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SPONDYLITIS TUBERCULOSIS

dr. Rieva Ermawan, SpOT(K)Spine

(Dr.dr. Pamudji Utomo, SpOT(K), dr Romaniyanto,SpOT(K), dr R.Andhi Prijosedjati


SpOT(K)
**Spine Division, Department of Orthopaedic & Traumatology, Faculty of Medicine Sebelas Maret
University – Dr. Moewardi General Hospital / Prof. Dr. R. Soeharso Orthopaedic Hospital Surakarta
INTRODUCTION
• TUBERCULOSIS is a disease caused by Mycobacterium tuberculosis infection1
• Tuberculosis is one of the most common problem in the developing countries

• The most TB contributing country : India – China - Indonesia


• Developed Countries  a bimodal distribution
with two peaks
(20-40) y.o : immigrants or patients with HIV infection
 (60-80)y.o : immunosuppressed or debilitating diseases

1. WHO | Tuberculosis (TB). Available at: http://www.who.int/tb/en/. (Accessed: 27th September 2017)
2. Houben, R. M. G. J. & Dodd, P. J. The Global Burden of Latent Tuberculosis Infection: A Re-estimation Using Mathematical Modelling. PLoS Med. 13, e1002152 (2016).
TUBERCULOSIS IN INDONESIA
• Indonesia  estimated >1 million new active
cases3
 one of the leading contributor of TB
cases worldwide1,3
• Estimated TB prevalence in Indonesia in 2014 
234/100.000;
• Tip of iceberg  1 out of 3 has yet to be
reported4

3. Collins, D., Hafidz, F. & Mustikawati, D. The economic burden of tuberculosis in Indonesia. Int. J. Tuberc. Lung Dis. Off. J. Int. Union Tuberc. Lung Dis. 21, 1041–1048 (2017).
4. Albana, R., Purba, J. A., Manihuruk, H. & Ariff, M. Cemented total hip arthroplasty for neglected tuberculosis of the hip in endemic area (Papua, Indonesia): A Case Report. J Clin Case Rep 6, 2
(2016).
5. Tuberculosis (TB ): India - Indpaedia [Internet]. [dikutip 7 Februari 2018]. Tersedia pada: http://indpaedia.com/ind/index.php/Tuberculosis_(TB_):_India
• Notorious for infecting respiratory system but it is actually a Multi-
systemic Disease
• Manifest  PULMONARY TB
 EXTRA-PULMONARY TB (EPTB)6
• One of the EPTB form is musculoskeletal TB
• There hasn’t been any prevalence data for musculoskeletal TB in
Indonesia  moreover data on spinal involvement as for spondylitis TB
• Long-lasting fever
• Cough of 2-week duration or more
at least one symptom4
• Night sweats
• Weight loss
• Gold standard diagnosis = culture
• Other tests  direct microscopic examinations, nucleic acid
amplification tests, tuberculin & IGRA test for LTBI
• Extra-pulmonary TB  atypical presentation  mimic other disease5

7. Tuberculosis image courtesy: Medcomic.com by Jorge Muniz (2014)


8. Think TB Poster image courtesy: CDC | TB | Publications | Posters | Think TB. Available at: https://www.cdc.gov/tb/publications/posters/thinktb.htm. (Accessed: 27th October 2017)
EXTRA-PULMONARY TB (EPTB)

• Ranging from 15-20% of all TB cases9


• Most frequent sites = lymph nodes (19%), pleura (7%),
musculoskeleteal (6%), GIT (e.g peritoneum, ileocaecal,
hepatosplenic; ±4%), CNS (3%), genitourinary (1%); or multisystem
involvement
• Some forms were life-threatening  TB meningitis & pericarditis10
• While others could cause significant ill-health & lasting disability  pleural
TB & spinal TB

9. Houston, A. & Macallan, D. C. Extrapulmonary tuberculosis. Medicine (Baltimore) 42, 18–22 (2014).
10 Sharma, S. K. et al. Index-TB Guidelines: Guidelines on extrapulmonary tuberculosis for India. Indian J. Med. Res. 145, 448–463 (2017).
MUSCULOSKELETAL
TUBERCULOSIS
• Compared to other musculoskeletal involvement, in spine  >50%11
• Spondylitis TB  1-3% of overall TB cases
• Other less common site  knee, hip, ankle, upper limbs
• Hematogenous dissemination from primarily infected visceral focus12
• Host bone tissue damage  by tubercle formation & its necrosis,
inflammatory substances e.g PGE2, free oxygen radicals & localized
osteoclast activity13

