spondilitis tb

1. Presenter : dr. Adam Firsyada & dr. Ledy Kumala Devi
Pengampu : dr. AndhikaYudistira, SpOT (K)

2.  TB: Oldest recognized disease of mandkind
 Known as ”Yakshma”, mention in RigVeda & AtharvaVeda
(3500-1800 BC) and Samhita of Charaka & Sushruta (1000 & 600
BC), India
 Pott’s disease: destruction of disc space and the adjacent
vertebral bodies, collapse of spinal element and progressive
kyphotic deformity.
 Robert Koch: Discovered MycobacteriumTuberculosis in 1882

3.  Bone and joint involvement develops in approximately 10% of
patients withTB
 The spine is the most common site of skeletal tuberculous,
50% of all musculoskeletalTB
 Tuberculous involvement of the spine has the potential for
serious morbidity, including permanent neurologic deficits
and severe deformity (10-47%)
 Medical treatment or combined medical and surgical
strategies can control the disease in most patients

4.  Mycobacterium tuberculosis
 0,2-0,5 µ in diameter, 2-4 µ in
length
 Have mycolic acid in its cell wall
 Aerobic, non-spore forming, non-
motile, slow growing, divide every
16-20 hours)
 Die with heat, UV light
 AFB with Ziehl-Neelsen

6.  Major agents :
 Bacteria : pyogenic (S.aureus 30-80%, S. epidermidis, E.Coli 25% & P.
aeruginosa) Gram negative -> genitourinary infection
 Tuberculosis & fungi : granulomatosis
 Parasites <<<<

8.  Any musculoskeletalTB is the result of a hematogenous
dissemination from a primarily infected visceral focus.
 Bone and jointTB (including spine) is said to develop generally 2-3
years after the primary focus.
 In spondylitisTB, infection may spread directly from the visceral
lesions to the vertebral column through the Batson’s plexus of
paravertebral veins
 7% spinalTB had “skipped lesions” in the vertebral column and
12% had involvement of extra vertebral bone involvement
 20% had involvement of viscera organs
 40% subclinical active lesions present

10. 1. CentralType & Skipped lesion
 Spread of infection along Batson’s
perivertebral plexus
2. Paradiscal lesion & vertebral lesion ass
with extra spinal skeletalTB
 Spread by way of arteries
3. Anterior type
 Spread by extension of an abscess beneath
the ALL and the periosteum
4. AtypicalType
 At Posterior column of the spine

14.  Most common during 1st 3 decades
 Equally between males and females

16.  Active stage
Constitutional Symptoms & Signs Specific Symptoms & Signs
Malaise Stiffness & Painful on movement
Loss of weight/ appetite Localized kyphotic deformity
Night sweats Tender on percussion
Evening rise of temperature Spasm of the paravertebral muscles
Night cries
Cold abscess
Enlarge Lymph nodes
Neurologic deficit

17.  Healed stage
Constitutional Symptoms & Signs Specific Symptoms & Signs
Malaise Stiffness & Painful on movement
Loss of weight/ appetite  regain weight Localized kyphotic deformity
Night sweats Tender on percussion
Evening rise of temperature Spasm of the paravertebral muscles
Night cries
Cold abscess +/-
Enlarge Lymph nodes
Neurologic deficit +/-

18.  Seen in 20% cases
 Cervical spine: along triangles of neck/ axilla along brachial
plexus, retropharynx
 Dorsal/Thoracic Spine: Paravertebral regions/ chest wall via
intercostal spaces
 Thoraco-Lumbar spine:Tracks along psoas sheath, may
present in:
 Iliac fossa
 Lumbar triangle (Petit triangle)
 Upper part of the thigh - knee

20.  X-RAY
 AP :
▪ NARROWING DISC SPACE
▪ FUSIFORM SHADOW
(PARAVERT ABSCESS)
 LATERAL :
▪ KYPHOTIC DEFORMITY
▪ LOSS BODY HEIGHTVERT
BODY
▪ END PLATE IRREGULAR
▪ NARROWING DISC SPACE

