Kyphosis:Kyphosis:

Kyphosis :Kyphosis : Mobile Postural &compnsatory kyphosis .Mobile Postural &compnsatory kyphosis .

fixed -Structural kyphosis :fixed -Structural kyphosis :

A kyphos or gibbus . A kyphos or gibbus .

Thorax kyphosisThorax kyphosis

Types of kyphosis :Types of kyphosis :

Child hood-Congenital,osteogenesis Child hood-Congenital,osteogenesis imperfecta TB,dysplsia.imperfecta TB,dysplsia.

Adolescent kyphosis (Sheuermann’s dis. )Adolescent kyphosis (Sheuermann’s dis. )

Adult-trauma,TB.ASAdult-trauma,TB.AS

Kyphosis in the elderly-degenerative and Kyphosis in the elderly-degenerative and osteoporosis. 1-2osteoporosis. 1-2

Congenital kyphosis :Congenital kyphosis :

Failure of formation “type1”.Failure of formation “type1”.Failure of segmentation “type 2” .Failure of segmentation “type 2” .Combination of both .Combination of both .

treatmenttreatment

Failure of segmentation. Left: block vertebra. Failure of segmentation. Left: block vertebra.

Right: unilateral unsegmented barRight: unilateral unsegmented bar. .

Adolescent kyphosis Adolescent kyphosis (Sheuermann’s disease) :(Sheuermann’s disease) :

In the thoracic spine.In the thoracic spine.

In the lumbar spine .In the lumbar spine .

Clinical features :Clinical features :

age.age.

gender.gender.

Cl/pCl/p

deformity : deformity :

backache and fatigue.backache and fatigue.

Examination :Examination :

Smooth thoracic kyphosis- marked hump.Smooth thoracic kyphosis- marked hump.

lumber lordosis.lumber lordosis.

Fixed deformity.Fixed deformity.

Movement-hamstringMovement-hamstring

Mild scoliosis is not uncommon.Mild scoliosis is not uncommon.

complications :complications :

Spastic paresis .Spastic paresis .

Cardiopulmonary dysfunction .Cardiopulmonary dysfunction .

lumbar backache.strain,facet, lumber lumbar backache.strain,facet, lumber sherman’s,hyperextension of lumber spinesherman’s,hyperextension of lumber spine

X-rays :X-rays :

Lat.view-end platesT6-T10 irregular .Lat.view-end platesT6-T10 irregular .

body may become wedge shaped.body may become wedge shaped.

Schmorl’s node .. ..

Overall kyphosis >40 is abnormal.5wedgeOverall kyphosis >40 is abnormal.5wedge

Mild scoliosis is common Mild scoliosis is common

Lateral X-ray Lateral X-ray

Preoperative lateral of a patient with an 85° thoracic Preoperative lateral of a patient with an 85° thoracic

deformity secondary to Scheuermann kyphosisdeformity secondary to Scheuermann kyphosis. .

Postoperative lateral Postoperative lateral

(Sheuermann’s disease) :(Sheuermann’s disease) :

Kyphosis measure :Kyphosis measure :

DDx. :DDx. :

Postural kyphosis : Postural kyphosis : Discitis , osteomyelitis, &TB spondylitis:Discitis , osteomyelitis, &TB spondylitis: Spondyloepiphyseal dysplasia: Spondyloepiphyseal dysplasia:

Rx. :Rx. :

Back straightening exercises r indicated if Back straightening exercises r indicated if curves < 40 degrees .curves < 40 degrees .

Bracing is indicated if curves 40-60 Bracing is indicated if curves 40-60 degrees in a child who still has some degrees in a child who still has some years of growth ahead .years of growth ahead .

