Long Case 4 Spine TB

Long Case 4

Spine TB

Name                                                   Age                                         Sex

Address                                               Profession                               Date of Admission

C/C      Lower Back deformity for 2 Years

            Multiple Discharging wounds on back for 1 ½ years

HOPI –

 In the same format

Pain , Swelling  ,Deformity ,Discharge ,Limping ,Movements,Functions,Fever ,Trauma,Infection,other Constitutional symptoms – loss of appetite , weight loss, loss of sleep and excessive night sweat

She has gradually progressive painless deformity on lower back first noticed by her mom 2 years back when she was changing the shirt .Since last 1.5 years she has  discharge around bilateral hip. She has serous discharge which needs dressing upto three times a day .She had normal gait during the onset of deformity but gradually she has stooping posture of body during walking.

Her movements are more and more affected. She can only sit with support of elbows on bed with chest on thigh but unable to sit on a chair legs hanging. She can’t lie supine.

Her Functions are also markedly limited, She can hardly walk 5 mintues with hands on thighs. She can climb stairs holding side-bars. She can only use Indian toilets.

She also has associated loss of appetite,  sleep ,wight loss and excessive night sweat .She has weight loss by 10 kgs over 2 years.

She has developed low grade fever in the evening for last 6 months not associated with chills and rigors .

She denies history of trauma and infections on other parts of body.

Treatment History

            Treated for fever with analgesics

            Incision and Drainage around left hip but not investigated further at a local clinic

           

Review of system

TB may be associated with Pulmonary / Genitourinary TB . So quick review of these systems during history taking.

MSK review – Other joints pain – neck , knee, ankle , shoulder , elbows , hands and feet during history taking.

Other systems during physical examination .

Past History – Drug allergy , Past history of Blood transfusion , Medical and Surgical Ilnesses

Family History – Socioeconomic status –

Poor or high

                                                             Congested living environment ?

                                                            Any history of contact with PTB

Personal ,Birth and Developmental ,Vaccination History – Unremarkable

Mesntrual History

Expectation

Summary

4 years old girl with progressive painless deformity with multiple discharing sinuses around bilateral hip with serous discharge compromising her ability to sit , walk and lie down with constitutional symptoms most likely TB low back .

Clinical Examination

Introduction ownself

Exposure – Upto Umbilicus 

Hand scrubbing

General Examination

Healthy looking

Coscious

Well oriented to time place and person

Coperative

Not in distress

Attitude –Sitting comfortably on bed with hips and knees bent

Jaudince Pallor Cyanosis Clubbing Oedema Dehydration

Vitals

Skin / Hair

Systemic

HEENT – No redness of eyes , no ear discharge , good oral hygiene

Chest – Bilateral vescicular breathing sounds, with equal air entry with no added sounds

Cardiovascular System – S1S2  , BOTH S1 and S 2 are auscultated with no murmurs .

Per Abdomen – Soft , non tender , with no organomegaly

                        Pelvic compression

                        Per Rectal

Musculoskeletal Syestem

Look- Standing Patient

Comment on Cervical Collar

Attitude of the limb

Alignment       -           Front    Head at Centre

 Both shoulders are leveled,

                                                Chest is symmetric on both the sides

                                    No wasting of muscles on chest , shoulder ,arm , forearm                                                     , thenar and hypothenar muscles with normal overlying skin

                                    Side       Normal cervical lordosis

                                                  Maintained deltoid contour , elbows extended ,

                                                   Hands anterior to Greater trochanter

                                    Back               

  Spinal curvature is maintained with no kyphoscoliosis

  Normal overlying skin on back with no dimpling , tuft of hair

      and swelling

 No wasting of muscles on supr and intraspinatus fossa ,shoulder               and dorsal surface of arm , forearm and hands

Gait                                         Normal / Stooped wide based gait /frequent fall or early shuffling

Ask Patient to Sit

Palpation                                 Superficial Palpation

                                                            Normal temperature ,no soft tissue tenderness

                                                Deep Paplation

                                                Thumb – palpate spinous process

                                                Percussion tenderness

                                                Twisting tenderness

                                                Deep with fist on ulnar border over spinous process

                                                Feel curve

                                                            Kyphosis - D 12 – L 4

Neck ROM –                          Decreased ROM particularly Lateral Flexion

Lumbar ROM                         Flexion / Extension

                                                Rt and Lt Bending

For C –spine

Spurling sign + -                      Hyperextension + Lateral rotation towards affected side + gentle           compression – if illicits Pain – s/o Radiculopathy

Shoulder Abduction sign        + , Relief of pain with hands putting on head with shoulder abducted.

