tuberculosis spine

TB SPINE with Neurology-“ What is expected from you”

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How do I present a case of TB Spine with neurological deficit

How to examine a spine case How to diagnose TB spine What are the other possible diagnosis How to differentiate from them clinically How they are investigated in your hospital Possible options in management How is it managed in your hospital Common problems involving spine Common problems causing similar deficit

How to examine a spine case

The sequence to present the case…like a CNS case protocol or ortho way-

Easy steps to find the motor and sensory level-

Specific findings and tests to be done in a spine with neurology case

What to say of bladder and bowel Should we do all the tests for sensations

like vibration, fine touch etc

The sequence to present the case…like a CNS case protocol or ortho way

You should present the case as you will proceed to do spine exam

History should take into consideration

Pathology part – TB and its D/D

Area of involvement – Spine

Complications – neuro deficit

History

TB – general symptoms and local symptoms specific to area of involvement

Leading questions specific to TB of spine Negative history of DDsAnkylosing spondylitis

Disc deg

Tumors

Septic

Trauma

History

Common problem Perfect diagnosis Not able to justify that

 Clinical exam of spine

Vital to the examination of the spine is to have a good knowledge of the anatomy of this area.

Clinical examination of spine

Clinical examination of spine

Gait Inspection Palpation Movement and measurement Neurology of the limbs Special tests SI joints  CNS exam

Patient Walking Observe the gait

Patient Standing Remember to inspect from all sides (front,

laterally and from behind):

Inspection

1. Attitude and deformity

2. Position of head, shoulder, scapula

3. swellings, sinus, skin

4. Gait

Skin – Scars (surgical scars) – Sinuses (deep infection)

Lumps: abscess, prominent paravertebral muscle spasm

Spine – Kyphosis (exaggerated or reduced) – Lumbar lordosis (exaggerated or

reduced) – Gibbus :

Expose the back and legs. Look for the following:

– sinuses; scars and nodes– deformity and asymmetries - postural or

permanent; direction / plane i.e. kyphosis or tilt

– muscle spasm, fasciculation, wasting - specifically calf and buttock

– legs / arms - wasting, movement, muscle imbalance, size

palpation

You have to know your anatomy to know what you are feeling!

With the patient standing and then perhaps later, lying supine, palpate the back for the:– skin temperature – deformity of the spine - steps or a steady contour?

vertebral tenderness - localised or general ? paraspinal spasm and muscle tenderness sacro-iliac tenderness in sacroilitis

Elsewhere:– feel for peripheral pulses – palpate groin and abdomen for abscesses – Chest, abdominal, rectal examination

Movts and measurements

Measurement of mobility of the spine Movements Chest expansion costovertebral movements are gauged by

asking the patient to breathe in and out: the distance between maximal inspiration and expiration is normally 5cm.

Special tests

Straight Leg Raising Test (SLR) Bowstring Sign Crossed SLR Reverse sciatic tension test Schober's test Femoral stretch

the patient is then asked to lie supine and the straight leg raise test is performed.

carry out neurological testing of power; sensation - reflexes - do a rectal examination - check tone, power,

sensation

Neurological examination

Easy steps to find the motor and sensory level

What to say of bladder and bowel- Should we do all the tests for sensations

like vibration, fine touch etc What the examiner is looking in a spine

neurology case

Neurological assessment

Neurological assessment is an essential part of the examination of the spine.

The examination should involve a full assessment of muscle wasting, fasiculation, tone, power, coordination / proprioception, sensation and reflexes.

perianal reflexes and sphincter tone should be tested.

NEUROLOGICAL EVALUATION

SEGMENTAL NEUROLOGY

When examining the cervical spine it is essential to examine the segmental neurology.

Root lesions may be indicated by weakness in the upper limbs in a segmental distribution, with loss of dermatomal sensation and altered reflexes.

If cervical cord compression is suspected the lower limbs should also be examined specifically looking for upgoing planters and hyperreflexia.

Sensation.

Know your C5 to T1 dermatomes.  Test light touch and sharp/dull sensation.

REFLEXES

Muscle stretch reflexes. Test the following reflexes:

Biceps - C5/6 Brachioradialis - C5/6 Pronator - C 6/7 Triceps - C7/8

Sensation Know your L4 to S1 dermatomes Light touch, sharp/dull sensation

Some tips

get the patient to stand on their toes, thus checking plantar flexion of the foot and the S1 nerve root.

