1. POTT’S POTT’S SPINE

2. VERTEBRAL ANATOMY

3.  Centre portion of each
intervertebral disc is filled
with gel like elastic
substance(NUCLEUS
PULPOSUS) which along
with sturdy elastic collagen
fibres(ANNULUS
FIBROSUS)transmits stress
from vertebra to vertebra
 Annulus fibrosus enhances
rotational stability of
spine and helps to resist
compressive forces

4. EMBRYOLOGY OF VERTEBRAL
COLUMN
 Formed from sclerotome portions of somites(derived
from paraxial mesoderm)
 Each sclerotome-loosely arranged cells cranially &
densely packed cells caudally.
 Some of the densely packed cells move cranially
opposite the centre of myotome
INTERVERTEBRAL DISC

6.  Remainin densely packed cells fuse with loosely
arranged cells of immediately caudal sclerotome
MESENCHYMAL CENTRUM(primordium of body of
vertebra)
 Nerves lie in close relation to IVD and intersegmental
arteries lie on each side of vertebral bodies.
 Notochord persists and enlarges only in the region of
IVD…..contributes to formn of NUCLEUS PULPOSUS
which later gets surrounded by circular fibres of
ANNULUS FIBROSUS

7.  NP+AF
INTERVERTEBRAL DISC
 Resegmentation of sclerotomes into definitive
vertebrae causes myotomes to bridge the
IVD…gives them the capacity to move the spine
F
O
R
M
S

8.  Spinous and transverse processes develop from
chondrification centres(which appear at 6th week of
embryonic life) in vertebral arch.
 Ossification in vertebral arches-8th week
 At birth-each vertebra has 3 bony parts connected
by cartilageBony halves fuse during 1st 3-5yrs
 Five secondary ossificn centres appear in vertebrae
after pubrty
 All secondary centres unite with rest of vertebrae-
25yrs

9. POTT’S POTT’S SPINE
Dr SREEDEVI PK

10. TUBERCULOSIS OF SPINE
 Vertebral TB-M.C form of skeletal TB(50% of all
cases of TB of bones&joints)
 M.C-1st 3 decades
 Equal in both sexes
 Any one/several vertebrae
 M.C-Lowr thoracic & lumbar spine

11. Infectious exudate may spread anteriorly beneath anterior
longitudinal ligament~>neighbouring vertebrae
Advances&destroys epiphyseal cortex,intervertebral
disc&adj vertebrae
Infection begins in cancellous area of vertebral
body(Central/anterior/epiphyseal in location)

12.  Note:infection of posterior bony arch and
tyransverse process is unusual
 Granulation tissue develops posteriorly-encircles &
compresses spinal cord & nerve roots(more likely in
thoracic spine ‘cause of small calibre of spinal canal
here)

13. Posterior element involvt of C2(axial
CT image showing reactive sclerosis)

14. COURSE……
 ANTERIORLY……………
Exudate forms&netrates
periosteum,accumulating beneath
anterior longit.ligament(ALL)
Penetrates the ligament
Abscess
Migrates in various directions.
Abscess tracks along lines of least
resistance(along fascial planes,blood
vessels & nerves

15. CERVICAL………
Collects
behind
prevertebral
fascia
Spreads laterally
to sterno mastoid
(a point at postr
edge))
Protrudes
fwd..bulge
into
pharynx
May
gravitate to
mediastinum
Trachea,esophagus
,pleural cavity

16. THORACIC
Remains
locally
confined as a
bulbous mass
for a long time
Back-pressre
against spinal
cord
PARAPLEGIA

17.  Exudate may spread laterally to extrapleural space-
induces NON SPECIFIC PLEURAL EFFUSION
 If exudate penetrates ALL,
 occupies mediastinum
OR
 gravitates through diaphragm to
the LUMBAR ASPECT
 Rarely,thoracic cold abscess may track backward b/w
transverse processes&follow intercostal nerve-erupts on
chest wall.

