TB SPINE & HIP

DR TG KrugerDept Orthopedic

University of Pretoria2012

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Tuberculosis of the SPINE

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HISTORY• Spinal TB has existed

for at least 5000 yrs• Evidence has been

found in mummies from Egypt dating to 3400 B.C

• 1st know written description was in Sanskrit (1500 – 700 B.C)

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HISTORY• Pott (18th century)

noticed the association of T-spine TB with paraplegia

• WHO estimates that 1/3rd of world population is infected with TB which is still a leading cause of death on a global scale

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Statistics• +/- 8 million new cases of

TB each year worldwide• +/- 9.3 cases of TB per

100000 in US mostly pulmonary

• 20% of TB infections are extrapulmonary

• Extra pulmonary TB mostly occurs in children under the age of 5yrs

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Statistics

• The spine is the extra pulmonary site in over 50 % of cases of bone and joint involvement

• 36 - 65% in T-spine• 19 - 57% in L-spine• 0 - 21% in C-spine ( mostly

in adults, rare in children)• Up to 80% of patients have

concomitant pulmonary TB

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Anatomy of spinal involvement

• TB affect the vertebral bodies and does not destroy the disc until late in the disease

• TB causes destruction of contiguous levels or skip lesions(15%) or abscess formation(50%)

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Anatomy of spinal involvement

• Types of vertebral TB:• Central: (12%) Arises in the middle of the body

as diffuse osteitis and later collapse.• Metaphyseal: (33%) Arises in the end plates,

spreads beneath the ALL, early disc space collapse.

• Anterior/periosteal: (2%) Begins and spreads beneath the ALL, anterior vertebral body scalloping.

• Posterior: (0.8%) Almost always in continuity with ant. body involvement, usually unilateral.

• True TB arthritis: Occurs in occipito-atlanto-axial group of joints.

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Central: (12%) Arises in the middle of the body as diffuse osteitis and later collapse.

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Metaphyseal: (33%) Arises in the end plates, spreads beneath the ALL, early disc space collapse.

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Anterior/periosteal: (2%) Begins and spreads beneath the ALL, anterior vertebral body scalloping.

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Posterior: (0.8%) Almost always in continuity with ant. body involvement, usually unilateral.

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Imaging• Plain X-rays:

• Often diagnostic in our setting

• Contiguous vertebral involvement with diffuse osteopenia, erosions, kyphosis, usually posterior element sparing, decrease in disc space, paravertebral cold abscess.

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•MRI scan:•Sagittal images useful in detecting noncontiguous lesions•Best method of delineating extradural compression in those patients with neurology, and extent of soft tissue abscess formation

Imaging

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•Can differentiate between fibrosis which requires surgical decompression, and granulation tissue with pus which is more amenable to chemotherapy alone.•Considered by most as an essential preoperative investigation especially in cases of low T-spine involvement

Imaging

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Histological Diagnoses• Indications for biopsy:

• Suspected TB in non endemic area• For MC&S in places where there is more

than 4% resistance to Izoniazid• In cases of no response to chemotherapy• When probability of other diagnoses are

high (esp. adults)

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Histological Diagnoses

• Method:• CT-guided FNAB• Open biopsy if failed FNAB or if operative

procedures are contemplated i.e. decompression

• In RSA:

• Acceptable to forgo biopsy in cases where

clinical symptoms and radiographic findings are highly suggestive of TB, and institute chemotherapy empirically.

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Chemotherapy• Izoniazid (10-15mg/kg/d):

• Batericidal for actively growing bacilli• Hepatotoxic• Peripheral neuropathy due to interference with

metabolism of pyridoxime• Rifampicin (10mg/kg/d):

• Can cause GIT upset and hepatitis• Effective against dormant bacilli

• Pyrazinamide (25-30mg/kg/d):• Causes arthralgia and hepatitis• Bactericidal for mycobacterium tuberculosis

• Ethambutol (10mg/kg/d):• Causes optic neuritis (colour vision is the first to

deteriorate)• Bacteriostatic

Basis of treatment for a period of 9/12 with FBC, ESR and X-ray every 3/12

Add if evidence of resistance,not used in kids routinely

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Surgery in TB Spine
Indications:

• Neurological deficit:• Decompression reliably leads to resolution

of paraplegia if performed within 9/12 of onset of paraplegia.

