CASE REPORT TB Spine-2.doc

8/10/2019 CASE REPORT TB Spine-2.doc

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CASE REPORT

PATIENT IDENTITY

Name : Mrs. R

Age : 43 years old

Sex : male

Occupation : Unemployeed

Date of admission : April !t"#$4

Registration : %&$'!

ANAMNESIS

Chief complain:(ump at t"e )ac*

Suffered since ' mont" ago.+nitially as )ig as a mar)le and gradually increase in

si,e. -"e consistency of t"e lum) is solid and "ard. atient also complained of

pain in "is )ac* since more t"an a year ago. Accompanied )y s"arp pain/ not

radiating/ continuous/ increase 0"en t"e patient 0al* and relie1ed if t"e patient

rest.

2istory of prolonged coug" 5/ "istory of dyspneu 5/ "istory of loose 0eig"t

5/ "istory of "ig" fe1er 65/ "istory of s0eat on nig"t5/ "istory of trauma 65/

"istory of -7 treatment 65 / "istory of family 0it" same disease 65/ "istory of

contact 0it" patient 0it" -7 5 Urination and defecation are normal.

PHYSICAL EXAMINATION

a. 8eneral Statue: oor nouris"ed9 onscious

). ;ital Sign

7lood ressure : $# 9


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+nspection : S*in colors same 0it" 1icinity/ Deformity 5 / S0elling 65/

2ematoma 65/ 8i))us 5

alpation : -enderness 65/ step off 65

LAORATORY RESULT

2


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(a)oratorium 2asil

=7 !.3. $#39Ul

287 $.4 g9Dl

R7 4/''. $#%9u(

2- 3.% >

(- 34 $#39u(

8O- & u9l

8- $


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c# MRI *ho$acol%m&al

4


5/21

5


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SUMMARY

Mr. R/ 43 years old/ c"ief complain (ump at t"e )ac* since ' mont"

ago.+nitially as )ig as a mar)le and gradually increase in si,e. -"e consistency of

t"e lum) is solid and "ard. atient also complained of pain in "is )ac* since more

t"an a year ago. Accompanied )y s"arp pain/ not radiating/ continuous/ increase

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0"en t"e patient 0al* and relie1ed if t"e patient rest.-"ere are 2istory of

prolonged coug"/ "istory of loose 0eig"t/ 2istory of nig"t s0eat and "istory of

contact 0it" -7 patient.

On p"ysical exam t"ere are deformity and gi))us.

(a)oratory findings: ?SR ele1ated

Radiological imaging: Destruction of in1erte)ra disc ; -$#6($ due to

Spondylitis -7.

DIA!NOSIS

Spondylitis -u)erculosis

DISCUSSION

A# INTRODUCTION

ANA-OM@ O S+N?

A )asic understanding of t"e spineBs anatomy and its functions is

extremely important for patients 0it" spinal disorders. -"e 1erte)ral

column in an adult typically consists of 33 1erte)rae arranged in fi1e

regions: ' cer1ical/ $ t"oracic/ & lum)ar/ & sacral/ and 4 coccygeal.$5/5

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igure $. anatomy of 1erte)ra and t"eir ner1e

-"e ner1e root exit spinal column 1ia inter1erte)ral foramen $6'

exit from a)o1e t"eir 1erte)ra/


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igure . ;asculari,ation of 1erte)rae

-"e spinal cord 1asculature "as a complex and "ig"ly 1aria)le

anatomy. +t consist of intercostales artery/ radicular arteries/ spinal arteries

0"ic" originated from t"oracoa)dominal aortae and 7atsonBs plexus. -"e

left arterial intercostales form an artery of Adam*ie0ic,/ t"e greatestanterior radicular artery/ it supplies inferior t"oracal segmental/ superior

