Case Pott's Disease
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Transcript of Case Pott's Disease
PREFACE
Assalamualaikum wr. wb
First I would like to say thank you to Allah S.W.T, for all blessing so through my
works, I could finish my paper in time. This paper would not have been possible without
encourage from my family, my group mate and my lecturer whom I most grateful.
I want to say thank you to our lecturer dr. Arsanto Triwidodo Sp.OT, FICS, K-Spine,
MHKes for his guidance to help me finish this case report. This paper is all about “Pott’s
Disease” that I arranged in order to complete my assignment for the department of surgery of
Koja Hospital.
I realize this paper is far from being perfect because of lack of my knowledge and
mistakes of my grammar. For that, I hope you could give some advices and critics to make it
better. I hope this paper is worth for all and can be useful for all of us.
Wassalamualaikum wr. wb
Jakarta, November 2013
Vallensia Nurdiana Febriyanti
1
CHAPTER 1
INTRODUCTION
Vertebral tuberculosis (Pott’s disease) is the most common form of skeletal
tuberculosis and is encountered most frequently in the first 3 decades of life, though it may
occur at any age between 1 to 80 years. 1 Many factors affect the clinical presentation of
Pott’s disease. These include; the clinical stage of the disease, the site of spine involved in the
disease process and the presence of absence of complications, like neurologic deficits,
paravertebral abscesses and sinuses. The classical presentation of Pott’s disease of the spine
is the spondylodiscitis, which is a combination of vertebral osteomyelitis, spondylitis and
discitis associated with destruction of two or more contiguous segments of the spine with or
without paraspinal mass. 2 Pott's disease is a rare form of extrapulmonary tuberculosis, and
presents with several clinical patterns. We conducted a retrospective study between 1991-
2006 to evaluate clinical presentation, radiologic and laboratory findings, and therapeutic
approaches to spinal tuberculosis. 3
2
CHAPTER II
CASE REPORT
PATIENTS IDENTITY
Name : Mr. Mustofa
Age : 32
Sex : Male
Address : Jln. Swasembada RBT XII No.8A RT 12/13
Occupation : Salesmen
Religion : Muslim
Father’s name : Mr. Santoso
Father’s occupation : Unemployed
Mother’s name : Mrs. Yusrina
Mother’s occupation : Housewife
Date of enter to hospital: 17.10.2013 (from 5th floor)
Date of examination: 20.10.2013
History taken have been done on 20.10.2013, 14.00 pm
Chief complaint
Low back pain since 1 years ago
Additional complaint:
Scars with pus
History of present illness
A man, 32 years old, came to General Koja Hospital with complaints of low back pain
since 1 year ago. Low back pain is felt as depressed and intermittent. The pain lost when
3
lying down , the pain felt when the patient walks. 8 months ago, pain radiating to the right
buttock and now since 1 month pain radiating to the left thigh when the patient walks, the left
thigh feel hot. Patients can walk normally, but he must walks like a pregnant person. He lost
of appetite, he admitted the weight loss from 80kg to 68 kg, but now his appetite is normal.
He denied any fever, long cough, night sweats, and fever. 8 months ago, there was a lump on
the left waist and on the lower left abdomen. The lump was bigger and bigger, swelling,
redness, there is pus, no blood, mobile, soft and tenderness. Urination and defecate no
complaints. Patient had treatment to an alternate, but no change. He went to the doctor in
July, the doctor said that patient have an infection. He had surgery 4 months ago to remove
the lump and now the scars still produce pus.
History of past illnes
Patient never had a problem like this before.
History of past treatment
Patient had surgery 4 months ago to remove the lump.
History of illnes
Never have the same illnes in his family. No hypertension, diabetes mellitus, asthma and
heart disease in his family.
Habits of history
Patient smokes. Never consume alcohol. Take the balanced diet (3x/every day + meet +
vegetable).
PHYSICAL EXAMINATION
Consciusness: Composmentis
Vital sign
- Blood preasure: 120/80 mmHg
- Heart rate: 80x/min
- Temperature: 36,4oC
- Respiration rate: 18x/min
4
Height: 68 cm Weight: 175 kg
Head : normalcephaly, black hair with normal distribution, difficult unpulg, no lesion
and bump
Eyes : normal shape, symmetric , pupile isokor, conjunctiva anemis(-/-), sclera icterik(-/-)
direct light reflex(+/+) undirectly light reflex(+/+)
Ears : normotia, no hyperemis, no secret(-/-), serumen(+/+), membran tympani intact with
light reflex at 5 oclock for right ear and 7 oclock for left ear, foreign bodies (-/-)
Nose : normal in shape, no deformity, septum deviation(-), concha hyperthrophy(-/-).
Hyperemi (-), discharge (-/-)
Mouth : lips not dry, trismus(-), tongue not dirty, teeth normal, good oral hygien, phrynx not
Anemic.
