Professional Documents
Culture Documents
110 Journal, Indian Academy of Clinical Medicine Vol. 8, No. 1 January-March, 2007
tenderness and paravertebral muscle spasm. A kyphotic existent infection by human immunodeficiency virus and
deformity due to prominence of spinous process may be other immune deficiency conditions can give a false
evident due to collapse and anterior wedging of vertebral negative skin test. The enzyme-linked immunosorbent assay
bodies. Tuberculous necrotic material from the dorso-lumbar (ELISA) has a reported sensitivity of 60 to 80 per cent. PCR
spine may lead to cold abscess in the rectus sheath and though very sensitive is not readily available in different
lower abdominal wall along the intercostal, ilioinguinal, and clinicalsettings.
iliohypogastric nerves; in the thigh along the psoas sheath;
in the back along the posterior spinal nerves; in the buttock Imaging studies
alongthesuperiorglutealnerve;inthePetit’strianglealong
Plain radiographs: Plain radiographs are the first line of
the flat muscles of abdominal wall, or, in the ischiorectal
investigations in our country. Earliest radiological features
fossa along the internal pudendal nerve. Disease involving
are narrowing of the joint space and indistinct paradiscal
the upper cervical spine though less common, can cause
margin of vertebral bodies. Gradually, the disc space narrows
dangerous and rapidly progressive symptoms. In the form
due to either atrophy or prolapse into the vertebral body of
of retropharyngeal abscesses, the abscess may track down
the disc tissue. The collection of tuberculous granulation
the mediastinum to enter trachea, oesophagus, or pleura;
tissue and necrotic material leads to formation of
may spread to sternomastoid muscle. Clumsiness in walking,
paravertebral abscess. In the region of thoracic spine it is
and spontaneous twitching of muscles are early signs of
visible on plain radiographs as a fusiform or globular
neurological involvement which can progress to a single
radiodense shadow called the bird nest appearance. Long
nerve palsy, to hemiplegia, or paraplegia with spasticity,
standing abscesses may produce concave erosions around
sensory impairment, bladder/bowel involvement.
the anterior margins of the vertebral bodies producing a
Paraplegia is very rarely a presenting manifestation.
scalloped appearance called the aneurysmal phenomenon.
Wedging of vertebral bodies leads to a kyphotic deformity.
Differential diagnosis Less commoner radiological presentations of spinal
– Actinomycosis tuberculosis are central type, anterior type, and appendiceal
– Blastomycosis type. Central disease presents as destruction, ballooning of
– Brucellosis vertebral bodies, and concentric collapse. Anterior type is
– Candidiasis more common in the paediatric dorsal spine and appears
– Cryptococcosis as erosion of anterior margin of vertebral bodies.
Appendiceal disease is involvement of the posterior arches.
– Histoplasmosis
CT scan examination and MR scanning are increasingly
– Metastatic cancer, unknown primary site
being used to diagnose various types of bony and soft tissue
– Multiple Myeloma
involvement and presence of associated abscess and
– Nocardiosis granulationtissue.
– Paracoccidioidomycosis
– Septicarthritis CT scanning and MRI
– Spinal cord abscess, spinal tumours
For a radiolucent lesion to be seen on a plain radiograph,
– Hemivertebra, Calves disease, Scheuermann’s disease,
30% of mineral loss must be there. CT and MRI detect lesions
Syphilis, Hydatid disease
at an earlier stage. CT scanning provides much better bony
– Diagnostic Workup
detailofirregularlyticlesions,sclerosis,disccollapse,and
disruption of bone circumference. Low-contrast resolution
Skin test and haematological investigations provides a better soft tissue assessment, particularly in
These are in the form of CBC with ESR. Erythrocyte epidural and paraspinal areas. CT is more effective for
sedimentation rate may be markedly elevated. Mantoux defining the shape and calcification of soft tissue abscesses.
demonstrates a positive finding in 84 - 95% of patients CTisusefulinassessingbonedestruction,butislessaccurate
who are non-HIV-positive 1 to 3 months after infection. Co- in defining the epidural extension of the disease, and
Journal, Indian Academy of Clinical Medicine Vol. 8, No. 1 January-March, 2007 111
therefore,itseffectonneuralstructures.
Treatment
General supportive measures include prolonged, complete
bedrest,externalbracing,nutritiousdiet,vitamins,calcium
Fig. 1: Images show the thoracic spine before and after an infusion of supplementation as required, care of bladder, bowels, good
intravenous gadolinium contrast. The abscess and subsequent nursing care is very essential.
destruction of the T11 - T12 disc interspace is marked with
arrowheads.
Medical treatment
Histopathology and microbiology Medical treatment is in the form of ATT. There is a lot of
discordance among experts on the duration of
Because of high prevalence, microbiological diagnosis is
anittuberculous treatment. Studies performed by the British
not mandatory to start chemotherapy in our country.
