SPINAL CORD INJURIES BECAUSE OF TB

1. SPINAL CORD INJURIESBECAUSE OF TB Ilse Lombard 2010

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

3. Tuberculosis (TB) • Mycobacterium tuberculosis mostly attacks the lungs, however it can also attack many parts of the body such as the kidney, the lymph nodes, and the spine.

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

5. Tuberculosis (TB) • TB has existed for thousands of years killing millions and millions of people. • King Tutankhamen • (Egyptian pharaoh)

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

7. PATHOLOGY • Tubercular bacteria are present everywhere. • They are often entering our body through breath, through the water that we drink and rarely through saliva. • They are normally efficiently dealt with and killed by our disease fighting immune system. • With reduction in body's resistance these bacteria can settle down in our body, thrive and multiply. • Earlier people with poor socio-economical conditions were commonly affected. • With changing behaviour of these bacteria even perfectly healthy individuals are also seen to be getting infected.

8. PATHOLOGY • People of all ages can be affected by this disease. • In growing children the disease can destroy parts responsible for their spinal growth ( Growth Plates in Vertebra). This makes Tuberculosis of the Spine in Children different than in adults. • These bacteria do not directly affect bones and joints. The Primary Focus of Infection is generally in the lungs, lymph nodes, intestines and other soft tissues. • Spine commonly receives bacteria from such primary focus through blood stream or through lymph stream.

9. PATHOLOGY • The vertebra body is commonly affected. • The affected bone undergoes progressive destruction. • The cartilage cushion between the vertebral bodies (Intervertebral Disc ) commonly gets destroyed. • The pus of various thickness forms. In an attempt to fight the infection body produces reactive tissue called Granulation Tissue.

10. PATHOLOGY • The destroyed bone looses strength, collapse due to the weight of the body above. • This produce local deformity and displacement of vertebra over each other. • The pus, granulation tissue and the dead pieces of bone called as Sequestra, get squeezed out all around the spine. • In the front they can form Abscesses which can track away and spread to different body areas. • When the abscess, granulation and sequestra get squeezed out backwards, they enter spinal canal which contains delicate Spinal Cord.

11. PATHOLOGY • The pressure on the spinal cord and the nerves can produce deficiency in the function like loss of sensation, weakness in the some body parts. • Sometimes this can be bad enough to produce Paralysis below the level of spinal destruction. • The destruction of the vertebrae in the neck can produce paralytic affection of both upper and lower limbs (Quadriparesis/ Quadriplegia ). • The destruction of vertebrae below the neck can produce paralytic affection of both lower limbs ( Paraparesis / Paraplegia ). • Control of the urinary bladder and bowels may be affected.

12. PATHOLOGY • The abscesses formed could be hidden deep inside the body or visible on the surface. • They are not as hot, warm and painful as other commonly seen abscesses. • They are therefore called as Cold Abscesses. • The abscesses may burst out leaving behind a track from within which has an opening on the body surface. This track called as Sinus , keeps discharging liquid pus, curdly yellowish white material called as Sequestra. • The sinuses take long time to stop discharges and dry up.

13. Causes for spreading of TB • HIV • proteïen energy malnutrition • Immuno depressed therapy • cronic degenerative disease

14. 1. Symptoms Fever Night sweats Anorexia Weight loss Localised back pain 2. Signs Kyphosis Paravertebral swelling Psoas abscess (lump in the groin) Protective stiff position Neurological signs (if there is neural involvement) Spinal cord compression with paraplegia Paresis Impaired sensation Nerve root pain and/or Cauda equina syndrome CLINICAL PICTURE

15. ANTERIOR SPINAL DECOMPRESSION IN HIV-POSITIVE 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.

16. ANTERIOR SPINAL DECOMPRESSION IN HIV-POSITIVE PATIENTS WITH TUBERCULOSIS • (A) Case 1: MRI showing an epidural mass with cord compression (arrow) of the myelum and with extension in the thoracic transverse process and thoracic paraspinal muscles. • (B) Case 1: sagittal T2 weighted image reveals increased intensity in vertebral body at Th10 and L2 (arrows) with epidural extension and compression on the conus. (A) Case 1 (B) Case 1

17. ANTERIOR SPINAL DECOMPRESSION IN HIV-POSITIVE PATIENTS WITH TUBERCULOSIS Figure 2 • Case 1: transversal sections through the vertebral bodies at levels from Th10 to L2 at autopsy show extensive infiltration with Kaposi’s sarcoma. • The yellow areas contain massive necrosis.

18. Complications • Vertebrale collaps with a kifoses • Spinal cord compression • Sinus formation • Paraplegia

19. Neurological complications of Tuberculosis of the Spine : • Physical compression of the neural tissues like spinal cord and nerves by the products of disease. • By inflammation of these neural tissues and their coverings by the disease ( Meningitis / Arachnoiditis / Neuritis ) . • Fluid retention in the local tissues - ( Oedema ) • By disturbances of the blood supply to these delicate neural tissues by blockage of the tiny blood vessels by the inflammatory local swelling or clotting. ( Vascular thrombosis ) • Due to chronic stretching of the neural tissue by stretching over a bony sequestra or deformity due to progressive angular growth or bony mal alignments. The functional deficit can be as insignificant as tingling numbness and mild weakness ( Paraparesis , Quadriparesis ) or as catastrophic as complete loss of sensations , power and bladder- bowel ( Paraplegia , Quadriplegia ) control in areas distal to the disease.

