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1 :
TUBERCULOSIS OF THE SPINE (Pott's Disease) Incidence Tuberculosis of the spine forms 50-60 percent of the total incidence of skeletal tuberculosis. It is a disease of childhood and adolescence, 50 percent of case occurring in the age group 1-20 years. The most common level of the lesion is in the thoraco-lumbar level. This is because movement and the stress of weight bearing are maximum at this level. The proximity of the cysterna chyli may cause lymphatic spread of the infection from foci in the mesenteric lymph glands. Pathology The disease affects the spine secondarily from a primary focus in the lungs or mediastinal glands through the blood stream. The focus in the spine may be found in one of the following sites. 1. para-discal lesion in the suvchodral area of the vertebral body. 2. Central body lesion in the centre of the vertebral body. 3. Anterior type in the anterior surface of the vertebral 4. Appendicial lesion in the pedicle, lamina, transverse process and spinous process. 5. Articular lesion in the posterior intervertebral joint. The lesion soon destroys the intervertebral disc and the adjacent surfaces of the vertebral bodies which slowly collapse and obliterate the intervertebral space. Destruction of the framework of the vertebral bodies results in their collapse and the development of an angular kyphosis called gibbus. The disease commonly involves two vertebrae but in children it can rapidly destroy three or more vertebrae and cause gross deformities. The histological changes in the bone are typical of the tuberculous lesions elsewhere. Spreading caseation results in osteolsis of the bony trabeculae, leading to the formation of cold abscess. Tuberculoma: compared to the total incidence of spinal tuberculosis, tuberculoma formation in the spinal cord is a rare phenomenon; it presents like an intra-medullary spinal tumour causing cord compression and paraplegia. Clinical features The classical symptoms of tuberculosis of the spine as described by percival Pott are pain, rigidily, deformity, cold absces and paraplegia. Pain Pain will be localised by the patient to one region of the spine. Localised tenderness over one vertebral spine is diagnostic of the level of the lesion. The disease can also present as referred pain. Disease in the cervical spine can present as pain in the ear or pain down the arm. Upper Thoracic spine lesion can present as pain in the chest and as intercostal neuralgia. Lower Thoracic spine can cause referred pain in the abdomen. The following clinical dictum should not be forgotten. Whenever a patient presents with pain in the back, examine the front by palpating the abdomen to detect a psoas abscess, aneurysm of the aorta or even a peptic ulcer. Rigidity Rigidity is caused by the spasm of the para spinal muscles due to the disease in the spine. A cervical lesion causes rigidity of the neck which at times may be asymmetrical producing torticollis. In lumbar lesions, there is marked rigidity of the back and the spine moves in one piece when the patient attempts to bend forward. This is demonstrated by the Coin test. The patient is asked to pick up a coin from the floor. He bends at the knee and hip and picks up the coin holding the spine rigid and straight all the time. Deformity In the cervical and lumbar spine the loss of the normal lordosis occurs first followed by the gibbus. In the thoracic spine angular kyphosos (gibbus) is characteristic. The prominence of gibbus depends on the number of the vertebrate involved. Gross kyphosis is seen in children when a number of dorsal vertebracare destroyed. Cold abscess A search for the cold abscess including a careful palpation of the abdomen is an essential part of the clinical examination. The formation of cold abscess is an invariable feature of tuberculosis of the spine. The abscess forms in the paravertebral areas and soon tracks downwards due to gravity and towards the surface following the tracks of nerves and blood vessels. As long as the abscess remains deep to the deep fascia it remains cold to touch without any nflammatory reaction and hence it is called cold abscess. There is no correlation between the size of the destructive lesion and the quantity of pus in the cold abscess. The size is determined by the degree of the allergic exudative reaction that produces the pus. In the cervical spine, the cold abscess can point retropharyngeally producing dysphagia or show up in the neck behind the sternomastoid. In the thoracic spine, the cold abscess fills up the posterior mediastinum and tracks along the intercostal nerves to point either in the lateral chest wall or in the anterior chest wall. Abscesses also reach the surface posteriorly under the sacrospinalis muscles. The cold abscess sometimes enters the spinal canal causing pressure on the spinal cord, resulting in paraplegia. Thoraco-lumbar cold abscess can point either in the back or enter the psoas sheath and track down as psoas and iliac abscesses. These abscesses collect as lumps in the iliac fossa and point above the inguinal ligament, ortrack down behind the inguinal ligament and point in the femoral triangle or even lower down. Paraplegia The paraplegia in spinal tuberculosis is called pot's paraplegia. This complication occurs in about 10 percent of the cases and is usually of the spastic type. The highest incidence of paraplegia is in lesions of the thoracic spine. In the clinical examination look for very early signs pressure on the cord, like slight spasticity of the legs causing unsteady gait, exaggerated knee and ankle jerks, and extensor plantar response. Depending on the severity of the paralysis, paraplegia is graded as Grade I, II and III- Grade I being a partial paralysis (paresis) and Grade III being a total paraplegia. Pott's paraplegia is classifed into 2 types. 