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SPINAL CORD
INJURIES
BECAUSE OF
TB
Ilse Lombard
2010
Tuberculosis (TB)

Tuberculosis (TB) is a disease caused by
bacteria called Mycobacterium
tuberculosis.
Tuberculosis (TB)

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Mycobacterium tuberculosis mostly attacks
the lungs, however it can also attack
many parts of the body such as the
kidney, the lymph nodes, and the spine.
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TB is mostly found in Africa and Southeast
Asia more. However, more than 25,000
people contract it every year in the United
States.
Tuberculosis (TB)

TB has existed for
thousands of years
killing millions and
millions of people.


King Tutankhamen
(Egyptian pharaoh)
DEFINITION
Spinal tuberculosis is a
presentation of extrapulmonary tuberculosis. It
is characterized by
destruction of the
vertebrae, often resulting
in curvature of the spine.
PATHOLOGY
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Tubercular bacteria are present
everywhere.
They are often entering our body through
breath, through the water that we drink
and rarely through saliva.
They are normally efficiently dealt with
and killed by our disease fighting immune
system.
With reduction in body's resistance these
bacteria can settle down in our body,
thrive and multiply.
Earlier people with poor socio-economical
conditions were commonly affected.
With changing behaviour of these
bacteria even perfectly healthy individuals
are also seen to be getting infected.
PATHOLOGY
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People of all ages can be affected by
this disease.
In growing children the disease can
destroy parts responsible for their
spinal growth ( Growth Plates in
Vertebra). This makes Tuberculosis
of the Spine in Children different than
in adults.
These bacteria do not directly affect
bones and joints. The Primary
Focus of Infection is generally in
the lungs, lymph nodes, intestines
and other soft tissues.
Spine commonly receives bacteria
from such primary focus through
blood stream or through lymph
stream.
PATHOLOGY
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The vertebra body is
commonly affected.
The affected bone
undergoes progressive
destruction.
The cartilage cushion
between the vertebral
bodies ( Intervertebral
Disc ) commonly gets
destroyed.
The pus of various
thickness forms. In an
attempt to fight the
infection body produces
reactive tissue called
Granulation Tissue.
PATHOLOGY
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The destroyed bone looses
strength, collapse due to the
weight of the body above.
This produce local deformity
and displacement of
vertebra over each other.
The pus, granulation tissue
and the dead pieces of bone
called as Sequestra, get
squeezed out all around the
spine.
In the front they can form
Abscesses which can track
away and spread to different
body areas.
When the abscess,
granulation and sequestra
get squeezed out
backwards, they enter spinal
canal which contains
delicate Spinal Cord.
PATHOLOGY
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The pressure on the spinal cord and the
nerves can produce deficiency in the
function like loss of sensation,
weakness in the some body parts.
Sometimes this can be bad enough to
produce Paralysis below the level of
spinal destruction.
The destruction of the vertebrae in the
neck can produce paralytic affection of
both upper and lower limbs
(Quadriparesis/ Quadriplegia ).
The destruction of vertebrae below the
neck can produce paralytic affection of
both lower limbs ( Paraparesis /
Paraplegia ).
Control of the urinary bladder and
bowels may be affected.
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PATHOLOGY
The abscesses formed could be
hidden deep inside the body or
visible on the surface.
They are not as hot, warm and
painful as other commonly seen
abscesses.
They are therefore called as
Cold Abscesses.
The abscesses may burst out
leaving behind a track from
within which has an opening on
the body surface. This track
called as Sinus , keeps
discharging liquid pus, curdly
yellowish white material called as
Sequestra.
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The sinuses take long time to
stop discharges and dry up.
Causes for spreading of TB
1.
2.
3.
4.
HIV
proteïen energy malnutrition
Immuno depressed therapy
cronic degenerative disease
CLINICAL PICTURE
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1. Symptoms
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Fever
Night sweats
Anorexia
Weight loss
Localised back pain
2. Signs
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Kyphosis
Paravertebral swelling
Psoas abscess (lump in
the groin)
Protective stiff position
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1.
