Case presentation on tb spine

CASE PRESENTATION

INTERN DR AMIT POUDEL

PATIENT PARTICULARS• 52yrs/ male, from Yamgha- 8 palpa• Literate • Hindu• Farmer

• Admitted on 2072-02-05 via emergency

c/o• Back-ache for 7 months• Tingling sensation below the umbilicus for 7 months• Weakness of the lower limbs for 15 days• Decreased sensation of the lower limbs for 15 days• Inablity to walk for 1 day

Back- ache• Mostly in the thoraco- lumbar region • Insidious in onset and gradual in progression• Dull aching pain in the beginning which progressed to severe pain

during the later course of the disease.• Initially no radiation of the pain but later occasionally radiated to the

outer aspect of the thigh.

• Mostly associated with movement and exercise• Initially used to occur during the night but later occurred throughout

the day and night.

Tingling sensation• part of body below the umbilicus.• b/l symmetrical• Non progressive• Hands are not involved

Weakness• Muscles below the umbilicus• Initially was mild in intensity and he could carry his normal activity

with support of a cane • Later the weakness progressed so that he was unable to stand on his

own

Decrease in sensation• Decreased sensation in the lower limbs as compared to the upper

limbs• But could perceive all the sensation throughout the period of disease

progression.

No h/o

• Evening rise of temperature• Loss of weight and appetite• Chest pain and sputum production• Local trauma• Mass in the back• Glove and stocking pattern of paraesthesia

Past hx• Took medication for fever from district hospital 2 yrs back. Relieved

after 20 days of medication.• No h/o of DM, HTN, Syphilis, HIV, Blood transfusion• No any surgical intervention in the past.

Family history

• Elder brother was a k/c/o PTB 20 yrs back and died of the same disease.• No other family members with TB known.• No other significant medical history in the family.

Personal history• Ex- smoker• Left smoking 3 yrs ago

• Has not consumed alcohol.• Consumes both veg and non veg diet.

O/E

• GC- fair• PILCCOD – nil• GCS- E4M5V6• Vitals- stable

S/E• CVS- S1S2 present, no murmur• RS- B/l equal air entry Nvbs• P/A- Soft, nontender, no organomegaly

CNS• Well oriented to time place and person• CN- intact• Motor examination

Bulk B/L equalTone normal tone of muscle on both the sides but RT>LT

• Power rt lt.• Iliopsoas (L1L2L3) 4/5 4/5• Adductor longus (L2L3) 5/5 3/5 • Quadriceps femoris (L3L4) 5/5 4/5• Tibialis anterior (L4L5) 4/5 5/5• Extensor digitorum longus (L5) 5/5 4/5• Extensor hallucis longus (L5) 5/5 4/5• Flexor digitorum longus (S1S2) 5/5 4/5

• Co-ordination of the muscle could not be tested.

• Sensory examination• Sensation impaired below the level of T10• Temperature sensation (impairment in rt > lt)• Pain sensation ( B/L similar)• Touch sensation (B/L similar) (both for crude and fine)• Vibration sensation ( B/L similar)

• Reflexes rt lt

• Knee +++ +++• Ankle + +• Planter flexor flexor

• Reflexes in the upper limb was bilaterally symmetrical and normal.

Local examination of the spine

• Look • Normal curvature of spine• No evidence of abscess or mass• No evidence of gibbus

• Feel • No any abnormality felt during the palpation of the spine• Tenderness absent• No mass or abscess

• Movement and measurement of the spine was not done

Investigation• Haematology• Hb-12.5 mg/dl• ESR-16 MM/1ST HOUR• WBC COUNT- 10,100 cells/cumm

• Neutrophils-70%• Lymphocytes- 25%• Eosinophils- 02%• Monocytes -03%

• Urine (RME) - WNL• Blood urea – 22.0 mg/dl• Serum creatinine – 1.0 mg/dl• Na – 133.0 meq/l• K – 4.8 meq/l• RBS – 78 mg/dl

• X ray thoraco lumbar spine

• Shows evidence of decreased joint space between T5-T6 vertebra• Destruction of lower margin of T5 vertebra• Destruction of upper margin of T6 vertebra

• MRI of spine• Wedging and inhomogenous signal intensity is seen in T5, T6 vertebra and

T5T6 intervertebral disc with epidural soft tissue component causing thecal compression and spinal cord narrowing. Cord is compressed and shows T2 hypersensitivity s/o cord oedema. Large prevertebral and paraspinal soft tissue component is also seen. The prevertebral soft tissue is extending from T4-T7 level .• Radiological features are suggestive of infective etiology ( pott’s ).

• Sputum examination - Negative

diagnosis• TB spine with neurological involvement (Grade II)

Treatment• Treatment as per the national tuberculosis programme guidelines• ATT (4 tab of HRZE) PO X OD

• Cap methylcobalamin 1 cap PO X OD• Cap multivitamin 1 cap PO X OD• Complete bed rest• Normal diet

National Tuberculosis Programme Guidelines• Based on case definition, a TB patient falls into 1 of 2 categoriesfor treatment.TB TREATMENT CATEGORY PATIENT• Category 1 new sputum smear-positive PTB,sputum negative PTB and

extra pulmonary TB.• Category 2 relapse treatment failure treatment after default.

• SEVERE EXTRAPULMONARY TB• meningitis• miliary• pericarditis• Peritonitis• bilateral or extensive pleural effusion• spinal• intestinal• genitor-urinary

• Nepal NTP use daily regimen, if recommended for 7 month continuation phase in patient with • TB Meningitis,• Miliary TB and • Spinal TB with neurological complication

Fixed dose combination• 1.Isoniazide [75 mg] + Rifampicin [150 mg] + Pyrazinamide [400mg] +Ethambutol [275mg] (HRZE)• 2. Isoniazide (150mg) +Rifampicin [150mg] (HR)• 3. Isoniazide [75 mg] + Rifampicin [150 mg] + Ethambutol [275mg]

(HRE)

• So in a 60 kg patient the required dose of ATT is 4 tablets of the first fixed dose regimen.

Future plans• Discharge the patient with thoracolumbar belt advising for very

limited movement.• Regular follow up for re- evaluation.• Surgery if indicated.

Indications of surgery• Absolute indications:1. Paraplegia developing when the patient is on adequate medical line of treatmen2. Paraplegia not showing improvement with adequate medical line of treatment.3. Paraplegia progressing even with adequate medical line of treatment.4. Complete paraplegia with no improvement with adequate medical line of treatment.5. Severe spastic paraplegia.6. Paraplegia of rapid onset.7. Long standing paraplegia >6 months, paraplegia in flexion, flaccid paraplegia, etc.

• Relative indications:1. Recurrent paraplegia.2. Paraplegia in old age.3. Painful paraplegia.4. Paraplegia with complications such as urinary infection and stones..

Surgical Procedures• Drainage of abscess• Costotransversectomy• Anterolateral decompression• Anterior decompression and fusion• Laminectomy