TREATMENT OF TB SPINE IN DETAILS

1. DR RAMACHANDRA REDDY
Under the guidance of
Prof. A. Devadoss
Dr. Sathish Devadoss

2.  The availability of anti tubercular drugs
(1948-1951), a significant milestone, divides
the treatment of tuberculosis into two eras

3.  Treatment is best described into
 A)Pre chemotherapy era
 B)Post chemotherapy era
 1)universal surgical extirpation
 2)middle path regime
 3)Surgery

4.  Hippocrates (450 BC) and Galen (131-201
AD) tried to correct kyphotic deformity due to
tuberculosis of spine, by manual pressure,
traction and mechanical appliances, but
failed.
 The orthodox conservative treatment
advocated recumbency, immobilization by
means of body cast, plaster beds and
braces.

5.  In general, results of these conservative
treatments were disappointing.
 Hence, operative procedures were
developed either for the treatment or for the
prevention of paralysis in tuberculosis of the
spine.

6. Laminectomy and Laminotomy:
Chipault in 1896 was the first to use
laminectomy in Potts paraplegia and
later
Fraser performed laminotomy, but,
finally in 1937, abandoned the operation
altogether as the late results were
disappointing.

7. Costo-transversectomy:
Menard in 1894 developed
costotransversectomy, which fell into
general disrepute, because of the high
incidence of sinus formation and of
secondary infection.

8. › Posterior mediastinostomy:
› Obalinski performed the procedure for
the evacuation of tuberculous
paravertebral abscess.

9. › Calve's operation:
› Calve in 1917 devised a method to
aspirate the contents of an abscess
without sinus formation.

10. › Lateral rhachiotomy of Capener:
› Norman Capener in 1933 devised lateral
rhachiotomy, which was a direct attack on the
solid compressing agent anterior to theca,
whereby he excised a part of the lamina and
pedicle from one side to enter the spinal
canal anteriorly and remove the cause of
pressure on the cord.

11. › Posterior decompression with posterior
spinal arthrodesis:
› Albee (1911, 1930) and Hibbs (1912, 1918)
introduced the operation of posterior spinal
fusion. Such operations were carried out 1911
onwards and were developed by many surgeons
to shorten the period of immobilization in the bed
and to provide a permanent internal stability to
the tuberculous spine to avoid recurrence of the
disease and development of paraplegia.

12.  1)universal surgical extirpation
 2)middle path regime
 3)Surgery

13. • Posterior decompression with posterior spinal
arthrodesis:
› Over the years it became increasingly obvious
that posterior fusion did nothing to the diseased
area where pus, debris and necrotic bone
remained enmeshed and encysted in dense
fibrous tissue, where the organisms remained
alive, sometimes mildly active, in other cases
dormant only to flare up at any chance or
provocation.

16.  Fellander , Hodson , Mukopadhya & others
advised for surgical extirpation in all patients
under the cover of anti tubercular drugs as
they thought that these drugs do not
penetrate wall into osseous tubercular
lesions.
 But later studies shows that (radioactive
isotopes of streptomycin & isoniazid) these
drugs can penetrate into osseous lesions
including cavities, abscess & even dry
caseous lesion.

17.  Usually spinal TB patients are anemic &
have poor nutrition.
 While waiting for fitness for surgical
decompression some patients some patients
show neural recovery & ulcer & sinuses
started healing.
 This lead to MIDDLE PATH REGIMEN
advocated by TULI.

18.  Admission rest in bed
 Chemotherapy
 X-ray & ESR once in 3 months
 MRI/ CT at 6 months interval for 2 years
 Gradual mobilization
 3-9 weeks- back extension exercise 5-10 min
3-4 times
 Spinal brace--- 18 months-2 years

19.  Abcesses – aspirate near surface
 Instill 1gm Streptomycin +/- INH in sol
 Sinus heals 6-12 weeks
 Neural complications if responds 3-4 weeks :-
surgery unnecssary
 Excisional surgery for posterior spinal disease
 Operative debridement for patients –if no arrest
after 3-6 months- spinal arthrodesis
(recommended)
 Post op--Spinal brace--- 18 months-2 years

20. phase duration drug
Intensive 5-6
months
INH
300-
400mg
Rifampicin
ofloxacin400-600mg /
streptomycin
Continua
tion
7-8
months
-do 3-4mth Pyrazinamide
1500mg
4-5mth Rifampicin
Prophyla
ctic
4-5
months
-do Ethambutol 1200mg

21.  India had a National Tuberculosis Programme
(NTP) in place from the '60s, following
epidemiological assessment of the situation
during 1955-1958.
 In 1993, the NTP in India was strengthened in
the form of Revised National Tuberculosis
Control Programme (RNTCP).
 DOTS is where the patient takes the drugs
under the direct observation (DO) of a health
worker to ensure regularity of consumption of
drugs.

