Every thing about tuberculosis of spine (potts spine)

1. PRESENTATION BY:
DR. K TARUN RAO
PG IN DEPT OF ORTHOPEDICS
CAIMS, KARIMNAGAR.

2.  Tuberculosis (TB), which is caused by bacteria of the
Mycobacterium tuberculosis complex, is one of the
oldest diseases known to affect humans and a major
cause of death worldwide.

3. ETIOLOGICAL AGENT:-
 M. tuberculosis - is a rod-shaped, non-spore-forming,
thin aerobic weakly grampositive bacterium measuring
0.5 μm by 3 μm .
 However, once stained, the bacilli cannot be
decolorized by acid alcohol. This characteristic
justifies their classification as acid-fast bacilli.
 Acid fastness is due mainly to the organism’s high
content of mycolic acids, long-chain cross-linked
fatty acids, and other cell-wall lipids.

4. WHY ARE MOST ANTIBIOTICS
INEFFECTIVE?
 In the mycobacterial cell wall, lipids (e.g., mycolic
acids) are linked to underlying arabinogalactan and
peptidoglycan. This structure results in very low
permeability of the cell wall, thus reducing the
effectiveness of most antibiotics.
 Microorganisms other than mycobacteria that display
some acid fastness include species of Nocardia and
Rhodococcus, Legionella micdadei, and the
protozoa Isospora and Cryptosporidium.

5. CELL WALL STRUCTURE:-

6. PREDISPOSING FACTORS:-
 1) Malnutrition
 2) poor sanitation
 3) over crowding
 4)close contact with TB patients
 5) multiple pregnancy
 6) immunodeficiency states.

7. PATHOPHYSIOLOGY:-

8. In order of frequency, the extrapulmonary sites most
commonly involved in TB are the :-
 1) lymph nodes,
 2) pleura,
 3)genitourinary tract,
 4)bones and joints, (50% of it being vertebral TB)
 5)meninges,
 6) peritoneum, and
 7)pericardium.

9. PATHOLOGY:-

10. Pathology:-
 Any osteoarticular tubercular lesion, is the result of a
hematogenous dissemination from a primarily infected
visceral focus.
 The primary focus may be active or quiescent, apparent or
latent,either in the lungs or in the lymph glands of the
mediastinum,mesentry or cervical region,or kidneys or other
viscera.
 The infection reaches skeletal system through vascular
channels , generally the arteries as a result of bacillemia or
rarely in axial skeletal through batson’s plexus of veins
It is most common during first 3 decades.
The disease is equally distributed in both sexes.

11. Symptoms and signs:-
Active stage:
1)constitutional symptoms: malaise , weight loss ,loss of
appetite, night sweats(TNF-alfa released by
macrophages) , evening rise of temperature ( IL-1).
2) back pain
3) spine stiffness: spasm of para -vertebral muscle
4)night cries.(release of spasm of muscles and movement
of structures involved)
5)deformity : knuckle( 1 or 2vertebrae) / gibbus (2 or 3
vertebrae)/ kyphus (angular kyphosis more than 3
vertebrae)
6)cold abscess may be present.

12. 7) paraplegia (if neglected in early stages)
But several of these signs and symptoms may be
absent.
Healed stage:
Pt neither looks ill nor feel ill,
 No systemic features but the deformity that occurred
during active stage however, persists.
 ESR falls.
 There is radiological evidence of bone healing in serial
x-rays.

13.  Healing is
indicated by
 Decreased soft
tissue shadow
 Return of normal
density
 Bony ankylosis

15. COLD ABSCESS:-
 An abscess is a collection of liquefied tissue(pus) in
the body, which is body’s defence reaction to foreign
material.
 It is called cold abscess because it is not accompanied
by the classic signs of inflamation i.e. heat , redness,
fever, pain etc., which are usually found with pyogenic
abscess.

16. OTHER CAUSES OF COLD
ABSCESS:-
1) actinomycosis
2) leprosy
3) fungal infections
4) Autosomal dominant hyperimmunoglobulin E
syndrome( jobs syndrome)
- recurrent staphylococcal cold abscess
- eczema
- increased igE

17. PATHOGENESIS:-
Phagocytosis of tubercle bacilli by RES (monocytes,
macrophages)
Tuberculous granulomas( langhans gaint cells)
Small patches of central caseous necrosis
Coalesce into a large yellow mass
Break down of center to form cold abscess.

19. A typical tuberculous granuloma, with central necrosis
and scattered giant cells surrounded by lymphocytes
and histiocytes:-

20. Absceses and sinuses:-
 Abscesses or sinuses from the cervical or dorsal
regions can present themselves far away from the
vertebral column along the fascial planes or course
of neurovascular bundles.They may be present in the
paraspinal region at the back in the posterior
/anterior cervical triangles ,along the intercostal
spaces on the chest wall.
 Abscesses from the dorso-lumbar and the lumbar
spine follow the psoas sheath abscesses may be
palpable in the iliac fossa, in the lumbar triangle , in
the upper part of the thigh below the inguinal
ligament or even downwards up to the knee .
sometimes bilateral psoas abscess.