1. Early onset paraplegia occuring during the active stage of the disease. 2. Late onset paraplegia occurring in patients whose lesion has reactivated after long years of quiescence. The early onset paraplegia is due to the pressure on the cord by the following; a) cold abscess b) granulation tissue c) necrotic debris and sequestra from the bone or the intervertebral disc tissue d) occasionally, a vascular thrombosis of the spinal arteries which produces a sudden total paraplegia. A rare type is the gradual onset of paraplegia due to a granulomatous mass developing inside the spinal cord. This is called the spinal cord tumour syndrome. Radiological features The earliest radiological sign is the narrowing of the intervertebral disc space. Later, there is erosion of the adjacent surfaces of the vertebral bodies. Still later, there is destruction and collapse of the vertebral bodies with obliteration of the intervertebral space para or prevertebral soft tissue shadows of the abscess may also be present which may be calcified. Sound healing usually ends in bony fusion of adjacent vertebrae. Neglected cases in children result in gross kyphotic deformities Conservative Treatment The patient is given complete rest in bed and measures to improve his general health. Antituberculous chemotherapy as described earlier is started. The spine is immobilized in a plaster shell for a short period. The patient is periodically assessed clinically,. radiologically and hematologically . When the lesion is quiescent, the patient is given a spinal brace and made ambulant. The chemotherapy is continued upto a total period of 9 months. Treatment of Pott's Paraplegia The intital treatment of the case is the same as before. The patient is immobilsed in the plaster shell and chemotherapy started. A neurological chart is maintained and the clinical status of the paraplegia recorded once a week. Special care should be taken to prevent contractures of the joints in the paralysed legs by full passive movements of all the joints. The limbs should be kept with knees in slight flexion and the feet in neutral position . With this regimen more than 60% of the cases with paraplegia recover in a few months. This is due to the resorption of the intrapinal cold abscess resulting in a medical decompression of the spinal cord. Surgical Treatment The indications for surgery in paraplegia are as follows;; 1. No sign of recovery after 3-4 weeks of conservative treatment. 2. Paraplegia getting worse in spite of conservative treatment. 3. Spastic paraplegia with severe and uncontrollable spasms of the legs. The operations for decompression are as follows; 1. Costo-transversectomy: In this operation the posterior ends of one or two ribs and the corresponding transverse processes of the vertebrae are excised and the cold abscess evacuated. 2. Antero-lateral decompression: In this operation, in addition to costotransversectomy, the pedicles and part of the vertebral bodies are excised to achieve decompression. 3. Anterior decompression and spinal fusion: (Hongkong operation). Through a standard thorocotomy, the abscess is evacuated and debridement done. The diseased vertebral bodies are excised (vertebrectomy) and the cord decompressed. Autologous bone grafts are placed between the vertebral bodies to promote anterior spinal fusion. In the rare case when the disease presents as a spinal (cord) tumour syndrome, laminectomy is done and the granuloma is removed. When the disease process gets quiescent, paraplegia recovers, the patient is fitted with a spinal brace and made ambulant. The patient is reviewed periodically for any evidence of reactivation. The above regimen of mainly conservative treatment and surgery only when indicated is the Indian middle path regimen as projected by TULI of Varanasi. This is the moderate apprach between the extremes of the classical 'prolonged complete and continuous immobilisation of Hugh Owen Thomas of Liverpool and the immediate radical surgery advocated by. Mukopadhaya (Patna), Masalawala (Bombay) and Wilkinson (UK) Madras Study of Tuberculosis of spine A research study under the auspices of Indian Council of Medical Research Council and the British Medical Research Council coordinated by the Tuberculosis Reasearch Centre, Madras was initiated by the senior author. It was conducted at the Orthopaedic department of Government General Hospital, Madras in 1975-78. Long term follow up of the study established the efficacy of a short duration chemotherapy with INH and Rifampicin for 9 months for spinal tuberculosis without paraplegia.