Neck: normal in shape, no palpable the enlargement of lymph node and thyroid
5
Chest:
- Lungs
Inspection : movement of brething left and right symmetric, retraction intercostal
space(-/-), lession(-)
Palpasion : vocal fremitus left and right symmetric, no compresive pain(-/-)
Percusion : sonor in both side of lung
Auscultation : sound of breathing right and left vesikuler, ronchi (-/-), wheezing(-/-)
- Heart
Inspection : no pulsation of ictus cordis appearance
Palpation : ictus cordis palpable on intercostal space V, 1cm media from left
midclavicle
Percusion : Right border: intercosta space V right parasterna line
Left border: intercosta space V, 1cm media from left midclavicula
Upper broder: intercosta space II from left parasternal line
Auscultation : sound of heart I-II reguler, gallop(-), murmur(-)
Stomach:
Inspection : flat, smilling umbilicus(-), operation scar(-), veins dilatation(-),
Palpation : supel, no compresive pain(-), defens muscular(-)
Liver: no palpable
Spleen: no palpable
Kidney: ballotement(-/-), CVA(-/-)
Percusion : tympani, shiffting dullness(-)
Auscultation : sound of intestine (+) 4x/min
6
Genital : No lession, no pain
Extrimity:
Upper extrimity
Right Left
Muscle Eutrophy Eutrophy
Tonnus Normotony Normothony
Mass No abnormality No abnormality
Joints No abnormality No abnormality
Movement Active Active
Edem No Edema No edema
Conclusion: There is no problem in upper extrimity
Lower extrimity
Right Left
Muscle Eutrophy Eutrophy
Tonnus Normotony Normothony
Mass No abnormality No abnormality
Joints No abnormality No abnormality
Movement Active Active
Edem No Edema No edema
Conclusion: There is no problem in upper extrimity
Local Examination (Lumbar Region)
Look
1. Shape and posture from behind:
- Deformity (-)
- Scoliosis (-)
- Gibbus (-)
2. The skin:
- Lump (-)
- Bruising (-)
7
- Wound (-)
- Ulceration (-)
- Pus (+)
- Scars (+)
- Colour reflects vascular status or Pigmentation:
the pallor of ischaemia (-)
the blueness of cyanosis (-)
the redness of inflammation (-)
the dusky purple of an old bruise (-)
- Shiny skin with no creases or oedema (-)
- Abnormal tufts of hair (-)
3. Seen from the side:
- Kyphosis (-)
- Lordosis (-)
Feel
1. The skin:
- It is warm
- Dry
- Sensation is normal
2. The soft tissues:
- No lump
3. Tenderness (-)
Move
Motoric
Right Left
L2 (Hip flexion)
L3 (Knee extension)
L4 (Dorso flexion)
L5 (Toe extension)
S1 (Plantar flexion)
power(5)
power(5)
power(5)
power(5)
power(5)
power(5)
power(5)
power(5)
power(5)
power(5)
Conclusion: There’s no motoric problem in this patient
8
Straight-leg raising test
The patient have no complains of tightness and pain in the buttock – around 20° until 80°
Neurological Examination
Sensory
Pain Light touch
Upper limbs
T12
L1
L2
L3
L4
L5
(2) symmetrical left and right
(2) symmetrical left and right
(2) symmetrical left and right
(2) symmetrical left and right
(2) symmetrical left and right
(2) symmetrical left and right
(2) symmetrical left and right
(2) symmetrical left and right
(2) symmetrical left and right
(2) symmetrical left and right
(2) symmetrical left and right
(2) symmetrical left and right
(2) symmetrical left and right
(2) symmetrical left and right
Conclusion: There’s no neurological problem in this patient, sensibility is normal
Motoric
Right Left
L2 (Hip flexion)
L3 (Knee extension)
L4 (Dorso flexion)
L5 (Toe extension)
S1 (Plantar flexion)
power(5)
power(5)
power(5)
power(5)
power(5)
power(5)
power(5)
power(5)
power(5)
power(5)
Conclusion: There’s no motoric problem in this patient
Physiological Reflex
- Biceps: +
- Triceps: +
- Patella: +
- Aschilles: +
Pathological Reflex
- Hoffman: -
- Trommer: -
- Oppenheim: -
9
- Babinski: -
- Chaddock: -
- Gordon: -
Bulbocavernosus reflex
- (+) normal
LABORATORY FINDING
On September 27th, 2013
Pemeriksaan Hasil Nilai Normal Satuan
Hemoglobin 11,2 13,5-17,5 g/Dl
Hematocrit 36 41-53 %
Lekocyte 8900 4100-10900 /uL
Thrombocytes 550.000 140000-440000 %
On October 5th, 2013
Pemeriksaan Hasil Nilai Normal Satuan
Hemoglobin 10.0 13,5-17,5 g/Dl
Hematocrit 31 41-53 %
Lekosit 11.200 4100-10900 /uL
Erythrocyte 3.92 4,5-5,5 juta/Ul
MCV 80 80-100 fl
MCH 26 26-34 pg
MCHC 32 31-36 g/dL
Differential Blood Count
Basophils 0 0-2 %
Eosinophils 1 0-5 %
Band 0 2~6 %
Neutrophils 73 47-80 %
Limphocytes 12 13-40 %
Monocytes 14 2~11 %
Thrombocytes 463.000 140000-440000 %
10
ESR 98 <10 /uL
RDW 16,8 11,6-14,6 mm/jam
Imunoserology
CRP 212.2 <5 mg/L
TB-EIA (IgG) Negative Negative
On October 17th, 2013
Pemeriksaan Hasil Nilai Normal Satuan
Hemoglobin 10,2 13,5-17,5 g/Dl
Hematocrit 32 41-53 %
Lekocyte 9800 4100-10900 /uL
Thrombocytes 758.000 140000-440000 %
On October 19th, 2013
Haematology
Pemeriksaan Hasil Nilai Normal Satuan
Hemoglobin 11,8 13,5-17,5 g/Dl
Hematocrit 27 41-53 %
Lekosit 8000 4100-10900 /uL
Erythrocyte 4,56 4,5-5,5 juta/Ul
MCV 80 80-100 Fl
MCH 26 26-34 Pg
MCHC 32 31-36 g/dL
Differential Blood Count
Basophils 1 0-2 %
Eosinophils 4 0-5 %
Band 0 2~6 %
Neutrophils 67 47-80 %
Limphocytes 21 13-40 %
Monocytes 7 2~11 %
Thrombocytes 702.000 140000-440000 %
11
ESR 101 <10 /uL
RDW 16,8 11,6-14,6 mm/jam
Bleeding time 01~06 Menit
APTT 39,2 31,0-47,0 Detik
PT 10,9 9,9-11,8 Detik
Glucose test 159 <180 mg/Dl
Liver function
SGOT 19 10~35 U/L
SGPT 23 9~43 U/L
Renal function
Creatinine 1.0 0,7-1,5 mg/Dl
Ureum 23 20-40 mg/Dl
IMAGING
Chest X-Ray, PA. on October 2nd, 2013
CTR <50 % Trachea: deviated to left
Lungs: normal shadowing and lucency
12
Pulmonary vessels: artery or vein looks
normal
Hila: looks normal
Heart: looks normal
Pleura: left pleural looks thickening
Bone: no lesions or fractures
Conclusion: suspect pleursy TB
Thoracolumbal AP & Lateral on October 2nd, 2013
Aligment : Follow the corners of the vertebral bodies from one level to the next, there is
a little scoliosis Cobb angle <10o
Bones : The the vertebral bodies should gradually increase in size from top to bottom.
