Spine tuberculosis :

What Is Tubercular Spinal Infection ?

Tuberculosis was previously the primary cause of infectious spondylitis. Before the advent of effective chemotherapy, time and surgery for paralysis were the only treatment options.

Tubercular bone and joint infections currently account for2% to 3% of all reported cases of M. tuberculosis. Spinal tubercular infections account for one third to one half of the bone and joint infections.

The thoracolumbar spine is the most commonly infected area. The incidence of infection seems to increase with age, but males and females are almost equally infected.

Cause of infection:

Pathologically, the infection is characterized by acid-fast–positive, caseating granulomas with or without pus. Tubercles composed of monocytes and epithelioid cells, forming minute masses with central caseation in the presence of Langerhans-type giant cells, are typical on microscopic examination. Abscesses expand, following the path of least resistance, and contain necrotic debris. Skin sinuses form, drain, and heal spontaneously.

Bone reaction to the infection varies from intense reaction to no reaction. In the spine, the infection spares the intervertebral discs and spreads beneath the anterior and posterior longitudinal ligaments. Epidural infection is more likely to result in permanent neurological damage.

Signs and Symptoms :

Slowly progressive constitutional symptoms are predominant in the early stages of the disease, including weakness, malaise, night sweats, fever, and weight loss. Pain is a late symptom associated with bone collapse and paralysis.

Cervical involvement can cause hoarseness because of recurrent laryngeal nerve paralysis, dysphagia, and respiratory stridor (known as Millar asthma). These symptoms may result from anterior abscess formation in the neck. Sudden death has been reported with cervical disease after erosion into the great vessels.

Neurological signs usually occur late and may wax and wane. Motor function and rectal tone are good prognostic predictors. Jain et al. calculated that the spinal canal can accommodate 76% encroachment on CT scan without neurological abnormality. investigators reported that 60% to 90% of patients with Pott paraplegia recovered with prolonged bed rest in an open-air hospital.

How to diagnose?

Laboratory studies suggest chronic disease. Findings include anemia, hypoproteinemia, and mild ESR elevation. Skin testing may be helpful, but is not diagnostic. The test is contraindicated in patients with prior tuberculous infection because of the risk of skin slough from an intense reaction and is not useful in patients with suspected reactivation of the disease.

Early radiographic findings include a subtle decrease in one or more disc spaces and localized osteopenia. Later findings include vertebral collapse, called “concertina collapse” by Seddon because of its resemblance to an accordion. Soft-tissue swelling and its late calcification are highly predictable radiographic findings.

CT scanning, with or without contrast, allows better evaluation of the pathological process and the degree of neural compromise. MRI permits further delineation of the pathological process. Abscess formation and the presence of bone fragments were the only MRI findings that helped distinguish spinal tuberculosis from neoplasia.

None of these tests is confirmatory for tuberculosis, however. Scientist noted that 67 Ga scanning was most useful in patients with disseminated tuberculosis.

Definitive diagnosis depends on culture of the organism and requires biopsy of the lesion. Percutaneous techniques with radiographic or CT control usually are adequate. Epithelioid granulomas were seen in 89%, positive acid-fast bacilli cultures in 83%, and positive acid- fast bacilli smears in 52%. Open biopsy may be required if needle biopsy is dangerous or nonproductive or if other open procedures are required.

Delayed diagnosis and missed diagnosis are common.

 i) Differential diagnoses include :

 ii) Pyogenic and fungal infections,

 iii) Secondary metastatic disease,

 iv) Primary tumors of bone (e.g., osteosarcoma, chondrosarcoma, myeloma, eosinophilic granuloma, and aneurysmal bone cyst),

 v) Sarcoidosis, giant cell tumors of bone, and bone deformities such as Scheuermann disease.

Definitive diagnosis by culture ofa biopsy specimen is important because of the toxicity of the chemotherapeutic agents and the length of treatment required. No patient developed paraplegia after surgery.

Better results with regard to deformity, recurrence, development of paralysis, and resolution when radical surgery is performed with chemotherapeutic coverage. The resolution of paraplegia did not depend on surgical intervention. Long-term bed rest, with or without cast immobilization, was ineffective. If the facilities for radical surgery are unavailable, ambulatory chemotherapy is the treatment of choice.

The indications for surgery in the absence of neurological symptoms vary widely. Involvement of more than one vertebra significantly increases the risk of kyphosis and collapse. Open biopsy for diagnosis, débridement, and grafting with or without anterior instrumentation may offer the most direct approach in these patients. Resistance to chemotherapy and recurrence of the disease are other indications for radical surgical treatment.