Operative Rx. Is indicated for curves >60 Operative Rx. Is indicated for curves >60 degrees.60-75,>75degrees.60-75,>75

Kyphosis in elderlyKyphosis in elderly

A-degenerative-OA of facet A-degenerative-OA of facet

B-osteoporosisB-osteoporosis

-post menopausal-post menopausal

-senile-exclude mm.2ndary-symptomatic-senile-exclude mm.2ndary-symptomatic

The infected spineThe infected spine

Pyogenic spinal infectionsPyogenic spinal infections

present acute or chronic present acute or chronic

depends on : the age , the immune depends on : the age , the immune response,organismresponse,organism

most common by is most common by is Staphylococcus Staphylococcus aureusaureus

Escherichia coli, Proteus, Escherichia coli, Proteus, and and streptococcal, pseudomonasstreptococcal, pseudomonas

PathologyPathologySource;Direct spr stab,gunshot ,disc surgery Source;Direct spr stab,gunshot ,disc surgery

indirect -2nd septic focus - haematogenus, indirect -2nd septic focus - haematogenus, Age, site -is in the lumbar, ,post,ant -multipl-usual. Age, site -is in the lumbar, ,post,ant -multipl-usual. Infection may track along tissue planes, and Infection may track along tissue planes, and without early control will cause 2dary abscess without early control will cause 2dary abscess vertebral canal may be invaded by pus and vertebral canal may be invaded by pus and granulation tissue either directly from the disk granulation tissue either directly from the disk space or through the exit foramenae causing space or through the exit foramenae causing meningitis or myelitis.--recovery is uncommonmeningitis or myelitis.--recovery is uncommon

Retropulsion of bone ordisk causes- neural compRetropulsion of bone ordisk causes- neural comp

destruction of vertebral body and disks causes destruction of vertebral body and disks causes local instability and deformity.- control, local instability and deformity.- control,

Pridisposing factorsPridisposing factors

•• thethe elderlyelderly•• intravenous drug usersintravenous drug users•• immune deficiency slates including AIDSimmune deficiency slates including AIDS•• rheumatoid arthritisrheumatoid arthritis•• malignancymalignancy•• spinal fractures and paraplegiaspinal fractures and paraplegia•• infective endocarditisinfective endocarditis•• renal failurerenal failure•• sickle cell diseasesickle cell disease•• chronic alcoholics.chronic alcoholics.

Clinical features Clinical features Hx-hx of spinal procedure,pain, unusual site Hx-hx of spinal procedure,pain, unusual site

and exacerbated by move and percussion, and exacerbated by move and percussion, asso muscle spasm asso muscle spasm

--Fever… a third of cases •tachycardia--Fever… a third of cases •tachycardia

SignsSigns

.localized tenderness.localized tenderness

•• muscle spasm and limitation of movementmuscle spasm and limitation of movement

•• local or distant fluctuant masslocal or distant fluctuant mass

•• sinus formationsinus formation

•• occasional angular defectoccasional angular defectNeurologic signs 15%-quadri,para,m-root def Neurologic signs 15%-quadri,para,m-root def

Investigations Investigations

ESR above 50 mm/h miror.response to treatment ESR above 50 mm/h miror.response to treatment C-reactive protein and alkaline phosphatase may C-reactive protein and alkaline phosphatase may be raisedbe raisedwhite cell count is raised in less than half of cases. white cell count is raised in less than half of cases. Blood cultures when the patient is febrile are more Blood cultures when the patient is febrile are more reliablereliableUrine culture may be valuable if urethral Urine culture may be valuable if urethral manipulation is considered to be causativemanipulation is considered to be causativeASO,brucella and salmonellaASO,brucella and salmonella

ImagingImaging

plain radiography …little value in early cases. plain radiography …little value in early cases. Disk-space narrowing and irregularity reactive new bone Disk-space narrowing and irregularity reactive new bone and occasionally paraspinal shadow.and occasionally paraspinal shadow.Radiographic changes are progressive with time but may Radiographic changes are progressive with time but may remain limited to the disk complex.remain limited to the disk complex. Plain radiographs are not very useful in assessing Plain radiographs are not very useful in assessing response to treatment.response to treatment.

loss of disc height, loss of disc height, irregularity of the disc irregularity of the disc space , end-plate space , end-plate erosion and reactive erosion and reactive sclerosissclerosis

Nuclear studiesNuclear studies

T99m bone scans can be positive as early T99m bone scans can be positive as early as 2 days… high sensitivity (95 per cent …as 2 days… high sensitivity (95 per cent …specificity (75 per cent)specificity (75 per cent)

Indium and gallium scans.Indium and gallium scans.