18. LUMBAR…..
A
• Tuberculous exudate enters PSOAS SHEATH
• Appears below inguinal ligament on medial aspect of thigh
B
• May spread laterally beneath iliac fascia
• Emerges at iliac crest at the anterior superior iliac spine
C
• Follows great vessels….may erupt alongside femoral vessels in
triangle of Scarpa or in gluteal region
• Or forms an abscess abpve iliac crest posteriorly

19. REGIONAL DISTRIBUTION….
 DORSAL-42%
 LUMBAR-26%
 DORSOLUMBAR-12%
 CERVICAL-12%
 CERVICODORSAL-5%
 LUMBOSACRAL-3%

20. Route of spread
 TB of spine is always secondary.
 Bacteria reach spine via hematogenous route from
lungs or lymph nodes.

21. TYPES OF VERTEBRAL TB
1) PARADISCAL –
COMMONEST TYPE.
BETWEEN THE TWO
CONTIGUOUS AREAS
OF TWO ADJACENT
VERTEBRAE.
2) CENTRAL- BODY OF
SINGLE VERTEBRA IS
AFFETED.

22. 3) ANTERIOR- INFECTION IS LOCALISED TO THE
ANTERIOR PORTION OF THE VERTEBRAE.
4)POSTERIOR-POSTERIOR COMPLEX i.e
PEDICLE,LAMIINA,SPINOUS OR TRANSVERSE
PROCESS ARE INVOLVED.
5)APPENDICEAL-RARE, INVOLVES TRANSVERSE
PROCESS.

23. COLD ABSCESS
 Collection of pus and tubercular debris from
diseased vertebrae.
 Can travel in any direction.

24.  Spread beneath the anterior longitudinal
ligament- pre vertebral abscess.
 Spread posteriorly and cause pressure over the
spinal cord.
 Spread through the sides of the vertebra –
para vertebral abscess.
Sometimes penetrates the anterior longitudinal
ligament – lines of least resistance i.e. fascial
planes,vessels,nerves

25. CLINICAL PICTURE
ACTIVE STAGE
 Constitutional symptoms antedate local spinal
involvement……anorexia,nausea,weakness,weight
loss,night sweats,afternoon or evenin rise of temp
 Frequently iniated by an exanthem or trauma.
 Spine- -Stiff and painful on movt.
- Pain is localised to site of involvement/referred
dependin on specific nerve root irritation
- Localised KYPHOTIC deformity.
(Tender to percussion)

26.  Vertebral muscle spasm+
 Night cries…..movt b/w inflamed surfaces.
 Cold abscess maybe +
 Pressure effects-dysphagia(mediastinal)
Dyspnoea
Hoarseness(retropharyngeal)
Restricted hip extensn(Psoas
abscess)

27. GIBBUS DEFORMITY IN TB

28.  If any suspicion of TB spine………..
Palpate spinous processes by sliding finger
from cervical spine to sacrum…….so that even a
small knuckle kyphosis (step/prominence) is not
missed…………..thus making the diagnosis before
gross vertebral destruction has occurred.
 Stiffness,weakness&awkwardness of lower
extremities herald onset of PARAPLEGIA.

29. CHARACTERISTICS OF SPECIFIC
SPINAL INVOLVEMENT
 CERVICAL
 Pain over cervical vertbrae/referred to
occiput/upper extremities
 Pain aggravated by pressure on top of head
 Neck rigidity
 Deformity-normal lordosis is reduced & head is
supported in hands
 Paralysis of arms before legs
 Occasionally death due to dislocation

30.  LOW CERVICAL & UPPER THORACIC
 Pain along brachial plexus or intercostal nerves
 Marked rigidity with angular kyphosis
 Abscess-
retropharyngeal,supraclavicular,mediastinal.
 Cord symptoms L.C
 Arms affected first
 Horners syndrome
 Neck rigidity-head&neck turn as one

31.  THORACIC&THORACOLUMBAR
 Pain referred to lower extremities(esp lateral
aspect of thighs)
 Girdle pain
 Marked angular kyphosis
 Iliac or psoas abscess

