SPONDILITIS TUBERCULOSA (Potts desease) BY Dr.WAHYU EKO W.Sp.OT Orthopaedi dan Tulang Belakang RS.BINA HUSADA

WEBSITE PRIBADI www.dokterbedahtulang.com

POTTS DESEASE 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.

Gibbus (Spondilitis TBC)

SPONDILITIS TBC

Gibbus

Spondilitis 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.

PATHOPHYIOLOGI 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 VB Pada anak2, Lesi primer bisa di Discus Inter vertebralis.

Gambar Corpus Vertebrae

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.

Kyphosis

Gibbus

Gibbus

Gibbus

Abcess TBC

Abcess

Abses Inginal

X ray Foto AP Foto Lat

FREQUENCY United States Masih ada tahun 1980-1990….. Turun drastis Spondilitis TBC==== 40-50% .4 musculoskeletal tuberculosis

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 @ 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 Tergantung riwayat kontak TBC. Sex male-to-female ratio of 1.5-2:1). Age Dewasa, dewasa muda dan anak2.

CLINICAL 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

HYSTORY 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. 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.

PHYSICAL The examination : Pemeriksaan Tulang belakang. Inspeksi kulit adakah sinus? Abdominal evaluation for subcutaneous flank mass Pemeriksaan Neurologi motorik dan sensorik.

PHYSICAL Pott 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

PHYSICAL 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 tuberculosis Penegakkan diagnosisi : imaging studies, microbiology, and anatomic pathology

Diferensial Diagnosis DIFFERENTIAL DIAGNOSIS Actinomycosis Blastomycosis Brucellosis Candidiasis Cryptococcosis Histoplasmosis Metastatic Cancer, Unknown Primary Site Miliary Tuberculosis

DIF.DIAGNOSIS Multiple Myeloma Mycobacterium Avium-Intracellulare Mycobacterium Kansasii Nocardiosis Paracoccidioidomycosis Septic Arthritis Spinal Cord Abscess Tuberculosis Other Problems to be Considered Spinal tumors

Work UP Lab Studies Tuberculin skin test (purified protein derivative [PPD]) results are positive in 84- 95% LED Microbiology studies CT-guided procedures

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 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 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 MRI is the criterion standard for evaluating disk- space infection and osteomyelitis of the spine and cold Abcess. MRI ==== Lihat neural compression.15, 1 6 MRI findings useful to differentiate tuberculous spondylitis from pyogenic

MRI

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 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 Microbiologic Patologi Anatomi : Gold standart Gross pathologic : exudative granulation tissue with abscesses. caseating necrosis.

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 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)

MEDICAL CARE TREATMENT 1.Kemoterapi dan konservative 2.Kemoterapi dan Operasi

PEMBEDAHAN

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 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 Orthopedic surgeons Neurosurgeons Rehabilitation teams

Debridemen stabilisasi

Post Operasi

Pasien Spondilitis TBC

Activitas Normal

Gambar Post Operasi

Happy post Operasi

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.

BRACE POST OPERASI

MEDICATION A 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

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 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 Abscess Spine deformities Neurologic deficits and paraplegia

PROGNOSIS Therapy 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.

TERIMA KASIH