luma)ales/ and lum)osacrales enlargement of cord. ="en damaged or

o)structed/ it can result inanterior spinal artery syndrome/0it" loss

ofurinaryandfecal continenceand impaired motor function of t"e legs

sensory function is often preser1ed to a degree. -"e 7atson 1enous

plexus 7atson 1eins5 is a net0or* of 1al1eless1einsin t"e "uman )ody

t"at connect t"e deeppel1ic1eins and t"oracic 1eins draining t"e inferior

9

Batsons

plexus
http://en.wikipedia.org/wiki/Anterior_spinal_artery_syndromehttp://en.wikipedia.org/wiki/Urinary_incontinencehttp://en.wikipedia.org/wiki/Urinary_incontinencehttp://en.wikipedia.org/wiki/Fecal_incontinencehttp://en.wikipedia.org/wiki/Veinhttp://en.wikipedia.org/wiki/Pelvichttp://en.wikipedia.org/wiki/Anterior_spinal_artery_syndromehttp://en.wikipedia.org/wiki/Urinary_incontinencehttp://en.wikipedia.org/wiki/Fecal_incontinencehttp://en.wikipedia.org/wiki/Veinhttp://en.wikipedia.org/wiki/Pelvic


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end of t"eurinary )ladder/ )reast andprostate5 to t"e internal 1erte)ral

1enous plexuses. 7ecause of t"eir location and lac* of 1al1es/ t"ey are

)elie1ed to pro1ide a route for t"e spread infection and some metastases. $5/

35

# SPONDYLITIS O" TUERCULOSIS

DE"INITION

Spondylitis tu)erculosis also *no0n as ott disease is one of t"e

oldest demonstrated diseases of "uman*ind/ "a1ing )een documented in

spinal remains from t"e +ron Age and in ancient mummies from ?gypt and

t"e acific coast of Sout" America.45

EPIDEMIOLO!Y

Data from (os Angeles and Ne0 @or* s"o0 t"at musculos*eletal

tu)erculosis affects primarily African Americans/ 2ispanic Americans/

Asian Americans/ and foreign6)orn indi1iduals. Approximately $6> of

total tu)erculosis cases are attri)uta)le to ott disease. +n t"e Net"erlands/

x)et0een $!!3 and ##$/ tu)erculosis of t"e )one and Eoints accounted for

3.&> of all tu)erculosis cases #.6$.$> in patients of ?uropean origin/

and .36%.3> in patients of non6?uropean origin5. As 0it" ot"er forms of

tu)erculosis/ t"e freCuency of ott Disease is related to socioeconomic

factors and "istorical exposure to t"e infection. +n t"e United States and

ot"er de1eloped countries/ ott disease occurs primarily in adults. +n

countries 0it" "ig"er rates of ott disease/ in1ol1ement in young adults

and older c"ildren predominates.45

ETIOLO!Y

Myco)acterium tu)erculosis is t"e pat"ogen responsi)le for spinal

tu)erculosis. +t is usually a secondary infection/ 0it" t"e primary

extraspinal lesion usually occurring in t"e c"est or genitourinary system.

-"ese primary sites may )e Cuiescent.$5

PATHOLO!Y

10
http://en.wikipedia.org/wiki/Urinary_bladderhttp://en.wikipedia.org/wiki/Prostatehttp://en.wikipedia.org/wiki/Internal_vertebral_venous_plexuseshttp://en.wikipedia.org/wiki/Internal_vertebral_venous_plexuseshttp://en.wikipedia.org/wiki/Urinary_bladderhttp://en.wikipedia.org/wiki/Prostatehttp://en.wikipedia.org/wiki/Internal_vertebral_venous_plexuseshttp://en.wikipedia.org/wiki/Internal_vertebral_venous_plexuses


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Myco)acterium tu)erculosisis spread )y small air)orne droplets/

called droplet nuclei/ generated )y t"e coug"ing/ snee,ing/ tal*ing/ or

singing of a person 0it" pulmonary or laryngeal tu)erculosis..

igure 3. atomec"anism Sc"ematic of -u)erculosis

Once in"aled/ t"e infectious droplets settle t"roug"out t"e air0ays.

+ntroduction of M tu)erculosisinto t"e lungs leads to infection of t"e

respiratory system. (esions in persons 0it" an adeCuate immune system

generally undergo fi)rosis and calcification/ successfully controlling t"e

infection so t"at t"e )acilli are contained in t"e dormant/ "ealed lesions.

or less immunocompetent persons/ granuloma formation is initiated yetultimately is unsuccessful in containing t"e )acilli "o0e1er/ t"e organisms

can spread to ot"er organs/ suc" as t"e lymp"atics/ pleura/ )ones9Eoints/ or

meninges/ and cause extrapulmonary tu)erculosis.

