Spine iSAWE 12

Deformity and diagnosis

• Angular kyphosis (gibbus) from anterior vertebral body destruction and collapse
• Spinal tuberculosis (Pott disease), with paradiscal involvement, subligamentous spread and a paravertebral abscess
• HIV and immigration from endemic regions are risk factors

Spine at risk signs (Rajasekaran)

• Separation of the facet joints at the apex
• Posterior retropulsion of the vertebral fragments
• Lateral translation of the vertebrae on the AP view
• Toppling sign, with the upper vertebra tilting so that a line along its anterior surface crosses the middle of the vertebra below
• Children with two or more signs are at high risk of progression with growth

Investigations

• MRI for abscess, cord compression and skip lesions
• CT guided biopsy for acid fast bacilli, GeneXpert PCR, culture and sensitivities
• Chest radiograph, HIV viral load and CD4 count

Management

• Antituberculous chemotherapy for 9 to 12 months (isoniazid, rifampicin, pyrazinamide and ethambutol), with infectious diseases input
• Start antiretroviral therapy and watch for immune reconstitution syndrome
• Surgery for neurological deficit, instability, progressive or severe kyphosis, large abscesses and failed medical treatment
• Anterior debridement and strut grafting with posterior instrumentation, or posterior vertebral column resection for rigid deformity

Related pages

• Pyogenic Spinal Infection