dr golwala - tuberculosis of spine -past president lecture

Dr. Paresh GolwalaDr. Paresh Golwala 11

Tuberculosis of spineTuberculosis of spine

DR.PARESH P.GOLWALADR.PARESH P.GOLWALAPROFESSOR AND HEAD, DEPT. OF PROFESSOR AND HEAD, DEPT. OF

ORTHOPAEDICSORTHOPAEDICSS.B.K.S.M.I.R.C.,S.B.K.S.M.I.R.C.,

PIPARIYAPIPARIYA


HISTORYHISTORY

RIGVEDA AND ATHARVA VEDAS: RIGVEDA AND ATHARVA VEDAS:

3500 – 1800 BC3500 – 1800 BC CHARAKA AND SUSHRUTA:CHARAKA AND SUSHRUTA:

1000 – 600 BC1000 – 600 BC HIPPOCRATES: 400 – 300 BCHIPPOCRATES: 400 – 300 BC

DESCRIBED AS YAKSHMADESCRIBED AS YAKSHMA


HISTORYHISTORY

PERCIVAL POTT – (1779)PERCIVAL POTT – (1779)

DESCRIBED TB SPINE AS A KIND OF DESCRIBED TB SPINE AS A KIND OF LOWERLOWER LIMB PALSYLIMB PALSY WHICH IS FREQUENTLY FOUND WHICH IS FREQUENTLY FOUND TO ACCOMPANY A CURVATURE OF THE TO ACCOMPANY A CURVATURE OF THE SPINESPINE

LAENAEC – (1781- 1826)LAENAEC – (1781- 1826)

IDENTIFIED AND DESCRIBED TUBERCLE IDENTIFIED AND DESCRIBED TUBERCLE BACILLI IN 1817BACILLI IN 1817

BCG VACCINE IN 1945BCG VACCINE IN 1945 SPECIFIC AKT IN 1948-1951SPECIFIC AKT IN 1948-1951


TB SPINETB SPINE

Disease of developing worldDisease of developing world Affects Affects young wage earnersyoung wage earners


NATURAL COURSE NATURAL COURSE WITHOUT WITHOUT

CHEMOTHERAPYCHEMOTHERAPY


STAGE OF ONSETSTAGE OF ONSET

Lasts 1 month to 1 yearLasts 1 month to 1 year Localised disease --- warm, tender Localised disease --- warm, tender

swelling --- Localised osteoporosis swelling --- Localised osteoporosis with minimised destructionwith minimised destruction


STAGE OF STAGE OF DESTRUCTIONDESTRUCTION

Lasts 1 to 3 yearsLasts 1 to 3 years Gross destruction of bones and joints Gross destruction of bones and joints

with deformity, subluxation, with deformity, subluxation, contractures and abscess formation contractures and abscess formation abscess ruptured abscess ruptured

Sinuses develop and secondary Sinuses develop and secondary pyogenic infections occurpyogenic infections occur

LOWERED Defence mechanism LOWERED Defence mechanism Severe cachexiaSevere cachexia


STAGE OF STAGE OF DESTRUCTIONDESTRUCTION Miliary tuberculosis and/or Miliary tuberculosis and/or

meningitismeningitis 1/31/3rdrd of patients die of patients die


STAGE OF REPAIR AND STAGE OF REPAIR AND ANKYLOSISANKYLOSIS Occures 3 years after onsetOccures 3 years after onset Improved general conditionImproved general condition Resorpton of abscessesResorpton of abscesses Healed sinusesHealed sinuses Destroyed bones remineralisedDestroyed bones remineralised Fusion in deformed position(kyphosis)Fusion in deformed position(kyphosis) Unsound ankylosis-unsatisfactoryUnsound ankylosis-unsatisfactory

(pain on movement and weight bearing)(pain on movement and weight bearing)

SO,OVERALL RESULTS SO,OVERALL RESULTS WITHOUT AKT ARE WITHOUT AKT ARE UNSATISFACTORYUNSATISFACTORY


LEVEL OF OCCURANCELEVEL OF OCCURANCE Dorsolumbar JunctionDorsolumbar Junction DorsalDorsal LumbarLumbar CervicalCervical


BOVINE T.BBOVINE T.B..

AbdomenAbdomen

Pelvic venous plexusPelvic venous plexus

Vertebrae Vertebrae


TWO TYPES OF TWO TYPES OF AFFECTIONAFFECTION

In children the blood supply is In children the blood supply is central to the vertebrae. That is why central to the vertebrae. That is why the affection is the affection is centralcentral. .

In adults the blood supply is In adults the blood supply is paradiscal that is why the affection paradiscal that is why the affection is is paradiscalparadiscal. .