20. The investigations which are generally needed are : • Routine blood counts with Erythrocyte Sedimentation Rate. ( ESR ) • Simple X-rays of the involved area (Digital quality films if possible). • High resolution C. T. Scan. • M. R. I. ( Magnetic Resonance Imaging ). • Blood Immunoglobin Profile for Tuberculosis. • Sometimes the local tissue can be acquired by Aspiration by thick bore needle ( Biopsy) is useful. • Any diseased material acquired during surgery is also studied. • This tissue helps in confirming the presence of tubercular bacteria. These bacteria can be further studied for effectiveness of various anti-bacterial drugs ( Antibiotic Sensitivity ).

21. TREATMENT • 1. Drug Treatment ( Chemotherapy ) : • Drugs form the mainstay of the management of Spinal Tuberculosis. • Presently very effective Chemotherapeutic drugs are available. • Due to various reasons bacteria resisting many drugs are evolving ( Multi-Drug Resistance - MDR ). • The drug regime, generally extending over 9 to 20 months. The resistant cases would need very carefully planned individualised medication plan. • 2. 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. • 3. Spinal Braces : Spinal Brace allows mobilization of the patient while the local diseased area gets rest.

22. TREATMENT • 4. Surgery : • If the disease is diagnosed in its early stage many a patient can be treated without surgery. • The surgery is no replacement for drug therapy. • It is complementary to drugs. • The surgery has 3 main aims. • Debridement : Removal of diseased tissue (pus, graunulation tissue, sequestra etc. ). • Neural Decompression : To relieve the Spinal Cord and nerves from the compressive effects of the disease. • 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 ). • Sometimes the surgery may be needed for correction of the spinal deformity and to reduce the effects of growth discrepancy produced by the disease. • 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 !

23. TREATMENT • Indications for surgery include: • Neurological deficits • Ineffectiveness of medication • Spinal deformity associated with instability or pain • Abscess in the paraspinal region • Aims of surgery: • Confirm diagnosis • Relieve compression on the spinal cord and/or nerve root . Correct spinal deformities • Drainage of pus • Surgical techniques include: • Anterior radical focal debridement • Posterior stabilization with instrumentation

24. PROGNOSIS • Tuberculosis of the spine may last for months or years. • Treatment modalities are highly effective unless complicated by drug resistance, severe spinal deformity and/or neurological discrepancies. • Cord compression and the resultant paraplegia usually responds well to chemotherapy. • Operative decompression greatly improves the recovery rate if treatment with medication and/or chemotherapy fails to show improvement. • Persistence of paraplegia may occur if the damage to the spinal cord is permanent.

25. PROGNOSIS • Early Onset Paraplegia : This usually occurs during the active stage of the disease or due to local reactivation of the disease at an already healed old disease. The weakness is often sudden and / or rapidly deteriorating. This would need aggressive care by drugs and if necessary by surgery. • When recognized early and treated appropriately, the outcome is hopeful even if the recovery sometimes may be incomplete. Each such case will have different reasons for such a complication and these cases will have to be dealt with after comprehensive thinking. • Late Onset Paraplegia : This occurs after the active disease has been controlled or cured. It usually happens due to slowly progressing degenerative changes in the neural tissues. • The neurological difficulties may come on so slowly that it may be too late before they are recognized. The structural changes in the neural tissues may be nonreversible and permanent. • The outcome is often less rewarding and significant residual functional deficiency may be a permanent feature for the patient.

26. PHYSIOTHERAPEUTIC AIMS • Pain reduction • Muscle re-education, Muscle strengthening • Spasticity reduction • Improvement of functional independence • Improve circulation • Maintain ranges of motion • Improve balance and proximal stability

27. PHYSIOTHERAPEUTIC MODALITIES • Combination Therapy: This includes: • Micropulse currents • Interferential currents • Customized exercise program including: • Stretching • Bobath • PNF matwork & techniques • Balance training • Gait training

28. Bibliography • 1. Brittish Society for Antimicrobial Chemotherapy. Pott's disease. www.basc.org.uk (accessed July 8, 2009). • 2. Hidalgo, Jose and Alangaden George. Pott Disease. 2008. www.emedicine.medscape.com (accessed July 23, 2009). • 3. King, Emily. What is Tuberculosis of the Spine? www.ehow.com (accessed July 18, 2009). • 4. Patient UK. Pott's Disease. October 18,2008. www.patient.co.uk (accessed June 18, 2009). • 5. Physio Line. Potts disease. www.physioline.in/ (accessed July 23, 2009). • 6. Sawar, Muhammad, and Jawad Ahmed. Early Recovery after Radical Anterior Surgery.September 1996. www.theprofessional.com (accessed July 23,2009).