32.  LUMBOSACRAL
 Referred pain to lower extremities
 Deformity slight
 Psoas abscess
 Flexion of hips

33.  ABSCESSES & SINUSES…..
 Cervical&dorsal-Can present away from vertebral
column:-
Paraspinal regions,posterior/anterior cervical
triangles,along brachial pkexus in axilla,along
intercostal spaces on chest wall.
 Dorsolumbar&lumbar-Abscess freq tracks down
psoas sheath……palpable in iliac fossa,lumbar
triangle,upper part of thigh below inguinal
ligmt,knee

34. Psoas abscess-Pseudo-hip flexion deformity(No limitation
of internal & external rotation of hip jt when tested in
position of flexion deformity)
- Can present as a lump in iliac foss
- HEALED STAGE
- -Not ill
- -Regains lost weight
- -No evening rise of temp
- -No spinal pain/tenderness
- -ESR falls

35. -Radiological E/O bone healing in serial Xrays
-But deformity persists
Bony ankylosis of L3-L4 resulting in kyphosis in an old
case of TB spondylitis

36. INVESTIGATIONS………
 BLOOD-Hb-anemia
TC –lymphocytosis
ESR raised
S.proteins-Hypoproteinemia
Mantoux-helpful in children<2-3yrs….not diagnostic
though

37. X-RAY APPEARANCES
 Depending on site of lesion TB spine………..
1) PARADISCAL-M.C
2) CENTRAL
3) ANTERIOR
4) APPENDICEAL

38.  Earliest radiological finding-narrowing of disc
space
 Loss of definition of paradiscal margins
 Bones look rarefied and osteopenic(40% Ca loss-
radiolucent signs)
 Observed before osseous destructive changes
 Trabecular destruction-atleast 3-5 months from
beginning of infectious process

39.  Late changes-Anterior wedge compression in
anterior vertebral involvement
 Central vertebral body collapse(CONCERTINA
COLLAPSE) in central involvement.
 Destruction of posterior elements in posterior
affection.
 Soft tissue swelling&calcificn-highly predictive of TB
 Healing stages-vertebral body&posterior elements
dense(sclerosis)

40. Collapsed vertebral body L1-L3

41.  Cervical-b/w vertebral
bodies&pharynx(retropharyngeal)-birdnest shadow
 Upper thoracic-V-shapd/bulbous/heart shaped
shadow&widened mediastinum
 Low thoracic&thoracolumbar-fusiform shadow
occupy site of psoas shadow
. Increased density and lessening of
size of shadow indicates calcification and healing

42. Axial CT-vertebral body
destruction,paravertebral abscess ext
into spinal canal

43. MODERN IMAGING TECHNIQUES
 CT SCAN
• Assessmt of destructive lesions of vertebral column
• Paravertebral soft tissue swellings
• Degree of neural compromise
• Specially useful in-
1) posterior spinal disease
2)CraNiovertebral&cervicodorsal TB
3)Sacroiliac joint TB
• Suspected areas of disease should be localized before
taking CT

44.  ISOTOPE BONE SCAN-Localises diseased area by
demonstratin a hot spot even when lesions<5mm
 Note:atleaqst 30-40% calcium must be removed
from a particlr area for radiolucent changes to
become visible

45. Anterior wedging and erosion of T9

46. Axial CT image showing vertebral
body destruction&adj soft tissue mass

47.  MRI
• Diagnosis of TB in rare sites incl posterior
elements,vertebral appendages&sacroiliac jt
• Excellent modality to judge health of spinal
cord…detects cord compression.
 ULTRASOUND ECHOGRAPHS
To diagnose presence & size of tuberculous abscess in
lumbar vertebral disease.

