I. PATIENT IDENTITY Name Age Sex Religion Occupation Address Date of admission Race : Mrs.

S : 67th : Female : Moslem : House wife : Jl. Manggar IX no 47, Rt 06/ Rw 06 : 12th june 2011 : moeslim

II. HISTORY TAKING This data was according to the information that has given by patient ( Auto- Anamnesis) on 28th june, 2011 at 15.15 WIB Cheif complaint : Pain in the lower back / waist area about 1 year before admission

Secondary complain : Difficulty in walking History of present illness Approximately one year before admission had a fall in a sitting position. Ever since the fall, patient been feeling pain on her back. The pain has been there always but never spread to other parts of the body. Perceived pain throbbed and felt like a stab. According to the patient initially the pain didnt bother her much. But since 3 months before admission, the pain has become more intense and progressively increases during the move. Patient said its harder now for her to walk. If the patient is lying down on the bed, she does not feel any pain. Until few days from admission, patient cant restrain pain. Patient did not complaim of any shortness of breath, nausea, fever and vomitting. Patient denied having urinating problem. Patient admits defecation isnt smooth going. Patient also denied having sweats at nights while sleeping. Patient came to clinic and advised to be examined by an orthopeadist.

History of past illness Patient admits to having a history of falling down in sitting position one year ago. She didnt faint during the fall. History of high blood pressure, diabetes and asthma is denied. History of family illness History of hypertension, allergy and uric acid are denied. Patient is the only one in the one suffering the illness and no else has the similar disease.

III. PHYSICAL EXAMINATION The physical examination was held o 28th june 2011, 16.00 WIB

Primary survey Airway Breathing Circulation Disability : Clear, Cynosis (-), Stridor (- ) : Spontaneous breathing, equal movement of hemithorax, ICS retraction (-) : pulse rate equal, blood pressure , temperature : ROM limited

Secondary Survey GENERAL STATUS General Condition Consciousness : moderately ill : Compos Mentis

Blood Pressure: 120/80 mmHg Respiratory rate Pulse Temperatur Head Eye Nose Mouth : 18x/ minute : 80x/ minute : 36. 5 C : Normocephali, Normal hair distribution, hair not easily revoked : isochor pupils, anemic conjuctiva -/-, icteric sclera -/: simetris, septum deviation (-), secret (-), concha oedem (-) : caries , stomatitis (-)

Throat Neck Thorax Lung Inspection Palpation Percussion Auscultation Heart Inspection Palpation Percussion

: tonsil T1-T1 calm, hyperemis pharing (-) : thyroid gland normal size, lymph nodes not palable

: symetrical shape, symetrical chest movement, costae retraction (-) : vocal fremitus symetrical : symetrical chest walls, sonor at bilateral hemithorax : vesicular breath sound, Ronchi -/-, Wheezing -/-

: ictus cordis not visible : ictus cordis palpable at ICS V linea mid clavicula : ICS III top boundary linea parasternalis sinistra ICS V left boundary lines midclavicularis sinistra ICS IV right boundary linea sternal dextra

Auscultation Abdomen Inspection Palpation Percussion Auscultation Extemity

: I dan II heart sounds reguler, murmur (-), gallop (-)

: abdomen flat, no tension, no dilated veins : no percussion pain, no defense muscular, no enlarged liver : timpanic, percussion pain (-), shifting dullness (-) : bowel movement (+), normal : warm , oedem (-), cynosis (-)

LOCAL STATUS Lower spine region LOOK \ FEEL : There is no swelling or nodule, there are no hematom, there are no fistulae,there is no discolouration : the temperature of the skin is the same with the surrounding area, there is No creapitation, no nodule, swelling or bulging on palpation. The patient felt a mild pain when pressure was applied around pelvic- sacrum region. MOVEMENT : ROM limited

