Tuberculosis Of Spine Flashcards
Anatomical classification of Tb spine
- paradiscal
- central
- anterior
- posterior
Pathology of Tb spine
note: TB joints heal by fibrous ankylosis whereas spine by bony ankylosis
- Granuloma
- Collapse
- Wedging
- Cold abscess( no signs of inflammation) - drain into spinal cord, anteriorly prevertebral and sides paravertebral
- bony ankylosis
C/F of Tb spine
- pain
- stiffness protective mechanism
- cold abscess
- paraplegia
- deformities: knuckle, gibbus, angular and rounded kyphosis
- constitutional symptoms: fever, weight loss, night sweat
Examination of Tb spine
-gait: short steps
-attitude and deformity:
>c spine straight and stiff neck
>thoracic knuckle gibbus and kyphosis
>lumbar loss of lordosis
- paravertebral swelling:fluctuation
- tenderness: side of spinous process
- neurological examination: earliest sign of neurological deficit is increased deep tendon reflexes
- chest: pectus carinatum
Investigations of TB spine
- X ray
-bone:
A) loss of cuvature of spine due to paravertebral spasm
B) decreased joint space
C) destruction or fusion of vertebral body
D) kyphosis: cobb angle in lateral view
E) diffuse rarefaction of vertebrae above and below the lesion
- soft tissue
A) paravertebral abscess: fusiform and globular
B) retropharyngeal abscess
C) aneurysmal sign
2) chest and abdominal xray
3) MRI ✅ hidden lesion and cord involvement
4) biopsy
5) ESR and mantoux test
D/D of TB spine
Pyogenic and fungal infection PIVD ankylosing spondylitis Spinal tumor Trauma
@PAST
T/T of Tb spine
-ambulant chemotherapy: early disease and no abscess =2HRZE +4HR
Minerva jacket and collar
-continuous bed rest and chemotherapy: advanced but no abscess =3HRZE +15HRE with high dose of vit B6
Collar and brace for immobilization for 2 years
-operative: abscess, marked destruction or kyphosis and neurological deficit =ant resection of diseased tissue +anterior spinal fusion with autogenous strut graft of rib
And aspiration,drainage and curettage of abscess
Complications of Tb spine
Cold abscess
Neurological deficit
Paraplegia
Pott spine
Tb spine with neurological involvement
Types of paraplegia in pott spine
1) early onset in the active phase <2 years
- cold abscess
- inflammatory edema
- granuloma
2) late onset in the quiescent phase >2 years
- sequestrum
- reactivation of TB
- internal gibbus
- fibrosis
C/F of pott’s spine
-insidious onset- clonus ankle or patellar most prominent early symptom- paralysis occurs in following phases:
: muscle weakness, spasticity
: paraplegia in extension
: paraplegia in flexion
: complete paralysis
Grades of pott paraplegia
I- pt unaware about the neurological deficit, physician detects babinski positive; ankle or patellar clonus on examination
II- pt presents with clumsiness, in coordination or spasticity but manages to walk with or without support
III- unable to walk, sensory loss <50%; paraplegia in extension
IV- unable to walk, paraplegia in flexion; bowel and bladder involvement or sensory loss>50%
Conservative t/t of pott paraplegia
For grade
I- ATT +rest+ monthly neurological examination
II- ATT+ rest+ weekly neurological examination
III- ATT+ rest+ daily neurological examination
IV- ATT+ decompression and bone graft
Operative treatment of pott paraplegia
- costo transversectomy
- anterior decompression and bone grafting
- anterolateral decompression and bone grafting
- radical debridement and arthrodesis
Investigation of pott paraplegia
MRI
Absolute indications of operative mgmt in pott paraplegia
1) onset of paraplegia during conservative treatment
2) non progressive or progressive loss of function even after 4 weeks of conservative treatment
3) severe paraplegia of rapid onset which indicates severe pressure or mechanical stress
4) paraplegia with severe spasm due to which adequate rest is impossible
5) severe paraplegia with:
- paraplegia in flexion with sensory or motor loss for >6 months
- complete motor loss with bowel and bladder involvement for 1 month even after conservative treatment
TB hip stages
1) synovitis
- FABER
- apparent lengthening
2) arthritis
- FADIR
- apparent shortening
3) erosion
- exaggerated FADIR
- true shortening
Tb hip pathology
- Granulation tissue erodes overlying cartilage
- synovial hypertrophy
- pannus of hypertrophied synovium extends over and under cartilage
- destruction of cartilage
- multiple cavitation typical of Tb in femoral head and acetabulum leading to absorption
- wandering acetabulum
- pus bursts through capsule
- fibrous ankylosis
Symptoms of Tb hip
- apathetic and pale
- onset insidious
- groin and thigh ache referring to knee
- limp due to stiffness
- night cries
- severe pain
Examination of Tb hip
1) posture- exaggerated lumbar lordosis
2) gait- initially stiff hip gait later antalgic gait
3) wasting- thigh and gluteal muscles
4) cold abscess- swelling around hip
5) deformity- later stage flexion adduction and internal rotation
6) shortening
7) restriction of movement
8) telescoping
9) trendelenburg test positive in all stages
Investigation in Tb hip
- xray findings \: haziness of bone around hip ✅ \: lytic lesion around head and acetabulum \: reduction of joint space \: irregular outline of articular ends
- MRI
- biopsy
- mantoux test
- ESR & CXR
D/D of Tb hip
- RA
- psoas abscess
- CDH
- perthes disease
- osteoarthritis
T/T of Tb hip
1) conservative
- ATT
- below knee skin traction for immobilization
- analgesic and antispasmodic
- physiotherapy
2) operative
- for arthritis: joint debridement and traction
- for joint destruction: arthodesis
- for residual pain and deformity: total hip replacement
Tb of short bone of hand
Spina ventosa or tuberculous dactylitis
Tb of shoulder is dry and called as
Caries sicca
Tb with polyarthritis is
Poncet’s disease
Pott’s fracture
Bimalleolar ankle fracture