Cartilage : Look normal.
Discus : Disc space gradually increase from superior to inferior.
13
Lumbosacral AP & Lateral on October 2nd, 2013
Aligment : Follow the corners of the vertebral bodies from one level to the next, lose of
lordosis on lumbar
Bones : Destruction of 2nd , 3nd and 5th lumbar. Pedicle of 2nd , 3nd and 5th lumbar are
not the same and not obvious
Cartilage : Cartilage of 2nd , 3nd and 5th lumbar looks thinning.
Discus : Disc space of 2nd and 3nd, 4th and 5th lumbar narrowing.
14
MRI Axial on October 10th, 2013
15
16
MRI Sagital on October 10th, 2013
17
Conclusion
- Scoliosis of thoracolumbar vertebrae
- Destruction of 3th lumbar and 1st sacral. Marrow abnormality of L3-S1.
18
- Abses paravertebral L3-L4
- Bulging of L4-5 disc
- Mild canal stenosis L4-L5
- Neural foramen of L3-L4 looks narrowing et causa destruction of L3
- Intrathecal looks normal
RESUME
A man, 32 years old, 20th october 2013 came to Koja General Hospital with
complaints of low back pain since 1 year ago. Low back pain is felt as depressed and
intermittent. The pain lost when lying down , the pain felt when the patient walks. 8 months
ago, pain radiating to the right buttock and now since 1 month pain radiating to the left thigh
when the patient walks, the left thigh feel hot. Patients can walk normally, but he must walks
like a pregnant person. He lost of appetite, he admitted the weight loss from 80kgs to 68 kgs.
8 months ago, there was a lump on the left waist and on the lower left abdomen. He had
surgery 4 months ago to remove the lump and now the scars still produce pus.
From phisycal examination, vital sign are stable, generalized examination is still
within normal limits. Sensory examination is normal. Motoric examination is normal.
Localized examination of the lumbar, there is scars with pus on the left waist and on the
lower left abdomen, no tenderness, no ulceration, no redness. There is no limitation of
movement.
Abnormal laboratory findings: decreased hemoglobin and hematocrit, increased
leukocyte, ESR, thrombocyte and CRP. From chest x ray, there is pleuritis tb. From thorco-
lumbar x-ray, there are destruction of 2nd , 3nd and 5th lumbar. From MRI, there are spondylitis
and paravertebral abscess.
WORKING DIAGNOSIS
Spondylitis L2-L3 and L5 et causa suspect tuberculosis on OAT
Base of diagnosis
1. From anamnesis
o low back pain since 1 year ago.
19
o He lost of appetite, he admitted the weight loss from 80kgs to 68 kgs
o 8 months ago, there was a lump on the left waist and on the lower left
abdomen
2. From physical examination
From local status
o Scars with pus on the left waist and on the lower left abdomen
3. From laboratory findings
o Increased leukocyte, ESR, thrombocyte and CRP
4. From x ray finding
o From chest x ray, suspect pleurisy TB. From thorco-lumbar x-ray, there are
destruction of 2nd , 3nd and 5th lumbar
5. From MRI
o there are spondylitis and paravertebral abscess.
DIFFERENTSIAL DIAGNOSIS
Metastatic bone disease
MANAGEMENT
Non operative: antituberculosis drugs: RHZE (Rifampicin, Isoniazid, Pyrazinamide,
Ethambutol)
Operative: Planning laminectomy
PROGNOSIS
Ad vitam : bonam
Ad sanationam: dubia ad bonam
Ad fungsionam: dubia ad bonam
20
ANATOMY
The lumbar spine consists of 5 moveable
vertebrae numbered L1-L5. The complex anatomy
of the lumbar spine is a remarkable combination of
these strong vertebrae, multiple bony elements
linked by joint capsules, and flexible
ligaments/tendons, large muscles, and highly
sensitive nerves. It also has a complicated
innervation and vascular supply.
The lumbar spine is designed to be
incredibly strong, protecting the highly sensitive
spinal cord and spinal nerve roots. At the same time, it is highly flexible, providing for
mobility in many different planes including flexion, extension, side bending, and rotation.
Bones
The lumbar vertebrae, numbered L1-L5, have a vertical height that is less than their
horizontal diameter. They are composed of the following 3 functional parts:
The vertebral body, designed to bear weight
The vertebral (neural) arch, designed to protect the neural elements
The bony processes (spinous and transverse), which function to increase the efficiency of
muscle action
The lumbar vertebral bodies are
distinguished from the thoracic bodies by
the absence of rib facets. The lumbar
vertebral bodies (vertebrae) are the
heaviest components, connected together
by the intervertebral discs. The size of the
vertebral body increases from L1 to L5,
indicative of the increasing loads that each
lower lumbar vertebra absorbs. Of note,
21
the L5 vertebra has the heaviest body, smallest spinous process, and thickest transverse
process.
