TB spine written

Introduction:
 Bone and joint tuberculosis remain as a major orthopaedic
problem in developing country like Bangladesh. The spine is the
most common site of skeletal tuberculosis (TB). It has special
importance due to risk of developing Paraplagia
 It was first described by a British surgeon Sir Percival
Pott, so also called Pott’s disease. He noted it as a painful
kyphotic deformity of the spine associated with paraplagia
Incidence:
 Accounts for 50 % of all musculoskeletal TB.
 At any age between 1 year to 80 years
 Most common during first three decade
 Equally distributed among both sexes
Sites:
Any part of the spinal column may be affected.

Regional distribution As frequency

Cervical — 12 % Dorsal — 42 %
Cervicodorsal — 05 % Lumbar — 26
Dorsal — 42 % %
Dorsolumbar— 12 % Dorsolumbar— 12 %
Lumbar — 26 % Cervical — 12
Lumbosacral — 03 % %
Cervicodorsal — 05
Commonest – Lower thoracic and Lumber%vertebra – 80%
Lumbosacral — 03 %
Route of infection: Mostly haematogenous
Paravertebral lymphatics – also important

Pathogenesis of skeletal TB
1. Skeletal TB is always secondary. Primary foci
Disseminated from Primary site (Lung, LN, Tonsils, abdomen)
↓
2. Blood-borne infection usually settles in a Bacillemia
vertebral body adjacent to the intervertebral ↓
disc. Reaches vertebra through Batson’s
3. Bone destruction and caseation follow plexus
↓
with infection spreading to the disc space and Infection – tubercular endarteritis –
the adjacent vertebrae. Marrow
4. A paravertebral abscess may form, and ↓ devitalization
then track along muscle planes to involve the Later -Tubercle follicle
↓
sacro-iliac or hip joint, or along the psoas Destruction of lamella (due to
muscle to the thigh. hyperaemia)
5. As the vertebral bodies collapse into each ↓ –
osteoporosis
other, a sharp angulation (gibbus or kyphos)
Compression of vertebral body
develops. ↓ **
6. There is a major risk of cord damage due Formation of cold abscess
to pressure by the abscess, granulation ↓
tissue, sequestra or displaced bone, or Penetrate epiphyseal cortex –
involved
(occasionally) ischaemia from spinal artery
↓ adjacent disc, vertebra
thrombosis. Ant. long.ligament - neighboring
7. With healing, the vertebrae recalcify and vertebra
bony fusion may occur between them. If there ↓
Pressure on spinal cord
has been much angulation, the spine is ↓
usually ‘unsound’, and flares are common, Paraplegia
 resulting in further illness and further
vertebral collapse.
8. With progressive kyphosis there is again a
risk of cord compression.

History
 Age of the patient
 Duration of symptom
 Past history of tuberculosis
 Incontinence of bowel and bladder
 Socioeconomic condition
 Any trauma
Clinical presentation:
Complain of Back pain & stiffness
Insidious in onset, dull aching, persistent, more at night
Site – may be over affecting vertebra or radiating pain due to
nerve root compression
Constitutional symptom
 Low grade fever
 Evening rise of temperature
 Anorexia
 Weight loss
 Weakness
 Palpitation
 Night cries
O/E
A. General examination –
i. Ill looking
ii. Anaemia
iii. Cachexia
iv. Regional lymphadenopathy
B. Local examination -
a. Look
i. Attitude
ii. Any paravertebral swelling (cold abscess)
iii. Discharging sinus
iv. Deformity Sites of cold abscess
1. Gibbus
2. Kyphosis
v. Any muscle wasting of both lower limb (paraplegia)
b. Feel
i. Tenderness
ii. Spasm of paraspinal muscles
iii. Distal vascular status
c. Move
i. Restriction of spinal movement
ii. If paraplegia – unable to move both lower limb
d. Neurological examination:
i. Sensation of lower limb
ii. Motor
 iii. Reflex in paraplagia
1. Tendon jerk
Exaggerated
2. Planter response Extensor
3. Ankle clonus Present

Investigation:
1. Routine blood
a) Hb% -
b) ESR –
c) Relative lymphocytosis
2. Mantoux test (Heaf test) – positive; Negative test
does not rule out tuberculosis.
3. X-ray chest
4. Pus – AFB staining & culture