Show incresed activityShow incresed activity

CT scanningCT scanning

CT scanning is useful for assessing the degree of bone CT scanning is useful for assessing the degree of bone destruction and examining the surrounding soft tissues.destruction and examining the surrounding soft tissues. guide for needle biopsy. guide for needle biopsy. usually combined with MRI to evaluate the degree of usually combined with MRI to evaluate the degree of cord compression cord compression

CT scan in a child CT scan in a child with sickle cell with sickle cell disease reveals the disease reveals the infected site which infected site which had been missed at had been missed at surgical exploration.surgical exploration.

CT scan in a patient CT scan in a patient demonstrates demonstrates extensive destruction extensive destruction of the vertebral of the vertebral endplate endplate

needle in a biopsy of needle in a biopsy of the infected disk the infected disk space guided by CT space guided by CT scan scan

Myelography Myelography

carries risks of spreading an infection and carries risks of spreading an infection and is rarely indicated nowadaysis rarely indicated nowadays

MRI scanningMRI scanning

most important investigation most important investigation

sensitivity of 96%sensitivity of 96%

specificity …up to 95% specificity …up to 95%

MRI shows the soft tissue well, including MRI shows the soft tissue well, including the neural componentsthe neural components

defines abscess cavities preciselydefines abscess cavities precisely

extensive extensive destruction of the destruction of the endplates of the endplates of the adjacent vertebral adjacent vertebral bodies bodies

thoracic diskitis with thoracic diskitis with an associated an associated epidural abscess and epidural abscess and spinal cord spinal cord compression compression

typical vertebral destruction from typical vertebral destruction from Staph. Staph. aureus. aureus. There is clearly cord compression There is clearly cord compression

MicrobiologyMicrobiology

Pus from needle biopsy of the primary focus or Pus from needle biopsy of the primary focus or from more distant abscess cavities is cultured.from more distant abscess cavities is cultured. Reports of 80 to 90% successful culture have Reports of 80 to 90% successful culture have been published been published Blood and midstream urine cultures may prove Blood and midstream urine cultures may prove to be useful to be useful

Differential diagnosisDifferential diagnosis

Infection Vs tumor. Infection Vs tumor.

Hematomas may mimic epidural infection.Hematomas may mimic epidural infection.

Nonoperative treatmentNonoperative treatment .indication;.indication; When the diagnosis is certain, the organism is When the diagnosis is certain, the organism is known,and there are no progressive neurologic known,and there are no progressive neurologic features, features, Bed rest and intravenous antibiotics may be Bed rest and intravenous antibiotics may be required initially with the acute presentation, and required initially with the acute presentation, and this should be continued until pain reduces and a this should be continued until pain reduces and a response can be confirmed.response can be confirmed. The patient may then be mobilized in a brace and The patient may then be mobilized in a brace and continue on oral antibiotics.continue on oral antibiotics.

As a guide, intravenous antibiotics should be used for a As a guide, intravenous antibiotics should be used for a period of 6 to 8 weeks followed by a similar period of period of 6 to 8 weeks followed by a similar period of treatment with oral antibiotics.treatment with oral antibiotics. Serial ESR examination is usually of value and antibiotics Serial ESR examination is usually of value and antibiotics should continue for a month after both symptoms and ESR should continue for a month after both symptoms and ESR have returned to normal.have returned to normal.

