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Spinal tuberculosis and spinal infections
- 1. SPINAL INFECTIONS DR. VIJAYAANAND S Ist year Primary DNB
- 2.
- 3. INTRODUCTION Tuberculosis of thevertebral column , first described by Percival Pott and since associated with his name. Is a slowly developing disease, characterized by pain, spinal deformity and occasionaly paralysis
- 4. • Spinal tuberculosisis the commonest form of skeletal tuberculosis • About 50% of all cases of tuberculosis of bones and joints • Is usually secondary to primary elsewhere
- 5. ETIOLOGY CAUSATIVE ORG: • Mycobacteriumtubercule bacilli are gram positive , acid fast bacilli, aerobic , grows at temperature between 30 – 40 degree and can be grown on LJ medium • Can be killed by heat at 60 degree in 15 to 20 min. • Survives for many weeks in moist condition.
- 6. PREDISPOSING FACTORS • Malnutrition •Poor sanitation • Living in crowded areas • Close contact with TB patients • Exanthematous fever • Immunodeficiency states • Hiv and aids • Chronic alcoholism
- 7. PATHOGENESIS • A minimumof 2 t0 3 years is required between the primary and skeletal TB • Hematogenous dissemination from a infected visceral focus • Primary focus may be active or quiescent, apparent or latent • Either in lungs ,lymph glands , mediastinum, mesentry,or cervical region or other viscera
- 8. • The infectionreaches the skeletal system through the vascular channels generally the arteries as a result of bacillemia or rarely in axial skeleton through bastons plexus of veins • The disease begins as infection of a single vertebrae. • The primary error is a tubercular endarteritis the marrow is converted into pale myxomatous tissue in the devitalized tissue, a tuberculous follicle develops until it is visible to naked eye as a small yellow gray nodule.
- 9. • The centreof the body being caseous the superimposed weight of the verterbral column is now borne by fragile shell of compact bone , which sooner collapses resulting the angular deformity – kyphus, gibbus or hunch back. • The IV disc in not involved primarily because it is a relatively avascular structure • The involvement of paradiscal bone effects its nutrition and this altered or necrosed disc may be involved by the infection later.
- 10. • The cartilaginousplate which acts a barrier once destroyed leads to disc invasion and destruction rapidly.
- 12. Most common levelof lesion is lower thoracic and thoracolumbar region. Thoracic is most commonly involved because Incresead stress of weight bearing Relatively large amount of spongy tissues Close relationship between cysterna chyli, thoracic duct and anterior surface of the vertebral body. Role of trauma- repeated mechanical stress in the mobile and weight bearing parts of the body results in minor hematoma or bone marrow edema Trauma activates the latent tuberculous focus
- 13.
- 14. TYPES OF VERTEBRALLESIONS Paradiscal type: • Commonest • Adolescents • Spreads through epiphyseal arteries • Involvement of adjacent bodies with decreased disc space
- 16. Central type: • Children •Either through baston’s plexus or through branches of posterior vertebral artery • Normal bony trabecuale lost • Reduction of disc space is minimal • Concentric collapse Anterior type: • Common in thoracic region • Begins underneath ALL • Anterior shallow erosion of vertebral bodies on xray • Collapse of body and decreased disc space are minimal • Clinical pictures resembles intraspinal tumor and hence known as spinal tumor syndrome
- 17. Posterior type : •Lesion may be in pedicle, transverse process, laminae, or spinous process • Higher incidence of neurological deficits • Pedicle and post articulation are destroyed as a result combination of both lateral deviation and rotation has been observed • Lateral shift and scoliosis may also be seen
- 18. Articular type: • Involvesfacet joints • Associated with radiculopathy • Very less incidence • Common in elderly
- 19. CLINICAL FEATURES • Equalsex predilection • Common in first three decades • Insidious in onset • Back pain is common presenting symptom • Diffuse later localized • Stiffness very early symptom • Is a protective mech wherein the paravertebral muscles go into spasm to prevent the movement
- 20. • During sleepthe muscle spasm relaxes – night cries • Pressure symptoms:dysponea, dysphagia, hoarness of voice, inability to extend hip(psoas abscess) • Deformity:gradually increasing promince of spine- gibbus
- 21. • Paraplegia: • Otherconstitutional symptoms: • Weakness, loss of weight, loss of appetite, evening temp, night sweats.
