2. CARIES SPINE AND SPINAL STENOSIS
DR. NADIR MEHMOOD
ASSOCIATE PROFESSOR SURGERY
IIMC-T, RLY HOSP

5. CLINICAL ASPECTS OF TUBERCULOSIS
Pathogenesis of tuberculosis
Infection versus disease
Host factors
Pathogen factors

6. PATHOGENESIS Host factors include Social e.g. Age e.g. Immunity e.g.
Poverty
alcoholism
Age e.g.
Newborn
Teenage girl
Old age
Immunity e.g.
HIV
Gamma interferon

7. PATHOGENESIS
Organism factors e.g.
Virulence factors
[Drug resistance]

8. PATHOGENESIS Tuberculous disease is a consequence of:
Primary infection e.g. In a baby
Reactivation
‘natural’
Associated with immunosupression
Re infection

10. PULMONARY TB TYPICALLY AFFECTS THE UPPER ZONES OF THE LUNG

16. CLINICAL FEATURES
Clinical illness
Pulmonary
Extrapulmonary

17. CLINICAL ILLNESS TB may affect any tissue of the body including:
Skin and soft tissue
Lymph nodes
Bones and joints
Intra abdominal structures including
peritoneum
Kidneys
Adrenal glands
Central nervous system
Tuberculoma
meningitis

18. Clinical clues for TB
Clinical symptoms – usually ‘chronic’ rather than acute
Fever
Sweats
Weight loss
Focal symptoms
Epidemiology
History of TB, HIV
Country of origin, recent travel/work
Contact with TB
Investigations- CP ESR,URINE R/E, CXR, X-RAYS, C/S, SKIN TESTS,ELISA, CRP, PCR, CT, MRI

21. TB – guidelines for the clinician
Great mimicker
Low index of suspicion
Pulmonary TB usually easy to consider
Non pulmonary often requires ‘lateral thinking’

22. What will happen if diagnosis or
treatment for TB spinal osteomyelitis is delayed?

25. MENINGES OF THE SPINAL CORD

34. What will happen if treatment delayed
What will happen if treatment delayed? – gibbus formation (acute angulation of spine with or without neurological damage)

35. The physical appearance – Potts disease of spine - gibbus

36. Progress
Increasing back pain and neurological symptoms – mild leg weakness
Treatment
Continue therapy
consider surgical decompression

37. Other considerations - clinical
Further progress
Weakness of legs
Neurosurgery and internal splinting
Other considerations - clinical
Has the patient got HIV?
Is vitamin D level normal?
Other considerations - epidemiological
From where has the pt got infection?
To whom might the pt have given it?

38. TREATMENT OF TB BTS guidelines – 1999 Thorax 2000: 55; 210-218
NICE guidelines – 2006
Sensitive TB – 4 drugs for 2 months drugs for 4 months
Resistant TB - 6 drugs for 24 months (second line drugs are not so effective)
[Eng, Wales & NI 2004, 6.8% Isoniazid resistant, 1% MDR TB (R to Isoniazid and rifampicin)]

39. Problems of TB therapy Toxicity e.g. liver Multiple therapy
Prolonged treatment
Drug interactions

40. Compliance Treatment will not work if not taken
DOTS (Directly Observed Therapy) if:
Likely poor compliance
MDRTB

41. Public health - avoiding transmission
TB is statutorily notifiable disease
Multidisciplinary approach – medical, TB nurses, CCDC etc.
Identify and manage possible sources of infection and contacts
Considerations
treat as OP where possible
multi occupancy housing, social deprivation
negative pressure rooms in hospitals (limited facility)
beware transmission in OP setting e.g. waiting area

42. WHY FAILURE? Patient non compliance
Deliberate
Failure to understand e.g. language, culture
Social e.g. alcohol
Patient movement e.g. ‘lost to follow up’
Lack of medical/nursing support
others

43. Summary TB is a challenging disease for the clinician
Must have microbiology before starting treatment – more rapid lab tests?
Need to encourage compliance
Need for multidisciplinary approach to diagnosis and management and control
Need shorter, better, cheap anti TB regimes

44. SAMPLE MSQs The starting pathogenesis in TB is;
Secondary TB
Miliary TB
Ghon focus
CNS involvment
GIT involvment
The advanced stage in Potts disease is
Paresis
Lost urinary control
Gibbus formation
Paraplegia
Death
Poor compliance to treatment, TB of any site becomes
Resistant to treat
MDRTB
XDRTB
MILIARY TB
TB ABSCESS

45. Thank You.