The intervertebral discal surface of an adult vertebra contains a ring of cortical bone
peripherally termed the epiphysial ring. This ring acts as a growth zone in the young while
anchoring the attachment of the annular fibers in adults. A hyaline cartilage plate lies within
the confines of this epiphysial ring.
Each vertebral arch is composed of 2 pedicles, 2 laminae, and 7 different bony
processes (1 spinous, 4 articular, 2 transverse) (see the following image), joined together by
facet joints and ligaments.
The pedicle, strong and directed posteriorly, joins the arch to the posterolateral body.
It is anchored to the cephalad portion of the body and function as a protective cover for the
cauda equina contents. The concavities in the cephalad and caudal surfaces of the pedicle are
termed vertebral notches.
Beneath each lumbar vertebra, a pair of intervertebral (neural) foramina with the same
number designations can be found, such that the L1 neural foramina are located just below
the L1 vertebra. Each foramen is bounded superiorly and inferiorly by the pedicle, anteriorly
by the intervertebral disc and vertebral body, and posteriorly by facet joints. The same
numbered spinal nerve root, recurrent meningeal nerves, and radicular blood vessels pass
through each foramen. Five lumbar spinal nerve roots are found on each side.
The broad and strong laminae are the plates that extend posteromedially from the
pedicle. The oblong shaped spinous processes are directed posteriorly from the union of the
laminae.
The 2 superior (directed posteromedially) and inferior
(directed anterolaterally) articular processes, labeled SAP and
IAP, respectively, extend cranially and caudally from the point
where the pedicles and laminae join. The facet or zygapophyseal
joints are in a parasagittal plane. When viewed in an oblique
projection, the outline of the facets and the pars interarticularis
appear like the neck of a Scottie dog
Between the superior and inferior articular processes, 2 transverse processes are
projected laterally that are long, slender, and strong. They have an upper tubercle at the
22
junction with the superior articular process (mammillary process) and an inferior tubercle at
the base of the process (accessory process). These bony protuberances are sites of
attachments of deep back muscles.
The lumbar spine has an anterior, middle, and posterior column that is pertinent for
lumbar spine fractures.
Lumbar vertebral joints
The mobility of the vertebral column
is provided by the symphyseal joints between
the vertebral bodies, formed by a layer of
hyaline cartilage on each vertebral body and
an intervertebral disc between the layers.
The synovial joints between the
superior and inferior articular processes on
adjacent vertebrae are termed the facet joints
(also known as zygapophysial joints or Z-
joints ). They permit simple gliding
movements. The movement of the lumbar
spine is largely confined to flexion and
extension with a minor degree of rotation
(see the image below). The region between the superior articular process and the lamina is the
pars interarticularis. A spondylolysis occurs if ossification of the pars interarticularis fails to
occur.
Lumbar intervertebral discs
Discs form the main connection between vertebrae. They bear loading during axial
compression and allow movement between the vertebrae. Their size varies depending on the
adjacent vertebrae size and comprises approximately one quarter the length of the vertebral
column.
Each disc consists of the nucleus pulposus, a central but slightly posterior mucoid
substance embedded with reticular and collagenous fibers, surrounded by the annulus
fibrosus, a fibrocartilaginous lamina. The annulus fibrosus can be divided into the outermost,
23
middle, and innermost fibers. The anterior fibers are strengthened by the powerful anterior
longitudinal ligament (ALL). The posterior longitudinal ligament (PLL) affords only weak
midline reinforcement, especially at L4-5 and L5-S1, as it is a narrow structure attached to
the annulus. The anterior and middle fibers of the annulus are most numerous anteriorly and
laterally but deficient posteriorly, where most of the fibers are attached to the cartilage plate.
(See the following image.)
Lateral drawing of the 3 spinal columns of the thoracolumbar junction. The
anterior column (black dotted line) includes the anterior spinal ligament, the
anterior annulus fibrosus (AF), the intervertebral disc, and the anterior two
thirds of the vertebral bodies. The middle column (red dotted line) includes
the posterior aspect of the vertebral bodies, the posterior annulus fibrosus,
and the posterior longitudinal ligament (PLL). The posterior column (thick
blue dotted line) includes the entire spine posterior to the longitudinal
ligament (thick blue dotted line). ALL = anterior longitudinal ligament; ISL
= interspinous ligament; LF = ligamentum flavum; NP = nucleus pulposus;
SSL = supraspinous ligament
Lumbar vertebral ligaments
The ALL covers the ventral surfaces of lumbar vertebral bodies and discs. It is
intimately attached to the anterior annular disc fibers and widens as it descends the vertebral
column. The ALL maintains the stability of the joints and limits extension.
The PLL is located within the vertebral
canal over the posterior surface of the vertebral
bodies and discs. It functions to limit flexion of
the vertebral column, except at the lower L-
spine, where it is narrow and weak.
24
The supraspinous ligament joins the tips of the spinous processes of adjacent
vertebrae from L1-L3. The interspinous ligament interconnects the spinous processes, from
root to apex of adjacent processes. Sometimes
described together as the interspinous/supraspinous
ligament complex, they weakly resist spinal
separation and flexion.
The ligamentum flavum (LF) bridges the
interlaminar interval, attaching to the interspinous
ligament medially and the facet capsule laterally,
forming the posterior wall of the vertebral canal. It
has a broad attachment to the undersurface of the
superior lamina and inserts onto the leading edge of
the inferior lamina. Normally, the ligament is taut, stretching for flexion and contracting its
elastin fibers in neutral or extension. It maintains constant disc tension.
The intertransverse ligament joins the transverse processes of adjacent vertebrae and
resists lateral bending of the trunk.
