BYDr.WAHYU EKO W.Sp.OT

Orthopaedi dan Tulang BelakangRS.BINA HUSADA

Dokterbedahtulang.com

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.

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.

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 VBPada anak2, Lesi primer bisa di Discus Inter vertebralis.

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

United StatesMasih ada tahun 1980-1990….. Turun drastis

Tuberculous spondylitis ==== 40-50% .4 musculoskeletal tuberculosis

4InternationalPott 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

@ 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%

RaceTergantung riwayat kontak TBC.

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

AgeDewasa, dewasa muda dan anak2.

The presentation of Pott disease depends on the following:  ◦ Stadium penyakit◦ Lokasi Kelainan◦ Adanya komplikasi seperti neurologic deficits,

abscesses, or sinus tracts

Dilaporkan rata2 : Durasi simptom sampai diagnosis > 4 bulan.

Sakit Pinggang yang lama, gejala awal yang paling umum

Bisa Spinal dan Radicular

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.

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

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.

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.

DIFFERENTIAL DIAGNOSISActinomycosisBlastomycosisBrucellosisCandidiasisCryptococcosisHistoplasmosisMetastatic Cancer, Unknown Primary Site

Miliary Tuberculosis

Multiple MyelomaMycobacterium Avium-IntracellulareMycobacterium KansasiiNocardiosisParacoccidioidomycosisSeptic ArthritisSpinal Cord AbscessTuberculosis

Other Problems to be Considered Spinal tumors

Lab Studies Tuberculin skin test (purified protein

derivative [PPD]) results are positive in 84-95%

LED Microbiology studies CT-guided procedures

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

◦ 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 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 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

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

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

Microbiologic

Patologi Anatomi : Gold standart

Gross pathologic : exudative granulation tissue with abscesses.

caseating necrosis.

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.

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.

TREATMENT1.Kemoterapi dan konservative2.Kemoterapi dan Operasi

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

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

Orthopedic surgeons Neurosurgeons Rehabilitation teams

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.

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.

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.

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.

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

Abscess Spine deformities Neurologic deficits and paraplegia

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.

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.

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.