tuberculosis of spine and its complications nishanth
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TUBERCULOSIS OF SPINETUBERCULOSIS OF SPINE
A TERTIARY LESION OF TB INFECTIONA TERTIARY LESION OF TB INFECTION MOST COMMON TYPE OF SKELETAL TBMOST COMMON TYPE OF SKELETAL TB BLOOD BORNE INFECTION SETTLES IN BLOOD BORNE INFECTION SETTLES IN
AVERTEBRAL BODYAVERTEBRAL BODY C/C INFLAMMATORY REACTIONC/C INFLAMMATORY REACTION MICROSCOPIC LESION – GRANULOMA MICROSCOPIC LESION – GRANULOMA
FORMATIONFORMATION SMALL PATCHES OF CASEOUSSMALL PATCHES OF CASEOUS
NECROSISNECROSIS
CONT……………………….CONT……………………….
COALESCE TO FORM YELLOWISH MASSCOALESCE TO FORM YELLOWISH MASS CENTER BREAKDOWN, FORM COLD CENTER BREAKDOWN, FORM COLD
ABCESSABCESS PUSS AND NECROSED BONE FRAGMENTSPUSS AND NECROSED BONE FRAGMENTS COLD ABSCESS MAY INVOLVE SOFT COLD ABSCESS MAY INVOLVE SOFT
TISSUE AND SINUS FORMATIONTISSUE AND SINUS FORMATION COLLAPSE OF IVD, GIBBUS FORMATIONCOLLAPSE OF IVD, GIBBUS FORMATION
CLINICAL FEATURESCLINICAL FEATURES
PAINPAIN STIFFNESSSTIFFNESS COLD ABSCESSCOLD ABSCESS PARAPLEGIAPARAPLEGIA DEFORMITYDEFORMITY
EXAMINATIONEXAMINATION
GAITGAIT ATTITUDE AND DEFORMITYATTITUDE AND DEFORMITY PARA-VERTEBRAL SWELLINGPARA-VERTEBRAL SWELLING TENDERNESSTENDERNESS MOVEMENTMOVEMENT NEUROLOGICAL EXAMINATIONNEUROLOGICAL EXAMINATION GENERAL EXAMINATIONGENERAL EXAMINATION
INVESTIGATIONSINVESTIGATIONS
RADIOLOGICAL EXAMINATIONRADIOLOGICAL EXAMINATION
REDUCTION IN DISC SPACEREDUCTION IN DISC SPACE DESTRUCTION OF VERTEBRAL BODYDESTRUCTION OF VERTEBRAL BODY EVIDENCE OF COLD ABSCESSEVIDENCE OF COLD ABSCESS RAREFACTIONRAREFACTION SIGNS OF HEALINGSIGNS OF HEALING
Central destruction of the lower half of the vertebral body, only seen on the anteroposterior view. The disc space is slightly narrowed
. The lower disc space is narrowed .the upper space is almost normal. A small lytic defect is present on the right side of the body below, and there is a small Para vertebral abscess.
CT scan of a child showing destruction of the neural arch on both sides, as well as of the vertebral body. Arrows, anterior spinal abscess.
CT SCAN
MYELOGRAPHYMYELOGRAPHY
There is narrowing of the There is narrowing of the disc space between the first disc space between the first and second &second and and second &second and third lumbar vertebraethird lumbar vertebrae
OTHER INVESTIGATIONSOTHER INVESTIGATIONS
ESR ESR MANTOUX TESTMANTOUX TEST ELISA TESTELISA TEST CHEST X -RAYCHEST X -RAY
DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS
BACK PAINBACK PAIN
1.1. TRAUMATICTRAUMATIC2.2. SECONDARIESSECONDARIES3.3. PROLAPSED DISCPROLAPSED DISC4.4. ANK.SPONDYLITISANK.SPONDYLITIS
NEUROLOGICAL DEFICITNEUROLOGICAL DEFICIT
1.1. SPINAL TUMOURSPINAL TUMOUR2.2. TRAUMATICTRAUMATIC3.3. SECONDARIES IN SPINESECONDARIES IN SPINE
TREATMENTTREATMENT
AIMAIM
1.1. TO ACHIEVE HEALINGTO ACHIEVE HEALING2.2. TO PREVENT ,DETECT AND TREAT TO PREVENT ,DETECT AND TREAT
EARLY ANY COMPLICATION LIKE EARLY ANY COMPLICATION LIKE PARAPLEGIAPARAPLEGIA
ANTI TUBERCULAR THERAPYANTI TUBERCULAR THERAPY GENERAL CAREGENERAL CARE CARE OF SPINECARE OF SPINE TREATMENTOF COLD ABSCESSTREATMENTOF COLD ABSCESS
COMPLICATIONSCOMPLICATIONS
COLD ABSCESSCOLD ABSCESS NEUROLOGICAL COMPRESSIONNEUROLOGICAL COMPRESSION
POTT’S PARAPLEGIAPOTT’S PARAPLEGIA
MOST COMMON IN TB OF MOST COMMON IN TB OF DORSAL SPINEDORSAL SPINE
--spinal canal is narrowest spinal canal is narrowest here.here.