9. Houston, A. & Macallan, D. C. Extrapulmonary tuberculosis. Medicine (Baltimore) 42, 18–22 (2014).
10 Sharma, S. K. et al. Index-TB Guidelines: Guidelines on extrapulmonary tuberculosis for India. Indian J. Med. Res. 145, 448–463 (2017).
SPONDYLITIS TUBERCULOSIS (TB)
• It is one of the oldest demonstrated
diseases of humankind.
• Percival Pott presented the classic
description of TB spine in 1779
• Most common sites 
THORACOLUMBAL

14. Shi, T. et al. Retrospective Study of 967 Patients With Spinal


Tuberculosis. Orthopedics 39, e838-843 (2016).
SPONDYLITIS TUBERCULOSIS
Types of Spinal TB15 =
1. Classic form  most common
2. Atypical form  spondylitis without disc involvement

Spondylitis TB  obscure clinical presentation  diagnosis is often


delayed or even missed (mean ±6.5 months, range from 3 to 12)6

15. Rasouli, M. R., Mirkoohi, M., Vaccaro, A. R., Yarandi, K. K. & Rahimi-Movaghar, V. Spinal tuberculosis: diagnosis and management. Asian Spine J. 6, 294–308 (2012).
6. Norbis, L. et al. Challenges and perspectives in the diagnosis of extrapulmonary tuberculosis. Expert Rev. Anti Infect. Ther. 12, 633–647 (2014).
PATOFISIOLOGI

Extra pulmo TB (TB


Spine 3 % )
Intermitten fever
Primary Pulmonary Tuberculosis
Back pain

Night sweat
Hematogenous Spread

Anterior Aspect of Vertebral Body


Infected

M Tuberculosis spreads to adjacent intervetebral disc


between two infected Vertebrae

Progressive Bone destruction Intermitten back pain

Infected anterior Caseation take place


intervertebral disc collapse

Spinal canal narrowed by


abses, granulation, tissue
Khyposis Gibbus deformity or direct dural invasion

Spinal cord compresion Neurological effect and


motor deficit
DIAGNOSIS

• Clinical sign & symptoms


• Radiographic findings
• History of prior TB
• (+) skin test
• Elevated ESR
• Biopsy and DNA amplification test (PCR)
• culture

14. Shi, T. et al. Retrospective Study of 967 Patients With Spinal Tuberculosis. Orthopedics 39, e838-843 (2016).
15. Rasouli, M. R., Mirkoohi, M., Vaccaro, A. R., Yarandi, K. K. & Rahimi-Movaghar, V. Spinal tuberculosis: diagnosis and management. Asian Spine J. 6, 294–308 (2012).
DIAGNOSIS IN SPONDYLITIS TB
Main symptom Spondylitis TB
Systemic or
 neck/back should always
other organ
pain  be suspected
involvement
insidious, when
symptoms such
progressive, radiograph
as fever or
unrelieved by demonstrate
sweating 
rest destructive
occur in less
(inflammatory spinal
than 50% cases
characteristic)16 process17

16. Colmenero, J. D., Ruiz-Mesa, J. D., Sanjuan-Jimenez, R., Sobrino, B. & Morata, P. Establishing the diagnosis of tuberculous vertebral osteomyelitis. Eur. Spine J. Off. Publ. Eur. Spine Soc.
Eur. Spinal Deform. Soc. Eur. Sect. Cerv. Spine Res. Soc. 22 Suppl 4, 579–586 (2013).
17. Rauf, F., Chaudhry, U. R., Atif, M. & ur Rahaman, M. Spinal tuberculosis: Our experience and a review of imaging methods. Neuroradiol. J. 28, 498–503 (2015).
RADIOGRAPHIC CONSIDERATION
• Conventional radiography  usually not helpful in initial stage
as vertebral change takes 2-6 months to be apparent18
• CT-scan
• MRI  modality of choice
• Histopathological dx remain essential19

18. Megaloikonomos, P. D., Igoumenou, V., Antoniadou, T., Mavrogenis, A. F. & Soultanis, K. Tuberculous Spondylitis of the Craniovertebral Junction. J. Bone Jt. Infect. 1, 31–33 (2016).
19. Ekinci, S., Tatar, O., Akpancar, S., Bilgic, S. & Ersen, O. Spinal Tuberculosis. J. Exp. Neurosci. 9, 89–90 (2015).
CT-scan combined with MRI

