1. TB SPINE with Neurology-
“ What is expected from you”
.

2. How do I present a case of TB Spine
with neurological deficit
 How to examine a spine case
 How to diagnose TB spine
 What are the other possible diagnosis
 How to differentiate from them clinically
 How they are investigated in your hospital
 Possible options in management
 How is it managed in your hospital
 Common problems involving spine
 Common problems causing similar deficit

3. How to examine a spine case
 The sequence to present the case…like a
CNS case protocol or ortho way-
 Easy steps to find the motor and sensory
level-
 Specific findings and tests to be done in a
spine with neurology case
 What to say of bladder and bowel
 Should we do all the tests for sensations
like vibration, fine touch etc

4. The sequence to present the case…like a
CNS case protocol or ortho way
 You should present the case as you will
proceed to do spine exam

5. History should take into consideration
Pathology part – TB and its D/D
Area of involvement – Spine
Complications – neuro deficit

6. History
 TB – general symptoms and local symptoms
specific to area of involvement
 Leading questions specific to TB of spine
 Negative history of DDs
Ankylosing spondylitis
Disc deg
Tumors
Septic
Trauma

7. History
 Common problem
 Perfect diagnosis
 Not able to justify that

8. Clinical exam of spine


9. Vital to the examination of the spine is to
have a good knowledge of the anatomy of this
area.
Clinical examination of spine

10. Clinical examination of spine
 Gait
 Inspection
 Palpation
 Movement and measurement
 Neurology of the limbs
 Special tests
 SI joints
 CNS exam

11. Patient Walking
 Observe the gait

12. Patient Standing
 Remember to inspect from all sides (front,
laterally and from behind):

13. Inspection
1. Attitude and deformity
2. Position of head, shoulder, scapula
3. swellings, sinus, skin
4. Gait

14.  Skin
– Scars (surgical scars)
– Sinuses (deep infection)
 Lumps: abscess, prominent
paravertebral muscle spasm

15.  Spine
– Kyphosis (exaggerated or reduced)
– Lumbar lordosis (exaggerated or
reduced)
– Gibbus :

16.  Expose the back and legs.
 Look for the following:
– sinuses; scars and nodes
– deformity and asymmetries - postural or
permanent; direction / plane i.e. kyphosis or
tilt
– muscle spasm, fasciculation, wasting -
specifically calf and buttock
– legs / arms - wasting, movement, muscle
imbalance, size

17. palpation
 You have to know your anatomy to know what
you are feeling!
 With the patient standing and then perhaps
later, lying supine, palpate the back for the:
– skin temperature
– deformity of the spine - steps or a steady contour?

18. vertebral tenderness - localised or general ?
paraspinal spasm and muscle tenderness
sacro-iliac tenderness in sacroilitis

19.  Elsewhere:
– feel for peripheral pulses
– palpate groin and abdomen for abscesses
– Chest, abdominal, rectal examination

20. Movts and measurements
 Measurement of mobility of the spine
 Movements
 Chest expansion
 costovertebral movements are gauged by
asking the patient to breathe in and out: the
distance between maximal inspiration and
expiration is normally 5cm.

21. Special tests
 Straight Leg Raising Test (SLR)
 Bowstring Sign
 Crossed SLR
 Reverse sciatic tension test
 Schober's test
 Femoral stretch

23.  the patient is then asked to lie supine and the
straight leg raise test is performed.
 carry out neurological testing of power;
 sensation -
 reflexes -
 do a rectal examination - check tone, power,
sensation
Neurological examination

24.  Easy steps to find the motor and sensory
level
 What to say of bladder and bowel-
 Should we do all the tests for sensations
like vibration, fine touch etc
 What the examiner is looking in a spine
neurology case

25. Neurological assessment
 Neurological assessment is an essential part of
the examination of the spine.
 The examination should involve a full
assessment of muscle wasting, fasiculation,
tone, power, coordination / proprioception,
sensation and reflexes.
 perianal reflexes and sphincter tone should be
tested.

26. NEUROLOGICAL EVALUATION

28. SEGMENTAL NEUROLOGY
 When examining the cervical spine it is essential to
examine the segmental neurology.
 Root lesions may be indicated by weakness in the
upper limbs in a segmental distribution, with loss of
dermatomal sensation and altered reflexes.
 If cervical cord compression is suspected the lower
limbs should also be examined specifically looking for
upgoing planters and hyperreflexia.