The iliolumbar ligament arises from the tip of the L5 transverse process and connects
to the posterior part of the inner lip of the iliac crest. It helps the lateral lumbosacral ligament
and the ligaments mentioned above stabilize the lumbosacral joint (see the following images).
Lumbar spine musculature
Four functional groups of
muscles govern the lumbar spine
and can be divided into extensors,
flexors, lateral flexors, and
rotators. Synergistic muscle
action from both the left and right
side muscle groups exist during
flexion and extension of the L-
spine.
25
Lumbar spine vasculature
Arterial
Lumbar vertebrae are contacted anterolaterally by paired lumbar arteries that arise
from the aorta, opposite the bodies of L1-L4. Each pair passes anterolaterally around the side
of the vertebral body to a position immediately lateral to the intervertebral canal and leads to
various branches. The periosteal and equatorial branches supply the vertebral bodies. Spinal
branches of the lumbar arteries enter the intervertebral foramen at each level. They divide
into smaller anterior and posterior branches, which pass to the vertebral body and the
combination of vertebral arch, meninges, and spinal cord, respectively.
These arteries give rise to ascending and descending branches that anastomose with
the spinal branches of adjacent levels. Nutrient arteries from the anterior vertebral canal
travel anteriorly and supply most of the red marrow of the central vertebral body. The larger
branches of the spinal branches continue as radicular or segmental medullary arteries,
distributed to the nerve roots and to the spinal cord, respectively.
Up to age 8 years, intervertebral discs have a good blood supply. Thereafter, their
nutrition is dependent on diffusion of tissue fluids through 2 routes: (1) the bidirectional flow
from the vertebral body to the disc and vice versa and (2) the diffusion through the annulus
from blood vessels on its surface. As adults, the discs are generally avascular structures,
except at their periphery.
Venous
The venous drainage parallels the arterial supply. Venous plexuses are formed by
veins along the vertebral column both inside and outside the vertebral canal (internal/epidural
and external vertebral venous plexuses). Both plexuses are sparse laterally but dense
anteriorly and posteriorly. The large basivertebral veins form within the vertebral bodies,
emerge from the foramen on the posterior surfaces of the vertebral bodies, and drain into the
internal vertebral venous plexuses, which may form large longitudinal sinuses. The
intervertebral veins anastomose with veins from the cord and venous plexuses as they
accompany the spinal nerves through the foramen to drain into the lumbar segmental veins.4
Spinal cord
26
Other than the brain, the spinal cord is one of the 2 anatomic components of the central
nervous system (CNS). It is the major reflex center and conduction pathway between the
brain and the body. The spinal cord is located inside the vertebral canal, which is formed by
the foramina of 7 cervical, 12 thoracic, 5 lumbar, and 5 sacral vertebrae, which together form
the spine. The spinal cord extends from the foramen magnum down to the level of the first
and second lumbar vertebrae (at birth, down to second and third lumbar vertebrae).
The spinal cord is composed of the following 31 segments:
8 cervical (C) segments
12 thoracic (T) segments
5 lumbar (L) segments
5 sacral (S) segments
1 coccygeal (Co) segment - mainly vestigial
The conus medullaris is the cone-shaped
termination of the caudal cord. The pia mater continues
caudally as the filum terminale through the dural sac and
attaches to the coccyx. The coccyx has only 1 spinal
segment. The cauda equina (Latin for horse tail) is the
collection of lumbar and sacral spinal nerve roots that travel caudally prior to exiting at their
respective intervertebral foramina. The cord ends at vertebral levels L1-L2.
Ventral (motor) roots
The cell body is in the anterior horn within the cord parenchyma. Clinically relevant
reflex center levels are as follows (spinal reflex center levels are presented in parentheses and
take into account anatomic variations in innervation):
Biceps - C5/6
Brachioradialis - C5/6
Triceps - C7 (C6-8)
Finger flexors - C8 (C7-T1)
Knee - L3 (L2-L4)
Ankle - S1 (L5-S2)
27
Dorsal (sensory) roots
The cell bodies of the sensory nerves are located in the dorsal root ganglia. Each
dorsal root contains the input from all the structures within the distribution of its
corresponding body segment. Dermatomal maps portray sensory distributions for each level.
These maps differ somewhat according to the methods used in their construction.
Clinically important dermatomes are as follows:
C2 and C3 - Posterior head and neck
C4 and T2 - Adjacent to each other in the upper thorax
T4 or T5 - Nipple
T10 - Umbilicus
Upper extremity - C5 (anterior shoulder), C6 (thumb), C7 (index and middle fingers), C 7/8
(ring finger), C8 (little finger), T1 (inner forearm), T2 (upper inner arm), T2/3 (axilla)
Lower extremity - L1 (anterior upper-inner thigh), L2 (anterior upper thigh), L3 (knee), L4
(medial malleolus), L5 (dorsum of foot), L5 (toes 1-3), S1 (toes 4, 5; lateral malleolus)
S3/C1 - Anus
As noted earlier, the spinal cord normally terminates
as the conus medullaris within the lumbar spinal canal at the
lower margin of the L2 vertebra, although variability of the
most caudal extension exist
All lumbar spinal nerve roots originate at the T10 to
L1 vertebral level, where the spinal cord ends as the conus
medullaris. In the lumbar vertebral canal, the posterior and
anterior roots of a given nerve (enclosed in their dural sacs)
cross the intervertebral disc that is located above the pedicle
below which the nerve exits. For example, the L2 nerve roots
cross the disc between L1 and L2 vertebrae before reaching
the appropriate foramen, below the pedicle of the L2
vertebra.5
DEFINITION
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Pott’s disease is a presentation of Extrapulmonary Tuberculosis (EPTB) which is
called so when tuberculosis bacillus is seen in any organ other than lung, can cause
significant morbidity and often poses diagnostic challenges to clinicians. Pott’s disease can
result from direct spread through lymphatic drainage from another focus of infection,
intracanalicular spread, or direct invasion during bacteremic stage of the disease 2
EPIDEMIOLOGY
The French physician, Laennec (1781–1826), discovered the basic microscopic lesion,
the “tubercle” in the beginning of the nineteenth century. The world at large has nearly 30
million people suffering from tuberculosis. After 1985, many affluent countries are recording
an increase in the number of patients by 10–30% annually. According to the current estimates
of the WHO, tuberculosis now kills 3 million people a year worldwide. However, it is
estimated that India alone has got one-fifth of the total world population of tuberculous
patients. Thus, there are nearly 6 million radiologically proven cases of tuberculosis in India.
