TUBERCULOUS TUBERCULOUS SPONDYLITISSPONDYLITIS

NISHANTH M KNISHANTH M K2008 MBBS2008 MBBS

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

GRANULOMAGRANULOMA

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

LOSS OF DISC SPACE

EROSION STARTS

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.

FUSIFORM ABSCESS TENSE ABSCESS

RETROPHARYNGEAL 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

MRIMRI

• SHOWS EXTENT OF CORD COMPRESSION

•CONDITION OF UNDERLYING NEURAL TISSUES

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

BIOPSYBIOPSY

CT GUIDED NEEDLE BIOPSYCT GUIDED NEEDLE BIOPSY

OPEN BIOPSYOPEN BIOPSY

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

INTERNAL GIBBUS

SPINAL CORD

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

INVESTIGATIONSINVESTIGATIONS

X-RAYX-RAY MYELOGRAPHYMYELOGRAPHY CTCT MRIMRI

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

Costo-transversectomy Antero-lateral decompression

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