PATHOLOGYPATHOLOGYBacteraemiaBacteraemia

Deposition in BoneDeposition in Bone

Necrosis + Casseation with Hyperemia Necrosis + Casseation with Hyperemia (increased blood supply)(increased blood supply)

Cavity in the boneCavity in the bone

Surrounding OsteoporosisSurrounding Osteoporosis


PATHOLOGY CONTD… …PATHOLOGY CONTD… …

Weight bearing stimulusWeight bearing stimulus

Collapse of vertebraeCollapse of vertebrae


PATHOLOGY CONTD… …PATHOLOGY CONTD… … No blood supply to disc that is Nucleus pulposus No blood supply to disc that is Nucleus pulposus

intervertebral discintervertebral disc Nutrition to disc is from paradiscal region.Nutrition to disc is from paradiscal region. 90% of disc content is water.90% of disc content is water. With the affection in paradiscal region the disc With the affection in paradiscal region the disc

gets dehydrated and looses height --- reduction gets dehydrated and looses height --- reduction in disc space.in disc space.

With surrounding cavity and destruction the With surrounding cavity and destruction the disc is resorbed.disc is resorbed.

This leads to pus formation and the surrounding This leads to pus formation and the surrounding ligaments are swollen --- soft tissue shadow.ligaments are swollen --- soft tissue shadow.


PATHOLOGY CONTD… …PATHOLOGY CONTD… … Casseation – pus formationCasseation – pus formation In x-ray --- soft tissue shadowIn x-ray --- soft tissue shadow So differentiate from malignancySo differentiate from malignancy


COLD ABSCESSCOLD ABSCESS 2 or more vertebra affected.2 or more vertebra affected. Pus spread due to pressurePus spread due to pressure If spread anteriorly If spread anteriorly

– Cervical --- posterior to esophagus / Cervical --- posterior to esophagus / oropharynx / nasopharynxoropharynx / nasopharynx

– Dorsal --- along the ribsDorsal --- along the ribs– DL / Lumbar --- along psoas sheath DL / Lumbar --- along psoas sheath

--- psoas abscess--- psoas abscess


If spread posteriorlyIf spread posteriorly– Pressure over the cordPressure over the cord– Causes Paraplegia or Quadruplegia Causes Paraplegia or Quadruplegia

depending on the leveldepending on the level


POTT’S PARAPLEGIAPOTT’S PARAPLEGIA Pus under pressurePus under pressure Collapse of vertebrae --- Collapse of vertebrae ---

SequestrumSequestrum Meningitis --- Pachy MeningitisMeningitis --- Pachy Meningitis Thrombosis of artery supplying Thrombosis of artery supplying

spinal cord (Artery of Adam & spinal cord (Artery of Adam & Kiewz) (At DKiewz) (At D9-109-10 level) level)


CLINICAL CLINICAL FINDINGSFINDINGS


SYMPTOMSSYMPTOMS BackacheBackache Backache --- Radiating PainBackache --- Radiating Pain Backache With Pus Discharging SinusBackache With Pus Discharging Sinus, ,

Cold AbscessCold Abscess Backache With Neurological DeficitBackache With Neurological Deficit Constitutional SymptomsConstitutional Symptoms Night Pain / Night CriesNight Pain / Night Cries H/O Immuno SuppressionH/O Immuno Suppression Any ageAny age


SIGNSSIGNS Gibbus --- Angular KyphosisGibbus --- Angular Kyphosis Smooth Kyphosis --- 2-3 VertebraeSmooth Kyphosis --- 2-3 Vertebrae Muscle Spasm --- Coin TestMuscle Spasm --- Coin Test Level Of TendernessLevel Of Tenderness Cold AbscessCold Abscess Neurological DeficitNeurological Deficit

– Lumbar --- LMNLumbar --- LMN– D.L. Junction --- MixedD.L. Junction --- Mixed– Dorsal --- UMNDorsal --- UMN– Cervical --- LL – UMNCervical --- LL – UMN, UL – LMN, UL – LMN– Lesion --- CLesion --- C11-C-CL1 L1 –UL-UMN–UL-UMN

CC5 5 – T– T11 – UL - LMN – UL - LMN


INVESTIGATIONSINVESTIGATIONS X-RAY:X-RAY:

– Soft Tissue ShadowSoft Tissue Shadow– CollapseCollapse– OsteoporosisOsteoporosis– ErosionErosion– Adult --- Decreased / No Disc SpaceAdult --- Decreased / No Disc Space– Children --- Central LesionChildren --- Central Lesion

