3POTTS DESEASEPott 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.
7Spondilitis TBC (Potts Desease) 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.
8PATHOPHYIOLOGIAsal Potts desease: secundair karena osteomyelitis dan Arthritis TBBisa 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.
10PATHOPHYSIOLOGYKerusakan 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.
19FREQUENCY United States Masih ada tahun 1980-1990….. Turun drastis Spondilitis TBC==== 40-50% .4 musculoskeletal tuberculosis
20FREQUENCY 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
21MORBIDITY/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%
22RACE,SEX AND AGE Race Tergantung riwayat kontak TBC. Sex male-to-female ratio of 1.5-2:1).AgeDewasa, dewasa muda dan anak2.
23CLINICAL The presentation of Pott disease depends on the following: Stadium penyakitLokasi KelainanAdanya komplikasi seperti neurologic deficits, abscesses, or sinus tractsDilaporkan rata2 : Durasi simptom sampai diagnosis > 4 bulan.Sakit Pinggang yang lama, gejala awal yang paling umumBisa Spinal dan Radicular
24HYSTORY Demam dan Berat Badan Turun Neurologic abnormalities : 50% of casesKompresi spinal cord diikuti paraplegia, paresis, impaired sensation, nerve root pain, and/or cauda equina syndrome.Spondilitis TBC di cervical – Jarang tapi serius komplikasinya,Pain and stiffness.Patients with lower cervical spine disease can present with dysphagia or stridor.Symptoms can also include torticollis and hoarseness,neurologic deficits.
25PHYSICAL The examination : Pemeriksaan Tulang belakang. Inspeksi kulit adakah sinus?Abdominal evaluation for subcutaneous flank massPemeriksaan Neurologi motorik dan sensorik.
26PHYSICALPott diseases menyebabkan deformitas tulang belakang (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.Defisit Neurologi
27PHYSICAL 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.(62-90% of patients in reported series6, 7) have no evidence of extraspinal tuberculosisPenegakkan diagnosisi : imaging studies, microbiology, and anatomic pathology
29DIF.DIAGNOSISMultiple Myeloma Mycobacterium Avium-Intracellulare Mycobacterium Kansasii Nocardiosis Paracoccidioidomycosis Septic Arthritis Spinal Cord Abscess TuberculosisOther Problems to be ConsideredSpinal tumors
30Work UPLab StudiesTuberculin skin test (purified protein derivative [PPD]) results are positive in %LEDMicrobiology studiesCT-guided procedures
31ImagingRadiographyLytic destruction of anterior portion of vertebral bodyIncreased anterior wedgingCollapse of vertebral bodyReactive sclerosis on a progressive lytic processEnlarged psoas shadow with or without calcification
32RADIOGRAPHYAdditional 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.
33CT SCANNINGCT 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.
34MRIMRI is the criterion standard for evaluating disk- space infection and osteomyelitis of the spine and cold Abcess.MRI ==== Lihat neural compression.15, 16MRI findings useful to differentiate tuberculous spondylitis from pyogenic
36BONE SCANOther TestsRadionuclide 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
37PROCEDURESUse 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
38Histologic Findings Microbiologic Patologi Anatomi : Gold standart Gross pathologic : exudative granulation tissue with abscesses.caseating necrosis.
39Medical CarePott disease : Prolonged bed rest or a body cast. Pott disease carried a mortality rate of 20%, and relapse was common (30%)==before OATThoracolumbar spine should be treated with combination chemotherapy for 6-9 months.19Many experts still recommend chemotherapy for 9-12 months.
40MEDICAL CARE 4-drug regimen Isoniazid and Rifampin (9-12 bln) Tambahan first 2 months (first-line drugs), pyrazinamide, ethambutol, and streptomycin.The use of second-line drugs is indicated in cases of drug resistance (cyprofloksasin)
41MEDICAL CARE TREATMENT 1.Kemoterapi dan konservative 2.Kemoterapi dan Operasi
44INDIKASI OPERASINeurologic deficit (acute neurologic deterioration, paraparesis, paraplegia)Spinal deformity with instability or painNo response to medical therapy (continuing progression of kyphosis or instability)Large paraspinal abscessNondiagnostic percutaneous needle biopsy sample
45SURGICAL CAREAnterior radical focal debridement and posterior stabilization with instrumentation.24, 10Involves the cervical spine, the following factors justify early surgical intervention: High frequency and severity of neurologic deficitsSevere abscess compression that may induce dysphagia or asphyxiaInstability of the cervical spine
55ACTIVITYJAMAN DAHULUplaster 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.
57MEDICATIONA 3-drug regimen usually includes isoniazid, rifampin, and pyrazinamide.The use of second-line drugs is indicated in cases of drug resistance.Lama Pengobatan 9-12
58FOLLOW-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 CarePatients 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.
59FOLLOW UPBecause of the risk of deformity exacerbations, children with Pott disease should undergo long-term follow-up until their entire growth potential is completed.25
60COMPLICATION Abscess Spine deformities Neurologic deficits and paraplegia
61PROGNOSISTherapy compliance and drug resistance are additional factors that significantly affect individual outcomes.Paraplegia : 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.