3. Introduction
One fifth of TB population … in India.
Spinal tubercular account for 30-60%
of the Musculoskeletal TB infections
Always secondary
Most common : 1st three decades
SEX : M=F
Most affected : Thoraco-lumbar region
3
6. A.Active stage
1.Pain: Back pain (Commonest), Diffuse in
early stages, but later become localised to the
affected diseased segments.
It may be a radicular pain.
Depending upon the nerve root affected, it may present
as:
1.Cervical root- Arm pain
2.Dorsal root- Girdle( pectoral ) pain
3.Dorso-lumbar root- Abdomen pain
4.Lumbar root- Groin pain , or
5.Lumbo-Sacral root- Sciatic pain
CLINICAL FEATURES
6
7. 2.Spine Stiffness: spasm of para-vertebral
muscle
3.Night cries
4.Deformity: Knuckle /Gibbus/Kyphus.
5.Cold abscess: May be present
6.Paraplegia (if neglected in early stages)
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8. 7.Constitutional Symptoms (Only in 20%
cases): Malaise, weight loss, loss of appetite,
night sweats, evening rise of temperature.
B. Healed stage
No systemic features but deformity persists.
Radiological evidence of bone healing
But several of these signs and
symptoms may be absent.
Important: c/f presentation depends on
1.Stage
2 Site
3.Presence of complications :neurologic
deficits, abscesses, or sinus tracts
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11. Infectious exudate may spread anteriorly beneath
Anterior longitudinal ligament &neighbouring
vertebrae
Advances&destroys the cortex,intervertebral
disc&adjacent vertebrae
Infection begins in cancellous area of vertebral
body(Central/anterior/epiphyseal in location)
Route of infection :1.hematogenous (Batesons
plexus)2.Lymph node spread 3.Direct spread
Focus of infection : possible from any sites M/C
pulmonary ,abdomen
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11
12. Granuloma formation
Tissue necrosis &
inflammatory
response
Paraspinal Abscess
LocalizedTrack along
tissue planes
Progressive necrosis of
vertebral body-Kyphotic
deformityAdjacent vertebral
bodies under the
longitudinal
ligaments
Along the fascial planes
Ex: Psoas abscess
PARAVERTEBRAL ABSCESS
13. PARAVERTEBRAL ABSCESS
Cervical region
• Between vertebral bodies, pharynx and trachea
Upper thoracic
• ‘V’ shaped shadow, stripping lung apices laterally
and downwards
Below T4 – Fusiform shape (Bird’s nest)
• Below Diaphragm – unilateral & blilateral psoas
shadow.
14. COLD ABSCESS :CERVICAL
SPINE
ANTERIORLY : 1.Retropharyngeal abscess,
2.paravertebral abscess
ON SIDE : 1.post.Border of SCM
2. POST of neck
ALONG MUSCULOFASCIAL PLANE : 1.Axilla
2.Arm
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14
15. COLD ABSCESS :THORACIC
SPINE
ANTERIORLY 1.mediastinal abscess
2. paravertebral abscess
ON SIDE : 1.psoas abscess
2. lumbar abscess
ALONG MUSCULO-FASCIAL PLANE:
1.Ant. Chest wall
2.Mid-axillary line
3.posterior chest wall
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15
16. COLD ABSCESS :LUMBAR
SPINE
ANTERIORLY :prevertebral abscess
: paravertebaral abscess
ON THE SIDE : lumbar abscess
: psoas abscess
ALONG MUSCULOFASCIAL PLANE : groin
,leg
along sciatic nerve to pelvis, gluteal region,
posterior aspect of thigh and popliteal
Region(KNEE)
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16
17. Pathophysiology
Potts disease is usually secondary
The basic lesion is a combination of osteomyelitis
and arthritis.
The area usually affected is the anterior aspect of
the vertebral body
Tuberculosis spread from that area to adjacent
intervertebral disks.
disk is secondary to the spread of infection
from the vertebral body.
18. Progressive bone destruction leads to vertebral
collapse, kyphosis & neurological involvement
Kyphotic deformity occurs in collapse of anterior spine.
Kyphotic def:; DORSAL SPINE THAN LUMBAR
The collapse is minimal in cervical spine because
most of the body weight is borne through the articular
processes.
Healing takes place by gradual fibrosis and
calcification of the granulmatous tuberculous
tissue:::FIROUS ANKYLOSIS
19. 7/24/2015
paravertebral abscess
Accumulate beneath the Anterior
longitudinal ligament.
Gravitate along the fascial planes
Present externally at some distance
from the site of the original lesion.
