Nursing Management

• As with all spinal injuries, suspected cord damage until proven otherwise.
Apply a properly sized cervical collar if cervical injury is suspected.
• During the initial assessment an X-rays, immobilize the patient on a firm
surface.
• Offer the patient comfort and reassurance, talking to him quietly and
calmly. Remember, the fear of paralysis will be overwhelming. Allowing a
family member who isn’t too distraught to stay with the patient.
• If the injury necessitates surgery, administer prophylactic antibiotics as
ordered. Catheterize the patient as ordered to avoid urine retention and
monitor defecation patterns to avoid impaction.
 Nursing Management
• Position the patient properly according to injuries to avoid aspiration.
• Suggest appropriate diversionary activities to fill the hours of
immobility.
• Watch closely for neurologic changes. Immediately report changes in
skin sensation and loss of muscle strength. Either could point to
pressure on the spinal chord, possibly as a result of edema or shifting
bone fragments.
• When the patient is able to ambulate, request a physical therapy
consultation for ambulation and proper application of a back brace.
 Medical Management
(Ideal)
Non Operative Treatment:
• Before collapse of more than 1-2 vertebral body
• Antibiotics and immobilization
• W/ mild kyphosis and but no neurologic deficit
• Antibiotics and bracing
• Resolution of neurologic symptoms
• Halt in progression of kyphosis
• Antibiotics for all patients at the outset
• Reserving surgery for cold abscesses palpable posteriorly
• Cases w/ neurological environment failed to improve in response to 2-3
months antiTB therapy and immobilization
 Medical Management
(Ideal)
Outcomes:
• Assessment of the outcomes should include:
• prevalence of symptoms
• Amount of physical activity
• Amount of CNS involvement
• Presence or absence of sinus and/or abscess
• Radiographic status of the lesion
 Medical Management
(Ideal)
Diagnostic Tests
• Blood tests – elevated erythrocyte sedimentation rate
• (+) Tuberculin skin test
• Bone scan
• Bone biopsy
 Medical Management
(Ideal)
• Spinal x-ray may not show early disease (50% of bone mass must be
lost)
• Plain radiographs show vertebral destruction & narrowed disc space
• MRI useful to demonstrate the extent of spinal compression & show
earlier stage than radiographs.
• Bone elements is visible within swelling/ abscesses that indicates
Pott’s disease
• CT scans and nuclear bone scan can also be used
 Medical Management
(Ideal)
Therapy
• Non-operative – antituberculosis drugs
• Analgesics
• Immobilization of the spine region
• Surgery – to drain spinal abscesses or to stabilize the spine
• Richards intramedullary hip screw - facilitating for bone healing
• Kuntcher Nail – intramedullary rod
• Austin Moore – intramedullary rod (for Hemiarthroplasty)
Medications
 MEDICATIONS
Conservative Treatment
1st Line Chemotherapy
BACTERICIDAL DRUGS DOSE

Isoniazid 5mg/kg

Rifampicin 10mg/kg

Streptomycin 20mg/kg

Pyrazinamide 20-25mg/kg

BACTERIOSTATIC DRUG DOSE

Ethambutol 25mg/kg (x 2mnths) then 15mg/kg

Rasouli, M. R., Mirkoohi, M., Vaccaro, A. R., Yarandi, K. K., & Rahimi-Movaghar, V. (2019). Spinal
tuberculosis: diagnosis and management. Asian spine journal, 6(4), 294–308.
https://doi.org/10.4184/asj.2019.6.4.294
 MEDICATIONS
Second Line Drugs
• Amikacin, Kinamycin, Capriomycin • Second line drugs are also active
• Aminosalicyclic Acid against tuberculosis but are less
• Capreomycin effective, more toxic and more
expensive.
• Ciprofloxacin, Ofloxacin, Levofloxacin
• Clarithromycin
• Clofazimine
• Cycloserine
• Ethionamide
• Rifabutin
• Rifapentine
Rasouli, M. R., Mirkoohi, M., Vaccaro, A. R., Yarandi, K. K., & Rahimi-Movaghar, V. (2019). Spinal
tuberculosis: diagnosis and management. Asian spine journal, 6(4), 294–308.
https://doi.org/10.4184/asj.2019.6.4.294
 POLICY OF DRUG TREATMENT
• Daily treatment regimen
• Intensive phase of 2 months
INH+RMP+PZN+ETM

• Continuation phase for 9-12 months

INH + RMP

• 10mg of pyridoxine for prevention of peripheral neuropathy

Rasouli, M. R., Mirkoohi, M., Vaccaro, A. R., Yarandi, K. K., & Rahimi-Movaghar, V. (2019). Spinal
tuberculosis: diagnosis and management. Asian spine journal, 6(4), 294–308.
https://doi.org/10.4184/asj.2019.6.4.294
 MIDDLE PATH REGIMEN
• Chemotherapy