Of all the patients suffering from tuberculosis, nearly 1–2% have involvement of the skeletal
system. Vertebral tuberculosis is the most common form of skeletal tuberculosis, and
constitutes about 50% of all cases of skeletal tuberculosis in the reported series. 6
PATHOPHYSIOLOGY
Tuberculous osteomyelitis and arthritis are generally believed to arise from foci of
bacilli lodged in the bone during the original mycobacteremia of primary infection. The
primary focus may be active or quiescent, apparent or latent, either in the lungs or in the
lymph glands of the mediastinum, mesentry or cervical region, or kidney or other viscera.
Alternatively, tuberculous bacilli may travel from the lung to the spine by Batson's
paravertebral venous plexus or by lymphatic drainage to the para-aortic lymph nodes. In most
otherwise healthy individuals, the cellular immune response is able to contain the bacilli
present in these sites, but not eradicate them. 6
The central type of vertebral body involvement, “skipped lesion” in the vertebral
column and vertebral disease associated with tubercular meningitis, are due to spread of
29
infection along the Batsons perivertebral plexus of veins. Simultaneous involvement of the
paradiscal part of two contagious vertebrae in an atypical tuberculous lesion of the spine
lends support to insemination of the bacilli through a common blood supply to this region.
Simultaneous involvement of the distant part of the spine or the skeletal system and
associated visceral lesion suggest spread of infection through the arterial blood supply. Seven
percent of the cases of spinal tuberculosis had skipped lesion in the vertebral column and
12% had involvement of other bones and joints (excluding spine), and 20% of the cases on
routine investigations had an evidence of tubercular involvement of viscera and/or glands
and/or other parts of the skeletal system. Spinal tuberculosis typically involves the initial
destruction of the anteroinferior part of the vertebrae. Bacilli may then spread beneath the
anterior spinal ligament and involve the anterosuperior aspect of the adjacent inferior
vertebra, giving rise to the typical “wedge-shaped” deformity. Further spread may result in
adjacent abscesses. Anterior type of involvement of the vertebral bodies seems to be due to
the extension of an abscess beneath the anterior longitudinal ligaments and the periosteum.
The infection may spread up and down, stripping the anterior and posterior longitudinal
ligaments and the periosteum from the front and the sides of the vertebral bodies. The
radiographic features of tuberculous osteomyelitis and arthritis are discussed further later.6
PATHOLOGY
Blood-borne infection usually settles in a vertebral body adjacent to the intervertebral
disc. Bone destruction and caseation follow, with infection spreading to the disc space and
the adjacent vertebrae. A paravertebral abscess may form, and then track along muscle planes
to involve the sacro-iliac or hip joint, or along the psoas muscle to the thigh. As the vertebral
bodies collapse into each other, a sharp angulation (gibbus or kyphos) develops. There is a
major risk of cord damage due to pressure by the abscess, granulation tissue, sequestra or
displaced bone, or (occasionally) ischaemia from spinal artery thrombosis. With healing, the
vertebrae recalcify and bony fusion may occur between them. Nevertheless, if there has been
much angulation, the spine is usually ‘unsound’, and flares are common, resulting in further
illness and further vertebral collapse. With progressive kyphosis there is again a risk of cord
compression7
CLINICAL FEATURES
30
There is usually a long history of ill-health and backache; in late cases a gibbus
deformity is the dominant feature. Concurrent pulmonary TB is a feature in most children
under 10 years with thoracic spine involvement. Occasionally the patient may present with a
cold abscess pointing in the groin, or with paraesthesiae and weakness of the legs. There is
local tenderness in the back and spinal movements are restricted. In cervical spine disease
dyspnoea and dysphagia are features of advanced infection, especially in children; these
patients present with a stiff painful neck. Children under 10 years of age with thoracic spine
TB usually develop a pectus carinatum (‘pigeon chest’) deformity. Neurological examination
may show motor and/or sensory changes in the lower limbs. As spinal tuberculosis is found
mostly in the thoracic spine, spastic paraparesis is a common presentation in adult. 7
Nonspecific presentation of chronic back pain which is the earliest and most common
symptom. Constitutional symptoms such as weight loss, loss of appetite, and evening rise of
temperature may occur. 1 In a review series of 1,997 patients with Pott’s disease, back pain
was found to be most commonly reported symptom and the disease affects mainly the
thoracic spine.2 The classical presentation of Pott’s disease of the spine is the
spondylodiscitis, which is a combination of vertebral osteomyelitis, spondylitis and discitis
associated with destruction of two or more contiguous segments of the spine with or without
paraspinal mass 2
Even in areas where tuberculosis is no longer as common as it was in the past, it is
important to be alert to the possibility of this diagnosis. The task is made harder when the
patient presents with atypical features:
• Lack of deformity, e.g. a patient with a primary epidural abscess
• Involvement of only the posterior vertebral elements
• Infection confined to a single vertebral body
• Involvement of multiple vertebral bodies and posterior elements (especially in HIV-positive
patients) resulting in a kyphoscoliosis.7
COMPLICATIONS
Delay in diagnosis can be catastrophic in vertebral tuberculosis. Compression of the
spinal cord can lead to severe neurological sequelae including paraplegia. 1 Kyphotic
deformity, spinal instability, neurological deficit, paravertebral abscesses and sinuses are the
