CARIES SPINE AND SPINAL STENOSIS DR. NADIR MEHMOOD ASSOCIATE PROFESSOR SURGERY IIMC-T, RLY HOSP.
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Transcript of CARIES SPINE AND SPINAL STENOSIS DR. NADIR MEHMOOD ASSOCIATE PROFESSOR SURGERY IIMC-T, RLY HOSP.
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CARIES SPINE AND SPINAL STENOSIS
DR. NADIR MEHMOODASSOCIATE PROFESSOR SURGERY
IIMC-T, RLY HOSP
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CLINICAL ASPECTS OF TUBERCULOSIS
•Pathogenesis of tuberculosis–Infection versus disease•Host factors•Pathogen factors
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PATHOGENESIS• Host factors include– Social e.g.• Poverty• alcoholism
– Age e.g.• Newborn• Teenage girl• Old age
– Immunity e.g. • HIV• Gamma interferon
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PATHOGENESIS
• Organism factors e.g.–Virulence factors –[Drug resistance]
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PATHOGENESIS• Tuberculous disease is a consequence
of:–Primary infection e.g. In a baby
–Reactivation • ‘natural’ • Associated with immunosupression
–Re infection
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PULMONARY TB TYPICALLY AFFECTS THE UPPER ZONES OF THE LUNG
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CLINICAL FEATURES • Clinical illness–Pulmonary –Extrapulmonary
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CLINICAL ILLNESSTB may affect any tissue of the body including:– Skin and soft tissue– Lymph nodes– Bones and joints– Intra abdominal structures including• peritoneum • Kidneys• Adrenal glands• Lymph nodes
– Central nervous system• Tuberculoma• meningitis
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Clinical clues for TB• Clinical symptoms – usually ‘chronic’ rather than
acute– Fever– Sweats – Weight loss– Focal symptoms
• Epidemiology– History of TB, HIV– Country of origin, recent travel/work– Contact with TB
• Investigations- CP ESR,URINE R/E, CXR, X-RAYS, C/S, SKIN TESTS,ELISA, CRP, PCR, CT, MRI
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TB – guidelines for the clinician
• Great mimicker• Low index of suspicion• Pulmonary TB usually easy to
consider• Non pulmonary often requires
‘lateral thinking’
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What will happen if diagnosis or treatment for TB spinal osteomyelitis
is delayed?
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MENINGES OF THE SPINAL CORDMENINGES OF THE SPINAL CORD
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What will happen if treatment delayed? – gibbus formation (acute angulation of spine with or without neurological
damage)
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The physical appearance – Potts disease of spine - gibbus
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• Progress– Increasing back pain and neurological
symptoms – mild leg weakness
• Treatment–Continue therapy – consider surgical decompression
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• Further progress• Weakness of legs• Neurosurgery and internal splinting
• Other considerations - clinical• Has the patient got HIV? • Is vitamin D level normal?
• Other considerations - epidemiological
• From where has the pt got infection?• To whom might the pt have given it?
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• BTS guidelines – 1999 Thorax 2000: 55; 210-218
• NICE guidelines – 2006– Sensitive TB – 4 drugs for 2 months
2 drugs for 4 months– Resistant TB- 6 drugs for 24 months (second
line drugs are not so effective)
[Eng, Wales & NI 2004, 6.8% Isoniazid resistant, 1% MDR TB (R to Isoniazid and rifampicin)]
TREATMENT OF TB
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Problems of TB therapy
• Toxicity e.g. liver• Multiple therapy• Prolonged treatment• Drug interactions
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Compliance
–Treatment will not work if not taken
–DOTS (Directly Observed Therapy) if:• Likely poor compliance• MDRTB
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Public health - avoiding transmission
• TB is statutorily notifiable disease• Multidisciplinary approach – medical, TB
nurses, CCDC etc.• Identify and manage possible sources of infection and
contacts
• Considerations• treat as OP where possible • multi occupancy housing, social deprivation• negative pressure rooms in hospitals (limited facility)• beware transmission in OP setting e.g. waiting area
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WHY FAILURE?• Patient non compliance–Deliberate–Failure to understand e.g. language,
culture–Social e.g. alcohol
• Patient movement e.g. ‘lost to follow up’• Lack of medical/nursing support• others
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Summary• TB is a challenging disease for the
clinician• Must have microbiology before starting
treatment – more rapid lab tests?• Need to encourage compliance• Need for multidisciplinary approach to
diagnosis and management and control• Need shorter, better, cheap anti TB
regimes
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SAMPLE MSQs• The starting pathogenesis in TB is;• Secondary TB• Miliary TB• Ghon focus• CNS involvment• GIT involvment
• The advanced stage in Potts disease is• Paresis• Lost urinary control• Gibbus formation• Paraplegia• Death
• Poor compliance to treatment, TB of any site becomes• Resistant to treat• MDRTB• XDRTB• MILIARY TB• TB ABSCESS
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