Pott's Spine

Arun Sigdel

2066-04-04

Mycobacterium Tuberculosis: Human type Rod shaped Slow growing aerobic organism, under favorable condition growth luxuriantly within 20 hours whereas in unfavorable condition it remains dormant for prolonged period. IUAT widely recommends solid media i.e. Lowenstein-jensen for routine culture that contains coagulated hen’s egg, mineral salt, asparagine and malachite green. Acid fastness due to presence of mycolic acid around cell which resists decolorisation by acid or alcohol when stained with carbol fuchsin in ZiehlNeelsen method.

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During 3rd week of development, Vertebral column development depends on the appropriate prior development of the notochord and somites from the paraxial mesoderm (segments). 4th week somite surrounds notochord collectively called scleretome. Segmental formation is due to extensive proliferation and condensation. Typical TB lesion shows paradiscal involvement of 2 contagious vertebra through a common blood supply

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At each vertebral level, the vertebral artery, intercostal artery, or lumbar arteries provide nutrient vessels that enter the vertebral body , Posterior spinal branch arteries enter the spinal canal through each neural foramen. These arteries separate into ascending and descending branches that anastomose with similar branches at each level This posterior network joins centrally to enter a large posterior nutrient foramen.

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The intervertebral disc is avascular, even in infants. In contrast, the surrounding cartilaginous material is highly vascular.

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Since immemorial, Lesion recorded in Egyptian mummies. Hippocrates described the clinical condition of spinal infection believed to be tuberculosis 30 million people infected and 2.5 million death annually. Infects a third of population worldwide. Sir Laennec first discovered microscopic lesion tubercle in early 19th century. 1779, Pott gave the first complete report of tuberculosis infection of the spine. 3-4 % incidence of bone TB. Vertebral TB constitutes 50% of skeletal TB. 88% chronic infections of spine accounts for tubercular infection. Incidence in Indian sub continental origin > whites

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Primary TB- 85% -90% heal spontaneously Route: Inhalation, ingestion Incidence of skeletal TB varies considerably from place to place and over time, and factors such as antibiotic resistance and increased infection in immunocompromised individuals, especially HIV-positive, are influencing the occurrence of disease even in developed countries.

Children>young adult, but no age bar. Male=Female Primary infection< 1 yrs Family history of tuberculosis Close contact with smear positive Chest x-ray – evidence of healed TB Immunocompromised- HIV ,steroid, DM, CRF, Malnutrition Malignancy-lymphoma, leukemia.

TB lesion is due to hamatogenous dissemination from primary infected foci. Mode of spread of Infection Paradiscal type: Commonest, paradiscal margin of vertebra. Central type: Body of vertebra Anterior type: Beneath Ant. Longitudinal Ligament Posterior type: Rare, involvement of vertebral arch Pathological Types : Caseous exudative- increase destruction and exudation and abscess formation, symptoms & signs of TB more marked. Granular- less destructive, rare abscess formation

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Infection-marked hyperemia and severe osteoporosis Granulomatous inflammation – tuberculoma formation hallmark Destruction of bone –compression, collapse and deformation Necrosis is also due to ischemic infraction – thromboembolism ,endarteritis periarteritis

Common during 1st three decades, Occurrence: Thoracic(42%) > lumbar(26)>thoracolumbar(12%)>cervical(12%)>cervicothoracic(5%)sacrum(3%). Active stage: 95% cases commonly have kyphotic deformity. Commonly presents with localized painful movement (tender on palpation) or referred pain depending upon the nerve root involvement. Cold abscess Insidious onset of Constitutional symptoms (loss of weight, malaise, decreased appetite, evening rise of temp with night sweats). 20%

Neurological deficits may occur early or late. Early onset suggests epidural extension of an abscess. Late may be the development of significant kyphosis, vertebral collapse with retropulsion of bone and debris, or late abscess formation. Neurological symptoms become more frequent at higher spinal levels ,cervical and thoracic areas and are least common with infections in the thoracolumbar region Healed Stage: •

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All signs and symptoms subsides except the deformity that occurs in active stage persists Radiologically signs of bone healing. However patient rarely presents with neurological deficits initially.