Neurological status a. GCS Eye : 4, verbal : 5, Movement : 6, total : 15 b. Meningeal stimulus Neck stiff (-), Laseq Tes (-), Kerniq Tes (-), brudzinski I (-), Bruzinski II (-) c. Motoric tes 1. Muscle strength 5555|5555 5555|5555 2. Spontaneous movement Twitching (-) Tremor (-) d. Sensibility Tes : there is no difference in pain stimulus e. Physiological Reflex : Biceps Reflex ++ / ++ Triceps Reflex ++ / ++ Patella Reflex ++ / ++ Achilles Reflex ++ / ++ Patological Reflex: babinsky Reflex -/-

VI. LABORATORY AND IMAGING EXAMINATION Laboratory data : 12th june 2011 Hematology Hb Ht Leukocyte Eritrocyte LED SGOT / ASAT SGPT / ALAT Gamma GT Immuno serology TB ELA Rontgen 14th june 2011 COLUMNA LUMBOSACRAL :
1. Lower surface of corpus vertebrae lumbal 4 and upper surface of corpus verterbrae

: 7.1 g/dl : 39% : 7.200/ ul : 4.29 juta/ UI : 99 fL : 23 U/I : 29 U/I : 59 U/I (+)

Liver Function Test

Alkali Phosphate : 264 U/I

lumbal 5 are not sharply visible. 2. There is destruction of corpus vertebrae L 4 & L5 and there is constriction in between intervertebralis space L4 & L5 3. Spur formation on vertebrae L1 L3 Findings : 1. Osteoathritis lumbalis 2. Spondilytis vertebrae L4 & L5 17th june 2011 VERTEBRAE THORACAL 1. Alignment of vertebrae thoracal is Normal 2. Spur formation on vertebrae T X & T XI 3. Inter vertebralis space Normal, no signs of bone destruction on corpus vertebrae thoracal.

Findings : 1. Osteoarthritis of Thoracal 2. no signs of spondylitis CT SCAN (24th june 2011) VERTEBRAE LUMBOSACRAL Working diagnosis Differential diagnosis : Spondylitis TB L5 : Secundary metastasis

1. Alignment of lumboscaral Normal 2. Visible destruction of lower surface of corpus vertebrae L2 & upper surface of corpus vertebrae L3 3. There is a shadow paravertebral abcess on left side f the vertebrae L3 & L4 4. There is also vaccum phenomenon & degeneration of lumbal intervertebralis disc 3 & 4. Findings : 1. Spondylitis TB vertebrae L 2-3 & L 4-5 2. Vaccum phenomenon intervertebralis disc L 3 & 4 USG ( 24th june 2011) ABDOMEN Findings : Liver Vesica fellea Pancreas Lien Ren : NORMAL : NORMAL, no stones or inflamation : NORMAL : NORMAL : - there is shadow of stone, size= 3mm at the mid minor calyx region ren dextra - ren sinistra NORMAL Vesica urinaria : NORMAL No signs of acites No signs of enlargement of para aortic lymph node 2. intra abdominal organs are NORMAL

Findings : 1. Nephrolithiasis dextra

VII. RESUME Patient is 67 years old female. 1 year before admission, patient felt pain on her lower back. The pain is localized around her lower back around pelvic region. The pain is perisitent and did not spread. Since 6 months before admission the pain had become more intense and makes walking or sitting more difficult. Patient admits having a history of falling in a sitting position 1 year before admisson to the hospital and the pain as started since then. BP : 120/80 mmHgRR : 18x/ minute LOCAL STATUS Lower spine region LOOK \ FEEL : There is no swelling or nodule, there are no hematom, there are no fistulae,there is no discolouration : the temperature of the skin is the same with the surrounding area, there is No creapitation, no nodule, swelling or bulging on palpation. The patient felt a mild pain when pressure was applied around pelvic- sacrum region. MOVEMENT : ROM limited T : 36.6 C Pulse : 78x/minute

VIII. WORKING DIAGNOSIS Spondylitis TB of Lumbal II-III & Lumbal IV-V with paravertebral abcess sinistra of L III-IV. IX. DIFFRENTIAL DIAGNOSIS Spondylitis piogenik

X. TREATMENT 1. Conservative theraphy - bed rest - high carbohidrat and high protein diet - OAT Rifampisin Etambutol Pirazinamid INH XI. PLANNING Pro debridement + decompression + stabilization XII. PROGNOSIS Ad Vitam Ad Fungsionam Ad Sanationam : dubia ad bonam : dubia ad bonam : dubia ad bonam 300 mg 1000 mg 1500 mg 450 mg

