Tb spine and pott’s paraplegia

1. TB SPINE AND POTT’S
PARAPLEGIA
PRESENTER : DR. KARTHIK S J
JUNIOR RESIDENT
MODERATOR : DR. PRABHU E
PROFESSOR AND HOU
DEPT OF ORTHOPAEDICS
RLJALAPPA HOSPITAL KOLAR

2. GLOBAL TUBERCULOSIS - REPORT
• WHO reports 10 million new cases of tuberculosis and 1.2 million
people die due to disease every year ( 0.17 million – CORONA)
• Eight countries accounted for 66 % new cases : India, China,
Indonesia, Phillipines, Pakistan, Nigeria, Bangladesh and South Africa
• 4.8 lakh have MDR TB with only 56% treatment success

3. HISTORY:
• Percival Pott first described Tuberculosis of
Spinal column in 1779, stating a classical
description as a destruction of disc space and
the adjacent vertebral bodies, collapse of
spinal element and kyphotic deformity
• It is estimated that India alone got one fifth of
the total world population of tuberculous
patients
• Nearly 6 million radiologically proven cases are
found in India and 1 to 3 percent has
involvement of skeletal system

4. MICROBIOLOGY
Mycobacterium tuberculosis:
 Bacillus with high lipid and Peptidoglycan rich cell wall
Slow growing, aerobic organism
Acid and alkali fast
In favourable conditions, doubling time is 20 hours
In unfavourable conditions, it can grow only intermittently or remain
dormant for a prolonged period
This explains why TB is difficult to diagnose, treat and eradicate

5. PREDISPOSING FACTORS:
• Malnutrition
• Poor Sanitation
• Over crowding
• Close contact with TB patient
• Immuno deficiency state

6. SURGICAL ANATOMY: VERTEBRAL BODIES
• It is compared to a compressed long
bone with intervertebral disc interposed
• Hyaline cartilage intervenes between
• 6 years : Ring or annular epiphysis
appears on the periphery of cephalic and
caudal surface
• 8 years : Calcification in the ring
epiphysis starts
• 18 years : Fuse with the vertebral bodies

7. SURGICAL ANATOMY : INTERVERTEBRAL JOINT
Second Cervical to first Sacral vertebra :
Articulations
Series of fibro cartilagenous joints formed by
intervertebral discs between the vertebral bodies
Series of paired synovial joints between the
posterior articular process
A typical vertebra articulates at 6 articulating
surfaces
 Two discs, Two proximal facet joints, Two distal
facet joints

8. SURGICAL ANATOMY : INTERVERBRAL DISC
• Lies between the bodies of vertebra
• Central portion : Semigelatinous – nucleus pulposus
• Peripheral ring : Lamellated fibrous tissue – Annulus
fibrosus
• Schmorl’s node : If there is deficiency in the hyaline
cartilage and the bone end plate, nucleus pulposus
herniates into the cancellous bone of vertebral
bodies where it may encircled by the reactive bone
• Fetal life: Small blood vessels penetrate the annulus.
It regress soon after birth; 18 years – discs are
relatively avascular

9. BLOOD SUPPLY OF VERTEBRAL COLUMN:
• Branches from each segmental
intercostal artery or lumbar artery
supplying adjacent halves of two vertebra
( lower half of one above and upper half
of one below)
• Inside the vertebral body the arterioles
ends as tortuous loops under the
epiphyseal end plates
• Juxta epiphyseal , paradiscal areas – more
vascular

10. BATSON’S PLEXUS
• Batson’s perivertebral plexus of veins : Veins from
the vertebral column drains here.
• Emerge from the posterior aspect of vertebral
bodies to form postcentral anastomosis
• It has ramifications into the base of brain and chest
wall and has free anastomosis with the intercostal,
lumbar and pelvic veins
• Retrograde flow of blood from the viscera to the
spine may be responsible for the spread of infection
• It is responsible for the association of chest wall
abcess with vertebral TB or tuberculous meningitis
with spinal tuberculosis