21. CT-SCAN :
 Calcification of soft
tissue abscess
 Posterior element
 Osteolytic lesion
MRI :
 Central necrosis
(abscess)
 Inhomogen
appearance

22.  Average involvement of vertebra: 2,5-3,8 vertebra
 Difficult to recognized radiologically(X-ray) in its early stages.
 Mainly 4 sites:
 Paradiscal
 Central
 Anterior
 Appendicial + Synovial

23.  The most common type of lesion
 Disc space narrowing present before the appearance of
osseous destructive changes
 Disc space narrowing caused by:
 Atrophy of the disc tissue due to lack of nutrition (more common in
pediatric patients)
 Prolapse of the nucleus pulposus into the soft necrotic vertebral
bodies (more common in adults)
 Foci in vertebral body < 1,5 cm are not seen in X-ray, must be
30%-40% of bone mineral loss to show radiolucent lesion on
X-ray, CT-scan may detected foci earlier
 If detected, patient already had infection for 3-5 months

26.  Infection starts in center of vertebra
body
 Reaches there through –Batson’s plexus
 Diseased body looses trabeculations in
central portion, shows destruction/
radiolucent lesion
 Vertebral body may expand then
Concentric collaps Vertebra plana /
“pancake”/ :coin on edge vertebra”
 Minimal disc space reduction

27. Central radiolucent lesions Vertebra Plana/ PancakeVertebra

28.  Begin at anterior vertebral margin
underneath the periosteum
 Spreads beneath the ALL
 Subtle anterior erosion of multiple
vertebrae, shown in lateral X-ray
 Late disk destruction

29.  Produced by extension ofTB granulation tissue and collection
of abscess in the paravertebral region
 Abscess in the cervical region usually presents as a soft tissue
shadow between the vertebral bodies and pharynx and
trachea. Normal value: above cricoid cartilage (C6): 0,5 cm;
below 1,5 cm
 In the upper thoracic abscess, on AP view cast aV-shaped
shadow stripping the lung apices laterally and downwards.
 Abscess below the levelTh4 vertebra produce typical fusiform
shape

31.  In Lumbar region, widening of the psoas shadows shown
psoas abscesses

32.  Forward wedging of 1 or 2 vertebral bodies would produce a
small kyphosis ( knuckle kyphosis)
 Wedge collapse of 3 or more vertebral bodies would produce
an angular kyphosis (Gibbus) and moderate wedging of a
large number of vertebra would create a round kyphosis.
 In children with untreated Pott’s disease, severe kyphosis
often developed with intact neural status.This caused by
gross destruction of anterior growth plates of vertebra with
unrestricted growth of posterior elements, this process
developed gradually and tolerated y neural elements.

35.  Rajasekaran et al proposed a formula to predict the final
kyphotic deformity in adult population affected with spinal
TB:
 Y = a + bx
 Y is the final angle, “a” and “b” are constants, 5.5 and 30.5,
respectively, and x is the initial loss of vertebral height in
thoracic and thoracolumbar spine

36.  CT-scan: good for assessing the destructive lesion of the
vertebral column, delineation of the shape, extend and route
of spread of cold abscess
 MRI: forTB in difficult and rare sites like cranio-vertebral,
cervico-thoracal, SI joint; judge the health of the cord;
differentiates from metastatic disease
 Ultrasound: to diagnose the presence of tubercular abscesses
in lumbar vertebra

37.  Paraspinal soft-tissue masses (73 %)
 Vertebral destruction and collapse (73 %)
 Epidural abscess (53 %)
 Posterior element involvement (40 %)
 Intraosseous abscess (20 %) with contrast enhancement

39.  CBC
 Low Hb
 Lymphocytosis
 ESR
 Raised in active stage
 Normal > 3 months  repair stage
 Mantoux test  not recommended in endemic area (INA)
 Erythema > 20mm at 72 hours  positive
 Gene Xpert PCR test
 Sensitivity of 95.6% and Specificity of 96.2%

