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.
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 .     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    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 
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.
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.
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.    
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 .   
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.
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.
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