21. Sinus and abscess

22. Composition:-
 Mostly composed of :-
 1) serum
 2) leucocytes
 3) caseous material
 4) bone debris
 5) tubercle bacilli.

23. Clinical features:-
1)Painless swelling which is:-
 - incidious in onset,
 - soft and smooth mass,
 - cystic consistency,
 - fluctuation present,
 - slip sign negative,
 - no transillumination.
2) Sinus or ulcer may be present,
3) Superadded infections with pyogenic organisms
4) Constitutional symptoms may be present like low
grade fever, loss of weight and loss of appetite.

24. Local pressure effects due to
swellings:-
C-spine:-
The exudate collects behind prevertebral
fascia and protrude forward as retropharyngeal abscess
causing 1) dysphagia
2) dysphonea
3) dyspnoea
4) hoarseness of voice.
the abscess may track down in mediastinum to
enter trachea, oesophagus or pleural cavity. It may
spread laterally into the sternocleidomastoid muscle
and form abscess in the neck.

26. T- spine:-
The exudate may be confined locally as
paravertebral abscess
It may enter in to spinal canal and copmpress
spinal cord leading to early onset pott’s paraplegia.
It can penetrate anterior longitudinal ligament
to form mediastinal abscess.
Pass down through medial arcuate ligament to
form a lumbar abscess.
Rarely , the thoracic cold abscess may follow
the intercostal nerve to appear anywhere along the
course of nerve.

29. length > width
( Bird nest abscess)
Width > length
(Globular abscess)

31. Lumbar abscess:-
Abscess can have pus tract along the
psoas muscle towards the groin and present as psoas
abscess.
Flexion deformity of hip can develop
due to the abscess ( pseudo flexion deformity of hip)
Can gravitate beneath the inguinal
ligament to appear on the medial aspect of thigh.
It can spread laterally beneath iliac
fossa to emerge at the iliac crest near the ASIS
The exudate can follow vessels to
form an abscess in scarpa’s triangle or gluteal region.

32. Psoas muscle:-
The psoas major is divided into a superficial and deep
part. The deep part originates from the transverse
processes of lumbar vertebrae I-V. The superficial part
originates from the lateral surfaces of the last thoracic
vertebra, lumbar vertebrae I-IV, and from
neighboring intervertebral discs.
Action:- flexion, lateral rotation and weak
adduction of hip.

33. Psoas abscess:-

34. BILATERAL PSOAS ABSCESS

36. TREATMENT:-
 1) anti tubercular drugs
 2) aspiration
 3) ultrasound guided pigtail catheter drainage
 4) surgical management.

37. ASPIRATION:-
Palpable cold abscess must be drained as early
as possible and instil 1gm streptomycin +/- INH in
solution.
Technique:- ZIG-ZAG aspiration using wide bore needle
from non-dependent area to prevent sinus formation.

39. SURGICAL:-
 open drainage may be performed if aspiration failed to
clear it.
 Drainage using non-dependent incision, later closure
of wound with out placing a drain to prevent sinus
formation.
 Correcting underlying bone lesion / defect.
 cold abscess of chest wall sometimes may require rib
resection , clavicle and sternum resection along with
abscess excision.

40. Regional distribution of
tuberculosis lesions in vertebral
column
 Cervical (including atlanto-occipital) : 12%
 Cervico-dorsal: 5%
 Dorsal : 42%
 Dorsolumbar : 12%
 Lumbar : 26%
 Lumbo-sacral (including sacrum) : 3%

41. Clinical features of spinal
tuberculosis
 Clinical kyphosis :95%
 Palpable cold abscesses : 20%
 Radiological perivertebral abscesses: 21%
 Tuberculosis sinuses (active/healed): 13%
 Associated extra-spinal skeletal foci : 12%
 Associated visceral or glandular foci : 12%
 Neurological involvement : 20%
 Lateral shift (radiological) : 5%
 Skipped lesions of spine : 7%

42. TYPES OF Vertebral lesion:-
 1)Paradiscal type-ARTERIAL SPREAD
 2)Central type (central part of the vertebral body) –
VENOUS SPREAD
 3)Anterior type (involving anterior surface of the
vertebral body) – SUBPERIOSTEAL SPREAD
 4)Appendicial type (involving pedicles, laminae,
spinous process or transverse processes ).

44. ARTERIAL SUPPLY OF VERTEBRA

46. BATSON’S PLEXUS OF VEINS :-

47. 1) Paradiscal lesions
 It is the most common type of lesion.
 Narrowing of the disc space is often the earliest
radiological finding.
 Destruction of subcondral bone
 Prolapse of the nucleus pulposus into the soft necrotic
vertebral bodies

48. Paradiscal lesions

49. Paradiscal
lesion

50. 2)Central lesions(tuberculosis of
the centrum)
 Central disease arises as a result of infection which
starts from the center of the vertebral body reached
through batson’s venous plexus or through the
branches of posterior vertebral artery.
 Vertebral body collapse.
 Resembles Vertebra plana or pan cake
vertebra( when a vertebral body has lost almost its
entire height anteriorly and posteriorly)

51. Central lesion /vertebra plana

52. 3)Anterior lesions:-
 This lesion occurs when the infection starts beneath
the anterior longitudinal ligament and the
periosteum.
 Pus spreads by stripping anterior longitudinal
ligament , periosteum from anterior surface of the
vertebral body.
 Vertebral body collapse due to pressure and ischemia,
followed by disc space narrowing.
 Lesion is relatively more common in thoracic spine .