Radiographic and MRI evaluation is useful, but there is a Radiographic and MRI evaluation is useful, but there is a distinct lag-time before healing can be confirmed. distinct lag-time before healing can be confirmed.

The risk of conservative management is failure to control The risk of conservative management is failure to control disease.disease.

Surgical managementSurgical management

Indication;Indication;

failure of conservative treatmentfailure of conservative treatment

the diagnosis and organism cannot be the diagnosis and organism cannot be confirmedconfirmed

neurologic deficit, particularly when there is neurologic deficit, particularly when there is epidural spread. epidural spread.

Mechanical instability.Mechanical instability.

The aims are: The aims are: to drain the abscessto drain the abscessmake a definitive diagnosismake a definitive diagnosisdecompress the neural tissue, either root or cord. decompress the neural tissue, either root or cord. to achieve stability and rapid healing of the lesion by to achieve stability and rapid healing of the lesion by bone grafting. bone grafting. If the organism has been identified and the patient is on If the organism has been identified and the patient is on antibiotic cover, it is acceptable to graft primarily and to antibiotic cover, it is acceptable to graft primarily and to use metallic implants for stability.use metallic implants for stability.Surgery…to the area of pathology.Surgery…to the area of pathology.In the debilitated patient it is possible to drain an In the debilitated patient it is possible to drain an abscess by the posterolateral approach. Iabscess by the posterolateral approach. I

Granulomatous infections of the Granulomatous infections of the spinespine

Granulomatous lesions Granulomatous lesions

The most common TB and brucellosis, The most common TB and brucellosis,

but fungi but fungi can can also be a cause.also be a cause.

PathologyPathology

Blood-borne infection usually settles in a vertebral body adjacent to Blood-borne infection usually settles in a vertebral body adjacent to the intervertebral disc.the intervertebral disc. Bone destruction and caseation follow… with spreading. Bone destruction and caseation follow… with spreading. As the vertebral bodies collapse into each other, a sharp angulation As the vertebral bodies collapse into each other, a sharp angulation (or kyphos) develops. (or kyphos) develops. Caseation and cold abscess formation may extend to neighbouring Caseation and cold abscess formation may extend to neighbouring vertebrae or escape into the paravertebral soft tissues.vertebrae or escape into the paravertebral soft tissues. There is a major risk of cord damage due to pressure by the There is a major risk of cord damage due to pressure by the abscess or displaced bone, or ischaemia from spinal artery abscess or displaced bone, or ischaemia from spinal artery thrombosis.thrombosis.With healing, the vertebrae recalcify and bony fusion may occur With healing, the vertebrae recalcify and bony fusion may occur between them.between them.

Clinical features Clinical features

1-Hx---usually long history .1-Hx---usually long history .

In some cases deformity is the dominant In some cases deformity is the dominant feature. feature.

Occasionally with a cold abscess pointing Occasionally with a cold abscess pointing in the groinin the groin

paraesthesia and weakness of the legsparaesthesia and weakness of the legs

2-Exam.2-Exam.

POTT'S PARAPLEGIAPOTT'S PARAPLEGIA Paraplegia is the most feared complication of spinal Paraplegia is the most feared complication of spinal tuberculosis. tuberculosis. Early-onset paresis Early-onset paresis is due to pressure by an abscess, is due to pressure by an abscess, caseous material or a bony sequestrum. caseous material or a bony sequestrum. The patient presents with lower limb weakness, upper The patient presents with lower limb weakness, upper motor neurone signs and sensory dysfunction, together motor neurone signs and sensory dysfunction, together with vertebral disease. with vertebral disease. CT and MRI may reveal cord compression. CT and MRI may reveal cord compression. Late-onset paresis Late-onset paresis is due to increasing deformity, or is due to increasing deformity, or reactivation of disease or vascular insufficiency of the reactivation of disease or vascular insufficiency of the cord.cord.

