Potts spine new

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TUBERCULOSIS OF SPINE

DR.B.PRAVEEN KUMAR PG FINAL YR M.S (ortho) GANDHI HOSPITAL TELANGANA

17/06/2015

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Outline

1. Introduction 2. Clinical features3. Pathology , pathogenesis &

pathophysiology4. Diagnosis 5. Management

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Introduction One fifth of TB population … in

India. Spinal tubercular account for 30-

60% of the Musculoskeletal TB infections

Always secondary Most common : 1st three decades SEX : M=F Most affected : Thoraco-lumbar

region

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REGIONAL DISTRIBUTION

CERVICAL 12% CERVICODORSAL 5% DORSAL 42%

(THORACIC) LUMBAR 26% DORSOLUMBAR 12% LUMBOSACRAL 3%

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Clinical features of spinal TB

Clinical kyphosis 95% Palpable cold abscess 20% Radiological paraverebral abscess 21% Neurological involvement 20% Tubercular sinuses (active/healed)

13% Associated extra spinal skeletal foci 12% Associated visceral foci 12% Skipped lesion in spine 7% Lateral shift(radiological ) 5%

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A.Active stage1.Pain: Back pain (Commonest), Diffuse in early stages, but later become localised to the affected diseased segments.It may be a radicular pain. Depending upon the nerve root affected, it may present as: 1.Cervical root- Arm pain 2.Dorsal root- Girdle( pectoral ) pain 3.Dorso-lumbar root- Abdomen pain4.Lumbar root- Groin pain , or 5.Lumbo-Sacral root- Sciatic pain

CLINICAL FEATURES

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2.Spine Stiffness: spasm of para-vertebral muscle

3.Night cries4.Deformity: Knuckle /Gibbus/Kyphus.5.Cold abscess: May be present6.Paraplegia (if neglected in early stages)

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7.Constitutional Symptoms (Only in 20% cases): Malaise, weight loss, loss of appetite, night sweats, evening rise of temperature.

B. Healed stageNo systemic features but deformity persists.Radiological evidence of bone healing

But several of these signs and symptoms may be absent.

Important: c/f presentation depends on

1.Stage

2 Site

3.Presence of complications :neurologic

deficits, abscesses, or sinus tracts

DEFORMITIES : KYPHOSIS

Knuckle 1 or 2

vertebra

Gibbus 2 or 3

vertebra

Angular kyphosis

More than 3

vertebra

PATHOLOGY

Hameatogenous spread

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Infectious exudate may spread anteriorly beneath Anterior longitudinal ligament

&neighbouring vertebrae

Advances&destroys the cortex,intervertebral disc&adjacent vertebrae

Infection begins in cancellous area of vertebral body(Central/anterior/epiphyseal in

location)

Route of infection :1.hematogenous (Batesons plexus)2.Lymph node spread 3.Direct spread

Focus of infection : possible from any sites M/C pulmonary ,abdomen

Granuloma formationTissue necrosis & inflammatory response

Paraspinal Abscess

Localized Track along tissue planes

Progressive necrosis of vertebral body-Kyphotic deformityAdjacent vertebral

bodies under the longitudinal ligaments

Along the fascial planes Ex: Psoas abscess

PARAVERTEBRAL ABSCESS

PARAVERTEBRAL ABSCESS

Cervical region• Between vertebral bodies, pharynx

and trachea

Upper thoracic• ‘V’ shaped shadow, stripping lung

apices laterally and downwards

Below T4 – Fusiform shape (Bird’s nest)• Below Diaphragm – unilateral &

blilateral psoas shadow.

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COLD ABSCESS :CERVICAL SPINE

ANTERIORLY : 1.Retropharyngeal abscess,

2.paravertebral abscess ON SIDE : 1.post.Border of SCM 2. POST of neck ALONG MUSCULOFASCIAL PLANE :

1.Axilla 2.Arm

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COLD ABSCESS :THORACIC SPINE ANTERIORLY 1.mediastinal abscess 2. paravertebral abscess ON SIDE : 1.psoas abscess 2. lumbar abscess ALONG MUSCULO-FASCIAL PLANE: 1.Ant. Chest wall 2.Mid-axillary line 3.posterior chest wall

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COLD ABSCESS :LUMBAR SPINE ANTERIORLY :prevertebral abscess : paravertebaral abscess ON THE SIDE : lumbar abscess : psoas abscess

ALONG MUSCULOFASCIAL PLANE : groin ,leg along sciatic nerve to pelvis, gluteal

region, posterior aspect of thigh and popliteal Region(KNEE)

Pathophysiology

Potts disease is usually secondary The basic lesion is a combination of

osteomyelitis and arthritis. The area usually affected is the anterior

aspect of the vertebral body Tuberculosis spread from that area to

adjacent intervertebral disks. disk is secondary to the spread of

infection from the vertebral body.

