Transcript tuberculosis spondilitis - Dokter bedah tulang belakang| bedah tulang

BY
Dr.WAHYU EKO W.Sp.OT
Orthopaedi dan Tulang Belakang
RS.BINA HUSADA
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Dokterbedahtulang.com
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Pott disease ( Spondilitis Tubercolosis)
merupakan penyakit manusia tertua.
Ditemukan dari jaman Batu, mummi Mesir
kuno dan Peru.
In 1779, Percivall Pott, pemberi nama
penyakit ini, menjelaskan perjalanan penyakit
ini.
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Dgn adanya Obat Antituberculous dan perbaikan
ukuran kesehatan masyarakat----spinal
tuberculosis di negara maju sangat jarang.
Di negara sedang berkembang ----- masih
banyak. (bogor)
Spondilitis TBC ---- menyebakan masalah serius
karena adanya gangguan motorik dan sensorik.
Pemberian OAT dan operasi ____ bisa mengontrol
penyakit ini.
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Asal Potts desease: secundair karena
osteomyelitis dan Arthritis TB
Bisa Lebih 2 vertebrae .
Melibatkan bagian anterior dari Corpus Vertebrae
…..discus vertebralis Rusak.
Pada orang dewasa discus rusak akibat infeksi
dari VB
Pada anak2, Lesi primer bisa di Discus Inter
vertebralis.
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Kerusakan CV yang progresive menyebabkan
CV kolaps dan menyebakan kyphosis.
Saluran Spinal menyempit ok abses, jaringan
granulasi ‘….. Menekan spinal cord====
defisit Neurologi.
Terutama bagian thorakal=== lebih kyphotic.
Cold absces== infeksi menyebar ke ligament
dan soft tisue.
Abscesses di lumbar==turun ke bawah ke
Psoas === trigonum femoral === ke kulit.
Foto AP
Foto Lat
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United States
Masih ada tahun 1980-1990….. Turun drastis
Tuberculous spondylitis ==== 40-50% .4
musculoskeletal tuberculosis
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Pott disease=== 1-2 persen kasus total TBC
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In the Netherlands between 1993 and 2001,
tuberculosis of the bone and joints accounted
for 3.5% of all tuberculosis cases
@ Pott disease penyakit musculo skeletal yang
paling berbahaya. Karena menyebakan
kerusakan tulang, deformitas dan paraplegi.
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Thoracic and lumbosacral spine.== Lower
thoracic vertebrae (40-50%),
the lumbar spine (35-45%).
Cervical spine 10%
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Race
Tergantung riwayat kontak TBC.
Sex
male-to-female ratio of 1.5-2:1).
Age
Dewasa, dewasa muda dan anak2.
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The presentation of Pott disease depends on the
following:
◦ Stadium penyakit
◦ Lokasi Kelainan
◦ Adanya komplikasi seperti neurologic deficits,
abscesses, or sinus tracts
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Dilaporkan rata2 : Durasi simptom sampai
diagnosis > 4 bulan.
Sakit Pinggang yang lama, gejala awal yang
paling umum
Bisa Spinal dan Radicular
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Demam dan Berat Badan Turun
Neurologic abnormalities : 50% of cases
Kompresi spinal cord diikuti paraplegia, paresis,
impaired sensation, nerve root pain, and/or
cauda equina syndrome.
Cervical spine tuberculosis :less common but
more serious,
◦ Pain and stiffness.
◦ Patients with lower cervical spine disease can present
with dysphagia or stridor.
◦ Symptoms can also include torticollis and hoarseness,
◦ neurologic deficits.
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The examination :
◦ Careful assessment of spinal alignment
◦ Inspection of skin, with attention to detection of
sinuses
◦ Abdominal evaluation for subcutaneous flank mass
◦ Meticulous neurologic examination
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Pott disease have some degree of spine
deformity (kyphosis).
Large cold abscesses of paraspinal tissues or
psoas muscle may protrude under the
inguinal ligament and may erode into the
perineum or gluteal area.
Neurologic deficits may occur early in the
course of Pott disease. Signs of such deficits
depend on the level of spinal cord or nerve
root compression.
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Pott disease that involves the upper cervical
spine can cause rapidly progressive symptoms.
◦ Retropharyngeal abscesses occur in almost all cases.
◦ Neurologic manifestations occur early and range from a
single nerve palsy to hemiparesis or quadriplegia.
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Many persons with Pott disease (62-90% of
patients in reported series6, 7) have no evidence of
extraspinal tuberculosis
Information from imaging studies, microbiology,
and anatomic pathology should help establish
the diagnosis.
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DIFFERENTIAL DIAGNOSIS
Actinomycosis
Blastomycosis
Brucellosis
Candidiasis
Cryptococcosis
Histoplasmosis
Metastatic Cancer, Unknown Primary Site
Miliary Tuberculosis
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Multiple Myeloma
Mycobacterium Avium-Intracellulare
Mycobacterium Kansasii
Nocardiosis
Paracoccidioidomycosis
Septic Arthritis
Spinal Cord Abscess
Tuberculosis
Other Problems to be Considered
Spinal tumors
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Lab Studies
Tuberculin skin test (purified protein
derivative [PPD]) results are positive in 8495%
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Microbiology studies
CT-guided procedures
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Radiography
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Lytic destruction of anterior portion of vertebral body
Increased anterior wedging
Collapse of vertebral body
Reactive sclerosis on a progressive lytic process
Enlarged psoas shadow with or without calcification
◦ Additional radiographic findings may include the
following:
Vertebral end plates are osteoporotic.
Intervertebral disks may be destroyed.
Vertebral bodies show variable degrees of destruction.
