Transcript Tuberculosis Spondylitis (TB spine/Pott’s diseasis)

Tuberculosis Spondylitis
(TB spine/Pott’s diseasis)
By
Dr Phillipo Leo Chalya
1. Introduction
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Tuberculous spondylitis has been
documented in ancient mummies from
Egypt and Peru
It is one of the oldest demonstrated
diseases of humankind.
Percival Pott presented the classic
description of TB spine in 1779.
Introduction (cont.)
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Since the advent of antiTB drugs and
improved public health measures, TB
spine has become rare in industrialized
countries.
However it is still a common diseasis in
developing countries.
Introduction (cont.)
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TB spine causes serious morbidity,
including permanent neurologic deficits
and severe deformity.
Medical treatment or combined medical
and surgical strategies can control the
disease in most patients
2. Epidemiology
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TB spine is common in developing
countries> developed countries
Internationally approx. 1-2% of total TB
cases are attributable to Pott disease.
As with other forms of TB, the
frequency is related to socioeconomic
factors and historical exposure to the
infection.
Epidemiology (cont.)
Sex: Males are more often affected
(1.5-2:1).
 Age: In developed countries Pott dx
primarily occurs in adults.
 In countries with higher rates of
infection, it mainly occurs in children
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Epidemiology (cont.)
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Mortality/Morbidity : Pott disease is
the most dangerous form of
musculoskeletal TB.
It can cause bone destruction,
deformity, and paraplegia
It commonly involves the thoracic and
lumbosacral spine.
4. Pathophysiology
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Pott disease is usually secondary to an
extraspinal source of infection.
The basic lesion is a combination of
osteomyelitis and arthritis.
Typically, more than one vertebra is
involved.
Pathophysiology (cont.)
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The area usually affected is the anterior
aspect of the vertebral body adjacent to
the subchondral plate
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.
Pathophysiology (cont.)
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In children, because the disk is
vascularized, it can be a primary site.
Progressive bone destruction leads to
vertebral collapse and kyphosis.
The spinal canal can be narrowed by
abscesses, granulation tissue, or direct
dural invasion
Pathophysiology (cont.)
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This leads to spinal cord compression
and neurologic deficits.
Kyphotic deformity occurs as a
consequence of collapse in the anterior
spine.
Lesions in the thoracic spine have a
greater tendency for kyphosis than
those in the lumbar spine.
Pathophysiology (cont.)
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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.
5. Clinical presentation
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Presentation depends on the following:
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Stage of disease
Site
Presence of complications such as neurologic
deficits, abscesses, or sinus tracts.
 The reported average duration of symptoms
at the time of diagnosis is 3-4 months.
Clinical presentation (cont.)
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The average duration of symptoms at
the time of diagnosis is 3-4 months
Back pain is the earliest and most
common symptom.
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Patients have usually had back pain for
weeks prior to presentation.
Pain can be spinal or radicular.
Clinical presentation (cont.)
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Constitutional symptoms 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, or
cauda equina syndrome.
Clinical presentation (cont.)
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Cervical spine tuberculosis is a less
common presentation but is potentially
more serious because severe neurologic
complications are more likely.
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This condition is characterized by pain and
stiffness.
Patients with lower cervical spine disease
can present with dysphagia or stridor.
Symptoms can also include torticollis,
hoarseness, and neurologic deficits.
Clinical presentation (cont.)
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The clinical presentation of TB in HIV
patients is similar to that of HIV
negative patients; however, the
relative proportion of individuals who
are HIV positive seems to be higher.
Clinical presentation (cont.)
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Physical examination should include the
following:
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Careful assessment of spinal alignment
Inspection of skin, with attention to
detection of sinuses
Abdominal evaluation for subcutaneous
flank mass
Meticulous neurologic examination
Clinical presentation (cont.)
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The thoracic spine is frequently
reported as the most common site of
involvement followed by lumber spine
The remaining cases correspond to the
cervical spine.
Spine deformity (kyphosis) of some
degree occurs in almost every patient.
Clinical presentation (cont.)
