Orthopaedics

1. Spinal tuberculosis
Dr. MD. SHAH ALAM
MBBS FCPS MS FRCS
Professor
Department of Spine & Ortho Surgery,
NITOR, Dhaka, Bangladesh

2. INTRODUCTION
• Evidence of spinal TB - in 5000-year-old mummies.
• In 1779, Percival Pott published -spinal TB.
• Tuberculosis is the chronic consumptive disease and
currently world’s leading cause of death.
• Tuberculous spondylitis is the most dangerous form
of skeletal TB.

3. Epidemiology
• One fifth of TB population is in India
• 3% are suffering from skeletal TB
• Vertebral TB - 50% of all cases of skeletal TB
• Almost 50% are from pediatric group
• Every day 1000 die of tuberculosis in India

4.  There were an estimated 10.4 million new cases of TB
disease in 2015.
 In 2015 an estimated 1.4 million people who were
died of TB.
 Bangladesh ranked 5th
in 2012 (WHO)
 Bangladesh ranked 7th
according to total cases of
incidence. (2,09,438 in 2015)
TB (Global Scenario)TB (Global Scenario)

5. Mortality 45/million
Incidence 225/million

6. SPINAL TUBERCULOSIS
Sl.
No.
REGIONAL
DISTRIBUTION
%
1. Cervical 12%
2. Cervicodorsal 5%
3. Dorsal 42%
4. Dorsolumbar 12%
5. Lumbar 26%
6. Lumbosacral 3%

7. PATHOLOGY
• Spinal tuberculosis is usually a secondary
• Hematogenous in origin
• Usually involves 2 adjacent vertebrae
• Delayed hypersensitivity immune reaction
• Initially : a pre-pus inflammatory reaction, with
Langerhan’s giant cells, epithelioid cells, and
lymphocyte
• The granulation tissue proliferates, producing
thrombosis of vessels

8. PATHOLOGY
• Tissue necrosis, tubercle formation result in 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

9. Pathology of spinal TB
• Can loose complete vertebrae
• Wedge shaped fractures are common

10. SIGNS & SYMPTOMS

11. A. Constitutional symptoms
• Kyphosis
• Scolosis
• Kypho Scoliosis
B. Spine Deformity

12. D. Local
• Cold abscess / Sinuses
• Pain
- Local /Radicular /both
• Motor deficits
• Spasticity
• Sensory deficits
• Bladder involvement
C. Neurological
Abscess
Bed Sore
Gibbus

13. Symptoms of Spinal TB
• Back pain (95%)
• 40-50% neurological symptoms –
weakness, paresthesia, bowel
symptoms
• 40-50% with systemic symptoms
–fever, night sweats, weight loss

14. DIAGNOSIS
•Diagnosis may take days to week.
• There is currently no single diagnostic method.

15. HISTORY
• Presentation depends on :
- Stage of disease,
- Site
- Presence of complications such as neurologic deficits,
abscesses, or sinus tracts
• Average duration of symptoms at the time of diagnosis
is 3 – 4 months.
• Back pain is the earliest & most common symptom
• Constitutional symptoms
• Neurologic symptoms (50 % of cases).

16. Lab studies
• Mantoux / Tuberculin skin test ( purified protein derivative {PPD})
• A positive test can be observed, one to 3 months after infection.
Positive in 84 – 95 %
Negative in almost 20 per cent patients with active disease if the
disease is disseminated, or if the patient is immunocompromised or
suffering from exanthematous fever

17. .
• ESR usually elevated (neither specific nor reliable).
• ELISA : sensitivity 60 – 80%
• ALS: anti-lymphocyte serum

18. • There are three diagnostic non- culture laboratory tests:
1. Immunological tests ( antigen & antibody)
2. Metabolic product detection test ( extra-corporeal IFN-y
test)
3. Amplification of DNA of M. Tuberculosis by PCR.
• Other than these
• - ELISA technique & T- SPOT Using 6 kDa & 10 kDa.
• - Xene expert for MDR TB.
DIAGNOSIS
Recent advance

19. • The major non-culture molecular diagnostic test, PCR
 Amplifies the DNA of M. tuberculosis
 Provide result within hour
 Monitor responses to treatment
 Provide rapid information on drug resistance & clonality.
DIAGNOSIS
Recent advance

20. Microbiology studies to confirm diagnosis :
• Ziehl-Neelsen staining: a quick and inexpensive method
• Obtain bone tissue or abscess samples to stain for acid-fast
bacilli (AFB), & isolate organisms for culture & drug
susceptibility
• Culture results are available only after a few weeks
• Histopathology

21. Radiological diagnosis
1. Plain radiograph
2. CT scan
3. MRI spine
4. Bone scan
TB bacilli are rarely found in CSF, therefore imaging plays a vital
role in suggesting the diagnosis.

22. EXTRA -DURAL INVOLVEMENT
• The primary focus of infection in the spine can be either in the vertebral
body or in the posterior elements.
• Four patterns :
- Paradiscal ( Commonest)
- Central
- Anterior, &
- Appendiceal
Radiological diagnosis

23. EXTRA-DURAL INVOLVEMENT

24. PLAIN RADIOGRAPH

26. CT SCAN MRI

27. EXTRA-DURAL INVOLVEMENT

28. Angle of Kyphosis

31. CLINICO-RADIOLOGICAL CLASSIFICATION OF
SPINAL TUBERCULOSIS

32. .

