spondilitis tb

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CASE REPORT PARAPLEGIA DUE TO SPONDYLITIS TUBERCULOSIS OF THE VERTEBRA TH VII- IX WITH PARAVERTEBRAL ABCESS LIM SAY HIANG C 111 08 751 ADVISOR Dr. SALMAN AL WAHABY Dr. WENDELIN WIDIA MADHIN SUPERVISOR Dr. JAINAL ARIFIN, M.Kes, Sp.OT DIBAWAKAN DALAM RANGKA TUGAS KEPANITERAAN KLINIK BAGIAN ORTOPEDI DAN TRAUMATOLOGI FAKULTAS KEDOKTERAN UNIVERSITAS HASANUDDIN MAKASSAR 2013

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  • CASE REPORT PARAPLEGIA DUE TO SPONDYLITIS TUBERCULOSIS OF THE VERTEBRA TH VII- IXWITH PARAVERTEBRAL ABCESS

    LIM SAY HIANGC 111 08 751

    ADVISORDr. SALMAN AL WAHABY Dr. WENDELIN WIDIA MADHIN

    SUPERVISORDr. JAINAL ARIFIN, M.Kes, Sp.OT

    DIBAWAKAN DALAM RANGKA TUGAS KEPANITERAAN KLINIKBAGIAN ORTOPEDI DAN TRAUMATOLOGIFAKULTAS KEDOKTERAN UNIVERSITAS HASANUDDINMAKASSAR 2013

  • IDENTITY Name : Mrs. YAge: 37 years old Sex : FemaleOccupation : HousewifeDate of admission : June 2nd , 2013Registration : 61 22 19

  • History Taking

    Chief complaints: Unable to move both of lower limbsHistory of illness: In the beginning since 4 months before admitted to the hospital, patient felt numbness and weakness at both of lower limbs intermittenly, complaints become persisten since 2 weeks ago and became worse 1 weeks later,which caused the patient inability to walk. History of mild fever since 4 months ago Patient previously also have complain back pain and was treated in nearby primary health centre and received analgetic drug but later complaint become worse and she refered to Dr. Wahidin Sudirohusodo Hospital.History of trauma (-)History of prolonged cough (+), Night sweat (+), Weight loss (+), loss of appetite (+)History of previous TB treatment (-) History of contact with TB patient (+)Cannot feel Defecation and urination Patient using pampers and cathether since 10 days ago

  • General Status Conscious / Poor nourishedBP: 120 / 80 mmHgHR: 96 x/mntRR: 20 x/mntT : 36,7 C

  • Vertebral region:I: Skin colours same with vicinity, no hiperemis Deformity (+) , Swelling (-), Hematoma (-) Gibbus (+) P: Tenderness (+) as level as Th VII , Step off (-) Gibbus (+)

    Localized status

  • Clinical Picture

  • 55555550550050000 0000yes

  • 2222222222222222222222222222222222222222222222222222111111111111111111111111111111111111111111111111111111111111

    0 Absent1 Impaired2 NormalNT Not testable

    Any anal sensationY

  • REFLEXPhysiologic reflex

    R LBiceps (N) (N) Triceps (N) (N)Patellar () ()Achilles () () Pathologic Reflex R LBabinski (+) (+)Chaddock (+) (+)Openheim (+) (+)

  • LaboratoryJune 2nd 2013WBC10,76 x 103/uLRBC4,00 x 106 /uLHGB 10,5 g/dLHCT 33,4 %PLT 457 x 103/uLUreum 21 mg/dlCreatinin 0,5 mg/dlSGOT 36 u/lSGPT 61 u/l