common complications associated with Pott’s disease. Signs of neurologic deficits depend on
the level of spinal cord or nerve root involved. Depending on the degree of spinal cord
31
involvement and spinal root compression, those deficits were range from single nerve palsy
to hemiparesis, paraplegia or quadriplegia.2
Pott’s disease most often affects the lower thoracic and lumbar spine while disease of
the upper thoracic and cervical spine is more disabling. Neurological complications are more
frequent when the upper and midthoracic spine is involved, as the spinal canal is narrowest
between T3–T10. Cervical spine tuberculosis is characterized by pain and neck stiffness and
patients may present with dysphagia or stridor. 1
Pott’s Paraplegia is the most feared complication of spinal tuberculosis. Early-onset
paresis (usually within 2 years of disease onset) is due to pressure by inflammatory oedema,
an abscess, caseous material, granulation tissue or sequestra. The patient presents with lower
limb weakness, upper motor neuron signs, sensory dysfunction and incontinence. CT and
MRI may reveal cord compression. In these cases the prognosis for neurological recovery
following surgery is good. Lateonset paresis is due to direct cord compression from
increasing deformity, or (occasionally) vascular insufficiency of the cord; recovery following
decompression is poor 7
IMAGING
The entire spine should be x-rayed, because vertebrae distant from the obvious site
may also be affected without any obvious deformity. The earliest signs of infection are local
osteoporosis of two adjacent vertebrae and narrowing of the intervertebral disc space, with
fuzziness of the end-plates. Progressive disease is associated with signs of bone destruction
and collapse of adjacent vertebral bodies into each other. Paraspinal soft-tissue shadows may
be due either to oedema, swelling or a paravertebral abscess. The radiological picture may
mimic those of other infections including fungal infections and parasitic infestations. A chest
x-ray is essential. With healing, bone density increases, the ragged appearance disappears and
paravertebral abscesses may undergo resolution or fibrosis or calcification.7
Computerised tomography (CT) scanning provides much better bony detail of
irregular lytic lesions, sclerosis, disk collapse, and disruption of bone circumference.
Lowcontrast resolution provides a better assessment of soft tissue, particularly in epidural and
paraspinal areas. 1 Magnetic resonance imaging of the spine is the standard method of
evaluation of disc space infection and is most useful in demonstrating extension into the soft
tissues 1 CT Scans and MRI are invaluable in the investigation of hidden lesions, involvement
32
of posterior vertebral elements, paravertebral abscesses, an epidural abscess and cord
compression7
DIFFERENTIAL DIAGNOSIS
Spinal tuberculosis must be distinguished from other causes of vertebral pathology,
particularly pyogenic and fungal infections, malignant disease and parasitic infestations such
as hydatid disease. Disc space collapse is typical of infection; disc preservation is typical of
metastatic disease. Metastases may cause vertebral body collapse similar to that seen in TB
but, in contrast to tuberculous spondylitis, the disc space is usually preserved. 7
THERAPY
The objectives are to: (1) eradicate or at least arrest the disease; (2) prevent or correct
deformity; (3) prevent or treat the major complication – paraplegia 7 Antituberculous
chemotherapy (rifampicin 600 mg daily plus isoniazid 300 mg daily plus pyrazinamide 2 g
daily) is as effective as any other method (including surgical debridement) in stemming the
disease. These drugs must be given in combination for 6 months, dropping the pyrazinamide
after the first 2 months. The dosages listed are for adults of average weight. Because so much
of current tuberculosis is a complication of acquired immune deficiency syndrome (AIDS),
resistant mycobacteria are an increasing problem. Ethionamide and streptomycin may have to
be substituted for isoniazid. However, conservative treatment alone carries the risk of
progressive kyphosis if the infection is not quickly eradicated. Anterior resection of diseased
tissue and anterior spinal fusion with a strut graft offers the double advantage of early and
complete eradication of the infection and prevention of spinal deformity. After weighing up
the pros and cons, the following approach is advocated:
• Ambulant chemotherapy alone – is suitable for early or limited disease with no abscess
formation or neurological deficit. Treatment is continued for 6–12 months, or until the x-ray
shows resolution of the bone changes. Therapeutic compliance is sometimes a problem.
• Continuous bed rest and chemotherapy – may be used for more advanced disease when the
necessary skills and facilities for radical anterior spinal surgery are not available, or where
the technical problems are too daunting (e.g. in lumbosacral tuberculosis) – provided there is
no abscess that needs to be drained.
• Operative treatment – is indicated: (1) when there is an abscess that can readily be drained;
(2) for advanced disease with marked bone destruction and threatened or actual severe
kyphosis; (3) neurological deficit including paraparesis that has not responded to drug
33
therapy. Through an anterior approach, all infected and necrotic material is evacuated or
excised and the gap is filled with iliac crest or rib grafts that act as a strut. If several levels are
involved, anterior or posterior fixation and fusion may be needed for additional stability.
Children who are growing and are seen to be at risk of developing severe kyphosis may need
fusion of the posterior elements to minimize the expected deformity. 7
Total Treatment by Prof.Soebroto Sapardan (1989 )
1) A therapy unit with a view of all the good aspects of the patient, the surgical and non
surgical
2) Underlying the birth of this treatment is a matter of total social and economic
problems.