5. Plain X- ray of affected spine AP and lateral view

a) Early findings –
i. Narrowing of disc space
ii. Rare faction and osteopenia
iii. Condition of vertebral margin or
body
 In Paradiscal type – Loss
of paradiscal margin
 In Central type – Area of
destruction and body may expand or ballooned out
like tumor
b) Late findings
i. In paradiscal type
 Wedge compression
fracture
 Paravertebral shadow
In Cervical region – Bird’s nest appearance
In lower thoracic region – Bulbous and heart
shaped
Lower dorsal and dorso lumber areas: fusiform
shaped
ii. In central type fracture
 Concertina/ central
collapse
 Paravertebral shadow –
usually not well marked
6. MRI – Area of
involvement & cord compression D/D
7. CT scan / CT 1. Pyogenic osteomyelitis
2. Compression fracture
myelogram 3. Osteoporosis
8. Special test 4. Osteomalacia
a) Serological 5. Spondylolisthesis
i. 6. Tumor
a. Haemangioma
ELISA b. GCT
ii. PCR c. ABC
iii. Anti d. Multiple myeloma
TB Ig G e. Secondary
 iv. Anti TB Ig M
v. ALS for TB

Complications of
tuberculosis spine
Stages of osseous TB
• Paraplegia
1. Stages of inflammatory exudates
• Cold abscess
and edema
• Sinuses
2. Stages of necrosis and cavitation
• Secondary infection
3. Stages of destruction and
• Amyloid disease
deformation
• Fatality
4. Stages of healing and repair

Treatment:
1. General treatment:
a. Initially hospitalization (in paraplegic patient who can’t walk)
b. Correction of anaemia
c. Improvement of nutritional status by high protein diet,
vitamin
In case of paraplegic patient
1. Bowl and bladder care
2. Management of bed sore –
- dressing
- pneumatic bed
- change of posture 2 hourly
2. Non operative treatment (middle path regime / rational treatment)
a. Rest: - Absolute bed rest in hard bed or in children -plaster of
paris bed
[cervical and cervicodorsal lesions, traction was used in the
early stages to put the diseased part at rest.]
b. Anti TB drug therapy
c. Radiographs and E.S.R
- for check-up at 3 to 6 months interval.
- Kyphosis was measured radiologically
- For craniovertebral, cervicodorsal, lumbosacral
regions and sacroiliac joints MRI or CT scan at 6
months interval for about 2 years
d. Gradual mobilization
- in the absence of neural deficit with suitable spinal
braces as soon as the comfort at the diseased site
permits.
- After 3 to 9 weeks of treatment
back extension exercises 5 to 10 minutes 3 to 4
times a day.
- Spinal brace is continued for about 18 months to 2
years
After that it is gradually discarded.
e. Abscesses
- If near the surface - aspirated and one gram of
streptomycin with or without INH in solution is
instilled at each aspiration.
- if aspiration fails - Open drainage
 paravertebral abscesses are not drained, drainage is
incidental
whenever a decompression is performed for Pott’s
paraplegia, or debridement is performed for an
active tuberculous disease.
Prevertebral abscesses in the cervical region are drained
when complicated by difficulty in deglutition and
respiration.
f. Sinuses Perispinal abscess per se- Drainage may be considered
- when its radiological size increases markedly
despite treatment.
majority of cases heal within 6 wks to 12 wks after onset
of treatment
- A small number requires longer treatment and
excision of the tract with or without debridement.
g. Neural complications
If responded on triple drug therapy between 3 to 4 weeks
and surgical decompression considered unnecessary

Operative treatment
Indication:
Absolute
1. Onset of paraplegia during the course of medical
treatment
2. Static or worsening paraplegia in the course of
conservative treatment
3. Severe motor or sensory losses or both losses for one
month
4. Severe paraplegia with severe spasticity for which patient
need immobilization for prolonged period that increase
risk of forming bed sore, DVT etc
5. H/O paraplegia for 6 month irrespective of degree of
neurological deficit
6. paraplegia of rapid onset
Relative
1. Doubtful diagnosis
2. symptomatic mechanical instability after healing
3. Recurrent paraplegia
Surgery: Decompression followed by interbody fusion with cage
and bone graft then
stabilization by pedicle screw and rod
Approach Surgical techniques
 Cervical upto T1 1. Costotransversectomy
– Anterior 2. Anterolateral
 Dorsal + DL – decompression
Anterolateral 3. Anterior decompression
Rarely, 4. Laminectomy
Various operation
1. Debridement (± fusion) in failure of response after 3 to 6 months of
nonoperative treatment
2. Decompression (± fusion) for neurological complications which failed to
The operation usually performed
respond to conservative therapy/too advanced.
1. to drain
3. Debridement ± decompression ± fusion in recurrence ofabscesses,
disease or of neural
complication. 2. to débride sequestered bone
and disc,
3. to decompress the spinal cord,
or
4. to stabilize the spine for the
prevention or correction of
deformity.
Postoperative management
1. Patient is nursed in a hard bed
2. Adequate analgesia
3. Antibiotic
4. Maintain hydration and nutrition
5. Physiotherapy
6. Patient is gradually mobilized 3-5 months after operationwith the
help of spinal brace
7. Brace is discarded 6month after completion of anti TB
chemotherapy