Progressive bone destruction leads to vertebral collapse, kyphosis & neurological involvement

Kyphotic deformity occurs in collapse of anterior spine.

Kyphotic def:; DORSAL SPINE THAN LUMBAR

The collapse is minimal in cervical spine because most of the body weight is borne through the articular processes.

Healing takes place by gradual fibrosis and calcification of the granulmatous tuberculous tissue:::FIROUS ANKYLOSIS

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paravertebral abscess Accumulate beneath the Anterior

longitudinal ligament. Gravitate along the fascial planes Present externally at some

distance from the site of the original lesion.

Thoracic ….fusiform shadow(longituninal lig limits)

Lumbar…..psaos abscess along sheath

LOCATION OF VERTEBRAL LESIONS

Paradiscal M/C Anterior Central

Appendeceal

PARADISCAL LESIONS

Most common• Adjacent to the I/V disc

leading to narrowing disc space

Disk space narrowing • Destruction of subchondral

bone with herniation of disc into the body.

• Direct involvement of the disc.

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Adjacent to the I/V Disc leading to a narrowing of the disc space

PARADISCAL

DISTRUCTION OF VERTIBRAL BODIES ,NARROWING OF IVD SPACE AND kyphotic DEFORMITY

ANTERIOR LESIONS• Subperiosteal lesion under

ALL• Pus spreads –by stripping

ALL, periosteum from anterior surface of vertebral body• Vertebral body collapse due to pressure and ischemia, followed by disc space narrowing.

• Relatively common in Thoracic spine

CENTRAL LESIONS

Center of vertebral body• Reaches through Batson’s

venous plexus or through posterior vertebral artery

Vertebra plane• Vertebral body collapse•

APPENDICULAR LESIONS

Uncommon lesion <5%• Isolated infection of pedicles, lamina

(neural arch0, transverse processes

Occurs in isolation or conjunction with paradiscal lesions

Radiographically appears as erosive lesions, paravertebral shadows with intact disc space.

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Management plan

DIAGNOSIS CLINICO RADIOLOGICAL & LAB STUDIES Microbiological studies Histopathological study CT SCAN MRI SCAN USG RADIONUCLIDE SCAN MYELOGRAPHY

DIAGNOSISComplete blood picture• ESR Increased / Increased Lymphocyte

countELISA• For antibody to mycobacterial antigen • Sensitivity 60-80%

PCR • Sensitivity of 40%

Chest radiograph

Mantoux / tuberculin skin test

Microbiology ZEIHL-NEELSEN STAINING/ACID FAST STAINING

Cultures :4-6 weeks(L-J MEDIUM)

Positive only in 50% cases

IFN – Release assays (IGRA’s)Assays that measure T-cell release of IFN – in response to stimulation with highly specific tuberculosis antigens ESAT6 & CFP 10

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Histopathological workup(Pre/PostOP)

PLAIN RADIOGRAPH

> 50% of bone destruction

Classic Radiological triad

Primary Vertebral

lesion

Disc space narrowing

Paravertebral

abscessTypical tubercular

spondylitic features in long

standing paraspinal abscesses

Aneurysmal phenomenon

Fusiform paraspinal soft tissue

shadow

Skip lesions 7-10%

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Plain radiograph

1. Disc space narrowing (COMMONEST & EARLIEST )

2. Erosion of end plate

3. Signs of infection with lucency in ANT. Portion of vertebra

4. Deformities (knuckle, gibbus ,kyphus Anterior wedging,Vertebra plana

5. Sclerosis resulting from chronic infection

6. Compression fracture (Concertinal collapse = single collapsed vertebra)

7. soft tissue swelling from paraspinal abscess +/- calcification

8. Bowing of rib cage with multiple vertebral fracture

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IMAGE 1

IMAGE 2

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End plate erosion,disc

space narrowing&compression

fracture

Vertebal end plate

sclerosis&compession fracture

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Compressive fracture with IVD narrowing

