Potts spine PART 1 TYPES KUMAR AND TULI CLASSIFICATION INVESTIGATIONS OF POTTS SPINE

1. POTTS SPINE –PATHOPHYSIOLOGY
AND MANAGEMENT PRINCIPLES
DR ARJUN K
RESIDENT
DEPT OF ORTHOPAEDICS , LHMC

2. • Robert Koch : Discovered Mycobacterium
tuberculosis in 1882

3. • Percival Pott : Described TB in
spinal column in 1779
• “Destruction of disc space and
adjacent vertebral bodies, collapse
of spinal elements and progressive
spinal deformity”
• TB recognized even in Egyptian
mummies

4. 1/5th of TB population is in India
• 3% are suffering from skeletal TB ,.
50% of these suffer from spinal lesion
50% are from Pediatric group
• Mc in 1st – 3rd decade
• Equally distributed in both sexes.
Reaches skeletal system through vascular channels
generally the arteries as a result of bacillemia or
rarely in axial skeletal through batson’s plexus of
veins

5. RISK FACTORS
• Malnutrition
• Poor Sanitation
• Over crowding
• Close contact with TB patient
• Immuno deficiency state

6. Symptoms
Constitutional symptoms:
• Malaise
• Loss of weight/appetite
• Night sweats
• Evening rise of
temperature
Specific Symptoms:
• Pain/Night cries
• Stiffness
• Deformity
• Restricted ROM
• Enlarged lymph nodes
• Abscess
• Neurodeficit

7. Active stage:
• constitutional symptoms:
malaise
weight loss
loss of appetite
night sweats(TNF-alfa released by macrophages)
evening rise of temperature ( IL-1)
back pain
spine stiffness: spasm of para -vertebral muscle
night cries(release of spasm of muscles and
movement of structures involved)

8. 5)deformity :.
knuckle( 1 or 2vertebrae) / gibbus (2 or 3
vertebrae)/ kyphus (angular kyphosis 3 or more
vertebrae) .
Round kyphosis: large number of vertibrae
6)cold abscess .
7) paraplegia (if neglected in early stages)
But several of these signs and symptoms may be
absent.

11. Healed stage
Pt neither looks ill nor feel ill,
• No systemic features but the deformity that
occurred during active stage persists.
• ESR falls.
• There is radiological evidence of bone healing in
serial
Healing is indicated by
• Decreased soft tissue shadow
• Return of normal density
• Bony ankylosis

12. Decreased soft tissue shadow Return of normal density
Return of normal density
Bony ankylosis
Healing is indicated by

13. paravertebral abscess
• Accumulate beneath the ALL
• Gravitate along the fascial planes Present externally
at some distance from the site of the original lesion.
Thoracic-fusiform shadow
Psoas abscess along sheath
Common sites of abscess
• Paraspinal region at back
• Anterior and posterior of neck
• Along brachial plexus in axilla
• IC space in chest
• Psoas abscess

14. PARAVERTEBRAL ABSCESS
A longitudinal incision lateral to midline taken.
Divide deeper layers
Usually abscess encounter immediately if not
puncture TL fascia & deeper structures.

15. Psoas abscess
• Lump in iliac fossa
• Palpable only when it pierces and spreads into iliac
sheath ( iliac fossa)
• Pseudo flexion deformity

16. .
Petit triangle is formed by lateral Margin of latismus dorsi &
medial border of external oblique m/s Base by iliac crest.
PSOAS ABSCESS
Abscess are extra peritoneal It follow course of muscle.
Drainage can be done through Petit triangle

17. • Cervical region
b/w vertebral bodies , pharynx and trachea
Upper thoracic
-V shaped shadow , stripping lung apices laterally and
downwards

18. Below T4 – fusiform shape (bird nest appearence)
• Below diaphragm – unilateral / bilateral psoas
shadow

19. PATHOPHYSIOLOGY
Usually secondary
osteomyelitis and arthritis.
• Area usually affected is the anterior aspect of the V.B
• TB spread from that area to adjacent IVD.
• Progressive bone destruction leads to vertebral
collapse, kyphosis & neurological involvement
• Kyphotic deformity occurs in collapse of anterior spine
• The collapse is minimal in cervical spine because most
of the body weight is borne through the articular
processes.
• Healing takes place by gradual fibrosis and calcification
of the granulmatous tuberculous

20. Typical tubercular spondylitic features in long
standing paraspinal abscesses
fusiform paraspinal soft tissue shadow with
calcification in few
Skip lesions as involvement of non contiguous
vertebrae (7 – 10 % cases).
concave erosions around the anterior margins of the
vertebral bodies producing a scalloped appearance
called the Aneurysmal phenomenon.