30. Sensation.
 Know your C5 to T1 dermatomes.
 Test light touch and sharp/dull sensation.

32. REFLEXES
 Muscle stretch reflexes. Test the following
reflexes:
 Biceps - C5/6
 Brachioradialis - C5/6
 Pronator - C 6/7
 Triceps - C7/8

34.  Sensation
 Know your L4 to S1 dermatomes
 Light touch, sharp/dull sensation

38. Some tips
 get the patient to stand on their toes, thus
checking plantar flexion of the foot and the S1
nerve root.
 If necessary, test each foot separately, giving
them some support with an outstretched arm.
 Ask them to rock onto their heels - test of L4/L5

39.  Should we do all the tests for sensations
like vibration, fine touch etc
 What the examiner is looking in a spine
neurology case

40.  The examination should include the following:
– Careful assessment of spine
– Examination for abscesses
– Abdominal evaluation for psoas / iliac mass
 Meticulous neurologic examination

41. TB SPINE - HISTORY AND
CLINICAL EXAMINATION

42. TB Spine – History
 The presentation of Pott disease depends
on the following:
– Stage of disease
– Affected site
– Presence of complications such as
neurologic deficits, abscesses, or sinus
tracts

43. TB Spine – History
 The reported average duration of symptoms at
diagnosis is 4 months but can be considerably
longer, even in most recent series.
 This is due to the nonspecific presentation of
chronic back pain.

44. TB Spine – History
 Back pain is the earliest and most common
symptom.
– Patients with Pott’s disease usually
experience back pain for weeks before
seeking treatment.
– The pain caused by Pott’s disease can be
spinal or radicular.

45. TB Spine – History
 Insidious onset of localised pain in the spine.
 This is usually accompanied by fever, malaise,
anorexia and weight loss.
 Clumsiness in walking and weakness in lower
limbs may be present.
 There may be evidences of associated
extraskeletal tuberculosis
 Presence of hoarseness, dysphagia, respiratory
stridor or torticollis indicate cervical involvement.

46. TB Spine – History
 The onset of is usually insidious and of slow
evolution.
 Potential constitutional symptoms of Pott’s
disease include fever and weight loss.
 Patient might have constitutional symptoms
like low-grade fever, anorexia and weight loss.

47. TB Spine – History
 They usually precede local symptoms and
signs such as pain, tenderness and swelling of
the affected part.
 However absence of constitutional symptoms
does not rule out the possibility of the disease
as it is common for patients to present without
any constitutional symptoms.

48. TB Spine – History
 Neurologic abnormalities occur in 50% of
cases and can include spinal cord compression
with paraplegia, paresis, impaired sensation,
nerve root pain, and/or cauda equina
syndrome.

49. On examination - TB Spine - spasm
 Muscle spasm makes the back rigid.
 Motion of the spine is limited in all direction.
 When picking an object up from the floor, the
patient flexes his hips and knees, keeping the
spine in extension.

50. In TB Spine - spasm
 Spasm of the paravertebral muscles in the
lumbar region is also elicited by passive
hyperextension of the hips with the patient in
prone position-this also puts stretch on the
iliopsoas muscle, which is in spasm and
contracture owing to psoas abscess

51. In TB Spine - deformity
 Almost all patients with Pott disease have
some degree of spine deformity
 A kyphus in the thoracic region may be the first
noticeable sign.
 As the kyphosis increases, the ribs will crowd
together and a barrel chest deformity will
develop.
 When the lesion is situated in the cervical or
lumbar spine, a flattening of the normal
lordosis is the initial finding.

52. In TB Spine - cervical
 Cervical spine tuberculosis is a less common
presentation but is potentially more serious
because severe neurologic complications are
more likely.

53. In TB Spine - cervical
– This condition is characterized by pain and
stiffness.
– Patients with lower cervical spine disease
can present with dysphagia or stridor.
– Symptoms can also include torticollis,
hoarseness, and neurologic deficits.

54. In TB Spine - cervical
 Pott disease that involves the upper cervical
spine can cause rapidly progressive
symptoms.
– Retropharyngeal abscesses occur in almost
all cases.
– Neurologic manifestations occur early and
range from a single nerve palsy to
hemiparesis or quadriplegia.

55. In TB Spine - HIV
 The clinical presentation of spinal tuberculosis
in patients infected with the human
immunodeficiency virus (HIV) is similar to that
of patients who are HIV negative; however,
spinal tuberculosis seems to be more common
in persons infected with HIV.

56. In TB Spine - Thoracic
 Although both the thoracic and lumbar spinal
segments are nearly equally affected in
persons with Pott disease, the thoracic spine
is frequently reported as the most common
site of involvement.
 Together, they comprise 80-90% of spinal
tuberculosis sites.
 The remaining cases correspond to the
cervical spine.

57. Cold abscess
 The abscesses may be palpated as fluctuant
swellings in the groin, iliac fossa, retropharynx,
or on the side of the neck, depending upon the
level of the lesion.