The indications for surgery in early or late disease as severe kyphosis with active disease, signs and symptoms of cord compression, progressive impairment of pulmonary function, and progression of the kyphotic deformity. Primary contraindications to surgery are cardiac and respiratory failure.

Posterior fusion, with or without spinal instrumentation, is indicated after anterior decompression and grafting to prevent late collapse and stress fracture of the graft if more than two vertebrae are involved and if anterior instrumentation is not used. Posterior fusion alone rarely is indicated at this time. High incidences of failure and late progression of kyphotic deformity, with or without fatigue fracture of the fusion, have followed posterior fusion alone. Tricortical iliac crest is the preferred bone graft material for all levels, provided that it is long enough. External immobilization is mandatory whenever débridement and grafting are performed.

Halo (vest, cast, or pelvic) immobilization for 3 months is used after cervical and cervicothoracic procedures. Removable or nonremovable thoracolumbar immobilization is used after thoracic and thoracolumbar procedures until the grafts have completely healed (9 to ≥12 months). Lumbosacropelvic immobilization is used after low lumbar procedures and should be from the hip to the knee of at least one leg for 6 to 8 weeks, followed by thoracolumbosacral immobilization until the graft has healed, and the infection has resolved.

Lumbar canal stenosis :

Spinal stenosis, a narrowing of the spaces in your spine, can compress your spinal cord and nerve roots exiting each vertebrae. Age-related changes in your spine is a common cause. Symptoms include back and/or neck pain, and numbness, tingling and weakness in your arms and legs. Treatments are self-care remedies, physical therapy, medications, injections and surgery.

What is spinal stenosis?

Spinal stenosis is the narrowing of one or more spaces within your spine. Less space within your spine reduces the amount of space available for your spinal cord and nerves that branch off your spinal cord. A tightened space can cause the spinal cord or nerves to become irritated, compressed or pinched, which can lead to back pain and sciatica.

Spinal stenosis usually develops slowly over time. It is most commonly caused by osteoarthritis or “wear-and-tear” changes that naturally occur in your spine as you age. For this reason, you may not have any symptoms for a long time even though some changes might be seen on X-rays or other imaging tests if taken for another reason. Depending on where and how severe your spinal stenosis is, you might feel pain, numbing, tingling and/or weakness in your neck, back, arms, legs, hands or feet.

Where does the stenosis occur ?

Spinal stenosis can occur anywhere along the spine but most commonly occurs in two areas:

i) Lower back (lumbar canal stenosis).

ii) Neck (cervical spinal stenosis).

What is Lumbar canal stenosis ?

Lumbar canal stenosis is the narrowing of the spinal canal or the tunnels through which nerves and other structures communicate with that canal. Narrowing of the spinal canal usually occurs due to changes associated with aging that decrease the size of the canal, including the movement of one of the vertebrae out of alignment.

The narrowing of the spinal canal or the side canals that protect the nerves often results in a pinching of the nerve root of the spinal cord. The nerves become increasingly irritated as the diameter of the canal becomes narrower.

Symptoms of lumbar canal stenosis include pain, numbness or weakness in the legs, groin, hips, buttocks, and lower back. Symptoms usually worsen when walking or standing and might decrease when lying down, sitting, or leaning slightly forward.

Who gets the spinal stenosis?

Spinal stenosis can develop in anyone but is most common in men and women over the age of 50. Younger people who are born with a narrow spinal canal can also have spinal stenosis. Other conditions that affect the spine, such as scoliosis, or injury to the spine can put you at risk for developing spinal stenosis.

SYMPTOMS AND CAUSES :

What causes spinal stenosis?

Spinal stenosis has many causes. What they share in common is that they change the structure of the spine, causing a narrowing of the space around your spinal cord and nerves roots that exit through the spine. The spinal cord and/or nerve roots become compressed or pinched, which causes symptoms, such as low back pain and sciatica.

The causes of spinal stenosis include:

Bone overgrowth/arthritic spurs: Osteoarthritis is the “wear and tear” condition that breaks down cartilage in your joints, including your spine. Cartilage is the protective covering of joints. As cartilage wears away, the bones begin to rub against each other. Your body responds by growing new bone. Bone spurs,or an overgrowth of bone, commonly occurs. Bone spurs on the vertebrae extend into the spinal canal, narrowing the space and pinching nerves in the spine. Paget’s disease of the bone also can also cause on overgrowth of bone in the spine, compressing the nerves.

