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SPONDILITIS TUBERCULOSA (Potts desease )

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.

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SPONDILITIS TUBERCULOSA (Potts desease )

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

  2. WEBSITE PRIBADI • www.dokterbedahtulang.com

  3. 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.

  4. Gibbus (Spondilitis TBC)

  5. SPONDILITIS TBC

  6. Gibbus

  7. Spondilitis TBC (Potts Desease) • DgnadanyaObatAntituberculousdanperbaikanukurankesehatanmasyarakat----spinal tuberculosis dinegaramajusangatjarang. • Di negarasedangberkembang ----- masihbanyak. (bogor) • Spondilitis TBC ---- menyebakanmasalahseriuskarenaadanyagangguanmotorikdansensorik. • Pemberian OAT danoperasi ____ bisamengontrolpenyakitini.

  8. PATHOPHYIOLOGI • Asal Potts desease: secundairkarenaosteomyelitisdan Arthritis TB • BisaLebih 2 vertebrae . Melibatkanbagian anterior dari Corpus Vertebrae …..discus vertebralisRusak. Padaorangdewasa discus rusakakibatinfeksidari VB Pada anak2, Lesi primer bisadi Discus Inter vertebralis.

  9. Gambar Corpus Vertebrae

  10. 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.

  11. Kyphosis

  12. Gibbus

  13. Gibbus

  14. Gibbus

  15. Abcess TBC

  16. Abcess

  17. AbsesInginal

  18. X ray Foto AP Foto Lat

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

  20. 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

  21. 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%

  22. 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.

  23. CLINICAL • The presentation of Pott disease depends on the following:   • Stadium penyakit • LokasiKelainan • Adanyakomplikasiseperti neurologic deficits, abscesses, or sinus tracts • Dilaporkan rata2 : Durasisimptomsampai diagnosis > 4 bulan. • SakitPinggang yang lama, gejalaawal yang paling umum • Bisa Spinal danRadicular

  24. HYSTORY • DemamdanBeratBadanTurun • Neurologic abnormalities : 50% of cases • Kompresi spinal cord diikuti paraplegia, paresis, impaired sensation, nerve root pain, and/or caudaequina syndrome. • Spondilitis TBC di cervical – Jarangtapiseriuskomplikasinya, • Pain and stiffness. • Patients with lower cervical spine disease can present with dysphagia or stridor. • Symptoms can also include torticollis and hoarseness, • neurologic deficits.

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

  26. 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

  27. 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 • Penegakkandiagnosisi : imaging studies, microbiology, and anatomic pathology

  28. Diferensial Diagnosis • DIFFERENTIAL DIAGNOSISActinomycosisBlastomycosisBrucellosisCandidiasisCryptococcosisHistoplasmosisMetastatic Cancer, Unknown Primary SiteMiliary Tuberculosis

  29. DIF.DIAGNOSIS • Multiple MyelomaMycobacterium Avium-IntracellulareMycobacterium KansasiiNocardiosisParacoccidioidomycosisSeptic ArthritisSpinal Cord AbscessTuberculosis • Other Problems to be Considered • Spinal tumors

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

  31. 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

  32. 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.

  33. 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.

  34. 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

  35. MRI

  36. 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

  37. 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

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

  39. 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.

  40. 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)

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

  42. PEMBEDAHAN

  43. 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 • Nondiagnosticpercutaneous needle biopsy sample

  44. 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

  45. Consultations • Orthopedic surgeons • Neurosurgeons • Rehabilitation teams

  46. Debridemenstabilisasi

  47. Post Operasi

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