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OR4.1 | Skeletal Tuberculosis — Assignment
CLINICAL SCENARIO
This assignment develops your clinical reasoning in skeletal tuberculosis — a treatable but potentially disabling disease that requires accurate diagnosis, systematic management, and recognition of complications. You will work up a structured management plan for a patient with caries spine and Pott's paraplegia, integrating clinical, investigative, and treatment principles.
Instructions
Read the following clinical scenario carefully, then respond to each section in sequence.
Clinical Scenario: Mr. Rajan, a 42-year-old agricultural labourer, presents to your outpatient clinic with progressive midthoracic back pain for 11 months, unintentional weight loss of 8 kg, and worsening weakness in both lower limbs over the past 6 weeks. He is unable to walk more than 50 metres. On examination: angular kyphosis at T8–T9, power 3/5 bilaterally in lower limbs, brisk reflexes, bilateral extensor plantar responses, and urgency of micturition. He has no cough and his CXR shows a calcified hilar node but no active pulmonary infiltrates.
Step 1 — Establish the diagnosis: Identify the most likely diagnosis and justify it with the clinical and examination findings presented. Discuss why the clinical picture points to skeletal TB rather than pyogenic spondylodiscitis or spinal malignancy.
Step 2 — Investigation workup: List the investigations you would order, divided into (a) baseline/haematological, (b) microbiological/confirmatory, and (c) imaging. For each, state what result you expect and what it tells you.
Step 3 — Pharmacological management: Detail the anti-tubercular regimen you would prescribe — drug names, phases, duration, and monitoring parameters for adverse effects.
Step 4 — Surgical decision-making: Explain when you would escalate to surgery, which surgical approach is appropriate for this anatomical location, and why posterior laminectomy is specifically contraindicated in Pott's paraplegia.
Step 5 — Rehabilitation and prognosis: Outline the multi-disciplinary rehabilitation plan for neurological recovery. Discuss prognostic factors that determine the degree of neurological recovery.
Length: 600–900 words
What to Submit
Diagnostic Justification
Guidance: Address the triad of indolent tempo, constitutional symptoms, and upper motor neuron signs. Contrast TB (months, low-grade fever, gibbus, upper MN signs) vs pyogenic (days, high fever, SIRS, lower MN + autonomic early) vs malignancy (older age, no fever, rapid cord deficit, elevated PSA/CEA/protein electrophoresis). Cite at least two clinical features and one radiological feature specific to TB.
Investigations
Guidance: Organise as: (a) Bloods — CBC, ESR, CRP, LFT, RFT, HIV, blood glucose; (b) Microbiological — CBNAAT (GeneXpert) on biopsy specimen, mycobacterial culture on LJ medium, tuberculin skin test / IGRA; (c) Imaging — MRI spine (whole) with contrast, plain X-ray, CT for bony detail. State expected findings for each modality in spinal TB.
Anti-Tubercular Therapy
Guidance: State the full RNTCP/WHO DOTS regimen: 2HRZE/4HR. Name each drug. Describe the intensive phase (2 months, 4 drugs), continuation phase (4 months, 2 drugs). Monitoring: monthly LFT (hepatotoxicity — most important), visual acuity/colour vision monthly (ethambutol optic neuritis), uric acid (pyrazinamide gout), pyridoxine supplementation with isoniazid.
Surgical Decision-Making
Guidance: Surgery indications: (1) neurological deficit not improving after 3–6 weeks of ATT, (2) worsening deficit on ATT, (3) sphincteric dysfunction, (4) large abscess with severe cord compression, (5) instability or progressive deformity. Approach: ANTERIOR debridement (Hong Kong operation for thoracic disease = anterolateral thoracotomy + corpectomy + strut graft + instrumented fusion). Contraindication of laminectomy: removes posterior arch (intact), destabilises anterior-deficient spine, does not decompress anterior lesion.
Rehabilitation and Prognosis
Guidance: Physiotherapy: passive limb movements from Day 1, active assisted exercises as power returns, gait training. Occupational therapy for ADLs. Bladder training. Psychological support. Prognostic factors: duration of paraplegia (shorter = better), degree of cord compression on MRI (partial > complete block), motor grade at presentation (grade ≥2 = better), age (younger = better), early surgery in active disease (better than healed disease). Note: paraplegia of healed phase has worse prognosis post-surgery.
Grading Rubric — Skeletal Tuberculosis Assignment Rubric
| Criterion | Points | Full-marks descriptor |
|---|---|---|
| Diagnostic reasoning — accuracy of diagnosis and differentiation from pyogenic and malignant spine disease | 10 pts | Correct diagnosis of Pott's disease with Pott's paraplegia. Clearly distinguishes from pyogenic spondylodiscitis (acute tempo, neutrophilia, no gibbus) and spinal malignancy (age, no systemic TB stigmata) using at least two clinical and one radiological criterion. |
| Investigative workup — completeness and relevance of investigations with expected findings | 10 pts | All three investigation categories covered: bloods (ESR, HIV, LFT/RFT), microbiology (CBNAAT, culture), and imaging (MRI spine with contrast + plain X-ray). Expected findings described for each relevant to spinal TB. |
| ATT regimen — accuracy of drug names, phases, duration, and adverse effect monitoring | 10 pts | 2HRZE/4HR correctly stated with all four drug names. Intensive and continuation phases distinguished. Monitoring includes LFT (hepatotoxicity), visual acuity (ethambutol), pyridoxine co-prescription, and uric acid for pyrazinamide. |
| Surgical reasoning — correct indications and approach; contraindication of posterior laminectomy explained | 10 pts | Surgical indications clearly listed (failure to improve/worsening on ATT, sphincteric dysfunction). Correct approach: anterior debridement (Hong Kong operation, anterolateral approach for thoracic). Clearly explains WHY laminectomy is contraindicated — anterior lesion not decompressed, posterior elements intact, laminectomy destabilises anterior-deficient spine. |
| Rehabilitation and prognosis — practical plan with prognostic factors accurately described | 10 pts | Rehabilitation plan mentions physiotherapy (passive → active), bladder training, occupational therapy. Prognostic factors include at least three: duration of paraplegia, degree of compression, motor grade at presentation, age, active vs healed disease at time of surgery. |
PEER REVIEW
Review your peer's management plan using the rubric provided. For each criterion, select the appropriate rating level and write 2–3 sentences explaining your rating. Focus on: (1) accuracy of factual content (drug names, surgical approach), (2) clarity of reasoning, and (3) completeness of coverage. Be constructive — note what was done well and one specific area for improvement.