SPONDILITIS TUBERCULOSA (Potts desease)

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SPONDILITIS TUBERCULOSA(Potts desease)

• BY
• Dr.WAHYU EKO W.Sp.OT
• Orthopaedi dan Tulang Belakang
• RS.BINA HUSADA

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WEBSITE PRIBADI

• Dokterbedahtulang.com

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definisi

• Pott disease ( Spondilitis Tubercolosis)
  merupakan penyakit manusia tertua.
• Ditemukan dari jaman Batu, mummi Mesir kuno dan
  Peru.
• In 1779, Percivall Pott, pemberi nama penyakit
  ini, menjelaskan perjalanan penyakit ini.

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Gibbus (Spondilitis TBC)
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SPONDILITIS TBC
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Gibbus
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Sopndilitis TBC (Potts Desease)

• Dgn adanya Obat Antituberculous dan perbaikan
  ukuran kesehatan masyarakat----spinal
  tuberculosis di negara maju sangat jarang.
• Di negara sedang berkembang ----- masih banyak.
  (bogor)
• Spondilitis TBC ---- menyebakan masalah serius
  karena adanya gangguan motorik dan sensorik.
• Pemberian OAT dan operasi ____ bisa mengontrol
  penyakit ini.

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PATHOPHYIOLOGI

• Asal Potts desease secundair karena
  osteomyelitis dan Arthritis TB
• Bisa Lebih 2 vertebrae .
• Melibatkan bagian anterior dari Corpus Vertebrae
  ..discus vertebralis Rusak.
• Pada orang dewasa discus rusak akibat infeksi
  dari VB
• Pada anak2, Lesi primer bisa di Discus Inter
  vertebralis.

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Gambar Corpus Vertebrae
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PATHOPHYSIOLOGY

• Kerusakan CV yang progresive menyebabkan CV
  kolaps dan menyebakan kyphosis.
• Saluran Spinal menyempit ok abses, jaringan
  granulasi .. Menekan spinal cord defisit
  Neurologi.
• Terutama bagian thorakal lebih kyphotic.
• Cold absces infeksi menyebar ke ligament dan
  soft tisue.
• Abscesses di lumbarturun ke bawah ke Psoas
  trigonum femoral ke kulit.

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Kyphosis
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Gibbus
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Gibbus
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Gibbus
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Abcess TBC
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Abcess
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Abses Inginal
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X ray

• Foto AP

• Foto Lat

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FREQUENCY

• United States
• Masih ada tahun 1980-1990.. Turun drastis
• Tuberculous spondylitis 40-50 .4
  musculoskeletal tuberculosis

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FREQUENCY

• 4International
• Pott disease 1-2 persen kasus total TBC
• In the Netherlands between 1993 and 2001,
  tuberculosis of the bone and joints accounted for
  3.5 of all tuberculosis cases

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MORBIDITY/MORTALITY

• _at_ Pott disease penyakit musculo skeletal yang
  paling berbahaya. Karena menyebakan kerusakan
  tulang, deformitas dan paraplegi.
• Thoracic and lumbosacral spine. Lower thoracic
  vertebrae (40-50),
• the lumbar spine (35-45).
• Cervical spine 10

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RACE,SEX AND AGE

• Race
• Tergantung riwayat kontak TBC.
• Sex
• male-to-female ratio of 1.5-21).
• Age
• Dewasa, dewasa muda dan anak2.

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CLINICAL

• The presentation of Pott disease depends on the
  following  
• Stadium penyakit
• Lokasi Kelainan
• Adanya komplikasi seperti neurologic deficits,
  abscesses, or sinus tracts
• Dilaporkan rata2 Durasi simptom sampai
  diagnosis gt 4 bulan.
• Sakit Pinggang yang lama, gejala awal yang paling
  umum
• Bisa Spinal dan Radicular

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HYSTORY

• Demam dan Berat Badan Turun
• Neurologic abnormalities 50 of cases
• Kompresi spinal cord diikuti paraplegia, paresis,
  impaired sensation, nerve root pain, and/or cauda
  equina syndrome.
• Cervical spine tuberculosis less common but
  more serious,
• Pain and stiffness.
• Patients with lower cervical spine disease can
  present with dysphagia or stridor.
• Symptoms can also include torticollis and
  hoarseness,
• neurologic deficits.