- 22. • Signs: • Ongeneral ex: Signs of anemia, debilities, involvement of lungs, lymphnodes Local attitude: Upper cervical: wry neck Upper thoracic: militiary position Lower thoracic:alderman”s gait Upper lumbar:prominent abdomen Lower lumbar:increased lordosis
- 23. Upper cervical Wryneck Lower cervical The head is thrown backwards and to one side and may be supported by hand Upper thoracic Militiary attitude: Shoulders are raised and the arms and shoulders drawn backwards The head appears sunken, owing to apparent shortening of the neck Lower thoracic Alderman”s gait: Thorax and head thrown backwards the abdomen is promient Patient walks with legs apart and waddles
- 24. • Gait • Tenderness: to pressure and percussion at local site • Movements: decreased in all directions mostly forward flexion • Neurological deficits:paraplegia or quadriplegia or paresis with or without region of involvement of bowel and bladder • Deformity: kyphotic deformity is common
- 25. Angulation of spine(kyphosis) • Result of collapse of affected vertebrae • 1 0r 2 – knuckle • 3 or more- wedge collapse - angular kyphosis • Large number- round kyphosis • Scoliosis • Lordosis:to compensate the kyphosis
- 26. COMPLICATIONS • Cold abscess •Paraplegia‘ • Sinuses • Secondary infections • Amyloid • fatality
- 27. Cold abscess • Commonestcomplication • 20 % of all cases • Body of vertebrae collapses – collection of tuberculous detritus consists granulation tissues,caseous matter, disintegrated bone marrow • It first collects under ALL – disseminates along one or other courses • Superficial abscess –bursts- sinus or ulcer
- 29. Neurological complications • Pottsparaplegia • Above L1 high incidence • Thoracic is common Classification • Based on motor involvement(goel , tuli, kumar) • Progressive severity of neurological deficits due to cord compression
- 30. goel , tuli,kumar stage Clinical features I negligible Patient unaware of neural deficits, physician detects plantar extensor II mild Patient aware of deficit but manages to walk with support III moderate Nonambulatory because of paralysis Sensory deficits less than 50 % IV severe III + flexor spasms/paralysis in flexion/flaccid/ sensory deficits > 50 % , sphincters involved
- 31. Cord involvement Betterprognosis Poor prognosis degree partial complete duration shorter Longer ( >12 months) type Early onset Late onset Speed of onset slow rapid age younger older General condition good poor Vertebral disease active healed Kyphotic deformity < 60 degree > 60 Cord on mri normal myelomalacia preoperative Wet lesion Dry lesion
- 32. Investigations Blood: • Hb :anemia • Tc:increased lymphocytes • Lymphocyte : monocyte ratio:5:1 is favorable • CRP Mantoux test:in doubtful cases in children with negative mantoux rules out TB
- 55. Radiological techniques: Xray APand Lateral views • Earliset finding is rarefaction present on either side of IVD space • Narrowing of disc space • Lytic destruction of ant vertebral end plate • Osteolytic destruction of vertebral body • Pathological collapse • Spinal deformity • Sclerosis reactive bone formation • Abscess shadow varies region of involvement
- 60. • K isthe angle of kyphosis by the technique of dickson • A line drawn from along the posterior margin of the bodies of the healthy vertebrae above and below the site of disease. • Angle k increases with increase in degree of kyphosis
- 61. CT- SCAN OFSPINE • Patterns of bony destruction. • Calcifications in abscess (pathognomic for TB) • Regions which are difficult to visualize on plain films, like : • 1. Cranio-vertebral junction (CVJ) • 2. Cervico-dorsal region, • 3. Sacrum • 4. Sacro-iliac joints. • 5. Posterior spinal tuberculosis because lesions less than 1.5cm are usually missed due to overlapping of shadows on x rays
- 62. MAGNECTIC RESONANCE IMAGING •highly sensitive &specicific for spinal TB • Spinal cord & soft tissue involvement • Detect marrow infiltration in vertebral bodies(EDEMA), leading to early diagnosis • Skip lesions • Changes of diskitis (EDEMA) • Assessment of extradural abscesses / subligamentous spread • Poor for calcification
- 66.