• X-ray and ESR once every 3 months

• MRI/CT at 6 months interval for 2 years

• Gradual mobilization is encouraged in absence & back extension

exercise at 3-9 weeks
Rasouli, M. R., Mirkoohi, M., Vaccaro, A. R., Yarandi, K. K., & Rahimi-Movaghar, V. (2019). Spinal
tuberculosis: diagnosis and management. Asian spine journal, 6(4), 294–308.
https://doi.org/10.4184/asj.2019.6.4.294
 DRUGS IN MIDDLE PATH
PHASE TREATAMENT
DURATION DRUGS
INTENSIVE 5-6 months INH + Rifampicin &
(for replicating Ofloxacillin
mycobacteria)
CONTINUATION 7-8 months INH + Pyrazinamide
(for persistent, slow X 3-4 months
growing or dormant or
intracellular Rifampicin X 4-5
mycobacteria) months
PROPHYLACTIC 4-5 months INH + Ethambutol

Rasouli, M. R., Mirkoohi, M., Vaccaro, A. R., Yarandi, K. K., & Rahimi-Movaghar, V. (2019). Spinal
tuberculosis: diagnosis and management. Asian spine journal, 6(4), 294–308.
https://doi.org/10.4184/asj.2019.6.4.294
 GOALS FO THE SURGICAL TREATMENT
Decompression
• Debridement and drainage of large abscesses
• Decompression of spinal cord and neural
Surgical structures
(both bony and soft tissue compression)
Management Deformity
• Kyphosis correction
Stability
• Recondstruction of the anterior column
• Stabilization of the spine with instrumentation
 The surgical goals can be achieved by three
different surgical approaches:

Surgical 1. Anterior decompression with stabilization

Managemen 2. Combined anterior decompression with
t posterior stabilization through two
approaches
3. All-posterior approach for anterior
decompression and posterior stabilization
Surgical
Management
Anterior decompression with
stabilization
• Anterior surgery offers the advantage
of direct access to the diseased region,
visualization of neural structures while
decompression and ability to insert
strut grafts.

• Initially involved radical removal of the

entire vertebrae that were involved.
Surgical
Management

Combined anterior decompression with posterior stabilization

through two approaches
• Indicated in patients with significant vertebral destruction and
kyphosis where anterior decompression w/ reconstruction of
the anterior column alone may not suffice.
• Anterior decompression and posterior instrumentation are
performed through two separate approaches in single or two
stages.
Surgical
Management
All-posterior approach for anterior
decompression and posterior
stabilization
• Posterior pedicle screw fixation is
performed by a posterior midline
approach followed by
decompression and reconstruction
of the anterior column through a
transpedicular or anterolateral
route with the same approach.
 Surgical Management
PREOPERATIVE MANAGEMENT
• Complete physical exam
• Done 1-4 weeks before surgery
• Arranged by the Spine Clinic nurse
• May be done by primary care physician or in the Spine Clinic
• This visit may take anywhere from 2-6 hours
• Medications to stop prior to surgery may include:
• Herbal products
• NSAIDs (Ibuprofen, Naprosyn)
• Anti-coagulants (blood thinners)
• Aspirin
• The surgeon will discuss risk factors of surgery
 Surgical Management
• Quit smoking before surgery/ avoid secondhand smoke
• Smoking will impair and delay healing time
• Do not drink alcohol after 8 pm
• Do not eat solid food after midnight
• Do not drink milk or juice w/ pulp after midnight
• Stop drinking clear liquids 4 hours before surgery
• Gelatin, water, popsicles, carbonated beverages, tea, clear protein drinks
• Bowel preparation, if needed
• Important to follow instructions
• If not followed, surgery may be canceled
 Surgical Management
POSTOPERATIVE MANAGEMENT
• After a week using narcotic pain relievers, patient shift gradually to non-narcotic
pain medication.
• acetaminophen, or Tylenol
• Certain pain medications should be avoided for the first several months after
surgery.
• nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin, ibuprofen, naproxen, and
COX-2 inhibitors.
• First week at home: patient needs to avoid lifting anything heavy, and bending
over. Driving must be avoided while taking narcotic pain medication or
muscle relaxers.
 Surgical Management
POSTOPERATIVE MANAGEMENT
• If the individual has smoked in the past, it is vital that smoking not be resumed
following surgery. Smoking, or any type of nicotine intake (including second-hand
smoke), increases the risk of complications and interferes with the bone-healing
process required for a successful fusion.

• Activity can gradually be increased during recovery, and physical therapy is often
helpful in this effort. Two to three months in physical therapy is common.