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Nearly 12% shows involvement of other bones and joints, excluding skipped lesions of spine. Generally may reveal signs of anemia, lungs and lymph nodes involvement. Night cries, Stiff Spine. Protective attitude with cautious and protective gait, movement decreased especially flexion. Pronounce wasting of back muscles. Suggestive family history raises suspicion.

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Cold abscess is formed by collection of liquefied products and reactive exudates, consists of serum, leucocytes, caseous material, bone debris and tubercle bacilli. Walls covered with TB granulations. Present far away from vertebral column along fascial plane or course of neurovascular bundles. Anterior and posterior cervical triangles, paraspinal region at back, along brachial plexus in axilla, intercostal space in chest wall, dorsolumbar abscess along psoas sheath to be palpable in iliac fossa, in upper part of thigh or even downward up to knee.

Clinical history and presentation. Routine investigations may show Anemia, lymphocytosis, raised ESR. Mantoux (Purified Protein Derivative) test may be positive but not diagnostic. PCR -100% specificity. ELISA for antibody to mycobacterial antigen-6 showed sensitivity of 94% and specificity 100% (stroebel et al. 1982). Chest X-ray and sputum for AFB Stain & c/s.

Radiological: important diagnostic test, Early- narrow disc space with osteopenic bone. Late- ant. wedge compression in ant. Involvement concertina collapse in central involvement destruction of post. element in post. involvement. Soft tissue swelling highly suggests TB.

Definitive diagnosis is dependent on culture of the organism and requires biopsy of the lesion.

Difficult in diagnosing early lesion. Lesion less than 1.5 cm not demonstrable in conventional x ray. Must have 30-40% of calcium removed from particular area to show radiolucent region on x-ray. Average vertebra involved at diagnosis – 3(in children) and 2.5 (adult). 7% may show skipped lesions in vertebral column. Radiological sites of Tuberculosis involvement: Paradiscal, Central, Anterior, Appendicial.

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commonest variety, narrowing of disc space at earliest findings. Any reduction in disc space associated with a loss of definition of paradiscal margin must invite suspicion.

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Infection starts from the centre of vertebral body. Diseased vertebra ballooned out like a tumor. Later stage-vertebra shows concentric collapse resembling vertebral plana. Minimal diminution of disc space and Paravertebral shadow

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Anterior Type

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Lesion starts beneath anterior longitudinal ligament and periosteum. Peripheral portion of vertebral body in front and side shows erosion in lateral view or oblique view as shallow excavations. Collapse of vertebral body and diminution of disc space is minimal and occurs late. More common in thoracic region and children.

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Appendicial Uncommon type 

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Isolated infection of lamina, spine, pedicle, transverse process. Shows erosive lesion, paravertebral shadow and intact disc space. 30% of typical paradiscal type show concomitant involvement of posterior element.

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Due to extension of TB granulation tissue and collection of abscess Cervical region-presents as soft tissue shadow between vertebral bodies, pharynx and trachea(normal space 0.5cm above Cricoid cartilage or 1.5cm below this level). Thoracic region-upper dorsal region abscess casts V shaped shadow stripping long laterally and downwards. Loss of anterior concavity (normal contour) of tracheal shadow or distance >8mm from vertebra( on lat. views). Below T4-fusiform shape (bird nest appearance) above the attachment of diaphragm, below it drains along psoas In thoracic region long standing tense paravertebral abscess show anaeurysmal phenomenon(scalloping effect).

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CT control percutaneous techniques are adequate. Useful for posterior spinal disease, TB of craniovertebral, sacroiliac joint and of sacrum. To detect early lesion not visible in x-ray. Anatomical localization, shape, size and route of extent.