48.  GALLIUM SCAN-For disseminated TB
 BIOPSY-By percutaneous technique with CT
guidance………biopsy mateial subjected to culture
BIOPSY & CULTURE-MOST DEFINITIVE
DIAGNOSTIC TEST

49.  Radiological & MRI e/o healing lags behind biological
healing processes in spinal TB.
 X-rays,MRI-Upto 5months of starting multidrugtherapy
may actually show deterioration in most pts.
 If images don’t show improvement whwn repeated>6
months after onset of Rx….consider alternate
diagnosis/therapeutically refractory disease.
 Rarely-healing accomp by fat replacemt of healed
area

50. COMPLICATIONS
1) PARAPLEGIA
2) COLD ABSCESS
3) SINUSES
4) SECONDARY INFECTION
5) FATALITY

51. DIFFERENTIAL DIAGNOSIS
 Pyogenic infections
 Typhoid spine
 Brucella spondylitis
 Mycotic spondylituis
 Syphilitic infection
 Tumorous conditions
 Primary malignant tumors
 Multiple myeloma

52.  Lymphomas
 Secondary neoplastic deposits
 HistiocytosisX
 Local developmental abnormalities of spine
 Spinal osteochondrosis
 Traumatic conditions
 Osteoporotic conditions
 Spondylolisthesis

53. MANAGEMENT
 AIMS OF Rx
 Halt progression of destruction and deformity
 Prevent and overcome paraplegia.
Treatment should be
prolonged ….and a cautious
attitude maintained for many
years…as recrudescence of
disease can occur even years
later!!

54. GENERAL
SUPPORTIVE
CHEMOTHERAPY
SURGERY

55. CHEMOTHERAPY
 Isoniazid(INH)-most effective anti-TB drug
 INH-5mg/kg/day……300mg usually(adults)
10-15mg/kg/day……………...children.
 S/E-peripheral neuropathy,anemia,hepatitis
 Pyridoxine 50mg to be supplemented daily
MONITOR LFT

56.  Ethambutol-25mg/kg/day X 60days
15mg/kg single dose thereafter.
S/E-Visual disturbances……avoid in children
PERIODIC
OPHTHALMIC
CHECK UPS

57.  Streptomycin
 Adults
0.75-1g/day X 60days
1g/day 2-3times weekly thereafter
Children
15-25mg/kg/day
 INTRAMUSCULAR
S/E-Ototoxicity,nephrotoxicity
AVOID IN RENAL
INSUFFICIENCY

58.  RIFAMPICIN
 Adult-600mg
 Children-10mg/kg/day
 Oral single daily dose given ½ hr before
breakfast
 Relatively mild toxic effects
 Colors urine&othr body fluids bright orange

59.  ***COMBINATION CHEMOTHERAPY***
 Delays emergence of drug resistant strains of
bacilli.
 Rx regimen-
HRE X 6MONTH….
If at the end of 6months,clinical & radiological
response satisfactory,
IE X 12-18MONTHS

60.  Failure to respond to first line drugs……(due to
bacterial resistance/allergic intolerance/toxic
effects)…..use SECOND LINE DRUGS
 Cycloserine,Ethionamide,Kanamycin,Amikacin,Thiocetazo
ne
 Failure to respond despite adq chemotherapy with
radiological e/o progression of disease or neurological
involvement emerges.
SURGICAL INTERVENTION


61. SURGICAL TREATMENT
 INDICATIONS
1) Failure to respond to ATT
2) Radiological e/o progression(enlargmt of
paraspinal abscess shadow)
3) Imminent vertebral collapse
4) Instability of spine
5) Progressive neurological deficit

62.  SURGICAL OBJECTIVES
1) Excise infected tissue as completely as possible
2) Decompress intraspinal neural elements
3) Reduce spinal deformity
4) Provide stability by spinal fusion

63.  PRINCIPLES
1) Removal of all diseased tissue by thorough
debridement
2) Correction of deformity
3) Interbody bone grafting & stabilization.
4) Relief of pressure on intraspinal contents.