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PHYSICAL

• The examination  
• Careful assessment of spinal alignment
• Inspection of skin, with attention to detection
  of sinuses
• Abdominal evaluation for subcutaneous flank mass
• Meticulous neurologic examination

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PHYSICAL

• Pott disease have some degree of spine deformity
  (kyphosis).
• Large cold abscesses of paraspinal tissues or
  psoas muscle may protrude under the inguinal
  ligament and may erode into the perineum or
  gluteal area.
• Neurologic deficits may occur early in the course
  of Pott disease. Signs of such deficits depend on
  the level of spinal cord or nerve root
  compression.

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PHYSICAL

• Pott disease that involves the upper cervical
  spine can cause rapidly progressive symptoms.  
• Retropharyngeal abscesses occur in almost all
  cases.
• Neurologic manifestations occur early and range
  from a single nerve palsy to hemiparesis or
  quadriplegia.
• Many persons with Pott disease (62-90 of
  patients in reported series6, 7) have no evidence
  of extraspinal tuberculosis
• Information from imaging studies, microbiology,
  and anatomic pathology should help establish the
  diagnosis.

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Diferensial Diagnosis

• DIFFERENTIAL DIAGNOSISActinomycosisBlastomycosis
  BrucellosisCandidiasisCryptococcosisHistoplasm
  osisMetastatic Cancer, Unknown Primary
  SiteMiliary Tuberculosis

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DIF.DIAGNOSIS

• Multiple MyelomaMycobacterium Avium-Intracellular
  eMycobacterium KansasiiNocardiosisParacoccidioi
  domycosisSeptic ArthritisSpinal Cord
  AbscessTuberculosis
• Other Problems to be Considered
• Spinal tumors

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Work UP

• Lab Studies
• Tuberculin skin test (purified protein derivative
  PPD) results are positive in 84-95
• LED
• Microbiology studies
• CT-guided procedures

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Imaging

• Radiography
•  
• Lytic destruction of anterior portion of
  vertebral body
• Increased anterior wedging
• Collapse of vertebral body
• Reactive sclerosis on a progressive lytic process
  
• Enlarged psoas shadow with or without
  calcification

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RADIOGRAPHY

• Additional radiographic findings may include the
  following
• Vertebral end plates are osteoporotic.
• Intervertebral disks may be destroyed.
• Vertebral bodies show variable degrees of
  destruction.
• Fusiform paravertebral shadows suggest abscess
  formation.
• Bone lesions may occur at more than one level.

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CT SCANNING

•  
• CT scanning provides much better bony detail of
  irregular lytic lesions, sclerosis, disk
  collapse, and disruption of bone circumference.
• Low-contrast resolution provides a better
  assessment of soft tissue, particularly in
  epidural and paraspinal areas.
• CT scanning reveals early lesions and is more
  effective for defining the shape and
  calcification of soft-tissue abscesses.
• In contrast to pyogenic disease, calcification is
  common in tuberculous lesions.

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MRI

• MRI is the criterion standard for evaluating
  disk-space infection and osteomyelitis of the
  spine and cold Abcess.
• MRI Lihat neural compression.15, 16
• MRI findings useful to differentiate tuberculous
  spondylitis from pyogenic

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MRI
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BONE SCAN

• Other Tests
• Radionuclide scanning findings are not
  specific for Pott disease.
• Gallium and Tc-bone scans yield high
  false-negative rates (70 and up to 35,
  respectively).18

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PROCEDURES

• Use a percutaneous CT-guided needle biopsy of
  bone lesions to obtain tissue samples.  
• This is a safe procedure that also allows
  therapeutic drainage of large paraspinal
  abscesses.
• Obtain a tissue sample for microbiology and
  pathology studies to confirm diagnosis and to
  isolate organisms for culture and susceptibility.
• Some cases of Pott disease are diagnosed
  following an open drainage procedure (eg,
  following presentation with acute neurologic
  deterioration

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Histologic Findings

• Microbiologic
• Patologi Anatomi Gold standart
• Gross pathologic exudative granulation tissue
  with abscesses.
• caseating necrosis.

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Medical Care

• Pott disease Prolonged bed rest or a body
  cast. Pott disease carried a mortality rate of
  20, and relapse was common (30)before OAT
• Thoracolumbar spine should be treated with
  combination chemotherapy for 6-9 months.19
• Many experts still recommend chemotherapy for
  9-12 months.

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MEDICAL CARE

• 4-drug regimen should be used empirically to
  treat Pott disease.20 
• Isoniazid and Rifampin should be administered
  during the whole course of therapy.
• Additional drugs are administered during the
  first 2 months of therapy. These are generally
  chosen among the first-line drugs, which include
  pyrazinamide, ethambutol, and streptomycin. The
  use of second-line drugs is indicated in cases of
  drug resistance.