SPONDYLITIS TUBERCULOSIS

Introduction Tuberculous spondylitis also known as Potts disease, is one of the oldest demonstrated diseases of humankind, having been documented in spinal remains from the Iron Age and in ancient mummies from Egypt and Peru. In 1779, Percivall Pott, for whom Pott disease is named, presented the classic description of spinal tuberculosis. Since the advent of antituberculous drugs and improved public health measures, spinal tuberculosis has become rare in developed countries, although it is still a significant cause of disease in developing countries. Tuberculous involvement of the spine has the potential to cause serious morbidity, including permanent neurologic deficits and severe deformities. Medical treatment or combined medical and surgical strategies can control the disease in most patients. Pathophysiology Pott disease is usually secondary to an extraspinal source of infection. The basic lesion involved in Pott disease is a combination of osteomyelitis and arthritis that usually involves more than one vertebra. The anterior aspect of the vertebral body adjacent to the subchondral plate is area usually affected.Tuberculosis may spread from that area to adjacent intervertebral disks. In adults, disk disease is secondary to the spread of infection from the vertebral body. In children, because the disk is vascularized, it can be a primary site.[3] Progressive bone destruction leads to vertebral collapse and kyphosis. The spinal canal can be narrowed by abscesses, granulation tissue, or direct dural invasion, leading to spinal cord compression and neurologic deficits. The kyphotic deformity is caused by collapse in the anterior spine. Lesions in the thoracic spine are more likely to lead to kyphosis than those in the lumbar spine. A cold abscess can occur if the infection extends to adjacent ligaments and soft tissues. Abscesses in the lumbar region may descend down the sheath of the psoas to the femoral trigone region and eventually erode into the skin.

Epidemiology Frequency United States Although the incidence of tuberculosis increased in the late 1980s to early 1990s, the total number of cases has decreased in recent years. The frequency of extrapulmonary tuberculosis has remained stable. Bone and soft-tissue tuberculosis accounts for approximately 10% of extra pulmonary tuberculosis cases and between 1% and 2% of total cases. Tuberculous spondylitis is the most common manifestation of musculoskeletal tuberculosis, accounting for approximately 40-50% of cases. International Approximately 1-2% of total tuberculosis cases are attributable to Pott disease. In the Netherlands between 1993 and 2001, tuberculosis of the bone and joints accounted for 3.5% of all tuberculosis cases (0.2-1.1% in patients of European origin and 2.3-6.3% in patients of non-European origin). Mortality/Morbidity Pott disease is the most dangerous form of musculoskeletal tuberculosis because it can cause bone destruction, deformity, and paraplegia.
Pott disease most commonly involves the thoracic and lumbosacral spine. However,

published series have show some variation. Lower thoracic vertebrae is the most common area of involvement (40-50%), followed closely by the lumbar spine (3545%). In other series, proportions are similar but favor lumbar spine involvement. Approximately 10% of Pott disease cases involve the cervical spine. Race Data from Los Angeles and New York show that musculoskeletal tuberculosis primarily affects African Americans, Hispanic Americans, Asian Americans, and foreign-born individuals. As with other forms of tuberculosis, the frequency of Pott Disease is related to socioeconomic factors and historical exposure to the infection.

Sex Although some series have found that Pott disease does not have a sexual predilection, the disease is more common in males (male-to-female ratio of 1.5-2:1). Age In the United States and other developed countries, Pott disease occurs primarily in adults. In countries with higher rates of Pott disease, involvement in young adults and older children predominates. History

The presentation of Pott disease depends on the following:

o o o

Stage of disease Affected site Presence of complications such as neurologic deficits, abscesses, or sinus tracts

The reported average duration of symptoms at diagnosis is 4 months but can be considerably longer, even in most recent series. This is due to the nonspecific presentation of chronic back pain.

Back pain is the earliest and most common symptom. o Patients with Pott disease usually experience back pain for weeks before seeking treatment. o The pain caused by Pott disease can be spinal or radicular.