53. Anterior lesion:-

54. 4)Appendicial lesions:-
 Isolated tuberculosis infection of the pedicles and
laminae(neural arch),transverse processes and spinous
processes does occur but uncommonly.
 Radiographically, these lesions may be appreciated by
erosive lesions, paravertebral shadows and intact disc
space.
 Occurs in isolation or conjunction with typical paradiscal
tuberculosis were considered to be very rare <5%

55. Appendicular lesion

56. Skipped lesions:-
 More than one
TB Lesion in
vertebral column
with one or more
healthy vertebrae
in between the 2
lesion.
 7% on routine
xray
 More frequently
detected on
CT/MRI

57. Management:-
Diagnosis:-
 Clinico radiological &
 Lab studies
 Microbiological studies
 Ct scan
 Mri scan
 Usg
 Radionuclide scan
 myelography

58. Diagnosis:-
 Complete blood picture:- increased ESR /increased
lymphocyte count
 ELISA: for antibody to mycobacterial antigen ,sensitivity
60-80%
 PCR : sensitivity of 40%
 Chest radiograph
 Mantoux / tuberculin test
 Microbiology:- zeihl-neelsen staining / acid fast
staining
 Cultures :4-6 weeks in LOWENSTEIN-JENSEN MEDIUM
positive only in 50% cases. ( L-J medium).

59.  IFN – GAMA release assays (IGRA’s):- Assays that
measure t-cell release of IFN in response to stimulation
with highly specific tubersulosis antigen ESAT6 & CFP
10

60. MENDEL-MANTOUX TEST OR
TUBERCULIN TEST OR PIRQUET
TEST OR PPD TEST:-

63.  5 mm or more is positive in
 An HIV-positive person
 Persons with recent contacts with a TB patient
 Persons with nodular or fibrotic changes on chest X-ray
consistent with old healed TB
 Patients with organ transplants, and other immunosuppressed
patients
10 mm or more is positive in
 Recent arrivals (less than five years) from high-prevalence
countries
 Injection drug users
 Residents and employees of high-risk congregate settings (e.g.,
prisons, nursing homes, hospitals, homeless shelters, etc.)
 Mycobacteriology lab personnel

64.  Persons with clinical conditions that place them at high
risk (e.g., diabetes,
prolonged corticosteroid therapy, leukemia, end-stage
renal disease, chronic malabsorption syndromes, low
body weight, etc.)
 Children less than four years of age, or children and
adolescents exposed to adults in high-risk categories
15 mm or more is positive in
 Persons with no known risk factors for TB

65. FALSE NEGATIVE RESULT:-
Reaction to the PPD or tuberculin test is suppressed by
the following conditions:
1)Recent TB infection(less than 8–10 weeks)
2) Infectious mononucleosis
3)Live virus vaccine - The test should not be carried out
within 3 weeks of live virus vaccination (e. g. MMR
vaccine or Sabin vaccine).
4) Sarcoidosis
5) Hodgkin's disease
6) Corticosteroid therapy/steroid use
7) Malnutrition
8) Immunological compromise- Those on immuno-
suppressive treatment or those with HIV and low
CD4 T cell counts, frequently show negative results
from the PPD test.

66.  This is because the immune system needs to be
functional to mount a response to the protein
derivative injected under the skin. A false negative
result may occur in a person who has been recently
infected with TB, but whose immune system hasn't yet
reacted to the bacteria.

67. PLAIN RADIOGRAPH:-
Classic radiological triad :-
1)primary vertebral lesion ;
2) disc space narrowing ;
3)paravertebral abscess.
The foci of less than 1.5cms in diameter are not
demonstratable in a conventional radiograph.
30-40% of calcium must be removed from a
particular area to show a radiolucent region on xray.

68. Plain radiograph findings:-
 Disc space narrowing ( commonest & earliest)
 Erosion of end plate
 Signs of infection with lucency in ant. portion of vertebra
 Deformities (knuckle , gibbus ,kyphus, anterior wedging ,
vertebra plana)
 Sclerosis resulting from chronic infection
 Compression fracture (concertinal collapse = single
collapse vertebra)
 Soft tissue swelling from paraspinal abscess+/- calcification
 Bowing of rib cage with multiple vertebral fracture.