21. X ray
• More than 30% -40 % of to be destroyed.
• May take approximately 4 months.
The classic roentgen triad in spinal tuberculosis is
• primary vertebral lesion
• disc space narrowing
• paravertebral abscess
DEFORMITIES:
• Anterior wedging
• Gibbous deformity.
• Vertebra plana = single collapsed vertebra

22. Early features
• Subchondral osteopenia
• Narrowing of joint space
• Indistinct paradiscal
margins
• Paravertebral sof tissue
shadow
Late features
•V. Collapse
•Kyphosis
•Lateral translation
•Asymmetrical wedging
•Scalloping

23. They are of use in follow up and to
look for response to treatment
1. Reduced disc space
2. Blurred paradiscal margins
3. Destruction of bodies
4. Loss of trabecular pattern
5. Increased prevertebral soft tissue shadow
6. Subluxation /dislocation
7. Decreased lordosis/Kyphosis

24. CT SCAN
• Patterns of bony destruction.
• Calcifications in abscess (pathognomic for Tb)
Regions which are difficult to visualize on plain films,
like :
1. Cranio-vertebral jn
2. Cervico-dorsal region
3. Sacrum
4. Sacro-iliac joints.
5. Posterior spinal tb
Percutaneous biopsy

25. MRI SCAN
• Gold std radiological invx
• Well defined paraspinal signal
• Thin & smooth abscess wall (90% specific)
• Subligamentous spread
• Multiple v body involvement/ collapse
Helps in
• Extension of ds in to soft tissues
• Spread in to epidural space
• Demostrating neural compresion
• Multifocal lesion
• Serial MRI: for response to Rx

26. MRI SCAN
• Detect marrow infiltration in vertebral bodies,
leading to early diagnosis.
• Changes of discitis
• Assessment of extradural abscesses/subligamentous
spread.
• Skip lesions / Marrow oedema
• Spinal cord involvement; edema, thinning,
myelomalacia, syringohydromyelia
• Assess the extent of disease, degree of bony
destruction , spinal cord changes

28. USG
- To find out primary in abdomen
- Detect cold abscess
- Guided aspiration

29. Radionucleotide Scan T 99m
• Increased uptake in up to 60 per cent patients with active
tuberculosis.
• >= 5mm lesion size can be detected.
• Avascular segments and abscesses show a cold spot due to
decreased uptake.
• Highly sensitive but nonspecific.
• Aid to localise the site of active disease and to detect
multilevel involvement

30. Types of vertebral lesions
1. Paradiscal- Arterial spread
2. Central – Venous spread
3. Anterior- Subperiosteal spread
4. Appendicular
5. Articular

32. The cartilaginous end plate acts
as barrier, destruction of the
disc progresses rapidly due to
its relative avascularity, and the
infection goes on to involve the
adjacent vertebrae.
• The early resorption of the disc
leads to narrowing of space
PARADISCAL LESION
•Begins in the vertebral metaphysis,
•Erodes the cartilage & destroys the disc.

33. ANTERIOR
• cortical bone destruction beneath the anterior
longitudinal ligament.
• Spread - subperiosteal and subligamentous planes
Extension of the infection to adjacent bodies
without involvement of the intervening disc space.
• Stripping of the periosteum - loss of blood supply
to the body.
• Thromboembolic phenomena, periarteritis and
endarteritis can lead to ischemic reactions of the
bone contributing to the vertebral collapse.

35. + More common in thoracic
spine in children.
• MR imaging shows the
subligamentous abscess,
• preservation of the disc
Collapse of the VB & diminution of the disc space is
usually minimal & occurs late

36. CENTRAL
• Begins at the centre of the vertibrae
• Extends centrifugally to involve the whole body.
• Following the infection, marked hyperaemia and
osteoporosis occur.
• The body, which is thus softened, easily yields
under gravity and muscle action, leading to
compression, collapse and bony deformation.

38. Centred on the vertebral body.
• Batson‟s venous plexus or
posterior vertebral artery.
• Disc not involved.
•Vertebral collapse occur - vertebra
plana appearance.
• MR - signal abnormality of the
vertebral body
with preservation of the disc.
• DD: Appearance is
indistinguishable from that of
lymphoma or metastasis.

