POTT'S DISEASE

Submitted To:

Mr. Joey A. Servan

Submitted By:

Carlo Luigi P. Zayco

BSN 4-2

November 17, 2010

I. INTRODUCTION

Pott's disease, also known as tuberculous spondylitis, is one of the oldest demonstrated diseases of humankind, having been documented in spinal remains from the Iron Age and in ancient mummies from Egypt and Peru. In 1779, Percivall Pott, for whom Pott's disease is named, presented the classic description of spinal tuberculosis.

Since the advent of antituberculous drugs and improved public health measures, spinal tuberculosis has become rare in developed countries, although it is still a significant cause of disease in developing countries. Tuberculous involvement of the spine has the potential to cause serious morbidity, including permanent neurologic deficits and severe deformities. Medical treatment or combined medical and surgical strategies can control the disease in most patients.

The frequency of extrapulmonary tuberculosis has remained stable. Bone and soft-tissue tuberculosis accounts for approximately 10% of extrapulmonary tuberculosis cases and between 1% and 2% of total cases. Tuberculous spondylitis is the most common manifestation of musculoskeletal tuberculosis, accounting for approximately 40-50% of cases. Approximately 1-2% of total tuberculosis cases are attributable to Pott's disease.

Pott's disease is the most dangerous form of musculoskeletal tuberculosis because it can cause bone destruction, deformity, and paraplegia. Pott's disease most commonly involves the thoracic and lumbosacral spine. However, published series have show some variation. Lower thoracic vertebrae is the most common area of involvement (40-50%), followed closely by the lumbar spine (35-45%). In other series, proportions

are similar but favor lumbar spine involvement. Approximately 10% of Pott disease cases involve the cervical spine.

Musculoskeletal tuberculosis primarily affects African Americans, Hispanic Americans, Asian Americans, and foreign-born individuals. As with other forms of tuberculosis, the frequency of Pott's Disease is related to socioeconomic factors and historical exposure to the infection. Although some series have found that Pott's disease does not have a sexual predilection, the disease is more common in males (male-to-female ratio of 1.5-2:1). In countries with higher rates of Pott's disease, involvement in young adults and older children predominates.

II. PATIENT PROFILE

PATIENT DATA

Ward: Pediatric Ward

Date of Admission: November 4, 2010

Patient’s Name: Patient F

Address: Mangatarem, Pangasinan

Gender: Female

Age: 4 yrs. old

Birth date: July 12, 2006

Religion: Roman Catholic

Nationality: Filipino

Civil Status: Child

Informant: Father

SOURCE AND RELIABILITY OF INFORMATION

The patient’s father, interviewed personally to collect more pertinent information

regarding the child’s past and present health status, serves as the primary source of

data. In addition, data were also gathered from the patient's hospital records at

Philippine Orthopedic Center.

ADMISSION DATA

Chief Complaint: Fever, back and chest pain

Initial Diagnosis: Pott's disease T-5 T-7 t/c T-6 T-12

Attending Physician: Dr. Yu

III. PATIENT HISTORY/ NURSING HISTORY

History of Present Illness

Last July of this year, Patient F was playing at their just inside their house with

her friends when suddenly she slipped on the floor, chest first. When her parents

arrived, she quickly complains of chest pain. Few days after, patient already

experiences fever and some episodes of back pain.

After a few weeks, her parents consulted an "albularyo", this, according to her

father, just worsen the condition of the patient, hence consultation at the hospital at their

province was prompted.

After a month of treatment at the hospital, the patient's parents decided to

transfer to Philippine Orthopedic Center, for further treatment of the patient since the

cost of treatment in the previous hospital was too expensive. Test results shows that the

patient is suffering from Pott's disease thus this prompted for confinement.

Past Medical History

The patient has suffered from lung infection before according to her father, but

didn't really prompt for confinement, the patient just undergone antibiotic therapy.

Family Health History

Both of her parents have a history of being hypertensive in their family's side. Her

mother's brother suffered from the same disease that the patient has and dies because

of it. They usually visit the Health Center for consultation when they get sick.

Personal and Social History

The patient is very friendly and outgoing thus gaining her many friends back in

their place. Being the youngest in the family, the attention is focused in her in the house.