Ultra sonogram: diagnose the presence of TB abscess in lumbar region and abscess composition and quantity

MRI: helps in delineation of disease to detect cord compression High-quality (MRI) is an accurate and rapid method for identifying spinal infection. It identifies infected and normal tissues and probably the best determiner about the full extent of the infection. Unfortunately, MRI cannot eliminate the need for diagnostic biopsy as it wont differentiate between pyogenic and non pyogenic infections

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Stage I:pre-destructive- straightening of curvatures, spasm of perivertebral muscles.MRI shows marrow edema. DURATION <3 month Stage II: Early destructive- diminished disc space + paradiscal erosion (knuckle<10) . MRI shows marrow edema and break of osseous margins , CT shows marginal erosions and cavitations. DURATION 2-4 month Stage III, IV, V: vertebral bodies destruction and collapse + appreciable kyphos. III: 2-3 vertebra involved (kyphos 10-30) Duration- 3-9 month. IV: >3 vertebra involved K: 30-60 Duration 6-24 month V: >3vertebra involved K:>60 Duration >2 yrs K: Dickson Angle ok Kyphosis

Forward wedge of 2 vertebral bodies- knuckle Wedge collapse of 3 or more vertebra- angular Wedging of large no of adjacent vertebra- round kyphosis

Tall vertebra-occurs only during growth period increase in height of lumbar vertebral bodies ( up to 1\3 rd) in healed thoracic pott’s disease

Age: confused with Young child calve”s disease, congenital defect and adults with Scheuermann”s disease. PYOGENIC SPONDYLITIS: sudden onset, severe localized pain, spasm, fever. initially rapid bone destruction which is replaced rapidly by bone sclerosis and new bone formation (Radiologically after 8th wks) usually follows recent surgery or infection(staphylococcal) examination of biopsy useful MRI shows inflammatory changes heals with marked sclerosis, proliferative bone formation, even with ankylosis.

Benign Hemangioma- most common (10.7%) . Asymptomatic usually and found incidentally , D12 to L4 most commonly involved. Involved vertebra radiologically shows characteristic coarsening of vertebral trabeculations more prominent in vertical than horizontal. GCT and ABC- typical osteoytic, expansile and usually eccentric growth on radiological examination. disc space is not involved in early stage. Final diagnosis made histologically.

Malignant Primary malignant are rare ,but Ewing's and Osteogenic sarcoma occasionally occur. Tumors have rapid course of disease with progressive paraplegia and radiological evidence of bony trabecular destruction. Diagnosis confirmed by biopsy.

Multiple myelomamay resemble potts TB with involvement of only 1 or 2 vertebra and if there is collapse and eccentric destruction. Involvement of multiple joints ,high ESR, anemia , bence jones protein, reversal of albumin globulin ratio, electrophoresis helpful in diagnosis. Confirmed by biopsy shows myeloma cells. Lymphomas-(Hodgkin”s disease, Leukaemias) may rarely involve ,diffuse sclerosis of bone and trabecular destruction. Enlargement of spleen , liver, and lymph node with characteristic blood change

Secondary neoplastic deposits -largest percentage of neoplasm of spine. onset more acute, progress more rapidly and local sign more widespread. secondary deposit nearly always involve vertebral body with no disc involvement. Involvement of other bone and destruction of pedicle more suggest metaplasia. Traumatic condition-usually traumatic fracture is wedge shaped with intact disc space. There may be marginal spurring and spondylolitic changes. Clinical history and examination usually able to diagnose.

Eosinophilic granuloma- self limiting. Develop in vertebral body which undergoes an extensive degree of concentric collapse. The disc above and below are not involved .usually disease occur between 6 and 12 years of age and patient complains of localized pain without constitutional symptom. Osteoporosis- generalized osteoporosis may lead to collapse of vertebral column. Senile osteoporosis, osteogenesis imperfecta, osteomalacia, rickets, cushing disease, iatrogenic steroid all show alike and typical features in x-ray. In pre-collapse stage vertical bony trabeculae are more prominent but there is no evidence of osteolytic destruction. Nucleus pulposus of disc expands and attain a biconvex appearance and biconcave vertebral bodies

Mycotic spondylitis- actinomyes or blastomycosis group. In blastomycosis paravetebral abscess formation and in actinomycosis sclerosis and destruction of bone occur. Anterior and lateral surface of several vertebral body may be involved and may show an irregular saw tooth appearance by periosteal new bone formation. SyphilisRare now a days. Thoraco-lumbar and lumbar spine are common Three types-athralgic type, gummatous type and charcots diseases. . Radiological-gross dis-organization and destruction of involved vertebra along with proliferative new bone formation. Serological test, biopsy. Typhoid spine Local developmental abnormalities

Due to Tubercular Infection Potts Paraplegia Cold Abscess Sinuses Fatality Secondary infection Amyloid Disease.

