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CERVICAL SPINE KOCHS : AN UNUSUAL PRESENTATION

JD Jagsai*, A Agarwal**, ML Saraf***

*Registrar; **Lecturer; ***Prof. and Head of Unit, Dept. of Orthopaedics, Bombay Hospital, Mumbai 400 020.

 INTRODUCTION

Any part of the spinal column may be affected with tuberculosis but it is commonly found in the lower thoracic and the thoraco-lumbar region. The order of frequency in Pausí series (1964) being lumbar, dorsal, dorso-lumbar, lumbo-sacral, cervicodorsal, sacral and cervical .[1] [3] [7] [9] [10] The overall higher incidence of cervical spine incidence being more common in children. The anterior type of involvement of vertebral bodies seems to be due to extension of an abscess beneath the anterior longitudinal ligament and the periosteum [7] [9] [10] The infection may spread up and down stripping the anterior or posterior longitudinal ligament and the periosteum from the front and the sides of the vertebral bodies [1]

CASE REPORT

Thirty year old malnourished, debilitated man came with dyspnoea (Grade IV NYHA classification) and dysphagia since past one week. Patient had discomfort in the cervical spine since past 3 months. This discomfort was insidious in onset and gradually progressing and became severe since past 1 week. He had inability to walk and repeated episodes of dyspnoea and dysphagia. Because of his dysphagia, he was on liquid diet since 1 week.

ON EXAMINATION

Patient had severe stiffness of cervical spine with painful range of movements, grade IV power in upper and lower limbs, without sensory deficit. Visualization of oral cavity revealed fullness in the retropharyngeal area, left side more than the right.

MANAGEMENT

Haematological investigation revealed
Investigation Patient value
Haemoglobin 9.8 gm
WBC count 8300 per mm3
 Polymorphs 80
 Lymphocytes 12
 Eosinophils 0
 Monocytes 8
Erythrocyte sedimentation rate 2 mm at the end of 1 hour

X-rays of cervical spine revealed destruction of C5 and C6 vertebra anteriorly with increase in prevertebral soft tissue shadow extending from C2-C7.

MRI revealed compression collapse of C5, C6 vertebral body with prevertebral signal intensity extending from C2-C7 anteriorly with loss of disc spaces. A small suspicious epidural collection at C4 level with indentation of cord at that level.

In view of the above critical condition of the patient and keeping the haematological and radiological picture in mind, it was decided to go down and do an emergency decompression procedure. [2] [4] [11] [12]

It was a difficult intubation in view of the retropharyngeal abscess. Left anterior cervical approach was taken and 100 ml of pus with caseous material was drained out from the retropharyngeal space. Cervical spine was exposed from C4-C7 vertebra. The body of C5, C6 and C7 with disc spaces were found to be destroyed, caseous material was scooped out of these vertebral bodies and a tricortical graft was placed in .[5] [6] [7] [8]

Post-operatively patient had complete relief from dyspnoea and dysphagia and has power of Grade V in both upper and lower limbs. He was put on four weeks of cervical traction and then in SOMI brace. Histopathology report revealed to be kochís spine. The patient was started on anti-kochs treatment, and is responding favorably to it.

CONCLUSION

This case is brought to notice, as this patient has presented to us with dyspnoea and dysphagia, which may mask the orthopaedic manifestation of cervical tuberculosis. 

REFERENCES

1. Adendorff JJ, Boeke EJ, Lazarus C. Tuberculosis of the spine, results of 300 patients. J R Coll Surg Edin 1987;         32 : 152-55.

2. Arct WW. Operative treatment of TB of the spine. JBJS 1968; 50-A : 255-67.

3. Dobson J. Tuberculosis of spine. JBJS 1951; 33-B : 517-31.

4. Fang HSY, Ong GB. Radical treatment of cervicodorsal spine. J R Coll Surg Edin 1969; 14 : 20-30.

5. Riley LH, Robinson RS, Johnson KA, Walker AE. Results of anterior interbody fusion of cervical spine. J      Neurosurg 1969; 30 : 127-33.

6. Robinson RA, Walker AE, Ferlic DC, Wiecking DK. Results of anterior interbody fusion of cervical spine. JBJS    1962; 44-A : 1569-87.

7. Shanmugasundarum TK. Tuberculosis of spine. Indian Journal of Tuberculosis 1982; 29 : 213-21.

8. Simmons EH, Bhalla SK. Anterior cervical discectomy and fusion. JBJS 1969; 51-B : 225-37.

9. Tuli SM, Srivastava TP, Verma BP, Sinha GP. Tuberculosis of cervical spine. Acta Orthop Scand 1967; 38 :     445-58.

10. Tuli SM. Tuberculosis of cervical spine. Nimhans Jr. 1988; 6 (suppl) : 79-83.

11. Wilkinson MC. Curettage of tuberculous vertebral disease in the treatment of spinal caries. Proc R Soc Med   1950; 43 :            114-116.

12. Wilkinson MC. Tuberculosis of spine treated by chemotherapy and operative debridement : A long-term   follow- up study.        JBJS 1969; 51-A : 1331-42.


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