1. SPONDYLITIS TUBERCULOSIS vs PYOGENIC
Dr. Tjuk Risantoso, SpB, SpOT(K)

2. SPONDYLITIS TUBERCULOSIS
OVERVIEW
SPONDYLITIS TUBERCULOSIS
PYOGENIC
EPIDEMIOLOGY
increasing incidence of TB in United States due to increasing immunocompromised population
cases per year
Indonesia is the 3rd most populous after China and India
50% of osteoarticular TB.
15% of extrapulmonary TB
3-5% of all TB cases.
More affects children and yound adults
2 - 4% all cases of “osteomyelitis”
Rare: 1 in 250,000/yr but rising incidence
Biphasic/bimodal age
Mostly in elderly
Mean age for childhood discitis is 7y.o
The second peak is ij 50 y.o
CLINICAL FEATURES
Chronic illness
Malaise
night sweats
weight loss
back pain
kyphotic deformity
neurologic deficits (present in 10-47% of patients)
Acute onset
Pain and focal tenderness
Fever
Root symptoms/signs
Abnormal neurology
deformity, muscle spasms, meningism, sinus, and unexplained septicaemia
ETIOLOGY
Mycobacterium tuberculosis
Other Mycobacterium sp. (rare)
Staphylococcus aureus (50%)
Haemophillus influenza
Escherichia coli, Pseudomonas sp. Proteus sp. Streptococcus viridans

4. Pathoanatomy (Spondylitis TB)
Early infection
begins in the metaphysis of the vertebral body
spreads under the anterior longitudinal ligament and leads to
contiguous multilevel involvement
skip lesion or noncontiguous segments (15%)
paraspinal abscess formation (50%)
usually anterior and can be quite large (much more common in TB than pyogenic infections) 
initially does not involve the disc space (distinguishes from pyogenic osteomyelitis, but can be misdiagnosed as a neoplastic lesion)

5. Pathogenesis (Spondylitis TB)
Secondarily focus infection from the other organ hematogenically
Small tubercle  activate Chaperonin 10  high stimulator of bone resorption  destructs anterior part of vertebrae body  kyphotic deformity respiratory problem & paraplegia
Granulomatous reaction  blocks bone formation  relatively avascular  sequester
Reach the soft tissue  paravertebrae abscess  following the fascia of psoas muscle  psoas abscess ( cold abscess )
Narrowing of adjacent disc ( being avascular )

6. Chronic infection leads to 
severe kyphosis
because the infection is often diagnosed late, there is often much more severe kyphosis in granulomatous spinal infections compared to pyogenic infections
sinus formation
Pott's paraplegia
spinal cord injury can be caused by abscess/bony sequestra or meningomyelitis
abscess/bony sequestra has a better prognosis than meningomyelitis as the cause of spinal cord injury

9. Mycobaterium tuberculosis ingested by macrophage
Mycobaterium tuberculosis ingested by macrophage. If it cannot be killed, then it will replicate inside the macrophage, and form the primary Focus of Ghon Which is tubercle formed

10. While the macrophage dying, the tubercle bacilli was released and form the caseous center  make a colony surrounded by cellular imunity and live dormantly  so called focus of Simon
When the immune system getting worse this focus will be activated

12. DIVIDED INTO 5 STAGES:
Implantation
Early destruction
Late destruction
Neurological deficit
Residual deformity

13. CLASSIFY INTO: DUE TO INFECTION SITES: Peridiscal Central Anterior
Posterior (RARE)

14. Risk Factors for Pyogenic Infections

16. Laboratory Findings TB
Leukocyte >>>
ESR is prolonged
CRP (C-reactive protein )
ELISA ( false negative >> )
PCR (95% sensitivity and 93% accuracy)
Tuberculin test ( Mantoux )

17. Immunology Test Intradermal tuberculin test ( Mantoux )
67,5 – 87,5 % positive

18. Biopsy
Identification basil tuberkel  definitive diagnosis acid stain, fluorokrome and Ziehl-Nielsen or culture

20. IMAGING Studies PYOGENIC
Vertebral metaphyseal blurring (osteolysis)
Loss of disc height
Endplate blurring
Subchondral reactive bone formation
Bone destruction (and deformity)
Soft-tissue shadows e.g.psoas abscess
TB early infection shows involvement of anterior vertebral body with sparing of the disc space late infection shows disk space destruction, lucency and compression of adjacent vertebral bodies, and development of severe kyphosis

