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POTT'S DISEASE

Submitted To:
Mr. Joey A. Servan

Submitted By:
Carlo Luigi P. Zayco
BSN 4-2

November 17, 2010


I. INTRODUCTION

Pott's disease, also known as tuberculous spondylitis, is one of the oldest


demonstrated diseases of humankind, having been documented in spinal remains from
the Iron Age and in ancient mummies from Egypt and Peru. In 1779, Percivall Pott, for
whom Pott's disease is named, presented the classic description of spinal tuberculosis.

Since the advent of antituberculous drugs and improved public health measures,
spinal tuberculosis has become rare in developed countries, although it is still a
significant cause of disease in developing countries. Tuberculous involvement of the
spine has the potential to cause serious morbidity, including permanent neurologic
deficits and severe deformities. Medical treatment or combined medical and surgical
strategies can control the disease in most patients.

The frequency of extrapulmonary tuberculosis has remained stable. Bone and


soft-tissue tuberculosis accounts for approximately 10% of extrapulmonary tuberculosis
cases and between 1% and 2% of total cases. Tuberculous spondylitis is the most
common manifestation of musculoskeletal tuberculosis, accounting for approximately
40-50% of cases. Approximately 1-2% of total tuberculosis cases are attributable to
Pott's disease.

Pott's disease is the most dangerous form of musculoskeletal tuberculosis


because it can cause bone destruction, deformity, and paraplegia. Pott's disease most
commonly involves the thoracic and lumbosacral spine. However, published series have
show some variation. Lower thoracic vertebrae is the most common area of involvement
(40-50%), followed closely by the lumbar spine (35-45%). In other series, proportions
are similar but favor lumbar spine involvement. Approximately 10% of Pott disease
cases involve the cervical spine.

Musculoskeletal tuberculosis primarily affects African Americans, Hispanic


Americans, Asian Americans, and foreign-born individuals. As with other forms of
tuberculosis, the frequency of Pott's Disease is related to socioeconomic factors and
historical exposure to the infection. Although some series have found that Pott's disease
does not have a sexual predilection, the disease is more common in males (male-to-
female ratio of 1.5-2:1). In countries with higher rates of Pott's disease, involvement in
young adults and older children predominates.
II. PATIENT PROFILE

PATIENT DATA
Ward: Pediatric Ward
Date of Admission: November 4, 2010
Patient’s Name: Patient F
Address: Mangatarem, Pangasinan
Gender: Female
Age: 4 yrs. old
Birth date: July 12, 2006
Religion: Roman Catholic
Nationality: Filipino
Civil Status: Child
Informant: Father

SOURCE AND RELIABILITY OF INFORMATION


The patient’s father, interviewed personally to collect more pertinent information
regarding the child’s past and present health status, serves as the primary source of
data. In addition, data were also gathered from the patient's hospital records at
Philippine Orthopedic Center.

ADMISSION DATA
Chief Complaint: Fever, back and chest pain
Initial Diagnosis: Pott's disease T-5 T-7 t/c T-6 T-12
Attending Physician: Dr. Yu
III. PATIENT HISTORY/ NURSING HISTORY

History of Present Illness

Last July of this year, Patient F was playing at their just inside their house with
her friends when suddenly she slipped on the floor, chest first. When her parents
arrived, she quickly complains of chest pain. Few days after, patient already
experiences fever and some episodes of back pain.
After a few weeks, her parents consulted an "albularyo", this, according to her
father, just worsen the condition of the patient, hence consultation at the hospital at their
province was prompted.
After a month of treatment at the hospital, the patient's parents decided to
transfer to Philippine Orthopedic Center, for further treatment of the patient since the
cost of treatment in the previous hospital was too expensive. Test results shows that the
patient is suffering from Pott's disease thus this prompted for confinement.

Past Medical History

The patient has suffered from lung infection before according to her father, but
didn't really prompt for confinement, the patient just undergone antibiotic therapy.

Family Health History

Both of her parents have a history of being hypertensive in their family's side. Her
mother's brother suffered from the same disease that the patient has and dies because
of it. They usually visit the Health Center for consultation when they get sick.

Personal and Social History


The patient is very friendly and outgoing thus gaining her many friends back in
their place. Being the youngest in the family, the attention is focused in her in the house.
IV. PHYSICAL ASSESSMENT
SYSTEM PHYSICAL ASSESSMENT

Patient is awake and responsive.