Thoracic ….fusiform
shadow(longituninal lig limits)
Lumbar…..psaos abscess along
sheath
19
21. PARADISCAL LESIONS
Most common
• Adjacent to the I/V disc leading to
narrowing disc space
Disk space narrowing
• Destruction of subchondral bone
with herniation of disc into the body.
• Direct involvement of the disc.
22. Adjacent to the I/V Disc leading to a
narrowing of the disc space
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22
PARADISCAL
DISTRUCTION OF VERTIBRAL BODIES ,NARROWING OF
IVD SPACE AND kyphotic DEFORMITY
23. ANTERIOR LESIONS
• Subperiosteal lesion under ALL
• Pus spreads –by stripping ALL,
periosteum from anterior
surface of vertebral body
• Vertebral body collapse due to
pressure and ischemia, followed
by disc space narrowing.
• Relatively common in Thoracic
spine
24. CENTRAL LESIONS
Center of vertebral body
• Reaches through Batson’s
venous plexus or through posterior
vertebral artery
Vertebra plane
• Vertebral body collapse
•
25. APPENDICULAR LESIONS
Uncommon lesion <5%
• Isolated infection of pedicles, lamina (neural
arch0, transverse processes
Occurs in isolation or conjunction with
paradiscal lesions
Radiographically appears as erosive lesions,
paravertebral shadows with intact disc space.
27. DIAGNOSIS
Complete blood picture
• ESR Increased / Increased Lymphocyte count
ELISA
• For antibody to mycobacterial antigen
• Sensitivity 60-80%
PCR
• Sensitivity of 40%
Chest radiograph
28. Mantoux / tuberculin skin test
Microbiology ZEIHL-NEELSEN
STAINING/ACID FAST STAINING
Cultures :4-6 weeks(L-J MEDIUM)
Positive only in 50% cases
IFN – Release assays (IGRA’s)
Assays that measure T-cell release of IFN –
in response to stimulation with highly
specific tuberculosis antigens ESAT6 &
CFP 10
36. Kumar’s clinico-radiological
Classification
stage features Usual duration
I Pre-
destructive
Straightening, spasm,
hyperemia
<3 mo
II Early-
destructive
Diminished space
paradiscal erosion
Knuckle <10
2-4 mo
III Mild kyphos 2-3 verte k:10-30 3-9 mo
IV Moderate
kyphos
>3 verte K:30-60 6-24 mo
V Severe
kyphos
>3 verte K:>60 >2 years
37. Paravertebral / prevertebral
Shadows(Radiological evidence of cold
abscess)
Abscess in cervical region: as a soft tissue
shadow b/n vertebral bodies and pharynx &
trachea.
On average, normal space b/n pharynx and
spine above level of Cricoid cartilage is 0.5 cm
and below it is 1.5 cm
In lateral view, the tracheal shadow is
Concave anteriorly (parallel to the upper dorsal
vertebrae),
if there is a change in normal contour &/or its
distance is >8mm from the vertebrae, it is strong7/24/2015
37
39. Abscess below the level of D4 vertebrae – Fusiform shape (Bird
nestappearance)
An abscess under tension may produce- Globular shape
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Paravertebral
Shadows39
40. CT- SCAN OF SPINE
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USE FULL FOR
Patterns of bony destruction.
Calcifications in abscess (pathognomic for TB)
Regions which are difficult to visualize on plain films, like :
1. Cranio-vertebral junction (CVJ)
2. Cervico-dorsal region,
3. Sacrum
4. Sacro-iliac joints.
5. Posterior spinal tuberculosis because lesions
less than 1.5cm are usually missed due to overlapping of
shadows on x rays.
40
41. MAGNECTIC RESONANCE
IMAGING
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highly sensitive &specicific for spinal TB
Spinal cord & soft tissue involvement
Detect marrow infiltration in vertebral bodies(EDEMA),
leading to early diagnosis
Skip lesions
Changes of diskitis (EDEMA)
Assessment of extradural abscesses / subligamentous
spread
Poor for calcification
41
43. RADIONUCLIDE BONE SCAN
Increased uptake in 60% patients
with active tuberculosis
>= 5mm lesion can be detected
Avascular segments & abscesses
show cold spot
Localize active disease and skip
lesions
Highly sensitive but non specific
48. TB spine
pyogenic
7/24/2015
• Long standing history of months
to yrs
• active PTB may be seen
• Most common location thoracic
spine
• > 3 contiguous vertebral body inv
• Vertebral collapse very common
• Bone destruction : more
• Skip lesions common
• Pra vertebral abscesses-Common
• History of days to months.
• Not present.
• Most common location lumbar
spine.
