tuberculosis of spine

1. Dr Hitesh Abhayraj Shukla

2. • Bone and joint – next common site afetr lung
and lymph nodes
• Spine – commonest (50%), followed by hip,
knee and elbow
• Affects ends of the long bones unlike
metaphysis as in pyogenic osteomyelitis
• Early involvement of adjacent joint present

3. • Mycobacterium tuberculosis
• Always secondary to some primary focus,
spread by blood stream or direct extension
• Chronic granulomatous inflammation with
caseation necrosis
• Response is either proliferative(common, with
fibrosis) or exudative/non
reactive(immunodeficient state, pus
formation)

4. • Inflammation -> local trabecular necrosis and
caseation-> intense local hyperemia->
demineralisation-> cortical erosion-> pus reach
subperiosteal and soft tissue lanes-> cold abcess-
> sinuses-> pathological fractures
• Joint involvement- low grade synovitis->
inflammatory synovium at the periphery of
articular cartilage(pannus)-> slow complete
destruction of cartilage-> capsule, ligaments lax->
joint subluxation->cold abcess->sinus

5. • Fibrosis- fibrosing ankylosis , common
• Bony trabeculae traverse between the bones
forming the joint, due to considerable
destruction of cartilage- bony ankylosis
spine

6. • Slow onset , non specific symptoms and signs
• Pain, swelling, deformity, inability to use that
part
• Fallacious history of trauma
• Lack of constitutional symptoms - in only
about 20% cases
• High index of suspicion required

7. • RADIOLOGY
• TB osteomyelitis- well defined area of bone
destruction , minimal reactive new bone
formation
• TB arthritis- reduction of the joint space,
erosion of articular surfaces, periarticular
rarefaction
• Chest X ray- routine

8. • Blood exaamination- lymphocytic
leukocytosis, high ESR
• Mantoux test – in children
• Serum ELISA
• Synovial fluid aspiration
• Aspiration of cold abcess
• Histopathological examination- by biopsy of
curettage

9. • Control of infection-
1. ANTI TUBERCULAR THERAPY-HRZE * 3
months .
2. Rest – plastic slab (upper limb), traction
(lower limb)
3. Building up the patient’s resistance- high
protein diet, fresh air and sunlight

10. • Care of affected part
1. Proper positioning of joint
2. Mobilisation
3. Exercises
4. Weight bearing

11. • Biopsy
• Apsiration or curettage od cold abcess
• Curettage of lesion
• Joint debridement
• Synovectomy
• Salvage operations
• Decompression

12. • Pott’s disease
• Dorsolumbar region

13. • Dorsal spine – wedging( line of weight bearing
pass anterior to vertebra)
• Cold abcess – no signs of inflammation,
• pus track backwards-> compress neural
structures
• Anterior-> prevertebral abcess
• Sides-> paravertebral abcess
• Along musculofascial or neuro vascular
bundles

14. • Pain- dull ache->localised, raddicular-> arm,
girdle, abdomen, groin, sciatic
• Stiffness- very early symptoms. Protective, spasm
to prevent movement
• Swelling or its effects of compression- dysphagia
• Paraplegia
• Deformity- gibbus in children
• Constitutional symptoms

15. • GAIT- short steps to avoid jerking,cautious
movements
• Attitude and deformity – stiff straight
neck(cervical), kyphus or gibbus(dorsal spine),
lumbar lordosis
• Paravertebral swelling – fluctuant
• Tenderness
• Neurological examination

16. • Cervical spine- retropharyngeal abscess,
paravertebral abscess, posterior border of
SCM, in posterior triangle of neck, axilla,arm
• Thoracic spine- mediastenal abscess,
paravertebralar abscess,lumbar abscess, psoas
abscess, anterior chest wall mid axillary line ,
posterior chest wall
• Lumbar spine- pre vertebrak o praravertebral
abscess, lumbar and psoas abscess, along leg
and groin

17. • CHEST XRAY
• Reduction of disc space- earliest sign
• Destruction of vertebral body
• Evidence of cold abcess:
1. Para vertebral abcess- fusiform(bird nest
abscess) or globular(tense abscess)
2. Widened mediatenum- dorsal spine

18. 3) Retro pharyngeal abcess- thickness of soft tissue
shadow in front of c3 >4 mm.
4)Psoas abcess
• Rarefaction above and below lesion
• Unusual signs- when posterior complex is
involved, anterior type- aneurysmal sign
• Signs of healing – sclerosis surrounding the lytic
lesion, bony fusion
• CT SCAN
• MRI
• MYELOGRAPHY
• BIOPSY
• OTHER GENERAL INVESTIGATIONS

19. • BACK PAIN- trauma, secondaries or myeloma,
prolapsed disc, ankylosing spondylitis
• NEUROLOGICAL DEFICIT- spinal tumor,
trauma, secondaries to spine

20. • ATT
• GENERA CARE
• CARE OF SPINE- rest, body cast in children,
mobilisation
• Treatment of col abcess- aspiration,
evacuation(curetted and closed without drain)

21. • Cold abscess
• Neurological compression

22. • Most commonly in TB of dorsal spine
• Inflammatory edema/ extradural pus and
granulation tisssue(commonest)/ sequestra/
internal gibbus/ infarction of spinal cord/
extradural granuloma(spinal tumor
syndrome)
• Types:
1. early onset –within 2 years of onset of
disease, inflammatory causes(abcess,
granulation tissue), mechanical
causes(sequestrum in canal, infected
degenerated disc in the canal
2. Late onset – recurrence, internal
gibbus, fibrous septae folllowing

