Spondylitis TB

INTRODUCTION
Evidence of spinal TB dates back to Egyptian
times and has been documented in 5000-year-old
mummies.
In 1779, Percival Pott published the first modern
description of spinal deformity and paraplegia
resulting from spinal TB.
According to WHO(2006), about one third of the
worlds population is infected by Mycobacterium
TB, and 9 million individuals develop TB each
year.

Tuberculosis of the spine in an Egyptian

mummy

Contd
Spinal tuberculosis (often called Pott's disease) is
by definition, an advanced disease, requiring
meticulous assessment and aggressive systemic
therapy.
It is usually secondary to lung or abdominal
involvement and may also be the first
manifestation of tuberculosis.
Skeletal involvement of Tb has been reported to
occur in approximately 10% of all patents with
extra-pulmonary tuberculosis,
-and half of these patients develop infection within
the spinal column.

What Is Spinal Tuberculosis?

Tuberculosis of the spine, also known as tuberculous spondylitis or Pott's

Disease, is a is an infection of the spine by the Mycobacterium
tuberculosis bacterium (TB).

It usually infects another area of the body first before moving into
the spine.

Spinal tuberculosis is rare in industrialized countries but still

common in developing nations.

TB Manifestations

Extrapulmonary TB

Symptoms

Some of the most common symptoms of Pott's Disease are:

Back pain
Fever
Night sweats
Anorexia

This leads to a significant, unhealthy weight-loss.

The back pain is sometimes so painful patients will develop a mass in the
spine which can cause:

Tingling
Numbness
Weakness in the legs
The deterioration and back pain will cause the sufferer to sit and walk in a rigid, upright
manner.

Causes

Pott's Disease, like other forms of TB, is caused by a mycobacterium which

is spread by way of blood or breathing droplets from an infected person into
your lungs where the bacteria will thrive and grow if not killed by your
immune system.

Once in your blood stream, tuberculosis can infect a number of organs, each
with their own set of symptoms and complications.

Pathogenesis
In children, the main route of infection of spinal
tuberculosis is through hematogenous spread
from a primary site of infection, which is often
unknown.
A concomitant active pulmonary disease is
present in <50% of the cases.
The mycobacterium is deposited via the end
arterioles in the vertebral body adjacent to the
anterior aspect of the vertebral end plate.
Thus, the anterior portion of the vertebral body is
most commonly involved.

 While the infection is developing, the cortex is disrupted and the

infection may spread up and down,
- stripping the anterior and posterior longitudinal ligaments and
the periosteum from the front and sides of the vertebral bodies.
This results in loss of the periosteal blood supply and distraction
of the anterolateral surface of the vertebrae.

Tissue necrosis and breakdown of inflammatory cells result

in a paraspinal abscess.
Progressive necrosis of bone leads to a kyphotic deformity
and Gibbus formation
The infection then spreads to the adjacent vertebral bodies
under the longitudinal ligaments.
In children, vertebral destruction is more severe because
most bone is cartilaginous

Potts Disease

Diagnosis

Tuberculosis causes the disks in the spine to die and break down,
which often leads to the narrowing of the vertebra and the
eventual collapse of the spine.

Radiographs and CT scans of the spine are sometimes able to

show tuberculosis of the spine, if present, a bone biopsy will be
done for confirmation.

A test is often performed to check a patient's Enthrocyte

Sedimentation Rate; a high ESR is a sign of Pott's Disease.

Physical examination of the

spine
Localised tenderness and paravertebral muscle
spasms,
Kyphotic deformity,
Cold abscess swelling / sinus tract
Cervical spine TB is a less common presentation,
-characterized by neck pain & stiffness with
dysphagia / stridor more common in lower
cervical spine involvement.

SPINAL TUBERCULOSIS
DIAGNOSIS
LAB STUDIES
Mantoux / Tuberculin skin test ( purified protein
derivative {PPD})
ESR may be markedly elevated (neither specific
nor reliable).
ELISA : for antibody to mycobacterial antigen-6 ,
sensitivity of 60 80%.
PCR : sensitivity of 40% only.
-The amplifiedM tuberculosisdirect test is an
isothermal transcription-mediated amplification
that targets RNA.

Contd
Microbiology studies to confirm diagnosis :
Ziehl-Neelsen staining:
-a quick and inexpensive method.
Obtain bone tissue or abscess samples to
stain for acid-fast bacilli (AFB), & isolate
organisms for culture & drug susceptibility.

Contd
RADIOLOGICAL DIAGNOSIS
1. PLAIN RADIOGRAPH
2. CT SCAN
3. MRI SPINE
4. BONE SCAN
. TB bacilli are rarely found in CSF, therefore
imaging plays pivotal role in suggesting the
diagnosis.

SPONDYLITIS TBC & PARA VERTEBRAL ABSCESS

PLAIN RADIOGRAPH
More than 50% of bone has to be destroyed
before a lesion can be seen on X-ray.
This process takes approximately six months.
The classic X-ray triad in spinal tuberculosis is
-primary vertebral lesion,
-disc space narrowing and
-paravertebral abscess.
Skip lesions as involvement of non contiguous
vertebrae (7 10 % cases).

DIFFERENTIAL DIAGNOSIS
The differential diagnosis of the tuberculous spine
includes:
1.SPINAL INFECTIONS- pyogenic, brucella & fungal.
2.NEUROPATHIC spine
3.NEOPLASTIC commonly lymphoma/ metastasis
4.DEGENERATIVE
No pathognomonic imaging signs allow
tuberculosis to be readily distinguished from
other conditions.
Biopsy is definitive.

COMPLICATIONS OF SPINAL
TUBERCULOSIS

Neurological complications paraplegia and spinal

deformity are the most dreaded complications of
tuberculosis of spine.
Neurological complications develop in the active
or healed stage of the disease.
The sequelae of these two complications affect
the quality and span of life.

Cold abscess
Sinuses
Secondary infection
Fatality

MEDICAL CARE
4-drug regimen
Isoniazid and Rifampin (9-12 bln)
Add. first 2 months (first-line drugs),
pyrazinamide, ethambutol, and
streptomycin.
The use of second-line drugs is
indicated in cases of drug resistance
(ciprofloksasin)

MEDICAL CARE

TREATMENT
1.chemoterapy & conservative
2.chemoterapy & operation

INDIKASI OPERASI

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

SURGICAL CARE
Anterior radical focal debridement
and posterior stabilization with
instrumentation.
Involves the cervical spine, the
following factors justify early surgical
intervention:
24, 10

High frequency and severity of

neurologic deficits
Severe abscess compression that may
induce dysphagia or asphyxia

BRACE POST OPERASI

Laporan Kasus

THANK YOU