Lying on bed
GENERAL (Temp: 36.4 °C) Afebrile
(+) fatigue

Skin is warm to touch


(+) dryness
(-) pallor
SKIN (-) edema
(-) lesions
(-) pruritus

Symmetrical round
(-) masses
(-) scalp lesion
HEAD Hair thin and distributed evenly
Lymph nodes non-palpable
Symmetric facial movements

Symmetrical
Bilateral blinking
EYES Thin, black eyebrows and lashes
Pinkish conjunctiva
Able to read newsprint

Equal size (symmetrical) and similar appearance noted


Dry earwax noted
(-) pain
EARS (-)
Pinna recoils after folded
Adequate hearing acuity
(-) discharges

Symmetrical and straight, uniform in color without discharges


NOSE Non tender and without lesions
Frontal and maxillary sinuses non-tender

Thin, pinkish lips


(+)dry lips
(-) mouth sores
MOUTH and THROAT Incomplete set of upper and lower teeth
Tongue pinkish in color
(-)ulcers in the floor of the mouth

NECK
Trachea midline, (-) lumps, (-) scars, (-) stiffness in neck

RR: 31cpm
(-) dyspnea
RESPIRATORY (+) cough
(-) wheezing
V. ANATOMY AND PHYSIOLOGY

THE SPINAL COLUMN

The spinal column is one of the most vital parts of the human body, supporting our
trunks and making all of our movements possible. Its anatomy is extremely well
designed, and serves many functions, including:

• Movement
• Balance
• Upright posture
• Spinal cord protection
• Shock absorption

All of the elements of the spinal column and vertebrae serve the purpose of protecting
the spinal cord, which provides communication to the brain and mobility and sensation
in the body through the complex interaction of bones, ligaments and muscle structures
of the back and the nerves that surround it.

The normal adult spine is balanced over the pelvis, requiring minimal workload on the
muscles to maintain an upright posture.

Loss of spinal balance can result in strain to the spinal muscles and spinal deformity.
When the spine is injured and its function impaired, the consequences may be painful
and even disabling.
Regions of the Spine

Humans are born with 33 separate vertebrae. By adulthood, we typically have 24 due to
the fusion of the vertebrae in the sacrum.

• The top 7 vertebrae that form the neck are called the cervical spine and are
labeled C1-C7. The seven vertebrae of the cervical spine are responsible for the
normal function and mobility of the neck. They also protect the spinal cord,
nerves and arteries that extend from the brain to the rest of the body.
• The upper back, or thoracic spine, has 12 vertebrae, labeled T1-T12.
• The lower back, or lumbar spine, has 5 vertebrae, labeled L1-L5. The lumbar
spine bears the most weight relative to other regions of the spine, which makes it
a common source of back pain.
• The sacrum (S1) and coccyx (tailbone) are made up of 9 vertebrae that are fused
together to form a solid, bony unit.

Spinal Curvature

When viewed from the front or back, the normal spine is in a straight line, with each
vertebra sitting directly on top of the other. Curvature to one side or the other indicates a
condition called scoliosis.

When viewed from the side, the normal spine has three gradual curves:

• The neck has a lordotic curve, meaning that it curves inward.


• The thoracic spine has a kyphotic curve, meaning it curves outward.
• The lumbar spine also has a lordotic curve.

These curves help the spine to support the load of the head and upper body, and
maintain balance in the upright position. Excessive curvature, however, may result in
spinal imbalance.

Elements of the Spine

The elements of the spine are designed to protect the spinal cord, support the body and
facilitate movement.

A. Vertebrae
The vertebrae support the majority of the weight imposed on the spine. The body of
each vertebra is attached to a bony ring consisting of several parts. A bony projection
on either side of the vertebral body called the pedicle supports the arch that protects the
spinal canal. The laminae are the parts of the vertebrae that form the back of the bony
arch that surrounds and covers the spinal canal. There is a transverse process on either
side of the arch where some of the muscles of the spinal column attach to the
vertebrae. The spinous process is the bony portion of the vertebral body that can be felt
as a series of bumps in the center of a person's neck and back.
B. Intervertebral Disc
Between the spinal vertebrae are discs, which function as shock absorbers and joints.
They are designed to absorb the stresses carried by the spine while allowing the
vertebral bodies to move with respect to each other. Each disc consists of a strong
outer ring of fibers called the annulus fibrosis, and a soft center called the nucleus
pulposus. The outer layer (annulus) helps keep the disc's inner core (nucleus) intact.
The annulus is made up of very strong fibers that connect each vertebra together. The
nucleus of the disc has a very high water content, which helps maintain its flexibility and
shock-absorbing properties.

