POTT’S SPINE POTT’S SPINE

DR. HEMENDRA SHARMA

ASST. PROF.

DEP. OF MGPC

ne

•This entity was first described by Percivall Pott. He

noted this as a painful kyphotic deformity of the spi

associated with paraplegia.

•Tuberculosis of the spine is one of the oldest

diseases afflicting humans.diseases afflicting humans.

• 1/5th of TB population is in India.

•3% are suffering from skeletal TB, 50% of these

suffer from spinal lesion and almost 50% are from

pediatric group. An estimated 2 million or more

patients have active spinal tuberculosis.

REGIONALREGIONAL DISTRIBUTIONDISTRIBUTION

CERVICAL 12%

CERVICODORSAL 5%

DORSAL 42%

DORSOLUMBAR 12%

LUMBAR 26%

LUMBOSACRAL 3%

Malnutrition

Poor Sanitation

Over crowding

PREDISPOSINGPREDISPOSING FACTORSFACTORS

Close contact with TB patient

Immuno deficiency state

TB of spine is always secondary.

PATHOLOGYPATHOLOGY

Bacteria reach the spine via hematogenous route.

Spreads via para-vertebral plexus of veins i.e., BATSON’S PLEXUS

• Paradiscal: This is the commonest type.In this, the contagious areas two adjacentvertebraealong with the intervening disc are affected.

• Central: Body of single vertebrae affected leading to early collapse of the weakened vertebrae. The nearby disc maybe normal. The collapse may be a ‘wedging’ or ‘concertina’ collapse.

• Anterior: Infection is localised to anterior part of vertebral body. Infection spreads up and down under the anterior longitudinal ligament.

• Posterior: Posterior complex vertebrae i.e., the pedicle, lamina, spinous processandtransverse process is affected.

CLINICALCLINICAL FEATURESFEATURES

ACTIVE STAGE HEALED STAGE

ACTIVEACTIVE STAGESTAGEBack pain- commonest

presenting complaint-diffuse-“radicular pain”

PAIN

Presents as pain-in the arm (cervical root),-girdle (dorsal root),-abdomen (dorso-lumbar root),-groin (lumbar root),

• Very early symptom.• -groin (lumbar root),

-sciatic (lumbo-sacral root)

• Very early symptom.STIFFNESS • Protective mechanism of

the body.

COLD ABSCESS Patient may present with a swelling‘cold abscess’ or problems secondary to its compression effects on nearby vicera.

PARAPLEGIA (IF NEGLECTED IN EARLY STAGES)

• Fever• Weight loss• Night sweats

DEFORMITY

CONSTITUIONAL SYMPTOMS

HEALEDHEALED STAGESTAGENo systemic features but deformity persists. Radiological evidence of bone healingPatient may present with cold abscess or due to its compression effects:compression effects:• Retropharyngeal abscess — Dysphagia ,dyspnea,

hoarseness of voice• Mediastina• Psoas ab

l abscess—Dysphagiascess— Flexion deformity of hip

NEUROLOGICALNEUROLOGICALCOMPLICATIONS

ETIOLOGY:Inflammatory: Inflammatory edema , tuberculous abscess.

Mechanical:Tubercular debris,

It is a most serious complication of spinal TB , incidence is approx 20%.

POTT'S PARAPLEGI

A

Mechanical:Tubercular debris, sequestra, cord constriction due to vertebral canal stenosis, localized pressure.

Intrinsic: Infective thrombosis,

EXAMINATIONEXAMINATION

Aim of examination is: —to pick up findings suggestive of TB

—to localise the site of lesion

—find skip lesions

—to detect any associated complications

Physical general examination - to detect active or healed primary lesion. The patient may have some other systemic illness ( diabetes, HTN, jaundice etc)

Following is the systematic way in which one should process to examine a case of suspected TB of spine:

• Gait - Patient walks with short steps in order to avoid jerking the spine. In TB of cervical spine, the patient often supports his head with both hands under the chin and twists his whole body in order to look sideways.

• Attitude and deformity - Tb of cervical spine patient has a stiff, straight neck. In dorsal spine TB, part of the spine becomes prominent (gibbus or kyphus)becomes prominent (gibbus or kyphus)

• Para-vertebral swelling - A superficial cold abscess maypresent as swelling on — the back, along the chest wall oranteriorly. It is easy to diagnose b/a of its fluctuant nature.

• Tenderness - Elicited by pressing upon the side of spinous process.

• Movement - Limited spinal movements.

• Neurological examination - Thorough neurological examination of the — limbs, upper or lower, depending on thesite of TB should be performed. In addition to motor, sensory reflexes examination, an assessment should be made of urinary or bowel functions.

1. weather of not there is any AIM OF NEUROLOGICAL

EXAMINATION IS TO FIND:neurological compression

2. level of neurological

compression

3. severity of neurological

compression

• Plain radiograph

• CT scan

SPINAL TBSPINAL TB DIAGNOSISDIAGNOSISRADIOLOGICAL

DIAGNOSIS

• CT scan

• MRI spine

• Bone scan

TB bacilli are rarely found in CSF, therefore imaging plays

important role in the suggesting the diagnosis.