39. Appendicial lesion
• Isolated Pedicles & laminae (neural arch),transverse
processes & spinous process.
• Uncommon lesion (< 5%).
• Radiographically - erosive lesions, paravertebral
shadows with intact disc space.
• Rarely, present as synovitis of facet joints
• Single pedicle involvement – winking owl
• Spinous process involvement – beakless owl

40. Appendicular type

41. Skipped lessions
more than 1 lesion in vertibral coloumn with 2 or more
normal vertibrae in between

42. INVESTIGATION
• CBC :haemoglobin levels and lymphocytosis.
• ESR
Highly sensitive not specific
Serial ESR assessing respose to Rx
Comes down to normal with in 3 months of ATT
• CRP- RAISED UP TO 70% of the cases
● Mantoux test: Tuberculin test
● HIV
● LFTs, KFTs (hepatotoxic drugs)
• QUANTIFERON ASSAY: IFN gamma(tb gold test)

43. Microbiological investigations
• Bacterial culture:
Confirmation of diagnosis and drug sensitivity
• Gene Xpert MTB( 90 min by PCR)
DNA sequence specific
Rifampicin resistance detected
HPE (BIOPSY for tissue diagnosis)
• Preferably c – arm guided
• Mandatory for labelling MDR
• Transpedicular true cut biopsy
• Multiple tissues: abscess , bones , tissue
• No need to stop ATT before

45. COMPLICATIONS
• Paraplegia
• Cold abscess
• Spinal deformity
• Sinuses
• Secondary infection
• Amyloid disease
• Fatality

46. dds
• Spinal infections-
Pyogenic, brucella & fungal, syphilitic
• Neoplastic
Hemangioma
Multiple myloma
Lymphoma/ metastasis
Giant cell tumor & aneurysmal bone cyst
• Degenerative
• Traumatic condition

47. Potts paraplegia
• Incidence : 10 – 30 %
• Dorsal spine most common
• Motor functions affected before / greater than
sensory.
• Sense of position & vibration last to disappear.

48. PATHOLOGY OF POTTS PARAPLEGIA
• Inflammatory Edema : Vascular stasis , Toxins. .
• Extradural Mass : Tuberculous osteitis of VB & Abscess.
• Meningeal Changes :Dura as a rule not involved
Extradural granulation Contraction / Cicatrization
Peridural fibrosis Recurrent Paraplegia
Bony disorders Sequestra , Internal Gibbus
•Infarction of Spinal Cord :
Endarteritis, Periarteritis or thrombosis of tributary to ASA.
• Changes in Spinal Cord : Thinning (Atrophy), Myelomalacia & Syrinx

49. Classification of paraplegia
griffiths,sedons,roafs 1956

50. spine at risk signs:
• Separation of facet joints
• Retropulsion
• Lateral transation
• Toppling sign.

51. Neurological assessment staging :
Tuli’s classification
Stage 1 : Negligible
• walks normally
Patient unaware of neural deficit, physician detects plantar
extensor and/or ankle clonus.
• Stage II :(mild)
Numbness incordination
• Patient aware of deficit but manages to walk with
support, clumsiness of gait.
• Stage III :(moderate)
• Paralysis in extension(spastic paraplegia), sensory deficit
less than 50%
• nonambulatory
• Stage IV : III + flexor spasm/ paralysis in flexion/ flaccid/
sensory deficit more than 50%/ sphincters involved.

52. Areflexic paraplegia
• Spasticity disappears and flaccidity appears
• Anesthesia and loss of bladder control
• It can mimic spinal shock
Causes of areflexic paraplegia
• Thrombotic occlusion
• Transection of cord
• Rapid accumulation of infected material

53. No other diagnosis to explain signs and
symptoms.
Positive microscopy for AFB
Positive culture of MTB
CB NAAT POSITIVE
LPA positive

54. CURRENT CONCEPT
• Uncomplicated spinal TB is predominantly a medical
disease
• Treat with ATT with for appropriate duration and
at adequate dosage
• Surgery is limited to prevent and treat
complications & has specific indications

55. Why combination of ATT
• Cell wall lipids and peptidoglycans have very low
permeability to usual Abx.
• 10- 20 hrs for replication
• Each colony,, there is different types of bacilli with
diff growth kinetics and metabolic charecterstics.
• Daily regimen(18-24 MONTHS)
• Two phases
Intensive phase(2 HRZE)
Continuation phase( HRE 10- 16 months)

