This is the presentation sent by Dr Paresh Golwal -Past President GOA

1. Tuberculosis of spine
DR.PARESH P.GOLWALA
PROFESSOR AND HEAD, DEPT. OF
ORTHOPAEDICS
S.B.K.S.M.I.R.C.,
PIPARIYA
Dr. Paresh Golwala
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2. HISTORY
RIGVEDA AND ATHARVA VEDAS:
3500 – 1800 BC
 CHARAKA AND SUSHRUTA:
1000 – 600 BC
 HIPPOCRATES: 400 – 300 BC

DESCRIBED AS YAKSHMA
Dr. Paresh Golwala
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3. HISTORY
PERCIVAL POTT – (1779)
DESCRIBED TB SPINE AS A KIND OF
LOWER LIMB PALSY WHICH IS
FREQUENTLY FOUND TO ACCOMPANY
A CURVATURE OF THE SPINE
 LAENAEC – (1781- 1826)
IDENTIFIED AND DESCRIBED
TUBERCLE BACILLI IN 1817
 BCG VACCINE IN 1945
 SPECIFIC AKT IN 1948-1951

Dr. Paresh Golwala
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4. TB SPINE
Disease of developing world
 Affects young wage earners

Dr. Paresh Golwala
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5. NATURAL COURSE
WITHOUT
CHEMOTHERAPY
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6. STAGE OF ONSET
Lasts 1 month to 1 year
 Localised disease --- warm, tender
swelling --- Localised osteoporosis
with minimised destruction

Dr. Paresh Golwala
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7. STAGE OF
DESTRUCTION
Lasts 1 to 3 years
 Gross destruction of bones and joints
with deformity, subluxation,
contractures and abscess formation
abscess ruptured
 Sinuses develop and secondary
pyogenic infections occur
 LOWERED Defence mechanism
 Severe cachexia

Dr. Paresh Golwala
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8. STAGE OF
DESTRUCTION
Miliary tuberculosis and/or meningitis
 1/3rd of patients die

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9. STAGE OF REPAIR AND
ANKYLOSIS







Occures 3 years after onset
Improved general condition
Resorpton of abscesses
Healed sinuses
Destroyed bones remineralised
Fusion in deformed position(kyphosis)
Unsound ankylosis-unsatisfactory
(pain on movement and weight bearing)
Dr. Paresh Golwala
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10. SO,OVERALL RESULTS
WITHOUT AKT ARE
UNSATISFACTORY

11. LEVEL OF OCCURANCE




Dorsolumbar Junction
Dorsal
Lumbar
Cervical
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12. BOVINE T.B.
Abdomen
Pelvic venous plexus
Vertebrae
Dr. Paresh Golwala
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13. TWO TYPES OF
AFFECTION

In children the blood supply is central to
the vertebrae. That is why the affection is
central .

In adults the blood supply is paradiscal
that is why the affection is paradiscal .
Dr. Paresh Golwala
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14. PATHOLOGY
Bacteraemia
Deposition in Bone
Necrosis + Casseation with Hyperemia
(increased blood supply)
Cavity in the bone
Surrounding Osteoporosis
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15. PATHOLOGY CONTD… …
Weight bearing stimulus
Collapse of vertebrae
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16. PATHOLOGY CONTD… …






No blood supply to disc that is Nucleus pulposus
intervertebral disc
Nutrition to disc is from paradiscal region.
90% of disc content is water.
With the affection in paradiscal region the disc gets
dehydrated and looses height --- reduction in disc
space.
With surrounding cavity and destruction the disc is
resorbed.
This leads to pus formation and the surrounding
ligaments are swollen --- soft tissue shadow.
Dr. Paresh Golwala
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17. PATHOLOGY CONTD… …



Casseation – pus formation
In x-ray --- soft tissue shadow
So differentiate from malignancy
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18. COLD ABSCESS



2 or more vertebra affected.
Pus spread due to pressure
If spread anteriorly
– Cervical --- posterior to esophagus /
oropharynx / nasopharynx
– Dorsal --- along the ribs
– DL / Lumbar --- along psoas sheath --psoas abscess
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19. 
If spread posteriorly
– Pressure over the cord
– Causes Paraplegia or Quadruplegia
depending on the level
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20. POTT’S PARAPLEGIA




Pus under pressure
Collapse of vertebrae --- Sequestrum
Meningitis --- Pachy Meningitis
Thrombosis of artery supplying spinal
cord (Artery of Adam & Kiewz) (At D9-10
level)
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21. CLINICAL
FINDINGS
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22. SYMPTOMS








Backache
Backache --- Radiating Pain
Backache With Pus Discharging Sinus,
Cold Abscess
Backache With Neurological Deficit
Constitutional Symptoms
Night Pain / Night Cries
H/O Immuno Suppression
Any age
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23. SIGNS






Gibbus --- Angular Kyphosis
Smooth Kyphosis --- 2-3 Vertebrae
Muscle Spasm --- Coin Test
Level Of Tenderness
Cold Abscess
Neurological Deficit
–
–
–
–
–
Lumbar --- LMN
D.L. Junction --- Mixed
Dorsal --- UMN
Cervical --- LL – UMN, UL – LMN
Lesion --- C1-CL1 –UL-UMN
C5 – T1 – UL - LMN
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24. INVESTIGATIONS

X-RAY:
–
–
–
–
–
–



Soft Tissue Shadow
Collapse
Osteoporosis
Erosion
Adult --- Decreased / No Disc Space
Children --- Central Lesion
Hb, TC, DC, ESR --- Increased --- Prognostic
Importance
Liver Function Test
MRI --- Neurological Deficit
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25. AIM OF TREATMENT
Eradication of infection
correction / prevention of angular
deformity
recovery of neurological deficit
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26. TREATMENT