40.  Smear and Culture
 Pus  Zeil-Nielson  AFB
 Pus in Lowenstein Jensen media  up to 4 weeks
 Pus in Bactec media  2 weeks only
 Biopsy
 In case of doubt, it is mandatory to prove the diagnosis by obtaining
the diseased tissue

42.  Pyogenic Infection
 Most common: staphylococcus aureus
 Fungal Infection
 Most common: actinomyces or blastomycosis group
 Malignant disease
 Most common: hemangioma, MBD
 Parasitic Infestation
 Example: hydatid disease

46. List of Problems:
• Infection
• Multiple lesion
• Poor general condition
• Instability
• Abses
• Neurological deficit
• Pain
• Pathologic fracture
• Deformity
• Socioeconomic
• Psychogenic
• Kyphus progression by growth

47.  Eradicate infection
 Prevent recurrence
 Relieve pain
 Prevent / reverse neurologic deficit
 Restore spinal stability
 Correct spinal deformity

48.  MedicalTherapy
 Middle Path Regime
 Radical Surgery

51.  Organism identified
 Antibiotic sensitivity
 Single disc space involvement without significant vertebral
body destruction
 Minimal or no instability
 Minimal or no neurologic deficit
 Medical-comorbidities (not tolerable for surgery)

52.  Percutaneous biopsy
 Antibiotics
 Brace and follow-up imaging at 8 weeks to verify stability
 Palliative therapy with pain medication

55.  Neurologic deficit
 Paravertebral abscess
 Spine instability
 Severe kyphotic deformity
 Resistance to the current anti-TB drugs (No effect after 4
weeks of medication)
 Open Biopsy

56.  Background:
 Large number of patient with spinalTB
 Lack number of hospital bed and medical staff
 Strategy:
 AntiTB medication
 Rest and spinal brace
 Indication for hospitalization/ surgery:
 Paraplegic patients
 Patient for abscess evacuation/ debridement
 Unstable and painful spinal lesion
 Extensive thoracic lesion in children for fusion

57.  Rest
 In hard bed, POP bed for uncooperative children
 Traction for spinalTB in cervical/ cervicothoracic region, to put the
disease part in rest
 Drugs & Supportive therapy
 AntiTB medication, multivitamins, hematinics, High protein diets
 Monitoring
 Radiograph and ESR at 3 to 6 months interval
 MRI or CT scan at 6 to 12 months interval for about 2 years

58.  Gradual Mobilization
 For patient with no neurological deficit, with support of spinal brace, as tolerated
 Back extension exercise 5-10 minutes, 3-4 times/day, after 3-9 weeks of starting of treatment
 Aspiration ofAbscesses
 Aspirated when near the surface, 1 gr of streptomycin with o/wo INH solution is instilled at each
aspiration.
 Open drainage if aspiration failed
 Cervical prevertebral abscess drained if causing difficulty in respiration/ swallowing
 Drainage of perispinal abscess considered when its radiological size increases markedly despite
treatment
 Sinuses
 Usually heal within 6-12 weeks after treatment start
 Seldom need longer treatment and excision of sinus

59.  Absolute indication for surgery
 No progressive recovery after fair trial of conservative treatment
 Neurological complications develops during conservative treatment
 Worsening of neurological deficit during treatment
 Recurrence of neurological complications
 Pressure effects (deglutition/ respiration)
 Advanced cases of neurological involvement (Sphincter
disturbances, flaccid paralysis or severe flexor spasm)

60.  Postoperative:
 Patient nursed on a hard bed for 2-3 weeks
 Patient mobilized 2-4 months after surgery with spinal brace
 The spinal brace is gradually discarded 1-2 years after surgery

62.  Indication:
 Early stage
 Good general condition
 Minimal symptoms
 Not amenable for surgery/ refuse surgery
 Conservative treatment with Anti-TB medication
 Brace
 Cervical Collar
 Jewett Brace
 Lumbar support
 Body cast

