ASHWINI BACK INSTITUTE

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( KOCH'S DISEASE OF THE SPINE )

DISCLAIMER

General Information :
Infection of the spine by Tubercular bacteria is common in many countries. Even in the countries, where such cases were rarely seen in the past, more and more cases are seen now. Health care providers believe that with the projected rise in AIDS cases, overall incidence of tubercular infection will rise in the world.

How one Gets Infected :

Tubercular bacteria are present everywhere. They are often entering our body through breath, through the water that we drink and rarely through saliva. They are normally efficiently dealt with and killed by our disease fighting immune system. With reduction in body's resistance these bacteria can settle down in our body, thrive and multiply. Earlier people with poor socio-economical conditions were commonly affected. With changing behaviour of these bacteria even perfectly healthy individuals are also seen to be getting infected.

People of all ages can be affected by this disease. In growing children the disease can destroy parts responsible for their spinal growth ( Growth Plates in Vertebra). This makes Tuberculosis of the Spine in Children different than in adults.

These bacteria do not directly affect bones and joints. The Primary Focus of Infection is generally in the lungs, lymph nodes, intestines and other soft tissues. Spine commonly receives bacteria from such primary focus through blood stream or through lymph stream.

The front portion of the vertebra ( the body ) is commonly affected. The affected bone undergoes progressive destruction. The cartilage cushion between the vertebral bodies ( Intervertebral Disc ) commonly gets destroyed. The pus of various thickness forms. In an attempt to fight the infection body produces reactive tissue called Granulation Tissue.

The destroyed bone looses its strength and can collpase due to the weight of the body above. This can produce local deformity and even displacement of vertebra over each other. The pus, granulation tissue and the dead pieces of bone called as Sequestra, get squizzed out all around the spine. In the front they can form Abscesses which can track away and spread to diferent body areas. When the abscess, granulation and sequestra get squizzed out backwards, they enter spinal canal which contains delicate Spinal Cord. The pressure on the spinal cord and the nerves can produce deficiency in the function like loss of sensation, weakness in the some body parts. Sometimes this can be bad enough to produce Paralysis below the level of spinal distruction. The destruction of the vertebrae in the neck can produce paralytic affection of both upper and lower limbs ( Quadriparesis / Quadriplegia ). The destruction of vertebrae below the neck can produce paralytic affection of both lower limbs ( Paraparesis / Paraplegia ). Control of the urinary bladder and bowels may be affected.

The patient typically suffers from :

  • Low grade evening fever,
  • Loss of apetite with weight loss,
  • Minor to severe, usually progressive local pain,
  • Difficulty in daily functioning due to painful and restricted spinal mobility.
  • Affection of the nervous system's function.
  • The abscesses formed could be hidden deep inside the body or visible on the surface. They are not as hot, warm and painful as other commonly seen abscesses. They are therefore called as Cold Abscesses.
    The abscesses may burst out leaving behind a track from within which has an opening on the body surface. This track called as Sinus , keeps discharging liquid pus, curdly yellowish white material called as Caseation and Sequestra. The sinuses take long time to stop discharges and dry up.

 

 

The investigations which are generally needed are :

The treatment of Spinal Tuberculosis :

 

Children of all ages can suffer from Spinal Tuberculosis. It is uncommon below the age of one year.

The mode of infection is similar to that in adults. The destruction usually starts in the centre of the vertebral body and spreads to adjacent disc and then on to the next vertebra. Sometimes it can affect multiple vertebrae and discs and produce major damage to the integrrity and strength of the vertebral column. The weakened spinal column can collapse in the front while the hind side of the column continues to maintain its height because it is usually unaffected. This can produce a hump-like deformity in the back. This of course can have nerves and spinal cord related problems of function like in adults.

 
During the usual destruction of the front parts of the column, the cartilage plates that are responsible for the local growth are destroyed to a variable extent, stopping their contribution to the growth altogether or retarding it to a major degree. The parts of the vertebra on the hinder side are usually unaffected and continue to grow in height. Thus there is a discrepancy in the front and back growth. With the passage of time this can produce a significant hunch back deformity. Major the destruction in the front, major is the growth retardation in the front parts. Also younger the child major is final growth discrepancy because the child has many years of growth left yet. The local deformity with growth can be serious cause of concern because of its potential for neurological complications.

In addition to the drug therapy, the local protection, the clearence surgery, this abnormal growing may have to be treated by certain types of surgery. Every treating surgeon diligently watches the child's growth till his teen years are over. It is necessary to have regular follow up check ups over these years even if the child is apperently normal after the primary treatment.



Neurological complications of Tuberculosis of the Spine :

The Neurological problems can arise due to :
- Physical compression of the neural tissues like spinal cord and nerves by the products of disease.
- By inflammation of these neural tissues and their coverings by the diasease
( Meningitis / Arachnoiditis / Neuritis ) .
- Fluid retention in the local tissues - ( Oedema )
- By disturbances of the blood supply to these delicate neuiral tissues by blockage of the tiny blood vessels by the inflammatory local swelling or clotting. ( Vascular thrombosis )
- Due to chronic stretching and attrition of the neural tissue by stretching over a bony sequstra or deformity due to progressive angular growth or bony malalignments.

The functional deficit can be as insignificant as tingling numbness and mild weakness ( Paraparesis , Quadriparesis ) or as catastrophic as complete loss of sensations , power and bladder- bowel ( Paraplegia , Quadriplegia ) control in areas distal to the disease.

Early Onset Paraplegia : This usually occurs during the active stage of the disease or due to local reactivation of the desease at an aleady healed old desaese. The weakness is often sudden and / or rapidly deteriorating. This would need agressive care by drugs and if necessary by surgery. When recognised early and treated appropriately, the outcome is hopeful even if the recovery sometimes may be incomplete. Occasionally, the neuro status may deteriorate inspite of accurate drug regime or inspite of accurately, competantly and carefully performed surgery. Each such case will have different reasons for such a complication and these cases will have to be dealt with after comprehensive thinking.

Late Onset Paraplegia : This occurs after the active disease has been contolled or cured. It usually happens due to slowly progressing degenerative changes in the neural tissues. This degeneration is usually brought about by stretching of the cord during growth and internal spinal deformation. The neurological difficulties may come on so slowly that it may be too late before they are recognised. The structural changes in the neural tissues may be nonreversible and permanent. The treatment will have to be planned as per the cause of neural damage. The outcome is often less rewarding and significant residual functional deficiency may be a permanent feature for the patient.

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DRUGS USED IN TUBERCULOSIS

Amikacin
Ciprofloxacin
Cycloserine
Ethambutol
Isoniazid.
Norfloxacin
Ofloxacin.
Pyrazinamide.
Rifampin
Sparfloxacin
Streptomycin

 

Useful Links for Tuberculosis :

http://www.who.int/gtb/
http://www.cpmc.columbia.edu/tbcpp/
http://www.tuberculosis.net/
http://dir.yahoo.com/Health/diseases_and_conditions/tuberculosis/
http://www.medwebplus.com/subject/Tuberculosis