SPINAL CORD SPINAL CORD INJURIESINJURIES

BECAUSE OF BECAUSE OF TBTB

Ilse LombardIlse Lombard20102010

Tuberculosis (TB)Tuberculosis (TB)

Tuberculosis (TB) is a disease caused Tuberculosis (TB) is a disease caused by bacteria called by bacteria called Mycobacterium Mycobacterium tuberculosis.tuberculosis.   

Tuberculosis (TB)Tuberculosis (TB) Mycobacterium tuberculosis mostly Mycobacterium tuberculosis mostly

attacks the lungs, however it can attacks the lungs, however it can also attack many parts of the body also attack many parts of the body such as the kidney, the lymph nodes, such as the kidney, the lymph nodes, and the spine.and the spine.

  

TB is mostly found in Africa and TB is mostly found in Africa and Southeast Asia more. However, more Southeast Asia more. However, more than 25,000 people contract it every than 25,000 people contract it every year in the United States. year in the United States.

Tuberculosis (TB)Tuberculosis (TB) TB has existed for TB has existed for

thousands of years thousands of years killing millions and killing millions and millions of people. millions of people.

King King TutankhamenTutankhamen

(Egyptian (Egyptian pharaoh)pharaoh)

DEFINITIONDEFINITION

Spinal tuberculosis is a Spinal tuberculosis is a presentation of extra-presentation of extra-pulmonary tuberculosis. pulmonary tuberculosis. It is characterized by It is characterized by destruction of the destruction of the vertebrae, often vertebrae, often resulting in curvature of resulting in curvature of the spine.the spine.

PATHOLOGYPATHOLOGY

Tubercular bacteria are present Tubercular bacteria are present everywhere. everywhere.

They are often entering our body through They are often entering our body through breath, through the water that we drink breath, through the water that we drink and rarely through saliva. and rarely through saliva.

They are normally efficiently dealt with They are normally efficiently dealt with and killed by our disease fighting and killed by our disease fighting immune system. immune system.

With reduction in body's resistance these With reduction in body's resistance these bacteria can settle down in our body, bacteria can settle down in our body, thrive and multiply. thrive and multiply.

Earlier people with poor socio-economical Earlier people with poor socio-economical conditions were commonly affected. conditions were commonly affected.

With changing behaviour of these With changing behaviour of these bacteria even perfectly healthy bacteria even perfectly healthy individuals are also seen to be getting individuals are also seen to be getting infected. infected.

PATHOLOGYPATHOLOGY People of all ages can be affected by People of all ages can be affected by

this disease. this disease. In growing children the disease can In growing children the disease can

destroy parts responsible for their destroy parts responsible for their spinal growth ( spinal growth ( Growth Plates in Growth Plates in VertebraVertebra). This makes Tuberculosis of ). This makes Tuberculosis of the Spine in Children different than in the Spine in Children different than in adults. adults.

These bacteria do not directly affect These bacteria do not directly affect bones and joints. The bones and joints. The Primary Focus Primary Focus of Infectionof Infection is generally in the lungs, is generally in the lungs, lymph nodes, intestines and other soft lymph nodes, intestines and other soft tissues.tissues.

Spine commonly receives bacteria Spine commonly receives bacteria from such primary focus through blood from such primary focus through blood stream or through lymph stream. stream or through lymph stream.

PATHOLOGYPATHOLOGY The vertebra The vertebra bodybody is is

commonly affected. commonly affected. The affected bone The affected bone

undergoes progressive undergoes progressive destruction. destruction.

The cartilage cushion The cartilage cushion between the vertebral between the vertebral bodies (bodies ( Intervertebral Intervertebral Disc Disc ) commonly gets ) commonly gets destroyed. destroyed.

The The puspus of various thickness of various thickness forms. In an attempt to fight forms. In an attempt to fight the infection body produces the infection body produces reactive tissue called reactive tissue called Granulation Tissue.Granulation Tissue.

PATHOLOGYPATHOLOGY The destroyed bone looses The destroyed bone looses

strength, collapse due to the strength, collapse due to the weight of the body above. weight of the body above.