2 :
TUBERCULOSIS OF THE SPINE (Pott's Disease) Incidence Tuberculosis of the spine forms 50-60 percent of the total incidence of skeletal tuberculosis. It is a disease of childhood and adolescence, 50 percent of case occurring in the age group 1-20 years. The most common level of the lesion is in the thoraco-lumbar level. This is because movement and the stress of weight bearing are maximum at this level. The proximity of the cysterna chyli may cause lymphatic spread of the infection from foci in the mesenteric lymph glands. Pathology The disease affects the spine secondarily from a primary focus in the lungs or mediastinal glands through the blood stream. The focus in the spine may be found in one of the following sites. 1. para-discal lesion in the suvchodral area of the vertebral body. 2. Central body lesion in the centre of the vertebral body. 3. Anterior type in the anterior surface of the vertebral 4. Appendicial lesion in the pedicle, lamina, transverse process and spinous process. 5. Articular lesion in the posterior intervertebral joint. The lesion soon destroys the intervertebral disc and the adjacent surfaces of the vertebral bodies which slowly collapse and obliterate the intervertebral space. Destruction of the framework of the vertebral bodies results in their collapse and the development of an angular kyphosis called gibbus. The disease commonly involves two vertebrae but in children it can rapidly destroy three or more vertebrae and cause gross deformities. The histological changes in the bone are typical of the tuberculous lesions elsewhere. Spreading caseation results in osteolsis of the bony trabeculae, leading to the formation of cold abscess. Tuberculoma: compared to the total incidence of spinal tuberculosis, tuberculoma formation in the spinal cord is a rare phenomenon; it presents like an intra-medullary spinal tumour causing cord compression and paraplegia. Clinical features The classical symptoms of tuberculosis of the spine as described by percival Pott are pain, rigidily, deformity, cold absces and paraplegia. Pain Pain will be localised by the patient to one region of the spine. Localised tenderness over one vertebral spine is diagnostic of the level of the lesion. The disease can also present as referred pain. Disease in the cervical spine can present as pain in the ear or pain down the arm. Upper Thoracic spine lesion can present as pain in the chest and as intercostal neuralgia. Lower Thoracic spine can cause referred pain in the abdomen. The following clinical dictum should not be forgotten. Whenever a patient presents with pain in the back, examine the front by palpating the abdomen to detect a psoas abscess, aneurysm of the aorta or even a peptic ulcer. Rigidity Rigidity is caused by the spasm of the para spinal muscles due to the disease in the spine. A cervical lesion causes rigidity of the neck which at times may be asymmetrical producing torticollis. In lumbar lesions, there is marked rigidity of the back and the spine moves in one piece when the patient attempts to bend forward. This is demonstrated by the Coin test. The patient is asked to pick up a coin from the floor. He bends at the knee and hip and picks up the coin holding the spine rigid and straight all the time. Deformity In the cervical and lumbar spine the loss of the normal lordosis occurs first followed by the gibbus. In the thoracic spine angular kyphosos (gibbus) is characteristic. The prominence of gibbus depends on the number of the vertebrate involved. Gross kyphosis is seen in children when a number of dorsal vertebracare destroyed. Cold abscess A search for the cold abscess including a careful palpation of the abdomen is an essential part of the clinical examination. The formation of cold abscess is an invariable feature of tuberculosis of the spine. The abscess forms in the paravertebral areas and soon tracks downwards due to gravity and towards the surface following the tracks of nerves and blood vessels. As long as the abscess remains deep to the deep fascia it remains cold to touch without any nflammatory reaction and hence it is called cold abscess. There is no correlation between the size of the destructive lesion and the quantity of pus in the cold abscess. The size is determined by the degree of the allergic exudative reaction that produces the pus. In the cervical spine, the cold abscess can point retropharyngeally producing dysphagia or show up in the neck behind the sternomastoid. In the thoracic spine, the cold abscess fills up the posterior mediastinum and tracks along the intercostal nerves to point either in the lateral chest wall or in the anterior chest wall. Abscesses also reach the surface posteriorly under the sacrospinalis muscles. The cold abscess sometimes enters the spinal canal causing pressure on the spinal cord, resulting in paraplegia. Thoraco-lumbar cold abscess can point either in the back or enter the psoas sheath and track down as psoas and iliac abscesses. These abscesses collect as lumps in the iliac fossa and point above the inguinal ligament, ortrack down behind the inguinal ligament and point in the femoral triangle or even lower down. Paraplegia The paraplegia in spinal tuberculosis is called pot's paraplegia. This complication occurs in about 10 percent of the cases and is usually of the spastic type. The highest incidence of paraplegia is in lesions of the thoracic spine. In the clinical examination look for very early signs pressure on the cord, like slight spasticity of the legs causing unsteady gait, exaggerated knee and ankle jerks, and extensor plantar response. Depending on the severity of the paralysis, paraplegia is graded as Grade I, II and III- Grade I being a partial paralysis (paresis) and Grade III being a total paraplegia. Pott's paraplegia is classifed into 2 types. 