11. BLOOD SUPPLY TO SPINAL CORD
• One anterior and two posterior spinal arteries
• Anterior spinal A : Union of terminal branches
of vertebral artery at level of foramen magnum
( Anterior 2/3)
• Posterior spinal A : Branches of Vertebral artery
at the level of Medulla oblongata ( Remaining
posterior part )
• Anterior and Posterior Radicular arteries which
enters through the intervertebral foramina
• Artery of Adamkiewicz : Originates from left
intercostal or left lumbar artery between 10th
thoracic and 2nd lumbar segents

12. TUBERCULOSIS OF SPINE
• Vertebral tuberculosis is the commonest form of skeletal tuberculosis
• It constitutes 50 percent of all tuberculosis of bones and joints
• It is most common during the first 3 decades

13. PATHOLOGY:
TB of spine is
always secondary
Bacteria reach the spine via
hematogenous route
Spreads via para-vertebral
plexus of veins i.e., BATSON’S
PLEXUS

14. Tubercle:
Accumulation of PMN cells(Released by macrophage and monocytes)
Transformation to Epitheloid cells
Formation of Langhans giant cells(Occurrence of caseation necrosis)
Lymphocytes appear and form a ring around the peripheral part of lesion
Tubercle formation

16. COLD ABCESS:
• Marked exudative reaction is a common feature of Tuberculosis in
skeletal system
• Cold abcess : Formed by collection of products of liquefaction and the
reactive exudation
• Components: Serum, Leukocytes, Caseous material, Bone debris,
Tubercle bacilli
• Migrates in various directions
• Feels warm ( not as such in pyogenic infections )
• It may burst to form a sinus or ulcer ( undermined edges )

17. TUBERCULAR SEQUESTRA:
• Osseus destruction : lysis of bone leading to compression /collapse/
deformation
• Necrosis : due to ischemic infarction of segments of bones
• Due to loss of nutrition the adjacent articular cartilage or intervening
disc degenerates and become separated as sequestra
• Intervertebral disc is not involved primarily ( Relatively avascular
structure)
• The early involvement of the paradiscal regions of vertebra
jeoparadizes the nutrition to the disc

18. Tuberculous granulomatous debris and abcess
may be compressed between the sound
vertebra above and below
Local extension, retropulsion and propulsion of
the material may occur
Spreading and extending due to
osteoperiosteal infiltration, passing along deep
to anterior longitudinal ligament

19. TUBERCLE : FUTURE COURSE
It may resolve completely
The disease may heal completely with varying degrees of residual
deformities or/and loss of function
Lesion may be completely walled off and caseous necrosis may get
calcified
Low grade chronic fibromatous granulating and caseating lesion may
still persist
Infection may spread locally or via bloodstream

20. TALL VERTEBRA:
• Pott’s disease which had healed with ankylosis and appreciable
kyphosis : considerable increase in height of vertebral bodies of
lumbar spine may be present
• “Tall Vertebra” : Develops when disease occurs in the growth period
• As the deformity develops gradually, neural elements tolerate the
progressive kyphosis for several years
• They reach adulthood with intact neural status

21. SIGNS AND SYMPTOMS:
ACTIVE STAGE HEALED STAGE
1. Symptoms are insidious but sometimes acute 1. Regains the lost weight
Symptoms: malaise, loss of weight, loss of appetite,
night sweats and evening rise of temperature
2. No evening rise of temperature or night cries
2. Localised kyphotic deformity which is tender on
percussion
3. Deformity persists
3. Spasm of vertebral muscles present 4. ESR falls and radiological evidence of bone healing
present
4. Night cries
5. Knuckle kyphosis may be detected by palpation

22. ABCESS AND SINUS:
• Abcess from cervical or dorsal regions can present themselves far
away from the vertebral column along the fascial planes or course of
neuro vascular bundles
• Present at paraspinal regions at back/ posterior or anterior cervical
triangles/ along the brachial plexus/ along intercostal spaces in chest
wall
• From dorsolumbar and lumbar spine : psoas abcess – palpable in iliac
fossa/ lumbar triangle or in upper part of thigh or even track towards
upto knee ( Hip flexion/ Pseudo hip flexion deformity)