• Pyogenic infections• Typhoid spine• Brucella Spondylitis• Mycotic Spondylitis• Syphilitic• Tumorous condition• Primary malignant tumor•

DIFFERENTIALDIFFERENTIALDIAGNOSIS

• Primary malignant tumor• Multiple Myeloma• Lymphomas• Secondary• Histocytosis-X• Spinal Osteochondrosis• Spondylolisthesis• Hydatid disease

COMPLICATIONSCOMPLICATIONS

ParaplegiaCold abscessSecondary infectionAmyloid diseaseAmyloid disease

TREATMENTTREATMENT

CONSERVATIVECONSERVATIVE� Specific drug therapy, nutritious diet

and rest are given.� Immobilization of the spine is done by

the bed rest or by plaster jacket or a brace. Immobilization in prone lying position is more advantageous as it further diminishes the compressive further diminishes the compressive forces on vertebra, relieves pain and thereby prevents the commomly seen flexion deformity

� Care of back and bladder should be taken if a patient develops paraplegia.

SURGICALSURGICALIndications-� No response to chemotherapy� Setting in and worsening of

paraplegia inspite of chemotherapySurgeries-• Aspiration of the cold abscess• Aspiration of the cold abscess• Costotransversectomy• Anterolateral decompression• Anterior decompression• Laminectomy

Physiotherapy managementPhysiotherapy management

FOR PATIENT TREATED FOR PATIENT TREATED CONSERVATIVELYCONSERVATIVELY� The patient should be educated on the

postural attitudes which may further compress the cord with its subsequent complications. complications.

� Gentle full range active movements are given to cervical spine and upper and lower extremities.

� Spinal immobilization reduces the efficiency of the respiratory system and therefore slow and deep breathing is valuable in maintaining the vital capacity.

� Proper positioning of the body is explained with emphasis on protecting the pressure points to avoid bed sores.

� Strength of the muscle group, innovated by the spinal segment of innovated by the spinal segment of the affected vertebra, should be checked often and exercised.

AFTER HEALING OF THE AFTER HEALING OF THE LESIONS LESIONS � Gradually progressive exercises are

begun to mobilize and strengthen the spine. Isometrics to the spinal flexors, rotator and side flexors can be initiated.

� Costal, diaphragmatic as well as apical � Costal, diaphragmatic as well as apical breathing should be made vigorous to improve mobility of the thoracic spine.

� Begin spinal exercise with extension gradually progressing to hyper extension in prone lying. Mobility and strengthening of side flexion, rotation and flexion should be initiated in stages.

� Mobility should be progressed further as small active free trunk movements

� Sitting up, standing and ambulation to be initiated with spinal brace.

� Preventive measures to avoid recurrence need to be explained and the use of spinal brace to be continued during working. continued during working.

FOR PATIENTS TREATED BY FOR PATIENTS TREATED BY SURGERY SURGERY � Chest physiotherapy. � Positioning and movements to avoid

immediate post surgical complications like thrombosis.

� Methodology of safe bed activities like turning, transfer with corset or POP jacket. turning, transfer with corset or POP jacket.

� Techniques of sitting from lying, getting down from bed, standing balance and ambulation.

� Mobility and strengthening exercise to the spine.

� Correct principles of ergonomics to be strictly observed post operatively and in future.

IMMEDIATE POSTOPERATIVE IMMEDIATE POSTOPERATIVE PHASEPHASE� The patient is nursed in bed, therefore,

care should be taken to avoid stresses over operated area.

� Chest physiotherapy in the form of deep breathing exercises and diaphragmatic breathing are initiated to avoid chest complications.complications.

� Thrombosis is prevented by early strong movements off the ankle and toes. In the presence of paraplegia, passive movements and the positioning of the body and lower extremities are important.

� Susceptible pressure points should be carefully inspected and protected.

� Simple resistive movements may be initiated to the arms, avoiding overhead stretching as this will put extra strain on the spine. extra strain on the spine.

� Functionally important muscles should be exercised to improve their strength and endurance.

Transverse Transverse myelitismyelitis

� Transverse Myelitis is a rare neurological syndrome. It is an inflammatory disorder of the spinal cord. TM may be due to virus or other infections, but in general, the cause is unknown.

� TM is an autoimmune disorder, meaning that the immune system attacks the body’s own tissues.

� In general, TM is a one time disease with a sudden onset followed by improvement or stabilization.

ETIOLOGYETIOLOGY� It is a post infectious disorder of the

spinal cord that is seen following an episode of influenza, mumps, measles or infections caused by Epstein-Barr virus.The disease is not obvious at the time � The disease is not obvious at the time of infection but occurs as the infection tapers off. It can occur after infection like small pox, rabies, etc.

Clinical features Clinical features � The onset is usually acute or

subacute .� Disease usually starts either at back

or neck area and is usually localized. � The spine becomes very tender The spine becomes very tender

around the affected area.� Sensory loss. � Motor loss.� Sphincter disturbances.

TREATMENT TREATMENT

� Medical treatmentIt consist of glucocorticoids given

with I.V. methylprednisolone .

� Physiotherapy treatment � Physiotherapy treatment It is same as that of pott’s spine.