  • Chest X-RayRadiological Finding

  • Thoracolumbar and lumbosacral X-Ray

  • Foto lateral Thoracolumbar and lateral lumbosacralRadiological Finding

  • MRI thoracolumbal

  • Summary -A 37 year-old woman admitted into hospital with chief complaint of inability to move both of lower limbs,-In the beginning since 4 months before admitted to the hospital, patient felt numbness and weakness at both of lower limbs intermittenly, complaints become persisten since 2 weeks ago and became worse 1 weeks later,which caused the patient inability to walk. -History of mild fever since 4 months ago -history of night sweat (+) , weight loss (+), loss of appetite. (+)-History of contact with TB patient (+)-Physical examination: defomity (+) gibbus (+). Tenderness (+) as level as V Th VII, Neurologic deficit (+). The motor power in the right and left lower limb was 0/5. A sensory disturbance was found at the both of limbs area (below T VII).-Radiological findings there was a destruction of vertebral body at vertebra thoracal VII- VIII, with the narrowing of intervertebral disc and paravertebral abscess

  • Diagnosis

    PARAPLEGIA DUE TO SPONDYLITIS TUBERCULOSIS OF THE VERTEBRA TH VII- IX WITHPARAVERTEBRAL ABSCESS AT VERTEBRA TH VII- IX

  • Treatment 1)Plan:Plan for ESR, Mantoux Test and AFB,PCRBiopsy, culture and sensivity(Intraoperative)2)Non operation:Bed restAntituberculosis drugs Antibiotic drugsAdequate nutritionInline mobilization3)Operation:Plan evacuation abscess

  • GENERAL INFORMATION33 Vertebrae:7 Cervical (lordosis)12 Thoracic (kyphosis)5 Lumbar (lordosis)5 Sacral fused (kyphosis)4 Coccygeal (fused)Thompson JC. Netters Concise Orthopaedic Anatomy 2nd Edition. Elsevier Saunders

  • GENERAL INFORMATION (2)Root exit spinal column via intervertebral foramenC1-7 : exit above their vertebraC8-L5 : exit below their vertebra (C7 exit above C7 vertebra and C8 exit below C7 vertebra)Medula spinalis end at L1 (Conus Medullaris)Lumbar and sacral nerve form cauda equina in spinal canal before exitThompson JC. Netters Concise Orthopaedic Anatomy 2nd Edition. Elsevier Saunders

  • Thoracal SpineThompson JC. Netters Concise Orthopaedic Anatomy 2nd Edition. Elsevier Saunders

  • DEVIDED INTO 3 COLUMN(DENIS THEORY)Anterior : 2/3 of vertebral bodyMiddle : 1/3 of vertebral bodyPosterior : Pedicles, lamina, spinous process, and ligamentThompson JC. Netters Concise Orthopaedic Anatomy 2nd Edition. Elsevier Saunders

  • Arterial SupplyThompson JC. Netters Concise Orthopaedic Anatomy 2nd Edition. Elsevier Saunders

  • DefinitionA spinal infection associated with tuberculosis Characterized by a sharp angulation of the spine where tubercle lesions are present. Also called Pott's disease.Pott Disease [homepage on the Internet]. No date [cited 2012 July 13]. Available from: http://emedicine.medscape.com/article/226141-overview#showall

  • Diagram Of Extrapulmonary TuberculosisLouis S, David M, and Selvadurai N Saji. Apleys System of Orthopaedics : Great Britian, Hodder Arnolds; 2010. Chapter 18, The Back ; p.491-492

  • EPIDEMIOLOGYFrom all the TB cases 10% develop bone or joint involmentSpine is the extrapulmonary site in over 50% of the cases of bone and joint involvement Thoracolumbar spine (50%)Ravindra Kumar Garg, Dilip Singh Somvanshi. Spinal tuberculosis: A reviewThe Journal of Spinal Cord Medicine [Available from: Chhatrapati Shahuji Maharaj Medical University, Lucknow, Uttar Pradesh, India

  • PATOPHYSIOLOGYRavindra Kumar Garg, Dilip Singh Somvanshi. Spinal tuberculosis: A reviewThe Journal of Spinal Cord Medicine