• detecting spinal TB earlier


• reveal the involved vertebrae & attachment clearly
• exhibit the degree of destruction, scope of central lesion,
location & number of cavities & abscesses, & spinal cord
compression19

19. Ekinci, S., Tatar, O., Akpancar, S., Bilgic, S. & Ersen, O. Spinal Tuberculosis. J. Exp. Neurosci. 9, 89–90 (2015).
PRINCIPLES OF TREATMENT

Mainstay of treatment  CONSERVATIVE & OPERATIVE20

Potent anti-TB therapy (ATT) & external immobilization 


irreplaceable21

Surgical is crucial when there are bone destruction, severe


kyphotic deformity, large abscess & spinal cord compression21

20. Zhang, Z. et al. The outcomes of chemotherapy only treatment on mild spinal tuberculosis. J. Orthop. Surg. 11, 49 (2016).
21. Zeng, H. et al. Comparison of three surgical approaches for cervicothoracic spinal tuberculosis: a retrospective case–control study. J. Orthop. Surg. 10, (2015).
CONSERVATIVE TREATMENT
• Fundamentally, TB treatment is chemotherapy
• Surgery only attempts to extirpate the complications  hence spondylitis
TB merit medical rather than surgical  especially mild cases
• Combination of Rifampicin, Isoniazid, Ethambutol, and Pyrazinamide for
2 months  followed by combination of Rifampicin and Isoniazid for a
total period of 6, 9, 12 or 18 months is the most frequent protocol

20. Zhang, Z. et al. The outcomes of chemotherapy only treatment on mild spinal tuberculosis. J. Orthop. Surg. 11, 49 (2016).
15. Rasouli, M. R., Mirkoohi, M., Vaccaro, A. R., Yarandi, K. K. & Rahimi-Movaghar, V. Spinal tuberculosis: diagnosis and management. Asian Spine J. 6, 294–308 (2012).
OPERATIVE TREATMENT

Surgery aims :
• elimination of TB
• removal of compression
• correction of kyphotic
• reconstruction and maintenance
of spinal stability

14. Shi, T. et al. Retrospective Study of 967 Patients With Spinal Tuberculosis. Orthopedics 39, e838-843 (2016).
OPERATIVE TREATMENT
• Currently used techniques15
1. Posterior decompression & fusion with bone autograft
2. Anterior debridement/decompression & fusion with bone autografts
3. Anterior debridement/decompressions & fusion, followed by
simultaneous or sequential posterior fusion with instrumentation
4. Posterior fusion with instrumentation, followed by simultaneous or
sequential debridement/decompression & fusion

15. Rasouli, M. R., Mirkoohi, M., Vaccaro, A. R., Yarandi, K. K. & Rahimi-Movaghar, V. Spinal tuberculosis: diagnosis and management. Asian Spine J. 6, 294–308 (2012).
SURGICAL CONSIDERATION22
• Anterior & anterolateral approaches  effective in resolving
neurological deficit but not in correcting kyphosis
• Anterior & Posterior approach  enable correction of both
neurological deficit & kyphosis
• Posterior approach combined with 3-column osteotomy 
technically challenging & require intra—operative neuro-
monitoring & spinal instrumentation, expensive

22. Panchmatia, J. R., Lenke, L. G., Molloy, S., Cheung, K. M. C. & Kebaish, K. M. Review article: Surgical approaches for correction of post-tubercular kyphosis. J. Orthop. Surg.
Hong Kong 23, 391–394 (2015).
OPERATION CASE SPONDILITIS TB IN RSOP
2017
No Month Total No Regio Total
1 January 9 1 Cervical 2
2 February 7 2 Thoracal 21
3 March 3 3 Lumbal 22
4 April 3 4 Thoracolumbal 9
5 May 3 Total 54
6 June 6
7 July 2
8 August 6
9 September 7
10 October 1
11 November 4
12 December 4
Total 54
OPERATION CASE SPONDILITIS TB IN RSDM
2017
No Month Total No Regio Total
1 January 0 1 Cervical 1
2 February 0 2 Thoracal 3
3 March 0 3 Lumbal 2
4 April 0 4 Thoracolumbal 1
5 May 1 Total 7
6 June 1
7 July 1
8 August 1
9 September 1
10 October 1
11 November 1
12 December 0
Total 7
CASE
1
• Name : Munawati
• Age : 26 y.o
• Occupation : housewife
• Chief complain : Neck Pain and radiculopathy since 1 year prior to
admission
• TB contact (+)
• History of TB treatment since 2 months before admission
• Lab findings : Hb 12.2 g/dl, AL 13.900 /UL, ESR 1
57 mm/h, ESR 2 79 mm/h, CRP (+)
NEUROLOGICAL EXAMINATION