- 67. MEDICAL MANAGEMENT • Thereis a lack of consensus regarding the ideal duration of multidrug chemotherapy for spinal TB. • WHO recommends nine months of treatment for TB of bones and joints (2HREZ + 7 HR) because of the serious risk of disability in addition to difficulties in assessing treatment response.
- 68. Current guidelines • Allcases of bone and joint TB – extended ATT • It includes two months of intensive phase and 10-16 months of continuation phase For spine • 2 HRZE and 10 HRE upto 18 months • Repeat Xray every third month • MRI at 6 , 9 , 12 , 18 months • At the end of the treatment, Follow up every six months for two years
- 71. MDR TB • TBis defined as resistance to at least both Isoniazid and Rifampicin. • Extensively drug-resistant tuberculosis or XDR- TB is defined as resistance to any fluoroquinolone and at least one injectable second-line antibiotic in addition to Isoniazid and Rifampicin resistance
- 72. • primary reasonsfor the emergence of MDR strains, unscientific use of multi-drug chemotherapy by clinicians, making it one of the most dangerous iatrogenic creations. • India ranks second amongst the high-burden MDR-TB countries.
- 73. • 1. Earlydetection of MDR and prompt initiation of effective treatment are important for successful outcomes • 2. A biopsy is a must, and all efforts must me made to culture the organism to obtain drug sensitivity testing. • 3. A lab competent in microbiological testing should be chosen. • 4. It is imperative to involve a chest physician or an infectious disease specialist for treatment. • 5. Never add a single drug to a failing regimen • 6. MDR-TB regimen should be composed of at least five drugs likely to be effective, including four second-line anti-TB drugs that are likely to be effective plus pyrazinamide
- 74.
- 75. INDICATIONS • Paraplegia duringconservative treatment (6 weeks) • Paraplegia worsening during treatment (6 weeks) • Complete motor loss for 1 month despite of conservative treatment • Paraplegia with uncontrolled spasticity • Severe and rapid onset paraplegia • Severe flaccid paraplegia/ sensory loss
- 76. OTHER INDICATIONS: • Spinaldeformity • Childhood spine tuberculosis • Disease (Poor response to medical treatment) • Drug resistance • Diagnosis in doubt
- 77. Surgical management • Anteriorspinal cord decompression and reconstruction • Posterior instrumentation without anterior column reconstruction • Posterior approach with anterior column reconstruction • Anterior and posterior approach
- 78. Anterior spinal corddecompression and reconstruction As tuberculosis affects the anterior spinal column, anterior debridement and fusion has long been the gold standard of treatment. It has several advantages, which include direct access to pathology, safe and effective decompression without handling of the spinal cord and optimal reconstruction of the anterior column without damaging intact posterior elements.
- 79. • In patientswith extensive spinal destruction (more than 2 VB loss in the thoracic spine and more than 1 VB loss in thoracolumbar and lumbar spine) or severe kyphosis, standalone anterior spinal instrumentation is biomechanically inferior to posterior pedicle screw construct
- 80. • In thepast few decades, surgeons have gained expertise in accessing the anterior column via the posterior approach, and the indications for a standalone anterior surgery are dwindling.
