Assesment : Spondylitis

Tuberculosa
AT/ZP

Identity

Name
:H
Date of birth : 24 09 -1993
Age
: 23 Years old
Admitted to the hospital : 09 / 04 /
2016
RM
:75 32 12
Job
: Student.

Anamnesis
Autoanmnesis taken at 09 / 04 /2016
Chief complain : Weakness both lower limb
since 3 months
Weakness felt gradually worsen,
At first patient only complain tried easily when
he stand for several time,
3 weeks before patient felt the condition got
worsen where patient cannot stand anymore.
Before this complain patient can normally walk.

Anamnesis
Patient also complain pain at back region since
3 years ago.
Pain was worsen when walking and reduce
when patient lying in bed.
No radicular pain, no night pain.
Pain got worsen 5 months before admitted to
the hospital escpecially at the back region at
the region where there is a protuding bone.
Since 1 months Patient also complain shortness
of breath.
This complain was felt regularly (not affected
by activity).

Anamnesis
Patient also compain decrease of body weight.
Approximatelly 10 kg since 3 months.
History of night sweat (+)
No history of fever.
No history of trauma.
No history of family with the same condition, but
patient said that some of his friend that he used
to hangout regularly also complain of regular
coughing.
Patient was a smoker.
No regular medication consumed by the patient.

General status
Compos mentis, Weak.
Vital sign:
BP :
HR :
RR :
Temp

110/70mmHg.
82 x / minute.
32 x / minute
: 36,7O.

PHYSICAL EXAMINATION
Thoraks region
Inspection: symetrical chest
movement.
Palpation : seven serial test
normal.
Percussion : Sonor from apex through
the basal.
Auscultation : veshicular +/+, ronchi
+/+, wheezing -/-.

PHYSICAL EXAMINATION
Vertebra Region
I
: Deformity (+), swelling (-), hematoma (-),
gibbus (+), cafe au lite sign (-)
P

: Tenderness (+)

5
5
5
5
5

5
5
5
5
5

2 NT
2
2 2
2 2
2 NT
2
2 NT
2
YES

2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
1
1
1
1
1
1
1
1
1
1
1
1

2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
1
1
1
1
1
1
1
1
1
1
1
1

2
2
2
2
2
2
2
2
2
2
2
2
2
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

2
2
2
2
2
2
2
2
2
2
2
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

Any anal sensation

Y

0 Absent
1 Impaired
2 Normal
NT Not testable

REFLEX
Physiologic
Reflex

Biceps
Triceps
Patellar
Achilles

R
L
(+) (+)
(+) (+)
(+ (+
+) +)
(+ (+
+) +)

Pathologic Reflex

Babinski
Chadock
Openheim
Hoffman
Tromner

R
L
(+) (+)
(+) (+)
(+) (+)
(-)

(-)

Laboratorium

WBC : 11.300 / ul
RBC : 3.190.000 / ul
HBG: 16.5 g/dl
HCT : 29 %
PLT
: 178.000 / ul
ESR : 31/54
HBs Ag : Non Reactive

Diagnosis :
Paraparese due to destruction of vertebra
thorakal IX X due to spondilitis TB with
TB millier
TB Milier
Plan :
Decompression
Posterior stabilisation

DISCUSSION

Introduction
A spinal infection associated with tuberculosis
Characterized by a sharp angulation of the spine
where tubercle lesions are present.
Also called Pott's disease.
Etiology = Mycobacterium tuberculosis
Straight or slightly curved rods

Pathophysiology
Spreads via:
Artery/hematogeno
us
Vein (batson plexus)
Percontinuitatum

Natural history of Spondylitis TB

Pathoanatomy
early infection
begins in the metaphysis of the vertebral
body
spreads under the anterior longitudinal
ligament and leads to
contiguous multilevel involvement
skip lesion or noncontiguous segments (15%)
paraspinal abscess formation (50%)

initially does not involve the disc space

(distinguishes from pyogenic osteomyelitis)

Pathoanatomy
chronic infection leads to
severe kyphosis
sinus formation
Pott's paraplegia
spinal chord injury can be caused by
abscess/bony sequestra or
meningomyelitis
abscess/bony sequestra has a better
prognosis than meningomyelitis as the
cause of spinal cord injury

Tuberculosi
s infection

Granulomatous
inflammation

Erosion of
the margins
of vertebrae

Destroyed
the
intervertebra
l disc

Weakening of
the trabeculae
of vertebral
body

Disc
degenerati
on

Collapse of
the
vertebrae

Loss its
height

Kyphotic deformity

Tuberculous bacilli spread to the disc space from surrounding tissues (contiguous spread) or through
the vascular supply (hematogenous spread). Over time the disc may be completely digested (discitis),
or the infection may progress to involve the bone of each of the adjoining vertebral bodies
(osteomyelitis). As the vertebrae degenerate and collapse, a kyphotic deformity results (Potts disease).