This produce local deformity and This produce local deformity and displacement of vertebra over displacement of vertebra over each other. each other.

The pus, granulation tissue and The pus, granulation tissue and the dead pieces of bone called as the dead pieces of bone called as SequestraSequestra, get squeezed out all , get squeezed out all around the spine. around the spine.

In the front they can formIn the front they can form AbscessesAbscesses which can track away which can track away and spread to different body and spread to different body areas. areas.

When the abscess, granulation When the abscess, granulation and sequestra get squeezed out and sequestra get squeezed out backwards, they enter spinal backwards, they enter spinal canal which contains delicate canal which contains delicate Spinal CordSpinal Cord. .

PATHOLOGYPATHOLOGY The pressure on the spinal cord and the The pressure on the spinal cord and the

nerves can produce deficiency in the nerves can produce deficiency in the function like loss of sensation, function like loss of sensation, weakness in the some body parts.weakness in the some body parts.

Sometimes this can be bad enough to Sometimes this can be bad enough to produce produce ParalysisParalysis below the level of below the level of spinal destruction. spinal destruction.

The destruction of the vertebrae in the The destruction of the vertebrae in the neck can produce paralytic affection of neck can produce paralytic affection of both upper and lower limbs both upper and lower limbs (Quadriparesis/ Quadriplegia ). (Quadriparesis/ Quadriplegia ).

The destruction of vertebrae below the The destruction of vertebrae below the neck can produce paralytic affection of neck can produce paralytic affection of both lower limbs ( Paraparesis / both lower limbs ( Paraparesis / Paraplegia ).Paraplegia ).

Control of the urinary bladder and Control of the urinary bladder and bowels may be affected. bowels may be affected.

PATHOLOGYPATHOLOGY The abscesses formed could be The abscesses formed could be

hidden deep inside the body or hidden deep inside the body or visible on the surface. visible on the surface.

They are not as hot, warm and They are not as hot, warm and painful as other commonly seen painful as other commonly seen abscesses. abscesses.

They are therefore called as They are therefore called as Cold Cold Abscesses. Abscesses.

The abscesses may burst out leaving The abscesses may burst out leaving behind a track from within which has behind a track from within which has an opening on the body surface. This an opening on the body surface. This track called as track called as Sinus , Sinus , keeps keeps discharging liquid pus, curdly discharging liquid pus, curdly yellowish white material called as yellowish white material called as Sequestra.Sequestra.

The sinuses take long time to stop The sinuses take long time to stop discharges and dry up. discharges and dry up.

    

Causes for spreading of Causes for spreading of TBTB

1.1. HIVHIV2.2. proteïen energy malnutritionproteïen energy malnutrition3.3. Immuno depressed therapy Immuno depressed therapy 4.4. cronic degenerative diseasecronic degenerative disease

CLINICAL PICTURECLINICAL PICTURE

1. Symptoms1. Symptoms FeverFever Night sweatsNight sweats AnorexiaAnorexia Weight lossWeight loss Localised back painLocalised back pain

2. Signs2. Signs KyphosisKyphosis Paravertebral swellingParavertebral swelling Psoas abscess (lump Psoas abscess (lump

in the groin)in the groin) Protective stiff Protective stiff

positionposition

Neurological signs (if Neurological signs (if there is neural there is neural involvement)involvement)

1.1. Spinal cord Spinal cord compression with compression with paraplegia paraplegia

2.2. ParesisParesis3.3. Impaired sensationImpaired sensation4.4. Nerve root pain Nerve root pain

and/orand/or5.5. Cauda equina Cauda equina

syndromesyndrome

ANTERIOR SPINAL DECOMPRESSION IN HIV-ANTERIOR SPINAL DECOMPRESSION IN HIV-POSITIVE PATIENTS WITH TUBERCULOSISPOSITIVE PATIENTS WITH TUBERCULOSIS

Figure 1a – Anteroposterior radiograph showing tuberculosis of T10/11, with a paravertebral abscess (arrows). Figure 1b – Radiograph at one month showing fixation of the allograft.Figure 1c – Lateral radiograph at five years showing incorporation and partial remodelling of the allograft.