- 81. Posterior instrumentation without anteriorcolumn reconstruction • Tuberculosis presents as posterior element disease with spinal cord compression. • In these patients, a standalone posterior approach is an obvious choice • In patients with less severe anterior column destruction, a posterior approach to decompress the spinal cord via transfacetal or transpedicular approach may be successful
- 82. • • As theantibiotics heal the anterior column and restore its integrity, the posterior instrumentation helps to maintain spinal alignment. • However, frequently the technique of spinal cord decompression via a posterior approach may involve excision of anterior column sufficient enough to warrant grafting of anterior column
- 83. Posterior approach withanterior column reconstruction • This approach is most popular to treat spinal tuberculosis of the thoracic and lumbar area. • The posterior approach is the workhorse of a spinal surgeon, and most surgeons are far more comfortable with it compared to the anterior approach
- 84. • As pernecessity, a progressive sacrifice of the posterior elements can provide increasing access to the anterior column. (Transfacetal, transpedicular, extracavitary lateral approach) • The approach also may involve spinal cord handling if one is not careful, and frequently a less experienced surgeon may end up doing a suboptimal job fearing injuring to the neural structures.
- 85. Anterior and posteriorapproach • Extensive anterior column destruction (3 or more vertebral bodies in thoracic spine or more than 1 vertebral body in the lumbar spine) with or without severe kyphosis, warrants a global access to take advantages of both anterior and posterior approach
- 87. • Usually, posteriorapproach is performed first to correct the alignment and stabilize the spine followed by anterior spinal cord decompression • reconstruction using a structural graft or cage. • A global approach can be morbid and potentially could be staged to avoid complications.
- 88. Take home message •Clinical features can be subtle, and the clinician needs to have a high degree of suspicion for spinal tuberculosis to be able to diagnose this infection early. • There are no radiological features that are pathognomonic for spinal tuberculosis • A biopsy is recommended not only for diagnosis but also to treat it with effective antibiotics. • New diagnostic tests, such as GeneXpert and LPA, can be used to diagnose MDR-TB early in the course of treatment • Surgeons who treat spinal tuberculosis should follow recommended guidelines when prescribing multi-drug chemotherapy • It is advisable to involve a chest physician or an infection disease specialist early in the course of treatment.
- 89. • Management ofMDR-TB is complex and potentially morbid, and all efforts should be taken not to generate iatrogenic cases of MDR-TB by prescribing irrational and unscientific chemotherapy • Surgical management is reserved for complications of spinal tuberculosis. • Childhood spinal TB can have a malignant progression of deformity, in spite of effective medical management and these should be identified early. • The treating physician or orthopedic surgeon should be cognisant of the indications for surgery and make an appropriate referral to a spine surgeon, especially
- 90. BRUCELLOSIS • Brucellosis resultsin a noncaseating, acid-fast– negative granuloma caused by a gram-negative capnophilic coccobacillus. • individuals involved in animal husbandry and meat processing (workers in abattoirs). • Symptoms include polyarthralgia, fever, malaise, night sweats, anorexia, and headache.
- 91. • Bone involvement,most frequently of the spine, occurs in 2% to 30% of patients. • The lumbar spine is the most frequently involved spinal region. • Radiographic changes of steplike erosions of the margin of the vertebral body require 2 months or more to develop.
- 92. Brucellosis of lumbarspine. Note vertebral sclerosis, spondylolisthesis, steplike irregularity in anterior vertebral body, and anterior osteophytes
- 93. • Treatment usuallyconsists of antibiotic therapy for 4 months and close monitoring of the Brucella titers. • Nas et al. recommended 6 months of antibiotic therapy (rifampicin and doxycycline) with surgery for spinal cord compression, instability, or radiculopathy.
- 94. FUNGAL INFECTIONS • Fungalinfections generally are noncaseating, acid-fast– negative infections. • They usually occur as opportunistic infections in immunocompromised patients. • Symptoms usually develop slowly. • Pain is less prominent as a physical symptom • than in other forms of spinal osteomyelitis.
- 95. • Direct cultureby biopsy is the only method of absolute determination of the infecting organism • Aspergillus and cryptococcal infections are of special note with regard to spinal infections. • predominant lumbar involvement and neurological involvement.
- 96. • Pain, tenderness,and an elevated ESR and CRP are the most common symptoms. • Cryptococcal infection is a less opportunistic but more prevalent fungal infection. • These organisms are found in avian excreta and usually infect the human respiratory system.
- 97. • Radiographs showlytic lesions that on biopsy reveal non–acid-fast, caseating granulomas without pus. • The indications for radical surgery are the same as for tuberculosis.