• Progression of kyphosis despite chemotherapy:• Likelihood of kyphus progression depends on age,

site and number of vertebrae involved.• Younger patients especially those < 5yrs have the

ability to improve wrt their kyphus angle due to remaining growth anteriorly

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Surgical indications

• In children who have not shown signs of ankylosis after 6/12 of chemotherapy:

• Large cold abscess with respiratory compromise or psoas abscess affecting ambulation

• Open biopsy for failed FNAB• Circumferential bony involvement

with instability :• Correction of deformity:

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HIGH THORACIC TB

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MID-THORACIC TB

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HIGH THORACIC AND LUMBAR TB

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LUMBAR TB

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Tuberculosis of the Hip

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TB Hip

• Common in first 3 decades of life • Developed countries + elder age

group• Reactivation, • HIV• alcoholism • steroids / immunosuppressive therapy • co-existent medical conditions (CRF,

diabetes)

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AETIOLOGY

• MycobacteriumTuberculosis - most common

• Mycobacterium Bovis - rare, spread by milk

• Atypical Mycobacteria - rare,

HIV, lymphoma, leukaemia

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PATHOLOGY• Haematogenous spread • Infect synovial tissue / subchondral bone • Hyperplasic synovium, granulation tissue

• Pannus erodes articular cartilage • Decalcification, sequestration • Spread across growth plate, • Focal necrosis• Cold abscess• Sinuses • Capsular contracture, fibrous ankylosis

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Type 1 : Normal1

54%

Type 2 : Travelling acetabulum4

Type 3 : Dislocating419%

Type 4: Perthes1Type 5: Protrusio-acetabuli1 Type 6:

Atrophic18.5%

Type 7: Mortar and pestle1

1Shanmugasundaram JK. Bone and Joint tuberculosis Madras: Kothandaram 1983!35

1: Normal Type

•Osteopenia•Erosions: acetabulum and femur•Normal joint space•Good prognosis

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2: Travelling acetabulum

•Erosions in acetabular roof•Upward displacement of femoral head•Joint space narrowing•Poor prognosis

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3: Dislocating type

•Head subluxed or destroyed•If normal joint space after reduction- good prognosis•Prognosis poor

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4: Perthes Type

•Femoral head : sclerotic, flattened•Diff Do: Perthes: acetabular erosion, osteopenia, whole head involvement•Prognosis good

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5: Protrusio Acetabuli

•Erosions in acetabulum floor•Medial displacement femoral head•Poor prognosis

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6: Atrophic Type

•Joint space narrowing

7: Mortar and pestle type

•Head destroyed•Prognosis poor

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CLINICAL FEATURES

• General: • Loss of appetite• Weightloss, • low grade fever - nightsweats• History of pulmonary TB

• Limp• Swelling• Muscle wasting• Night cries • Starting pain

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CLINICAL FEATURES

• Early (effusion): Apparent lengthening• Flex • Abduction• Ext.rot

• Late (capsular fibrosis): Apparent shortening• Flex • Adduction• Int.rot

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DIAGNOSIS

• Bloods: Lymphocytosis, ESR 60mm/Hr

• Mantoux + 95%3 False - ve in HIV, malnutrition, advanced disease• X-ray chest: 50% + ve for Active or healed PTB• XR Pelvis : Generalised osteoporosis

: Area of destruction without reaction : Enlarged epiphysis : Erosions cross physis - 40% : Cysts, Sequestrum : Joint space narrowing - late

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DIAGNOSIS

• Bone scan: 37% -ve scans

• MRI / CT: Effusion, synovial thickening, periarticular osteoporosis

• Biopsy: Stain, histology & culture (80-90%) & PCR

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ANTI TB DRUGS2 
R.I.P.

• Rifampicin (10mg/kg/day)• INH (15mg/kg/day)• Pyrazinamide (30mg/kg/day• Hospitalized for 3 to 6 months

depending upon home circumstances

• 6 month treatment is adequate

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ANTI TB DRUGS


• Longer treatment advised for immunocompromised hosts (9-12months)

• Ethambutol added to regimen for endemic isoniazid resistance in USA

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TREATMENT Rationale


• Stage of acute symptoms 1. Anti TB drugs:2. Arthrotomy:3. Skin traction: functional position, overcome

deformity, minimise pain

• Stage of cure

Synovial disease or focus in the neck

: Aim for mobile joint

Fem.head eroded or diseased acetabulum : Aim for ankylosis- Hip spica

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Stage of acute symptoms 
 ARTHROTOMY

• Tissue diagnosis • Debride necrotic bone & soft tissue • Excise affected synovial tissue • Assists in relocation dislocated type

hip• May benefit Perthes type • Hazard: secondary infection

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Stage of acute symptoms

• Post arthrotomy• Treat in abduction traction for 4/52• Flexion encouraged as soon as possible• Dislocating type hips kept in abduction

traction for 3/12• Hips with predicted poor outcome spica

for 3/12 neutral position- aim for ankylosis

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Management of sequelae 
ARTHRODESIS

• Stable joint • Relieves pain• Slow asymmetrical gait• Rate of non-union: 6-70%  

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TOTAL HIP REPLACEMENT

• Technically demanding • implant loosening • wound infection • reactivation of infection• Age of the patient is very important

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Thank you

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