3) Principle : Providing solutions to problems found in accordance with the modalities
that are available8
The Aim of Total Treatment
Healing of Spondilitis in a stable and painless spine without unacceptable deformity
with return of function, return to the society, family and occupation
Steps The Total Treatment
1) Identification and clarification of existing problems
2) Make a list of modalities from conservative to aggressive operative
3) Fit the individual patient: Customize list of issues with appropriate treatment
4) Give 10 or 10 alternative treatment options8
Problems
• Infection
• Poor general condition
• Multiple lesions
• Cold abscess
• Painful
• Pathological Fractures
• Instability
• Neurological Deficit
• Deformity
• Kifosis progressive
• Pulmonary Dysfunction
• Cardiac diasability
• Sosioekomi
• Psychogenic
Therapeutic Modalities
- Basic therapy - Abscess Drainage
34
- Kostotransversektomi
- Debridement Torakoskopik
- Anterior Debridement and
strutgrafting (Hongkong Method)
- Anterior Instrumentation
- Posterior Instrumentation
- Transpedikular debridement and
biopsy
- Debridement Translateral or
posterior lumbar interbody fusion
- and Shortening procedures for
correction kyphus
- Rehabilitation
- Circumferential decompression
- Fusion Cages8
Anti Tuberculosis Drugs (OAT)
Isoniazid, Rifampin, Pyrazinamide & Ethambutol
If a positive skin test without symptoms and signs of infection are given isoniazid for
6 to 9 months.
Active TB are given 3 or 4 drug combinations RHZE for 6 to 9 months can be
extended to 1 and a half years with rigorous evaluation of anatomy and function of the
spine8
Alternative I
o Early Case
o Patients who refused all surgery
Basic treatment
Alternative II
o Patients with a large abscess but with minimal destruction
o Good general condition
Basic Therapy
Debridement anterior
evacuation of abscess with graft
Alternative IIIo Tuberculosis in the thoracolumbar spine single or two levels affected by the minimum
kifosis
Basic Therapy
Hongkong method
body cast post
operatif
35
Alternative IV
o Patients with problems of infection, pain, posterior instability, deformity, with or
without neurological deficit
Basic Therapy & instrumentasi posterior & Hongkong method
Approach anterior, debridement toraskokopik with or without fusion.
Alternative V
o Patients like the alternative IV with rigid kyphosis spontaneous fusion of the facet
joints as long deformity
Posterior shortening
Instrumentation anterior
Hongkong Method
Alternative VI
o Patients like the alternative IV, for patients who refuse posterior and anterior approach
or with poor tolerance or a combination approach
Basic therapy and decompression laminectomy
Posterior approach with costotransversectomy for debridement
Evacuation of paravertebral abscess continue posterio instrumentation and fusion
Alternative VII
o For patients with an abscess in the lumbar paravertebral warm.
o Significant abscess should be continued with alternative IV.
Basic Therapy with laminektomi
Limited shortening procedures & debridement & fusion translateral or approach
posterior lumbar interbody with instrumentation posterior segmenta
Posterior only, limited shortening lumbar spine + TLIF / PLIF / None
Alternative VIII
o Khifosis 60-89o
Approach posterior
Kostotransversektomi- Shortening
Dekompresi sirkumferensial
Alternative IX
o For correction of severe kifosis
o Neurological deficit
Only Posterior
36
Decompresion Sirkumferensial
Minimal corection
Alternative X
o Indications of more than 90o kifosis
Circumferential decompression of the anterior longitudinal ligament, the entire thing
into the pedicle screw, the correction with reduction screw or sublaminal wiring 8
DISCUSSION
In this case there is a man, 32 years old has complaints of low back pain since
1 year ago and scars with pus since 4 months ago. Low back pain is felt as depressed
and intermittent. The pain lost when lying down , the pain felt when the patient
walks. 8 months ago, pain radiating to the right buttock and now since 1 month pain
radiating to the left thigh when the patient walks, the left thigh feel hot. Patients can
walk normally, but he must walks like a pregnant person. He lost of appetite, he
admitted the weight loss from 80kg to 68 kg, but now his appetite is normal. 8 months
ago, there was a lump on the left waist and on the lower left abdomen. The lump was
bigger and bigger, swelling, redness, there is pus, no blood, mobile, soft and
tenderness.He had surgery 4 months ago to remove the lump and now the scars still
produce pus. From history of present illness, there are sign and symptom of pott’s
disease; low back pain, lost of appetite, weight loss and abscess. Nonspecific
presentation of chronic back pain which is the earliest and most common symptom.
Constitutional symptoms such as weight loss, loss of appetite. Paravertebral abscesses
is one complication of Pott’s disease.
Localized examination of the lumbar, there are scars with pus on the left waist
and on the lower left abdomen, paravertebral abscesses is one complication of Pott’s
disease. From laboratory findings, there are increased leukocyte, ESR, and CRP.
Leukocyte means white blood cells who fight infection, if leukocyte count is high
there is cronic infection. Erythrocyte sedimentation rate detects inflammation that
may be caused by infection. High levels of CRP is caused by infection. High
leukocytes, ESR and CRP in Pott’s disease.
Conclusion from chest x-ray is suspect pleurisy TB, it can confirm the
diagnosis of Pott’s disease. From thorco-lumbar x-ray, there are destruction of 2nd , 3nd
and 5th lumbar, spinal tuberculosis causes the destruction of vertebrae. From MRI
37
there are destruction of 3th lumbar and 1st sacral, marrow abnormality of L3-S1,
abscess paravertebral L3-L4, bulging of L4-5 disc, mild canal stenosis L4-L5, neural
foramen of L3-L4 looks narrowing et causa destruction of L3. For the diagnosis of
spinal tuberculosis magnetic resonance imaging is more sensitive imaging frequently
demonstrate technique than x-ray and more specific than computed tomography. And
MRI results from patien very specific for Pott’s disease.
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