Middle path regime of SM Tuli: treated on non operative anti TB chemotherapy, Rest and spinal braces. Hospitalization for those who require surgical evacuation of abscess or debridement of vertebral lesions or those who agree for fusion of spine for extensive dorsal lesion in children or for an unstable and painful spinal lesion or paraplegics who are unable to walk. PROTOCOLS: i) Rest: in hard bed or plaster of Paris bed to put the disease part in rest

ii) Anti-tubercular Drugs: Intensive phase consist of isoniazid(300-400), rifampicin(450-600)and),ethambutol(8001200mg),pyrazinamide(25-30mg\kg) for 3 months. Continuation phase with isoniazid and ethambutol for 15 months. Pyridoxine 10mg prevent peripheral neuropathy due to INH. Supportive therapy with haematinics, analgesics, multivitamins and high protein diet.

90% Bony healing, 10% Fibro-osseous. early stage of healing shows disease foci surrounded by sclerotic bones (ivory vertebra). early radiological signs of healing: sharpening of the fuzzy paradiscal margins, & reappearance and mineralization of bone which had earlier been absorbed. disc space gap is repaired by fibrous tissue.

iv) Gradual mobilization is encouraged in the absence of neural deficit with help of suitable spinal braces after the comfort at the diseased site permits. At 8 to9 weeks of treatment back extension exercise. Spinal brace continued for 18 months to 2 years. v) Sinuses usually heals within 2 to 3 months. Less number may require excision of tract.

vi) Abscesses are aspirated when its near the surface and one gram of streptomycin with or without INH instilled at each aspiration. Sufficient to heal about 95%. 5% requires surgery Open drainage or suction drainage for 72 hours of abscess is performed if aspiration fails to clear. Neurological complication- nearly 38% recovers with ATT.

vii) Neural complicationIf the patient shows progressive neurological recovery with in 3 to 4 wks surgical debridement is not necessary. Indication of surgical decompression If progressive recovery to satisfactory level after of fair trial of conservative therapy do not start. Neurological complication develops during the conservative Tx. Neurological complication become worse or Hx of recurrence. Para vertebral cervical abscess with difficulty in deglutition or respiration. Advance case with Motor, Sensory and Sphincter involvement. Doubtful diagnosis

viii) Operative debridement advised for cases who don’t show arrest of the activity of the spinal lesion after 3 to 6 months of chemotherapy or the cases with recurrence. Posterior spinal arthrodesis recommended for unstable spinal lesions in which the disease otherwise seems to be arrested. ix) Post-operative- Patient are nursed on hard bed for 2 to 3 weeks, in case of neural complications 3 to 5 months, the patient is gradually mobilized with the help of spinal braces.

Approaches for the decompression or debridement, with or without bone grafting: Cervical spine or cervico dorsal junction up to T1 approached through anterolateral approach Dorsal spine or dorsolumbar junction--approached through anterolateral approach and rarely through trans pleural approach. Lumbar spine and lumbosacral junction approach through extra peritoneal transvertebrotomy approach.

C1-C2:Anterior, Transoral/ Transthyroid Cervical Region: Anterior, Through Anterior/ Posterior triangle. C7-D1:Transpleural (3rd rib), Anterior Cervical, Low Ant. Cervical. Dorsal: Anterolateral or Transpleural, Ant. Transpleural D5D12, Trans-sternal D3-D4. Dorso-lumbar: Anterolateral ,11th rib Extra pleural/ Extra peritoneal or 9th rib Left Transpleural. Lumbar: Retroperitoneal, or Ureter or Sympathectomy Approach, Antero-lateral, Renal Approach L5-S1:Transperitoneal in Trendelenburg position with paramedian or low midline Incision, Retroperitoneal through oblique renal or hemisection incision, Retropsoas transverse vertebrotomy.

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