SPINE TB

SPINE TB/POTTS
DISEASE
Most common form of skeletal TB.
Accounts for 50% of all cases of skeletal
TB.
Neurological complications are the most
crippling
complications of spinal TB.

REGIONAL
DISTRIBUTION
Cervical

(12%)
Thoracic(42%)
Lumbar (26%)
Sacral (3%)

Patterns of Vertebral
Involvement
Four
patterns :
Paradiscal
( common)

PATHOGENESIS
Progressive bone destruction leads to
vertebral collapse and kyphosis
Spinal canal can be narrowed by
abscesses, granulation tissue, or direct
dural invasion leading to spinal cord
compression and neurologic deficits.
Healing takes place by gradual fibrosis and
calcification of the granulomatous
tuberculous tissue. Eventually the fibrous
tissue is ossified, with resulting bony
ankylosis of the collapsed vertebrae.

 Paravertebral abscess formation occurs in

almost every case.
With collapse of the vertebral body,
tuberculous granulation tissue, caseous
matter, and necrotic bone and bone marrow
are extruded through the bony cortex and
accumulate beneath the anterior
longitudinal ligament forming cold abscess.

Clinical features

Back pain
Stif spine
Deformity
Cold abscess
Neuro deficit(spinal cord compression
with paraplegia, paresis, impaired
sensation, nerve root pain, or cauda
equina syndrome.)
Constitutional symptoms

DEFORMITY

Knuckle:
Prominence of one
spinous
process

Angular Kyphus :
Prominence of two or
more spinous
processes due to
destruction of two or
more bodies.

Gibbus:
Difuse kyphosis
due to
involvement of
more number of
vertebrae.

COLD ABSCESS
Pus produced at the
site of pathology
may stay at the
same vertebral level
or
May track down the
paths of least
resistance along the
fascial planes of
vessels or nerves and
present as a cold
abscess in diferent
regions far away from
the site
of
pathology.

 FROM T4 T 10
LESIONS;
Present on either
side of vertebral
body contained in a
thick walled sac
leading to a birds
nest abscess

PLAIN RADIOGRAPH

Reduced disc space

Blurred paradiscal
margins

Destruction of bodies

Increased
Prevertebral soft
tissue shadow

Decreased Lordosis

TREATME
NT

MIDDLE PATH REGIME

Rationale
All spine TB cases do not require
surgery and only those who do not
respond to conservative measures
should be operated

 Treatment

is on non-operative
lines with anti-tubercular drug,
rest & spinal braces
1.Rest: in hard bed or plaster
of Paris bed( in children)
2.Drugs :
.INH
INTENSIVE
(5mg/Kg) PHASE+Rifampicin (10mg/Kg) +ETB
(15mg/Kg) +
CONTINUATION
PHASEPZA(25mg/Kg) for 6 months
INH (5mg/Kg) +Rifampicin (10mg/Kg) for
next 12 months.

supportive therapymultivitamins,
hematinics if necessary &
high protein diet.
3.Radiographs & ESR: at 3-6
months interval
4.Gradual mobilisation:
with the help of spinal
braces

Indications of
surgery :

1. No progressive recovery after a fair

trial of
conservative t/t (3-4 wks)
2. Neurological complication develops
during
conservative treatment
3. Worsening of Neuro-deficit during
t/t
4. Pressure efects
(deglutition/respiratory)

Tuberculosis of joints
Arthritis
Hip
Knee
Ankle&Foot

Hip

Hip
Involvement in about 15 % cases of osteoarticular TB
Lesions can arise in acetabulum, femoral
epiphysis or metaphysis or spread to the hip
from foci in the greater trochanter

CLINICAL FEATURES
h/o previous TB infection or contact
Insidious onset, chronic course
Most pts are children
Prior constitutional symptoms
First symptom stiffness of hip with
a limp
Pain may be absent in early stages
Pain worse at night night cries

EXAMINATION

Look
Gait - stiff hip gait, antalgic, trendelenburg
Muscle wasting
Swelling due to cold abscess, Discharging sinuses
Flexion deformity, Limb length
Feel
Skin temperaturess, any swelling
Tenderness
Assess any pelvic tilt
Move
All mvts usually restricted due to pain and muscle spasm
Special tests
Thomas test
Bryants triangle/ Nelatons line
Galleazis test
Gauvains sign

Stage of arthritis

Peri-articular erosions
Ill-defined articular margin
Reduction
of
joint
space
(destruction of articular cartilage)
Lesions can usually be picked up
on CT before they are apparent on
plain radiographs

Stage of arthritis Peri-articular erosions

Ill defined articular
margins
Joint space reduced

GALLEAZI TEST
flexing theknees when
they arelying downso
that the feet touch the
surface and
theanklestouch
thebuttocks. If the
knees are not level then
the test is positive,
indicating a hip
dislocation.