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IMAGE 1
IMAGE 2

73. Kumar’s clinico-radiological
classification:-
stage Clinico-radiological features Usual duration
1.Pre destructive Straightening of curvatures,spasm of
perivertebral muscles,scinti-scan would
show hyperemia mri shows marrow
edema
<3 months
2.Early - destructive Diminished disc-space+paradiscal
erosion (knuckle<10degree)mri shows
marrow edema and break of osseous
margins, ct scan shows marginal erosions
or cavitations
2-4 months
3.Mild angular
kyphosis
2-3 vertebrae involved k:10-30 degree 3-9 months
4.Moderate angular
kyphos
>3vertebrae involved k:30-60 degree 6-24 months
5.severe kyphos
(humpback)
>3vertebrae involved k:>60 degree >2 years

74. Angle of kyphosis

75. Paravertebral / prevertebral
shadows (radiological evidence of
cold abscess):-
 Abscess in cervical region: as a soft tissue shadow
b/n vertebral bodies and pharynx & trachea.
 On average, normal space b/n pharynx and spine
above level of Cricoid cartilage is 0.5 cm and below
it is 1.5 cm
 In lateral view, the tracheal shadow is Concave
anteriorly (parallel to the upper dorsal vertebrae),
if there is a change in normal contour &/or its
distance is >8mm from the vertebrae, it is strong
indicator of the disease from C7 to D4 vertebrae.

76. Paravertebral shadow
Abscess below the level of D4 vertebrae – Fusiform
shape (Bird nestappearance)
An abscess under tension may produce- Globular
shape

77. Prevertebral shadow

78. Ct scan of spine:-
It is useful tool in assessing patterns of bony destruction.
 Delineation of the shape, extent and route of spread of a cold
abscess can also be very well visualized
 Regions which are difficult to visualize on plain films, like :
1. Cranio-vertebral junction (CVJ)
2. Cervico-dorsal region,
3. Sacrum
4. Sacro-iliac joints.
5. Posterior spinal tuberculosis because lesions less
than 1.5cm are usually missed due to overlapping of shadows
on x rays

79. MRI:-
 Highly sensitive & specific for spinal TB.
 Spinal cord & soft tissue involvement.
 Detect marrow infiltration in vertebral
bodies(EDEMA), leading to early diagnosis.
 Skip lesions.
 Changes of discitis (EDEMA).
 Assessment of extradural abscesses / subligamentous
spread.
 Poor for calcification.

80. Radionuclide bone scan:-
 Increased uptake in 60% patients with active
tuberculosis
 >= 5mm lesion can be detected
 Avascular segments & abscesses show cold spot
 Localize active disease and skip lesions
 Highly sensitive but non specific

81. USG:-
1)Employed to diagnosis the presence of tubercular
abscesses in the lumbar vertebral disease.
2)Guided aspiration.
3) to find out primary in abdomen.

83. Differential diagnosis:-
1)Pyogenic infections:-
It is sudden in onset with severe
localized pain,spasm and swinging temperature like
acute osteomyelitis.
 In early stages,there is bone destruction which is rapidly
replaced by bony sclerosis and new bone formation
observed radiologically from 8th week onwards.
 The intervertebral disc space shows varying degree of
destruction.low grade pyogenic infection may have an
insidious course and onset like tuberculosis.
 Most common causative organism staphylococcus aureus.
 Antistaphylococcal titer and/or examination of biopsy
material useful in final diagnosis

84. 2)Typhoid spine:-
It is a rare complication of enteric fever , most cases
present at time intervals of 4 weeks to a few months
after the disappearance of clinical features of typhoid
fever.
Clinically the condition is manifested by an
excruciating pain and muscle spasm.
Radiological picture resembles that of tuberculosis
and allow pyogenic spondylitis.
 Confirmation can be obtained by agglutinations test
therapeutic trail or by biopsy.

85. 3)Brucella spondylitis:-
 This can produce changes which can be very similar to those
seen in tuberculosis of the spine.
 History of undulent fever ( rising and falling type) may be
suggestive of diagnosis.
 however diagnosis is best established by identification of the
causative organisms, agglutination tests or by the biopsy.
 Brucella infections of the spine , skeletal system and synovial
sheath is essentially encountered in endemic areas and in
communities consuming unboiled/unpasturized milk.

86. 4)Mycotic spondylitis:-
 The most frequent infecting fungi are of actinomyces group
or blastomycosis group.
 In blastomycosis , paravertebral abscess formation is a
common feature.
 In actinomyces, sclerosis and destruction of bone proceed
hand in hand.
 The anterior and lateral surfaces of the several vertebral
bodies may be involved and show an irregular saw-tooth
apperance by periosteal new bone formation .collapse of
the vertebra is rare, sometimes the involved vertebrae
appears as honeycomb or lattice like and accompanied by
multiple sinus formation and involvents of subcutaneous
tissue.
 Confirmation of diagnosis from discharging sinuses, pus or
from diseased bone.

87.  5)Syphilitic infection of the spine:-
Three main types of syphilitic infection of the spine
 1.artharlgic type
 2.gummatous type and
 3. charcot’s disease of spine.
 Most common site of involvement is thoracolumbar and
lumbar spine.
 X ray shows a gross disorganization and destruction of the
involved vertebrae along with proliferative new bone
formation extending into adjacent paraspinal tissues .
 When neuroarthropatic changes are present, varying
degrees of subluxation of the vertebrae is eveident.
 Diagnosis is confirmed by serological tests, tissue biopsy or
by response to antisyphilitic treatment.