Compressive fracture

with osteosclero

sis

Kumar’s clinico-radiological Classification

stage features Usual duration

I Pre-destructive

Straightening, spasm, hyperemia

<3 mo

II Early-destructive

Diminished space paradiscal erosion Knuckle <10

2-4 mo

III Mild kyphos 2-3 verte k:10-30 3-9 mo

IV Moderate kyphos

>3 verte K:30-60 6-24 mo

V Severe kyphos

>3 verte K:>60 >2 years

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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.

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Prevertebral Shadows

RETROPHARYNGEAL ABSCESS

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

Paravertebral Shadows

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CT- SCAN OF SPINE

USE FULL FOR Patterns of bony destruction. Calcifications in abscess (pathognomic for TB) 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.

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MAGNECTIC RESONANCE IMAGING

highly sensitive &specicific for spinal TB Spinal cord & soft tissue involvement Detect marrow infiltration in vertebral

bodies(EDEMA), leading to early diagnosis Skip lesions Changes of diskitis (EDEMA) Assessment of extradural abscesses /

subligamentous spread Poor for calcification

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Infection and distruction of total body

Compression of spinal cord causes

cauda equina

Total vertebral body distruction

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

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USG - to find out primary in abdomen - Detect cold abscess - Guided aspiration

Myelography Spinal tumor syndrome Multiple vertebral lesions Patients not recovered after decompression 1.Block present : second decompression 2.Block not present : intrinsic damage

1.Ischemic infarction 2.Interstitial gliosis

3.atrophy 4. tuberculous myelitis 5.Myelomalacia

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DIFFERENTIAL DIAGNOSIS

Back pain 1. Traumatic 2. Secondaries to spine /myeloma/lymphoma 3. Prolapsed disc 4. Ankylosing spondylitisNeurological deficit 5. Spinal tumor 6. Traumatic 7. Secondaries to spine Radiologically SPINAL INFECTIONS : pyogenic, BRUCELLA SPONDYLITIS

NEUROPATHIC SPINE : Diabetes NEOPLASTIC : commonly lymphoma/

metastasis/primary DEGENERATIVE

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TB spine pyogenic

• Long standing history of months to yrs

• active PTB may be seen

• Most common location thoracic spine

• > 3 contiguous vertebral body inv

• Vertebral collapse very common

• Bone destruction : more

• Skip lesions common

• Pra vertebral abscesses-Commoncalcification if present is pathognomic.

• History of days to months.

• Not present.

• Most common location lumbar spine.

• Mostly involves 1 spinalsegment – 2vertebrae & interveningdisc.• less common

• very less

• Rare

• Rare

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TB SPINE VS MALIGNANCY

A destructive bone lesionassociated with a poorly definedvertebral body endplate &with loss of disc space

which has abetter prognosis

A destructive bonelesion associated with a well preserveddisk space & sharp endplates

“Good disk, bad news; bad disk, good news"

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Complication of spinal tuberculosis

Paraplegia Cold abscess Spinal deformity Sinuses Secondary infection Amyloid disease Fatality

TUBERCULOUS SPINE WITH PARAPLEGIA

Incidence 10-30%

Dorsal spine most common

Motor functions affected > sensory

Sense of position & vibration last to disappear

STAGES OF PARAPLEGIA

Paraplegia in extension

Paraplegia in flexion

Paraplegia in flaccidity

Depends on the severity of involvement of long tracts

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KUMAR’S CLASSIFICATION OF TUBERCULOUSPARA/TETRAPLEGIA (Predominantly based on motorweakness)

MOTOR

SEVERE MOTOR

SENSORY

SEV. SENSORY +AUTONOMIC

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SEDDON’S CLASSIFICATION OFTUBERCULOUS PARAPLEGIA

10-09-2014

GROUP A (EARLY ONSET PARAPLEGIA) a/k/a Paraplegia associated with activedisease :

Active phase of the disease within first 2 years of onset.

Pathology - inflammatory edema, granulation tissue, abscess, caseous material or ischemia of cord.