2.
3.
4.
5.
Neurological signs (if
there is neural
involvement)
Spinal cord
compression with
paraplegia
Paresis
Impaired sensation
Nerve root pain and/or
Cauda equina
syndrome
ANTERIOR SPINAL DECOMPRESSION IN HIVPOSITIVE PATIENTS WITH TUBERCULOSIS
Figure 1a – Anteroposterior radiograph showing tuberculosis of T10/11, with a paravertebral abscess (arrows).
Figure 1b – Radiograph at one month showing fixation of the allograft.
Figure 1c – Lateral radiograph at five years showing incorporation and partial remodelling of the allograft.
ANTERIOR SPINAL DECOMPRESSION IN HIVPOSITIVE PATIENTS WITH TUBERCULOSIS
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(A) Case 1: MRI showing an
epidural mass with cord
compression (arrow) of the
myelum and with extension
in the thoracic transverse
process and thoracic
paraspinal muscles.
(B) Case 1: sagittal T2
weighted image reveals
increased intensity in vertebral
body at Th10 and L2 (arrows)
with epidural extension and
compression on the conus.
(A) Case 1
(B) Case 1
ANTERIOR SPINAL DECOMPRESSION IN HIVPOSITIVE PATIENTS WITH TUBERCULOSIS
Figure 2
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Case 1: transversal
sections through the
vertebral bodies at levels
from Th10 to L2 at
autopsy show extensive
infiltration with Kaposi’s
sarcoma.
The yellow areas contain
massive necrosis.
Complications
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Vertebrale collaps with a kifoses
Spinal cord compression
Sinus formation
Paraplegia
Neurological complications of
Tuberculosis of the Spine :
Physical compression of the neural tissues like spinal cord
and nerves by the products of disease.
2. By inflammation of these neural tissues and their coverings
by the disease ( Meningitis / Arachnoiditis / Neuritis ) .
3. Fluid retention in the local tissues - ( Oedema )
4. By disturbances of the blood supply to these delicate neural
tissues by blockage of the tiny blood vessels by the
inflammatory local swelling or clotting. ( Vascular
thrombosis )
5. Due to chronic stretching of the neural tissue by stretching
over a bony sequestra or deformity due to progressive
angular growth or bony mal alignments.
The functional deficit can be as insignificant as tingling
numbness and mild weakness ( Paraparesis , Quadriparesis
) or as catastrophic as complete loss of sensations , power
and bladder- bowel ( Paraplegia , Quadriplegia ) control in
areas distal to the disease.
1.
The investigations which are
generally needed are :
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Routine blood counts with Erythrocyte Sedimentation Rate. ( ESR )
Simple X-rays of the involved area (Digital quality films if possible).
High resolution C. T. Scan.
M. R. I. ( Magnetic Resonance Imaging ).
Blood Immunoglobin Profile for Tuberculosis.
Sometimes the local tissue can be acquired by Aspiration by thick
bore needle ( Biopsy) is useful.
Any diseased material acquired during surgery is also studied.
This tissue helps in confirming the presence of tubercular bacteria.
These bacteria can be further studied for effectiveness of various
anti-bacterial drugs ( Antibiotic Sensitivity ).
TREATMENT
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1. Drug Treatment ( Chemotherapy ) :
 Drugs form the mainstay of the management of Spinal
Tuberculosis.
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Presently very effective Chemotherapeutic drugs are available.
 Due to various reasons bacteria resisting many drugs are
evolving ( Multi-Drug Resistance - MDR ).
 The drug regime, generally extending over 9 to 20 months. The
resistant cases would need very carefully planned
individualised medication plan.
2. Bed Rest :
 During the phase of destruction and during the period of
potential complications like developing neurological
compression, enforced Bed Rest is needed. The duration of rest
varies as per the case and is to be decided by the treating
Physician.
