dr.

Jainal Arifin, Mkes, SpOT

SPONDYLITIS TB
 Epidemiology
Tuberculosis is one of the most common
problem in the developing countries
Indonesia is in the 3rd place for the most
TB contributing country after India &
China
583.000 cases per year
Almost of all the patient is in the range
of productive age ( 15 54 years old )
Epidemiology

Vertebrae is the 2nd common place for

infected organ by Mycobacterium
Tuberculosis ( 50% )
15% of all extra pulmonary TB cases
Male > female & Children > adults
The most common site ; thoraco-
lumbar , thoracal, lumbar, and
cervical
 Pathogenesis
Primary tuberculosis :
In a non immunized individual children*
adult*
Deep inhalation of airborne droplet
Spondylitits TB :
Secondarily focus infection from the other
organ via blood transmission ( hematogen )
Small tubercel ( superior or inferior-anterior
site of subchondral vertebrae body )
activate Chaperonin 10 high stimulator of
bone resorption destruction of anterior
part of vertebrae body khypose
respiratory problem & paraplegia
 Pathogenesis
Primary tuberculosis :
In a non immunized individual children*
adult*
Deep inhalation of airborne droplet
 Pathogenesis
Spondylitits TB :
Secondarily focus infection from the
other organ via blood transmission (
hematogen )
Small tubercel ( superior or inferior-
anterior site of subchondral vertebrae
body ) destruction of anterior part of
vertebrae body khypose
respiratory problem & paraplegia
Pathogenesis

Granulomatous reaction blocking

bone formation relatively avascular
sequester
Reach the soft tissue paravertebrae
abscess following the fascia of
psoas muscle psoas abscess ( cold
abscess )
Narrowing of adjacent disc ( being
avascular )
 Clinical Appearance
Systemic symptoms ( fever,
malaise, night sweat, loss of body
weight )
Back pain ( chronic, local or
radicular )
Back stiffness
back color
Bone alignment
Mass or gibbus
Tenderness
Bone structural & muscle spasm
Neurological deficit
Limited range of movement
 Laboratory Findings

Leukocyte >>>
ESR is prolonged, >100 mm/h
CRP (C-reactive protein )
PCR ( polymerase chain reaction )
Tuberculin test ( Mantoux )
 Immunology Test

Intradermal tuberculin
test ( Mantoux )

67,5 87,5 % positive

Sub cutaneous
Weal formation
Read after 72 hours.
5-10-15mm (non-ende)
Biopsy

Identification basil
tuberkel definitive
diagnosis acid stain,
fluorokrome and Ziehl-
Nielsen or culture
 Plain Radiographs

Affected vertebrae
( segment & number )
Bone destruction rate
Khypose angle
Anterior part destruction
Narrowing of adjacent
discs
 Plain Radiographs

Paravertebrae abscess
(fusiform shadow )
 MRI :

Central necrosis
(abscess)
Inhomogen appearance

16
Spinal TB - Potts Disease
Histo - pathology

Granuloma and
caseous appearance,
Consists central zone
granular and
acidophilic which is
circled by the
epitheloid cell and
Langhans giant cell
with cluster of
lymphosit at the outer
margin of the
granuloma.
Tuberculous Granuloma
Treatment

Improve general condition

Supportive therapy
TB Drug
Surgery
 Treatment

The aim : eradicate the infection, stabilize the

vertebrae & to correct the khypose
The combination of chemotherapy or surgical
therapy
INH ( 5-15mg/KgBW/ day ) orally
Rifampicin ( 10-15mg/KgBW/day ) orally
Pirazinamid ( 25-35/KgBW/day ) orally
Ethambutol ( 15-20mg/KgBW/day ) orally
Streptomycin ( 15-30mg/KgBW/day ) IV
Treatment

Surgery :
To drain abcses, debride sequester
In spine : to decompress, to stabilize
Large psoas abces retroperitoneal approach.
Simple deb. without fussion 90 % fusion at 10 ys
Hongkong procedure > superior 97 % fusion
 Surgical Therapy

The indications :
Significant neurological deficit
Cervical segment abscess
Posterior lesion with abscess or sinus
Vertebrae instability / progressive khypose
Failed of chemotherapy treatment in 3 6
months
Recurrence infection
 Surgery Techniques

Hongkong Methods ( anterior debridement & strut

grafting )
Anterior fusion ( Upadhay et al )
Anterior instrumentation & strut graft ( Yilmaz )
Anterior bone graft & posterior osteotomy &
arthrodesis
Anterior approach
Posterior approach
Costotransversectomy approach
T E R I M A K A S I H