33. ..

34. ..

35. • The three main causes of Pott’s paraplegia are:
1) cord compression by abscess and granulation tissue;
2) cord compression by sequestrums and the posterior bony
edge of the vertebral body at the level of the kyphosis; and
3) Bony canal stenosis of the deformed spine above the
level of the kyphosis.
Pott’s Paraplegia

36. Factors affect recovery from Pott’s paraplegia.
• 1. Patient’s general physical condition and age;
• 2. Condition of the spinal cord; level and number of
vertebrae involved;
• 3. Duration and severity of the paraplegia;
• 4. Time to initiation of treatment.
Pott’s Paraplegia

38. Tuli and Kumar’s Staging of Pott’s Paraplegia ::
Stage I :Patient unaware of neural deficit, physician
detects plantar extensor and/or ankle clonus.
Stage II : Patient aware of deficit but manages to walk
with support, clumsiness of gait.
Stage III : Paralysis in extension, sensory deficit less
than 50%
Stage IV : III + flexor spasm/ paralysis in flexion/ flaccid/
sensory deficit more than 50%/ sphincters involved.

39.  Treatment should be individualized according to
different indications which is essential to recovery.
 Treatment outcome of secondary TB is not as good as
primary.
 In case of early diagnosis, outcome is very good. But in
our perspective, patient present very late with
complications partly due to ignorance and partly due to
delay in the diagnosis. So result is not always very
rewarding.
TREATMENT OF POTT’S DISEASETREATMENT OF POTT’S DISEASE

40. TREATMENT OF POTT’S DISEASETREATMENT OF POTT’S DISEASE

41. • Primary goal:
 Eradicate the infection and to save life.
• Secondary goal:
 Provide stability for the affected spine.
 To meet patient’s aesthetic demand.
 To prevent or treat paralysis.
Current views: Healing of the lesion with near normal spine

42. Components:
1. Conservative
Supportive
Chemotherapy
2. Surgery
MANAGEMENT

43. Chemotherapy/ConservativeChemotherapy/Conservative
1. Anti-tubercular Chemotherapy – Total period 18-24
months
Intensive phase (2 months): 4FDC (Rifampicin, INH,
Ethambutol, Pyrazinamide)
Continuation phase (After 2 months): 2FDC (Rifampicin,
INH)
2. High-protein diet, Open fresh air, Good sanitation etc.
3. Brace

44. ConservativeConservative
•In early presentation with minimal to moderate bony
involvement that does not seem to cause noticeable
deformity.
Can be given on an ambulatory basis without bracing.
Delayed and/or less neurological recovery.

45. ResponseResponse
There are no clear-cut definitions of good (or rapid)
response, poor (or slow) response and non-response.
The recommended observation period for drug response
in non-paralytics, a 6- to-8-week (maximum 3 months)
whereas in paralytics the assessment should take 3 to 4
weeks.

46. Advantages of surgical treatment :
 Early healing
 Histological confirmation
 Reduction of late-recurrence rates
 Correction and/or prevention of deformity
 Early effective neurological recovery
 To meet the patient aesthetic demands

47. INDICATION OF SURGERY:INDICATION OF SURGERY:
A. Absolute indications:A. Absolute indications:
1. Paraplegia with onset1. Paraplegia with onset
2. Paraplegia getting worse2. Paraplegia getting worse
3. Complete loss of motor power3. Complete loss of motor power
4.Paraplegia with spasticity4.Paraplegia with spasticity
5. Severe paraplegia5. Severe paraplegia
B. Relative indications:B. Relative indications:
1. Recurrent paraplegia1. Recurrent paraplegia
2. Paraplegia in old age2. Paraplegia in old age
3. Painful paraplegia3. Painful paraplegia
4. Complications4. Complications
C. Rare indications:C. Rare indications:
1. Posterior spinal disease.1. Posterior spinal disease.
2. Spinal tumor syndrome.2. Spinal tumor syndrome.
3. Severe paralysis secondary3. Severe paralysis secondary
to cervical disease.to cervical disease.
4.Severe cauda equina4.Severe cauda equina
syndromesyndrome..

48. Goals of SurgeryGoals of Surgery
• Eradication of diseased vertebrae
• Decompression of spinal cord
• Correction of deformities
• Stabilization of spine & further protection of spinal
cord

49. • Surgical measures include:
1. Cold abscess drainage & Focal debridement
2. Decompression surgery
3.Decompression surgery and posterior
instrumentation
4. Anterior radical surgery and anterior instrumentation;
5. Anterior radical surgery and posterior instrumentation
6. Corrective spinal osteotomy for healed rigid kyphosis

50.  Long segment stabilization
 3600
decompression
 Three column fixation is possible
Posterior Surgery

51. Types of surgery
 Cervical spine - Anterior approach
 Thoracic spine - Anterior & anterolateral
decompression by Thoraco-
abdominal approach
 Posterior - Costotransversectomy
Laminectomy.
 Lumbar - Posterior ,Anterior and Ant-lateral

52. ConclusionConclusion
 Spinal tuberculosis is curable & rewarding.rewarding.
 Early detection, institution of chemotherapy and
improved surgical techniques are imperative to achieve
expected result.
 Paraplegic patients can be well managed with minimal
residuals.