ANTERIOR SPINAL DECOMPRESSION IN HIV-ANTERIOR SPINAL DECOMPRESSION IN HIV-POSITIVE PATIENTS WITH TUBERCULOSISPOSITIVE PATIENTS WITH TUBERCULOSIS

(A) Case 1: MRI showing an (A) Case 1: MRI showing an epidural mass with cord epidural mass with cord compression (arrow) of the compression (arrow) of the myelum and with extensionmyelum and with extension

in the thoracic transverse in the thoracic transverse process and thoracic process and thoracic paraspinal muscles.paraspinal muscles.

(B) Case 1: sagittal T2 (B) Case 1: sagittal T2 weighted image reveals weighted image reveals increased intensity in increased intensity in vertebral body at Th10 and vertebral body at Th10 and L2 (arrows) with epidural L2 (arrows) with epidural extension and compression extension and compression on the conus.on the conus.

(A) Case 1(A) Case 1 (B) Case 1(B) Case 1

ANTERIOR SPINAL DECOMPRESSION IN HIV-ANTERIOR SPINAL DECOMPRESSION IN HIV-

POSITIVE PATIENTS WITH TUBERCULOSISPOSITIVE PATIENTS WITH TUBERCULOSIS Figure 2Figure 2

Case 1: transversal Case 1: transversal sections through the sections through the vertebral bodies at vertebral bodies at levels from Th10 to L2 levels from Th10 to L2 at autopsy show at autopsy show extensive infiltration extensive infiltration with Kaposi’s with Kaposi’s sarcoma.sarcoma.

The yellow areas The yellow areas contain massive contain massive necrosis.necrosis.

ComplicationsComplications

Vertebrale collaps with a kifoses Vertebrale collaps with a kifoses Spinal cord compressionSpinal cord compression Sinus formationSinus formation ParaplegiaParaplegia

Neurological complications Neurological complications of Tuberculosis of the Spine of Tuberculosis of the Spine

::1.1. Physical Physical compressioncompression of the neural tissues like spinal of the neural tissues like spinal

cord and nerves by the products of disease.cord and nerves by the products of disease.2.2. By inflammation of these neural tissues and their By inflammation of these neural tissues and their

coverings by the disease coverings by the disease ( Meningitis / Arachnoiditis / ( Meningitis / Arachnoiditis / NeuritisNeuritis ) . ) .

3.3. Fluid retention in the local tissues - Fluid retention in the local tissues - ( Oedema ) ( Oedema ) 4.4. By disturbances of the blood supply to these delicate By disturbances of the blood supply to these delicate

neural tissues by blockage of the tiny blood vessels neural tissues by blockage of the tiny blood vessels by the inflammatory local swelling or clotting. by the inflammatory local swelling or clotting. ( Vascular thrombosis ) ( Vascular thrombosis )

5.5. Due to chronic stretching of the neural tissue by Due to chronic stretching of the neural tissue by stretching over a bony sequestra or deformity due to stretching over a bony sequestra or deformity due to progressive angular growth or bony mal alignments. progressive angular growth or bony mal alignments.

The functional deficit can be as insignificant as tingling The functional deficit can be as insignificant as tingling numbness and mild weakness ( numbness and mild weakness ( Paraparesis , Paraparesis , QuadriparesisQuadriparesis ) or as catastrophic as complete loss of ) or as catastrophic as complete loss of sensations , power and bladder- bowel (sensations , power and bladder- bowel ( Paraplegia , Paraplegia , Quadriplegia Quadriplegia ) control in areas distal to the disease. ) control in areas distal to the disease.

The investigations which The investigations which are generally needed are :are generally needed are :

Routine blood counts with Erythrocyte Sedimentation Rate. Routine blood counts with Erythrocyte Sedimentation Rate. ( ESR ) ( ESR )

SimpleSimple X-rays X-rays of the involved area (Digital quality films if of the involved area (Digital quality films if possible). possible).