1. Early onset paraplegia occuring during the active stage of the disease. 2. Late onset paraplegia occurring in patients whose lesion has reactivated after long years of quiescence. The early onset paraplegia is due to the pressure on the cord by the following; a) cold abscess b) granulation tissue c) necrotic debris and sequestra from the bone or the intervertebral disc tissue d) occasionally, a vascular thrombosis of the spinal arteries which produces a sudden total paraplegia. A rare type is the gradual onset of paraplegia due to a granulomatous mass developing inside the spinal cord. This is called the spinal cord tumour syndrome. Radiological features The earliest radiological sign is the narrowing of the intervertebral disc space. Later, there is erosion of the adjacent surfaces of the vertebral bodies. Still later, there is destruction and collapse of the vertebral bodies with obliteration of the intervertebral space para or prevertebral soft tissue shadows of the abscess may also be present which may be calcified. Sound healing usually ends in bony fusion of adjacent vertebrae. Neglected cases in children result in gross kyphotic deformities Conservative Treatment The patient is given complete rest in bed and measures to improve his general health. Antituberculous chemotherapy as described earlier is started. The spine is immobilized in a plaster shell for a short period. The patient is periodically assessed clinically,. radiologically and hematologically . When the lesion is quiescent, the patient is given a spinal brace and made ambulant. The chemotherapy is continued upto a total period of 9 months. Treatment of Pott's Paraplegia The intital treatment of the case is the same as before. The patient is immobilsed in the plaster shell and chemotherapy started. A neurological chart is maintained and the clinical status of the paraplegia recorded once a week. Special care should be taken to prevent contractures of the joints in the paralysed legs by full passive movements of all the joints. The limbs should be kept with knees in slight flexion and the feet in neutral position . With this regimen more than 60% of the cases with paraplegia recover in a few months. This is due to the resorption of the intrapinal cold abscess resulting in a medical decompression of the spinal cord. Surgical Treatment The indications for surgery in paraplegia are as follows;; 1. No sign of recovery after 3-4 weeks of conservative treatment. 2. Paraplegia getting worse in spite of conservative treatment. 3. Spastic paraplegia with severe and uncontrollable spasms of the legs. The operations for decompression are as follows; 1. Costo-transversectomy: In this operation the posterior ends of one or two ribs and the corresponding transverse processes of the vertebrae are excised and the cold abscess evacuated. 2. Antero-lateral decompression: In this operation, in addition to costotransversectomy, the pedicles and part of the vertebral bodies are excised to achieve decompression. 3. Anterior decompression and spinal fusion: (Hongkong operation). Through a standard thorocotomy, the abscess is evacuated and debridement done. The diseased vertebral bodies are excised (vertebrectomy) and the cord decompressed. Autologous bone grafts are placed between the vertebral bodies to promote anterior spinal fusion. In the rare case when the disease presents as a spinal (cord) tumour syndrome, laminectomy is done and the granuloma is removed. When the disease process gets quiescent, paraplegia recovers, the patient is fitted with a spinal brace and made ambulant. The patient is reviewed periodically for any evidence of reactivation. The above regimen of mainly conservative treatment and surgery only when indicated is the Indian middle path regimen as projected by TULI of Varanasi. This is the moderate apprach between the extremes of the classical 'prolonged complete and continuous immobilisation of Hugh Owen Thomas of Liverpool and the immediate radical surgery advocated by. Mukopadhaya (Patna), Masalawala (Bombay) and Wilkinson (UK) Madras Study of Tuberculosis of spine A research study under the auspices of Indian Council of Medical Research Council and the British Medical Research Council coordinated by the Tuberculosis Reasearch Centre, Madras was initiated by the senior author. It was conducted at the Orthopaedic department of Government General Hospital, Madras in 1975-78. Long term follow up of the study established the efficacy of a short duration chemotherapy with INH and Rifampicin for 9 months for spinal tuberculosis without paraplegia
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