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Tuberculosis of Spine- Pott's Disease

General Considerations:

Tuberculosis: A systemic infectious disease, involving almost all organs of the body except- cardiac tissue, pancreas, Thyroid tissue.
Infectious agent:

Mycobacterium tuberculosis- human and bovine
Atypical mycobacterium- Avian and others

Mode of infection:

Inhalation
Ingestion
Inoculation

Pathology:

Basic Pathology- Chronic granulomatous lesion

Granuloma: Caseating, foreign body type. Langerhan’s type of giant cell.

Tuberculosis may be of 2 types: Primary and secondary

Primary sites of TB: Lungs, intestine, lymph nodes, skin, tonsil.

Secondary sites of TB: Other tissues of body.
Mode of Spread:

Haematogenous
Lymphatic
Direct
Transcolonic

Bone Tuberculosis:

It is a secondary type of TB. Commonest site is spine- about 50%.

Sites of Predilection:

Thoracic spine esp. lower thoracic.
Cervical spine
Lumbar spine esp. upper lumbar
Sacral spine

Pott’s Disease

# Tuberculosis of spine primarily involves the bone i.e.; vertebra causing vertebral osteomyelitis. Then it may spread to inter-vertebral disc leading to develop discitis. Then it may affect or involve neural tissue.

# TB spreads to bone/ spine through haematogenous route (vertebral venous plexus) or directly.
Pathology:

Pathology of TB
Pathology of Bone involvement
Pathology of neural tissue involvement

Pathology of Bone Involvement:

Osteomyelitis of vertebrae
Discitis
Collapse of vertebral body- pathological fracture( Wedge shaped collapse- compression collapse)
Paravertebral abscess, Prevertebral abscess, Epidural abscess
Deformity of spine- Kyphosis, kyphoscoliosis

Pathology of Neural Involvement:

Compression of spinal cord
Compression of spinal nerve roots and cauda equina. [Compression occurs by- Bone fragments, granulation tissue, Pus.]

Diagnosis of Pott’s Disease:

History
Physical Examination
Investigation

History:
General features of TB:

Low grade evening temperature
Weakness
Anorexia
Weight loss
Night sweating
Prostration
Cough
Haemoptysis

For bone involvement:

Pain over spine according to the site of invelvement
Swelling on the back
Deformity

For neural tissue involvement:

According to the level of involvement

Motor- Localized weakness, wasting
Secondary- Loss of sensation, altered sensation. Pain along the distribution of nerve root.
Autonomic- Retention or incontinence of urine and feces.

Physical Examination:

For tuberculosis and systemic disease
For bone involvement:
# Swelling over the back due to abscess or Gibbus (prominent spinous process of the wedge shaped collapse)
# Deformity (Kyphosis, kyphoscoliosis)
# Tenderness over the involvement
# Spine is shifted and painful on spasm of paravertebral muscle
For Neurological involvement: According to level of involvement
# Motor: (1) Paraplegia most common presenting feature, (2) Wasting of muscles either flaccid or spastic., (3) Decreased muscle power, reflexes either exaggerated or decreased or absent.
#Sensory: (1) Loss of sensation, (2) Sensory level will be found.
# Autonomic: (1) Urinary bladder may be distended or dribbling of urine, (2) Anal sphincter will be patulous.

Investigation:

For diagnosis of TB:
# Blood: ESR, Hb%, TC, DC
# Mantoux test
# Chest x-ray
For bone involvement
# X-ray spine Antero-posterior and lateral view. Findings: (1) Osteolytic lesions are near the metaphyseal region, (2) wedge shaped or compression collapse (3) Reduced intervertebral disc space (4) Paravertebral shadow (5) Deformity (6) Some fragments may be seen in spinal canal
# CT scan of spine
For diagnosis of neural involvement
# MRI
— condition of the cord
— Extent of compression over cord or root
— paravertebral collection
— Condition of vertebra
# Myelogram (not performed now a days)

Treatment:

Treatment of TB
Treatment for bone disease
Treatment for neural involvement
Treatment for paraplegia/ quadriplegia
Rehabilitation: with suitable occupation
follow up

Treatment of TB:

Antitubercular chemotherapy
General tuberculosis treatment

Treatment of bone disease:

Drainage of pus
Decompression
Stabilization by fixation and fusion.

Treatment of neural involvement:

Decompression of cor and roots of cauda equina.
Treatment of paraplegia:

Care of skin
Care of bladder
Catheteization (CISC- Cin intermittent Self catheterization
Incontinence: Condom catheter for male, Indwell catheter for female.
Care of bowel: Enema
Physiotherapy- passive movement.

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