tuberculosis spondylitis ii
DESCRIPTION
referat spondilitis tuberculous IITRANSCRIPT
Tuberculosis Spondylitis (TB spine/Pott’s diseasis)
By Dr Phillipo Leo Chalya
1. Introduction Tuberculous spondylitis has been
documented in ancient mummies from Egypt and Peru
It is one of the oldest demonstrated diseases of humankind.
Percival Pott presented the classic description of TB spine in 1779.
Introduction (cont.) Since the advent of antiTB drugs
and improved public health measures, TB spine has become rare in industrialized countries.
However it is still a common diseasis in developing countries.
Introduction (cont.) TB spine causes serious morbidity,
including permanent neurologic deficits and severe deformity.
Medical treatment or combined medical and surgical strategies can control the disease in most patients
2. Epidemiology TB spine is common in developing
countries> developed countries Internationally approx. 1-2% of total
TB cases are attributable to Pott disease.
As with other forms of TB, the frequency is related to socioeconomic factors and historical exposure to the infection.
Epidemiology (cont.) Sex: Males are more often affected(1.5-2:1). Age: In developed countries Pott dx
primarily occurs in adults. In countries with higher rates of
infection, it mainly occurs in children
Epidemiology (cont.) Mortality/Morbidity : Pott
disease is the most dangerous form of musculoskeletal TB.
It can cause bone destruction, deformity, and paraplegia
It commonly involves the thoracic and lumbosacral spine.
4. Pathophysiology Pott disease is usually secondary
to an extraspinal source of infection.
The basic lesion is a combination of osteomyelitis and arthritis.
Typically, more than one vertebra is involved.
Pathophysiology (cont.) The area usually affected is the
anterior aspect of the vertebral body adjacent to the subchondral plate
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.
Pathophysiology (cont.) 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
Pathophysiology (cont.) This leads to spinal cord
compression and neurologic deficits. Kyphotic deformity occurs as a
consequence of collapse in the anterior spine.
Lesions in the thoracic spine have a greater tendency for kyphosis than those in the lumbar spine.
Pathophysiology (cont.) 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.
5. Clinical presentation Presentation depends on the following:
Stage of disease Site Presence of complications such as neurologic
deficits, abscesses, or sinus tracts.
The reported average duration of symptoms at the time of diagnosis is 3-4 months.
Clinical presentation (cont.) The average duration of symptoms
at the time of diagnosis is 3-4 months
Back pain is the earliest and most common symptom. Patients have usually had back pain
for weeks prior to presentation. Pain can be spinal or radicular.
Clinical presentation (cont.) Constitutional symptoms include
fever and weight loss. Neurologic abnormalities occur in
50% of cases and can include spinal cord compression with paraplegia, paresis, impaired sensation, nerve root pain, or cauda equina syndrome.
Clinical presentation (cont.) Cervical spine tuberculosis is a less
common presentation but is potentially more serious because severe neurologic complications are more likely. This condition is characterized by pain
and stiffness. Patients with lower cervical spine disease
can present with dysphagia or stridor. Symptoms can also include torticollis,
hoarseness, and neurologic deficits.
Clinical presentation (cont.) The clinical presentation of TB in
HIV patients is similar to that of HIV negative patients; however, the relative proportion of individuals who are HIV positive seems to be higher.
Clinical presentation (cont.) Physical examination should include
the following: Careful assessment of spinal alignment Inspection of skin, with attention to
detection of sinuses Abdominal evaluation for subcutaneous
flank mass Meticulous neurologic examination
Clinical presentation (cont.) The thoracic spine is frequently
reported as the most common site of involvement followed by lumber spine
The remaining cases correspond to the cervical spine.
Spine deformity (kyphosis) of some degree occurs in almost every patient.
Clinical presentation (cont.) There may be large cold abscesses
of paraspinal tissues or psoas muscle that protrude under the inguinal ligament.
They may erode into the perineum or gluteal area.
Clinical presentation (cont.) Neurologic deficits may occur early
in the course of disease. Signs depend on the level of spinal
cord or nerve root compression
Clinical presentation (cont.) Disease involving 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
Clinical presentation (cont.) If there is no evidence of
extraspinal tuberculosis, diagnosis can be difficult.
Information from imaging studies, microbiology, and anatomic pathology should help establish the diagnosis
6.Workup 6:1 Lab studies Tuberculin skin test demonstrates
a positive finding in 84-95% of patients who are non–HIV-positive.
ESR may be markedly elevated (>100 mm/h).
Workup (cont.) Microbiology studies to confirm
diagnosis: Obtain bone tissue or abscess samples to stain for acid-fast bacilli (AFB), and isolate organisms for culture and susceptibility.
These study findings may be positive in only about 50% of the cases.
Workup (cont.)6:2 Imaging studies Plain radiography demonstrates
the following characteristic changes of spinal tuberculosis: Lytic destruction of anterior portion of
vertebral body Increased anterior wedging
Workup (cont.) Collapse of vertebral body Reactive sclerosis on a progressive lytic
process Enlarged psoas shadow with or without
calcification Additional findings
Vertebral end plates are osteoporotic. Intervertebral disks may be shrunk or
destroyed.
Workup (cont.) Fusiform paravertebral shadows
suggest abscess formation. Bone lesions may occur at more than
one level.
Workup (cont.) Intervertebral disks may be
shrunk or destroyed. Vertebral bodies show variable
degrees of destruction
Workup (cont.) CT scanning
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 soft tissue assessment, particularly in epidural and paraspinal areas.
Workup (cont.) It detects 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
Workup (cont.) MRI
MRI is the criterion standard for evaluating disk space infection and osteomyelitis of the spine and is most effective for demonstrating the extension of disease into soft tissues and the spread of tuberculous debris under the anterior and posterior longitudinal ligaments
Workup (cont.) MRI is most effective for
demonstrating neural compression. In developed countries, MRI has
nearly replaced CT myelography. Procedures:
Some patients are diagnosed following an open drainage procedure (eg, following presentation with acute neurologic deterioration).
Workup (cont.)Histologic Findings: Since microbiologic studies may be
nondiagnostic, anatomic pathology can be very significant.
Gross pathologic findings include exudative granulation tissue with interspersed abscesses.
Coalescence of abscesses results in areas of caseating necrosis.
7. Treatment 7:1 Medical treatment Medical therapy requires
combination regimens with at least 3 antituberculous drugs.
A 3-drug regimen usually includes INH, rifampin, and pyrazinamide.
The duration of treatment ranges from 9-12 months
Treatment (cont.)7:2 Surgical treatment Indications
Neurologic deficit (acute neurologic deterioration, paraparesis, paraplegia)
Spinal deformity with instability No response to medical therapy
Treatment (cont.) Resources and experience are key
factors in the decision to use a surgical approach
The most appropriate method of reconstruction depends on the level of vertebral spine involved and the extent of bony destruction.
Treatment (cont.) The lesion site, extent of vertebral
destruction, and presence of cord compression or spinal deformity determine the specific operative approach.
Treatment (cont.) In disease involving the cervical
spine, the following factors justify early surgical intervention: High incidence and severity of
neurologic deficits Severe abscess compression that
may induce dysphagia or asphyxia Instability of the cervical spine
Treatment (cont.) Contraindications
Vertebral collapse of a lesser magnitude is not considered an indication for surgery because with appropriate treatment and therapy compliance, it is less likely to progress to severe deformity.
Vertebral damage is considered significant if more than 50% of the vertebral body is collapsed or destroyed or if there is spinal deformity of more than 5°.