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TUBERCULOSE SPONDYLITIS

Dr. Karya Triko Biakto, Sp.OT (K) Spine


Patient Identity
• Name : Mr. D
• Age : 35 years old
• Sex : Male
• RM : 593316
• Date admittance : Feb 8th 2013
History Taking
• Chief complain: cannot move both lower extremity
• Suffered since about 4 month ago, appeared suddenly
and continually without any trigerring factor. Initially, he
have cramps & heavy at both of lower extremity and
then become difficult to walk or even standing. Pain on
back (+) suffered since 6 month, pain feel more intense
day by day, spread to thigh, pain at night (-). Numbness
(+) on both of his legs.
• History of trauma (-), history of fever (+), history of
chronic cough (-), history of loose weight (+), history of
night sweat (+) since 6 month before admittance, history
of TB treatment (-), history of family with same disease
(-)
• Defecation and urination are inkotinented
General Status
Good nourished/ Composmentis

VITAL SIGN
• BP: 120/80 mmHg
• HR: 80x/mnt, regular
• RR: 20x/mnt,
• T : 36,7 ˚C (axiller)
CLINICAL PICTURE
LOCAL STATUS

Vertebra Region :
I : Kyphotic deformity (+), scar (+),
gibbus as level as Vertebra
Thoracal VII, hematome (-),
eritema (-), swelling (-)

P: tenderness (-) step off (-)


5 5
5 5
5 0
5
5 5
5 5
Motor
Function
Examination

0 0
0 0
0 0
0 0
0 0
yes
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2 Any anal sensation
2 2 2 2 0 → Absent Y
2 2 2 2 1 → Impaired
1 1 1 1 2 → Normal
1 1 1 1 NT → Not testable
1 1 1 1
1 1 1 1
1 1 1 1
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
Reflex
Physiologic Reflex Pathologic Reflex

R L R L
• Biceps (+)N (+)N • Babinski (+) (+)
• Triceps (+)N (+)N • Chadock (-) (-)
• Achilles (+) ↑ (+) ↑ • Openheim (+) (+)
• Patellar (+) ↑ (+) ↑ • Hoffman (-) (-)
• Tromner (-) (-)
Laboratory
• RBC : 5,69 x 10^3/µL • CT : 7’00”
• Hb : 15,6 g/dl • BT : 3’00”
• WBC : 18,35 x 10^3/µL Mycotec TB Positive
• PLT : 166 x 10^3/µL ESR : 17/42
• GDS : 114 mg/dl
• Ur/Cr : 48/1.3
• SGOT : 52 U/l
• SGPT : 184 U/l
Radiologic Findings
Thoracolumbal AP & Lateral
Radiologic Findings
Lumbosacral AP & Lateral
Radiologic Findings
CT-Scan Thoracolumbal
MRI Thoracolumbal
Summary
A 35 years old male presented with 4 months
history of cannot move both lower extremity,
appeared suddenly and continually without any
trigerring factor. cramps (+), heavy sensation (+)
at both of lower extremity then become difficult
to walk or even standing. Pain on back (+) suffered
since 6 month, pain feel more intense day by day,
spread to thigh, pain at night (-). Numbness (+) on
both of his legs. There are history of fever (+),
history of loose weight (+), history of night sweat
(+) since 6 month before admittance.
Cont..
On physical exam found Kyphotic deformity (+), scar
(+), gibbus as level as Vertebra Thoracal V. Neurological
deficit at lower motoric which is anastesia at the level
L1 and hipostesia at the level Th 7 downward. There is
an increase of fisiologic reflex at both of leg and
pathologic reflex found at both of leg.
Laboratory findings:
Radiological imaging: (Plain X-Ray)-Destruction of
invertebra disc CV Th. 7 and 8 and also paravertebra
abscess due to a possibility of Spondylitis. (MRI)-
Spondylitis TB at level T7-8 with paravertebra
abscess.
Diagnose
Paraplegia due to Suspect of Tuberculous Spondylitis as
level as Vertebra Thoracal 7th - 8th + paravertebra
abscess
Treatment
• Non operative
• Bed rest
• Anti-tuberculosis drugs
• Adequate nutrition
• Plan for culture bacteria

• Operation
• Debridement/ Evacuation of abcess
Discussion
Anatomy
33 Vertebrae:
 7 Cervical (lordosis)
 12 Thoracic (kyphosis)
 5 Lumbar (lordosis)
 5 Sacral fused
(kyphosis)
 4 Coccygeal fused
(kyphosis )
Anatomy
Anatomy
Tuberculose
Spondylitis
INTRODUCTION
• Tuberculosis of the spine also known Pott’s
disease.
• Since the advent of antituberculosis drugs and
improved public health measured,
Tuberculosis of the spine has become rare in
industrialised countries, although it is still a
significant cause of disease in developing
cauntries
Definition
• A spinal infection associated with tuberculosis
• Characterized by a sharp angulation of the
spine where tubercle lesions are present.
• Also called Pott's disease.