23. REGIONAL DISTRIBUTION:
CERVICAL 12%
CERVICODORSAL 5%
DORSAL 42%
DORSOLUMBAR 12%
LUMBAR 26%
LUMBOSACRAL 3%

24. RADIOLOGY:
• Spinal TB is difficult to diagnose radiologically
in early stages
4 sites :
Paradiscal
Central
Anterior
Appendical
3

25. PARADISCAL TYPE:
• Commonest type
• The paradiscal lesion begins in the vertebral
metaphysis, erodes the cartilage plate and
destroys the disc.
• The cartilaginous end plate acts as a barrier, but
once invaded, destruction of the disc progresses
rapidly due to its relative avascularity, and the
infection goes on to involve the adjacent
vertebrae.
• The early resorption of the disc leads to
narrowing of the disc space

26. PARAVERTEBRAL SHADOWS:
• Extension of tuberculous granulation tissue and the collection of abcess
in the paravertebral region
• In cervical region, it presents as a shadow between vertebral bodies,
pharynx and trachea
• Upper thoracic abcess – V shaped shadow stripping over the lung apices
laterally and downwards
• Abcess below the level of 4th dorsal vertebra : typical fusiform shape
(bird nest appearance)

29. • Abcess above the level of vertebral attachment of diaphragm :
Remain within thorax
• Below the diaphragm : Extend along the course of psoas muscle
• Psoas abcess : Widening of psoas shadow
• Abcess under tension : Globular shape
• Psoas abcess can be aspirated through Petit’s triangle while iliopsoas
abcess can be aspirated through Petit’s triangle as well as iliac fossa

31. • Long standing paravertebral abcess : Scalloping effect / Aneurysmal
phenomenon as concave erosions along the anterior margins of
vertebral bodies
• Healthy discs, because of their elasticity : Saw tooth apperance

32. KYPHOTIC DEFORMITY:
• Paradiscal bodies shows areas of destruction and one or both bodies
are usually wedged with forward angulation
• Involvement of large number of vertebra : Severe kyphotic deformity
• Forward wedging of one or two vertebra : Knuckle kyphos
• Wedge collapse of 3 or more vertebral bodies : Angular kyphosis
• Moderate wedging of large number of vertebra : Round kyphosis
Gibbus deformity / Kyphotic deformity are interchangeable expressions

34. CENTRAL TYPE:
• In the central type of lesion the infection begins in the midsection ofthe body.
It extends centrifugally to involve the wholebody.
• The infection ususally spreads through Batson plexus of veins or through
branches of posterior vertebral artery
• Following the infection, marked hyperemia and osteoporosis occur
• The body, which is thus softened, easily yields under gravity andmuscle
action, leading to compression, collapse and bony deformation.
• Diminution of disc space is minimal and paravertebral shadow is not marked

36. ANTERIOR TYPE:
• This lesion occurs when infection starts beneath the anterior
longitudinal ligament.
• Peripheral portion of the vertebral body shows erosion in lateral or
oblique views as shallow excavations
• More common in thoracic spine
• More erosion is caused when the abcess is near the aorta permitting
the transmission of aortic pulsation to the abcess

37. APPENDICIAL TYPE:
• Isolated tuberculous infection of the pedicles, lamina, transverse
process, spinous process
• Uncommon
• Radiologically : Appreciated by erosive lesions, paravertebral shadows
and intact disc space
• CT/ MRI are best modalities to diagnose Appendicial type

38. LATERAL SHIFT AND SCOLISIS:
• Lateral curvature and lateral deviation : Rare deformity
• It occurs in those patients where there is involvement of posterior
spinal articulations in addition to the usual paradiscal lesions
• Majority of cases donot have neurological complications

39. NATURAL COURSE OF DISEASE :
• Before the modern anti TB drugs : Patients developed crippling
deformities, cold abcess, multiple discharging sinus, spread of
infection to other parts of body, paraplegia and amyloidosis
• In modern era : If adequately treated in early stage, healing takes
place well with a little radiological deformity
• IVORY VERTEBRA : In the healing stage, new bone formation occurs as
a result of secondary infection usually associated with sinus formation

40. MODERN IMAGING TECHNIQUES: CT SCAN
• It is useful tool in assessing the destructive lesions of the vertebral
column
• It is of special help for posterior spinal disease, TB of cranio vertebral
and cervico dorsal region, sacro iliac joints and sacrum
• Delineation of shape, extent and route of spread of cold abcess can
be visualized by CT scan