22.  Main stay of treatment is prolonged
uninterrupted multi drug anti tubercular
chemotherapy for 12-18mths.
 Current guidelines for extra pulmonary TB
involves daily regimen
 Intensive phase : 2mths RHZE
 Continutation phase: 10-16mths RHE

23.  Treatment of tuberculosis of spine can be
discussed in two groups:
 1) TB SPINE WITHOUT NEURAL DEFICIT
 2) TB SPINE WITH NEURAL DEFICIT

24.  The management varies from radical surgery
to ambulant chemotherapy.
 Varies multicentre trails conducted with a
follow up of 3 to 10yrs.

25.  RECOMMENDATIONS ARE:
 No difference in status of tuberculous lesions on
comparison of 2 & 3 antitubercular drugs.
 No difference in cure rate on comparision
between bed rest & ambulant chemotherapy.
 No difference in results on comparision between
conservative treatment & after radical clearance
of lesion.
 No difference on comparision between Hong
Kong method of anterior decompression & fusion
with anterior spinal instrumentation.

26.  As the results of ambulant chemotherapy are
comparable so all TB spine patients without
neural complications are treated non
operatively.
 These cases operated only in following
conditions:
 Doubtful lesions.
 Pan vertebral lesions
 TB spine with severe kyphosis.
 Failure of conservative treatment.

27.  A. Braces
 B. Vitamin D supplementation
 C. Protein supplementation.

28. MONITORING TREATMENT RESPONSE:
 All cases of spinal TB should be monitored every
2mths.
 A) CLINICAL
 B) HEMATOLOGICAL
 C) RADIOLOGICAL:
Appearance of remineralization of VB
Sharpening of disc margin.
D)IMAGING: MRI @ 9,12, & 18mths.
E)AMBULATORY CHEMOTHERAPY patients

29.  FAILURE OF CONSERVATIVE
TREATMENT
 Drug resistance to anti tubercular drugs has
been reported in 1948.
 Drug resistance is one of the cause failure of
treatment.
 It could be due to :
 Inappropriate treatment
 Exposure to pulm. MDR TB case
 Infection in immunocompramised pts.

30.  When a pt develops resistance to one drug -
MONORESISTANCE
 Resistance to two or more drugs –
POLYRESISTANCE
 Resistance to RIFAMPICIN & ISONAZID –
MULTI DRUG RESISTANCE(MDR-TB)
 Resistance to RIFAMPICIN & ISONAZID &
ALSO injectable aminoglycosides & a
fluoroquinolone –EXTENSIVE DRUG
RESISTANCE

31.  CLINICAL
 HAEMATOLOGICAL
 MRI
 NEW LESION
 NON HEALING ULCER
 NEW COLD ABSCESS/LYMPH NODE
 WOUND DEHISCENCE
 In these cases lesion should be debrided &
sent for histopathology , AFB,Gene Xpert &
Line Probe Assay , C/S.

37.  Management of multi drug resistant -
tuberculosis
Should be referred to specialized units with
facilities for quality-controlled drug
susceptibility testing (DST) and experience
in handling such cases.
Drug selection must rely on prior treatment
history, results of susceptibility testing and
an evaluation of the patient's adherence.

42.  Neurological complications is the most
dreaded complications & crippling
complication of spinal TB.
 Overall incidence is between 10%-30%.
 Paraplegia results from interference with
function of cord.

43.  Parplegia due to TB spine classified into 2
main groups (Griffith, Seddon & Roaf 1956)
in pre antibiotic era.
 GROUP A (EARLY ONSET
PARAPLEGIA)
 GROUP B (LATE ONSET
PARAPLEGIA)

50.  The three definite methodologies have
evolved about treatment of TB spine with
neurological deficit:
 A)Absolute non-operative
 B)Universal surgical extirpation
 C)Middle path regimen

51.  A)Absolute non-operative :
 Dabsen (1951) reported that 48% of
paraplegia improved neurologically by
traditional conservative care in pre antibiotic
era.
 MRC trails (1978) considering early disease
(involving with little kyphosis &
paraparesis)have concludes that pott’s
paraplegia with active disease can be
managed by conservative methods on ATT
only.