Prognosis:
 The prognosis depends on the age and general health of the
patient,
 the severity and duration of the neurologic deficit, and
 the treatment selected

Management a addition in case of potts paraplagia

classified into 2 main groups (Griffiths, Seddon and Roaf 1956)

Group A: Early onset Group B: Late onset paraplegia

paraplegia This appears many years (> 2 years) after
Active phase of the vertebral onset of disease (inactive persist in vertebra)
disease usually within first 2 years  Neurological complications may be
of the onset. associated with
 Underlying pathology a. Recrudescence of the disease similar
1. inflammatory edema, to those of early onset paraplegia
2. tuberculous granulation b. Due to mechanical pressure on the
tissue, cord. Underlying pathology
3. tuberculous abscess, 1. tuberculous caseous tissue,
4. tuberculous caseous tissue 2. tubercular debris,
or 3. sequestra from vertebral body
5. rarely ischemic lesion of and disc,
the cord. 4. internal gibbus,
 Prognosis - 5. stenosis of the vertebral canal
favorable or
6. severe deformity.
 Prognosis: Surgical
removal of mechanical causes is
mandatory and prognosis is less
favorable
 Principle of treatment (for paraplegia)

Hodgson radical Anterior decompression

Tuli and Kumar’s – Middle path regime

Boswarth – immobilization and early
Three schools of thought

posterior arthrodesis

and arthrodesis

Drugs
For an average adult is to start with
All replicating
“intensive phase” sensitive
Daily dosage of mycobacteria are
isoniazid 300 to 400 mg, likely to be killed by
rifampicin 450 to 600 mg and this bactericidal
ofloxaxcin 400 to 600 mg for
5 to 6 months..
Aim is to attack the persisters, slow growing or
The “continuation phase for 7 to 8 months
interm-ittently growing or dormant or intracellular
mycobacteria.
isoniazid and pyrazinamide (1500 mg per day) for 3 to 4
months,
Followed by isonazid and rifampicin for another 4 to 5
months.

The “prophylactic phase” The aim is to offer prophylaxis to the patient

during the time his body is developing
adequate protective immunity
isoniazid and ethambutal (1200 mg) for 4 to 5 months.
This is the time when the treated patient is back to his normal
working environments

The doses and drugs were modified according to the weight of the
patient, existing co-mobidities and any adverse drug reactions.
Doses are modified according to the age and drug response of the patient.

For patients who are hospitalized streptomycin replaces one of the drugs
except isoniazid. Supportive therapy with
 multivitamins, hematinics if necessary and,
high protein diet are advised.

Types of spinal TB
1. Typical – affect vertebral body
a. Paradiscal (70%) – due to peculiarity of blood supply
b. Central (23%) – due to peculiarity of Batson’s plexus
c. Anterior type (7%) – due to spread from paradiscal or body
type lesion
2. Atypical (posterior or appendicular type) – affect lamina or other
parts
a. Pedicle
b. Lamina
c. Transverse process
d. Spinoues process
e. Facet joint
f. Atlanto-axial joint
g. Atlanto-occipital joint

Diagrammatic representation of the frequency of location of tuberculosis of the

vertebral column. The most common (1) variety of tubercular spondylitis
(spondylodiscitis) occurs in the paradiscal region, and the least common is
synovitis in the posterior facet joints (5). (1) = paradiscal, (2) = central, (3)
anterior, (4) = appendicial, (5) = synovial
N.B – Probable reasons for lower thoracic spine
Commonly affects the lower thoracic as common site:
and lumbar vertebra. The reasons are  More spongy bone.
 Large amounts of spongy  Batson’s plexus of veins
tissues within the vertebral body.  Cysterna chyli begins at lower
 Degree of weight bearing, which border of T12.
is comparatively more.  Close relation of thoracic duct.
 More vertebral mobility is seen  Continuous movement with
here. respiration which helps in
 A vertebra develops from the sclerotomes which lie on either side of the
notochord.
 The lower-half of one vertebra and upper-half of the below it, along with the
intervening disc develop from each pair of sclerotomes and have the common
blood supply.
 Therefore, infections via the arteries involve the 'embryological' section, as
 In Cleveland’s series the peak incidence was at the 11th thoracic vertebra
the incidence curve falling away more or less smoothly in each direction along
the vertebral column.
 In Hodgson’s series the peak incidence was observed at L1 and the curve
had a uniform fall proximal and distal to this level. He suggested that the peak
incidence at lumbar one vertebra was possibly due to spread of infection to the