IV. PHYSICAL ASSESSMENT

SYSTEM PHYSICAL ASSESSMENT

GENERAL

Patient is awake and responsive.Lying on bed(Temp: 36.4 °C) Afebrile(+) fatigue

SKIN

Skin is warm to touch(+) dryness(-) pallor(-) edema(-) lesions(-) pruritus

HEAD

Symmetrical round(-) masses(-) scalp lesionHair thin and distributed evenlyLymph nodes non-palpableSymmetric facial movements

EYES

SymmetricalBilateral blinkingThin, black eyebrows and lashes Pinkish conjunctivaAble to read newsprint

EARS

Equal size (symmetrical) and similar appearance notedDry earwax noted(-) pain (-) Pinna recoils after foldedAdequate hearing acuity(-) discharges

NOSESymmetrical and straight, uniform in color without dischargesNon tender and without lesionsFrontal and maxillary sinuses non-tender

MOUTH and THROATThin, pinkish lips(+)dry lips

(-) mouth sores Incomplete set of upper and lower teethTongue pinkish in color(-)ulcers in the floor of the mouth

NECK Trachea midline, (-) lumps, (-) scars, (-) stiffness in neck

RESPIRATORY

RR: 31cpm(-) dyspnea(+) cough(-) wheezing

CARDIOVASCULARPR – 113 bpm. Strong and fast pulsations noted per palpation.(-) chest tightness

GASTROINTESTINAL

(-) excessive belching(-) constipation or diarrhea noted.(-) dysphagia (-) vomitus(-) pain

GENITO – URINARYInadequate urination(-) bowel movement

MUSCULOSKELETALPoor muscle tone(+) body weaknessNeeds assistance with ADLs.

NEUROLOGIC(-) seizures(-) numbness

ENDOCRINE (-) diaphoresis

PSYCHIATRIC(-) nervousness(-) tension

V. ANATOMY AND PHYSIOLOGY

THE SPINAL COLUMN

The spinal column is one of the most vital parts of the human body, supporting our trunks and making all of our movements possible. Its anatomy is extremely well designed, and serves many functions, including:

Movement Balance Upright posture Spinal cord protection Shock absorption

  

All of the elements of the spinal column and vertebrae serve the purpose of protecting the spinal cord, which provides communication to the brain and mobility and sensation in the body through the complex interaction of bones, ligaments and muscle structures of the back and the nerves that surround it.

The normal adult spine is balanced over the pelvis, requiring minimal workload on the muscles to maintain an upright posture.

Loss of spinal balance can result in strain to the spinal muscles and spinal deformity. When the spine is injured and its function impaired, the consequences may be painful and even disabling.

Regions of the Spine

Humans are born with 33 separate vertebrae. By adulthood, we typically have 24 due to the fusion of the vertebrae in the sacrum.

The top 7 vertebrae that form the neck are called the cervical spine and are labeled C1-C7. The seven vertebrae of the cervical spine are responsible for the normal function and mobility of the neck. They also protect the spinal cord, nerves and arteries that extend from the brain to the rest of the body.

The upper back, or thoracic spine, has 12 vertebrae, labeled T1-T12. The lower back, or lumbar spine, has 5 vertebrae, labeled L1-L5. The lumbar

spine bears the most weight relative to other regions of the spine, which makes it a common source of back pain.

The sacrum (S1) and coccyx (tailbone) are made up of 9 vertebrae that are fused together to form a solid, bony unit.

Spinal Curvature

When viewed from the front or back, the normal spine is in a straight line, with each vertebra sitting directly on top of the other. Curvature to one side or the other indicates a condition called scoliosis.

When viewed from the side, the normal spine has three gradual curves:

The neck has a lordotic curve, meaning that it curves inward. The thoracic spine has a kyphotic curve, meaning it curves outward. The lumbar spine also has a lordotic curve.

These curves help the spine to support the load of the head and upper body, and maintain balance in the upright position. Excessive curvature, however, may result in spinal imbalance.

Elements of the Spine

The elements of the spine are designed to protect the spinal cord, support the body and facilitate movement.

A. VertebraeThe vertebrae support the majority of the weight imposed on the spine. The body of each vertebra is attached to a bony ring consisting of several parts. A bony projection on either side of the vertebral body called the pedicle supports the arch that protects the spinal canal. The laminae are the parts of the vertebrae that form the back of the bony arch that surrounds and covers the spinal canal. There is a transverse process on either side of the arch where some of the muscles of the spinal column attach to the vertebrae. The spinous process is the bony portion of the vertebral body that can be felt as a series of bumps in the center of a person's neck and back.