56. MONITORING THE TREATMENT
CLINICAL
• Regains weight and apetite by 6 weeks
• Spinal pain and muscle spasm reduces
HEMATOLOGICAL
• ESR Shows a demostrable change after 1 onth of att
and normalises by end of 3 months
RADIOGRAPHS
• Abscess shadow decreases and sclerosis of bone
begins by 2-4 months
• Complete bonty fusion occurs by 9 months
MRI signs of healing
• Resolution of marrow edema/ replacement of marrow
fat
• Complete resoluton of para vertibral abscess

57. Middle path regime
• Admission rest in bed
• Chemotherapy
X-ray & ESR once in 3 months
• MRI/ CT at 6 months interval for 2 years
Craniovertebral ,cervicodorsal, lumbosacral&
sacroiliac joints
• Gradual mobilization
3-9 weeks- back extention exercise 5-10 min 3-4 times
• Spinal brace--- 18 months-2 years

58. Role of rest, bracing, and ambulation in
the proven patients?
• In patients with severe pain, short period of rest
may be useful.
• In patient who were ambulatory at the time of
diagnosis are kept ambulatory.
• While patient not ambulatory at the time of
diagnosis, are provided with 3-4 weeks rest and
made ambulatory as early as possible.
• Bracing is controversial, can be provided in cases to
relieve pain.

59. Goals of surgical treatment
DECOMPRESSION
• Debridement and drainage of large abscesses
• Decompression of spinal cord and neural structures
(both bony and soft tissue compression)
DEFORMITY
• Kyphosis correction
STABILITY
• Reconstruction of the anterior column( weight
bearing)
• Stabilization of the spine with intrumentation

60. SURGICAL INDICATIONS
NEUROLOGIC DEFICIT
• Severe neurologic deficit at presentation
• New onset or deteriorating or unimproved deficits
during ATT
• Paraplegia /(worsening ) during conservative treatment
(6 weeks)
SEVERE VETEBRAL INFECTION
• Panvetebral disease
• Spine at risk in children
• Lack of improvement in pain after 6 weeks of
chemotherapy
• Spinal instability pain

61. KYPHOTIC DEFORMITY
• Early - > 30 degrees of kyphosis
• Late - severe kyphosis with late onset neurological
deficits

62. Surgical goals can be achieved by 3
different surgical approaches
• Anterior decompression with stablilization
through an anterior approach
• Combined ant decompression with posterior
stabilization through two approaches
• All posterior approach for anterior
decompression and posterior stabilization

63. Anterior decompression with stablilization through
an anterior approach
Advantage
• Direct access to diseased region, visualisation of
neural structures while decompression , and ability
to insert grafts.
• Ant decompression Sx performed initially involved
radical removal of the entire vertibrae thats
involved.
• Removal of infected foci up to bleeding normal
bone is sufficient as the ATT is efficient enough in
clearing the residual infection

64. Combined approach
• Indicated in vertibral body destruction with
kyphosis where reconstruction of the anterior
column may not suffice
• Anterior decompression with posterior
instrumentation done with separate
approaches using staged procedure

65. All posterior approach
current std surgical care
• Posterior pedicle scew fixation is performed by a
posterior midline approach followed by
decompression and reconstruction of anterior
column.

66. ADVANTAGES
• Familiar approach
• Excellent exposure for circumferential spinal cord
decompression
• Intrumentation can be easily extended for multiple
levels
• Instrumentation is stronger and allows better control of
deformity correction
•Depending up on the approach anterior recontruction
too can be performed
•All posterior approaches are extrapleueral and hence
prefered in patients where lung function may be poor

67. How to proceed with treatment of the patient?
Anterior decompression of spinal column with
internal kyphectomy to remove internal
salient which is indenting upon spinal cord.
This allows for anterior transposition of kinked
spinal cord.

68. APPROACH
1. Cervical spine – Anterior retropharyngeal
(smith-Robinson’s)
Anterior approach – Anterior/Medial border of
sternocleidomastoid.
2. Dorsal spine (D1 to L1) –
• Transthoracic transpleural
• Anterolateral decompression(D2 – L1)
3. Lumbar spine –
•Anterolateral(Lumbovertebrotomy)
•Extraperitoneal Ant. approach

69. ANTERIOR APPROACH TO THE CERVICAL SPINE (C2 to
D1)
Smith & Robinson
• Oblique / transverse incision.
• Plane b/w SCM & carotid sheath laterally & T-O
medially.
• Longitudinal incision in ALL open a perivertebral
abscess, or the diseased vertebrae may be exposed
by reflecting the ALL & the longus colli muscles.
Hodgson approach via posterior triangle by
retracting
• SCM, Carotid sheath, T & O anteriorly & to the
opposite side.