Hb, TC, DC, ESR --- Increased --- Prognostic Hb, TC, DC, ESR --- Increased --- Prognostic ImportanceImportance

Liver Function TestLiver Function Test MRI --- Neurological DeficitMRI --- Neurological Deficit


AIM OF TREATMENTAIM OF TREATMENT

Eradication of infection Eradication of infection

correction / prevention of correction / prevention of angular deformityangular deformity

recovery of neurological deficitrecovery of neurological deficit


TREATMENTTREATMENT CONSERVATIVE :CONSERVATIVE :

– Bed rest --- 3 months --- Wedging / Bed rest --- 3 months --- Wedging / compression is more than 50%compression is more than 50%

– AKT --- DOTS Category 1AKT --- DOTS Category 1– Rifampicin, Isoniazide, Ethambutol, Rifampicin, Isoniazide, Ethambutol,

Pyrizinamide along with Inj. Streptomycin Pyrizinamide along with Inj. Streptomycin --- preferably for two months--- preferably for two months

– Rifampicin, Isoniazide, Ethambutol for Rifampicin, Isoniazide, Ethambutol for another 7 to 8 months depending on another 7 to 8 months depending on healing --- ESR / X-RAY / Clinicalhealing --- ESR / X-RAY / Clinical


OPERATIVE :OPERATIVE :– Backache Alone --- ConservativelyBackache Alone --- Conservatively– Backache With Cold AbscessBackache With Cold Abscess– Backache With Neurological DeficitBackache With Neurological Deficit

Historically in India mid path regime was followed Historically in India mid path regime was followed with the advent of MRI and after study from with the advent of MRI and after study from Rajshekharan more emphasis has been put on to Rajshekharan more emphasis has been put on to prevent post Tuberculous Kyphosis --- internal prevent post Tuberculous Kyphosis --- internal GibbusGibbus

Hongkong school believes in anterior curettage and Hongkong school believes in anterior curettage and stabilization of vertebrae --- gold standard treatmentstabilization of vertebrae --- gold standard treatment


NEWER INDICATIONS OF NEWER INDICATIONS OF SURGERYSURGERY

Global disease: instabilityGlobal disease: instability Long segment disease > 3 Long segment disease > 3

vertebrae with severe kyphosisvertebrae with severe kyphosis Spinal cord compression:Spinal cord compression:

PusPusGranulation tissueGranulation tissueCaseous tissueCaseous tissueDiscsDiscsBony sequestraBony sequestra


Cord compressionCord compression on MRI does on MRI does not correlate with not correlate with neural deficitneural deficit (76% encroachment of canal may (76% encroachment of canal may also have intact neural state)also have intact neural state)


INTRINSIC CAUSES OF INTRINSIC CAUSES OF CORD COMPRESSIONCORD COMPRESSION Cord oedemaCord oedema MyelomalaciaMyelomalacia Direct affection of meninges and Direct affection of meninges and

cordcord Infective thrombosis and Infective thrombosis and

endarteritisendarteritis Poor prognosisPoor prognosis


PARAPLEGIC PATIENT:PARAPLEGIC PATIENT:– Not responding to drugs after 1 Not responding to drugs after 1

month of AKTmonth of AKT– Sudden bladder bowel involvementSudden bladder bowel involvement

RELATIVE INDICATIONS:RELATIVE INDICATIONS:– Kyphosis --- severeKyphosis --- severe– Children costo transversectomyChildren costo transversectomy


ALD – ANTERO LATERAL ALD – ANTERO LATERAL DECOMPRESSION PARAPLEGIC / DECOMPRESSION PARAPLEGIC /

NEUROLOGICAL DEFICITNEUROLOGICAL DEFICIT

RibRib Transverse processTransverse process PediclePedicle Curette vertebrae anteriorlyCurette vertebrae anteriorly Leaves big void anteriorly --- instability Leaves big void anteriorly --- instability

--- kyphosis --- later internal Gibbus--- kyphosis --- later internal Gibbus Not a favoured procedure now a days.Not a favoured procedure now a days.