Fusiform paravertebral shadows suggest abscess
formation.
 Bone lesions may occur at more than one level.
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◦ CT scanning provides much better bony detail of
irregular lytic lesions, sclerosis, disk collapse, and
disruption of bone circumference.
◦ Low-contrast resolution provides a better
assessment of soft tissue, particularly in epidural
and paraspinal areas.
◦ CT scanning reveals early lesions and is more
effective for defining the shape and calcification of
soft-tissue abscesses.
◦ In contrast to pyogenic disease, calcification is
common in tuberculous lesions.
◦ MRI is the criterion standard for evaluating diskspace infection and osteomyelitis of the spine and
cold Abcess.
◦ MRI ==== Lihat neural compression.15, 16
◦ MRI findings useful to differentiate tuberculous
spondylitis from pyogenic
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Other Tests
Radionuclide scanning findings are not
specific for Pott disease.
Gallium and Tc-bone scans yield high falsenegative rates (70% and up to 35%,
respectively).18
Use a percutaneous CT-guided needle biopsy
of bone lesions to obtain tissue samples.
◦ This is a safe procedure that also allows therapeutic
drainage of large paraspinal abscesses.
◦ Obtain a tissue sample for microbiology and
pathology studies to confirm diagnosis and to
isolate organisms for culture and susceptibility.
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Some cases of Pott disease are diagnosed
following an open drainage procedure (eg,
following presentation with acute neurologic
deterioration
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Microbiologic
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Patologi Anatomi : Gold standart
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Gross pathologic : exudative granulation
tissue with abscesses.
caseating necrosis.
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Pott disease : Prolonged bed rest or a body
cast. Pott disease carried a mortality rate of
20%, and relapse was common
(30%)==before OAT
Thoracolumbar spine should be treated with
combination chemotherapy for 6-9 months.19
Many experts still recommend chemotherapy
for 9-12 months.
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4-drug regimen should be used empirically
to treat Pott disease.20
Isoniazid and Rifampin should be
administered during the whole course of
therapy.
Additional drugs are administered during the
first 2 months of therapy. These are generally
chosen among the first-line drugs, which
include pyrazinamide, ethambutol, and
streptomycin. The use of second-line drugs is
indicated in cases of drug resistance.
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TREATMENT
1.Kemoterapi dan konservative
2.Kemoterapi dan Operasi
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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
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Anterior radical focal debridement and
posterior stabilization with instrumentation.24,
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Involves the cervical spine, the following
factors justify early surgical intervention:
◦ High frequency and severity of neurologic deficits
◦ Severe abscess compression that may induce
dysphagia or asphyxia
◦ Instability of the cervical spine
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Orthopedic surgeons
Neurosurgeons
Rehabilitation teams
JAMAN DAHULU
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plaster beds, plaster jackets, and braces are
still used.
Cast or brace immobilization was a traditional
form of treatment but has generally been
discarded. Patients with Pott disease should
be treated with external bracing.
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A 4-drug regimen should be used empirically
to treat Pott disease. Treatment can be
adjusted when susceptibility information
becomes available.
Isoniazid and rifampin should be
administered during the whole course of
therapy. Additional drugs are administered
during the first 2 months of therapy. These
are generally chosen among the first-line
drugs, which include pyrazinamide,
ethambutol, and streptomycin.
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A 3-drug regimen usually includes isoniazid,
rifampin, and pyrazinamide.
The use of second-line drugs is indicated in
cases of drug resistance.
The duration of treatment is somewhat
controversial. Although some studies favor a 6to 9-month course, traditional courses range
from 9 months to longer than 1 year. The
duration of therapy should be individualized and
based on the resolution of active symptoms and
the clinical stability of the patient.
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Further Inpatient Care
Once the diagnosis of Pott disease is established and
treatment is started, the duration of hospitalization
depends on the need for surgery and the clinical stability
of the patient.
Further Outpatient Care
Patients with Pott disease should be closely monitored to
assess their response to therapy and compliance with
medication. Directly observed therapy may be required.
The development or progression of neurologic deficits,
spinal deformity, or intractable pain should be considered
evidence of poor therapeutic response. This raises the
possibility of antimicrobial drug resistance as well as the
necessity for surgery.
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Because of the risk of deformity
exacerbations, children with Pott disease
should undergo long-term follow-up until
their entire growth potential is completed.25
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Abscess
Spine deformities
Neurologic deficits and paraplegia
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Current treatment modalities are highly effective if
not complicated by severe deformity or established
neurologic deficit.
Therapy compliance and drug resistance are
additional factors that significantly affect individual
outcomes.
Paraplegia resulting from the active disease causing
cord compression usually responds well to
chemotherapy.
If medical therapy does not result in rapid
improvement, operative decompression will greatly
increase the recovery rate.
Paraplegia can manifest or persist during healing
because of permanent spinal cord damage.
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Patients with Pott disease should be
instructed on the importance of therapy
compliance.
For excellent patient education resources,
visit eMedicine's Bacterial and Viral Infections
Center. Also, see eMedicine's patient
education article Tuberculosis.
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Medical/Legal Pitfalls
A large proportion of patients with Pott disease do not present
with extraskeletal disease. In reported series, only 10-38% of
cases of Pott disease are associated with extraskeletal
tuberculosis.
The diagnosis of tuberculous spondylitis should be investigated
if strong clinical suspicion exists, even if suggestive pulmonary
radiology findings are absent.
Other features suggestive of tuberculosis include the following:
◦ Positive PPD result
◦ Chest radiograph that shows apical scarring, infiltrates, or cavitary disease
◦ Presence of risk factors for tuberculosis
Spinal tuberculosis should always be suspected when
radiographs demonstrate a destructive spine process.