tb

1. VIJESH VIJAYAN
2008 MBBS

3. TB IS CALLED AS “WHITE PLAGUE’’ OR
”CAPTAIN OF ALL MEN OF DEATH”
 SPINE IS THE COMMONST SITE OF BONE AND
JOINT TB
 UPPER THORACIC SPINE – IN CHILDREN
 LOWER THORACIC AND - IN ADULTS
UPPER LUMBAR

4. EPIDEMIOLOGY
 1/3 RD OF WORLD POPULATION HARBOUR TB
INFECTION
 INDIA IS ONE OF THE WORST AFFECTED
COUNTRIES
 ONE PERSON PER MINUTE DIE OF TB IN INDIA

5. TB IS AN ANCIENT DISEASE
EVIDENCE OF SPINAL TB HAS BEEN
FOUND IN SOME EGYPTIAN
MUMMIES

6.  BONES & JOINTS ARE THE 4TH COMMONST SITE
OF EXTRA PULMONARY TB
 CONSTITUTE ~10% OF EXTRA PULMONARY TB
 WEIGHT BEARING JOINTS ARE MOST AFFECTED
SPINE : 40%
HIPS : 13%
KNEES : 10%

7. PATHOLOGY
 TB SPINE IS ALWAYS SECONDARY
 REACTIVATION OF HEMATOGENOUS FOCI OR
SPREAD FROM PARAVERTEBRAL LYMPH NODE
 HEMATOGENOUS SPREAD VIA PARAVERTEBRAL
VENOUS PLEXUS OF BATESON
 RESPONSE WILL BE EITHER PROLIFERATIVE
OR EXUDATIVE
 PROLIFERATIVE: C/C GRANULOMA WITH FIBROSIS
 EXUDATIVE : NON REACTIVE, WIDE CAESEATION
NECROSIS, IN IMMUNOCOMPROMISED

8. TB GRANULOMA

10. TYPES OF VERTEBRAL TB
 1. PARADISCAL - COMMONST , CONTIGOUS AREA
OF TWO ADJACENT VERTEBRA ALONG WITH
INTER VERTEBRAL DISC IS AFFECTED
 2. CENTRAL -BODY OF SINGLE VERTEBRA ,
NEARBY DISC MAY BE NORMAL
 3. ANTERIOR-ANTERIOR PART OF THE BODY
 4. POSTERIOR- POSTERIOR COMPLEX (PEDICLE ,
LAMINA , SPINOUS PROCESS OR TRANSVERSE
PROCESS) AFFECTED

11. AFTER EFFECT
 PARADISCAL : C/C GRANULOMATOUS
INFLAMMATION -> EROSION OF MARGINS OF
THE VERTEBRAE -> COMPROMISE OF NUTRITION
OF IV DISC-> DISC DEGN-> DESTRUCTION
 CENTRAL : WEAKENING OF TRABECULAE ->
COLLPSE OF VERTEBRAE
 ANTERIOR : INFN SPREAD UP OR DOWN UNDER
ANT. LONGI.LIGAMENT
 POSTERIOR : BONY DESTRUCTION CAN
COMPRESS THE CORD

12. COLD ABSCESS
 PUS & TRABECULAR DEBRIS OF DISEASED
VERTEBRA
 NOT ASSO. WITH USUAL SIGNS OF
INFLAMMATION - COLD ABSCESS
 NOTE: PUS CAN TRACK IN ANY DIRECTION
1.BACKWARDS : COMPRESS CORD
2. ANTERIORLY: PRE VERTEBRAL ABSCESS
3. SIDES : PARA VERTEBRAL ABSCESS
4.ALONG MUSCULOFASCIAL PLANES :
EX.PSOAS ABSCESS

13. HEALING
 OCCURS BY FIBROSIS
 IN THE SPINE BONY ANKYLOSIS FOLLOWS MORE
OFTEN
 LYTIC AREAS ARE REPLACED BY NEW BONE AND
ADJACENT VERTEBRA UNDERGO FUSION

14. CLINICAL FEATURES
 PRESENTATION VARIES FROM NON SPECIFIC
BACK ACHE TO CATASTROPHIC PARAPLEGIA
 COMPLAINTS:
PAIN
STIFFNESS
COLD ABSCESS ( IF EVIDENT EXTERNALLY)
PARAPLEGIA
DEFORMITY
CONSTITUTIONAL SYMPTOMS