63.  Indication:
 Stable spine with paravertebral abscess
 Back pain secondary to abscess
 Anterior/ Posterior approach, depend on
location of abscess
 Percutaneous approach / CT-guided if
abscess superficial
 MRI help determined abscess location

64.  Indication:
 Infection at anterior thoraco-lumbar level with minimal
kyphosis
 Anterior column destruction with intact posterior column
 Neurologic intact/ with hemiparesis
 Surgery
 Hong Kong method: Anterior debridement with anterior
fusion
 Classic: using strut graft from ribs/ iliac bone
 Modern: using anterior cage

65.  Indication
 Unstable spine with severe pain, neurologic
deficit, deformity
 Active infection at anterior and posterior
column
 Surgery
 Combine anterior and posterior approach
 Hongkong method + Posterior instrumented
stabilization
 One step/ two step

66.  Indication
 Infection on treatment/ resolved with stiff kyphotic
deformity (gibbus)
 Infection site/ lesion at anterior and posterior column
 Surgery
 Combine anterior and posterior approach
 Hongkong method + Posterior instrumented stabilization
 One step/ two step

67.  Indication:
 Stable anterior column, unstable posterior
column
 Posterior site infection
 No deformity
 Surgery
 All posterior approach debridement with
instrumented stabilization & fusion

68.  Indication:
 Infection at Lumbar area
 Mild kyphotic deformity (40-75°)
 Surgery
 All posterior approach debridement with rod and screw corrective
manipulation (RSCM) technique without needed for posterior
destruction like osteotomy, laminectomy, costotranversectomy or
decompression.

69.  Indication
 Moderate kyphotic deformity (75-90°)
 Anterior and posterior column collapse
 Surgery
 Posterior approach, shortening procedure
 Circumferential debridement, resection of 1-2 vertebral segment and
fusion
 Decompression with laminectomy, costotranversectomy,
corpectomy from posterior approach

70.  Indication
 Severe kyphotic deformity (75-90°) with neurologic deficit
 Active or resolved infection at cervical, thoracic, thoracolumbar, and lumbar.
 Surgery
 Posterior approach
 Debridement, deformity correction, distraction, posterior instrumented fusion
 Deformity correction using osteotomy, RSCM technique or combination
 Intraoperative nerve monitoring should be use while performing distraction/
deformity correction
 Anterior defect might be addressed at 2nd stage

71.  Indication
 Severe kyphotic deformity (75-90°) without neurologic deficit
 Active or resolved infection at cervical, thoracic, thoracolumbar, and lumbar.
 Surgery
 Posterior approach
 Debridement, deformity correction, distraction, posterior instrumented fusion
 Deformity correction using osteotomy, RSCM technique or combination
 Intraoperative nerve monitoring should be use while performing distraction/
deformity correction
 Goal is to prevent neurologic deficit

72.  Retrospective study of 184 patients w/ thoracicTB, 2003-2010
 55% Men, average age 39.3 ± 14.4 y.o.
 Divided into 3 groups:
 Group A: posterior debridement, interbody fusion w/
instrumentation
 Group B: combined anterior-posterior surgery (one/two stage)
 Group C: Hong Kong method
 Followed up for average ±73 months

73.  Conclusion:
 Posterior approach is
recommended in thoracic spinal
TB because it has good results,
reduced complications, operative
time and blood loss.

74.  Goals: Functional optimization of
 Vertebral structures
 Extremities
 Sexual
 Urination and defecation

75.  Muscle function rehabilitation
 Skeletal and joint rehabilitation
 Urinary bladder rehabilitation
 Colon rehabilitation
 Sexual rehabilitation
 Ambulation rehabilitation
 Sanitation
 Social rehabilitation

76.  Functional rehabilitation:
 ROM exercises
 Bladder and bowel training
 Mobilization, transfer and ambulation training
 Spinal brace
 Systemic rehabilitation
 Breathing exercises
 Proper bed positioning
 Transcutaneous Electrical Nerve Simulation (TENS)
 Heat treatment
 Nutrition and diet