43. MRI SCAN:
• It is useful in the diagnosis of tuberculous infection of difficult and
rare sites like
cranio vertebral region
cervico dorsal region
disease of posterior elements and vertebral appendages
infections of sacro iliac region
sacrum and coccyx

45. ULTRASOUND ECHOGRAPHS:
• To diagnose the presence of tubercular abcess in lumbar vertebral
disease
• To assess the composition of iliopsoas mass and the quantity of the
liquid material contained therein
In case of doubt for confirmation a biopsy of small prevertebral abcess or
of atypical vertebra may be obtained by core biopsy needle under
fluoroscopic control
Open biopsy with debulking/ decompression is mandatory if semi invasive
techniques donot prove the pathology

46. CLINICO RADIOLOGICAL CLASSIFICATION:
STAGE CLINICO RADIOLOGICAL FEATURES USUAL DURATION
I : PRE DESTRUCTIVE Straightening of curvatures, spasm of
prevertebral muscles, MRI shows
marrow edema
< 3 months
II : EARLY – DESTRUCTIVE Diminished disc space + paradiscal
lesion ( knuckle < 10 deg) ; MRI :
shows marrow edema; CT : marginal
erosions or cavitations
2 – 4 months
III, IV, V – all have vertebral body destruction + collapse + appreciable kyphosis
III – Mild angular kyphos 2 -3 vertebra involved (K: 10 -30
deg)
3 -9 months
IV – Moderate angular kyphos > 3 vertebra ( K : 30 to 60 deg ) 6 – 24 months
V – Severe kyphos ( Humpback
deformity )
> 3 vertebra involved ( K: > 60 deg) > 2 years

47. BIOLOGICAL HEALING AND IMAGING
• Radiological evidence of healing : lags behind the biological process
in spinal TB.
• If images donot show improvement when repeated after 6 months of
therapy, one should consider the possibility of alternative pathology
or therapeutically refractory disease
• Once the disease is healed, bony architecture is restored

48. DIFFERENTIAL DIAGNOSIS:
• Clinical and radiological re examinations after 6 to 12 weeks are of
great help in arriving final diagnosis
• In case of doubt, histological and micro biological investigations
should be sent

49. CONSIDERATION OF AGE:
• Congenital defects of spine
• Calves disease in young children
• Schmorl’s disease
• Scheuerman’s disease in adolescent
All these conditions may have no constitutional symptoms but a
characteristic radiological appearance
Primary tumour of vertebra
Metastasis should be considered in adults

50. PYOGENIC INFECTIONS:
• Onset is sudden with severe localised pain, spasm and swinging
temperature
• Early stages: Bone destruction present, rapidly replaced with sclerosis
and new bone formation
• IVD shows varying degrees of destruction
• ASO titre/ Microbiological investigations : Final diagnosis

51. TYPHOID SPINE:
• Most cases present in the time interval of 4 weeks to few months
after the disappearance of typhoid fever
• Radiological picture : Resembles that of tuberculosis and low grade
pyogenic spondylitis
• Confirmations: Agglutination test, Therapeutic trial or by biopsy

52. SYPHILITIC INFECTION OF SPINE:
• Arthralgic type
• Gummatous type
• Charcoat’s disease
Most common site: Thoraco lumbar and Lumbar spine
Diagnosis : Serological tests, Tissue biopsy or response to Anti syphilitic
treatment

53. TUMOUROUS CONDITIONS:
• Hemangioma: most common beningn tumour (D12 to L4)
Radiologically : Pin head appearance
Involved vertebra shows characteristic coarsening of vertebral
trabeculations and more prominent in vertical than in horizontal
trabeculae ( Corduroy appearance )
• Giant cell tumour and Aneurysmal Bone cyst:
Osteolytic expansile and usually eccentric growth on radiological
examination; Disc space is not involved in early stages
RESPPONSE TO RADIATION TREATMENT IS OBSERVED IN THESE CASES