Potential constitutional symptoms of Pott disease include fever and weight loss. Neurologic abnormalities occur in 50% of cases and can include spinal cord compression with paraplegia, paresis, impaired sensation, nerve root pain, and/or cauda equina syndrome.

Cervical spine tuberculosis is a less common presentation but is potentially more serious because severe neurologic complications are more likely.

This condition is characterized by pain and stiffness. Patients with lower cervical spine disease can present with dysphagiaor stridor. Symptoms can also include torticollis, hoarseness, and neurologic deficits.

The clinical presentation of spinal tuberculosis in patients infected with the human immunodeficiency virus (HIV) is similar to that of patients who are HIV negative; however, spinal tuberculosis seems to be more common in persons infected with HIV.

Physical

The examination should include the following:

Careful assessment of spinal alignment Inspection of skin, with attention to detection of sinuses Abdominal evaluation for subcutaneous flank mass Meticulous neurologic examination

Although both the thoracic and lumbar spinal segments are nearly equally affected in persons with Pott disease, the thoracic spine is frequently reported as the most common site of involvement. Together, they comprise 80-90% of spinal tuberculosis sites. The remaining cases correspond to the cervical spine.

Almost all patients with 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 series ) have no evidence of extraspinal tuberculosis, further complicating a timely diagnosis.

Information from imaging studies, microbiology, and anatomic pathology should help establish the diagnosis.

Differential Diagnosis

Actinomycosis Blastomycosis Brucellosis Candidiasis Cryptococcosis Histoplasmosis Metastatic Cancer, Unknown Primary Site Miliary Tuberculosis Multiple Myeloma Mycobacterium Avium-Intracellulare Mycobacterium Kansasii Nocardiosis Paracoccidioidomycosis Septic Arthritis Spinal Cord Abscess Tuberculosis

Laboratory Studies

Tuberculin skin test (purified protein derivative [PPD]) results are positive in 84-95% of patients with Pott disease who are not infected with HIV. The erythrocyte sedimentation rate (ESR) may be markedly elevated (>100 mm/h). Microbiology studies are used to confirm diagnosis. Bone tissue or abscess samples are obtained to stain for acid-fast bacilli (AFB), and organisms are isolated for culture and susceptibility. CT-guided procedures can be used to guide percutaneous sampling of affected bone or soft-tissue structures. These study findings are positive in only about 50% of the cases.

Imaging Studies

Radiography Radiographic changes associated with Pott disease present relatively late. The following are 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

radiographic changes characteristic of spinal tuberculosis on plain radiography:

Additional radiographic findings may include the following: Vertebral end plates are osteoporotic. Intervertebral disks may be shrunk or 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 Low-contrast resolution provides a better assessment of soft tissue, particularly in epidural

collapse, and disruption of bone circumference.

and paraspinal areas.

CT scanning reveals early lesions and is more effective for defining the shape and 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

calcification of soft-tissue abscesses.

spine and is most effective for demonstrating the extension of disease into soft tissues and the spread of tuberculous debris under the anterior and posterior longitudinal ligaments. MRI is also the most effective imaging study for demonstrating neural compression.

MRI findings useful to differentiate tuberculous spondylitis from pyogenic spondylitis

include thin and smooth enhancement of the abscess wall and well-defined paraspinal abnormal signal, whereas thick and irregular enhancement of abscess wall and ill-defined paraspinal abnormal signal suggest pyogenic spondylitis. Thus, contrast-enhanced MRI appears to be important in the differentiation of these two types of spondylitis.

The images below are studies of a 31-year-old man with tuberculosis of the spine.

MRI of a 31-year-old man with tuberculosis of the spine. Images show the thoracic spine

before and after an infusion of intravenous gadolinium contrast. The abscess and subsequent destruction of the T11-T12 disc interspace is marked with arrowheads. Vertebral body alignment is normal. Courtesy of Mark C. Diamond, MD, and J. Antonio Bouffard, MD, Detroit, Mich.