ANTERIOR SURGERYANTERIOR SURGERY Gold standard treatment Gold standard treatment Radical surgeryRadical surgery Deals with the precise pathology Deals with the precise pathology Stabilizes vertebraeStabilizes vertebrae Decompresses thoroughlyDecompresses thoroughly Done in our institute Done in our institute


PREFERRED APPROACHESPREFERRED APPROACHES Cervical Spine --- Anterior Cervical Spine --- Anterior Cervico Dorsal --- Thoracotomy Cervico Dorsal --- Thoracotomy

Through Second RibThrough Second Rib Dorsal --- Thoracotomy Dorsal --- Thoracotomy Dorsolumbar Junction --- Thoraco Dorsolumbar Junction --- Thoraco

Abdominal ApproachAbdominal Approach Lumbar --- RetroperitonealLumbar --- Retroperitoneal Lumbosacral --- Anterior LaparotomyLumbosacral --- Anterior Laparotomy


INSTRUMENTATIONINSTRUMENTATION

Anterior : preferred by mostAnterior : preferred by most Posterior : TULI Posterior : TULI et alet al


BONE GRAFTINGBONE GRAFTING

Tricortical iliac crest : good , Tricortical iliac crest : good , preferred preferred

Rib graft : good osteo-inductionRib graft : good osteo-induction likely to fracture orlikely to fracture or collapsecollapse Fibular good strengthFibular good strength femoral : andfemoral : and tibial poor osteo inductiontibial poor osteo induction


HARDWAREHARDWARE

Anterior plating or screw and rod Anterior plating or screw and rod fixation fixation

OROR Post segmental pedicle screw Post segmental pedicle screw

fixation fixation


RAJNIBEN PATIDAR, RAJNIBEN PATIDAR, 25/F FRANKEL’S GR- D25/F FRANKEL’S GR- D

PREOP: L3-4 KOCH’S WITH PSOAS PREOP: L3-4 KOCH’S WITH PSOAS ABSCESSABSCESS


RAJNIBEN : IMMEDIATE POST RAJNIBEN : IMMEDIATE POST OP OP


RAJNIBEN : 3 MONTHS POST RAJNIBEN : 3 MONTHS POST OP OP


YOGESH PATEL, 18/M, YOGESH PATEL, 18/M, KOCH’S C 3, FRANKEL’S GR- DKOCH’S C 3, FRANKEL’S GR- D

PREOPPREOP


YOGESH : IMMEDIATE POST YOGESH : IMMEDIATE POST OPOP


YOGESH : 3 MONTHS POST YOGESH : 3 MONTHS POST OPOP


KANJIBHAI,34/M, KOCH’S D3-4 KANJIBHAI,34/M, KOCH’S D3-4 FRANKEL’S GR- AFRANKEL’S GR- A

PREOPPREOP


POST OPPOST OP


MALE PATIENT – 60 YEARS WITH HUGE COLD ABSCESS – PREOP - MRI


MALE PATIENT – 60 YEARS WITH HUGE COLD ABSCESS – PREOP – CT SCAN


MALE PATIENT – 60 YEARS WITH HUGE COLD ABSCESS -

POSTOP


COMPLICATIONSCOMPLICATIONS ParaplegiaParaplegia

– Difficult to rehabilitateDifficult to rehabilitate– Bed soresBed sores– UTIUTI

Unyielding TB infection associated Unyielding TB infection associated with HIV may lead to death.with HIV may lead to death.


AUTONOMIC AUTONOMIC DYSFUNCTIONDYSFUNCTION

SPINAL CORD LESION WITH SPINAL CORD LESION WITH NEUROLOGICAL DEFICIT IS NEUROLOGICAL DEFICIT IS ASSOCIATED WITH SIGNIFICANT ASSOCIATED WITH SIGNIFICANT DYSFUNCTION OFDYSFUNCTION OF SYMPATHETICSYMPATHETIC NERVOUS SYSTEMNERVOUS SYSTEM

LOSS OF SUPRA-SPINAL CONTROL OF LOSS OF SUPRA-SPINAL CONTROL OF SYMPATHETIC NERVOUS SYSTEMSYMPATHETIC NERVOUS SYSTEM

ASSOCIATED WITH ASSOCIATED WITH CERVICAL ANDCERVICAL AND DORSAL SPINE TUBERCULOSISDORSAL SPINE TUBERCULOSIS


AUTONOMIC AUTONOMIC DYSFUNCTION CONT…DYSFUNCTION CONT… COMPLICATED BY 3 PHENOMENON COMPLICATED BY 3 PHENOMENON

BELOW THE LEVEL OF LESION:BELOW THE LEVEL OF LESION: 1) REDUCED SYMPATHETIC ACTIVITY1) REDUCED SYMPATHETIC ACTIVITY LEADS TO LEADS TO ORTHOSTATIC ORTHOSTATIC

HYPOTENSIONHYPOTENSION 2)2) LOW RESTING BLOOD PRESSURELOW RESTING BLOOD PRESSURE 3)3) REFLEX BRADYCARDIAREFLEX BRADYCARDIA 4) 4) CARDIAC ARRESTCARDIAC ARREST

dr golwala - tuberculosis of spine -past president lecture

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