54. MULTIPLE MYELOMA:
• There is involvement of only one or two vertebra and there is collapse
and eccentric destruction
• Involvement of multiple bones, High ESR, Anemia, reversal of AG
ratio, Urine Bence Jones Proteins are the charecteristics
• Diagnosis : Confirmation of myeloma cells in the bone marrow

55. OTHER CONDITIONS:
• Lymphomas
• Secondary neoplastic deposits
• Histiocytosis – X
• Spinal osteochondrosis
• Traumatic conditions
• Osteoporotic conditions
• Spondylolisthesis
• Hydatid Disease

56. NEUROLOGICAL COMPLICATIONS- POTT’S
PARAPLEGIA
• It is the most dreaded and crippling complication of spinal
tuberculosis
• Incidence : 10 to 30 percent
• Paraplegia most commonly results due to the involvement of the
spinal cord, thus below the level of first lumbar vertebra rarely causes
paraplegia due to the involvement of cauda equina
• Pathology : Compression paraplegia

57. TUBERCULOUS PARAPLEGIA- CLASSIFICATION:
GROUP A : EARLY ONSET PARAPLEGIA :
Occurs during the active phase of the disease
Within first 2 years of onset
Underlying pathology : Inflammatory edema, Tuberculous granulation
tissue, Tubercular abcess, Tuberculous caseous tissue or ischemic
lesion of spinal cord
Good prognosis

58. GROUP B : LATE ONSET PARAPLEGIA:
Appears > 2 years after the disease
Underlying pathology : Tuberculous caseous tissue, Tubercular debris,
Sequestra from vertebral body and disc, internal gibbus, stenosis of
vertebral canal or severe deformity
Prognosis is less favourable

59. STAGE CLINICAL FEATURES
I Negligible Patient unaware of neural deficit, physician detects plantar
extensor/ ankle clonus
II Mild Patient aware of deficit but manages to walk with support
III Moderate Non ambulatory because of paralysis(in extension), sensory
deficit < 10 %
IV Severe Stage III + Flexor spasm/ paralysis in flexion/ flaccid/ sensory
deficit > 10%/ sphincters involved

60. PATHOLOGY OF TUBERCULOUS PARAPLEGIA:
• Inflammatory edema:
Due to vascular stasis and due to toxins from the tuberculous
inflammation in the neighbouring vertebrae
• Extradural mass :
A state of tuberculous osteitis of the vertebral bodies with an abcess
in the extradural space causing compression of the cord from the
anterior aspect
Components : Fluid, Pus, Granulation tissue, Caseous material
Best visualised by MRI

61. • Bony disorders:
Sequestra from avascular portions may be responsible for narrowing
of the spinal canal and pressure on the cord
Angulation of the diseased spine : Due to the formation of bony ridge
called internal Gibbus on the anterior wall of spinal canal
Concomitant mechanical instability can produce neural complications
in TB or in pathological subluxation or dislocation

62. • Meningeal changes:
Thick layer of tuberculous granulation tissue lying outside the dura
Extra dural granulation : May contract and undergo cicatrisation in
long standing cases
Peri dural fibrosis : Responisble for recurrence of paraplegia

63. • Infarction of Spinal cord:
Caused by : Endarteritis, Periarteritis or thrombosis of any tributary to
the anterior spinal artery caused by inflammation reaction
Paralysis caused by infaraction is irreversible
Rarely it may occur because of surgery or due to thrombo embolic
phenomenon

64. • Changes in spinal cord:
Unrelieved compression of the spinal cord shows loss of neurons and
white matter in the damaged segment
The lost cells and fibres are replaced by gliosis and loss of myelin may
be seen
Neuronal plasticity : It is induced when compression or deformation of
the cord takes place slowly over a length of time. A sudden
compression or gross deformation would almost lead to near
transection of the neural elements

65. EXTRADURAL GRANULOMA:
• It may be responsible for the neurological complications without any
radiological evidence of involvement of vertebra
• These cases are called as “ Spinal tumour syndrome”
• The patients who did not recover after satisfactory decompression
may be persumed to have these factors
MRI is the investigation of choice.
Intradural tuberculomas can be managed by ATT drugs; But extradural
tuberculoma has to be managed by surgical decompression