B. Intervertebral DiscBetween the spinal vertebrae are discs, which function as shock absorbers and joints. They are designed to absorb the stresses carried by the spine while allowing the vertebral bodies to move with respect to each other. Each disc consists of a strong

outer ring of fibers called the annulus fibrosis, and a soft center called the nucleus pulposus. The outer layer (annulus) helps keep the disc's inner core (nucleus) intact. The annulus is made up of very strong fibers that connect each vertebra together. The nucleus of the disc has a very high water content, which helps maintain its flexibility and shock-absorbing properties.

C. Facet JointThe facet joints connect the bony arches of each of the vertebral bodies. There are two facet joints between each pair of vertebrae, one on each side. Facet joints connect each vertebra with those directly above and below it, and are designed to allow the vertebral bodies to rotate with respect to each other.

D. Neural ForamenThe neural foramen is the opening through which the nerve roots exit the spine and travel to the rest of the body. There are two neural foramen located between each pair of vertebrae, one on each side. The foramen creates a protective passageway for the nerves that carry signals between the spinal cord and the rest of the body.

E. Spinal Cord and NervesThe spinal cord extends from the base of the brain to the area between the bottom of the first lumbar vertebra and the top of the second lumbar vertebra. The spinal cord ends by diverging into individual nerves that travel out to the lower body and the legs. Because of its appearance, this group of nerves is called the cauda equina - the Latin name for "horse's tail." The nerve groups travel through the spinal canal for a short distance before they exit the neural foramen.

The spinal cord is covered by a protective membrane called the dura mater, which forms a watertight sac around the spinal cord and nerves. Inside this sac is spinal fluid, which surrounds the spinal cord.

The nerves in each area of the spinal cord are connected to specific parts of the body. Those in the cervical spine, for example, extend to the upper chest and arms; those in the lumbar spine the hips, buttocks and legs. The nerves also carry electrical signals back to the brain, creating sensations. Damage to the nerves, nerve roots or spinal cord may result in symptoms such as pain, tingling, numbness and weakness, both in and around the damaged area and in the extremities.

Spinal Muscles

Many muscle groups that move the trunk and the limbs also attach to the spinal column. The muscles that closely surround the bones of the spine are important for maintaining posture and helping the spine to carry the loads created during normal activity, work and play. Strengthening these muscles can be an important part of physical therapy and rehabilitation.

Nervous System

All of the elements of the spinal column and vertebrae serve the purpose of protecting the spinal cord, which provides communication to the brain, mobility and sensation in the body through the complex interaction of bones, ligaments and muscle structures of the back and the nerves that surround it.

The true spinal cord ends at approximately the L1 level, where it divides into the many different nerve roots that travel to the lower body and legs. This collection of nerve roots is called the cauda equina, which means "horse's tail," and describes the continuation of the nerve roots at the end of the spinal cord.

VI. PATHOPHYSIOLOGY

Pott's disease is usually secondary to an extraspinal source of infection. The

basic lesion involved in Pott's disease is a combination of osteomyelitis and arthritis that

usually involves more than one vertebra. The anterior aspect of the vertebral body

adjacent to the subchondral plate is area usually affected. Tuberculosis may spread

from that area to adjacent intervertebral disks. In adults, disk disease is secondary to

the spread of infection from the vertebral body. In children, because the disk is

vascularized, it can be a primary site.

Progressive bone destruction leads to vertebral collapse and kyphosis. The

spinal canal can be narrowed by abscesses, granulation tissue, or direct dural invasion,

leading to spinal cord compression and neurologic deficits. The kyphotic deformity is

caused by collapse in the anterior spine. Lesions in the thoracic spine are more likely to

lead to kyphosis than those in the lumbar spine. A cold abscess can occur if the

infection extends to adjacent ligaments and soft tissues. Abscesses in the lumbar region

may descend down the sheath of the psoas to the femoral trigone region and eventually

erode into the skin.

Pathophysiology of Pott's Disease

Trauma, Previous Lung infection

Spread of bacteria (mycobacterium tuberculosis) to extrapulmonary

Back pain, fever

Vertebra is affected, intervetebral disc cannot

receive nutrients and collapseDark tissue caseation

occursVertebral collapse

Spinal damageKyphosis

Spreads from to adjacent vertebrae into

adjoining disc space