Referat

Tuberculous Spondylitis
Pembimbing
Dr. dr. Erwin Isparnadi, SpOT

Oleh:
Ajeng Ayu Erwati 2016.04.2.003
Angga Yogi Laksmana 2016.04.2.0012
SMF Bedah RSU HAJI Surabaya
Fakultas Kedokteran Universitas Hang Tuah Surabaya
 Identitas pasien
Nama : tn abdul rosyid
Usia : 53 th
Alamat : jl wahid hasyim 66 V, surabaya
Tgl ke poli : 7/9/2013
Jam : 10.00
Anamnesa (autoanamnesa)

Complaint : waist pain

History disease now : patient camed orthopedi poli at RS.Haji with
lamentation wairst pain 1 year ago. This pain creeping at back pain.
This pain felt disappers and increasingly 3 month ago. Patient come
to special neurologist and given medication analgesic but this
complaint no better. Patient referred at docter orthopedi. Patient
complaint feet cant moved and leg tingling, numbness. Patient
complaint nausea, weight loss 10 kg, and sweet night 2 mont ago.
Cought (-) demam (-). Dificullty of swalowing (-)
Patient complaint mass at the regio scapula
sinistra size 2 cm x 2cm, mass consistensi soft,
mobile, uclear margin, pain (-).
History of past illness :
HT(-); DM (-); allergic (-); TB (-)
History of family illness :
HT (-); DM (-); asma (-); TB (-)
History medication :
- ar-gout tablet
- allopurinol
- meloxicam
- thiamine
 Physical examination
general examination : moderat illness
consiouness : compos mentis (GCS 456)
weight : 55 kg
height : 165cm
blood presure : 120/80
pulse rate : 80 x/second
RR : 20x/second
temperature : 36
A/I/C/D : -/-/-/-
Status general : normal
Status neurologis:
GCS : 456
pupil : bulat isokor, 3mm, light refleks (+)
N. Cranialis : normal
Motorik Sensoris
+5 +5 + +
+2 +2 - -

Status
Look : cant evaluasion
localis
Feel : cant evaluasion
Move :
paraplegy (+)
Add Examination
CT- Scan
CT- SCAN
 Introductions

Pott disease, also known as tuberculous

spondylitis
Indonesia: The 3rd largest TB patients in the
world,after India and China
HIV/AIDS TB
1-2% TB case TB spondylitis
TB Spondylitis : 10% TB extrapulmonary
TB Spondylitis : 50% from bone and joint TB
ANATOMI VERTEBRAE
ANATOMI VERTEBRAE
 DEFINITION

Spondylitis
Is an inflammation of the vertebra

Tuberculous Spondylitis (Potts Disease)

Granulomatous inflammation of the vertebral column ,
chronic destructive,
caused by Mycobacterium tuberculosis
 PATHOGENESIS TUBERCULOSIS

Droplet nuclei from M. tuberculosis Respiratory tract

lung infection (primary focus) lymphatic local
limphangitis & regional limphadenitis PRIMARY
COMPLEX
Hematogenous/Limphatic dissemination The whole body
Brain, GI, Renal, Genitalia, skin, lymph node, bone, endometrium
TB Spondylitis often caused by primary infection in :
Lung
Genitourinary
Other Vertebrae Skipping lesion/ spondylitis TB non-
contiguous
 PATHOGENESIS OF SPONDYLITIS TB
Infection Inflammation bone tissue lysis
Destructions Soft & flat
Kiphotic / gibbus deformity:
V. Thoracic : load transmission in anterior The anterior
is more flattened
V. Cervical & lumbal: load transmission in posterior
5 STADIUM Pathophysiology according Kumar
Implantation
Early Destruction
Continue Destruction
Neurologic Disorder
Residual Deformity
 NEUROLOGIC DISORDER
Compression in extradural spine canal & radix is caused
by :
Paravertebral abscess
Facet joints subluxation
Vertebrae collaps
Extradural abscess
Duramater invasion by bacteria
 VERTEBRAL INVOLVEMENT
Paradiscal: infection metaphyse Anterior
longitudinal ligament adjacent bodies
Central: the central part, remain isolated in one
vertebral similiar to tumor, it can be deformity &
collaps (Pathologic fracture)
Anterior: from under anterior longitudinal ligament
expand to another segment anterior part of the
vertebrae is erosion R: scalloping
 Clinical Manifestation
Back Pain
Spasm of back muscle
Limitations of movement
Spine deformity Kiphosis
Deficit neurologic Paraplegia
Abscess: paravertebral
Weight loss,Fever,Lethargic, appetite

Residual deformity: Pain (-) Abscess (-)

NEUROLOGIC DEFISIT DEGREE according Kumar
I Weakness in the lower limb occurs after doing the activity or
after walking away.
At this stage there has been no sensory nerve disorder

II There is a weakness in the lower limbs but the patient can

still do the job
III There is a weakness in the lower limbs, limiting the
movement / activity of the patient and hypesthesia /
anesthesia
IV Sensory and motor nervous disorders accompanied
defecation and micturition disorders. Tuberculosis paraplegia
or Pott's paraplegia may occur early or later, depending on
the condition of the illness
 PEMERIKSAAN PENUNJANG
Lab: ESR LEU
Screening TB Mantoux / Tuberculin test
Urine Cultur M. Tuberkulosa (+)
Sputum (+)
Lymphatic Biopsy Tuberkel (+)
Vertebrae Xray
Thorax Photo Lung TB?
Spine Biopsy Lesion
Abcess aspiration Tuberkel (+)
CT Scan & MRI
 STANDART EXAMINATION of Spondylitis TB
Gejala Klinis dan Pemeriksaan Neurologis lengkap
Clinical manifestations and Complete neurologic
examination
Vertebra AP/ Lateral xray
Mantoux test
Sputum and pus cultur

Differential Diagnosis
Malignancy involved the Discus Acute, Abscess (-),
Mild deformity, Cervical & lumbal, 1 vertebrae
 Risk Factor
Endemic Region
Contact with TB patients
Low Sosio Economic ,
Malnutritions
Imunocompromised
- + HIV
- DM
Imunosuppresan consumption
Kortikosteorid
 Management

Inhibit the progress of disease

Prevent/ repotition of deformity
Prevent / treat the complications

Conservative -> OAT category 1:2 (HRZE)/4(HR) 3

Given 3 weeks pre op
6-12 months / till the spine xray photo : resolution
Operative : early operation is best options
Paraplegia Stabilisation
Paralisis Decompression
progresif kyphotion Stabilitations + Instrumentations
Anti TB DRUG FDC Category 1 (2HRZE/4HR3)

(KEMENKES RI, 2014)

 Management

Operative indications :

Acute neurologic defisit compression medspin

Spine deformity ,Progressive kyphosis/ severe
Anti TB Drugs 4 weeks less efective
Wide abscess drainage, debridement, bone graft
IC Biopsy is failed for diagnosis
Severe pain caused by compression of the abscess
 Complications

Paraplegia
Early Onset Paresis: Caused by inflammations
Paraparese,UMN,Parestesia, Inkontinensia

Late Onset Paresis: Caused by deformity/vascular

insuficiency

Kiphosis
Neurologic deficit , Heart failure & Respiratory distress
 Prognosis

Age
Kiphotic Deformity
Deficit Neurologic grade
Deficit neurologic duration
Immunity
General status
Active infection/ residual
Therapy regiments