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BSPT 4TH YEAR BATCH 2007

Topics of discussion
Introduction Epidemology Symptoms Age Frequency Mortality/Morbidity Risk factors Spinal Damage

Sex
Race

Diagnosis
Treatment

(TB OF SPINE)

ALTERNATE NAMES

Pott's syndrome Pott's caries Pott's curvature angular kyphosis kyphosis secondary to tuberculosis tuberculosis of the spine tuberculous spondylitis David's disease

Tuberculosis (TB) is an infection that usually occurs in the lungs

(tuberculosis bacillus); but sometimes it happens in the spine

DISTRIBUTION
The commonest area affected is T10 to L1. The lower thoracic region is the most

common area of involvement at 40 to 50%, with the lumbar spine in a close second place at 35 to 45%.
The cervical spine accounts for about 10%.

EPIDEMIOLOGY
Rare in the UK but in developing countries it

represents about 2% Tuberculosis worldwide accounts for 1.7 billion infections, and 2 million deaths per year. Over 90% of tuberculosis occurs in poorer countries, but a global resurgence is affecting richer ones.

EPIDEMIOLOGY
India, China, Indonesia, Pakistan and

Bangladesh have the largest number of cases The disease affects males more than females in a ratio of between 1.5 and 2:1. In the USA it affects mostly adults but in the countries where it is commonest it affects mostly children.

back pain Fever weight loss loss of appetite Imbalance Clumsiness sometimes even paralysis

Tuberculosis spondylitis often causes damage

to the spine. It can result in the collapse of vertebrae and fracturing of the bones. Abscesses and tissue formation can narrow the spinal canal, leading to neurological damage

RISK FACTORS
Endemic tuberculosis

Poor socio-economic conditions.

HIV infection

Blood cp( ESR)


Range of motion in the spine. A series of neurological tests complete medical history blood immunoglobin profile

X-rays magnetic resonance images (MRIs) CT scan guided biopsy Bone scans

DIFFERENTIAL DIAGNOSIS
Pyogenic osteitis of the spine. Spinal tumours

X-RAY Spinal x-ray may

not show early disease as 50% of bone mass must be lost for changes to be visible on x-ray

MRI
MRI is useful to demonstrate the extent of

spinal compression and can show changes at an earlier stage than plain radiographs

CT scans and nuclear bone scans can also be

used.

FUNCTIONAL DEFICIT
Paraparesis , Quadriparesis Paraplegia , Quadriplegia Early Onset Paraplegia Late Onset Paraplegia

NEUROLOGICAL COMPLICATIONS OF TUBERCULOSIS OF THE SPINE


Physical compression of the neural tissues inflammation of these neural tissues

(Meningitis / Arachnoiditis / Neuritis ) Fluid retention in the local tissues ( Oedema ) By disturbances of the blood supply to these delicate neural tissues ( Vascular thrombosis) Due to chronic stretching and attrition of the neural tissue

TREATMENT
Drug treatment

Bed rest
Spinal braces Surgery PT treatment

DRUGS USED IN TUBERCULOSIS


Amikacin Ciprofloxacin

Cycloserine Ethambutol Isoniazid. Norfloxacin Ofloxacin Pyrazinamide Rifampin Sparfloxacin Streptomycin

BED REST

During the phase of destruction and during

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

SPINAL BRACES
In a true sense the brace can not avoid vertical loading forces on the diseased part longer the brace better is the control of the spine more rigid the brace better is the control The brace must be appropriately selected, perfectly crafted and properly used

SURGERY

SURGERY
The surgery has 3 main aims.

1) Debridement : Removal of diseased tissue (pus, graunulation tissue, sequestra etc. ). 2)Neural Decompression : To relieve the Spinal Cord and nerves from the compressive effects of the disease. 3)Stabilization : Restoring strength and stability of the destroyed area by bone grafting ( fusion ) and if required by instrumentation ( using metalic implants for internal support of the spine

SURGERY
Sometimes the surgery may be needed for

correction of the spinal deformity and to reduce the effects of growth discrepancy produced by the disease

PT TREATMENT
During the period of recumbancy and support Requiring lengthy immobilization (lower limb

mobilization) Chest physiotherapy (in adult there may be also risk of respiratory infection and thrombosis)

PT TREATMENT
Minimization of for

stiffness atrophy (by exercises) pressure sores positioning careful bladder training programme

PT TREATMENT
Massage (maintain circulation and nutrition

of tissue Gentle passive and active movements Breathing exercises

PT TREATMENT

When healing has been taken place Treatment plane Strengthing of patient muscle Increase mobility in any joint in which it is impaired in except those in the area attack by the disease Low forcible strengthing and mobilization of spine Massage it should be given to the limb and disease area and may be given cautiously

EXERCISES
ROM of all joints Active movements done by patient of upper

limb No over stretch over pressure should be given in any trunk exercises Thorax need mobilizing with care and no movement should be undertaken which could put any strain on spine

EXERCISES
Especial care is necessory with regard to any

movement to take place most freely in the region for example specific trunk rotation and turning to the lower thoracic region Forward flexion should not be done

BREATHING EXERCISES
Costal diaphragmatic and apical breathing Most freely movements must be given to arm

and leg with simple resistance may be added but no over stretch when arm raise above the head

GENERAL MEASURES
SKIN CARE: Change posture every 2-4 hrly to avoid bed sores. Keep skin dry and clean. BLADDER CARE: CATHETERIZATION for urinary retention. BOWEL CARE: Avoid constipation by suitable diet and laxatives.

GENERAL MEASURES
PREVENTION OF CONTRACTURES

By regular passive movements. REHABILITATION By using wheel chair,standing frames,vocational training etc.

PREVENTION
As for all tuberculosis, BCG vaccination

Improvement of socio-economic conditions.

Prevention of HIV and AIDS

CONTRAINDICATIONS
Any form of hanging Trunk rolling

Exercise with over stretching


Movement with strong resistance by force of

gravity

PROGNOSIS
The progress is slow and lasts for months or

even years. Prognosis is better if caught early and modern regimes of chemotherapy are more effective. A study from London showed that diagnosis can be difficult and is often late.1

USEFUL LINKS FOR TUBERCULOSIS


http://www.who.int/gtb/

http://www.cpmc.columbia.edu/tbcpp/ http://www.tuberculosis.net/ http://dir.yahoo.com/Health/diseases_and_ conditions/tuberculosis/ http://www.medwebplus.com/subject/Tube rculosis

SUMMARY
TB is a challenging disease for the clinician Must have microbiology before starting

treatment more rapid lab tests? Need to encourage compliance Need for multidisciplinary approach to diagnosis and management and control Need shorter, better, cheap anti TB regimes

Dpt. Infection and Tropical Medicine, Sheffield Teaching Hospitals

MOST IMPORTANT
When diagnosed promptly, treated

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

GREAT SAYING

I can never try to teach my people i can only

provide the condition in which they can learn Albert Ainstien