Spondilitis Tb Ppt

P O T T ‘S D I S E A S E

Pembuat : TONDO BAYU (11-2011-048)MERCY SYLVIA (11-2012-009)

Pembimbing : dr. Suhana, SpOT

POTT’s DISEASE

• Definition– Pott’s disease is a presentation of extrapulmonary

tuberculosis that affects the spine, a kind of tuberculous arthritis of the intervertebral joints.

– It is named after Percivall Pott (1714-1788), a London surgeon who trained at Barts.

– Scientifically, it is called tuberculous spondylitis and it is most commonly localized in the thoracic portion of the spine.

– AKA: Pott's syndrome, Pott's caries, Pott's curvature, angular kyphosis, kyphosis secondary to tuberculosis, tuberculosis of the spine, tuberculous spondylitis and David's disease

POTT’s DISEASE

• Etiology– Pott’s disease is caused when the vertebrae

become soft and collapse as the result of caries or osteitis. Typically, this is caused by mycobacterium tuberculosis. As a result, a person with Pott'sdisease often develops kyphosis, which results in a hunchback.

Pathophysiology Of Tuberculous Spondylitis

Tuberculous spondylitis

“Cold Abscesses”• Not as hot, warm or painful as other

abscesses

• Hidden deep inside the body

• May burst out leaving behind a track, or sinus, which discharges pus

POTT’s DISEASE

• Epidemiology– Approximately 1-2% of total tuberculosis cases are attributable to

Pott’s disease. The incidence rate here in the Philippines is approximately 20-30% of the entire patient diagnosed to have Tuberculosis. Most of the cases of the Pott's disease in the Philippines are caused by the non-compliance of the treatment regimen of TB.

– Tuberculosis worldwide accounts for 1.7 billion infections, and 2 million deaths per year. Over 90% of TB occurs in poorer countries, but a global resurgence is affecting richer ones.

– The disease affects males more than females in a ratio of between 1.5 and 2:1.

– In the USA it affects mostly adults but in the countries where it is commonest itaffects mostly children.

POTT’s DISEASE

• Risk Factors– Tuberculosis/Endemic TB– Poor socioeconomic conditions– Diabetes– Steroid Use– Chronic Disease– Immunosuppression– IV drug Abuse– Rheumatoid Arthritis

POTT’s DISEASE

• Signs and Symptoms– Localized back pain– Paravertebral swelling – Systematic signs and symptoms of TB – Neurological signs may occur leading to paraplegia– Spinal mass, sometimes associated with numbness,

tingling, or muscle weakness of the leg

POTT’S DISEASE

POTT’S DISEASE

POTT’S DISEASE

PHYSICAL ASSESSMENT

POTT’S DISEASE

Body Parts Actual Findings Analysis

Height Change of shape of back

kyphosis

Weight Weight loss Anorexia

Vital signs Normal Findings Actual Findings Analysis

Temperature 36.5-37.5 degrees Celsius

Increase in temperature Febrile

General SurveyNormal Findings Actual Findings Analysis

Body built mesomorph Ectomorph Deviation from Normal

Overall hygiene and grooming

clean and neat Self bathing hygiene deficit

Deviation from Normal

PHYSICAL ASSESSMENT

Assessment of the SkinNormal Findings Actual Findings Analysis

Skin color

Varies from light to deep brown; from ruddy pink to

light pink; from yellow overtones to olive

-Fundamentals of Nursing 8th edition Kozier and Erb’s

page 579

redness erythema

Presence of edema

No edema

-Fundamentals of Nursing 8th edition Kozier and Erb’s

page 579

with edema edema

Skin temperature

Uniform: within normal range

-Fundamentals of Nursing 8th edition Kozier and Erb’s

page 579

Warm skin temperatureFebrile

Deviation from Normal

PHYSICAL ASSESSMENT

Assessment of the Nose

Palpate the maxiliary and frontal sinuses for tenderness

Not tenderTenderness in one or more sinuses

Deviation from normal

Assessment of the Thorax

Posterior Thorax Normal Findings Actual Findings Analysis

Inspect the spinal alignment for deformities.

Spine is vertically aligned. Spinal column is straight, right and left shoulder and hips are at

the same height.

- Fundamentals of Nursing 8th edition

Kozier and Erb’s page 614

Exaggerated spinal curvatures

Kyphosis due to gibbous formation

Palpate the posterior thorax

No tenderness, no masses

Pain with palpation over the spine

Deviation from normal

PHYSICAL ASSESSMENTAssessment of the Musculoskeletal System

Normal Findings Actual Findings Analysis

Inspect the muscle for size.

Equal in size on both body parts.