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MEDICAL CARE

• TREATMENT
• 1.Kemoterapi dan konservative
• 2.Kemoterapi dan Operasi

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PEMBEDAHAN
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Surgical Care

• INDIKASI OPERASI
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• Neurologic deficit (acute neurologic
  deterioration, paraparesis, paraplegia)
• Spinal deformity with instability or pain
• No response to medical therapy (continuing
  progression of kyphosis or instability)
• Large paraspinal abscess
• Nondiagnostic percutaneous needle biopsy sample

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SURGICAL CARE

• Anterior radical focal debridement and posterior
  stabilization with instrumentation.24, 10
• Involves the cervical spine, the following
  factors justify early surgical intervention  
• High frequency and severity of neurologic
  deficits
• Severe abscess compression that may induce
  dysphagia or asphyxia
• Instability of the cervical spine

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Consultations

• Orthopedic surgeons
• Neurosurgeons
• Rehabilitation teams

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(No Transcript)
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Debridemen stabilisasi
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Post Operasi
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Pasien Spondilitis TBC
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Activitas Normal
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Gambar Post Operasi
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Happy post Operasi
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ACTIVITY

• JAMAN DAHULU
• plaster beds, plaster jackets, and braces are
  still used.
• Cast or brace immobilization was a traditional
  form of treatment but has generally been
  discarded. Patients with Pott disease should be
  treated with external bracing.

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BRACE POST OPERASI
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medication

• A 4-drug regimen should be used empirically to
  treat Pott disease. Treatment can be adjusted
  when susceptibility information becomes
  available. 
• Isoniazid and rifampin should be administered
  during the whole course of therapy. Additional
  drugs are administered during the first 2 months
  of therapy. These are generally chosen among the
  first-line drugs, which include pyrazinamide,
  ethambutol, and streptomycin.

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MEDICATION

• A 3-drug regimen usually includes isoniazid,
  rifampin, and pyrazinamide.
• The use of second-line drugs is indicated in
  cases of drug resistance.
• The duration of treatment is somewhat
  controversial. Although some studies favor a 6-
  to 9-month course, traditional courses range from
  9 months to longer than 1 year. The duration of
  therapy should be individualized and based on the
  resolution of active symptoms and the clinical
  stability of the patient.

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FOLLOW-UP

• Further Inpatient Care
• Once the diagnosis of Pott disease is established
  and treatment is started, the duration of
  hospitalization depends on the need for surgery
  and the clinical stability of the patient.
• Further Outpatient Care
• Patients with Pott disease should be closely
  monitored to assess their response to therapy and
  compliance with medication. Directly observed
  therapy may be required.
• The development or progression of neurologic
  deficits, spinal deformity, or intractable pain
  should be considered evidence of poor therapeutic
  response. This raises the possibility of
  antimicrobial drug resistance as well as the
  necessity for surgery.

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FOLLOW UP

• Because of the risk of deformity exacerbations,
  children with Pott disease should undergo
  long-term follow-up until their entire growth
  potential is completed.25

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COMPLICATION

• Abscess
• Spine deformities
• Neurologic deficits and paraplegia

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PROGNOSIS

• Current treatment modalities are highly
  effective if not complicated by severe deformity
  or established neurologic deficit.
• Therapy compliance and drug resistance are
  additional factors that significantly affect
  individual outcomes.
• Paraplegia resulting from the active disease
  causing cord compression usually responds well to
  chemotherapy.
• If medical therapy does not result in rapid
  improvement, operative decompression will greatly
  increase the recovery rate.
• Paraplegia can manifest or persist during healing
  because of permanent spinal cord damage.

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PATIENT EDUCATION

• Patients with Pott disease should be instructed
  on the importance of therapy compliance.
• For excellent patient education resources, visit
  eMedicine's Bacterial and Viral Infections
  Center. Also, see eMedicine's patient education
  article Tuberculosis.

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MISCELANEOUS

• Medical/Legal Pitfalls
• A large proportion of patients with Pott disease
  do not present with extraskeletal disease. In
  reported series, only 10-38 of cases of Pott
  disease are associated with extraskeletal
  tuberculosis.
• The diagnosis of tuberculous spondylitis should
  be investigated if strong clinical suspicion
  exists, even if suggestive pulmonary radiology
  findings are absent.
• Other features suggestive of tuberculosis include
  the following
•  
• Positive PPD result
• Chest radiograph that shows apical scarring,
  infiltrates, or cavitary disease
• Presence of risk factors for tuberculosis
• Spinal tuberculosis should always be suspected
  when radiographs demonstrate a destructive spine
  process.