If necessary, test each foot separately, giving them some support with an outstretched arm.

Ask them to rock onto their heels - test of L4/L5

Should we do all the tests for sensations like vibration, fine touch etc

What the examiner is looking in a spine neurology case

The examination should include the following:– Careful assessment of spine– Examination for abscesses– Abdominal evaluation for psoas / iliac mass

Meticulous neurologic examination

TB SPINE - HISTORY AND CLINICAL EXAMINATION

TB Spine – History

The presentation of Pott disease depends on the following:– Stage of disease– Affected site– Presence of complications such as

neurologic deficits, abscesses, or sinus tracts

TB Spine – History

The reported average duration of symptoms at diagnosis is 4 months but can be considerably longer, even in most recent series.

This is due to the nonspecific presentation of chronic back pain.

TB Spine – History

Back pain is the earliest and most common symptom.– Patients with Pott’s disease usually

experience back pain for weeks before seeking treatment.

– The pain caused by Pott’s disease can be spinal or radicular.

TB Spine – History

Insidious onset of localised pain in the spine. This is usually accompanied by fever, malaise,

anorexia and weight loss. Clumsiness in walking and weakness in lower

limbs may be present. There may be evidences of associated

extraskeletal tuberculosis Presence of hoarseness, dysphagia, respiratory

stridor or torticollis indicate cervical involvement.

TB Spine – History

The onset of is usually insidious and of slow evolution.

Potential constitutional symptoms of Pott’s disease include fever and weight loss.

Patient might have constitutional symptoms like low-grade fever, anorexia and weight loss.

TB Spine – History

They usually precede local symptoms and signs such as pain, tenderness and swelling of the affected part.

However absence of constitutional symptoms does not rule out the possibility of the disease as it is common for patients to present without any constitutional symptoms.

TB Spine – History

Neurologic abnormalities occur in 50% of cases and can include spinal cord compression with paraplegia, paresis, impaired sensation, nerve root pain, and/or cauda equina syndrome.

On examination - TB Spine - spasm

Muscle spasm makes the back rigid. Motion of the spine is limited in all direction. When picking an object up from the floor, the

patient flexes his hips and knees, keeping the spine in extension.

In TB Spine - spasm

Spasm of the paravertebral muscles in the lumbar region is also elicited by passive hyperextension of the hips with the patient in prone position-this also puts stretch on the iliopsoas muscle, which is in spasm and contracture owing to psoas abscess

In TB Spine - deformity

Almost all patients with Pott disease have some degree of spine deformity

A kyphus in the thoracic region may be the first noticeable sign.

As the kyphosis increases, the ribs will crowd together and a barrel chest deformity will develop.

When the lesion is situated in the cervical or lumbar spine, a flattening of the normal lordosis is the initial finding.

In TB Spine - cervical

Cervical spine tuberculosis is a less common presentation but is potentially more serious because severe neurologic complications are more likely.

In TB Spine - cervical

– This condition is characterized by pain and stiffness.

– Patients with lower cervical spine disease can present with dysphagia or stridor.

– Symptoms can also include torticollis, hoarseness, and neurologic deficits.

In TB Spine - cervical

Pott disease that involves the upper cervical spine can cause rapidly progressive symptoms.– Retropharyngeal abscesses occur in almost

all cases.– Neurologic manifestations occur early and

range from a single nerve palsy to hemiparesis or quadriplegia.

In TB Spine - HIV

The clinical presentation of spinal tuberculosis in patients infected with the human immunodeficiency virus (HIV) is similar to that of patients who are HIV negative; however, spinal tuberculosis seems to be more common in persons infected with HIV.

In TB Spine - Thoracic

Although both the thoracic and lumbar spinal segments are nearly equally affected in persons with Pott disease, the thoracic spine is frequently reported as the most common site of involvement.

Together, they comprise 80-90% of spinal tuberculosis sites.

The remaining cases correspond to the cervical spine.

Cold abscess

The abscesses may be palpated as fluctuant swellings in the groin, iliac fossa, retropharynx, or on the side of the neck, depending upon the level of the lesion.

Cold abscess

Large cold abscesses of paraspinal tissues or psoas muscle may protrude under the inguinal ligament and may erode into the perineum or gluteal area.