GROUP B (LATE ONSET PARAPLEGIA) a/k/a Paraplegia associated with healed disease :

After 2 years of onset of disease.

Recrudescence of the disease or due to mechanical pressure on the cord.

Pathology can be sequestra, debris, internal gibbus or stenosis of the canal

BASIC PRINCIPLES OFMANAGEMENT

• Early diagnosis

• Expeditious medical treatment

• Aggressive surgical approach

• Prevent deformity

• Best outcome “The captain of the men of death”

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Three approach

CONSERVATIVE PLAN MIDDLE PATH REGIME RADICAL SURGERY APPROACH

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MIDDLE PATH REGIME

Rest on hard bed Chemotherapy X-ray & ESR once in 3 months kyphosis

measurement MRI/ CT at 6 months interval for 2 years

Gradual mobilization is encouraged in absence of neural deficits with spinal braces & back extension exercises at 3 – 9 weeks.

Abscesses – aspirate when near surface & instil 1gm

Streptomycin +/- INH in solution

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CHEMOTHERAPY

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MIDDLE PATH REGIME

Sinus heals 6-12 weeks Neural complications if showing progressive

recovery on ATT b/w 3-4 weeks :surgery unnecessary

IF NOT Excisional surgery for posterior spinal

disease associated with abscess / sinus formation +/- neural involvement.

Operative debridement–if no arrest of symptoms after 3-6 months of ATT / with recurrence of disease

Posterior spinal arthrodesis : symptomatic unstable lesion

Post op spinal brace→12 months-24

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ABSOLUTE INDICATIONS FOR SURGERY:

Paraplegia during conservative treatment (6 weeks)

Paraplegia worsening during treatment (6 weeks)

Complete motor loss for 1 month despite of conservative treatment

Paraplegia with uncontrolled spasticity

Severe and rapid onset paraplegia

Severe flaccid paraplegia/ sensory loss

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Other indications

Relative indications

1. Recurrent paraplegia 2. Paraplegia in

elderly 3. Painful and

spastic paraplegia 4. Paraplegia

with complications (UTI)

Rare indications1. Posterior elementdisease2. Spinal tumorsyndrome3. Severe cervicallesion c paraplegia4. Cauda equinopathy

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10-09-2014

Type of Surgery…

APPROACH

1. Cervical spine – Anterior retropharyngeal(smith-Robinson’s)

Anterior approach – Anterior/Medial border of sternocleidomastoid

2. Dorsal spine (D1 to L1) – 1 Transthoracic transpleural

2 Anterolateral decompression(D2 – L1)

3. Lumbar spine – Anterolateral(Lumbovertebrotomy)

Extraperitoneal Ant. approach

Tuli’s recommended approch Cervical spine –T1 Anterior approch Dorsal spine –DL junction Antrolateral

approch Lumbar spine &Lumboscral junction

Extraperitoneal Transverse Vertebrotomy

Posterior fixation: Fixation of posterior element of diseased vertebra by instrumentation are done:

1.To prevent and correct kyphotic deformity.

2. To maintain stability of the spine

Fig : Pedicel screw fixation

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TB Paraplegia or Quadriplegia

MDT, Bed rest for 6 weeks

Progressive neurological recovery No improvement

Continue MDT, walking allowed

when recovery complete

Surgical decompression

Recovering Not recovering

FLOW CHART FOR THE MANAGEMENT OF PARAPLEGIA :SM TULI 04/15/2023

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Not recovering

MRI / Myelogram (IMMUNOMODULATION THERAPY)

No block Block present

Intrinsic damage to cord has occurred

Repeat surgical decompression

No recovery Recovery Continue MDT,

Rehabilitation

Continue MDT and permit walking when recovery complete

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CLINICAL FACTORS INFLUENCINGPROGNOSIS IN CORD INVOLVEMENT

ANTERIOR APPROACH TO THECERVICAL SPINE (C2 to D1)

Smith & Robinson Oblique / transverse incision. Plane b/w SCM & carotid sheath laterally & T-O

medially. Longitudinal incision in ALL open a perivertebral

abscess, or the diseased vertebrae may be exposed by reflecting the ALL

& the longus colli muscles.

Hodgson approach via posterior triangle by retracting SCM,

Carotid sheath, T & O anteriorly & to the opposite side.

