This document discusses Pott's paraplegia, which occurs in 20% of cases of tuberculosis of the spine with neurological involvement. The dorsal spine is most commonly affected due to the narrow spinal canal in that region. Paraplegia can occur either early during active TB disease due to inflammatory causes like abscesses, or late after the disease becomes quiescent due to factors like kyphosis reducing the spinal canal size. Clinical features include gradual or sudden onset of spastic then flaccid paralysis. Investigations include blood tests, xray, CT and preferably MRI. Treatment involves anti-tubercular drugs, rest, bracing, and sometimes surgery for decompression if paraplegia deteriorates with conservative treatment. Progn

1. Dr Lokesh Chugh
Senior Resident
Deptt. of orthopaedics
GMC Amritsar

2. Introduction
 T.B. spine with neurological
involvement
 20% incidence
 M/c in dorsal spine
 As spinal canal is narrowest in
dorsal spine

3. Pathology
 Pressure on neural tissues within
canal by the products from diseased
vertebrae
Inflammatory edema
Extradural abscess and granulation
tissue
Sequestra of extruded disc

4.  Internal gibbus
 Infarction of spinal cord
 Extradural granuloma

5. Types of Pott’s paraplegia
 Early onset : paraplegia during active stage of
disease.
Usually within 2 yrs of onset of disease.
 Late onset: paraplegia occuring several years after
disease has become quiescent.
Usually occurs at least 2 years after the onset of
the disease.

6. Causes of paraplegia in T.B. spine
 Early onset :
Inflammatory causes
Abscess-m/c
Granulation tissue
Circumscribed tuberculous
focus
Posterior spinal disease
Infective thrombosis of spinal
blood supply

7.  Mechanical causes
Sequestrum in canal
Infected degenerated disc in
canal
Pathological dislocation

8.  Late onset
Recurrence of disease
Prominent anterior wall of spinal canal
in case of severe kyphosis ( internal
gibbus)
Fibrous septae following healing
More than one cause may be responsible
for particular patient

9. Clinical features
 Onset : gradual, some cases may be
sudden
 Spastic to start
 Clonus is most prominent early
sign
 Clinical features of associated
tuberculosis spine: weight loss,
night sweat, night cries, evening
rise of temperature

10. Stages of paraplegia
 Muscle weakness, spasticity and
incoordination: due to pressure on
corticospinal tract, anteriorly placed.
 Paraplegia in extension: tone of muscle
increased

11.  Paraplegia in flexion: absence of paraspinal tract
functions in addition to corticospinal tract.
 Complete flaccid paraplegia: all transmission
across cord stops

12. Grades of Pott’s paraplegia
 Grade 1: patient unaware of neural deficit
Doctor elicits babinski positive, ankle or patellar
clonus.
 Grade 2: spasticity while walking
Patient is able to walk with or without support

13.  Grade 3 : patient not able to walk because of severe
weakness.
Paraplegia in extension.
partial loss of sensation.
 Grade 4: unable to walk.
Paraplegia in flexion
Near complete loss of sensation with sphincter
disturbances

14. Investigations
 +/- History of spinal tuberculosis
 Clinical features: paraplegia
 Blood investigation: raised ESR, lymphocytosis
 X ray
 CT scan: vertebral destruction
 MRI : investigation of choice

15. Treatment principles
Promote recovery ( ATT/
decompression surgery)
Achieve healing ( supporting
spine till diseased segment
becomes stable)
Rehabilitation to prevent
contractures

16. Conservative
 ATT: mainstay of treatment
 Intensive phase: 2 months HRZE
 Continuation phase: 8 to 16 months HRE
 MDR TB: 5 drugs in intensive phase.
( pyrazinamide+ 4 second line drugs)

17.  Absolute rest
Cervical spine : sling traction
Dorsolumbar spine: bed rest
 Repeated neurological examination of
limb is carried out to detect any
deterioration or improvement
Bracing 6-12 months.

18. Operative treatment
Indications
 Paraplegia occuring during
conservative treatment
 Paraplegia deteriorates or remains
stationary despite conservative
treatment
 Severe paraplegia with rapid onset

19.  Complete loss of motor power for
one month despite adequate
treatment
 Motor or sensory loss for more
than 6 months
 paraplegia with uncontrolled
spasticity

20. Relative indication of surgery
 Recurrant paraplegia
 Paraplegia in old age
 Painful paraplegia: spasm or
root compression

21. SURGERY
 COSTO TRANSVERSECTOMY
Removal of section of rib and
transverse process.
Indicated in child with
paraplegia with tense abscess

22. Anterolateral decompression
 Removal of rib, transverse
process, pedicle and part of
body of vertebra is done
 laminae and facet joint are
not removed.

23. Other surgeries
 Radical debridement and
arthrodesis
Dead and diseased vertebrae
excised and replaced with rib
graft
 Laminectomy : spinal cord
syndrome

24. Cervical spine surgery
 Anterior decompression

25. Prognosis of pott’s paraplegia
Good prognosis
 Children respond better than
adults
 Acute onset has better prognosis
Poor prognosis
 Long duration paraplegia
 More severe grade( eg. With
sphincter involvement)
 Sudden progress

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