8enerally/ -7 spine is a secondary infection. -"e primary disease

may )e in t"e lung 8"onFs focus5/ t"e alimentary tract/ t"e tonsil/ or t"e

genitournay tract. 7one and Eoint in1ol1ement de1elop in approximately

$#> of patients 0it" -7 and "alf of t"em "a1e -7 of t"e spine. 2alf of

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-7 spine occurs in t"e t"orax/ up to 4#> in t"e lum)er and anot"er $#> in

t"e cer1ical region/ t"oug" t"e figures may 1ary. =atts G (ifeso $!!%

Moon/ $!!'5. Neurological deficit may de1elop in up to "alf of t"e

patients. Moon $!!'5.

-"e disease )egins in t"e anteroinferior portion of t"e 1erte)ral

)ody and tends to spread )eneat" t"e anterior longitudinal ligament to

in1ol1e adEacent 1erte)ral )odies. Narro0ing of t"e disc space occurs as a

late p"enomenon 0"en destruction of t"e cancellous )one on t"e )ot"

sides of a disc allo0s t"e disc to "erniate into t"e affected 1erte)ral )ody

or )odies infarct and osteonecrosis may lead to a decrease in 1erte)ral

"eig"t and may )e accompanied )y para1erte)ral and possi)ly epidural

formation of an a)scess. +n adults/ dis* disease is secondary to t"e spread

of infection from t"e 1erte)ral )ody. +n c"ildren/ t"e dis*/ )ecause it is

1asculari,ed/ can )e t"e primary site. rogressi1e )one destruction leads to

1erte)ral collapse and *yp"osis.

-"e spinal canal can )e narro0ed )y a)scesses/ granulation tissue/

or direct dural in1asion/ leading to spinal cord compression and neurologic

deficits.-"e *yp"otic deformity is caused )y collapse in t"e anterior spine.

(esions in t"e t"oracic spine are more li*ely to lead to *yp"osis t"an t"ose

in t"e lum)ar spine. A cold a)scess can occur if t"e infection extends to

adEacent ligaments and soft tissues.

CLINICAL MANI"ESTATION

otential constitutional symptoms of ott disease include fe1er and0eig"t loss. -"e reported a1erage duration of symptoms at diagnosis is 4

mont"s )ut can )e considera)ly longer. -"is is due to t"e nonspecific

presentation of c"ronic )ac* pain. 7ac* pain is t"e earliest and most

common symptom of ott disease/ 0it" patients usually experiencing t"is

pro)lem for 0ee*s )efore see*ing treatment. -"e pain caused )y ott

disease can )e spinal or radicular. -"e pain is usually of insidious onset

and may )e mec"anical in nature during t"e initial stages of disease.

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=eig"t loss/ fe1er and malaise may )e associated 0it" t"e c"ronic illness

t"at precedes identification of t"e spinal lesion.

-"e p"ysical findings include local tenderness/ muscle spasm/ and

restricted motion. Neurologic a)normalities can occur in of > cases

t"ose 0it" tu)erculosis spondylitis and can include spinal cord

compression 0it" paraplegia/ paresis/ impaired sensation/ ner1e root pain/

and9or cauda eCuina syndrome. A neurological deficit 0ill de1elop in $# to

4' percent.

DIA!NOSIS

-"e diagnosis is usually made 0it" "ig" index of suspicion in

endemic areas in t"e presence of pain and appropriate clinical symptoms

and signs of a systemic c"ronic infection. +f t"e diagnosis cannot )e

esta)lis"ed )y clinical manifestation/ radiograp"ic c"arges/ - and MR+/

cultures of )lood and9or percutaneous 1erte)ral aspirates/ t"en )one

)iopsy/ eit"er )y an open or percutaneous procedure is recommended.