INCIDENCE-20% INCIDENCE-20%
PATHOLOGYPATHOLOGY PRESSURE ON NEURAL TISSUES WITHIN PRESSURE ON NEURAL TISSUES WITHIN
THE CANAL BY PRODUCTS OF DISEASED THE CANAL BY PRODUCTS OF DISEASED VERTEBRAVERTEBRA
1.1. INFLAMMATORY EDEMAINFLAMMATORY EDEMA2.2. EXTRADURAL PUS AND GRANULATION EXTRADURAL PUS AND GRANULATION
TISSUETISSUE3.3. SEQUESTRASEQUESTRA4.4. INTERNAL GIBBUSINTERNAL GIBBUS5.5. INFARCTION OF SPINAL CORDINFARCTION OF SPINAL CORD6.6. EXTRADURAL GRANULOMAEXTRADURAL GRANULOMA
TYPESTYPES
1.1. EARLY ONSET PARAPLEGIA-Within EARLY ONSET PARAPLEGIA-Within 2 years of onset of disease2 years of onset of disease
2.2. LATE ONSET PARAPLEGIA-At least LATE ONSET PARAPLEGIA-At least 2 years after onset of disease2 years after onset of disease
CAUSESCAUSES
EARLY ONSET PARAPLEGIAEARLY ONSET PARAPLEGIA
INFLAMMATORY CAUSESINFLAMMATORY CAUSES
1.1. ABSCESSABSCESS2.2. GRANULATION TISSUEGRANULATION TISSUE3.3. CIRCUMSCRIBED TB FOCUSCIRCUMSCRIBED TB FOCUS4.4. POSTERIOR SPINAL DISEASEPOSTERIOR SPINAL DISEASE5.5. INFECTIVE THROMBOSIS OF SPINAL INFECTIVE THROMBOSIS OF SPINAL
BLOOD SUPPLYBLOOD SUPPLY
MECHANICAL CAUSESMECHANICAL CAUSES
1.1. SEQUESTRUM IN THE CANALSEQUESTRUM IN THE CANAL2.2. INFECTED DEGENERATED DISC IN THE INFECTED DEGENERATED DISC IN THE
CANALCANAL3.3. PATHOLOGICAL DISLOCATION –A RIDGE PATHOLOGICAL DISLOCATION –A RIDGE
OF BONE PRESSING ON THE CORDOF BONE PRESSING ON THE CORD
LATE ONSET PARAPLEGIALATE ONSET PARAPLEGIA
1.1. RECURRENCE OF DISEASERECURRENCE OF DISEASE2.2. INTERNAL GIBBUSINTERNAL GIBBUS3.3. FIBROUS SEPTAE FOLLOWING HEALINGFIBROUS SEPTAE FOLLOWING HEALING
CLINICAL FEATURESCLINICAL FEATURES
ONSET IS USUALLY GRADUAL BUT ONSET IS USUALLY GRADUAL BUT IN SOME IT IS SUDDENIN SOME IT IS SUDDEN
TUBERCULAR PARAPLEGIA-spastic at TUBERCULAR PARAPLEGIA-spastic at firstfirst
CLONUS (ankle or patellar)CLONUS (ankle or patellar) ++
STAGES OF PARALYSISSTAGES OF PARALYSIS
MUSCLE WEAKNESSMUSCLE WEAKNESS PARAPLEGIA IN EXTENSIONPARAPLEGIA IN EXTENSION PARAPLEGIA IN FLEXIONPARAPLEGIA IN FLEXION COMPLETE FLACCID PARAPLEGIACOMPLETE FLACCID PARAPLEGIA
GRADES OF POTTS GRADES OF POTTS PARAPLEGIAPARAPLEGIA
GRADE I-GRADE I- PATIENT ISPATIENT IS UNAWARE OF NEURAL UNAWARE OF NEURAL
DEFICIT,PHYSICIAN DETECTS DEFICIT,PHYSICIAN DETECTS BABINSKI +& PATELLAR OR ANKLE BABINSKI +& PATELLAR OR ANKLE CLONUS ON EXAMINATIONCLONUS ON EXAMINATION
GRADE IIGRADE II PATIENT PRESENTS WITH PATIENT PRESENTS WITH
COMPLAINTS OF COMPLAINTS OF CLUMSINESS,INCOORDINATION OR CLUMSINESS,INCOORDINATION OR SPASTICITY WHILE WALKING BUT SPASTICITY WHILE WALKING BUT MANAGES TO WALK WITH OR MANAGES TO WALK WITH OR WITHOUT SUPPORTWITHOUT SUPPORT
GRADE IIIGRADE III PATIENT IS NOT ABLE TO WALK PATIENT IS NOT ABLE TO WALK
BECAUSE OF SEVERE WEAKNESS.ON BECAUSE OF SEVERE WEAKNESS.ON EXAMINATION HE HAS PARAPLEGIA EXAMINATION HE HAS PARAPLEGIA ON EXTENSION.THERE MAY BE ON EXTENSION.THERE MAY BE PARTIAL LOSS OF SENSATION.PARTIAL LOSS OF SENSATION.