88. Tumorous conditions:-
1)HEMANGIOMA:- Most common benign tumors of the
vertebral column.
 Most common area being from D12 to L4 .
 Diagnosed by pin head appearance on axial sections in CT
and MRI scan.
 Involved vertebra – shows coarsening of vertebral
trabaculations more prominent in vertical than in
horizontal trabaculae (corduroy appearance).

89. 2)GIANT CELL TUMOR & ANEURYSMAL BONE
CYST of spine produce typical osteolytic expansile &
usually eccentric growth. This is confused with
expansil type of central tuberculous lesion in vertebral
body.
 Disc space is not involved in early stage.
 Investigation: repeated X-ray at 6-12wks
intervals,MRI &CT-scan.
 Final confirmation of diagnosis is only by
HISTOLOGY.

90.  3)PRIMARY MALIGNANT TUMOR:-
 Very rare but ewings sarcoma and osteogenic sarcoma occasionally
occur.
 Vertebral tumors had rapid course of the disease with progressive
paraplegia and radiological evidence of destruction of bony
trabaculae,soft tissue paravertebral shadowusually on one side and
mild diminution of disc space in late stages

91.  Diagnosis was confirmed only on biopsy from the vertebral
bodies.
 Osteosarcomas, fibrosarcomas and chondrosarcomas are
very rare and confirmed only by histological examination .
 Chordoma is thought to arise from the remnants of
notochord, most common sites are cephalic and caudal
ends of spinal column
 Xray appearance is predominantly alytic and destructive
lesion .

92. 4)Multiple myeloma:-
 This condition may rarely resemble tuberculosis clinically
and radiologically,especially if there is involvement of only
one or two vertebrae and there is collapse and eccentric
destruction.
 Involvement of multiple bones, high sedimentation rate,
anemia , reversal of albumin globulin ratio and myeloma cells
detected on bone marrow.
 Diagnosis may confirm by presence of myeloma cells in
biopsy.

93. 5)Lymphomas:-
 Hodgkin’s disease and leukemias may rarely involve the vertebral
column.
 Hodgkin disease may show deposits in the vertebra as diffuse
sclerosis of the bone with disruption of trabeculae pattern and
paravertebral soft tissue shadows
 Leukemias may occasionally present as vague pain in the back
associated with collapse of several vertebral bodies and
generalized osteoporosis.
 Enlargement of spleenn liver and lymph nodes with characteristic
blood changes help to arrive at correct diagnosis.

94. Traumatic conditions:
Careful history,clinical examnination and x-rays are almost
always able to diagnose a recent case of fracture or fracture
dislocation of the spine.
Radiological features of healed fracture :
Traumatic compression fracture is wedge-shaped with
intact disc spaces and there may be marginal spurring and
spondylolitic changes .
When fracture is associated with damage of intervertebral
disc ,in long- standing cases complete and incomplete
osseous bridging is seen on both sides of the disc space in
AP and lat view .
Disc may show patchy calcification.
In case of old trauma , there is no paravertebral shadow.

95. Complications of spinal
tuberculosis:-
 Paraplegia
 Cold abscess
 Spinal deformity
 Sinuses
 Secondary infection

96. TUBERCULOSIS OF SPINE WITH
PARAPLEGIA:-
 Neurological complication is
the most dreaded and crippling
complication of spinal
tuberculosis.
 Overall incidence is 10-30%.
 Common during first 3 decades
of life.
 Highest incidence of paraplegia
is associated with tuberculosis
disease of the lower thoracic
region.

97. Classification of TB Paraplegia
Griffiths, Seddon and Roaf 1956 (Pre anti-tubercular era)
Early onset paraplegia
(group A)
Late onset paraplegia
(Group B)
 Appears within 2 years of
onset – during the Active
phase
 Underlying pathology
 Inflammatory edema
 TB Granulation tissue
 Abscess
 Caseous tissue
 Ischaemic lesion of cord
(Rare)
 Good prognosis
 Appears more than 2 years of
disease in vertebral column
 Underlying pathology –due to
mechanical pressure on cord
 TB Debris
 TB Sequestra from body and
disc
 Localized Internal gibbus
 Canal stenosis / Severe
kyphotic deformity
 Poor prognosis

98. Kumars classification of tuberculosis
para/tetraplegia (predominantly
based on motor weakness):-

99.  STAGE - 1:-
patient walks normally, not aware of any
motor weakness. Phycisian on clinical examination
finds ankle clonus and extensor plantar response with
or without brisk tendon reflexes.
STAGE – 2 :-
patient presents with c/o clumsiness or
spasticity or jumpiness of limbs while walking. Pt
is able to walk with or with out support. c/e reveils
signs of spastic paresis.