High resolution High resolution C. T. ScanC. T. Scan. . M. R. I.M. R. I. ( Magnetic Resonance Imaging ). ( Magnetic Resonance Imaging ). Blood Immunoglobin ProfileBlood Immunoglobin Profile for Tuberculosis. for Tuberculosis. Sometimes the local tissue can be acquired by Aspiration Sometimes the local tissue can be acquired by Aspiration

by thick bore needle ( by thick bore needle ( Biopsy)Biopsy) is useful. is useful. Any diseased material acquired during surgery is also Any diseased material acquired during surgery is also

studied. studied. This tissue helps in confirming the presence of tubercular This tissue helps in confirming the presence of tubercular

bacteria. These bacteria can be further studied for bacteria. These bacteria can be further studied for effectiveness of various anti-bacterial drugs effectiveness of various anti-bacterial drugs ( Antibiotic ( Antibiotic Sensitivity )Sensitivity ). .

TREATMENTTREATMENT 1. Drug Treatment ( Chemotherapy ) : 1. Drug Treatment ( Chemotherapy ) :

Drugs form the mainstay of the management of Spinal Drugs form the mainstay of the management of Spinal Tuberculosis.Tuberculosis.

Presently very effective Chemotherapeutic drugs are Presently very effective Chemotherapeutic drugs are available. available.

Due to various reasons bacteria resisting many drugs are Due to various reasons bacteria resisting many drugs are evolving evolving ( Multi-Drug Resistance - MDR ). ( Multi-Drug Resistance - MDR ).

The drug regime, generally extending over 9 to 20 months. The drug regime, generally extending over 9 to 20 months. The resistant cases would need very carefully planned The resistant cases would need very carefully planned individualised medication plan. individualised medication plan.

2. Bed Rest : 2. Bed Rest : During the phase of destruction and during the period of During the phase of destruction and during the period of

potential complications like developing neurological potential complications like developing neurological compression, enforced compression, enforced Bed RestBed Rest is needed. The duration of is needed. The duration of rest varies as per the case and is to be decided by the treating rest varies as per the case and is to be decided by the treating Physician. Physician.

3. Spinal Braces : 3. Spinal Braces : Spinal Brace allows mobilization of the patient while the local Spinal Brace allows mobilization of the patient while the local

diseased area gets rest.diseased area gets rest.

TREATMENTTREATMENT 4. Surgery4. Surgery : :

If the disease is diagnosed in its early stage many a If the disease is diagnosed in its early stage many a patient can be treated without surgery.patient can be treated without surgery.

The surgery is no replacement for drug therapy.The surgery is no replacement for drug therapy. It is complementary to drugs. It is complementary to drugs. The surgery has 3 main aims. The surgery has 3 main aims.

DebridementDebridement : Removal of diseased tissue (pus, : Removal of diseased tissue (pus, graunulation tissue, sequestra etc. ). graunulation tissue, sequestra etc. ).

Neural DecompressionNeural Decompression : To relieve the Spinal Cord and : To relieve the Spinal Cord and nerves from the compressive effects of the disease. nerves from the compressive effects of the disease.

StabilizationStabilization : Restoring strength and stability of the : Restoring strength and stability of the destroyed area by bone grafting ( fusion ) and if destroyed area by bone grafting ( fusion ) and if required by instrumentation ( using metalic implants required by instrumentation ( using metalic implants for internal support of the spine ). for internal support of the spine ).

Sometimes the surgery may be needed for correction Sometimes the surgery may be needed for correction of the spinal deformity and to reduce the effects of of the spinal deformity and to reduce the effects of growth discrepancy produced by the disease.growth discrepancy produced by the disease.

When diagnosed promptly, treated properly and When diagnosed promptly, treated properly and adequately, tuberculosis of the spine has a good adequately, tuberculosis of the spine has a good prospect of recovery. Earlier the disease is caught in prospect of recovery. Earlier the disease is caught in its course the better it is !its course the better it is !

