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SPONDILITIS TUBERCULOSA (Potts desease ). BY Dr.WAHYU EKO W.Sp.OT Orthopaedi dan Tulang Belakang RS.BINA HUSADA. WEBSITE PRIBADI. Dokterbedahtulang.com. definisi. Pott disease ( Spondilitis Tubercolosis) merupakan penyakit manusia tertua.

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spondilitis tuberculosa potts desease

SPONDILITIS TUBERCULOSA(Potts desease)

BY

Dr.WAHYU EKO W.Sp.OT

Orthopaedi dan Tulang Belakang

RS.BINA HUSADA

website pribadi
WEBSITE PRIBADI
  • Dokterbedahtulang.com
definisi
definisi
  • 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.
sopndilitis tbc potts desease
Sopndilitis TBC (Potts Desease)
  • DgnadanyaObatAntituberculousdanperbaikanukurankesehatanmasyarakat----spinal tuberculosis dinegaramajusangatjarang.
  • Di negarasedangberkembang ----- masihbanyak. (bogor)
  • Spondilitis TBC ---- menyebakanmasalahseriuskarenaadanyagangguanmotorikdansensorik.
  • Pemberian OAT danoperasi ____ bisamengontrolpenyakitini.
pathophyiologi
PATHOPHYIOLOGI
  • Asal Potts desease: secundairkarenaosteomyelitisdan Arthritis TB
  • BisaLebih 2 vertebrae .

Melibatkanbagian anterior dari Corpus Vertebrae …..discus vertebralisRusak.

Padaorangdewasa discus rusakakibatinfeksidari VB

Pada anak2, Lesi primer bisadi Discus Inter vertebralis.

pathophysiology
PATHOPHYSIOLOGY
  • 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.
x ray
X ray

Foto AP

Foto Lat

frequency
FREQUENCY
  • United States

Masih ada tahun 1980-1990….. Turun drastis

  • Tuberculous spondylitis ==== 40-50% .4 musculoskeletal tuberculosis
frequency1
FREQUENCY
  • 4International

Pott disease=== 1-2 persen kasus total TBC

  • In the Netherlands between 1993 and 2001, tuberculosis of the bone and joints accounted for 3.5% of all tuberculosis cases
morbidity mortality
MORBIDITY/MORTALITY

@ Pott disease penyakit musculo skeletal yang paling berbahaya. Karena menyebakan kerusakan tulang, deformitas dan paraplegi.

  • Thoracic and lumbosacral spine.== Lower thoracic vertebrae (40-50%),
  • the lumbar spine (35-45%).
  • Cervical spine 10%
race sex and age
RACE,SEX AND AGE
  • Race

Tergantung riwayat kontak TBC.

  • Sex

male-to-female ratio of 1.5-2:1).

  • Age

Dewasa, dewasa muda dan anak2.

clinical
CLINICAL
  • The presentation of Pott disease depends on the following:  
    • Stadium penyakit
    • LokasiKelainan
    • Adanyakomplikasiseperti neurologic deficits, abscesses, or sinus tracts
  • Dilaporkan rata2 : Durasisimptomsampai diagnosis > 4 bulan.
  • SakitPinggang yang lama, gejalaawal yang paling umum
  • Bisa Spinal danRadicular
hystory
HYSTORY
  • DemamdanBeratBadanTurun
  • Neurologic abnormalities : 50% of cases
  • Kompresi spinal cord diikuti paraplegia, paresis, impaired sensation, nerve root pain, and/or caudaequina 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.
physical
PHYSICAL
  • 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
physical1
PHYSICAL
  • 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.
physical2
PHYSICAL
  • 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.
  • 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.
diferensial diagnosis
Diferensial Diagnosis
  • DIFFERENTIAL DIAGNOSISActinomycosisBlastomycosisBrucellosisCandidiasisCryptococcosisHistoplasmosisMetastatic Cancer, Unknown Primary SiteMiliary Tuberculosis
dif diagnosis
DIF.DIAGNOSIS
  • Multiple MyelomaMycobacterium Avium-IntracellulareMycobacterium KansasiiNocardiosisParacoccidioidomycosisSeptic ArthritisSpinal Cord AbscessTuberculosis
  • Other Problems to be Considered
  • Spinal tumors
work up
Work UP
  • Lab Studies
  • Tuberculin skin test (purified protein derivative [PPD]) results are positive in 84-95%
  • LED
  • Microbiology studies
  • CT-guided procedures
imaging
Imaging
  • Radiography
      • 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
radiography
RADIOGRAPHY
  • 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.
ct scanning
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 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.
slide34
MRI
  • MRI is the criterion standard for evaluating disk-space infection and osteomyelitis of the spine and cold Abcess.
  • MRI ==== Lihat neural compression.15, 16
  • MRI findings useful to differentiate tuberculous spondylitis from pyogenic
bone scan
BONE SCAN
  • Other Tests

Radionuclide scanning findings are not specific for Pott disease.

Gallium and Tc-bone scans yield high false-negative rates (70% and up to 35%, respectively).18

procedures
PROCEDURES

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.
  • Some cases of Pott disease are diagnosed following an open drainage procedure (eg, following presentation with acute neurologic deterioration
histologic findings
Histologic Findings
  • Microbiologic
  • Patologi Anatomi : Gold standart
  • Gross pathologic : exudative granulation tissue with abscesses.
  • caseating necrosis.
medical care
Medical Care
  • 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.
medical care1
MEDICAL CARE
  • 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.
medical care2
MEDICAL CARE
  • TREATMENT

1.Kemoterapi dan konservative

2.Kemoterapi dan Operasi

surgical care
Surgical Care
  • 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
surgical care1
SURGICAL CARE
  • Anterior radical focal debridement and posterior stabilization with instrumentation.24, 10
  • 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
consultations
Consultations
  • Orthopedic surgeons
  • Neurosurgeons
  • Rehabilitation teams
activity
ACTIVITY

JAMAN DAHULU

  • 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.
medication
medication
  • 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.
medication1
MEDICATION
  • 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 6- to 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.
follow up
FOLLOW-UP
  • 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.
follow up1
FOLLOW UP
  • 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
complication
COMPLICATION
  • Abscess
  • Spine deformities
  • Neurologic deficits and paraplegia
prognosis
PROGNOSIS

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.
patient education
PATIENT EDUCATION
  • 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.
miscelaneous
MISCELANEOUS
  • 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 tuberculousspondylitis 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.
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