15. PAIN
 BACKACHE : COMMON PRESENTING COMPLAINT
 INITIALLY DIFFUSE & LATE LOCALISED
 ‘RADICULAR PAIN’
 DEPENDING ON ROOT:
PAIN IN ARM – CERVICAL ROOTS
GIRDLE PAIN – DORSAL ROOTS
GROIN PAIN - LUMBAR ROOTS

16. COLD ABSCESS
 CERVICAL : RETROPHARYNGEAL / AT POST
BORDER OF STERNO MASTOID IN POST
TRIANGLE OF THE NECK / AT AXILLA
 THORACIC : MEDISTINAL / ANTERIOR CHEST
WALL ALON THE SPINAL NERVES
 LUMBAR : PRE VERTEBRAL SWELLING/ PSOAS
ABSCESS / ABSCESS PRESENTING AT GROIN

17.  STIFFNESS : EARLY SYMPTOM
PARAVERTEBRAL MUSCLES UNDERGO
SPASM
PARAPLEGIA
DEFORMITY – IN CHILDREN
CONSTITUTIONAL SYMPTOMS : FEVER , WEIGHT
LOSS

18. EXAMINATION
 SHOULD HAVE A HIGH INDEX OF SUSPICION
 AIMS : LOOK FOR FINDINGS OF TB SPINE
 LOCALISE SITE OF LESION
 DETECT COMPLICATIONS- COLD ABSCESS /
PARAPLEGIA
1. GAIT : SHORT STEPS
 2. ATTITUDE & DEFORMITY
 3. PARAVERTEBRAL SWELLING
 4. TENDERNESS ON THE AFFECTED SPINE
 5. REDUCED MOBILITY

19. DEFORMITY : GIBBUS

21. NEUROLOGICAL EXAMINATION
 AIMS: DETECT ANY COMPRESSION
LEVEL OF COMPRESSION
SEVERITY OF COMPRESSION
 LIMBS – UPPER OR LOWER BASED ON SITE
MOTOR , SENSORY , REFLEXES , BOWEL AND
BLADDER FUNCTIONS
GENERAL EXAMINATION
PHYSICAL EXAMINATION
SYSTEMIC ILLNESS : DM , HYPERTENSION

22. INVESTIGATIONS
 RADIOLOGY :
• X-RAY – SPECIFY THE LEVEL
• 2 VIEWS AP & LATERAL
• CHEST X-RAY
• X-RAY ABDOMEN
• KUB - IF PSOAS ABSCESS SUSPECTED

23. FINDINGS
 1. REDUCTION OF DISC SPACE- EARLY SIGN
• COMPARE WITH NORMAL
LATERAL X-RAY IS BETTER
IMPORTANCE : SECONDARIES TO
BONES USUALLY PRESERVE THE DISC
2. DESTRUCTION OF VERTEBRAL BODY
EROSIONS AND WEDGING
3. DEFORMITY : DEPEND ON THE NO.
OF VERTEBRA AFFECTED

24. BONE DESTRUCTION

27.  DESTRUCTION
OF THE BONE

28. COLD ABSCESS
 1. PARAVERTEBRAL ABSCESS : A SOFT TISSUE
SHADOW CORRESPONDING TO AFFECTED
VERTEBRA.
 WIDENED MEDIASTINUM
 RETROPHARYNGEAL ABSCESS
 PSOAS ABSCESS

29. RETROPHARYNGEAL ABSCESS

31. MEDISTINAL WIDENING

33. OTHER FINDINGS
 RAREFACTION : ABOVE AND BELOW AFFECTED
VERTEBRA
 OBLIQUE X RAY MAY SHOW POSTERIOR
COMPLEX INVOLVEMENT
 SIGNS OF HEALING : ADJACENT VERTEBRAE
UNDERGO FUSION

34. OTHERS
 CT : ACCURATE CONFIRMATIONS
 MRI : TO ASSES NEURAL STATUS
 MYELOGRAPHY : SUSPECTED SPINAL TUMOR
SYNDROME
 BIOPSY : CT GUIDED NEEDLE OR OPEN BIOPSY

35.  RETROPHARYNGEAL
SWELLING
CAN PRESENT AS
DYSPHAGIA

36.  PSOAS ABSCESS

37.  PSOAS ABSCESS

38. GENERAL INVESTIGATIONS
 ESR
 MANTOUX
 ELISA : ANTI TB ANTIBODY
 CHEST X RAY : FOR PULMONARY TB

39. D/D S
 BACK ACHE : 1. TRAUMATIC
• 2. SECONDARIES OR MYELOMA
• 3. PROLAPSED DISC
• 4.ANKYLOSING SPONDYLITIS
• NEUROLOGICAL
• SPINAL TUMOR
• TRAUMATIC
• SECONDARIES IN THE SPINE