64. WHAT IS DONE??????
 Major focus of disease is removed
 Spinal deformity reduced
 Intraspinal neural elements decompressed
 Bone defect obliterated
 Spinal stability provided by autogenous bone grafts

65.  PREOPERATIVELY, an ATT regimen is
maintained(atleast 3months)…….
 Severe destruction-external skeletal fixation with a
HALO-PELVIC DEVICE.
 Following removal of diseased focus,distraction aids
in overcoming kyphosis.
 Later…bone grafting

66. OPERATIVE AAPROACHES
 Lesions of C4-C6-lateral approach or anterior
approach
 Lesions of C7-T4-posterior thoracoplasty approach
by removing third rib on left side
 Lesions below T40Spine is approached from left
Aorta –landmark
Incision- Along a rib that’s 2ribs
higher than the rib that arises at apex of kyphosis.

67. Surgical procedures
 Lateral rhachotomy
 Costotrasversectomy
 Albee procedure-aims to unite the spinous processes
by a single cortical graft(s/c aspect of
tibia)….fixed by sewing muscles over it.
 Hibbs procedure-only local bone is used
 Combined procedure
 Circumduction fusion

68. POTT’S PARAPLEGIA

69. POTT’S PARAPLEGIA
Pott’s paraplegia can be due to –
- inflammatory causes- oedema,abscess
- mechanical causes-tubercular debris
- intrinsic causes-pathological dislocation
- spinal tumour d/s- extradural granuloma
Most commonly occurs in TB of dorsal spine because
spinal canal is narrowest in this part

70. Seddon’s Classification:

GROUP A_-Early onset - This comes up in active stage of the disease
within first 2 years.
Compressive Agents are inflammatory edema, granulation, abscess,
casseous material, sequestra and rarely ischaemic lesion.
GROUP B -Late onset- Usually after 2 years of onset of the disease.
 due to recurrence or by mechanical pressure. This can be better divided into
paraplegia with active disease and with healed disease.
Active disease - Caseous material, debris, sequestrated disc or
bone, internal gibbus, stenosis and deformity can cause
compression.
Healed disease - Usually internal gibbus and acute kyphotic
deformity can also give late onset paraplegia. Usually there is a
continuous traction, compression leading to paraplegia.

71. Kumar’s classification of
tuberculous paraplegia
stage Clinical features
1 Negligible Unaware of neural deficit,
Upgoing Plantar / Ankle clonus
2 Mild Walk with support
3 Moderate Nonambulatory,
Paralysis in extention,sensory loss
<50%
4 Severe 3+ paralysis in flexion/sensory
loss>50%/ Sphinters involved

72. CLINICAL FEATURES OF PARAPLEGIA-
- clumsiness
- twitching
- increased reflexes
- clonus
- positive Babinski’s sign

73.  In Pott’s paraplegia , motor functions are affected
first.
 The paralysis follows the following stages-
muscle weakness, spasticity , incoordination,
paraplegia in extension , flexor spasms,paraplegia
in flexion and flaccid paraplegia lastly.

74.  TREATMENT OF POTT’S PARAPLEGIA
1) ATT
2)SPINE PUT TO ABSOLUTE REST
3)PARALYSED LIMBS SHOULD BE TAKEN CARE OF.
4)REPEATED NEUROLOGICAL EXAMINATION TO
CHECK FOR WORSENING.

75. Surgical indications
1. No sign of Neurological recovery after trial of 3-4
weeks therapy
2. Neurological complication during treatment
3. Neuro deficit becoming worse
4. Recurrence of neuro complication
5. Prevertebral cervical abscesses,neurological signs&
difficulty in deglutition& respiration
6. Advanced cases- Sphincter involvement,
flaccid paralysis,
Severe flexor spasms

76. MIDDLE PATH REGIMEN
Widely accepted regimen for tb spine
 Admission,rest in bed or pop cast.
 Chemotherapy
 X-ray and ESR once in 3 months
 Gradual mobilisation in the absence of neurological
involvement.
 Spinal braces-18 months to 2 years.

77.  Abscesses are aspirated out drained.
 Sinuses heal within 6-12 weeks
 If no neurological complications develop and patient
is responding to the 3-drug therapy , surgery is
unnecessary.
 Excisional surgery for posterior spinal disease.
 Operational debridement for patients who do not
show arrest of disease after 3-6 months of
chemotheray.

78. Thank you
Thank you