CARIES SPINE AND SPINAL STENOSIS

DR. NADIR MEHMOODASSOCIATE PROFESSOR SURGERY

IIMC-T, RLY HOSP

CLINICAL ASPECTS OF TUBERCULOSIS

•Pathogenesis of tuberculosis–Infection versus disease•Host factors•Pathogen factors

PATHOGENESIS• Host factors include– Social e.g.• Poverty• alcoholism

– Age e.g.• Newborn• Teenage girl• Old age

– Immunity e.g. • HIV• Gamma interferon

PATHOGENESIS

• Organism factors e.g.–Virulence factors –[Drug resistance]

PATHOGENESIS• Tuberculous disease is a consequence

of:–Primary infection e.g. In a baby

–Reactivation • ‘natural’ • Associated with immunosupression

–Re infection

PULMONARY TB TYPICALLY AFFECTS THE UPPER ZONES OF THE LUNG

CLINICAL FEATURES • Clinical illness–Pulmonary –Extrapulmonary

CLINICAL ILLNESSTB may affect any tissue of the body including:– Skin and soft tissue– Lymph nodes– Bones and joints– Intra abdominal structures including• peritoneum • Kidneys• Adrenal glands• Lymph nodes

– Central nervous system• Tuberculoma• meningitis

Clinical clues for TB• Clinical symptoms – usually ‘chronic’ rather than

acute– Fever– Sweats – Weight loss– Focal symptoms

• Epidemiology– History of TB, HIV– Country of origin, recent travel/work– Contact with TB

• Investigations- CP ESR,URINE R/E, CXR, X-RAYS, C/S, SKIN TESTS,ELISA, CRP, PCR, CT, MRI

TB – guidelines for the clinician

• Great mimicker• Low index of suspicion• Pulmonary TB usually easy to

consider• Non pulmonary often requires

‘lateral thinking’

What will happen if diagnosis or treatment for TB spinal osteomyelitis

is delayed?

MENINGES OF THE SPINAL CORDMENINGES OF THE SPINAL CORD

What will happen if treatment delayed? – gibbus formation (acute angulation of spine with or without neurological

damage)

The physical appearance – Potts disease of spine - gibbus

• Progress– Increasing back pain and neurological

symptoms – mild leg weakness

• Treatment–Continue therapy – consider surgical decompression

• Further progress• Weakness of legs• Neurosurgery and internal splinting

• Other considerations - clinical• Has the patient got HIV? • Is vitamin D level normal?

• Other considerations - epidemiological

• From where has the pt got infection?• To whom might the pt have given it?

• BTS guidelines – 1999 Thorax 2000: 55; 210-218

• NICE guidelines – 2006– Sensitive TB – 4 drugs for 2 months

2 drugs for 4 months– Resistant TB- 6 drugs for 24 months (second

line drugs are not so effective)

[Eng, Wales & NI 2004, 6.8% Isoniazid resistant, 1% MDR TB (R to Isoniazid and rifampicin)]

TREATMENT OF TB

Problems of TB therapy

• Toxicity e.g. liver• Multiple therapy• Prolonged treatment• Drug interactions

Compliance

–Treatment will not work if not taken

–DOTS (Directly Observed Therapy) if:• Likely poor compliance• MDRTB

Public health - avoiding transmission

• TB is statutorily notifiable disease• Multidisciplinary approach – medical, TB

nurses, CCDC etc.• Identify and manage possible sources of infection and

contacts

• Considerations• treat as OP where possible • multi occupancy housing, social deprivation• negative pressure rooms in hospitals (limited facility)• beware transmission in OP setting e.g. waiting area

WHY FAILURE?• Patient non compliance–Deliberate–Failure to understand e.g. language,

culture–Social e.g. alcohol

• Patient movement e.g. ‘lost to follow up’• Lack of medical/nursing support• others

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

SAMPLE MSQs• The starting pathogenesis in TB is;• Secondary TB• Miliary TB• Ghon focus• CNS involvment• GIT involvment

• The advanced stage in Potts disease is• Paresis• Lost urinary control• Gibbus formation• Paraplegia• Death

• Poor compliance to treatment, TB of any site becomes• Resistant to treat• MDRTB• XDRTB• MILIARY TB• TB ABSCESS