Tuberculosis of Spine

This entity was initially described by Percivall Pott. He noted this like a painful kyphotic deformity from the spine associated with paraplegia. Since that time condition is often known as Pott’s disease.
The spine is easily the most common site of skeletal tuberculosis makes up about 50 percent of the cases. Lower thoracic region is easily the most common segment involved then lumbar, upper dorsal, cervical and sacral regionsin decreasing order of frequency.

Pathology
Focus of infection usually begins within the cancellous bone of the vertebral body. Occasionally it's in the posterior neural arch, transverse process, or subperiosteally deep towards the anterior longitudinal ligament in front of the vertebral body
The region of infection gradually enlarges and spreads to involve several adjacent vertebrae by extension underneath the anterior longitudinal ligament or directly over the intervertebral disc.
The vertebral bodies loose their mechanical strength due to progressive destruction underneath the force of bodyweight and eventually collapse using the intervertebral joints and the posterior neural arch intact; thus, an angular kyphotic deformity is produced, the seriousness of which depends upon the extent of destruction, the amount of the lesion, and also the number of vertebrae involved.
Kyphosis is most marked in thoraccic area due to the normal dorsal curvature. Within the lumbar area it's less because of the normal lumbar lordosisbecasue which the body weight is transmitted posteriorly and collapse is partial
 Healing happens by gradual fibrosis and calcification from the granulmatous tuberculous tissue. Eventually the fibrous tissue is ossified, with resulting bony ankylosis from the collapsed vertebrae.
Paravertebral abscess formation happens in almost every case. With collapse from the vertebral body, tuberculous granulation tissue, caseous matter, and necrotic bone and bone marrow are extruded with the bony cortex and accumulate underneath the anterior longitudinal ligament.
• In the lower back the abscess gravitates along the psoas fascial sheath in most cases points into the groin just beneath the inguinal ligament.
• In the thoracic region, the longitudinal ligaments limit the abscess, that is seen in the radiogram like a fusiform radiopaque shadow at or simply below the level of the involved vertebra.
• Thoracic abscess may get to the anterior chest wall within the parasternal area by tracking through the intercostal vessels.
Compression from the cord by the abscess or through the caseating or granulating mass, or through the posteriorly protruding border from the intervertebral disc or fringe of bone can result into neural deficit. Other contributory factors might be thrombosis of the local vessels and edema from the cord.
Neural deficit could be paraparesis to begin with and eventually result in paraplegia. It occurs most often within the mid-or upper-thoracic region, where the kyphosis is most acute, the spinal canal is narrow, and also the spinal cord is relatively large.

Clinical Features
The start of is usually insidious as well as slow evolution. Initial symptoms are vague, composed of generalized malaise, easy fatiguability, appetite loss and weight, and lack of desire to play outdoors. There might be an afternoon or evening fever.
Muscle spasm helps make the back rigid. Motion from the spine is limited in most direction..
Spasm of the paravertebral muscles within the lumbar region is also elicited by passive hyperextension from the hips with the patient in prone position-this also puts stretch around the iliopsoas muscle, which is in spasm and contracture because of psoas abscess.
A kyphus in the thoracic region could be the first noticeable sign. Because the kyphosis increases, the ribs will crowd together along with a barrel chest deformity will build up.
On gentle percussion or pressure within the spinous process of the affected vertebrae, tenderness is usually present. The abscesses might be palpated as fluctuant swellings within the groin, iliac fossa, retropharynx, or along the side of the neck, based upon the level of the lesion.
If paraplegia develops, you will see spasticity of the lower limbs with hyperactive deep tendon reflexes, a spastic gait, a varying amount of motor weakness, and disturbances of bladder and anorectal function.

Radiographic Features
Findings are suggestive, although not pathognomonic. In addition to the routine anteroposterior and lateral views from the spine, linear tomograms, CAT scan, and nuclear magnetic resonance imaging are utilized to delineate bone and spinal-cord pathology in detail. Chest radiograms as well as an intravenous pyelogram are come to rule out outer foci of systemic disease in the event of a suspected person.
The vertebral body depicts the first changes; it becomes rarefied with loss and haziness of their bone trabecular pattern. Soon the vertebral body expands and it is borders are indistinct. With progressive destruction of bone the vertebral body collapses. The intervertebral disc space first narrows and then is obliterated. Paraspinal abscesses might be seen quite early, presenting as fusiform or rounded shadows water density.
In the differential diagnosis you ought to consider
• Suppurative spondylitis
• Leukemia
• Hodgkin’s disease
• Eosinophilic granuloma
• Aneurismal bone cyst
• Ewing’s sarcoma.
Each one of these conditions may causes destruction and collapse from the vertebral body, narrowing and obliteration of intervertebral disc spaces, and paraspinal soft-tissue swelling, an image also seen in tuberculosis.

Treatment
When the diagnosis of tuberculous spondylitis is suspected, the individual is placed on bed rest and chemotherapy is initiated immediately. Patient is observed for response from the disease. A number of patients recover on chemotherapy.
A few of the patient may require surgical debridement or decompression from the cord

PHYSIOTHERAPY MANAGEMENT
Combination Therapy-. It includes:-
-Micropulse currents
-Interferential currents
-Mentamove therapy -an internationally recognized and scientifically proven therapy from Germany and customised exercise program which has revolutionized the therapy paralysis & other neurological disorders like crania-cerebral trauma, ms, nerve injuries, spinal-cord injuries, cerebral palsy worldwide .It has lead to 95% recovery in stroke patients.
-Customized workout program inclusive of stretching, Bobath and latest PNF techniques
- Balance Training
-Gait Training

Benefits:-Helps in alleviating pain
 Muscle re-education and strengthening
 Reducing spasticity
 Improving over-all functional independences