Motoric: D S
C5 5 5 Physiological reflex :
C6 5 5
C7 5 5 +2 +2
C8 5 5 +2 +2
T1 5 5
L2 5 5
Pathological reflex :
L3 5 5 Hoffman Tromer -/-Babbinsky
Sensoric: L4 5 5 -/-
normal L5 5 5 Clonus -/-
S1 5 5
PRE OPERATIVE X-RAY

Kyphotic
Deformity : 44o
MRI
OPERATIVE PLAN
2nd Stage Procedure :
1st Stage Procedure: Anterior Expandable Cage
Anterior Debridement + Posterior Fusion
CT SCAN POST OP
MRI POST OP
2
• Nama : Alfarez
• Umur : 1 th 3 bulan
• DPJP : Dr. RVA
• Diagnosa : destruksi VL2 + kyphotic deformity ec Spondylitis TB
• Plan : Anterior debridement lumbotomy + stabilisasi anterior
(cage add plus) + body jacket hemispica cast
NEUROLOGICAL EXAMINATION PRE OP
VAS : 5-6
Reflek Fisiologis
Motoric :
D S
C5 5 5 +2 +2
C6 5 5 +2 +2
C7 5 5
C8 5 5 Reflek Patologis:
T1 5 5 Hoffman-Tromner -/-
Babinski -/-
L2 4 4
Clonus -/-
L3 4 4
L4 5 5 OAT 1 bulan
L5 5 5
S1 5 5

Sensoric : sulit dievaluasi


X-RAY
Lumbar kyphotic : 4°


MRI
MRI
MRI
MRI
MRI
MRI
PROBLEM LIST

• Klinis : Back pain, Paraparese inferior

• Topis : destruksi VL2 + kyphotic deformity ec Spondylitis TB

• Penyerta : OAT 1 bulan


DURANTE OP
NEUROLOGICAL EXAMINATION POST OP
VAS : 3-2
Reflek Fisiologis
Motoric :
D S
C5 5 5 +2 +2
C6 5 5 +2 +2
C7 5 5
C8 5 5 Reflek Patologis:
T1 5 5 Hoffman-Tromner -/-
Babinski -/-
L2 sde 4
Clonus -/-
L3 4 4
L4 5 5
L5 5 5
S1 5 5

Sensoric : sulit dievaluasi


X-RAY POST OP
Lumbar lordotic : 10°

10°
2 MONTH POST OPERATIVE
3
• Nama : Agus Ronal
• Umur : 27 th
• Pekerjaan : Karyawan swasta
• DPJP : Dr. RVA
• Diagnosa : Paraparese inferior ec destruksi L1-2 susp Spondilitis TB

• Plan : Debridement + Laminectomy dekompresi + PSF Th11-12,


L2-3
NEUROLOGICAL EXAMINATION PRE OP
VAS : 4-5
Reflek Fisiologis
Motoric :
D S
+2 +2
C5 5 5
+3 +3
C6 5 5
C7 5 5 Reflek Patologis:
C8 5 5 Hoffman-Tromner -/-
T1 5 5 Babinski -/-
Clonus -/-
L2 4 4
L3 4 4 OAT 1 bulan
L4 4 4
L5 4 4 (11 Januari 2018)
LED 1/2 : 52/65
S1 4 4
CRP :-
ALP : 163
Sensoric : hipoesthesia setinggi L2-distal bilateral
X-RAY

Kyphotic angle 26°

10°

26°
MRI
MRI
MRI
MRI
PROBLEM LIST

Klinis : paraparese inferior, hipoesthesia setinggi L2-


distal bilateral

Topis : destruksi L1-2 susp Spondilitis TB

Penyerta : OAT 1 bulan


DURANTE OP
NEUROLOGICAL EXAMINATION POST OP
VAS : 2-3
Reflek Fisiologis
Motoric :
D S
C5 5 5 +2 +2
C6 5 5 +2 +2
C7 5 5
C8 5 5 Reflek Patologis:
T1 5 5 Hoffman-Tromner -/-
Babinski -/-
L2 4 4
Clonus -/-
L3 4 4
L4 4 4
L5 4 4
S1 4 4

Sensoric : hipoesthesia setinggi L2-distal bilateral


X-RAY POST OP

Kyphotic angle : 8°


2 MONTH POST OPERATIVE
THANK YOU

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