advent of anti TB drugs • 70% patients with surgery • Severity of neurological deficit • 11% in patients with severe neurologic deformity • Kyphosis • Neurologic, respiratory and cardiac failure • Associated with non operative management
  • 87.
    Prognosis • Neurology • Mayimprove with chemotherapy • Better after anterior decompression 94% • 79% after non operative • 48% with severe neurology recovered • Poor results • Atrophic cord • Pachymeningitis
  • 88.
  • 89.
    Future Trends • XpertMTB/RIF Ultra, as they found it, to have better detection rates of Mycobacterium tuberculosis in specimens with low numbers of bacilli.
  • 90.
    Conclusion • Tuberculosis ofthe spine is a severe debilitating disease • High index of suspicion is required in patients with chronic back pain • Mainstay of treatment is chemotherapy • Surgery has a big role to play
  • 91.
    References • Onuminya JE,Morgan E, Shobode MA. Spinal tuberculosis - Current management approach. Niger J Orthop Trauma 2019;18:35-43 • Mohammad R. R et al Spinal Tuberculosis: Diagnosis and Management Asian Spine Journal Vol. 6, No. 4, pp 294~308, 2012 • Kirkman MA, Sridhar K. Posterior listhesis of a lumbar vertebra in spinal tuberculosis. Eur Spine J 2011;20:1-5. • Rajasekaran S. The natural history of post-tubercular kyphosis in children. Radiological signs which predict late increase in deformity. J Bone Joint Surg Br 2001;83:954-62. • Neradi, D., Sengupta, D.K. (2022). Epidemiology of Tuberculosis of Spine. In: Dhatt, S.S., Kumar, V. (eds) Tuberculosis of the Spine. Springer, Singapore. https://doi.org/10.1007/978-981-16-9495-0_3 • Google images

Editor's Notes

  • #8 Our definition for close contact included either high exposure rates (>15 hours) in 1 or more weeks or high total exposure (>180 hours) during the index patient’s infectious period.
  • #41 Chest xray has a sensitivity of 96% and low specificity of 46% for diagnosis of pulmonary TB
  • #55 MDR-TB is resistance to Rifampicin and INH XDR-TB(Extensively Drug –Resistance TB ) is defined as resistance to INH and Rifampicin along with resistance to any flouroquinolone and at least one injectable second-line drug. Leads to relentlessly progressive disease with very high morbidity and mortality Result from improper patient compliance
  • #57 Signs of spinal instability Pathological fractures, Involvement of the anterior and posterior spinal elements, Translation or dislocation of the destroyed vertebrae, and Long segment disease with kyphosis
  • #61 Spinal TB mainly affects the anterior column and thus At the c- spine abscess drainage, corpectomy and fixation are done via anterior approach Dorsal spine via thoracotomy or by anterior lateral approach
  • #68 Described by MENARD in 1894
  • #90 , especially in smear-negative, culture-positive specimens, in pediatric specimens and in extrapulmonary specimens. The combined procedures become invaluable in patients with large vertebral defects involving 2 – 3 vertebrae, revision surgeries, and in thoracolumbar TB.