Affected
vertebra

Vertebra
l
abscess

Collection of
pus and
tubercular
debris

Comes out

Anteriorly

Form psoas absces

Posteriorly

Press neural
structures in
spinal canal

INVOLVEMENT
1
1

1. Paradiscal/peridiscal
end plate deposition of
organisms, > 50% of cases
2. Central
usually restricted to one
segment, collapse and
deformity common
3. Anterior
infection is localized to the
anterior part of the vertebral
body,infection spread up and
down under the anterior
longitudinal ligament

CLINICAL
History Taking
Constitutional
symptoms

Weakness
Loss of appetite
Loss of body weight
Night sweat

Back pain (spinal or

radicular), worsen with
activity

Physical Examination
Spine deformity
(kyphotic)
Localized tenderness
Paravertebral muscle
spasm
Neurologic deficit

Laboratorium
WBC
often normal

ESR
usually elevated but may be normal in
up to 25%

PPD (purified protein derivative of

tuberculin)
positive in ~ 80%

Radiograph
CXR
66% will have an abnormal CXR

Spine radiographs
early infection
shows involvement of anterior vertebral body
with sparring of the disc space (this finding
can differentiate from pyogenic infection)

late infection
shows disk space destuction, lucency and
compression of adjacent vertebral bodies,
and development of severe kyphosis

Pengukuran angulasi kifotik metode Konstam.

Pertama, tarik garis khayal sejajar end-plate superior badan
vertebra yang sehat di atas dan di bawah lesi. Kedua garis
tersebut diperpanjang ke anterior sehingga bersilangan.
Sudut K pada gambar adalah sudut Konstam, sedangkan
Sudut A adalah angulasi aktual yang dihitung. Pada contoh
gambar ini, angulasi kifotik adalah sebesar 30

CT SCAN OF THE SPINE

Assessing bone destruction,
Less accurate in defining the epidural
extension of the disease
More effective for defining the shape
Calcification of soft tissue abscess
Bone lesions: irregular lytic lesions,
sclerosis, disc collapse, disruption of
bone circumference

CT SCAN OF THE SPINE

MRI

Best to show soft tissue involvement

Poorly visualizes calcification in abscess

Pyogenic Spondylitis

Metastasis

Treatment
Nonoperative
chemotherapyis the mainstay of
treatment
treated with isoniazid, rifampin, and
pyrazanamide for 9 to 18 months
ethambutol and streptomycin added for part
of treatment

spinal orthosis
may be used for pain control and prevention
of deformity

MANAGEMENT
Anti TB drugs
Aims of anti TB drugs :
To
To
To
To

cure the potent TB

prevent death from active TB
prevent TB relapse
decrease TB transmision to others

Anti TB
drugs
H
R
Z
S
E

Mode of action Potency

Bactericidal
Bactericidal
Bactericidal
Bactericidal
Bacteriostatic

Daily
recommended
dose (mg/kg)

High
High
Low
Low
low

Side Effect : - Peripheral neuropathy, Liver failure

- GI: anorexia, nausea, vomiting, abd pain, liver failure
- Joints pains, liver failure
- Auditory and vestibular nerve damage, renal failure
- Optic neuritis

5
10
25
15
15

Treatment
Operative
radical anterior debridement with
uninstrumented strut grafting(Hong
Kong procedure) with or without
posterior stabilization
indications
neurologic deficit
spinal instability or progressive kyphosis
advanced disease with caseation
preventing access by antibiotics
failure of nonoperative treatment after 3
to 6 months

Treatment
advantages of surgical treatement
less progressive kyphosis
earlier healing
decreased sinus formation
in patients with neurologic deficits, early
debridement and decompression led to improved
neurologic recovery

technical aspects
autogenous and allograft strut grafts are
acceptable with good results

begin adjuvant chemotherapy ten days

prior to surgery

Treatment
Halo traction, anterior decompression,
bone grafting, anterior plating
indications
cervical kyphosis

Pedicle subtraction osteotomy

indications
lumbar kyphosis

Direct decompression / internal

kyphectomy
indications
correction of healed thoracic/thoracolumbar kyphosis
allows spinal cord to transpose anteriorly

Complication

Paraplegia
Spinal Deformity
Cold Abscess
Secondary infection

THANK YOU