Medical Research Council indicate that tuberculous
However, a biopsy/aspiration may be needed in cases of
spondylitis of the thoraco-lumbar spine should be treated
doubtfulclinicoradiologicalfindings,lackofproperresponse
with combination chemotherapy for 6 - 9 months. According
to drug therapy, and suspicion of drug-resistant strains.
to a 1994 US Centers for Disease Control and Prevention
Biopsy: Bone tissue or abscess samples are obtained to stain recommendation, this is the treatment of choice. However,
for acid-fast bacilli (AFB), and isolate organisms for culture British Medical Research Council studies did not include
and sensitivity. These study findings may be positive in only patients with multiple vertebral involvement (which is
112 Journal, Indian Academy of Clinical Medicine Vol. 8, No. 1 January-March, 2007
commoner in our country), cervical lesions, or major not complicated by severe deformity or established
neurologic involvement. WHO/RNTCP guidelines consider neurologic deficit results, are usually good.
spinal tuberculosis with neurological deficit to be severe
extrapulmonary (category 1 ) and should receive treatment References
for 6 months. In rare and exceptional cases of relapse or 1
. Keers RY. Pulmonary Tuberculosis: A Journey down the
treatment failure, it should be given treatment according Centuries. London: Balliere Tindall 1978; 246-50.
to category 2, i.e., for 9 months (should be supported by 2
. Duraiswamy PK, Tuli SM. Five thousand years of
orthopaedics in India. Clin Orthop 1971; 75: 269-80.
current tubercular activity by culture or histology)9. The
3
. Pott P. Remarks on that kind of palsy of the lower limbs
currently recommended regime is four-drug therapy. These
which is frequently found to accompany a curvature of
include isoniazid, rifampicin, pyrazinamide, and ethambutol. the spine, and is supposed to be caused by it, together
In children, ethambutol is replaced by streptomycin. In view with its method of cure. Med Classics 1936-1937; 1: 281-97.
of multiple vertebrae involvement, extensive disease, and 4
. Mukopathaya B, Mishra NK. Tuberculosis of the spine.
Indian J Surg 1957; 19: 59-81.
often neurological involvement, most of the authorities in
. Tuli SM. International Orthopaedics 2004; 327-31.
5
India prefer to give ATT for 18 months – HRZE 4 + HR14 .
. Pertuiset E, Beaudreuil J, Liote F et al. Medicine (Baltimore)
6
Treatment protocol of HIV positive patients is same as of
1999;78(5):309-20.
HIV negative. Patients with lower CD4 counts have poor . Bloch AB, Reider HL, Kelly GD et al. The epidemiology of
7
prognosis10. tuberculosis in the United States. Sem Resp Infect 1989; 4:
157-70.
Surgical treatment . Tuli SM. Tuberculosis of the Skeletal System. 2nd ed. New Delhi:
8
Jaypee Brothers, 1997; 177-8.
Opinion varies regarding the operative indication for Pott’s 9
. Wares F, Balasubramanian R, Mohan A, Sharma SK.
spine. A large group of surgeons perform debridement and TuberculosisControlinIndia,2005;2:96-7,Elsevier.
decompression in all cases, irrespective of neurological 10. Govender S, Annamalai K, Kumar KP et al. Spinal
involvement. Others perform operative decompression only tuberculosis in HIV positive and negative patients:
immunological response and clinical outcome. Int Orthop
in those patients who do not respond to chemotherapy. 2000;24(3):163-6.
Resources and experience are key factors in the decision 11. Misra UK, Kalita J. The role of sensory and motor evoked
to use a surgical approach. Indications for surgery are potentials in the prognosis of Pott’s paraplegia. Clin
neurologic deficit, spinal deformity with instability, severe Neurophysiol 2004; 115 (10): 2267-73.
or progressive kyphosis, retropulsed bone fragments in the Senior Resident* Ajay Chauhan*
canal, large abscess causing respiratory embarrassment, and Consultant & Prof. of Medicine** BB Gupta**
no response to medical therapy. Post-operatively the patient Department of Medicine,
is advised absolute bed rest for three months, and then Dr. Ram Manohar Lohia Hospital, New Delhi - 110 001.
gradually mobilised in a spinal brace. A lower threshold for
surgery is recommended in case of cervical spine Pentology of Cantrell
involvement as it is more commonly associated with higher
incidence and severity of neurological deficits and abscess A 12-year-old boy born out of a non-consanguineous
compression. marriage was referred with history of dyspnoea, recurrent
lower respiratory tract infections, and a reducible mass in
Prognosis the upper abdomen since birth. There was no family history
Poor prognostic factors include neurological deficit of more of similar complaints or exposure to teratogenic substances.
than one year duration, myelopathic changes in the cord, The pregnancy itself was uneventful.
and increased pre-treatment kyphotic angle, poor
Physical examination revealed a midline supra-umbilical
compliance, drug resistance. Newer techniques such as
abdominal wall defect extending almost upto the
sensory and motor evoked potentials are being studied as
umbilicus, and also a midline defect of the sternum. The
a prognostic marker of outcomes of Pott’s paraplegia11.
cardiac pulsations could be both visualised and felt very
Current treatment modalities are highly effective and if
Journal, Indian Academy of Clinical Medicine Vol. 8, No. 1 January-March, 2007 113