- 98. EPIDURAL SPACE INFECTION •The incidence of this infection is increased in immunosuppressed patients. • direct extension from infected adjacent structure, hematogenous spread, and iatrogenic inoculation. • Epidural abscess usually spans three to five vertebral segments.
- 99. • Spinal epiduralabscess caused by direct extension from a vertebral osteomyelitis usually is on the ventral side of the canal anterior to the thecal sac. • Clinical findings : • (1) a more rapid development of neurological symptoms (days instead of weeks); • (2) a more acute febrile illness; and • (3) signs of meningeal irritation, including radicular pain with a positive straight-leg raising test and neck rigidity
- 100. • MRI iscrucial to the determination of diagnosis • A few authors have reported successful treatment without surgical drainage. • For selected patients with an epidural abscess presenting with back pain alone or neurological symptoms that have been stable for more than 72 hours follow-up is necessary • any deterioration of the patient’s neurological status or development of systemic sepsis requires urgent surgical decompression.
- 101. • Acute orchronic isolated dorsal (posterior), lateral, and some ventral (anterior) infections are best treated with total laminectomy. • Epidural infections associated with osteomyelitis are best exposed by anterior or posterolateral exposures that allow treatment of the osteomyelitis and the epidural infection.
- 102. POSTOPERATIVE INFECTIONS • Therate of postoperative spine infections ranges from less than 3% in discectomies and laminectomies to approximately 12% in patients with instrumented fusions. • Increased exposure and blood loss, increased operative time, and increased dead space. • Age older than 60 years, previous surgical infection, poorly controlled diabetes, obesity, alcohol abuse, and smoking.
- 103. OPERATING ROOM • Prophylacticantibiotics should be given 30 minutes • prior to the incision and redose after 3 to 4 hours or 1500-mL blood loss. • Reduce traffic in and out of the operating room. • Release soft tissue retraction regularly. • Irrigate regularly. • Maintain strict aseptic techniques. • Close and seal wounds. • Maintain sterile dressings in the immediate • Postoperative period unless the wound is chemically sealed.
- 104. POSTOPERATIVE MANAGEMENT • Concomitantinfections (e.g., urinary tract infections, pneumonia) should be aggressively evaluated and treated. • Sterile dressings should be maintained for 48 hours. • Nutritional status of the patient should be carefully maintained, particularly during the postoperative period
- 105. PYOGENEIC VERTEBRAL OSTEOMYELITIS •Usually caused by s.aureus (hematogenous spread) • Risk factors: old and debiliated patients , IV drug users • Recent history of pneumonia, UTI, skin infections, immunologic compromise, • Unremitting spinal pain at any level is characteristic • Neurologic deficits seen around 40 % in older patients, mostly in cephalic level of spine • Laboratory studies – elevated ESR, CRP and WBC count
- 106. Plain radiographs shows •Osteopenia • Paraspinous soft tissue swelling • Erosion of vertebral end plates • Disc space destruction • Gadolinium enhances the MRI sensitivity
- 107. Treatment: Non operative: • Aftertissue diagnosis 6 to 12 weeks of IV antibiotics is the treatment of choice Operative: • Open biopsy indicated when tissue diagnosis has not made • Anterior debridement and strut grafting are for refractory cases. • May required posterior stabilization
- 108. osteodiscits • Blood borneinfections can primarily invade the disc space in children • S.aureus is the most common offender , gram negative org are common in older patients • Children are most common affected • History – may or may have spinal procedures as spinal injection
- 109. • Inability towalk or stand • Back pain with tenderness • Restricted range of motion • Laboratory studies: elevated ESR, CRP, WBC Imaging: • Loss of lumbar lordosis • Disc space • End plate erosions • Findings do not occur until 10 days to 3 weeks
- 110. Treatment: • Typically medical: •Obtain percutaneous biopsy if possible • Targeted antibiotic therapy once culture and sensitivity completed.
- 111. Surgical includes : •Patient medically systemically ill • Evidence of epidural abscess • Unable to obtain percutaneous biopsy.