58. Cold abscess
 Large cold abscesses of paraspinal tissues or
psoas muscle may protrude under the inguinal
ligament and may erode into the perineum or
gluteal area.
 Tuberculous necrotic material from the cervical
spine may collect in the form of a cold abscess
in the retropharyngeal region; at the posterior
border of sternomastoid; in the back of neck
along spinal nerves and in the axilla along
axillary sheath

59. Cold abscess
 Pott disease that involves the upper cervical
spine can cause rapidly progressive
symptoms.
– Retropharyngeal abscesses occur in almost
all cases.
– Neurologic manifestations occur early and
range from a single nerve palsy to
hemiparesis or quadriplegia.

60. Cold abscess
 Involvement of the dorsolumbar spine may lead to cold
abscess in the rectus sheath and lower abdominal wall
along the intercostal, ilioinguinal and iliohypogastric
nerves;
 in the thigh along the psoas sheath;
 in the back along the posterior spinal nerves;
 in the buttock along superior gluteal nerve;
 in the Petit's triangle along the flat muscles of
abdominal wall or,
 in the ischiorectal fossa along the internal pudendal
nerve.

61. Gait
 The gait of the person with Pott’s disease is
peculiar, reflecting the protective rigidity of the
spine.
 His steps are short, as he is trying to avoid any
jarring of his back.
 In tuberculosis of the cervical spine, he holds
his neck is extension and supports his head
with one hand under the chin and the other
over the occiput.

62. Neurology
 Neurologic deficits may occur early in the
course of Pott disease.
 Signs of such deficits depend on the level of
spinal cord or nerve root compression.

63. Neurology
 If paraplegia develops, there will be spasticity
of the lower limbs with hyperactive deep
tendon reflexes, a spastic gait, a varying
degree of motor weakness, and disturbances
of bladder and anorectal function.

64. Extraspinal tuberculosis
 Many persons with Pott disease (62-90%) of
patients in reported series have no evidence of
extraspinal tuberculosis, further complicating a
timely diagnosis..

65. Rare presentation
 The presence of a sinus in the back with a thin
watery discharge is a strong evidence of
tuberculous involvement of the posterior arch
of vertebral bodies.
 Rarely, tuberculous spondylitis may present as
synovitis of posterior vertebral articulations,
atlanto-occipital or atlanto-axial joints or as
spinal tumour syndrome

66. How to say the final diagnosis
 Anatomoical
 Pathological
 Level
 Neuro – Cord compression
 Level – Motor, Sensory and Reflex
 Cord level, Vertebral level

67. What to say of bladder and bowel
 History
 Subject may be already catheterised

68. Provisional diagnosis
 Only one Diagnosis if there are no reasons (
points) against that diagnosis
 Otherwise give DD

69. Investigations
1. ESR
2. Mantoux / Elisa -
3. Xrays including chest
4. CT
5. MRI
6. CT-guided procedures.
7. Microbiology studies are used to confirm
diagnosis.

70. What are the common surgical treatments
given
 Treatment – ATT –regime, duration.
 Surgical

71.  Indications ???
 Middle path regime ???
 Instrumentation ???

72. Indications for surgical treatment
 Neurologic deficit (acute neurologic
deterioration, paraparesis, paraplegia)
 Spinal deformity with instability or pain
 No response to medical therapy (continuing
progression of kyphosis or instability)
 Large paraspinal abscess
 Nondiagnostic percutaneous needle biopsy
sample

73. Surgical options
 Costo-transversectomy
 ALD
 Anterior decompression and fusion
 Anterior decompression and fusion and
instrumentation ( posterior or anterior)
 Thoracoscopic surgery
 Posterior approach with transpedicular
decompression and fusion with
instrumentation.

74.  Resources and experience are key factors in
the decision to use a surgical approach.
 The lesion site, extent of vertebral destruction,
and presence of cord compression or spinal
deformity determine the specific operative
approach (kyphosis, paraplegia, tuberculous
abscess).
 Vertebral damage is considered significant if
more than 50% of the vertebral body is
collapsed or destroyed or a spinal deformity of
more than 5° exists.

75.  The most conventional approaches include
anterior radical focal debridement and posterior
stabilization with instrumentation.
 In Pott disease that involves the cervical spine,
the following factors justify early surgical
intervention:
 High frequency and severity of neurologic
deficits
 Severe abscess compression that may induce
dysphagia or asphyxia
 Instability of the cervical spine

76. Contraindications:
 Vertebral collapse of a lesser magnitude
is not considered an indication for
surgery because, with appropriate
treatment and therapy compliance, it is
less likely to progress to a severe
deformity.

77. ICS 2010
a combined meeting of
SPINE SOCIETY OF EUROPE &
ASSOCIATION OF SPINE SURGEONS OF INDIA
3,4,5 September 2010
International & National Faculty
Venue:
Golden Landmark Resort, Mysore.
Theme: Iatrogenic complications in Spine
Residential and Non-Residential Packages