Post Operative Severe Acute Neck Pain- A diagnostic Dilemma!

Dr Rajiv Jha, Dr GR Sharma, Prof Pawan Kumar

Introduction

• Neck pain (or cervicalgia) is a common problem, with two-thirds of the population having neck pain at some point in their lives

Objective

To analyze the co-incidence of tuberculous cervical spondylitis after tracheal intubation,

and to find the risk factors, presentations, and outcome of the disease process.

Study Design

• A prospective study• September 2009- September 2010• NNRC,Bir Hospital / Department Of

Neurosurgery OHRC

Age

0-10 20-Nov 21-30 31-40 41-50 51-60 >600

0.5

1

1.5

2

2.5

3

3.5

N0

Sex

3

8

MF

Clinical Presentation

• Isolated neck pain - 4• Neck pain with radiculopathy -6 • Neck pain with focal neurological deficit - 1

Objective Findings

• Restricted neck movements – 11• Radiculopathy – 6• Focal neurological deficit - 1

DD

• Manipulation after ET intubation• Rheumatoid arthritis• Osteoarthritis• Infection• Cervical spondylosis• Cervical PIVD• Spinal tumor etc.

investigations

• ESR• CRP• RA Factor• X-Ray Cervical Spine

ESR RAF CRP X-ray C. Spine

Patient 1 42 -ve Abnormal

Patient 2 29 -ve +ve Abnormal

Patient 3 37 -ve +ve Abnormal

Patient 4 25 -ve Abnormal

Patient 5 56 -ve +ve Abnormal

Patient 6 27 -ve Abnormal

Patient 7 114 -ve Abnormal

Patient 8 68 -ve +ve Abnormal

Patient 9 12 -ve Abnormal

Patient 10 32 -ve +ve Abnormal

Patient 11 34 -ve +ve Abnormal

P Dahal 30/F I Bhattarai 40/F

CK Shrestha 36/F R Devi 45/F

Provisional Diagnosis

• Cervical Tubercular Spondylitis

Further Investigations

• MRI Cervical spine• Mantoux Test• S. Mycodot• S. ADA• Chest X-ray

MRI C Spine Mantoux Test

S. Mycodot S. ADA CXR

Patient 1 Abnormal 14 +ve 31 Normal

Patient 2 Abnormal 18 +ve Normal

Patient 3 Abnormal 13 +ve Normal

Patient 4 Abnormal 14 Normal

Patient 5 Abnormal 12 +ve Normal

Patient 6 Abnormal 11 Normal

Patient 7 Abnormal 13 37 Normal

Patient 8 Abnormal 21 +ve 39 Normal

Patient 9 Abnormal 9 Normal

Patient 10 Abnormal 11 +ve Normal

Patient 11 Abnormal 10 +ve Normal

P Dahal 30/F S Pradhan 42/M

MRI C Spine

Cervical Level involved

Patient 1 C3,4 and C6,7

Patient 2 C3,4,5

Patient 3 C5,6

Patient 4 C4,5

Patient 5 C5,6,7

Patient 6 C3,4

Patient 7 C6,7

Patient 8 C4,5

Patient 9 C4,5,6

Patient 10 C6,7

Patient 11 C5,6

Final Diagnosis

• Cervical tubercular spondylitis

Management

• Chemotherapy: By controlling the morbid process and improving the prognosis for spinal tuberculosis, antituberculosis agents are the mainstay of management

• Surgical procedures - still play an important role

Drug Treatment Regimens• The standard triple chemotherapy (isoniazid, rifampin, and pyrazinamide),

should be given for at least 12 months• triple chemotherapy for a period of 18 months is recommended for slowly

responsive cases or, alternatively, a 12-month four drug regimen (soniazid, rifampin, ethambutol, and pyrazinamide) is appropriate for such cases.

• rifampin and isoniazid for 6 or 9 months, to be at least as effective as the 18-months course of isoniazid and para-amino salicylic acid (Griffith )

• 6 months of three-drug chemotherapy in conjunction with radical surgery was adequate for the management of tuberculosis of the spine because it produced results comparable with 9-month and 18-month chemotherapeutic regimens. (Upadhayay et al)

• HRZE(3 months) followed by HR(15 months) – NNRC protocol

F/U

Surgical procedures

• Cervical traction • Posterior fusion • Anterior radical surgery • Two-stage operation:(Posterior instrumentation

followed by anterior radical surgery +Anterior release and graft, followed by posterior instrumentation)

• Three-stage operation (anterior release followed by posterior instrumentation and delayed anterior radical surgery).

Overview• In 1779- Percivall Pott• Most lethal infectious disease - 3 million deaths/year• Bone and soft-tissue tuberculosis accounts for approximately 10%

of extrapulmonary tuberculosis cases and between 1% and 2% of total cases.

• Tuberculous spondylitis is the most common manifestation of musculoskeletal tuberculosis, accounting for approximately 40-50% of cases.

• Cervical spine – 10%,thoracic spine -50% and lumbar spine – 40%• Spread – haematogenous/local extension/Batson’s venous plexus• the frequency of Pott Disease is related to socioeconomic factors

and historical exposure to the infection.• Pott disease does not have a sexual predilection• Pott disease occurs primarily in adults

WHO. World tuberculosis toll on the rise. Asian Medical News 2001:3:9.

• Tuberculosis has become the world's most deadly infectious disease, killing nearly 3 million people per year.

• Each year there are 8 million new cases of tuberculosis, and 50% of them are infectious.

• There are approximately 20 million active cases, and 1.7 billion (one third of the world's population) are, or have been, infected with the tuberculosis bacillus.

• Most tuberculosis deaths are in the developing world, with 1.8 million occurring in Asia annually. In some East and Central African countries, reported cases of tuberculosis have nearly doubled in the last 4 to 5 years; one of the main reasons for the resurgence of tuberculosis is the spread of human immunodeficiency virus (HIV) infection.

• Spinal tuberculosis, the most common form of articuloskeletal tuberculosis, is a paucibacillary disease with slow-growing bacilli. In HIV-negative patients, between 3% and 5% of tuberculosis cases are skeletal, compared with 60% of cases in HIV-positive patients. These statistics emphasize the need to prepare for a resurgence of spinal tuberculosis during the coming years.

Summary

• With the increased prevalence of spinal tuberculosis, a review of the management of spinal tuberculosis and its complications is timely.

• In all early cases and in the moderately advanced cases without unacceptable complications, conservative chemotherapy should be pursued as the mainstay of treatment.

• In advanced cases with spinal deformity and/or neurologic deficit, surgery should be considered with chemotherapy.

• As a result of early detection, the introduction of chemotherapy, and improved surgical techniques, patients with kyphosis rarely are seen today, particularly in urban centers that have an effective medical system.

Conclusion