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There may be large cold abscesses of
paraspinal tissues or psoas muscle that
protrude under the inguinal ligament.
They may erode into the perineum or
gluteal area.
Clinical presentation (cont.)
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Neurologic deficits may occur early in
the course of disease.
Signs depend on the level of spinal cord
or nerve root compression
Clinical presentation (cont.)
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Disease involving the upper cervical
spine can cause rapidly progressive
symptoms.
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Retropharyngeal abscesses occur in almost
all cases.
Neurologic manifestations occur early and
range from a single nerve palsy to
hemiparesis or quadriplegia
Clinical presentation (cont.)
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If there is no evidence of extraspinal
tuberculosis, diagnosis can be difficult.
Information from imaging studies,
microbiology, and anatomic pathology
should help establish the diagnosis
6.Workup
6:1 Lab studies
 Tuberculin skin test demonstrates a
positive finding in 84-95% of patients
who are non–HIV-positive.
 ESR may be markedly elevated (>100
mm/h).
Workup (cont.)
 Microbiology studies to confirm
diagnosis: Obtain bone tissue or
abscess samples to stain for acid-fast
bacilli (AFB), and isolate organisms for
culture and susceptibility.
 These study findings may be positive in
only about 50% of the cases.
Workup (cont.)
6:2 Imaging studies
 Plain radiography demonstrates the
following characteristic changes of
spinal tuberculosis:
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Lytic destruction of anterior portion of
vertebral body
Increased anterior wedging
Workup (cont.)
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Collapse of vertebral body
Reactive sclerosis on a progressive lytic
process
Enlarged psoas shadow with or without
calcification
Additional findings
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Vertebral end plates are osteoporotic.
Intervertebral disks may be shrunk or
destroyed.
Workup (cont.)
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Fusiform paravertebral shadows suggest
abscess formation.
Bone lesions may occur at more than one
level.
Workup (cont.)
Intervertebral disks may be shrunk or
destroyed.
 Vertebral bodies show variable
degrees of destruction
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Workup (cont.)
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CT scanning
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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
soft tissue assessment, particularly in
epidural and paraspinal areas.
Workup (cont.)
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It detects 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
Workup (cont.)
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MRI
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MRI is the criterion standard for evaluating
disk space infection and osteomyelitis of
the 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
Workup (cont.)
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MRI is most effective for demonstrating
neural compression.
In developed countries, MRI has nearly
replaced CT myelography.
Procedures:
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Some patients are diagnosed following an
open drainage procedure (eg, following
presentation with acute neurologic
deterioration).
Workup (cont.)
Histologic Findings:
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Since microbiologic studies may be
nondiagnostic, anatomic pathology can be
very significant.
Gross pathologic findings include exudative
granulation tissue with interspersed
abscesses.
Coalescence of abscesses results in areas of
caseating necrosis.
7. Treatment
7:1 Medical treatment
 Medical therapy requires combination
regimens with at least 3 antituberculous
drugs.
 A 3-drug regimen usually includes INH,
rifampin, and pyrazinamide.
 The duration of treatment ranges from
9-12 months
Treatment (cont.)
7:2 Surgical treatment
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Indications
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Neurologic deficit (acute neurologic
deterioration, paraparesis, paraplegia)
Spinal deformity with instability
No response to medical therapy
Treatment (cont.)
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Resources and experience are key
factors in the decision to use a surgical
approach
The most appropriate method of
reconstruction depends on the level of
vertebral spine involved and the extent
of bony destruction.
Treatment (cont.)
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The lesion site, extent of vertebral
destruction, and presence of cord
compression or spinal deformity
determine the specific operative
approach.
Treatment (cont.)
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In disease involving the cervical spine,
the following factors justify early
surgical intervention:
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High incidence and severity of neurologic
deficits
Severe abscess compression that may
induce dysphagia or asphyxia
Instability of the cervical spine
Treatment (cont.)
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Contraindications
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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 severe deformity.
Vertebral damage is considered significant
if more than 50% of the vertebral body is
collapsed or destroyed or if there is spinal
deformity of more than 5°.