MRI of the T11 in a 31-year-old man with tuberculosis of the spine. Extensive bone

destruction consistent with tuberculous osteomyelitis is evident. The spinal cord has normal caliber and signal. No evidence of spinal cord compression or significant spinal stenosis is distinguishable. Courtesy of Mark C. Diamond, MD, and J. Antonio Bouffard, MD, Detroit, Mich. 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).

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 Because microbiologic studies may be nondiagnostic of Pott disease, anatomic pathology can be significant. Gross pathologic findings include exudative granulation tissue with interspersed abscesses. Coalescence of abscesses results in areas of caseating necrosis. Medical Care

Before the advent of effective antituberculosis chemotherapy, Pott disease was treated with immobilization using prolonged bed rest or a body cast. At the time, Pott disease carried a mortality rate of 20%, and relapse was common (30%).

The duration of treatment, surgical indications, and inpatient care have since evolved. Studies performed by the British Medical Research Council indicate that tuberculous spondylitis of the thoracolumbar spine should be treated with combination chemotherapy for 6-9 months.

According to the most recent recommendations issued in 2003 by the US Centers for Disease Control and Prevention, the Infectious Diseases Society of America, and the American Thoracic Society, a 4-drug regimen should be used empirically to treat Pott disease.

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.

Regarding the duration of therapy, the British Medical Research Council studies did not include patients with multiple vertebral involvement, cervical lesions, or major neurologic involvement. Because of these limitations, many experts still recommend chemotherapy for 9-12 months.

Opinions differ regarding whether the treatment of choice should be conservative chemotherapy or a combination of chemotherapy and surgery. The treatment decision should be individualized for each patient. Routine surgery does not to seem to be indicated. Most common indications for surgical procedures are discussed below.

Surgical Care

Indications for surgical treatment of Pott disease generally include the following: 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

Resources and experience are key factors in the decision to use a surgical approach.

The lesion site, extent of vertebral destruction, and presence of cord compression or spinal deformity determine the specific operative approach (kyphosis, paraplegia, tuberculous abscess).

Vertebral damage is considered significant if more than 50% of the vertebral body is collapsed or destroyed or a spinal deformity of more than 5 exists. The most conventional approaches include anterior radical focal debridement and posterior stabilization with instrumentation.

In Pott disease that 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

Contraindications: Vertebral collapse of a lesser magnitude is not considered an indication for surgery because, with appropriate treatment and therapy compliance, it is less likely to progress to a severe deformity.

Physiotheraphy

Despite questionable efficacy, prolonged recumbence and the use of frames, 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.

Theraphy

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 6to 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. Antituberculous drugs These agents inhibit growth and proliferation of causative organism. Isoniazid (Laniazid, Nydrazid) Highly active against Mycobacterium tuberculosis. Has good GI absorption and penetrates well into all body fluids and cavities. Rifampin (Rifadin, Rimactane) For use in combination with at least one other antituberculous drug; inhibits DNA-dependent bacterial but not mammalian RNA polymerase. Cross-resistance may occur. Pyrazinamide Bactericidal against M tuberculosis in an acid environment (macrophages). Has good absorption from the GI tract and penetrates well into most tissues, including CSF. Ethambutol (Myambutol) Has bacteriostatic activity against M tuberculosis. Has good GI absorption. CSF concentrations remain low, even in the presence of meningeal inflammation. Streptomycin Bactericidal in an alkaline environment. Because it is not absorbed from the GI tract, must be administered parenterally. Exerts action mainly on extracellular tubercle bacilli. Only about 10% of the drug penetrates cells that harbor organisms. Enters the CSF only in the presence of meningeal inflammation. Excretion is almost entirely renal. 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.

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]

Complications

Abscess Spine deformities Neurologic deficits and paraplegia

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

Patients with Pott disease should be instructed on the importance of therapy compliance.

CASE PRESENTATION

SPONDILITIS TUBERKULOSIS

CONSULTANT

dr.Arsanto Widodo, SpOT, FICS K-Spine, Mhkes BY :

SENTILAWATHI A/P ANNAMALAI 11.2010.008

KEPANITERAAN RADIOLOGI UNIVERSITAS KRISTEN KRIDA WACANA

RUMAH SAKIT UMUM DAERAH KOJA 2011