Bulging disks/herniated disk : Between each vertebrae is a flat, round cushioning pad (vertebral disk) that acts as shock absorbers along the spine. Age-related drying out and flattening of vertebral disks and cracking in the outer edge of the disks cause the gel-like center of these disks to break through a weak or torn outer layer. The bulging disk then press on the nerves near the disk.

Herniated disks and bone spurs are two common causes of spinal stenosis.

Thickened ligaments:

Ligaments are the fiber bands that hold the spine together. Arthritis can cause ligaments to thicken over time and bulge into the spinal canal space.

Spinal fractures and injuries: Broken or dislocated bones and inflammation from damage occurring near the spine can narrow the canal space and/or put pressure on spinal nerves.

Spinal cord cysts or tumors:

Growths within the spinal cord or between the spinal cord and vertebrae can narrow the space and put pressure on the spinal cord and its nerves.

Congenital spinal stenosis:

 This is a condition in which a person is born with a small spinal canal. Another congenital spinal deformity that can put a person at risk for spinal stenosis is scoliosis (an abnormally shaped spine).

What are the symptoms of spinal stenosis?

You may or may not have symptoms when spinal stenosis first develops. The narrowing of the spinal canal is usually a slow process and worsens over time. Although spinal stenosis can happen anywhere along the spinal column, the lower back (number one most common area) and neck are common areas. Symptoms vary from person to person and may come and go.
 

Symptoms of lower back (lumbar) spinal stenosis include:

i) Pain in the lower back. Pain is sometimes described as dull ache or tenderness to electric-like or burning sensation. Pain can come and go.

ii) Sciatica. This is pain that begins in the buttocks and extends down the leg and may continue into your foot.

iii) A heavy feeling in the legs, which may lead to cramping in one or both legs.

iv) Numbness or tingling (“pins and needles”) in the buttocks, leg or foot.

v) Weakness in the leg or foot (as the stenosis worsens).

vi) Pain that worsens when standing for long periods of time, walking or walking downhill.

vii) Pain that lessens when leaning, bending slightly forward, walking uphill or sitting.

viii) Loss of bladder or bowel control (in severe cases).

Symptoms of cervical spinal stenosis include:

i) Neck pain.

ii) Numbness or tingling in the arm, hand, leg or foot. (Symptoms can be felt anywhere below the point of the nerve compression.)

iii) Weakness or clumsiness in the arm, hand, leg or foot.

iv) Problems with balance.

v) Loss of function in hands, like having problems writing or buttoning shirts.

vi) Loss of bladder or bowel control (in severe cases).

Symptoms of Thoracic spinal stenosis include:

i) Pain, numbness, tingling and or weakness at or below the level of the abdomen.

ii) Problems with balance.

How is stenosis diagnosed ?

Your healthcare provider will review your medical history, ask about your symptoms and conduct a physical exam. During your physical exam, your healthcare provider may feel your spine, pressing on different area to see if this causes pain. Your provider will likely ask you to bend in different directions to see if different spine positions bring on pain or other symptoms. Your provider will check your balance, watch how you move and walk and check your arm and leg strength.
You will have imaging tests to examine your spine and determine the exact location, type and extent of the problem. Imaging studies may include:

X-rays: X-rays use a small amount of radiation and can show changes in bone structure, such as loss of disk height and development of bone spurs that are narrowing the space in the spine.

MRI: Magnetic resonance imaging (MRI) uses radio waves and a powerful magnet to create cross-sectional images of the spine. MRI images provide detailed images of the nerves, disks, spinal cord and presence of any tumors.

CT or CT myelogram: A computed tomography (CT) scan is a combination of X-rays that creates cross-sectional images of the spine. A CT myelogram adds a contrast dye to more clearly see the spinal cord and nerves.

Management and treatment :

What are the treatments of spinal Stenosis?

Choice of stenosis treatments depend on what is causing your symptoms, the location of the problem and the severity of your symptoms. If your symptoms are mild, your healthcare provider may recommend some self-care remedies first. If these don’t work and as symptoms worsen, your provider may recommend physical therapy, medication and finally surgery.
Self-help remedies include:

Apply heat: Heat usually is the better choice for pain due to osteoarthritis. Heat increases blood flow, which relaxes muscles and relieves aching joints. Be careful when using heat – don’t set the settings too high so you don’t get burned.

Apply cold: If heat isn’t easing your symptoms, try ice (an ice pack, frozen gel pack, or frozen bag of peas or corn). Typically is applied 20 minutes on and 20 minutes off. Ice reduces swelling, tenderness and inflammation.

Exercise: Check with your healthcare provider first, but exercise is helpful in relieving pain, strengthening muscles to support your spine and improving your flexibility and balance.