Apley, System of Orthopaedics and Fractures, 9th ed


Etiology
• Mycobacterium tuberculosis
• Straight or slightly curved rods
Types of
Spondylitis TB
1

1 1.Paradiscal type
2. Central type
3. Anterior type
2

Crenshaw AH. Spinal anatomy and surgical approach. In : Campbell’s operative orthopaedics. 8th
Ed. Missouri : Mosby Year Book 1992.p.3493 – 514; 3792 – 817
• The most common form, peridiscal, occurs
adjacent to the vertebral endplate and
spreads around a single intervertebral disc as
the abscess material tracks beneath the
anterior longitudinal ligament.
• Central involvement occurs in the middle of
the vertebral body and eventually leads to
vertebral collapse and kyphotic deformity.
• Anterior infections begin beneath the anterior
longitudinal ligament, causing scalloping of
the anterior vertebral bodies, and extend over
multiple levels.
Pathophysiology
• Spreads via:
– Artery/hematogenous
– Vein (batson plexus)
– Percontinuitatum

Tuli SM. Tuberculosis of the spine. New Delhi : Amerind, 1975 .p. 564 – 7.
Pathophysiology
Tuberculosis Granulomatous
infection inflammation

Erosion of the Destroyed the


margins of intervertebral
vertebrae disc

Weakening of
the trabeculae Disc
of vertebral degeneration
body

Collapse of Loss its


the vertebrae height

Kyphotic
deformity
Tuli SM. Tuberculosis of the spine. New Delhi : Amerind, 1975 .p. 564 – 7.
Affected
vertebra
Vertebral
abscess Collection of pus
and tubercular
debris

Comes out

Anteriorly Posteriorly

Press neural
Form psoas absces
structures in
spinal canal
Tuberculosis of the Musculoskeletal SystemDavid A. Spiegel, M.D.,* Girish K. Singh, M.D., and Ashok K. Banskota, M.D.
Diagnosis
History & Physical
Examination

Laboratory
Investigation

Radiology
History Taking
• Back pain
• Numbness
• Neurological deficit
• History of pulmonary
tuberculosis
Physical Examination

• Deformity
• Tenderness
• Spinal movement are
limited
• Gait
• Neurological deficite
Radiological
• X – Ray
 Early sign – local
osteoporosis of two
adjacent vertebra,
Early disease narrowing of intervertebral
– loss of disc disc space
space
 Later - bone destruction,
collapse of adjacent
vertebra bodies produce
angular deformity
• CT-Scan and MRI
 Investigation of cord
compression
Laboratory finding

• Blood examination – ESR markedly elevated


• Tuberculin skin test – positive
• Bacteriology examination – Acid fast bacilli
• Culture
• Histopathological examination – granulation
tissue
Treatment
Medical Treatment
• Chemotherapy (four-drug regimen, for a minimum of
6-month duration, includes isoniazid, rifampin,
pyrazinamide, and ethambutol) and brace
immobilization are the initial treatment-patients with
no neurologic deficit
• WHO guidelines: Spinal tuberculosis with neurological
deficit to be severe extrapulmonary (category 1 ) and
should receive treatment for 6 months.
• In rare and exceptional cases of relapse or treatment
failure, it should be given treatment according to
category 2, i.e., for 9 months. The currently
recommended regime is four-drug therapy. These
include isoniazid, rifampicin, pyrazinamide, and
ethambutol
ATT Types Everyday/m Everyday/mg 3 times/ week Dosage per
g BW > 50 kg mg KW BB
BW < 50 kg
R – Rifampicin 450 600 600 10

H – INH 300 400 600 5

E – Ethambutol 1000 1500 1500 15

Z – Pyrazinamide 1500 2000 2000 25

S – Streptomycin 750 1000 - 15


Operative treatment
Surgery may be necessary, especially to drain
spinal abscesses or to stabilize the spine. A
large group of surgeons perform debridement
and decompression in all cases, irrespective of
neurological involvement

Devlin, VJ. Spine Secret Plus, Second ed. Missouri: Mosby Elsevier; 2010
Complications

• Vertebral collapse resulting in


severe kyphosis
• Spinal cord compression
• Paraplegia (Pott's paraplegia)

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