CONSERVATIVE :
– Bed rest --- 3 months --- Wedging /
compression is more than 50%
– AKT --- DOTS Category 1
– Rifampicin, Isoniazide, Ethambutol,
Pyrizinamide along with Inj. Streptomycin
--- preferably for two months
– Rifampicin, Isoniazide, Ethambutol for
another 7 to 8 months depending on
healing --- ESR / X-RAY / Clinical
Dr. Paresh Golwala
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27. 
OPERATIVE :
–
–
–


Backache Alone --- Conservatively
Backache With Cold Abscess
Backache With Neurological Deficit
Historically in India mid path regime was followed with
the advent of MRI and after study from Rajshekharan
more emphasis has been put on to prevent post
Tuberculous Kyphosis --- internal Gibbus
Hongkong school believes in anterior curettage and
stabilization of vertebrae --- gold standard treatment
Dr. Paresh Golwala
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28. NEWER INDICATIONS OF
SURGERY
Global disease: instability
 Long segment disease > 3 vertebrae
with severe kyphosis
 Spinal cord compression:

Pus
Granulation tissue
Caseous tissue
Discs
Bony sequestra
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29. 
Cord compression on MRI does not
correlate with neural deficit (76%
encroachment of canal may also have
intact neural state)
Dr. Paresh Golwala
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30. INTRINSIC CAUSES OF
CORD COMPRESSION
Cord oedema
 Myelomalacia
 Direct affection of meninges and cord
 Infective thrombosis and endarteritis
 Poor prognosis

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31. 
PARAPLEGIC PATIENT:
– Not responding to drugs after 1 month of
AKT
– Sudden bladder bowel involvement

RELATIVE INDICATIONS:
– Kyphosis --- severe
– Children costo transversectomy
Dr. Paresh Golwala
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32. DECOMPRESSION
PARAPLEGIC / NEUROLOGICAL
DEFICIT






Rib
Transverse process
Pedicle
Curette vertebrae anteriorly
Leaves big void anteriorly --- instability --kyphosis --- later internal Gibbus
Not a favoured procedure now a days.
Dr. Paresh Golwala
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33. ANTERIOR SURGERY




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Gold standard treatment
Radical surgery
Deals with the precise pathology
Stabilizes vertebrae
Decompresses thoroughly
Done in our institute
Dr. Paresh Golwala
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34. PREFERRED
APPROACHES






Cervical Spine --- Anterior
Cervico Dorsal --- Thoracotomy Through
Second Rib
Dorsal --- Thoracotomy
Dorsolumbar Junction --- Thoraco
Abdominal Approach
Lumbar --- Retroperitoneal
Lumbosacral --- Anterior Laparotomy
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35. INSTRUMENTATION
Anterior : preferred by most
 Posterior : TULI et al

Dr. Paresh Golwala
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36. BONE GRAFTING
Tricortical iliac crest : good ,
preferred
 Rib graft : good osteo-induction
likely to fracture or
collapse
 Fibular
good strength
femoral :
and
tibial
poor osteo induction

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37. HARDWARE
Anterior plating or screw and rod
fixation
OR
 Post segmental pedicle screw fixation

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38. RAJNIBEN PATIDAR,
25/F FRANKEL’S GR- D
PREOP: L3-4 KOCH’S WITH PSOAS
ABSCESS
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39. Dr. Paresh Golwala
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40. RAJNIBEN : IMMEDIATE POST
OP
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41. RAJNIBEN : 3 MONTHS POST
OP
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42. YOGESH PATEL, 18/M,
KOCH’S C 3, FRANKEL’S GR- D
PREOP
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43. Dr. Paresh Golwala
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44. YOGESH : IMMEDIATE POST
OP
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45. YOGESH : 3 MONTHS POST
OP
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46. KANJIBHAI,34/M, KOCH’S D3-4
FRANKEL’S GR- A
PREOP
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47. Dr. Paresh Golwala
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48. POST OP
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49. MALE PATIENT – 60
YEARS WITH HUGE COLD
ABSCESS – PREOP - MRI
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50. MALE PATIENT – 60 YEARS WITH HUGE COLD ABSCESS – PREOP – CT SCAN
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51. MALE PATIENT – 60
YEARS WITH HUGE
COLD ABSCESS POSTOP
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52. MALE PATIENT – 60
YEARS WITH HUGE
COLD ABSCESS POSTOP
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53. COMPLICATIONS
 Paraplegia
– Difficult to rehabilitate
– Bed sores
– UTI
 Unyielding
TB infection associated with
HIV may lead to death.
Dr. Paresh Golwala
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54. AUTONOMIC
DYSFUNCTION
SPINAL CORD LESION WITH
NEUROLOGICAL DEFICIT IS
ASSOCIATED WITH SIGNIFICANT
DYSFUNCTION OF SYMPATHETIC
NERVOUS SYSTEM
 LOSS OF SUPRA-SPINAL CONTROL
OF SYMPATHETIC NERVOUS
SYSTEM
 ASSOCIATED WITH CERVICAL AND

Dr. Paresh Golwala
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55. AUTONOMIC
DYSFUNCTION CONT…

COMPLICATED BY 3
PHENOMENON BELOW THE LEVEL
OF LESION:
1) REDUCED SYMPATHETIC
ACTIVITY
LEADS TO ORTHOSTATIC
HYPOTENSION
2) LOW RESTING BLOOD
PRESSURE
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56. Dr. Paresh Golwala
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