Hoffman’s Reflex                   Reflex – thumb and other fingers extend with sudden long finger DIP joint extension

Scapulohumeral Reflex           Taping spine of scapula illicits a brisk scapular elevation and abduction of humerus .

Reverse Asymmetric Jerk       Biceps / Supinator

Inverted Radial Reflex           During testing Brachioradialis reflex , the response is reciprocal spastic contracture of fingers.

Lhermitte’s Sign                     Neck – Flexion leads to burning sensation involving upper and lower extremities and trunk.

Finger Escape Sign                 In making a grip , 2 ulnar digits drift out.

                                                In grip and release test , patient unable to form a fist and release all digits within 10 seconds period

Examine upper and lower limbs for C-spine in a more detailed way.

UE – C 5 – T 1 , LE – l2 – S 5

For Lumbar spine – Lower Extremity Neurology in a more detailed manner .

Gait

Sqautting

Trendelburg test

Inspection

Alignment

Muscles wasting

Attitude of the limb

Inspection – Sinuses – Active / Healed – Site , Size , discharge ,

Palpation – Temperature ,tenderness ,Scar tenderness ,mobility

Movement

Hip /Knee /Ankle  / Toes 

Neurology

HMF – Speech ,Memory , Gait

Cranial Nerves ,

LE – l2 – S 5

Spasticity / Clonus

Sensation – including joint position which is maintained

Motor – Bulk , tone, Power – L2 – S 1

Power

Supine

Quadriceps TA , TP , Peronei

Lateral Abductor Adductor

Prone

Hamstrings , Gluteus Maximus , Medius  , Gatrocsoleus

Reflexes –        Biceps ,Triceps , Brachioradialis ,

Knee and Ankle – Brisk bilaterally

                         Plantar reflex upgoing

In case of Myelopathy spasticity , clonus , brisk reflexes , plantar upgoing.

Radiculopathy has LMN type presentation .

DPA and PTA

Per rectal examination and Bulbocavernous reflex is important when patient has areflexia.

Investigations

Blood test -                             CBC ,ESR

X--RAY

T-L Spine - AP , Lateral ,Pelvis

CXR (AP)

MRI-                                       to see cord status, TB, Abscess

Sinus fluid –                            PCR , Analysis – TC,DC , G-stain , C/S

Immunological assays

IgM and IgG – to see response to A60 Antigen , PCR highly sensitive and specific.

Staining –                                Zeihl –Neelson

Cultures –                                Ultimate diagnosis , takes time

Rapid Methods

Centrifuged Samples , using Gas liquid interphase chromatography              Lipid and long chain fatty acids

Radiolabelled DNA Probes , -Identify genus and species and subspecies in 2-8 hours

MDR –rapid diagnosis - Identifies 6 codons

Note – staining requires 10,000 bacilli / mm3 ; Culture requires 1000 bacilli /mm3.

Biopsy –demonstrates Caseous necrosis and granulation tissues .

Management           

Conservative

Rest

Nutrition

Chemotherapy

                        HRZE – 3/12

                        HRZ    -4/12

                        HR      - 11/12

            WHO –DOTS Regimen

            Cat I for extrapulmonary TB

            2(HRZE) _{3 ,} 4( HR)₃

2^nd Line ATT

            Salicyalates

            Ethionamide

            Cycloserine

            Old Drug – Thioacetazone

            New drugs- Quinolones – Cipro , Levo , Gatifloxacin , Max

                                 Macrolides -  Azithro , Clarirtho

            Drugs – Aminoglycosides – Amikacin , Kanamycin, Rifbutin

                       

Traction          

Middle Path Regime

Surgery

 Discussion 

Mantoux Test

            Delayed Hypersensitivity reaction type IV , in response to PPD 0.1 u injected intradermally forming induration which is palpable and raised.

Transeverse diameter is measured. > 15 mm is positive. Longitudinal diameter is not measured because lymphatic drainage increases diameter.

In conditions

HIV , Milliary TB < 5 mm is positive.

AO Pedicle screw fixation

Lumbar

 Pars IA , Mamillary Process , Lateral border of superior articular facet , mid transverse process

Thoracic

Lateral border of superior / inferior facet , ridge of pars and transverse process.