TUBERCULOUS SPONDYLITIS

Supervisor: Dr. Wisman Dalimunthe, Sp.A (K)

Presenters: M.ARIPANDI WIRA 080100054 SHALINI SHANMUGALINGAM 080100402

INTRODUCTION

In 2011, nearly 9 million people around the world become sick with TB disease.

Annually, 250.000 new cases of tuberculosis in Indonesia and approximately 100.000 death because of tuberculosis

Children below the age of 15 years old contribute 15% of the total tuberculosis case

INTRODUCTION

Report on children in Indonesia are rarely obtained, but it is estimated number of TB cases in children is about 5% -6% of the total TB cases.Tuberculous spondylitis (TS) or spinal tuberculosis is usually secondary to pulmonary or intestinal tuberculosis and may also be the first manifestation of tuberculosis (TB).

According WHO, November 2004 it has been estimated that about 2,5% - 5% of spinal TB from the total TB cases occurs in children.The epidemiology of spinal TB in Indonesia has not been obtained but they are many cases of tuberculous spondylitis among children has been reported.

DEFINITION Infectious

disease of the spine which is typically caused by an extraspinal infection. typical site of involvement is the anterior aspect of the vertebral body adjacent to the subchondral plate and occurs most frequently in the lower thoracic vertebrae. possible effect of this disease is vertebral collapse and when this occurs anteriorly, anterior wedging results, leading to kyphotic deformity of the spine.

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EPIDEMIOLOGY

In developed countries musculoskeletal TB is often a disease in older adults.It is mainly a disease in children, with 50% of all cases reported in children less than 10 years of age, and young adults in developing countries with a high TB incidence. The spine is involved in approximately 50% of musculoskeletal TB. Thoracic spine involvement accounting for 25-50%. Lumbar and lumbosacral spine for 25-50% Cervical for 5-25%.

ETIOLOGY

M.

tuberculosis complex, subspecies M. tuberculosis.

RISK FACTORTrauma Low social economy status Age Previous infection of pulmonary tuberculous Immune deficiency

PATHOGENESISPrimary or reactivated focusextension of an abscess beneath the anterior longitudinal ligament and the periosteum haematogenous spread "anterior type" of vertebral body "paradiscal" lesions of vertebral body 3 types

"central type" of vertebral body

Spread infection along Batsons plexus of vein.

Spread of disease via the arteries

loss of the periosteal blood supply and destruction of the anterolateral surface of many contiguous vertebral bodies

DELAYED HYPERSENSITIVITY Caseous necrosis muscle, tendon, ligament and bone destroyed

CLINICAL MANIFESTATION

Gibbus Back pain

Weakness or paralysis of lower extremitiesDuring the late stages of the disease the two main complications remain: deformity and paraplegia

DIAGNOSIS

HISTORY

Average duration of symptoms at the time of diagnosis is 3-4 months and back pain is the earliest and most common symptom. Constitutional symptoms. Neurological symptoms weakness.

PHYSICAL EXAMINATION

Localised tenderness Paravetebral muscle spasm Kyphotic deformity Cervical spine TB is a less common pain and stiffness with dysphagia or stidor (LOWER CERVICAL SPINE).

INVESTIGATIONHematological ESR elevated, generalized lymphocytosis Skin test A positive Mantoux test can be observed, one to 3 months after infection. Microbiology test Ziehl-Neelsen staining IFN- release assay (IGRAs) can measure T-cell release of IFN in response to stimulation with highly specific tuberculosis antigen ESAT-6 and CFP-10.

IMAGING

PLAIN RADIOGRAPH

The classic roentgen triad in spinal tuberculosis is primary vertebral lesion, disc space narrowing and paravertebral spacing. More than 50% of bone has to be destroyed before a lesion can be seen on X-ray. Typical tuberculous spondylitis features in long standing paraspinal abscess :

concave erosion around the anterior margin of the vertebral bodies producing a scalloped appearance called the aneurysmal phenomenon. fusiform paraspinal soft tissue shadow with calcification.

CT-SCAN

Bone destruction is seen but nerve involvement is not clear. Abscess with calcification is diagnostic for spinal TB.