GRADE IVGRADE IV PATIENT IS UNABLE TO WALK PATIENT IS UNABLE TO WALK
&HAS PARAPLEGIA IN FLEXION &HAS PARAPLEGIA IN FLEXION WITH SEVERE MUSCLE WITH SEVERE MUSCLE SPASM.THERE IS NEAR COMPLETE SPASM.THERE IS NEAR COMPLETE LOSS OF SENSATION WITH LOSS OF SENSATION WITH SPHINCTER DISTURBANCESSPHINCTER DISTURBANCES
TREATMENTTREATMENT
AIMAIM
TO PROMOTE RECOVERYTO PROMOTE RECOVERY TO ACHIEVE HEALINGTO ACHIEVE HEALING TO UNDERTAKE REHABILITATIVE TO UNDERTAKE REHABILITATIVE
MEASURESMEASURES
TYPESTYPES
CONSERVATIVE CONSERVATIVE OPERATIVEOPERATIVE
CONSERVATIVE
1. ANTI TUBERCULAR CHEMOTHERAPY
2. ABSOLUTE SPINE REST
3. CARE OF THE PARALYSED LIMBS
4. REPEATED NEUROLOGICAL EXAMINATION
IF ANY IMPROVEMENT TREATMENT IS CONTINUED
OPERATIVE TREATMENTOPERATIVE TREATMENT
INDICATIONSINDICATIONSABSOLUTEABSOLUTE
1.1. PARAPLEGIA OCCURING DURING USUAL PARAPLEGIA OCCURING DURING USUAL CONSERVATIVE TREATMENTCONSERVATIVE TREATMENT
2.2. NOT RESPONDING TO TREATMENTNOT RESPONDING TO TREATMENT3.3. RAPID ONSETRAPID ONSET4.4. UNCONTROLLED SPASTICITYUNCONTROLLED SPASTICITY5.5. SEVERE PARAPLEGIA WITHSEVERE PARAPLEGIA WITH MOTOR OR SENSORY LOSS FOR >6 MOTOR OR SENSORY LOSS FOR >6
MONTHSMONTHS TOTAL MOTOR LOSS>1 MONTHTOTAL MOTOR LOSS>1 MONTH
RELATIVERELATIVE
1.1. RECURRENT PARAPLEGIARECURRENT PARAPLEGIA2.2. ONSET IN OLD AGEONSET IN OLD AGE3.3. PAINFUL PARAPLEGIAPAINFUL PARAPLEGIA4.4. COMPLICATIONS SUCH AS UTI AND COMPLICATIONS SUCH AS UTI AND
STONESSTONES
OPERATIVE PROCEDURESOPERATIVE PROCEDURES
AIM AIM
TO REMOVE AGENTS CAUSING COMPRESSION ONTO REMOVE AGENTS CAUSING COMPRESSION ONNEURAL STRUCTURESNEURAL STRUCTURES
1.1. COSTOTRANSVERSECTOMYCOSTOTRANSVERSECTOMY2.2. ANTERO LATERAL DECOMPRESSIONANTERO LATERAL DECOMPRESSION3.3. RADICAL DEBRIDEMENT AND RADICAL DEBRIDEMENT AND
ARTHRODESISARTHRODESIS4.4. LAMINECTOMYLAMINECTOMY
PROGNOSISPROGNOSIS
AGE-AGE-CHILDRENCHILDREN DURATION OF PARAPLEGIA- DURATION OF PARAPLEGIA-
LONG STANDINGLONG STANDING SEVERITYSEVERITY--MOTOR PRALYSISMOTOR PRALYSIS --SPHINCTERSPHINCTER
INVOLVEMENTINVOLVEMENT ACUTE ONSET OF PARAPLEGIAACUTE ONSET OF PARAPLEGIA SUDDEN PROGRESSSUDDEN PROGRESS
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