• Mostly involves 1 spinal
segment – 2vertebrae & intervening
disc.
• less common
• very less
• Rare
• Rare
49. A destructive bone lesion
associated with a poorly
defined
vertebral body endplate
&
with loss of disc space
which has a
better prognosis
A destructive bone
lesion associated with a well
preserved
disk space
&
sharp endplates
“Good disk, bad news;
bad disk, good news"
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49
54. SEDDON’S CLASSIFICATION OF
TUBERCULOUS PARAPLEGIA
10-09-2014
54
GROUP A (EARLY ONSET
PARAPLEGIA) a/k/a Paraplegia
associated with active
disease :
Active phase of the disease within
first 2 years of onset.
Pathology - inflammatory
edema, granulation tissue, abscess,
caseous material or ischemia of cord.
GROUP B (LATE ONSET
PARAPLEGIA) a/k/a Paraplegia
associated with healed disease :
After 2 years of onset of
disease.
Recrudescence of the
disease or due to mechanical
pressure on the cord.
Pathology can be sequestra,
debris, internal gibbus or stenosis of
the canal
55. BASIC PRINCIPLES OF
MANAGEMENT
• Early diagnosis
• Expeditious medical treatment
• Aggressive surgical approach
• Prevent deformity
• Best outcome
“The captain of the men of death”
61. MIDDLE PATH REGIME
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Rest on hard bed
Chemotherapy
X-ray & ESR once in 3 months kyphosis
measurement MRI/ CT at 6 months interval for 2
years
Gradual mobilization is encouraged in absence of
neural deficits with spinal braces & back extension
exercises at 3 – 9 weeks.
Abscesses – aspirate when near surface & instil
1gm
Streptomycin +/- INH in solution
61
63. MIDDLE PATH REGIME
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Sinus heals 6-12 weeks
Neural complications if showing progressive
recovery on ATT b/w 3-4 weeks :surgery
unnecessary
IF NOT
Excisional surgery for posterior spinal disease
associated with abscess / sinus formation +/-
neural involvement.
Operative debridement–if no arrest of symptoms
after 3-6 months of ATT / with recurrence of
disease
63
64. ABSOLUTE INDICATIONS FOR
SURGERY:
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Paraplegia during conservative treatment (6 weeks)
Paraplegia worsening during treatment (6 weeks)
Complete motor loss for 1 month despite of conservative
treatment
Paraplegia with uncontrolled spasticity
Severe and rapid onset paraplegia
Severe flaccid paraplegia/ sensory loss
64
65. Other indications
Relative
indications
1. Recurrent
paraplegia
2. Paraplegia in
elderly
3. Painful and
spastic
paraplegia
Rare indications
1. Posterior element
disease
2. Spinal tumor
syndrome
3. Severe cervical
lesion c paraplegia
4. Cauda equinopathy
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65
70. Posterior fixation:
Fixation of posterior element
of diseased vertebra by
instrumentation are done:
1.To prevent and correct
kyphotic deformity.
2. To maintain stability
of the spine
Fig : Pedicel screw fixation
71. TB Paraplegia or Quadriplegia
MDT, Bed rest for 6 weeks
Progressive neurological recovery No improvement
Continue MDT, walking allowed
when recovery complete
Surgical decompression
Recovering Not recovering
FLOW CHART FOR THE MANAGEMENT OF PARAPLEGIA
:SM TULI 7/24/201571
72. Not recovering
MRI / Myelogram
(IMMUNOMODULATION THERAPY)
No block Block present
Intrinsic damage to cord has
occurred
Repeat surgical decompression
No recovery RecoveryContinue MDT,
Rehabilitation
Continue MDT and permit
walking when recovery
complete
7/24/201572
74. ANTERIOR APPROACH TO THE
CERVICAL SPINE (C2 to D1)
Smith & Robinson
Oblique / transverse incision.
Plane b/w SCM & carotid sheath laterally & T-O
medially.
Longitudinal incision in ALL open a perivertebral
abscess, or the diseased vertebrae may be exposed
by reflecting the ALL
& the longus colli muscles.
Hodgson approach via posterior triangle by retracting
SCM,
Carotid sheath, T & O anteriorly & to the opposite
side.
75. SURGICAL APPROACHES TO
DORSAL SPINE
Anterior transpleural transthoracic approach
Anterolateral extrapleural approach
Posterolateral approach
{Dura is exposed by hemilaminectomy first & then
extended laterally to remove the posterior
ends of 2 – 4
ribs, corresponding transverse processes &
the pedicles}.
