TUBERCULOSIS OF THE SPINE

Incidence
 Tuberculosis of the spine forms 50-60 percent
of the total incidence of skeletal tuberculosis. It
is a disease of childhood and adolescence, 50
percent of case occurring in the age group 1-20
years.

 The most common level of the lesion is in the

thoraco-lumbar level. This is because
movement and the stress of weight bearing are
maximum at this level.
 Pathology
 The lesion destroys the intervertebral disc and the
adjacent surfaces of the vertebral bodies which
slowly collapse and obliterate the intervertebral
space. Destruction of the framework of the vertebral
bodies results in their collapse and the development
of an angular kyphosis called gibbus. The disease
commonly involves two vertebrae but in children it
can rapidly destroy three or more vertebrae and
cause gross deformities.
 Spreading caseation results in osteolysis of
the bony trabeculae, leading to the formation
of cold abscess.
 Tuberculoma: compared to the total incidence
of spinal tuberculosis, tuberculoma formation
in the spinal cord is a rare phenomenon; it
presents like an intra-medullary spinal tumour
causing cord compression and paraplegia.
 Clinical features
Pain
 Pain will be localised by the patient to one region
of the spine. Localised tenderness over one
vertebral spine is diagnostic of the level of the
lesion. The disease can also present as referred
pain. Disease in the cervical spine can present as
pain in the ear or pain down the arm. Upper
Thoracic spine lesion can present as pain in the
chest and as neuralgia. Lower Thoracic spine can
cause referred pain in the abdomen.
Rigidity
 Rigidity is caused by the spasm of the spinal muscles

due to the disease in the spine. A cervical lesion causes

rigidity of the neck which at times may be asymmetrical
producing torticollis. In lumbar lesions, there is
marked rigidity of the back and the spine moves in one
piece when the patient attempts to bend forward. This is
demonstrated by the Coin test （ The patient is asked
to pick up a coin from the floor. He bends at the knee
and hip and picks up the coin holding the spine rigid
and straight all the time. ） .
Deformity
 In the cervical and lumbar spine the loss of

the normal lordosis occurs first followed by

the gibbus. In the thoracic spine angular
kyphosos (gibbus) is characteristic. The
prominence of gibbus depends on the number
of the vertebrae involved.
Cold abscess
 The formation of cold abscess is an invariable feature

of tuberculosis of the spine. The abscess forms in the

paravertebral areas and soon tracks downwards due to
gravity and towards the surface following the tracks
of nerves and blood vessels. As long as the abscess
remains deep to the deep fascia it remains cold to
touch without any inflammatory reaction and hence it
is called cold abscess.
Paraplegia
 The paraplegia in spinal tuberculosis is called Pott's
paraplegia. This complication occurs in about 10
percent of the cases and is usually of the spastic
type. The highest incidence of paraplegia is in
lesions of the thoracic spine. Depending on the
severity of the paralysis, paraplegia is graded as
Grade I, II and III- Grade I being a partial paralysis
(paresis) and Grade III being a total paraplegia.
 Radiological features
 The earliest radiological sign is the narrowing of
the intervertebral disc space. Later, there is erosion
of the adjacent surfaces of the vertebral bodies.
Still later, there is destruction and collapse of the
vertebral bodies with obliteration of the
intervertebral space para or prevertebral soft tissue
shadows of the abscess may also be present which
may be calcified. Sound healing usually ends in
bony fusion of adjacent vertebrae. Neglected cases
in children result in gross kyphotic deformities
 Conservative Treatment
 The patient is given complete rest in bed and
measures to improve his general health.
 Antituberculous chemotherapy as described earlier
is started. The spine is immobilized in a plaster
shell for a short period.
 The patient is periodically assessed clinically,.
radiologically and hematologically . When the
lesion is quiescent, the patient is given a spinal
brace and made ambulant. The chemotherapy is
continued upto a total period of 9 months.
 Treatment of Pott's Paraplegia
 The initial treatment of the case is the same as before. The
patient is immobiled in the plaster shell and chemotherapy
started. A neurological chart is maintained and the clinical
status of the paraplegia recorded once a week.
 Special care should be taken to prevent contractures of the
joints in the paralysed legs by full passive movements of all
the joints. The limbs should be kept with knees in slight
flexion and the feet in neutral position .
 With this regimen more than 60% of the cases with
paraplegia recover in a few months. This is due to the
resorption of the cold abscess resulting in a medical
decompression of the spinal cord.
 Surgical Treatment