52.  B)Universal surgical extirpation:
 In all tuberculous paraplegia cases surgery
performed by anterior decompression with or
without fusion.
 Reported neurological recovery vary from
37-94%.

53.  Advantages :
 Diagnosis was established beyond doubt.
 Quality & speed of neural recovery was
good.(<2mths vs conservative 2-6mths).
 Decompression removes fibrous barrier to
drugs.

54.  C)TULI has advocated based on his
experience in treating TB spine with
paraplegia:
 A judicious combination of conservative
therapy & operative decompression when
needed should form a comprehensive
integrated course of treatment for TB spine
with neurological complications.

55.  Indications of surgery are adapted from Griffith,
Seddon, Tuli & Jain et al.
 TREATMENT FACTORS
 1.Worsening of neurological complications
 2.No signs of improvement
 3.Worsening of neural deficit.

56.  CLINICAL FACTORS:
 1.Paraplegia with rapid onset
 2.Severe paraplegia
 3.Spinal tumor syndrome
 4.Paraplegia with neural arch affection.
 5.Recurrent paraplegia
 6.Paraplegia with spasticity
 7.Patients with massive pre vertebral
abscess.

57.  IMAGING FACTORS:
 1.Painful paraplegia
 2.Parraplegia with onset in old age.

58.  It includes full exposure of the front of the
duramater at the apex of kyphosis.

59.  DEBRIDEMENT SURGERY:
 Removal of all pus, caseous tissue, sequestra
but without removal of unaffected or viable bone
except to provide adequate access to the focus &
to decompress spinal cord.
 RADICAL SURGERY:
 By Hodgson & Stock.
 Radical excision of tuberculous focus with repair
of resultant gap with autogenous bone graft.

60.  The cancellous bone exposed.
 Upadhyay(1994) reported that neurological
recovery in both radical & debridement
surgery was equally good & no patient had
pain.

61. 1. Cervical spine – Anterior retropharyngeal
(smith-Robinson’s)
Anterior approach – Anterior/Medial border of
sternocleidomastoid
2. Dorsal spine (D1 to L1) –
1 Transthoracic transpleural
2 Anterolateral decompression(D2 – L1)
3. Lumbar spine –
Anterolateral(Lumbovertebrotomy)
Extraperitoneal Ant. approach

62.  Cervical spine –T1  Anterior approch
 Dorsal spine –DL junction  Antrolateral
approch
 Lumbar spine &Lumboscral junction
Extraperitoneal Transverse Vertebrotomy

63.  Anterior approach can be performed through
 TRANSORAL
 RETROPHARYNGEAL

64.  Tracheostomy before
operation
 Position: Place head in
hyperextension & pack
hypo pharynx.
 Incision: Midline posterior
pharyngeal wall from tip of
anterior tubercle of atlas,
which is palpable.
 Strip subperiosteally
 Anterior archof atlas body
of axis & atlantoaxial joints
exposed.
 Anterior decompression &
fusion can performed.

65. Incision: Collar incision of neck between hyoid
bone & thyroid cartilage.
Divide sternohyoid & thyrohyoid m/s.
Avoid injuring ILN & SL vessels

66. Expose posterior pharyngeal wall & elevate
superiosteally.
Bodies of C2, C3, C4 are exposed.
It allows Extramucosal exposure, anterior
debridement & fusion of upper cervical spine.
Less risk of secondary infection.

67. POSITION: Supine with head rotated
to side opposite & neck in extension.
Longitudinal incision along medial
border of SCM.
Open space between SCM & IJV.
Transverse process identified with
finger.
Identify sympathetic chain lies on
longus colli.
Retract it laterally & expose vertebral
bodies between two longus colli.

68.  In severe kyphotic deformity of cervical spine
with long segment disease .
 It may need two stage surgery where
posterior instrumentation is followed by
anterior decompression & bone grafting.
 Three approaches are used for this are:
 LOW ANTERIOR CERVICAL APPROACH
 HIGH TRAANSTHORACIC APPROACH
 TRANSSTERNAL APPROACH

69.  A transverse incision taken one finger
breadth above clavicle.
 Extend across midline and take care
dissecting around carotid sheath.
 Then follow conventional anterior approach.
 This approach limited exposure upto T1.

70.  It allows exposure from C6 to T4.
 A kyphotic deformity of thoracic spine tends to force
cervical spine into chest.
 This approach is a logical choice.
 Periscapular incision.
 Remove 2nd & 3rd rib helps sufficient working place if a
kyphotic deformity present in a child.

