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TB SPINE with Neurology-“ What is expected from you”
.
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
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
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
History should take into consideration
Pathology part – TB and its D/D
Area of involvement – Spine
Complications – neuro deficit
History
TB – general symptoms and local symptoms specific to area of involvement
Leading questions specific to TB of spine Negative history of DDsAnkylosing spondylitis
Disc deg
Tumors
Septic
Trauma
History
Common problem Perfect diagnosis Not able to justify that
Clinical exam of spine
Vital to the examination of the spine is to have a good knowledge of the anatomy of this area.
Clinical examination of spine
Clinical examination of spine
Gait Inspection Palpation Movement and measurement Neurology of the limbs Special tests SI joints CNS exam
Patient Walking Observe the gait
Patient Standing Remember to inspect from all sides (front,
laterally and from behind):
Inspection
1. Attitude and deformity
2. Position of head, shoulder, scapula
3. swellings, sinus, skin
4. Gait
Skin – Scars (surgical scars) – Sinuses (deep infection)
Lumps: abscess, prominent paravertebral muscle spasm
Spine – Kyphosis (exaggerated or reduced) – Lumbar lordosis (exaggerated or
reduced) – Gibbus :
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
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?
vertebral tenderness - localised or general ? paraspinal spasm and muscle tenderness sacro-iliac tenderness in sacroilitis
Elsewhere:– feel for peripheral pulses – palpate groin and abdomen for abscesses – Chest, abdominal, rectal examination
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.
Special tests
Straight Leg Raising Test (SLR) Bowstring Sign Crossed SLR Reverse sciatic tension test Schober's test Femoral stretch
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
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
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.
NEUROLOGICAL EVALUATION
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.
Sensation.
Know your C5 to T1 dermatomes. Test light touch and sharp/dull sensation.
REFLEXES
Muscle stretch reflexes. Test the following reflexes:
Biceps - C5/6 Brachioradialis - C5/6 Pronator - C 6/7 Triceps - C7/8
Sensation Know your L4 to S1 dermatomes Light touch, sharp/dull sensation
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
Should we do all the tests for sensations like vibration, fine touch etc
What the examiner is looking in a spine neurology case
The examination should include the following:– Careful assessment of spine– Examination for abscesses– Abdominal evaluation for psoas / iliac mass
Meticulous neurologic examination
TB SPINE - HISTORY AND CLINICAL EXAMINATION
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
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.
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.
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.
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.
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.
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.
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.
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
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.
In TB Spine - cervical
Cervical spine tuberculosis is a less common presentation but is potentially more serious because severe neurologic complications are more likely.
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.
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.
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.
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.
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.
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
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.
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.
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.
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.
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.
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..
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
How to say the final diagnosis
Anatomoical Pathological Level Neuro – Cord compression Level – Motor, Sensory and Reflex Cord level, Vertebral level
What to say of bladder and bowel
History Subject may be already catheterised
Provisional diagnosis
Only one Diagnosis if there are no reasons ( points) against that diagnosis
Otherwise give DD
Investigations
1. ESR 2. Mantoux / Elisa - 3. Xrays including chest 4. CT5. MRI6. CT-guided procedures.7. Microbiology studies are used to confirm
diagnosis.
What are the common surgical treatments given
Treatment – ATT –regime, duration. Surgical
Indications ??? Middle path regime ??? Instrumentation ???
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
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.
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.
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
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.
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