MRI

bone marrow oedema and enhancement. posterior element involvement canal stenosis spinal cord or nerve root compression. Inter-vertebral disc enhancement, vertebral collapse and kyphosis deformity are particularly suggestive of tuberculosis.

MANAGEMENT

Standard drug anti-tuberculous therapy:

usually administered with isoniazid, rifampicin, ethambutol and pyrazinamide.

Aggressive surgery approach.

Prevent deformity. Expect good outcome.

INDICATION OF SURGERY TYPE

PROGNOSIS Patients

with dorsolumbar lesions have the worst prognosis ;

as they tend to collapse more during the active phase of the disease and even more during the growth period.

Those

with lumbar lesions have the best prognosis;with the least deformity at presentation, a lesser increase during the active phase, and also a tendency for substantial decrease during the growth period.

CASE REPORTsince 3 months ago.

a hump on the back since one year ago

Major Complaint: BACK PAIN

and the pain has deteriorate since one week ago.

Decrease in limb coordination (+) since 2 months ago

Analgesic drugs are effective (+).

But patient was noncompliant because after 2 months.

medication anti tuberculosis ( RHZE2 months & RH 4 months)

Patient was never brought to Hospital for evaluation until on the 5th November

dry coughs one week later, the cough productive but phlegm of the cough was repeatedly swallow .

2 years ago, patient was diagnosed with pulmonary tuberculosis

history of expose with a person who had prolonged cough and coughing out blood.

chief complaint of coughing for almost 6 months.

History of Birth: spontaneous labor, first child, birth weight: 2900 gram, birth length: 48cm, immediate crying (+), cyanosis (-) Feeding History From birth to 6 months : Breast milk only From 6 months to 9 months : Milk Porridge + Breast milk From 9 months to 12 months : Baby rice + Breast Milk From 12 months to now : Family food + formula milk

History of Growth and Development: The patient could hold head steady when held sitting by the age of 2 months. The patient was able to sit without support by the age of 7 months. The patients is able to crawl by the age of 8 months. The patient is able to imitates speech sounds by the age of 9 months. The patient is able to stand by herself without guidance at the age of 11 months. The patients uses mama and dada specifically for parents at the age of 11 months. The patient could walk with guidance since age 12 months. The patient is able to walk without guidance at the age of 15 months. The patient was able to talk in a complete sentence at the age of 24 months. The patient is able to use toilet with guidance at the age of 36 months.

History of Immunization : None History of previous illness : Pulmonary Tuberculosis History of previous medications : Isoniazid, Rifampicin, Pyrazinamid, Ethambutol

Physical Examination : Generalized status Body weight: 12.0 kg, Body length: 89 cm Body weight in 50th percentile according to age: 16.0 kg Body length in 50th percentile according to age: 103 cm Body weight in 50th percentile according to body length: 16.0 kg BW/BL: 14.5/16.0 x 100% = 90.6 % (normo weight) BW/age: 14.5/16.0 x 100% = 90.6 % BL/ age : 89/103 x 100% = 86.4 %

Presence Status :

Sensorium : Compos Mentis, Blood Pressure : 100/70 mmHg Temperature : 36.3C, HeART Rate : 90 bpm, Respiratory Rate : 20 tpm, Dyspnea (-), Edema (-), Cyanosis (-), Icteric (-), Anemic (-)

Localized Status : Head : Eye

Ear Mouth NoseNeck

Light reflex (+/+), isochoric pupil, pale inferior conjunctiva palpebra (-/-). Nose : nasal flare (-), NGT (-), nasal canul (-). Ear and mouth: within normal limit.

Lymph node enlargement (-), jugular vein pressure: R2 cmH2O

Localized Status : Chest : Gibbus, kyphosis, chest retraction (-).RR: 20 tpm, regular, crackles (-/-), HR: 90 bpm, regular, murmur (-)., stridor (-) : Tender , peristaltic (+) N, Hepar and Lien wasn't palpable

Abdomen

Extremities :

Pulse: 90 bpm, regular, adequate pressure/volume, CRT