71.  7.5-cm incision along
the posterior border of
the SCM mid-upper 3rd
.
 Protect SAN.
 Using blunt dissection
 palpate the abscess
 Drain abscess

72.  EXTRAPLEURAL ANTEROLATERAL
APPROACH:
 Initiated by MENARD in 1895
 Redefined by SEDDON (1935)
 GRIFFITH(1952) & ROAF(1958).

73.  ALEXANDER developed an operation with
DOTT EDINBURGH
 He removed posterior ends of 3 or more ribs
& their corresponding transverse process, &
pedicles adjacent VB.
 Then opened paravertebral abscess &
decompression achieved at respective level.
 CAPNER described LATERAL RACHOTOMY
main purpose was to deal directly with cause
of cord compression.

74. Described by MENARD in 1894
This approach helps in evacuating
abscess in dorsal spine .
Midline incision
Elevate soft tissue & periosteum
from spinous process & laminae
over abscess.
Resect transverse process at its
base.
Resect the contiguous rib of 5cm.
Open abscess by blunt dissection.
Wash & close in layers.

75. Described by SEDDON.
Incision over midline
proximal to apex of kyphosis.
Divide erector spinae m/s
transversely apposite to
apex of deformity.

76. Expose about 8.3cm of rib & Lateral 3rd laminae.
Transect rib of about 6.8cm lateral to costotransversre joint.
Expose abscess with finger , reaching vertebralbodies
small cavities, &
dislodging necrotic
material.
Remove tuberculous
material.
Fill cavity with
streptomycin powder.
close wound without drain.

77.  Patient in lateral
decubitus position with
bean bag .
 Incision over
correcsponding involved
vertebra & expose
subperiosteally.
 Disarticulate rib from
transverse process &
VB.
Hodgson & stock described propagated for anterior
clearance of lesion & Reconstruction by bone grafting.

78.  Incise parietal pleura &
reflect it off the spine.
 Pleural adhesions cleared
gradually.
 It allows adequate exposure
for debridement & grafting.

79.  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.

80.  JAIN ET AL. (2004) modified the incision to a
T- INCISION.
 A midline incision taken centering apex of
kyphosis on left side.
 Two triangular fasciocutaneous flaps were
held with stay sutures.
 Anterolateral decompression done.

82.  Patient is stable in lateral position.
 Anterior & posterior column can be exposed
simultaneously.
 Anterior corpectomy & bone grafting with
simultaneous posterior Hartshill fixation can be
done.
 It avoids 2nd stage procedure.
 Thoracolumbar lesions at D12 Vb can be
exposed by removing 12th rib & ICN.
 Avoids pulmonary sequelae as plane of surgery
if extrapleural & retroperitoneal.

83. Patient in right lateral
decubitus position.
Curvilinear incision taken.
Resection of 10th rib
exposure T10 to L2.
Avoid entering abdominal cavity.
As transversalis fascia & peritoneum do not diverge.
So dissect with caution.

84. Reflect diaphragm from lower ribs & crus from side of spine.
Incise prevertebral fascia.
Identify segmental arteries & veins over VB.
Expose bone.

85.  It is popularized in recent past.
 Spine exposed by midline posterior approach.
 Disadvantage of this approach in TB spine is that
it necessitates resection of lamina(post-complex
)which is healthy verterbra in anterior disease
leads spine unstable.
 Spine is temporarily stabilized by pedicle screws.

86.  Anterior decompression also can be done by
removing 2-3 ribs on both sides at affected
level.
 Anterior lesion can be approached.
 Advantage of this approach is that
decompression & deformity can be
performed in single stage.
 Good approach when 2-3 VB are diseased.
 Less morbid & hospital stay.

87.  Approached through Retroperitoneal
approach (similar to sympathectomy
approach).

88.  Approach through Hypogastric para median
trans peritoneal approach.
 Lumbar & Lumbosacral region approached
through retroperitoneal sympathectomy
approach.

89. Patient placed in lateral
position
Depending on level of
involvement oblique incision
taken between 12th rib & iliac
crest.
Abdominal m/s cut in line. I,e sc tissue,fascia & m/s of
external oblique, internal oblique.
Retroperitoneal space reached.

90. Lumbar vertebrae are palpated & lumbar vessels are
ligated over affected level.
Psoas m/s is elevated from anterior border.
Pedicles & intervertebral foramina identified.
Anterior decompression & instrumentation can be
performed now.
If posterior instrumentation needed separate approach
needed

91. PARAVERTEBRAL ABSCESS
A longitudinal incision lateral to
midline taken.
Divide deeper layers
Usually abscess encounter
immediately if not puncture TL fascia
& deeper structures.
After thorough evacuation of abscess
Close incision in layers.

