Tuberculosis of the spine forms 50-60 percent of the total incidence of skeletal tuberculosis. It is a disease of childhood and adolescence, 50 percent of cases occurring in the age group 1-20 years.
The most common level of the lesion is in the dorsi lumbar level. This is because movement and the stress of weight bearing are maximum at this level.
The lesion soon destroys the intervertebral disc and the adjacent surfaces of the vertebral bodies which slowly collapse and obliterate the intervertebral space. Destruction of the framework of the vertebral bodies results in their collapse and the development of an angular kyphosis called gibbus. The disease commonly involves two vertebrae but in children it can rapidly destroy three or more vertebrae and cause gross deformities.
The classical symptoms of tuberculosis of the spine as described by Percival Pott are pain, rigidity, deformity, cold abscess and paraplegia.
Pain will be localised by the patient to one region of the spine. Localised tenderness over one vertebral spine is diagnostic of the level of the lesion. The disease can also present as referred pain. Disease in the cervical spine can present in the ear or pain down the arm. Upper Dorsal spine lesion can present as pain in the chest and as intercostal neuralgia. Lower Dorsal spine can cause referred pain in the abdomen.
Rigidity is caused by the spasm of the para spinal muscles due to the disease in the spine. A cervical lesion causes rigidity of the neck which at times may be asymmetrical producing torticollis. In lumbar lesions, there is marked rigidity of the back and the spine moves in one piece when the patient attempts to bend forward. This is demonstrated by the Coin test. The patient is asked to pick up a coin from the floor. He bends at the knee and hip and picks up the coin holding the spine rigid and straight all the time.
In the cervical and lumbar spine the loss of the normal lordosis occurs first followed by the gibbus. In the dorsal spine angular kyphosis (gibbus) is characteristic. The prominence of the gibbus depends on the number of the vertebrae involved. Gross kyphosis is seen in children when a number of dorsal vertebrae are destroyed.
A search for the cold abscess including a careful palpation of the abdomen is an essential part of the clinical examination. The formation of cold abscess is an invariable feature of tuberculosis of the spine. The abscess forms in the paravertebral areas and soon tracks downwards due to gravity and towards the surface following the tracks of nerves and blood vessels. As long as the abscess remains deep to the deep fascia it remains cold to touch without any inflammatory reaction and hence it is called cold abscess.
In the cervical spine, the cold abscess can point retropharyngeally producing dysphagia or show up in the neck behind the sternomastoid. In the dorsal spine, the cold abscess fills up the posterior mediastinum and tracks along the intercostal nerves to point either in the lateral chest wall or in the anterior chest wall. Abscesses also reach the surface posteriorly under the sacrospinalis muscles. The cold abscess sometimes enters the spinal canal causing pressure on the spinal cord, resulting in paraplegia.
The paraplegia in spinal tuberculosis is called Pott's paraplegia. This complication occurs in about 10 percent of the cases and is usually of the spastic type. The highest incidence of paraplegia is in lesions of the dorsal spine. In the clinical examination look for very early signs of pressure on the cord, like slight spasticity of the legs causing unsteady gait, exaggerated knee and ankle jerks, and extensor plantar response.
The earliest radiological sign is the narrowing of the intervertebral disc space. Later, there is erosion of the adjacent surfaces of the vertebral bodies. Still later, there is destruction and collapse of the vertebral bodies with obliteration of the intervertebral space.
The patient is given complete rest in bed and measures to improve his general health. Antituberculous chemotherapy is started. The spine is immobilized in a plaster shell for a short period.
The patient is periodically assessed clinically, radiologically and hematologically. When the lesion is quiescent, the patient is given a spinal brace and made ambulant. The chemotherapy is continued upto a total period of 9 months.
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