 The indications for surgery in paraplegia are

as follows:
 1. No sign of recovery after 3-4 weeks of
conservative treatment.
 2. Paraplegia getting worse in spite of conservative
treatment.
 3. Spastic paraplegia with severe and
uncontrollable spasms of the legs
 Anterior decompression and spinal fusion:
(Hongkong operation). Through a standard
thorocotomy, the abscess is
evacuated and debridement done. The
diseased vertebral bodies are
excised (vertebrectomy) and the cord
decompressed. Autologous bone grafts
are placed between the vertebral bodies
to promote anterior spinal fusion.
 TUBERCULOSIS OF THE HIP JOINT

 Next to the spine, the hip joint is the most

common site for involvement by tuberculosis.
This also occurs most commonly in children,
the highest incidence being between the ages
of 5-15 yrs.
 Clinical features
 Pain and swelling in the region of the hip
and limping are the usual presenting
symptoms.
 Sometimes the child complains of pain in
the knee. This is referred pain and is often
misleading. There will be constitutional
symptoms like loss of appetite, loss of
weight, low grade fever and a sense of
tiredness coming on early during games.
 Stage I (Synovitis)
 This is the stage when the disease is a synovitis
with effusion into the cavity. The hip joint assumes
the position of flexion, abduction and external
rotation. There is a pelvic tilt downwards which
causes an apparent lengthening of the affected limb.
There is an increased lordosis in the lumbar spine.
There are also other local signs of muscle spasm,
warmth, tenderness and painful limitation of all
movements of the joint.
 Thomas Hip Flexion Test
 The unmasking of the flexion deformity of the
hip by tilting back the pelvis and obliteration
of the lumbar lordosis is the basis of the
Thomas Hip Flexion Test for measuring
flexion deformity in the hip.
 Stage II(Arthritis)
 When the disease is untreated and the patient
is bed-ridden for sometime the destructive
process spreads to the articular surfaces. In this
stage, the spasm of the adductors predominate
and the limb assumes the position of flexion,
adduction and internal rotation.
StageIII (Pathological Dislocation)
 the destruction spreads in the acetabulum and
pathological dislocation of the hip joint occurs.
The position of adduction, flexion and internal
rotation gets more exaggerated due to the
dislocation. There is real shortening of the
limb. The cold abscess bursts and there are
sinuses discharging thin pus.
 Radiological features
 Stage I: At this stage radiographs show only generalised
rarefaction of bones. No bony focus will be seen. The joint space
appears widened due to the effusion.

 Stage II : Radiographs at this stage show erosion of the articular

surface and narrowing of the joint space.

 Stage III: Radiographs show destruction of the head of the

femur, travelling acetabulum with dislocation of the hip and a
break in the Shenton's line.
 Conservative Management
 The patient is put to bed and the hip joint
immobilised. Antituberculous chemotherapy is
started. The method of local treatment depends
on the stage of the disease.
 In Stage I the deformity of flexion abduction and
external rotation is corrected by gradual continuous
skin traction in a Thomas' splint over period of two
to three weeks. When the deformity is corrected,
the hip is immobilised in the position of function in
15 degree abduction and neutral rotation. This
immobilisation with traction is continued till the
disease gets controlled .


 In Stage II the hip is immobilised with skin
traction in the position of function. The
traction is meant to overcome the muscle
spasm and prevent erosion of the articular
surfaces by lessening their contact.
 When the disease is stabilised, the traction is
discarded and the hip is immobilised in a full
plaster spica for about 3 months. When the
stage of quiescence is reached, the plaser is
removed, the hip is mobilised in bed. The
patient is then made ambulant with a
protection of a weight relieving caliper.
 Indications for early surgery:
 When the disease is stabilised, the presence of
a well localised cavity in the neck of the femur
or the acetabulum is an indication for surgical
curettage.
 When there is progressive destruction of the
articular surfaces, surgical debridement helps
in eraddication of the disease and obtain a
mobile joint .
 surgery
 Synovial resection.
 Local focus clearup.
 Hip joint fuse
 Total hip arthroplasty(THA).
 Osteotomy below rotor