Tuberculous necrotic material from the cervical spine may collect in the form of a cold abscess in the retropharyngeal region; at the posterior border of sternomastoid; in the back of neck along spinal nerves and in the axilla along axillary sheath

Cold abscess

Pott disease that involves the upper cervical spine can cause rapidly progressive symptoms.– Retropharyngeal abscesses occur in almost

all cases.– Neurologic manifestations occur early and

range from a single nerve palsy to hemiparesis or quadriplegia.

Cold abscess

Involvement of the dorsolumbar spine may lead to cold abscess in the rectus sheath and lower abdominal wall along the intercostal, ilioinguinal and iliohypogastric nerves;

in the thigh along the psoas sheath; in the back along the posterior spinal nerves; in the buttock along superior gluteal nerve; in the Petit's triangle along the flat muscles of

abdominal wall or, in the ischiorectal fossa along the internal pudendal

nerve.

Gait

The gait of the person with Pott’s disease is peculiar, reflecting the protective rigidity of the spine.

His steps are short, as he is trying to avoid any jarring of his back.

In tuberculosis of the cervical spine, he holds his neck is extension and supports his head with one hand under the chin and the other over the occiput.

Neurology

Neurologic deficits may occur early in the course of Pott disease.

Signs of such deficits depend on the level of spinal cord or nerve root compression.

Neurology

If paraplegia develops, there will be spasticity of the lower limbs with hyperactive deep tendon reflexes, a spastic gait, a varying degree of motor weakness, and disturbances of bladder and anorectal function.

Extraspinal tuberculosis

Many persons with Pott disease (62-90%) of patients in reported series have no evidence of extraspinal tuberculosis, further complicating a timely diagnosis..

Rare presentation

The presence of a sinus in the back with a thin watery discharge is a strong evidence of tuberculous involvement of the posterior arch of vertebral bodies.

Rarely, tuberculous spondylitis may present as synovitis of posterior vertebral articulations, atlanto-occipital or atlanto-axial joints or as spinal tumour syndrome

How to say the final diagnosis

Anatomoical Pathological Level Neuro – Cord compression Level – Motor, Sensory and Reflex Cord level, Vertebral level

What to say of bladder and bowel

History Subject may be already catheterised

Provisional diagnosis

Only one Diagnosis if there are no reasons ( points) against that diagnosis

Otherwise give DD

Investigations

1. ESR 2. Mantoux / Elisa - 3. Xrays including chest 4. CT5. MRI6. CT-guided procedures.7. Microbiology studies are used to confirm

diagnosis.

What are the common surgical treatments given

Treatment – ATT –regime, duration. Surgical

Indications ??? Middle path regime ??? Instrumentation ???

Indications for surgical treatment

Neurologic deficit (acute neurologic deterioration, paraparesis, paraplegia)

Spinal deformity with instability or pain No response to medical therapy (continuing

progression of kyphosis or instability) Large paraspinal abscess Nondiagnostic percutaneous needle biopsy

sample

Surgical options

Costo-transversectomy ALD Anterior decompression and fusion Anterior decompression and fusion and

instrumentation ( posterior or anterior) Thoracoscopic surgery Posterior approach with transpedicular

decompression and fusion with instrumentation.

Resources and experience are key factors in the decision to use a surgical approach.

The lesion site, extent of vertebral destruction, and presence of cord compression or spinal deformity determine the specific operative approach (kyphosis, paraplegia, tuberculous abscess).

Vertebral damage is considered significant if more than 50% of the vertebral body is collapsed or destroyed or a spinal deformity of more than 5° exists.

The most conventional approaches include anterior radical focal debridement and posterior stabilization with instrumentation.

In Pott disease that involves the cervical spine, the following factors justify early surgical intervention:

High frequency and severity of neurologic deficits

Severe abscess compression that may induce dysphagia or asphyxia

Instability of the cervical spine

Contraindications:

Vertebral collapse of a lesser magnitude is not considered an indication for surgery because, with appropriate treatment and therapy compliance, it is less likely to progress to a severe

deformity.

ICS 2010 a combined meeting of

SPINE SOCIETY OF EUROPE &ASSOCIATION OF SPINE SURGEONS OF INDIA

3,4,5 September 2010

International & National Faculty

Venue:

Golden Landmark Resort, Mysore.

Theme: Iatrogenic complications in Spine

Residential and Non-Residential Packages