Diagnostic procedures suc" as culture/ antigen demonstration/

serology tests and polymerase c"ain reactions are "ig" priority.

olymerase c"ain reactions "as opened up anot"er exciting era in t"e

diagnosis and management of tu)erculosis. -"roug" t"e polymerase c"ain

reaction test/ it 0as found t"at drug resistance of myco)acterium

tu)erculosis in many cases "as )een associated 0it" discrete genetic

mutation.

-ypical plain radiograp"ic c"anges include destruction of t0oadEacent 1erte)ral )odies/ narro0ing of t"e inter1ening disc/ scalloping of

t"e anterior 1erte)rae and a fusiform para1erte)rae a)scess s"ado0.

Alt"oug" - demonstrates t"e details and soft tissue calcification )etter/

MR+ is most useful in diagnosing early or multicentric lesions )efore plain

radiograp" c"arges )ecome o)1ious. -"e lesion in -$ 0eig"ted image

appears "ypointense and in t"e - images "yperintense/ and lesions are

furt"er en"anced )y intra1enous gadolinium D-A inEection. MR+ is also

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http://emedicine.medscape.com/article/1148690-overviewhttp://emedicine.medscape.com/article/1148690-overview


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more superior in s"o0ing tu)erculosis arac"noiditis and extradural or

intradural spread of t"e a)scess or granulation tissue. -ec"etium !!m

met"ylene dip"osp"onate and gallium %' isotope scanning "a1e

sensiti1ities of a)out !> and


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Con)e$/a*i/e *$ea*men*

-"e mainstay of treatment is antitu)erculosis c"emot"erapy. -"e

first line of drugs currently in use include isonia,id +N25/ rifampicin

RM5/ pyra,inamide HA5/ streptomycin S-M5/ and et"am)utol

?M75. A ne0 num)er of second line agents t"at are used in special

condition include et"ionamide/ cycloserine/ *anamycin and para

aminosalicyclic acid AS5. -"ese drugs are used in cases of poor clinical

response/ side effects or demonstra)le resistance of )acillus to t"e first line

drugs. +N2 and RM are )actericidal against )ot" extracellular and

intracellular organism.

HA are )actericidal only in an acidic en1ironment and effecti1e

against intracellular organism or 0it"in caseous lesions. S-M is acti1ely

only in t"e extracellular space and often used to complement HA. ?M7 is

)acteriostatic against )ot" intra and extracellular organisms. All drugs

"a1e potential toxicity 2epatitis may )e caused )y )ot" +N2 and RM/

and it is 4 times more common in patents recei1ing agent t"an in t"ose

recei1ing +N2 alone. +N2 also can cause perip"eral neuritis 0"ic" is dose

dependent. MaEor toxicity of S-M is 1esti)ulococ"lear ner1e damage and

nep"rotoxicity and ?M7 could cause significant optic neuritis 2o and

(eong/ $!!45.

-"e recommended regimen for a ne0ly diagnosed patient is

mont"s of HA/ +N2 and RM daily follo0ed )y 4 mont"s of +N2 and

RM gi1en daily. An alternati1e )ut less patent regimen is +N2 and RM

gi1en daily for ! mont"s/ 0it" or 0it"out addition of streptomycin or

et"am)utol daily for t"e first mont"s. Nine6mont" and more recent six6

mont" regimes "a1e found to )e effecti1e 0"en +N2 and RM are

com)ined and augmented )y HA and eit"er S-M or ?M7 in early stages

of disease urrier/ $!!5.

Antimicro)ial resistance may occur from t"e multiplication of resistant

mutant under monot"erapy regime. ortunately/ resistance is lo0 0it"

drug regimens as long as t"e patient is compliant. -"roug" a series of

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prospecti1e studies performed )y Medical Researc" ouncil is Asia/ and

Africa c"emot"erapy 0as esta)lis"ed as an effecti1e treatment for t"e

maEority of patients 0it" spinal tu)erculosis. $3t"MR reports $!!! "a1e

s"o0n excellent results of c"emot"erapy as an outpatient )asis 0it"out

)ed rest/ splintage or surgery/ in term of "ealing of spinal disease and )ony

fusion. 7ed rest/ splintage/ operati1e treatment or addition of streptomycin

to com)ination of AS and +N2 did not gi1e any significant impro1ement

in t"e results.

