Tuberculosis Of The Spine2
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TUBERCULOSIS OF THE SPINE
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.
Pathology
The lesion 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.
Spreading caseation results in osteolysis 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 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 neuralgia. Lower Thoracic spine can cause referred pain in the abdomen.
Rigidity Rigidity is caused by the spasm of the 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 vertebrae involved.
Cold abscess 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 inflammatory reaction and hence it is called cold abscess.
Paraplegia
The paraplegia in spinal tuberculosis is called Pott'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. 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.
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 initial treatment of the case is the same as before. The patient is immobiled 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 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
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.
TUBERCULOSIS OF THE HIP JOINT
Next to the spine, the hip joint is the most common site for involvement by tuberculosis. This also occurs most commonly in children, the highest incidence being between the ages of 5-15 yrs.
Clinical features
Pain and swelling in the region of the hip and limping are the usual presenting symptoms. Sometimes the child complains of pain in the knee. This is referred pain and is often misleading. There will be constitutional symptoms like loss of appetite, loss of weight, low grade fever and a sense of tiredness coming on early during games.
Stage I (Synovitis)
This is the stage when the disease is a synovitis with effusion into the cavity. The hip joint assumes the position of flexion, abduction and external rotation. There is a pelvic tilt downwards which causes an apparent lengthening of the affected limb. There is an increased lordosis in the lumbar spine. There are also other local signs of muscle spasm, warmth, tenderness and painful limitation of all movements of the joint.
Thomas Hip Flexion Test
The unmasking of the flexion deformity of the hip by tilting back the pelvis and obliteration of the lumbar lordosis is the basis of the Thomas Hip Flexion Test for measuring flexion deformity in the hip.
Stage II(Arthritis)
When the disease is untreated and the patient is bed-ridden for sometime the destructive process spreads to the articular surfaces. In this stage, the spasm of the adductors predominate and the limb assumes the position of flexion, adduction and internal rotation.
StageIII (Pathological Dislocation)
the destruction spreads in the acetabulum and pathological dislocation of the hip joint occurs. The position of adduction, flexion and internal rotation gets more exaggerated due to the dislocation. There is real shortening of the limb. The cold abscess bursts and there are sinuses discharging thin pus.
Radiological features
Stage I: At this stage radiographs show only generalised rarefaction of bones. No bony focus will be seen. The joint space appears widened due to the effusion.
Stage II : Radiographs at this stage show erosion of the articular surface and narrowing of the joint space.
Stage III: Radiographs show destruction of the head of the femur, travelling acetabulum with dislocation of the hip and a break in the Shenton's line.
Conservative Management
The patient is put to bed and the hip joint immobilised. Antituberculous chemotherapy is started. The method of local treatment depends on the stage of the disease.
In Stage I the deformity of flexion abduction and external rotation is corrected by gradual continuous skin traction in a Thomas' splint over period of two to three weeks. When the deformity is corrected, the hip is immobilised in the position of function in 15 degree abduction and neutral rotation. This immobilisation with traction is continued till the disease gets controlled .
In Stage II the hip is immobilised with skin traction in the position of function. The traction is meant to overcome the muscle spasm and prevent erosion of the articular surfaces by lessening their contact.
When the disease is stabilised, the traction is discarded and the hip is immobilised in a full plaster spica for about 3 months. When the stage of quiescence is reached, the plaser is removed, the hip is mobilised in bed. The patient is then made ambulant with a protection of a weight relieving caliper.
Indications for early surgery:
When the disease is stabilised, the presence of a well localised cavity in the neck of the femur or the acetabulum is an indication for surgical curettage. When there is progressive destruction of the articular surfaces, surgical debridement helps in eraddication of the disease and obtain a mobile joint .
surgery
Synovial resection. Local focus clearup. Hip joint fuse Total hip arthroplasty(THA). Osteotomy below rotor
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.
Pathology
The lesion 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.
Spreading caseation results in osteolysis 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 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 neuralgia. Lower Thoracic spine can cause referred pain in the abdomen.
Rigidity Rigidity is caused by the spasm of the 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 vertebrae involved.
Cold abscess 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 inflammatory reaction and hence it is called cold abscess.
Paraplegia
The paraplegia in spinal tuberculosis is called Pott'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. 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.
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 initial treatment of the case is the same as before. The patient is immobiled 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 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
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.
TUBERCULOSIS OF THE HIP JOINT
Next to the spine, the hip joint is the most common site for involvement by tuberculosis. This also occurs most commonly in children, the highest incidence being between the ages of 5-15 yrs.
Clinical features
Pain and swelling in the region of the hip and limping are the usual presenting symptoms. Sometimes the child complains of pain in the knee. This is referred pain and is often misleading. There will be constitutional symptoms like loss of appetite, loss of weight, low grade fever and a sense of tiredness coming on early during games.
Stage I (Synovitis)
This is the stage when the disease is a synovitis with effusion into the cavity. The hip joint assumes the position of flexion, abduction and external rotation. There is a pelvic tilt downwards which causes an apparent lengthening of the affected limb. There is an increased lordosis in the lumbar spine. There are also other local signs of muscle spasm, warmth, tenderness and painful limitation of all movements of the joint.
Thomas Hip Flexion Test
The unmasking of the flexion deformity of the hip by tilting back the pelvis and obliteration of the lumbar lordosis is the basis of the Thomas Hip Flexion Test for measuring flexion deformity in the hip.
Stage II(Arthritis)
When the disease is untreated and the patient is bed-ridden for sometime the destructive process spreads to the articular surfaces. In this stage, the spasm of the adductors predominate and the limb assumes the position of flexion, adduction and internal rotation.
StageIII (Pathological Dislocation)
the destruction spreads in the acetabulum and pathological dislocation of the hip joint occurs. The position of adduction, flexion and internal rotation gets more exaggerated due to the dislocation. There is real shortening of the limb. The cold abscess bursts and there are sinuses discharging thin pus.
Radiological features
Stage I: At this stage radiographs show only generalised rarefaction of bones. No bony focus will be seen. The joint space appears widened due to the effusion.
Stage II : Radiographs at this stage show erosion of the articular surface and narrowing of the joint space.
Stage III: Radiographs show destruction of the head of the femur, travelling acetabulum with dislocation of the hip and a break in the Shenton's line.
Conservative Management
The patient is put to bed and the hip joint immobilised. Antituberculous chemotherapy is started. The method of local treatment depends on the stage of the disease.
In Stage I the deformity of flexion abduction and external rotation is corrected by gradual continuous skin traction in a Thomas' splint over period of two to three weeks. When the deformity is corrected, the hip is immobilised in the position of function in 15 degree abduction and neutral rotation. This immobilisation with traction is continued till the disease gets controlled .
In Stage II the hip is immobilised with skin traction in the position of function. The traction is meant to overcome the muscle spasm and prevent erosion of the articular surfaces by lessening their contact.
When the disease is stabilised, the traction is discarded and the hip is immobilised in a full plaster spica for about 3 months. When the stage of quiescence is reached, the plaser is removed, the hip is mobilised in bed. The patient is then made ambulant with a protection of a weight relieving caliper.
Indications for early surgery:
When the disease is stabilised, the presence of a well localised cavity in the neck of the femur or the acetabulum is an indication for surgical curettage. When there is progressive destruction of the articular surfaces, surgical debridement helps in eraddication of the disease and obtain a mobile joint .
surgery
Synovial resection. Local focus clearup. Hip joint fuse Total hip arthroplasty(THA). Osteotomy below rotor
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