92. PSOAS ABSCESS
Abscess are extra peritoneal
It follow course of muscle.
Drainage can be done through
Petit triangle.

93. Petit triangle is formed by lateral
Margin of latismus dorsi & medial
border of external oblique m/s
Base by iliac crest.
Floor is the internal oblique m/s.
Incision made parallel to posterior
crest of ilium.
Expose petit triangle.
Bluntly dissect in floor m/s directly
into abscess.
Wash & close incision in layers.

94.  Pan vertebral disease: Instrumentation should
be done to prevent subluxation /dislocation of
spine.
 Long segment disease: Disease of 4 or more
vertebral bodies .
 In lumbar & cervical spine:As there are no
costotransverse & costovertebral articulation as
like in dorsal spine.
 When kyphosis correction surgery is completed
 In junctional area such as CD spine & DL spine.

104.  Main complication of TB spine is KYPHOTIC
DEFORMITY.
 Pathology:
 TB lesion start as paradiscal inflammation
 Vertebral end plates becomes weak & IVD
herniating into VB.
 Severity depends on number of VB
affected,loss of VB height & segment of
spine.

107.  By the time kyphosis appears in spine,
disease is already about 3 to 4 mths of
pathogenesis of disease.

108.  multiple vertebral involvement, active growth
and situation of the lesion in the thoracic
spine were responsible for the excessive
increase in kyphosis.
 Increase in kyphosis was observed in 67% of
the thoracolumbar region, 55% of the
thoracic and 33% of the lumbar lesions.

109.  Rajasekaran and Shanmugasundaram,
1987, calculated that future angle (Y) of
kyphotic deformity in tuberculosis of the
spine could be reasonably predicted by
using a formula Y = a + bx, where x is the
initial loss of vertebral bodies (height in cm)
and a and b are constants 5.5 and 30.5,
respectively.

110.  In young children having thoracic lesions
with involvement of three or more vertebrae,
recumbency in the prone position in the early
active stage and operative debridement and
bone grafting posteriorly for panvertebral
stabilization may minimize the development
of progressive kyphotic deformity.

111.  The only operative procedure that has been
claimed to prevent increase of kyphotic
deformity is the radical excision and bone
grafting performed in Hong Kong by pioneers
of the radical operation themselves.

112.  severe deformity in the presence of active
disease should be an absolute indication for
decompression, correction and stabilization,
as late reconstruction of tuberculous
kyphosis was a difficult and dangerous
procedure.

113.  Rajasekaran (2002) suggested stabilization
of the spine posteriorly followed by anterior
debridement and bone grafting in the active
stage of the disease.
 In the healed stage with rigid deformity, he
suggested anterior debridement first to be
followed by posterior instrumentation and
anterior fusion.

114.  VATS provides a significant advantage of
minimum blood loss, less tissue damage,
less pain in the postop period, short hospital
stay, better illumination and better
magnification.
 difficult to perform endoscopy in TB as there
is poor distinction of tissues, adhesions and
bleeding granulation tissue.

115.  Pedicle screw fixation for kyphosis correction
in healed TB is the most suitable implant.
 Hartshill sublaminar wiring stabilisation in
active disease is a suitable implant to
stabilise the spine, ensuring purchase
against the healthy posterior complex of the
vertebral body to save a segment.

116.  To control mechanical instability or pain due
to this instability and not due to grumbling
disease,
 For arresting the progress of kyphosis and
 During correction of spinal deformity in a
panvertebral operation.

117.  Anterior radical debridement and strut
grafting with instrumentation is indicated in
all patients – especially those with thoracic
TB and those already treated – but is
dangerous in patients with lumbosacral
spinal TB due to the complicated anatomy.

118.  Is indicated in patients with thoracic or
thoracolumbar spinal TB whose lesion are
located in the posterior part of the vertebral
body or who are not fit for thoracotomy or
elderly

119.  In patients with lower lumbar spinal TB
whose foci are located in the posterior part of
the vertebral body, with compressed nerve
roots and spinal cord, resulting in spinal
stenosis, but without obvious caseous
abscess or sequestra in the anterior part of
the vertebral body.

120.  Severe destruction by the lesion, resulting in
the impossibility of anterior instrumentation,
or in patients with severe lower lumbar
kyphosis that requires lordosis correction
and restoration
 In whom Initial anterior instrumentation
failed.

122. Thank you