72. SURGICAL APPROACHES TO DORSAL SPINE
• Anterior transpleural transthoracic approach
• Anterolateral extrapleural approach
• Posterolateral approach

73. • TRANSTHORACIC
• TRANSPLEURAL
• Left sided -incision preferable
Incision made along the rib which in the mid-axillary line,
lies opposite the centre of the lesion (i.e. usually 2 ribs
higher than the centre of the vertebral lesion).
• For severe kyphosis, a rib along the incision line should
be removed.
• J-shaped parascapular incision for C7 – D8 lesions,
scapula uplift & rib resection.
• After cutting the muscles & periosteum, rib is resected
subperiosteally.

75. • Parietal pleural incision applied & lung freed from
The parieties & retracted anteriorly.
A plane developed b/w the descending aorta & the
Paravertebral abscess / diseased vertebral bodies by
Ligating the intercostal vessels & branches of
hemiazygos veins.
• T-shaped incision over the paravertebral abscess.
• Debridement / decompression with or without
bone grafting.

76. Griffith et al -- prone position
Tuli --- Right lateral position
Advantage:-
1. avoid venous congestion
2 . avoid excessive bleeding
3. permits free respiration
4. Lung & mediastinal contents fall
anteriorly
Parts to remove :
• Posterior part of rib (~8cm from the TP)
• Transverse process (TP)
• Pedicle
• Part of the vertebral body
ANTEROLATERAL DECOMPRESSION

77. ANTEROLATERAL DECOMPRESSION
• Semicircular incision
• For severe kyphosis, additional 3-4 transverse
processes and ribs have to be removed.

79. ANTERO-LATERAL APPROACH TO LUMBAR
SPINE ( LUMBOVERTEBROTOMY)
Left side approach
• Semicircular incision
• Expose and remove transverse process subperiosteally.
• Preserve lumbar nerves
• 45 ⁰ right lateral position with bridge centred over the area to
be exposed.
• Similar incision as nephroureterectomy or sympathectomy
Strip peritoneum off posterior abdominal wall and kidney,
preserving ureter.
• Longitudinal incision along psoas fibres for abscess drainage
• Retract the sympathetic chain
• Double ligation of lumbar vessels.

80. Extra peritoneal approach to lumbo-sacral region
• Left side preferred ( left Common iliac vessels longer &
retracted easily).
• Lazy “S” incision
• Strip & reflect the parietal peritoneum along
• with ureter & spermatic vessels towards right side.

82. POSTERIOR SPINAL ARTHRODESIS
• Albee– Tibial graft inserted longitudinally in to the split
spinous processes across the diseased site.
• Hibbs– overlapping numerous small osseous flaps from
contiguous laminae , spinous processes & articular facets
Indications–
• Mechanical instability of spine in otherwise healed
disease.
• To stabilize the craniovertebral region (in certain cases
of T.B.)

83. SURGERY IN SEVERE KYPHOSIS
HIGH RISK PATIENTS:
- Patients < 10 years
- Dorsal lesions
- Involvement of >= 3 vertebrae
-Severe deformity in presence of active disease, especially in
children is an absolute indication for decompression
correction and stabilization.
Staged operations-
1. Anteriorly at the site of disease,
2. Osteotomy of the posterior elements at the deformity
3. Halopelvic or halofemoral tractions post

84. SURGICAL CORRECTION OF SEVERE KYPHOTIC DEFORMITY
Fundamentals of correction:
1. To perform an osteotomy on the concave side of
the curve and wedge is open ( secured with strong
autogenous iliac grafts) .
2. To remove a wedge on the convex side and close
this wedge ( Harrington compression rods and
hooks)

85. TREATMENT OF PARAPLEGIA IN SEVERE KHYPHOSIS
Griffiths et al :anterior transposition of cord
through laminectomy
Rajasekaran : posterior stabilization f/b
Anterior debridement and bone grafting (titanium
cages) in active stage of disease and vice versa for
healed disease.
• Antero-lateral (Preferred approach)

86. Radical debridement and arthrodesis(hongkong
procedure)
• Excision of diseased tissue and anterior arthrodesis is about
the same at all levels of spine
• Remove debris,pus ,sequsterated bone/disc
• Partially correct kyphosis by direct pressure posteriorly on
spine
• After cutting mortise in vertebra at each end insert strut
bone grafts correct length keeping the vertebra sprung
apart
• IBG are taken
• Put streptomycin and isoniazide into cavity before before
closure