21. TB PG

22. PYOGENIC SPONDYLITIS
T2=  signal
T1=  signal
Ring enhancement

23. Ms. SA/F/20y.o/Spondylitis TB

25. TB Pyogenic

26. Epidural Abcess in Pyogenic Spondylitis

27. Abcess formation through the Petite Triangle

28. CT-SCAN & MRI CT-SCAN : Calcification of soft tissue abscess
Posterior element
Osteolytic lesion
MRI :
Central necrosis (abscess)
Inhomogen appearance

29. Histo - pathology
Granuloma and caseous appearance, Consists central zone granular and acidophilic which is circled by the epitheloid cell and Langhans giant cell with cluster of lymphosit at the outer margin of the granuloma.

30. Spinal Infections Treatment
Antibiotics
sensitivities
adequate dose (iv then oral)
ensure MBC reached
adequate duration (> 6 weeks)
monitor response (clinical/ indices/ imaging)
toxicity profile and monitoring

31. Spinal Infections Treatment
Immobilisation
bed rest
moulded orthoses (low thoracic / lumbar)
halo-vest or orthosis (cervical / high thoracic)

32. Treatment for TB
The aim : eradicate the infection, stabilize the vertebrae & to correct the khypose
The combination of chemotherapy or surgical therapy
INH ( 5-15mg/KgBW/ day ) orally
Rifampicin ( 10-15mg/KgBW/day ) orally
Pirazinamid ( 25-35/KgBW/day ) orally
Ethambutol ( 15-20mg/KgBW/day ) orally
Streptomycin ( 15-30mg/KgBW/day ) IV

33. Surgical Therapy The indications :
Failed of chemotherapy treatment in 3 – 6 months
Recurrent infection
Cervical segment abscess
Posterior lesion with abscess or sinus
Sequester formation
Vertebrae instability / progressive kyphosis
Significant neurological deficit

34. Mrs.A/F/50y.o
BEFORE (IMPLANT FAILURE)
AFTER REVISION

35. Surgery Techniques
Hongkong Methods ( anterior debridement & strut grafting )
Anterior fusion ( Upadhay et al )
Anterior instrumentation & strut graft ( Yilmaz )
Anterior bone graft & posterior osteotomy & arthrodesis
Anterior approach
Posterior approach
Costotransversectomy approach

36. Total Treatment List of Problems: Infection Poor general condition
Multiple lesion
Cold abcess
Pain
Pathologic fracture
Instability
Neurological deficit
Deformity
Kyphus progression by growth
Socioeconomic
Psychogenic
Cor
Lung
List of type of treatment:
Basic treatment: Anti TB drugs Supportive treatment External support (Plaster body
jacket/ spica or brace ) Bed rest Abcess drainage
Costotransversectomy
Thoracoscopic debridement
Anterior debridement and strutgrafting ( Hongkong Method )
Anterior instrumentation
Posterior instrumentation
Transpedicular debridement and biopsy
Translateral or posterior lumbar interbody debridement and fusion
Shortening procedures for kyphus correction
Rehabilitation

37. Treatments alternative:
1. Basic tx only
2. HK methode (AD, struthgrafting, plester body jacket)
3. Antor debride (AD), fussion(F) w/wo antor instrmt (AI)
4. AD, F + PI for nonrigid kyphotic (combined approach: antor &
postor approach)
5. Alternative 4 for rigid kyphotic deformity
6. PD (Costotransversectomy + laminectomy), PI + Fussion
for thoracal region
7. PD (laminectomy), PI + Fussion (PLIF + TLIF) for lumbal
region
8. PD (Transpedicular laminectomy), PI + Fussion for upper
thoracal (Th 2, 3, 4)
9. Alternative 7 + Circumferrential decompr for kyphotic curve
60o - 90o
10. Alternative 9 for kyphotic curve >90o w/wo shorthening &
distraction

38. Total treatment with 10 alternatives treat all existing problems in TB-Spine with the aim healing of the infection in stable and painless spine without unacceptable deformity with return of function, return to the society, family and occupation

39. Total treatment is the most acceptable, comprehensive, rational and problem solving approach to the management of tuberculosis of the spine  CURRENT TREATMENT