3. Spinal Braces :
Spinal Brace allows mobilization of the patient while the local
diseased area gets rest.
TREATMENT
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4. Surgery :
 If the disease is diagnosed in its early stage many a patient can
be treated without surgery.
 The surgery is no replacement for drug therapy.
 It is complementary to drugs.
 The surgery has 3 main aims.
 Debridement : Removal of diseased tissue (pus,
graunulation tissue, sequestra etc. ).
 Neural Decompression : To relieve the Spinal Cord and
nerves from the compressive effects of the disease.
 Stabilization : Restoring strength and stability of the
destroyed area by bone grafting ( fusion ) and if required by
instrumentation ( using metalic implants for internal
support of the spine ).
 Sometimes the surgery may be needed for correction of the
spinal deformity and to reduce the effects of growth
discrepancy produced by the disease.
When diagnosed promptly, treated properly and adequately,
tuberculosis of the spine has a good prospect of recovery.
Earlier the disease is caught in its course the better it is !
TREATMENT
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Indications for surgery include:
Neurological deficits
Ineffectiveness of medication
Spinal deformity associated with instability or pain
Abscess in the paraspinal region
Aims of surgery:
Confirm diagnosis
Relieve compression on the spinal cord and/or nerve root .
Correct spinal deformities
Drainage of pus
Surgical techniques include:
Anterior radical focal debridement
Posterior stabilization with instrumentation
PROGNOSIS
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Tuberculosis of the spine may last for months or years.
Treatment modalities are highly effective unless
complicated by drug resistance, severe spinal deformity
and/or neurological discrepancies.
Cord compression and the resultant paraplegia usually
responds well to chemotherapy.
Operative decompression greatly improves the recovery
rate if treatment with medication and/or chemotherapy
fails to show improvement.
Persistence of paraplegia may occur if the damage to the
spinal cord is permanent.
PROGNOSIS
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Early Onset Paraplegia : This usually occurs during the active
stage of the disease or due to local reactivation of the disease at an
already healed old disease. The weakness is often sudden and / or
rapidly deteriorating. This would need aggressive care by drugs and
if necessary by surgery.
When recognized early and treated appropriately, the outcome is
hopeful even if the recovery sometimes may be incomplete. Each
such case will have different reasons for such a complication and
these cases will have to be dealt with after comprehensive thinking.
Late Onset Paraplegia : This occurs after the active disease has
been controlled or cured. It usually happens due to slowly
progressing degenerative changes in the neural tissues.
The neurological difficulties may come on so slowly that it may be
too late before they are recognized. The structural changes in the
neural tissues may be nonreversible and permanent.
The outcome is often less rewarding and significant residual
functional deficiency may be a permanent feature for the patient.
PHYSIOTHERAPEUTIC AIMS
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Pain reduction
Muscle re-education, Muscle strengthening
Spasticity reduction
Improvement of functional independence
Improve circulation
Maintain ranges of motion
Improve balance and proximal stability
PHYSIOTHERAPEUTIC
MODALITIES
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1.
2.
3.
4.
5.
Combination Therapy: This includes:
Micropulse currents
Interferential currents
Customized exercise program including:
Stretching
Bobath
PNF matwork & techniques
Balance training
Gait training
Bibliography
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1. Brittish Society for Antimicrobial Chemotherapy. Pott's disease.
www.basc.org.uk (accessed July 8, 2009).
2. Hidalgo, Jose and Alangaden George. Pott Disease. 2008.
www.emedicine.medscape.com (accessed July 23, 2009).
3. King, Emily. What is Tuberculosis of the Spine? www.ehow.com
(accessed July 18, 2009).
4. Patient UK. Pott's Disease. October 18,2008. www.patient.co.uk
(accessed June 18, 2009).
5. Physio Line. Potts disease. www.physioline.in/ (accessed July 23,
2009).
6. Sawar, Muhammad, and Jawad Ahmed. Early Recovery after
Radical Anterior Surgery.September 1996. www.theprofessional.com
(accessed July 23,2009).