TREATMENTTREATMENT Indications for surgery include:Indications for surgery include: Neurological deficitsNeurological deficits Ineffectiveness of medicationIneffectiveness of medication Spinal deformity associated with instability or painSpinal deformity associated with instability or pain Abscess in the paraspinal regionAbscess in the paraspinal region Aims of surgery:Aims of surgery: Confirm diagnosisConfirm diagnosis Relieve compression on the spinal cord and/or nerve Relieve compression on the spinal cord and/or nerve

root . Correct spinal deformitiesroot . Correct spinal deformities Drainage of pusDrainage of pus Surgical techniques include:Surgical techniques include: Anterior radical focal debridementAnterior radical focal debridement Posterior stabilization with instrumentationPosterior stabilization with instrumentation

PROGNOSISPROGNOSIS

Tuberculosis of the spine may last for months or Tuberculosis of the spine may last for months or years. years.

Treatment modalities are highly effective unless Treatment modalities are highly effective unless complicated by drug resistance, severe spinal complicated by drug resistance, severe spinal deformity and/or neurological discrepancies.deformity and/or neurological discrepancies.

Cord compression and the resultant paraplegia Cord compression and the resultant paraplegia usually responds well to chemotherapy.usually responds well to chemotherapy.

Operative decompression greatly improves the Operative decompression greatly improves the recovery rate if treatment with medication and/or recovery rate if treatment with medication and/or chemotherapy fails to show improvement.chemotherapy fails to show improvement.

Persistence of paraplegia may occur if the damage Persistence of paraplegia may occur if the damage to the spinal cord is permanent.to the spinal cord is permanent.

PROGNOSISPROGNOSIS

Early Onset ParaplegiaEarly Onset Paraplegia : This usually occurs during the active : This usually occurs during the active stage of the disease or due to local reactivation of the disease at stage of the disease or due to local reactivation of the disease at an already healed old disease. The weakness is often sudden and / an already healed old disease. The weakness is often sudden and / or rapidly deteriorating. This would need aggressive care by drugs or rapidly deteriorating. This would need aggressive care by drugs and if necessary by surgery. and if necessary by surgery.

When recognized early and treated appropriately, the outcome is When recognized early and treated appropriately, the outcome is hopeful even if the recovery sometimes may be incomplete. Each hopeful even if the recovery sometimes may be incomplete. Each such case will have different reasons for such a complication and such case will have different reasons for such a complication and these cases will have to be dealt with after comprehensive these cases will have to be dealt with after comprehensive thinking. thinking.

Late Onset ParaplegiaLate Onset Paraplegia : : This occurs after the active disease has This occurs after the active disease has been controlled or cured. It usually happens due to slowly been controlled or cured. It usually happens due to slowly progressing degenerative changes in the neural tissues. progressing degenerative changes in the neural tissues.

The neurological difficulties may come on so slowly that it may be The neurological difficulties may come on so slowly that it may be too late before they are recognized. The structural changes in the too late before they are recognized. The structural changes in the neural tissues may be nonreversible and permanent. neural tissues may be nonreversible and permanent.

The outcome is often less rewarding and significant residual The outcome is often less rewarding and significant residual functional deficiency may be a permanent feature for the patient. functional deficiency may be a permanent feature for the patient.

PHYSIOTHERAPEUTIC AIMSPHYSIOTHERAPEUTIC AIMS

Pain reductionPain reduction Muscle re-education, Muscle strengtheningMuscle re-education, Muscle strengthening Spasticity reductionSpasticity reduction Improvement of functional independenceImprovement of functional independence Improve circulationImprove circulation Maintain ranges of motionMaintain ranges of motion Improve balance and proximal stabilityImprove balance and proximal stability

PHYSIOTHERAPEUTIC PHYSIOTHERAPEUTIC MODALITIESMODALITIES

Combination Therapy: This includes: Combination Therapy: This includes: Micropulse currentsMicropulse currents Interferential currentsInterferential currents Customized exercise program including: Customized exercise program including: 1.1. StretchingStretching2.2. BobathBobath3.3. PNF matwork & techniquesPNF matwork & techniques4.4. Balance trainingBalance training5.5. Gait trainingGait training

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