- Fundamentals of Nursing 8th edition Kozier and Erb’s page 640

Muscle atrophy Deviation from Normal

Test muscle strength.

Equal strength on each body sides

( sternocleidomastoid, trapezius, deltoid, biceps, triceps, wrist and

finger, grip strength, hip and hamstring.

- Fundamentals of Nursing 8th edition Kozier and Erb’s page 640

Weakness Deviation from Normal

Assess range of motion

Varries in accordance to a person genetic make-up Fundamentals of Nursing 8th edition Kozier and Erb’s

page 641

Decrease range of motion. Pain in movement

Deviation from Normal

BonesInspect the skeleton for

structureNo deformities Bones misaligned Deviation from normal

Palpate the bones to locate any areas of edema or tenderness

No tenderness or swelling Presence of tenderness or swelling Deviation from normal

Joints

Inspect the swelling. Palpate each joint for tenderness, smoothness of movement, swelling, crepitation, and

presence of nodules.

No swelling

No tenderness, crepitation or nodules

Joints move smoothly

Swelling joints Deviation from Normal

Assess joint range of motion

Varies to some degree in accordance with person’s genetic make-up and degree of physical activity

Decreased range of motion Deviation from normal

DIAGNOSTICS

Blood cp( ESR)

Range of motion in the spine.

A series of neurological tests

complete medical history

blood immunoglobin profile

X-rays

magnetic resonance images (MRIs)

CT scan guided biopsy

Bone scans

Diagnosis

DIAGNOSTIC PROCEDURE

– Blood Test- elevated ESR– Tuberculine Test– Radiographs of the spine– Bone Scan– CT of the Spine– Bone biopsy

• MICROBIOLOGY– Needle biopsy– Acid-fast strain and culture

DIAGNOSTIC PROCEDURE

• Imaging Studies

– 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.

– MRI• MRI is the criterion standard for evaluating disk-space infection

and osteomyelitis of the spine and is most effective for demonstrating the extension of disease into soft tissues and the spread of tuberculous debris under the anterior and posterior longitudinal ligaments. MRI is also the most effective imaging study for demonstrating neural compression.

LABORATORY RESULTS:

• Laboratory Studies

– Tuberculin skin test (purified protein derivative [PPD])-• Results are positive in 84- 95% of patients with Pott disease who

are not infected with HIV

– The erythrocyte sedimentation rate (ESR)• May be markedly elevated (>100mm/h).

– Microbiology studies • Are used to confirm diagnosis. Bone tissue or abscess samples

are obtained to stain for acid-fast bacilli (AFB), and organisms are isolated for culture and susceptibility. CT-guided procedures can be used to guide percutaneous sampling of affected bone or soft-tissue structures. These study findings are positive in only about 50% of the cases.

LABORATORY RESULTS

• Aspirate from joint space & abscess• Transparency: turbid.• Colour: creamy.• Consistency: cheesy.• Fibrin clot: large.• Mucin clot: poor.• WBC: 25000/cc.mm.

LABORATORY RESULTS

• Imaging Studies– Radiography

• •Radiographic changes associated with Pott disease present relatively late. The following are radiographic changes characteristic of spinal tuberculosis on plain 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

– •Additional radiographic findings may include the following:• •Vertebral end plates are osteoporotic.• •Intervertebral disks may be shrunk or destroyed.• •Vertebral bodies show variable degrees of destruction.• •Fusiform paravertebral shadows suggest abscess formation.• •Bone lesions may occur at more than one level.

LABORATORY RESULTS

• Imaging Studies

– X-Ray spine

• Early:-• Narrowed joint space.• Diffuse vertebral osteoporosis adjacent to joint.• Erosion of bone.• Fusiform paraspinal shadow of abscess in soft tissue.

• Late:-• Destruction of bone.• Wedge-shaped deformity (collapse of vertebrae anteriorly).• Bony ankylosis.

LABORATORY RESULTS• Imaging Studies

– CT SCAN• 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.

– MRI• MRI findings useful to differentiate tuberculous spondylitis

from pyogenic spondylitis include thin and smooth enhancement of the abscess wall and well-defined paraspinal abnormal signal, whereas thick and irregular enhancement of abscess wall and ill-defined paraspinal abnormal signal suggest pyogenic spondylitis. Thus, contrast-enhanced MRI appears to be important in the differentiation of these two types of spondylitis.

DIFFERENTIAL DIAGNOSIS

– Osteitis Piogen – Poliomielitis– Skoliosis idiopatik– Metastasis spinal cord– Pulmo infection after empiema

– Kifosis senilis

Complication • Spinal cord injury• Empyema tuberculosis

Treatment

• Drug treatment

• Bed rest

• Spinal braces

• Surgery