66. SIGNS AND SYMPTOMS:
• In a paraplegia of slow onset : Spontaneous twitching of muscles in
the lower limbs, clumsiness in walking, extensor plantar response and
exaggerated reflexes
• Sustained clonus of ankle and patella may be present
• Motor functions are affected more than sensory because the
diseased area lies nearer to the motor tracts

67. PARAPLEGIA STAGES:
• Spastic motor paralysis
• Spastic paraplegia in extension
• Spastic paraplegia in flexion
As the compression increases the patient develops flexor spasms which in
later stages remains established in flexion
In very advanced cases bladder and anal sphincters may be involved
In extremely severe cases spasticity disappers and paralysis become flaccid

68. MYELOGRAPHY:
• In cases of Spinal Tumour syndrome / cases with multiple vertebral
lesions myelography is indicated
• It is useful in assessing the level of obstruction
• It is also used in conditions where patients donot recover after
decompression

69. CLINICAL FACTORS INFLUENCING PROGNOSIS
CORD INVOLVEMENT BETTER PROGNOSIS RELATIVELY POOR PROGNOSIS
Degreee Partial ( Stage I, II, III) Complete ( Stage IV)
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 degree
Cord on MRI Normal Myelomalcia
Preoperative Wet lesion Dry lesion

70. TREATMENT OF
POTTS PARAPLEGIA:

71. USUAL CAUSES AND MANAGEMENT
PROTOCOL
INFLAMMATORY
1. Inflammatory edema Recovers by rest and drug therapy
2. Tuberculous granulation tissue Mostly recovers by rest and drug therapy
3. Tubercular abcess Conservative management ; Rarely requires decompression
4. Tuberculous caseous tissue Rarely by conservative ; Requires Evacuation and Decompression

72. MECHANICAL
1. Tubercular debris Operative removal and decompression
2. Sequestra from vertebral body and disc Operative removal and decompression
3. Constriction of cord due to stenosis Operative decompression
4. Localised pressure Operative decompression

73. Intrinsic
1. Prolonged stretching of cord Decompression, Release of cord and anterior
transposition may lead to recovery
2. Infective thrombosis Difficult to recover
3. Pathological dislocation of spine Rare complication; Indiscriminate laminectomy and
irrepairable severance of cord
4. Tuberculous meningomyelitis Myelitis doesnot recover completely
5. Syringomyelic changes Poor recovery
SPINAL TUMOUR SYNDROME
Diffuse extradural granuloma/ tuberculoma Laminectomy

74. MANAGEMENT OF TB SPINE:
BASIC PRINCIPLES OF MANAGEMENT:
Early diagnosis
Aggressive medical treatment
Surgical approach
Prevent Deformity
Best outcome

75. MIDDLE PATH REGIMEN:
A. Rest in hard bed or Plaster of Paris Bed
In cases of cervical and cervico dorsal lesions, traction is used to
put the diseased part in rest
POP bed is used for children or for a few un co operative patients

76. B.DRUGS:
INTENSIVE PHASE
( 5 to 6 months)
CONTINUATION PHASE
( 7 to 8 months )
PROPHYLACTIC PHASE
Isoniazid 300 to 400mg Isoniazid and Pyrazinamide
(1500mg) for 3 to 4 months
Isoniazid and Ethambutol (
1200mg) fot 4 to 5 months
Rifampicin 450 to 600mg Isoniazid and Rifampicin for
another 4 to 5 months
Ofloxacin 400 to 600mg
For hospitalised patients Streptomycin replaces
one of the drugs except Isoniazid
Supportive therapy with Multivitamins, Hematinics may be added if necessary

77. C. Radiographs and ESR are taken at 6 months interval.
For Cranio vertebral/ cervicodorsal/ Lumbosacral regions, CT or MRI
has to be repeated at 6 to 12 months interval
D. General mobilization of the patient is encouraged in the absence of
neural deficit with the help of suitable spinal braces

78. • 3 to 9 weeks : Patient is put on back extension exercises for 5 to 10
minutes ( 3 to 4 times a day )
• Spinal brace is continued for 18 months to 2 years
E. Abcess are drained when near the surface and one gram of
streptomycin with or without INH is instilled at each aspiration
F. Sinus may heal within 6 to 12 weeks of treatment; Some may require
longer treatment and excision