100.  STAGE – 3 :-
bedridden, cannot walk coz of severe
weakness. Reveals spastic paraplegia in extension.
Sensory deficit if present is generally less than 50%.
STAGE – 4 :-
pt has paraplegia with flexor spasms.
A case of paraplegia in extension who develop
complications like spontaneous flexor spasms , >50%
of sensory deficit and/or sphincter disturbances also
included. Flaccid paralysis due to very severe cord
compression or flacid paralysis due to sudden
compression also included.

101. Pathology of tuberculous
paraplegia:-
The essential pathology of paraplegia associated with
tuberculosis of vertebra in majority of cases is
pressure on the tissues of the cord as follows:
1)Inflamatory edema:-
Edema of the spinal cord due to
vascular stasis and due to toxins from the
tuberculous inflammation ,recovers by rest and drug
therapy.

102. KYPHOTIC DEFORMITY
WITH CORD COMPRESSION

103. 2)Extradural mass :-
The commonest mechanism by which
the spinal cord function is affected is a state of tuberculous
osteitis of the vertebral bodies with an abscess in the extra
dural space causing compression of the cord from anterior
aspect.
3)Bony disorders :-
1)Sequestra from avascular portions of the diseased
vertebral bodies or intervertebral disc may be responsible
for narrowing of spinal canal and pressure on the cord.
2) Angulation of the diseased spine may lead to the
formation of a bony ridge or spur called internal Gibbus.
3)Rarely, a Pathological Dislocation may damage the neural
structures.

105. 4) Meningeal changes:
Dura is not involved
Cicatrisation of extradural TB granulation
tissue (Peridural fibrosis)
Poor recovery despite adequate surgical
decompression
5)Infarction of spinal cord:
This is unusual but important
cause of paralysis. Infarction is caused by endarteritis ,
periarteritis or thrombosis of an anterior spinal artery or
other spinal arteries caused by inflammatory reaction.
Irrepairable.
 Ischaemic necrosis seen as an area of High intensity in T2
MRI.
 Can also happen postoperatively.

106. PERIDURAL FIBROSIS:-

107. 5)Changes in spinal cord : -
Unrelieved compression of the
spinal cord shows loss of neurons and white matter in the
damaged segment.
 The lost cells and fibers are replaced by gliosis and the
neural fibers show a gross loss of myelin
 Mri shows myelomalacic and syringomyelic changes
6)Extradural granuloma and tuberculoma :-
very rarely a small tuberculoma of
the spinal cord or diffuse extradural granuloma of the cord
may be responsible for neurological complications with out
any radiological evidence such cases present as spinal
tumor syndrome.

109. Clinical features of Pott’s
Paraplegia:-
 Paraplegia itself – Rare
 Spontaneous muscle twitching in lower limbs
 Clumsiness while walking
 Extensor plantar response
 Exaggerrated reflexes – Sustained clonus of patella
and ankle
 Motor affected first – then Sensory
 Sense of position and vibration – last to disappear

110. Prognosis of recovery of cord
functions:-
Cord involvement Better prognosis Poor prognosis
Degree Partial (Stage I & II) Complete (Stage IV)
Duration Shorter Longer(>12 months)
Type Early onset Late onset
Speed of onset Slow Rapid
Age Younger Older
General condition Good Poor
Vertebral disease Active Healed
Kyphotic deformity <60 degree >60 degree
Cord on MRI Normal Myelomalacia

111. Treatment of pott’s paraplegia:-
 Treatment of tuberculous paraplegia is still
controversial.
 Paraplegia of early onset associated with
inflammatory causes is likely to recover in most of the
cases, by anti tubercular drugs alone.
 Paraplegia of late onset due to mechanical causes
requires surgical decompression of the cord in
majority

113. TREATMENT:-
 Conservative plan
 Middle path regime
 Radical surgery approach
 Supportive treatment like
1) rest
2) braces
3) high protein diet
4) multivitamins and hematinics
5) hygiene
6) back care
7) chest? Urinary tract care
8) improve immune status
9) treat other co morbid conditions.

114. ANTI-TUBERCULAR DRUGS:-

116. 1st line chemotherapy drugs:-
Bactericidal drugs Dose
Isoniazid 5 mg/kg (300-400mg in single/two
divided doses)
Rifampicin 10-15 mg/kg (450-600mg in
single/two divided doses)
Streptomycin 20 mg/kg ( max 1gm)
Pyrazinamide 40 mg/kg in single/two divided doses
Bacteriostatic drugs Dose
Ethambutol 15-25 mg/kg in single/two divided
doses

117. CATEGORY TYPE OF PATIENT INTENSIVE
PHASE
CONTINOUS
PHASE
DURATION
CAT 1 New sputum smear-
positive,
New sputum smear-
negative but
seriously ill,
New
extrapulmonary
tuberculosis,
2(HRZE)3 4(HR)3 6 MONTHS
CAT 2 Sputum smear-
positive relapse,
Sputum smear-
positive failure,
Sputum smear-
positive treatment
after default,
2(HRZES)3+1
(HRZE)3
5(HRE)3 8 MONTHS
CATEGORIZATION AND TREATMENT REGIMES IN
RNTCP NEW GUIDELINES 2015-2016