40. TREATMENT
 PT SHOULD BE GIVEN A HIGH PROTEIN DIET
& GOOD ATMOSPHERE
1. MULTIDRUG THERAPY OF TB
2. REST TO THE SPINE : CHILDREN BODY CAST ,
COLLAR IF CERVICAL
3. MOBILISATION : ADVISED TO AVOID SPORTS
FOR TWO YEARS

41. RX COLD ABSCESS
 SMALLER ONES SUBSIDE WITH TB THERAPY
 IN SUPERFICIAL ABSCESSES :
 ASPIRATION : USING THICK NEEDLE
 EVACUATION
 PSOAS ABSCESS : EXTRAPERITONEALLY VIA KIDNEY
INCISCION

42. MRCB CONTROLLED TRIAL
 BED REST NOT NECESSARY
 STREPTOMYCIN NOT NECESSARY
 POP JACKETS PROVIDE NO BENEFIT
 DEBRIDEMENT IS NOT A GOOD OPERATION
COMPLICATIONS
 COLD ABSCESS
 NEUROLOGICAL COMPLICATIONS : PARAPLEGIA

44. 20 % INCIDENCE
COMMON IN DORSAL SPINE TB
 CAUSES :
 INFLAMMATORY EDEMA
 EXTRADURAL PUS & GRANULATION TISSUE –
COMMOMN
 SEQUESTRA
 INTERNAL GIBBUS
 INFARCTION OF SPINAL CORD
 EXTRADURAL GRANULOMA

45. TYPES
 EARLY ONSET
 LATE ONSET
 C/F :
 EITHER A KNOWN TB OR NEUROLOGICAL
SYMPTOMS PRESENTING FOR THE 1ST TIME
 GRADUAL ONSET
 CLONUS – ANKLE OR PATELLAR – PROMINENT

46. PARALYSIS : STAGES
 1. MUSCLE WEAKNESS : SPASTICITY AND
INCORDINATION
 2. PARAPLEGIA IN EXTENSION
 3. PARAPLEGIA IN FLEXION
 COMPLETE FLACCID PARALYSIS

47. GRADES : GOEL (1967)
 BASIS IS EXTENT OF MOTOR INVOLVEMENT
 GRADE ONE : CLINICIAN DETECTS THE DEFECIT
 GRADE TWO : SYMPTOMATIC BUT MANAGES TO WALK
 GRADE THREE: UNABLE TO WALK
PARAPLEGIA IN EXTENSION
PARTIAL SENSORY LOSS
GRADE FOUR : UNABLE TO WALK
PARAPLEGIA IN EXTENSION
NEAR COMPLETE SENSORY LOSS
SPHINCTER DISTURBANCES

48. TREATMENT
 INVESTIGATIONS : CT & MRI ( INVESTIGATION
OF CHOICE)
 CONSERVATIVE : ANTI TB RX , REST TO SPINE ,
NEUROLOGICAL EXAMINATION TO ASSES Px
 SURGICAL :
 INDICATIONS : PARAPLEGIA IN CONSERVATIVE Rx
 SUDDEN ONSET SEVERE PARAPLEGIA
 SEVERE PARAPLEGIA : IN FLEXION, MOTOR / SENSORY
LOSS > 6 MONTHS OR COMPLETE MOTOR LOSS ONE
MONTH DESPITE CONSERVATIVE Rx
 PARAPLEGIA WITH UNCONTROLLED SPASTICITY

49.  RELATIVE INDICATIONS :
 RECURRENT PARAPLEGIA
 PARAPLEGIA IN OLD AGE
 PAINFUL PARAPLEGIA
 COMPLICATIONS : UTI / STONES

50. PROCEDURES
 1. COSTO TRANSVERSECTOMY
 2. ANTEROLATERAL DECOMPRESSION
 3. RADICAL DEBRIDEMENT AND ARTHRODESIS
( HONKONG OPERATION)
 4. LAMINECTOMY

51. PROGNOSIS
 AGE : CHILDREN HAS BETTER Px
 DURATION OF PARAPLEGIA : LONG STANDING
HAS BAD Px
 SEVERITY : MOTOR ALONE HAS GOOD Px
 ONSET OF PARAPLEGIA : A/C ONSET HAS BETTER
 SUDDEN PROGRESS : BAD Px