S%$0ical Mana0emen* of Spinal *%&e$c%lo)i)#

An operation is done aiming to drain a)scess/ to de)ride )one and

disc/ decompress t"e spinal cord or sta)ili,e t"e spine to pre1ent or correct

deformity. An a)solute indication for surgery is paraplegia of acti1e

disease and operation gi1es rapid cord decompression and t"us early and

complete reco1ery. Ot"er indications for surgery are:

a. patient 0it" neurologic deficit 0"o failed conser1ati1e treatment

). posterior spinal lesion

c. insta)ility after "ealing

d. neurological complication

-"ere 0ere t0o main types of surgeries/ 0"ic" 0ere also studied )y

t"e UI Medical Researc" ouncil

$. De)ridement/ 0"ic" entailed remo1al of all pus and necrotic tissue/

ac"ie1ing neural decompression 6 )ut 0it" no attempt of fusion and

. Radical surgery/ 0"ic" in1ol1ed complete remo1al of t"e disease

focus until normal )leeding )one is reac"ed/ and fusion 0it"

autogenous )one graft.

Radical anterior excision of t"e diseased 1erte)ra and strut graft

fusion 0as de1eloped )y 2odgson in 2ong Iong in $!&%. -"e indications

of surgery included se1ere pan from t"e expending a)scess/ tissue )iopsy

for diagnosis/ neurologic deterioration from spinal cord compression/

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correction of se1ere *yp"osis and tissue )iopsy for diagnosis in dou)tful

cases. -uli $!'&5 ad1ised a Jmiddle pat"J regimen of operating 0"en

medical management failed. (ifero et al. $!


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a)scess can )e e1acuated/ a1ascular material excised safe anterior

decompression of t"e spinal cord done/ tissue easily o)tained for culture

and sensiti1ity and correction of *yp"osis 0it" sta)ilisation of insta)ility

)y autologous grafting. +t is generally *no0n t"at reco1ery rate from

paraplegia is influenced )y many factors: t"e patientFs general state/ age

and spinal cord condition t"e le1el and t"e num)er of in1ol1ed 1erte)rae

t"e se1erity of spinal deformity t"e duration and se1erity of paraplegia

t"e time of initiation of treatment t"e type of treatment and drug

sensiti1ity.

araplegia caused )y 1ascular em)arrassment "as a 0orse prognosis.

atients 0it" an atrop"ic spinal cord or pre6operati1e MR+ usually do poor

after decompression. +n t"e early acti1e stage of t"e disease/ ottFs

paraplegia is caused )y an a)scess and deformity Moon $!!'5. +n

contrast/ 0"en an operation is indicated/ it is easier to do it early )ecause

a)scesses dissect along tissue planes and if delayed/ fi)rons ma*e t"e

procedure tec"nically more difficult.

7ecause paraplegia usually resol1es rapidly after adeCuate

decompression/ many surgeons )elie1e t"at is unfair to allo0 patients to

lie paralysed for 0ee*s to mont"s a0aiting cue t"roug" conser1ati1e

means and prefer management )y anterior decompression and sta)ilisation

0it" )one graft. +t is generally agreed t"at decompressi1e laminectomy

s"ould not )e done )ecause it desta)ilises t"e spine 0"ile offering no

ad1antages. urrently/ t"e only indication for laminectomy in t"e

treatment of ottFs paraplegia is atypical disease in1ol1ing t"e neural arc"

and causing posterior spinal cord compression or in posterior epidural or

intradural tu)erculomas. (i*e0ise/ costotrane1ersectomy rarely 0as

performed to decompress t"e cord in t"e less deformed spine )ecause t"e

procedure ma*es t"e spine more unsta)le/ 0orsens t"e *yp"osis and is less

effecti1e in decompression t"an radical surgery.