118. CATEGORY TYRPE OF
PATIENT
INTENSIVE
PHASE
CONTINOUS
PHASE
DURATION
CAT 4* MDR TB 4(KLCZEEt) 12-8(LCEEt) 18-24 MONTHS
CAT 5 XDR TB 6-12 (HhCm
CzLAMP)
18
(HhCzLAMP)
24-30 MONTHS
 H: Isoniazid (300 mg) R: Rifampicin (450 mg),
Z: Pyrazinamide(1500 mg) E: Ethambutol (1200 mg),
S: Streptomycin (750 mg)
 K: Kanamycin , L :Levofloxacin , Et : Ethionamide,
 C : cycloserine , Hh: high dose isoniazid,
 Cm: capriomycin, Cz: clofazimine, L : Linezolid,
 A: Amoxy clav, M : Moxifloxacin , P : PAS (p- amino
salicylic acid)
CAT 4* DOTS PLUS ; CAT3 HAS BEEN MERGED IN CAT 1

119. Newer drugs
 Amikacin, Kanamycin, Capriomycin
 Ethionamide
 Cycloserine
 ciprofloxacin, Ofloxacin, Levofloxacin
 Rifabutin
 Clarithromycin
 Clofazimine

120. MIDDLE PATH REGIME:-
 Rest in hard bed or plaster of paris bed
 Drugs (chemo- therapy)
 Radiographs and ESR are taken 3 to 6 months interval
MRI or CT scan may be advisable at 6 to 12 months
interval for about 2 years
 Gradual mobilization of patient is encouraged in
absence of neural deficit with spinal braces after 3-9
weeks of starting treatment and back extension
exercises 5 to 10 mins, 3 to 4 times a day continued for 18
months to 2 years
 Abscesses are aspirated when near the surface, and 1gm
steptomycin with or without INH in solution is instilled
at each aspiration

121. CHEMOTHERAPY
INH 300-400MG; Rifampicin 450-600mg; ofloxaxin400-600mg; pyrazinamide 1500mg
;ethambutol 1200mg

122.  Sinuses heals with in 6 to 12 weeks .
 Neural complications if showing progressive
recovery on triple drug therapy between 3 to 4 weeks
surgery is unnecessary.if not decompression of the
cord is performed .
 Excisional surgery is recommended for posterior
spinal disease associated with abscess or sinus
formation (with or with out neural involvement).
 Operative debridement is advised for cases who
do not show arrest of the activity of spinal lesions
after 3 to 6 months of ATT

123. Sinus and abscess

126. Psoas abscess:-

127. BILATERAL PSOAS ABSCESS

128.  Posterior spinal arthodesis is recommended for
symptomatic unstable spinal lesions.
 Post operative pts with neural complications 3 to 5
months after sx made good recovery pt is mobilized out
of bed with spinal braces, the spinal brace is gradually
discarded about 12 to 24 months after the operation.

130. SURGERY INDICATIONS
Decompression (+/-
Fusion)
Advance disease, failure to respond
to 3-6 weeks conservative therapy
Debridement +/-
decompression +/-
fusion
Recurrence of disease or of neural
complication
Anterior transposition
of cord ( extrapleural
anterolateral
approach)
Severe Kyphosis (>60 deg) + neural
deficits.
laminectomy Extradural granuloma /
tuberculoma/ Old healed disease
presenting as secondary canal
stenosis / posterior spinal disease.

131. ABSOLUTE INDICATIONS FOR
OPERATIVE DECOMPRESSION
 Neurological complications which do not start
showing signs of progressive recovery to a satisfactory
level after a fair trail of conservative therapy 3-4
weeks.
 Patients with spinal caries in whom neurological
complications develop during the conservative
treatment.
 Patients with neurological complications which
become worse while they are undergoing therapy with
antituberculous drugs and bed rest .

132.  Patients who have a recurrence of neurological
complications .
 Patients with prevertebral cervical abscesses
neurological signs and difficulty in deglutination and
respiration .
 Advanced cases of neurological involvements such as
marked sensory and sphincter disturbances,flaccid
paralysis or severe flexor spasms .

134. Tuli’s recommended approach
 Cervical spine –T1
Anterior approach
 Dorsal spine –DL junction
Anterolateral approach
 Lumbar spine &Lumbosacral junction
Extraperitoneal Transverse Vertebrotomy

135. Atlanto - axial region (C1-C2)– transoral approach and
transthyrohyoid approach developed by fang and ong.
Retropharyngeal extramucosal approach by mc afee
Cervical spine – Anterior approach
(smith-Robinson’s)
Cervico-dorsal region:
Transpleural thoracotomy,
extrapleural anterolateral approach by kirkaldy-willis
and thomas .
APPROACHES

136. Dorsal spine (D1 to L1) –
1) Transpleural anterior approach by
hodgson and stock.
2) Anterolateral extrapleural by
griffiths,seddon and roaf.
Thoracolumbar region: Extra-pleural anterolateral by
kirkaldy-willis.
Lumbar spine – Retroperitoneal approach by arct and
hodgson.
Lumbo-sacral region (L5-S1): Hypogastric paramedian
transperitoneal approach by kirkaldy-willis,
paus,arct, hodgson and pun et al.