X-rayX-ray

The entire spine should be x-rayed, because vertebrae The entire spine should be x-rayed, because vertebrae distant from the obvious site may also be affected. distant from the obvious site may also be affected. The earliest signs of infection are local osteoporosis of The earliest signs of infection are local osteoporosis of two adjacent vertebrae and narrowing of the two adjacent vertebrae and narrowing of the intervertebral disc spaceintervertebral disc spaceLater an angular deformity of the spine. Later an angular deformity of the spine. Paraspinal soft-tissue shadows may be due either to Paraspinal soft-tissue shadows may be due either to oedema and swelling or to a paravertebral abscess…oedema and swelling or to a paravertebral abscess…thoracic disease. thoracic disease. With healing paravertebral abscesses may calcify.With healing paravertebral abscesses may calcify.

Early disease Early disease with loss of the with loss of the disc space disc space

InvestigationsInvestigations

The Mantoux test The Mantoux test

ESRESR

Doubt... needle biopsy Doubt... needle biopsy

Differential diagnosisDifferential diagnosis

pyogenic infection pyogenic infection

malignant disease.malignant disease.

If the patient presents with paraplegia, other If the patient presents with paraplegia, other causes of cord compression have to be causes of cord compression have to be excluded. excluded.

TreatmentTreatment

The objectives are The objectives are

(1) to eradicate or at least arrest the (1) to eradicate or at least arrest the diseasedisease

(2) to prevent or correct deformity(2) to prevent or correct deformity

(3) to prevent or treat the major (3) to prevent or treat the major complication - paraplegia.complication - paraplegia.

Antituberculous chemotherapy is as Antituberculous chemotherapy is as effective as any other method (including effective as any other method (including surgical debridement) in stemming the surgical debridement) in stemming the disease.disease.

conservative treatment alone carries the conservative treatment alone carries the risk of progressive kyphosis if the infection risk of progressive kyphosis if the infection is not quickly eradicated.is not quickly eradicated.

With modern anlituberculous drugs, With modern anlituberculous drugs, a a reasonable compromise would be as follows:reasonable compromise would be as follows:

Ambulant chemotherapy alone Ambulant chemotherapy alone is appropriate for is appropriate for early or limited disease with no abscess early or limited disease with no abscess formation. Treatment is continued for 6-12 formation. Treatment is continued for 6-12 months, or until the x-ray shows resolution of the months, or until the x-ray shows resolution of the bone changes. Compliance is sometimes a bone changes. Compliance is sometimes a problem.problem.

Continuous bed rest and chemotherapy Continuous bed rest and chemotherapy may be used for more advanced disease may be used for more advanced disease when the necessary skills and facilities for when the necessary skills and facilities for radical anterior spinal surgery are not radical anterior spinal surgery are not available, or where the technical problems available, or where the technical problems are too daunting (e.g. in lumbosacral are too daunting (e.g. in lumbosacral tuberculosis) - provided there is no tuberculosis) - provided there is no abscess that needs draining.abscess that needs draining.

Operative treatment Operative treatment is indicated is indicated (I) abscess that can readily be drained and(I) abscess that can readily be drained and(2) for advanced disease with marked bone destruction (2) for advanced disease with marked bone destruction (3) threatened or actual severe kyphosis or paraparesis.(3) threatened or actual severe kyphosis or paraparesis.(4) instability(4) instability(5) sequestrae (5) sequestrae Through an anterior approach, all infected and necrotic material is Through an anterior approach, all infected and necrotic material is evacuated or excised and the gap is filled with rib grafts that act as evacuated or excised and the gap is filled with rib grafts that act as a strut. a strut. If several levels are involved, posterior fixation and fusion may be If several levels are involved, posterior fixation and fusion may be needed for additional stability.needed for additional stability.Antituberculous chemotherapy is still necessary, of courseAntituberculous chemotherapy is still necessary, of course

Thank youThank you