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

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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 (-)

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- 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

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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














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: -

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- 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


Hemoglobin 10.0 13,5-17,5 g/Dl


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 %

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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





Lekocyte 9800 4100-10900 /uL

Thrombocytes 758.000 140000-440000 %


Haematology




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 %

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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

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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.

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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.

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MRI Axial on October 10th, 2013

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MRI Sagital on October 10th, 2013

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Conclusion

- Scoliosis of thoracolumbar vertebrae

- Destruction of 3th lumbar and 1st sacral. Marrow abnormality of L3-S1.

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- 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.

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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

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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,

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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

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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,

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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.

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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.

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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

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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)

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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.

REFERENCES

1. Masavkar S, Shanbag P, Inamdar P.(2012) Pott’s Spine with Bilateral Psoas

Abscesses. Hindawi Publishing Corporation Case Reports in Orthopedics. 1-4.

doi:10.1155/2012/208946

2. Ahmed Elbashir G, Elbdawi Nour E.E, Ibrahim Elwathiq K, Mohammed Mamoun

M. (2013). Clinical Presentation of Pott’s disease of the Spine in Adult Sudanese

Patients. OMICS Publishing Group. 1-2.

3. Ehsaei Mohammadreza, Samini Fariborz, Bahadorkhan Gholamreza. (2010).

POTT'S Disease: a review of 58 cases. Medical Journal of the Islamic Republic of

Iran.1-7

4. Kishner Stephen. Lumbar Spine Anatomy. Available at:

http://emedicine.medscape.com/article/1899031-overview#showall. Accessed on

1st November 2013.

5. Gondim Francisco de Assis Aquino. Topographic and Functional Anatomy of the

Spinal Cord. Available at: http://emedicine.medscape.com/article/1148570-

overview. Accessed on 29th October 2013

6. Agrawal, Patgaonkar P.R and Nagariya S.P. Tuberculosis of Spine. Available at:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3075833/. Accessed on 1st

November 2013

7. Eisenstein Stephen, Tuli Surendar, Govender Shunmugam. Tuberculosis. Apley’s

System Orthopaedics and Fractures. 9th ed. London: Hodder Education; 2010. p.

472-75

8. Rahyussalim. Update on Spondylitis TB Treatment in Indonesia. Available at:

http://www.internafkui.or.id/?page=download.download_process&id=2. Accessed

on 9th November 2013.

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http://emedicine.medscape.com/article/1148570-overview

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case pott's disease

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