  • PATHOPHYSIOLOGYMalnutrition, overcrowding population, immunocompromising disease prominent risk factorsHematogenous spreadRich vascularity near the anterior longitudinal ligamentAbscess formation and extension beneath anterior longitudinal ligament and periosteum stripped of ALL and periosteumPeriosteal stripping and arterial occlusion ischemic infarction necrosis of involved bone

  • Pathogenesis of Spinal Tuberculosis

  • Presenting complaintLouis S, David M, and Selvadurai N Saji. Apleys System of Orthopaedics : Great Britian, Hodder Arnolds; 2010. Chapter 18, The Back ; p.491-492

  • Hodgson, et al: The pathogenesis of Pott's paraplegia. Journal of Bone and Joint Surgery 49A:1147-1156, 1967

  • History TakingHump in the vertebraeHistory of pulmonary tuberculosisHistory of contact with tuberculosis patientBack pain

    Louis S, David M, and Selvadurai N Saji. Apleys System of Orthopaedics : Great Britian, Hodder Arnolds; 2010. Chapter 18, The Back ; p.491-492

  • Physical Examination

    DeformityGibbusCold abscessTendernessNeurological examination

    Louis S, David M, and Selvadurai N Saji. Apleys System of Orthopaedics : Great Britian, Hodder Arnolds; 2010. Chapter 18, The Back ; p.491-492

  • Radiological

    X Ray Earliers sign local osteoporosis of two adjacent vertebra, narrowing of intervertebral disc space Later - bone destruction, collapse of adjacent vertebra bodies produce angular deformity

    CT-Scan and MRI Investigation of cord compression Louis S, David M, and Selvadurai N Saji. Apleys System of Orthopaedics : Great Britian, Hodder Arnolds; 2010. Chapter 18, The Back ; p.491-492

  • Laboratory finding

    Blood examinationTuberculin skin test Bacteriology examinationAcid Fast BaciliPolymerase Chain ReactionCulture Sensivity Test

    Harry Skinner. Current Diagnosis and Treatment in Orthopaedics. 3rd ed. Appleton & Lange; 2003. Chapter 8, Orthopedic Infection; p.699

  • Treatment Non operationBed restAntituberculous drugsAdequate nutritionImmobilization

    Operation Draining of abscessIn presence of deformity stabilization by internal fixation and fusion

    C.R. Wheeless MD. Wheeless Textbook of Orthopaedics. 3rd ed. American College of physician; 2003., Tuberculous Spondylitis; p749

  • Complications Cold abscessSpine deformitiesNeurologic deficits and paraplegia

    Millers. Reviews of Orthopaedics 4th ed. America Saunders;2004. Chapter 7, Spine; p.445

  • THANK YOU

    ****CiprofloxacinPACulture sensivitasBTA****ArteriesIn the cervical region, branches arise from the occipital artery, a branch of the external carotid; from the vertebral artery, a branch of the subclavian; and from the deep cervical artery, a branch of the costocervical trunk.In the thoracic region branches arise from the posterior intercostal arteries.In the lumbar region branches arise from the subcostal and lumbar arteries.In the sacral region branches arise from the iliolumbar and lateral sacral arteries, branches of the internal iliac artery

    *Mycobacterium tuberculosisis spread by small airborne droplets, called droplet nuclei, generated by the coughing, sneezing, talking, or singing of a person with pulmonary or laryngeal tuberculosis. Once inhaled, the infectious droplets settle throughout the airways. Introduction of M tuberculosisinto the lungs leads to infection of the respiratory system; - Lesions in persons with an adequate immune system generally undergo fibrosis and calcification, successfully controlling the infection so that the bacilli are contained in the dormant, healed lesionsFor less immunocompetent persons, granuloma formation is initiated yet ultimately is unsuccessful in containing the bacilli; however, the organisms can spread to other organs, such as the lymphatics, pleura, bones/joints, or meninges, and cause extrapulmonary tuberculosis.

    *lanjut baca bagan hijau-kuning-abu2*

    ***