137. ANTERIOR APPROACH TO THE CERVICAL
SPINE (C2-D1)
 Cervical spine is best approached by anterior
approach.
 If several cervical vertebral bodies are to be exposed
Oblique incision following anterior/medial border of
the sternocleidomastoid muscle
 If only one or 2 vertebral bodies are to be exposed a
short transverse incision at the appropriate level
should be used
 Pt kept in supine with a low sand bag in between
scapulae.
 It is preferable to work from the left side because less
chance of injury to the recurrent laryngeal nerve.

139.  A transverse skin incision is made at the level of the
vertebra to be operated beginning the incision at
midline and extending it laterally for about 7-10 cm
well over the belly of sternocleidomstoid .
 Skin and platysma are cut transversely in the same line
 Blunt dissection between the sternocleidomastoid and
carotid sheath laterally and esophagus and trachea
medially
 Ant surface of the vertebral bodies are now visualized
the are to be operated must be confirmed by lat x ray
 A longitudinal incision may open a perivertebral
abscess or the diseased vertebra by reflecting ALL and
longus colli muscle

144. TRANSTHORACIC TRANSPLEURAL(D1-L1)
 Left sided
incision preferable
 Incision made along the rib which in the mid-axillary line, lies
opposite the centre of the lesion (i.e. usually 2 ribs higher than
the centre of the vertebral lesion).
 For severe kyphosis, a rib along the incision line should be
removed.
 J-shaped parascapular incision for C7 – D8 lesions, scapula
uplift & rib resection.
 After cutting the muscles & periosteum, rib is resected
subperiosteally.

145. TRANSTHORACIC TRANSPLEURAL
CONT…
 Parietal pleural incision applied & lung freed from
the parieties & retracted anteriorly.
 A plane developed b/w the descending aorta & the
paravertebral abscess / diseased vertebral bodies by ligating
the intercostal vessels & branches of hemiazygos veins.
 T-shaped incision over the paravertebral abscess.
 Debridement / decompression with or without bone grafting.

147. ANTERIOR RETROPERITONEAL APPROACH
(L1-L5)
 Patient placed in the 45 degrees right lateral position with a
bridge centered over the area to be operated.
 Incision resembles that of nephroureterectomy or that of
sympathectomy.
 extending from renal angle posteriorly to the lower part of
lateral margin of the rectus abdominis anteriorly .
 Layers of abdominal muscles are split or incised in the line of
the skin incision.

148.  Parietal peritoneum is gently stripped off the posterior
abdominal wall and the kidney ,ureter is protected by
reflecting anteriorly along the parietal peritoneum.
 If psoas abscess is present it is drained and diseased
bodies are exposed.
 If no psoas abscess is present psoas muscle is stripped
from its origin from the vertebral bodies and retracted
laterally
 The aorta and inferior vena cava are gently displaced to
the right side after double ligation of the respective
lumbar arteries and veins.
 The sympathetic chain maybe retracted laterally
diseased bodies are exposed and dealt with.

149. ANTERIOR RETROPERIOTONEAL APPROACH (L1-L5)

150. Anterior debridement, fusion and
posterior instrumentation

151. Anterior debridement fusion with posterior
instrumentation

154. Spinal braces:-
 Spinal braces are mostly used for ambulation of cases
of spinal tuberculosis.
 Commonly used spinal braces for lesions from fourth
dorsal to second lumbar vertebra are jewett brace, ASH
(anterior spinal hyperextension) brace , taylor brace.
Jewett brace ASH brace Taylor brace

155.  MILWAUKEE BRACE OR JEWETT BRACE:-
Recommended for tuberculous
lesions in dorsal spine throughout the growing age,
especially if the number vertebra involved is more than
2 or there is panvertebral disease or radiologically
there is wedging in anterio-posterior as well as lateral
views or after performance of pan vertebral operation.

157.  ANTERIOR SPINAL HYPER EXTENSION BRACE:-
(ASH BRACE)
Found to be more acceptable by
young girls and ladies as it gets accomadated in
contours of the body and clothing. The rapid metal
upright extends anteriorly from symphisis pubis to
manubrium sterni, a band pasing around trunk holds
the up right in front and a pad over vertebral column.
ASH brace has replaced taylors brace for adults.

159.  For lesions from third lumbar to lumbo sacral region
goldthwait brace or lumbar corset is used.
 Cervico dorsal junction is very difficult area for
satisfactory bracing. A tylor brace extended to four-
post collar,or a SOMI (sternal-occipital-mandibular-
immmobilizer) brace cauded with extensions.
Lumbosacral orthosis SOMI

162. REFERENCES:-
TUBERCULOSIS OF THE
SKELETAL SYSTEM .
--- SM TULI .(5TH EDITION)

163. THANK YOU.