SURGICAL APPROACHES TODORSAL SPINE

Anterior transpleural transthoracic approach Anterolateral extrapleural approach Posterolateral approach

{Dura is exposed by hemilaminectomy first & then

extended laterally to remove the posterior ends of 2 – 4

ribs, corresponding transverse processes & the pedicles}.

TRANSTHORACIC TRANSPLEURAL

Left sided incision preferable Incision made along the rib which in the mid-axillary line,

liesopposite the centre of the lesion (i.e. usually 2 ribs higher

than thecentre 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.

TRANSTHORACIC TRANSPLEURAL….

Parietal pleural incision applied & lung freed fromthe 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.

ANTEROLATERAL DECOMPRESSION

Griffith et al -- prone position Tuli --- Right lateral positionAdvantage:- 1. avoid venous congestion 2 . avoid excessive bleeding 3. permits free respiration 4. Lung & mediastinal contents fall anteriorly Parts to remove : Posterior part of rib (~8cm from the TP) Transverse process (TP) Pedicle Part of the vertebral body

ANTEROLATERAL DECOMPRESSION….

• Semicircular incision • For severe kyphosis, additional 3-4

transverse processes and ribs have to be removed. • Intercostal nerves serve as guide to

the intervertebral foramina & the pedicles.

ANTERO-LATERAL APPROACH TOLUMBAR SPINE ( LUMBOVERTEBROTOMY)

Left side approach Semicircular incision Expose and remove transverse process

subperiosteally. Preserve lumbar nerves

CONT…

45 ⁰ right lateral position with bridge centred over the area to be exposed.

Similar incision as nephroureterectomy or sympathectomy

Strip peritoneum off posterior abdominal wall and kidney, preserving ureter.

Longitudinal incision along psoas fibres for abscess drainage

Retract the sympathetic chain Double ligation of lumbar vessels.

EXTRA PERITONEAL APPROACH TOLUMBO-SACRAL REGION

Left side preferred ( left Common iliac vessels longer & retracted easily).

Lazy “S” incision Strip & reflect the parietal peritoneum

along with ureter & spermatic vessels towards right side.

POSTERIOR SPINALARTHRODESIS

Albee– Tibial graft inserted longitudinally in to the split

spinous processes across the diseased site.

Hibbs– overlapping numerous small osseous flaps from contiguous laminae , spinous processes & articular facets

Indications– 1. Mechanical instability of spine in otherwise

healed disease. 2. To stabilize the craniovertebral region (in

certain cases of T.B.)

SURGERY IN SEVERE KYPHOSIS HIGH RISK PATIENTS: - Patients < 10 years - Dorsal lesions - Involvement of >= 3 vertebrae - Severe deformity in presence of active disease,

especially in children is an absolute indication for decompression , correction and stabilization.

Staged operations- 1. Anteriorly at the site of disease, 2. Osteotomy of the posterior elements at the

deformity & 3. Halopelvic or halofemoral tractions post-

operatively.

TREATMENT OF PARAPLEGIA INSEVERE KHYPHOSIS

Griffiths et al :anterior transposition of cord through

laminectomy Rajasekaran : posterior stabilization f/b Anterior debridement and bone grafting ( titanium cages) in active stage of disease and vice versa for healed disease. Antero-lateral (Preferred approach) .

SURGICAL CORRECTION OF SEVEREKYPHOTIC DEFORMITY

Fundamentals of correction: 1. to perform an osteotomy on

the concave side of the curve and wedge is open ( secured with strong autogenous iliac grafts) .

2. to remove a wedge on the convex side and close this wedge ( Harrington compression rods and hooks)

Radical debridement and arthrodesis(hongkong procedure)

Excision of diseased tissue and anterior arthrodesis is about the same at all levels of spine

Remove debris,pus ,sequsterated bone/disc Partially correct kyphosis by direct pressure

posteriorly on spine After cutting mortise in vertebra at each end

insert strut bone grafts correct length keeping the vertebra sprung apart

IBG are taken Put streptomycin and isoniazide into cavity before

closure

Order of recovery irrespective of mode of rx

Take home message

MRI is the gold standard for diagnosis of potts spine

Maintain high suspicion not to overlook diagnosis

EARLY DAIGNOSIS ATT GOOD OUT COME REST

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