76. TRANSTHORACIC
TRANSPLEURAL
Left sided
incision preferable
Incision made along the rib which in the mid-axillary line,
lies
opposite the centre of the lesion (i.e. usually 2 ribs higher
than the
centre of the vertebral lesion).
For severe kyphosis, a rib along the incision line should
be removed.
J-shaped parascapular incision for C7 – D8 lesions,
scapula uplift & rib resection.
After cutting the muscles & periosteum, rib is resected
77. TRANSTHORACIC
TRANSPLEURAL….
Parietal pleural incision applied & lung freed from
the parieties & retracted anteriorly.
A plane developed b/w the descending aorta & the
paravertebral abscess / diseased vertebral bodies by
ligating the intercostal vessels & branches of hemiazygos
veins.
T-shaped incision over the paravertebral abscess.
Debridement / decompression with or without bone
78. ANTEROLATERAL
DECOMPRESSION
Griffith et al -- prone position
Tuli --- Right lateral position
Advantage:-
1. avoid venous congestion
2 . avoid excessive bleeding
3. permits free respiration
4. Lung & mediastinal contents fall anteriorly
Parts to remove :
Posterior part of rib (~8cm from the TP)
Transverse process (TP)
Pedicle
Part of the vertebral body
79. ANTEROLATERAL
DECOMPRESSION….
• Semicircular incision
• For severe kyphosis, additional 3-4
transverse processes and
ribs have to be removed.
• Intercostal nerves serve as guide to the
intervertebral foramina & the pedicles.
80. ANTERO-LATERAL APPROACH TO
LUMBAR SPINE
( LUMBOVERTEBROTOMY)
Left side approach
Semicircular incision
Expose and remove transverse process
subperiosteally.
Preserve lumbar nerves
81. CONT…
45 ⁰ right lateral position with bridge centred
over the area to be exposed.
Similar incision as nephroureterectomy or
sympathectomy
Strip peritoneum off posterior abdominal wall
and kidney, preserving ureter.
Longitudinal incision along psoas fibres for
abscess drainage
Retract the sympathetic chain
Double ligation of lumbar vessels.
82. EXTRA PERITONEAL APPROACH
TO
LUMBO-SACRAL REGION
Left side preferred ( left Common iliac vessels
longer & retracted easily).
Lazy “S” incision
Strip & reflect the parietal peritoneum along
with ureter & spermatic vessels towards right
side.
83. POSTERIOR SPINAL
ARTHRODESIS
Albee– Tibial graft inserted longitudinally in to the split
spinous processes across the diseased site.
Hibbs– overlapping numerous small osseous flaps from
contiguous laminae , spinous processes & articular facets
Indications–
1. Mechanical instability of spine in otherwise healed
disease.
2. To stabilize the craniovertebral region (in certain cases
of T.B.)
84. SURGERY IN SEVERE
KYPHOSIS HIGH RISK PATIENTS:
- Patients < 10 years
- Dorsal lesions
- Involvement of >= 3 vertebrae
- Severe deformity in presence of active disease,
especially in children is an absolute indication for
decompression , correction and stabilization.
Staged operations-
1. Anteriorly at the site of disease,
2. Osteotomy of the posterior elements at the
deformity &
3. Halopelvic or halofemoral tractions post-
85. TREATMENT OF PARAPLEGIA IN
SEVERE KHYPHOSIS
Griffiths et al :anterior transposition of cord
through
laminectomy
Rajasekaran : posterior stabilization
f/b
Anterior debridement and bone grafting (
titanium cages) in active stage of disease
and
vice versa for healed disease.
Antero-lateral (Preferred approach) .
86. SURGICAL CORRECTION OF
SEVERE
KYPHOTIC DEFORMITY
Fundamentals of correction:
1. to perform an osteotomy on the
concave side of the curve and wedge is open
( secured with strong autogenous iliac grafts) .
2. to remove a wedge on the convex
side and close this wedge ( Harrington
compression rods and hooks)
87. Radical debridement and
arthrodesis(hongkong procedure)
Excision of diseased tissue and anterior
arthrodesis is about the same at all levels of
spine
Remove debris,pus ,sequsterated bone/disc
Partially correct kyphosis by direct pressure
posteriorly on spine
After cutting mortise in vertebra at each end
insert strut bone grafts correct length keeping the
vertebra sprung apart
IBG are taken
Put streptomycin and isoniazide into cavity before
closure
88. Order of recovery irrespective of
mode of rx
89.
90. Take home message
MRI is the gold standard for diagnosis of potts
spine
Maintain high suspicion not to overlook
diagnosis
EARLY DAIGNOSIS
ATT GOOD OUT COME
REST