C. Facet Joint
The facet joints connect the bony arches of each of the vertebral bodies. There are two
facet joints between each pair of vertebrae, one on each side. Facet joints connect each
vertebra with those directly above and below it, and are designed to allow the vertebral
bodies to rotate with respect to each other.

D. Neural Foramen
The neural foramen is the opening through which the nerve roots exit the spine and
travel to the rest of the body. There are two neural foramen located between each pair
of vertebrae, one on each side. The foramen creates a protective passageway for the
nerves that carry signals between the spinal cord and the rest of the body.

E. Spinal Cord and Nerves


The spinal cord extends from the base of the brain to the area between the bottom of
the first lumbar vertebra and the top of the second lumbar vertebra. The spinal cord
ends by diverging into individual nerves that travel out to the lower body and the legs.
Because of its appearance, this group of nerves is called the cauda equina - the Latin
name for "horse's tail." The nerve groups travel through the spinal canal for a short
distance before they exit the neural foramen.

The spinal cord is covered by a protective membrane called the dura mater, which
forms a watertight sac around the spinal cord and nerves. Inside this sac is spinal fluid,
which surrounds the spinal cord.

The nerves in each area of the spinal cord are connected to specific parts of the body.
Those in the cervical spine, for example, extend to the upper chest and arms; those in
the lumbar spine the hips, buttocks and legs. The nerves also carry electrical signals
back to the brain, creating sensations. Damage to the nerves, nerve roots or spinal cord
may result in symptoms such as pain, tingling, numbness and weakness, both in and
around the damaged area and in the extremities.

Spinal Muscles

Many muscle groups that move the trunk and the limbs also attach to the spinal column.
The muscles that closely surround the bones of the spine are important for maintaining
posture and helping the spine to carry the loads created during normal activity, work
and play. Strengthening these muscles can be an important part of physical therapy and
rehabilitation.

Nervous System

All of the elements of the spinal column and vertebrae serve the purpose of protecting
the spinal cord, which provides communication to the brain, mobility and sensation in
the body through the complex interaction of bones, ligaments and muscle structures of
the back and the nerves that surround it.

The true spinal cord ends at approximately the L1 level, where it divides into the many
different nerve roots that travel to the lower body and legs. This collection of nerve roots
is called the cauda equina, which means "horse's tail," and describes the continuation of
the nerve roots at the end of the spinal cord.
VI. PATHOPHYSIOLOGY

Pott's disease is usually secondary to an extraspinal source of infection. The


basic lesion involved in Pott's disease is a combination of osteomyelitis and arthritis that
usually involves more than one vertebra. The anterior aspect of the vertebral body
adjacent to the subchondral plate is area usually affected. Tuberculosis may spread
from that area to adjacent intervertebral disks. In adults, disk disease is secondary to
the spread of infection from the vertebral body. In children, because the disk is
vascularized, it can be a primary site.

Progressive bone destruction leads to vertebral collapse and kyphosis. The


spinal canal can be narrowed by abscesses, granulation tissue, or direct dural invasion,
leading to spinal cord compression and neurologic deficits. The kyphotic deformity is
caused by collapse in the anterior spine. Lesions in the thoracic spine are more likely to
lead to kyphosis than those in the lumbar spine. A cold abscess can occur if the
infection extends to adjacent ligaments and soft tissues. Abscesses in the lumbar region
may descend down the sheath of the psoas to the femoral trigone region and eventually
erode into the skin.

Pathophysiology of Pott's Disease

Spread of bacteria (mycobacterium Spreads from to


Trauma, Previous
tuberculosis) to extrapulmonary adjacent vertebrae into
Lung infection
adjoining disc space

Vertebra is affected,
Vertebral collapse Dark tissue caseation
intervetebral disc cannot
occurs
receive nutrients and collapse

Spinal damage Kyphosis


Back pain, fever