23. • Muscle weakness,spasticity and
incorodination( corticospinal tracts are more
sensitive to pressure)
• Paraplegia in extension( absence of normal
corticospinal inhibition)
• Paraplegia in flexion(absence of paraspinal
tract functions)
• Complete flaccid paraplegia

24. • I- Patient unaware, babinski positive, ankle or
patellar clonus
• II- Clumsiness, in coordination or spasticity while
walking, can walk with or without support
• III- not able to walk, severe weakness, paraplegia
in extension, partial loss of sensation
• IV- unable to walk, paraplegia in flexion, severe
muscle spasm, complete loss of sensation with
sphincter disturbances

25. • X ray
• CT
• MRI

26. • Promote recovery – reverse the cause by
drugs or operation
• Achieve healing of vertebra, support spine
• Rehabilitative measures to prevent
contractures and regain strength

27. • ATT
• Rest by sling traction(cervical), bed rest
(dorsolumbar)
• Care of paralysed limbs
• Allowed to sit with the help of a brace as soon
as spine gain enough strength
• Bracing continued till 6 to 12 months

28. • Absolute indications
1. paraplegia occuring during conservative treatment
2. Worsening or remaining stationary despite
conservative treatment
3. Rapid onset paraplegia(abcess/ mechanical accident)
4. Any severe paraplegia > 6 months, complete loss
motor power> 1 month
5. Paraplegia accompanied by uncontrolled
spasticity(rest and immobilisation not possible)

29. • Relative indications
1. Recurrent paraplegia
2. Paraplegia with onset in old age
3. Painful paraplegia
4. Complications like UTI and stones
• Rare indications
5. Paraplegia due to posterior spinal disease
6. Spinal tumor syndrome
7. Severe paralysis secondary to the cervical
disease
8. Severe cauda equina paralysis

30. • COSTO TRANSVERSECTOMY- removal of 2 inches of a
rib and transverse process. (child with tense abscess)
• ANTEROLATERAL DECOMPRESSION(ALD)- rib,
transverse process, pedicle , part of body removed,
access to front and side of the cord
• RADICAL DEBRIDEMENT AND
ARTHRODESIS(HONGKONG OPERATION)- transthoracic
or transperitoneal approach. Early healing and no
progress of kyphosis
• LAMINECTOMY- in spinal tumor syndrome and
paraplegia from posterior spinal disease
• ANTERIOR DECOMPRESSION- in cervical spine TB

31. • Age- children respond better
• Onset- acute onset better
• Duration – long standing worse
• Severity- motor paralysis alone good,
sphincter involvement bad sign
• Progress – sudden progress bad sign

32. • Children and adoloscents
• Initial lesion- bone adjacent to acetabulum or
head of femur (osseous tuberculosis), synovium(
synovial TB)
• Multiple cavitation is typical-> head or
acetabulum partially absorbed-> remaining head
dislocates into ilium by constant pull of muscles
acting on hip-> wandering acetabulum
• Cold abcess- groin, region of greater trochanter,
pelvis
• Healing- fibrous ankylosis

33. • Insidious in onset, chronic course
• Child pale and apethetic with loss of appetite
• Stiffness of hip limp , initially only after rest,
later persists all the time
• Pain absent in early stages, if present referred to
knee
• Night cries/ starting pain – rubbing of diseases
surfaces when movement occurs as a result of
muscle relaxation during sleep
• Cold abcess, discharging sinuses

34. • Gait – lameness –first sign. Flexion deformity of
hip-> compensatory exaggerated lumbar lordosis,
while walking hip stiff, forward backward
movement at lumbar spine used for propulsion of
lower limb- stiff hip gait; later limp exaggerated
by pain ->hastens to take weight off the affected
side-> painful or antalgic gait
• Muscle wasting- gluteal and thigh muscles
• Swelling

35. • Discharging sinuses
• Deformity –flexion adduction and internal
rotation of hip, minimal deformities
compensated by pelvic tilt
• Shortening
• Movements
• Abnormal position of the head
• Telescopy
•

36. • I- stage of synovitis- flexion, abduction,
external rotation, apparent lengthening
• II- stage of arthritis- flexion, adduction ,
internal rotation- apparent shortening
• III- stage of erosion- true shortening

37. • XRAY
• Haziness
• Lytic lesion
• Reduction of joint space
• Irregular outline
• Acetabular changes- wandering acetabulum ,
pestle and mortar appearance
• Signs of heaaling- sclerosis around the hip

38. • Other causes of monoarthritis
• Inguinal lymphadenopathy or psoas abscess
• CDH, Congenital coxa vera, Perthe’s disease
• Osteoarthritis

39. • Conservative- ATT, care of hip(immobilisaton
using below knee skin traction), general care
• Operative treatment
1. Joint debridement
2. Gridlestone arthroplasty
3. Arthrodesis
4. Corrective osteotomy
5. Total hip replacement

41. • Early stages-ATT, below knee skin traction,
physiotherapy
• Late stages- ATT, Traction initially, XRAY on
symptom relief
• Minimum destruction- mobilisation
• Significant joint damage-
1. Painless, mobile, unstable joint- excision
arthroplasty- able to squat
2. Painless, fixed, stable joint- arthrodesis- surgical
fusion of joint