79. G. Neural complications : Patients who are on triple drug regimen and
shows recovery of neurological complications within 3-4 weeks,
Surgical decompression is not indicated.
Surgical Decompression should be performed if the patient donot
recover after a fair trial of conservative therapy
In patients with motor, sphincter, sensory involvement or having severe
flexor spasms, operative management should not be delayed

80. H. Excisional surgery : Recommended for posterior spinal disease
associated with abcess or sinus formation
I : Operative management : Adviced for cases who donot show arrest of
activity of spinal lesions after 3 to 6 months of chemo therapeutic
regimen
J. Posterior Spinal Arthrodesis : For symptomatic unstable spinal lesions
These lesions show significant destruction of more than 2 vertebra and
lack of regeneration of vertebral bodies during the process of healing

81. K. Post operative : Patient should be nursed on a hard bed for 2 to 3
weeks; In cases with neural complications, 3 to 5 months after the
operation when the patient had a good recovery, patient is mobilized
out with spinal braces
The spinal brace is discarded after 12 to 24 months of surgery

82. INDICATIONS FOR VARIOUS SURGICAL
PROCEDURES:
• Decompression ± fusion : Neurological complications which failed to
response after 3 to 6 weeks of treatment’
• Debridement ± fusion : Failure of response after 3 to 6 months of non
operative management
• Debridement ± Decompression ± fusion : Recurrence of neurological
complications
• Prevention of severe kyphosis by posterior fusion ± debridement :
Young children with extensive dorsal lesions
• Anterior transposition of cord : Neural complications due to severe
kyphosis

83. TUBERCULSOSIS OF SACRUM AND COCCYX:
• Rare localisation of tuberculous infection (<1%)
• Tuberculous abcess may form anteriorly in pre sacral space
• Persistent pain in sacro coccygeal region with local warmth and
tenderness may be present
• In neglected cases it may form sinus and drains in the gluteal region
or peri anal areas

84. SURGICAL MANAGEMENT :
Tuli’s recommended approach:
 Cervical spine –T1 : Anterior approch
 Dorsal spine –DL junction: Anterolateral approch
 Lumbar spine &Lumboscral junction : Extraperitoneal Transverse
Vertebrotomy

85. Posterior fixation
Fixation of posterior element of diseased vertebra by instrumentation
are done:
1.Toprevent and correct kyphotic deformity.
2. Tomaintain stability of the spine

86. SURGERIES:
• Antero lateral decompression : Spine is exposed from the anterior
and the lateral side; Cord is laid free from the granulation tissue/
sequestrum/ caseous material. It is the most commonly used method
• Costo – transversectomy : Ribs and the transverse process of vertebra
is removed and the pus is drained
• Radical debridement and arthrodesis
• Laminectomy and posterior stabilisation : In cases of Spinal cord
syndrome and in cases where neural complications present

87. TREATMENT OF PARAPLEGIA IN SEVERE KHYPHOSIS
 Griffiths et al (1956) :anterior transposition ofcord through laminectomy
 Rajasekaran (2002): posterior stabilization followed by anterior
debridement and bone grafting ( titanium cages) in active stage of disease
and vice versa for healed disease

88. SURGICAL CORRECTION OF SEVERE KYPHOTIC
DEFORMITY
 Fundamentals of correction:
1. to perform an osteotomy on the concave side of the curve and
wedge it open ( secured with strong autogenous iliac grafts) .
2. to remove a wedge on the convex side and close this wedge (
Harrington compression rods and hooks)

89. Drainage of paravertebral abscess
•Through lumbodorsal fascia
between Erector spinae and
quadratus lumborum muscle.
•7 cm longitudinal paraspinal
incision

90. DRAINAGE OF PSOAS ABCESS:
• Through lateral incision –
along the middle third ofthe
crest of the ilium
• Through Petit’s triangle

91. SPINAL BRACES:
• For diseases from fourth dorsal to second lumbar vertebra :
Traditional braces extending from seventh cervical vertebra to lower
end of sacrum is used

92. TAYLOR BRACE MILWAUKEE BRACE

93. ASH BRACE SOMI BRACE