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-u)erculous *yp"osis is an unsta)le lesion t"at tends to progress at

least until t"ere is sound )ony fusion anteriorly. Rapid progression is more

li*ely in t"e t"oracic spine/ 0"ere a natural *yp"osis exists. Anterior

radical surgery for *yp"osis in multile1el fusion anterior strut graft is

necessary 0it" posterior sta)ilisation and instrumentation. osterior

sta)ilisation "as ad1antages including arrest of t"e disease early/

en"ancing early fusion and allo0ing correction of mo)ile deformity. -"is

procedure is only indicated in t"ose patients li*ely to de1elop or 0"o "a1e

pre6existing deformity. Ot"er indications for t"is procedure include a

t"oracic *yp"osis of more t"an 4#o/ a t"oracolum)ar *yp"osis of more t"an

3#o and any *yp"osis deformity in t"e lum)osacral region t"at disrupts t"e

mec"anical competence of t"e anterior spinal column.

COMPLICATION AND PRO!NOSIS +,-1+.-

araplegia is anot"er serious complication of spinal tu)erculosis.

+ts incidence "as )een reported to )e )et0een $# to 4%> and t"e maEority

occurred in t"ose 0it" t"oracic in1ol1ement 2odgson et al. $!%#/ Moon

et al. $!!%/ (u* ###/ Kain ##5. Neurologic deficit can occur early

during t"e acti1e stage of t"e disease5 or late after t"e lesion "ealed L

may occur years after t"e initial disease "as "ealed5. -"e prognosis

depends on t"e age and general "ealt" of t"e patient/ t"e se1erity and

duration of neurological deficit and t"e treatment selected.

?arly paraplegia may )e caused )y mec"anical pressure )y

tu)ercular a)scess/ granulation tissue/ tu)ercular de)ris and caseous tissue.

Neurologic in1ol1ement during t"e acti1e p"ase of infection can also )e

caused )y pat"ologic su)luxation or dislocation of 1erte)rae/ inflammation

from direct affection )y t"e disease on t"e meninges and t"e spinal cord

itself/ and from infecti1e t"rom)osis and endarteritis of spinal 1essels

leading to spinal cord infarction (u* ###/ Kain ##5.

(ate6onset paraplegia can )e caused )y local pressure on t"e spinal

cord )y anterior )ony ridge/ scar tissue or t"roug" formation of interstitial

gliosis =atts et al. $!!%/ (u* ###/ Kain ##5. ?arly6onset paraplegia

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usually "as a )etter prognosis for response to treatment conser1ati1e

and9or surgical5 compared to late onset paraplegia =atts et al. $!!%/

Moon et al. $!!%/ Moon $!!'/ Kain ##5.

Ot"er factors t"at influence reco1ery from paraplegia are : t"e

patientBs general state/ age and preexisting spinal cord condition t"e le1el/

se1erity and num)er of 1erte)ral in1ol1ement t"e se1erity of spinal

deformity t"e duration and se1erity of paraplegia t"e time to initiation of

treatment t"e type of treatment and drug sensiti1ity Moon et al. $!!%/

Kain ##5. Moon et al. $!!%5 also found out t"at prognosis 0as poor in

patients 0it" paraplegia longer t"an % mont"s/ paraplegia associated 0it"

1ascular em)arrassment and spinal cord atrop"y on MR+5/ and in patients

0it" late6onset paraplegia.

CONCLUSION

Spinal tu)erculosis/ 0it" its dreaded complications/ imposes

c"allenge for surgeons and p"ysicians to continue studying and

constructing t"e )est treatment protocol. "emot"erapy/ )eing t"e

mainstay of treatment/ "as to )e supplemented in certain conditions )y

surgery. +n t"e end/ 0"at 0e 0ant out of t"ese treatment regimes is an

efficient/ properly6timed and patient6centered management of spinal

tu)erculosis and its complications.

RE"ERENCES

$. Raymond K. 8ardoc*i/ et all. Spine. Campbell Operative Orthopaedics 8th

Edition. Mos)y/ An +mprint of ?lse1ier.

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. -"ompson K. Netters Concise Orthopaedic Anatomy 2nd Edition. ?lse1ier

Saunders.

3. Moulton A. Understanding Spinal Anatomy. Online. ited 3 e)ruari #$4

from UR(: "ttp:99ptEournal.apta.org9content9

CASE REPORT TB Spine-2.doc

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