Nelaton's line
-line drawn from
anterior
superior iliac spineto
thetuberosityof the
ischium. Greater
trochanterof thefemur
lies below this line, but
in cases ofiliacjoint
dislocation of thehipor
fractureof the
neck of the femurthe
trochanter is felt above
or in the line

Bryant's
triangle
-Quantitative

measurement of supratrochanteric shortening of

hip
-Measurements on the
afected and unafected

INVESTIGATION
Haemogram relative lymphocytosis
ESR
Mantoux test
Synovial fluid aspiration
AFB positive in 10-20% of cases
Cultures positive in 50% of cases

Aspiration of cold abscess for microbiology

Synovial Biopsy
More reliable
Cultures positive in 80% of pts
Histology
Granulomatous inflammation/ caseous necrosis
Melon seed bodies

RADIOLOGY
Earliest sign

A general haziness of the bones

Normal joint space
An area of rarefaction in the babcocks triangle
Increased joint space

Later
Lytic lesions with no or minimal reactive
sclerosis
Travelling or wandering acetabulum
Posterior dislocation of the hip
Mortar and pestle appearance
Protrusio acetabulare
Fibrous ankylosis

MORTAR AND PESTLE TYPE :

femoral
head and neck are grossly destroyed, collapsed and contained in a large
acetabulum

29

MORTAR AND PESTLE TYPE :

femoral
head and neck are grossly destroyed, collapsed and contained in a large
acetabulum

30

Treatment
In early stagesConservative treatment-which includes
1.
ATT
2.
General care
3.
Care of hip- The affected hip is put to rest by immobilisation
using below knee skin
Gentle hip mobilisation and sitting in bed for short period are started
during the period of traction. For the next 12 weeks, non weight bearing
walking is allowed with crutches followed by another 12 week period of
partial weight bearing. Unprotected weight bearing should not be
permitted early to avoid collapse and deformity.
. In stage 2- Partial synovectomy and curettage of osteolytic lesions
along with grafting.
. In stage 3- aim is to achieve fibrous ankylosis in a functional
position.

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Operative Management

In case of advanced disease where X-ray picture

suggests significant joint damage and normal joint
functions can not be regained. Surgical options
are:
Girdlestone arthroplastry- To provide a
painless, mobile but unstable joint.
Arthrodesis(artificial induction ofjoint ossificationbetween
twobones bysurgery)-To provide painless, stable but
fixed joint(patient unable to squat).
Corrective osteotomy
Total hip replacement
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Knee

Knee
Largest intra-articular space
Involved in about 10 % of osteo-articular
tuberculosis
Any age group
Focus of infection may be from:1.Synovium(MC)
2.Subchondral cancellous bone.
3.Juxta-articular osseous focus in the epiphysis.
4.Physeal plate.
5.Metaphysis.
6.Patella(rare)

Stage of synovitis
Osteoporosis, soft tissue swelling, joint /
bursa efusion.
Distension of supra-patellar bursa on lateral
radiograph of knee
Infection in childhood can lead to
accelerated growth and maturation resulting
in big bulbous squared epiphysis
Widening of the inter-condylar notch
(synovitis)

Examination
Pain and swelling in the knee- Gradual onset and later
increases and knee takes the attitude of flexion. There is
inflammatory exudates in the joint with supra patellar fullness
and filling of fossa on either side of patellar tendon.
The synovium and capsule becomes palpably thickened and
tenderDoughy swelling
Movements-In synovial disease,may be terminally restricted
movements,but as arthritis sets in there is pain accompanied
by muscle spasm.
Muscle atrophy of thigh muscles(quadriceps)
Cold abscess either arround the knee or in the calf
Sinus formation
Deformity-In the early cases mild flexion deformity and later
triple deformity due to spasm and contracture of biceps
femoris and tensor fascia lata.It is:--Flexion of knee
--Posteriolateral subluxation of tibia&
--Lateral rotation and abduction of the leg
36

Tuberculous arthritis of the

knee joint. Frontal radiograph
demonstrates
periarticular
osteopenia (black arrow),
peripheral osseous erosions
(white arrow), and relative
preservation of the joint
space.

37

Management
Aim is to achieve a painless mobile joint.But it is possible
in early stages.In later stages,some amount of pain and
stiffness persists in spite of treatment.
General care
Local care-In early stages the treatment is usually
conservative with antitubercular drugs and
immobilization in a below knee skin traction or an aboveknee POP cast till the disease is quiescent after which
the patient can be mobilized.

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Operative Treatment
Synovectomy: may be required in cases
of purely synovial TB,which is not
responding to conservative treatment or
doubtfull treatment.
Joint debridement: the pus is
drained,synovium excised and all cavities
curetted.
Arthrodesis: In advanced stage with
triple subluxation and cartilage
destruction.One such method is Charnleys
compression arthrodesis
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TB of Ankle and Foot

Accounts for less than 5% of osteoarticular TB.
Tarsals and the ankle joint are usually involved
together due to intercommunicating synovial
channels.
Most commonly starts as synovitis. Usually it
presents as synovial disease or extra-synovial soft
tissue disease associated with bony focus.
Most commonly affected bone is calcaneum
followed by talus,1st metatarsal, navicular and
medial 2 cuneiform bones.
Clinical and radiological features are same as of
other joints.
Synovial biopsy may be needed for the confirmation
of diagnosis
40

D Collapse and destruction of the os calcis with marked soft

tissue swelling and generalized osteoporosis. The infection is
in the os calcis, but the whole joint will 41eventually be

Tuberculous arthritis of the ankle joint

Sagittal T1-weighted MRI demonstrates hypointense periarticular

efusions (black arrows) with bone erosion of the
42 talus and tibia

Management
Antitubercular drugs along with pain killer(if
required)&genaral care.
POP cast to give rest: in 10 degree equines position.
An extensive,long standing disease requires arthrotomy
and synovectomy.
An isolates bony lesion should be curetted and large
cavities should be packed with bone grafts.
In extensive joint destruction,arthrodesis of ankle or
subtalar joint alone or together.

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