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
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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
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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
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TB SPINETB SPINE
Disease of developing worldDisease of developing world Affects Affects young wage earnersyoung wage earners
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NATURAL COURSE NATURAL COURSE WITHOUT WITHOUT
CHEMOTHERAPYCHEMOTHERAPY
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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
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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
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STAGE OF STAGE OF DESTRUCTIONDESTRUCTION Miliary tuberculosis and/or Miliary tuberculosis and/or
meningitismeningitis 1/31/3rdrd of patients die of patients die
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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
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LEVEL OF OCCURANCELEVEL OF OCCURANCE Dorsolumbar JunctionDorsolumbar Junction DorsalDorsal LumbarLumbar CervicalCervical
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BOVINE T.BBOVINE T.B..
AbdomenAbdomen
Pelvic venous plexusPelvic venous plexus
Vertebrae Vertebrae
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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. .
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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
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PATHOLOGY CONTD… …PATHOLOGY CONTD… …
Weight bearing stimulusWeight bearing stimulus
Collapse of vertebraeCollapse of vertebrae
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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.
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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
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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
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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
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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)
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CLINICAL CLINICAL FINDINGSFINDINGS
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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
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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
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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
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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
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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
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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
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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
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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)
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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
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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
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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.
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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
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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
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INSTRUMENTATIONINSTRUMENTATION
Anterior : preferred by mostAnterior : preferred by most Posterior : TULI Posterior : TULI et alet al
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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
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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
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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
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RAJNIBEN : IMMEDIATE POST RAJNIBEN : IMMEDIATE POST OP OP
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RAJNIBEN : 3 MONTHS POST RAJNIBEN : 3 MONTHS POST OP OP
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YOGESH PATEL, 18/M, YOGESH PATEL, 18/M, KOCH’S C 3, FRANKEL’S GR- DKOCH’S C 3, FRANKEL’S GR- D
PREOPPREOP
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YOGESH : IMMEDIATE POST YOGESH : IMMEDIATE POST OPOP
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YOGESH : 3 MONTHS POST YOGESH : 3 MONTHS POST OPOP
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KANJIBHAI,34/M, KOCH’S D3-4 KANJIBHAI,34/M, KOCH’S D3-4 FRANKEL’S GR- AFRANKEL’S GR- A
PREOPPREOP
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POST OPPOST OP
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MALE PATIENT – 60 YEARS WITH HUGE COLD ABSCESS – PREOP - MRI
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MALE PATIENT – 60 YEARS WITH HUGE COLD ABSCESS – PREOP – CT SCAN
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MALE PATIENT – 60 YEARS WITH HUGE COLD ABSCESS -
POSTOP
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MALE PATIENT – 60 YEARS WITH HUGE COLD ABSCESS -
POSTOP
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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.
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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
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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
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